The literature on 'knowledge translation' presents challenges for the reviewer because different terms have been used to describe the generation, sharing and application of knowledge and different research approaches embrace different philosophical positions on what knowledge is. We present a narrative review of this literature which deliberately sought to highlight rather than resolve tensions between these different framings. Our findings suggest that while 'translation' is a widely used metaphor in medicine, it constrains how we conceptualise and study the link between knowledge and practice. The 'translation' metaphor has, arguably, led to particular difficulties in the fields of 'evidence-based management' and 'evidence-based policymaking' - where it seems that knowledge obstinately refuses to be driven unproblematically into practice. Many non-medical disciplines such as philosophy, sociology and organization science conceptualise knowledge very differently, as being (for example) 'created', 'constructed', 'embodied', 'performed' and 'collectively negotiated' - and also as being value-laden and tending to serve the vested interests of dominant elites. We propose that applying this wider range of metaphors and models would allow us to research the link between knowledge and practice in more creative and critical ways. We conclude that research should move beyond a narrow focus on the 'know-do gap' to cover a richer agenda, including: (a) the situation-specific practical wisdom (phronesis) that underpins clinical judgement; (b) the tacit knowledge that is built and shared among practitioners ('mindlines'); (c) the complex links between power and knowledge; and (d) approaches to facilitating macro-level knowledge partnerships between researchers, practitioners, policymakers and commercial interests.
Objective To assess whether weekend admissions to hospital and/or already being an inpatient on weekend days were associated with any additional mortality risk. Design Retrospective observational survivorship study. We analysed all admissions to the English National Health Service (NHS) during the financial year 2009/10, following up all patients for 30 days after admission and accounting for risk of death associated with diagnosis, co-morbidities, admission history, age, sex, ethnicity, deprivation, seasonality, day of admission and hospital trust, including day of death as a time dependent covariate. The principal analysis was based on time to in-hospital death. Participants National Health Service Hospitals in England. Main Outcome Measures 30 day mortality (in or out of hospital). Results There were 14,217,640 admissions included in the principal analysis, with 187,337 in-hospital deaths reported within 30 days of admission. Admission on weekend days was associated with a considerable increase in risk of subsequent death compared with admission on weekdays, hazard ratio for Sunday versus Wednesday 1.16 (95% CI 1.14 to 1.18; P < .0001), and for Saturday versus Wednesday 1.11 (95% CI 1.09 to 1.13; P < .0001). Hospital stays on weekend days were associated with a lower risk of death than midweek days, hazard ratio for being in hospital on Sunday versus Wednesday 0.92 (95% CI 0.91 to 0.94; P < .0001), and for Saturday versus Wednesday 0.95 (95% CI 0.93 to 0.96; P < .0001). Similar findings were observed on a smaller US data set. Conclusions Admission at the weekend is associated with increased risk of subsequent death within 30 days of admission. The likelihood of death actually occurring is less on a weekend day than on a mid-week day.
Background Psychiatric illnesses are known risk factors for self-harm but associations between self-harm and physical illnesses are less well established. We aimed to stratify selected chronic physical and psychiatric illnesses according to their relative risk of self-harm. Design Retrospective cohort studies using a linked dataset of Hospital Episode Statistics (HES) for 1999–2011. Participants Individuals with selected psychiatric or physical conditions were compared with a reference cohort constructed from patients admitted for a variety of other conditions and procedures. Setting All admissions and day cases in National Health Service (NHS) hospitals in England. Main outcome measures Hospital episodes of self-harm. Rate ratios (RRs) were derived by comparing admission for self-harm between cohorts. Results The psychiatric illnesses studied (depression, bipolar disorder, alcohol abuse, anxiety disorders, eating disorders, schizophrenia and substance abuse) all had very high RRs (> 5) for self-harm. Of the physical illnesses studied, an increased risk of self-harm was associated with epilepsy (RR = 2.9, 95% confidence interval [CI] 2.8–2.9), asthma (1.8, 1.8–1.9), migraine (1.8, 1.7–1.8), psoriasis (1.6, 1.5–1.7), diabetes mellitus (1.6, 1.5–1.6), eczema (1.4, 1.3–1.5) and inflammatory polyarthropathies (1.4, 1.3–1.4). RRs were significantly low for cancers (0.95, 0.93–0.97), congenital heart disease (0.9, 0.8–0.9), ulcerative colitis (0.8, 0.7–0.8), sickle cell anaemia (0.7, 0.6–0.8) and Down's syndrome (0.1, 0.1–0.2). Conclusions Psychiatric illnesses carry a greatly increased risk of self-harm as well as of suicide. Many chronic physical illnesses are also associated with an increased risk of both self-harm and suicide. Identifying those at risk will allow provision of appropriate monitoring and support.
Objectives To understand why mortality increased in England and Wales in 2015. Design Iterative demographic analysis. Setting England and Wales Participants Population of England and Wales. Main outcome measures Causes and ages at death contributing to life expectancy changes between 2013 and 2015. Results The long-term decline in age-standardised mortality in England and Wales was reversed in 2011. Although there was a small fall in mortality rates between 2013 and 2014, in 2015 we then saw one of the largest increases in deaths in the post-war period. Nonetheless, mortality in 2015 was higher than in any year since 2008. A small decline in life expectancy at birth between 2013 and 2015 was not significant but declines in life expectancy at ages over 60 were. The largest contributors to the observed changes in life expectancy were in those aged over 85 years, with dementias making the greatest contributions in both sexes. However, changes in coding practices and diagnosis of dementia demands caution in interpreting this finding. Conclusions The long-term decline in mortality in England and Wales has reversed, with approximately 30,000 extra deaths compared to what would be expected if the average age-specific death rates in 2006–2014 had continued. These excess deaths are largely in the older population, who are most dependent on health and social care. The major contributor, based on reported causes of death, was dementia but caution was advised in this interpretation. The role of the health and social care system is explored in an accompanying paper.
Objective There has been significant concern that austerity measures have negatively impacted health in the UK. We examined whether budgetary reductions in Pension Credit and social care have been associated with recent rises in mortality rates among pensioners aged 85 years and over. Design Cross-local authority longitudinal study. Setting Three hundred and twenty-four lower tier local authorities in England. Main outcome measure Annual percentage changes in mortality rates among pensioners aged 85 years or over. Results Between 2007 and 2013, each 1% decline in Pension Credit spending (support for low income pensioners) per beneficiary was associated with an increase in 0.68% in old-age mortality (95% CI: 0.41 to 0.95). Each reduction in the number of beneficiaries per 1000 pensioners was associated with an increase in 0.20% (95% CI: 0.15 to 0.24). Each 1% decline in social care spending was associated with a significant rise in old-age mortality (0.08%, 95% CI: 0.0006–0.12) but not after adjusting for Pension Credit spending. Similar patterns were seen in both men and women. Weaker associations observed for those aged 75 to 84 years, and none among those 65 to 74 years. Categories of service expenditure not expected to affect old-age mortality, such as transportation, showed no association. Conclusions Rising mortality rates among pensioners aged 85 years and over were linked to reductions in spending on income support for poor pensioners and social care. Findings suggest austerity measures in England have affected vulnerable old-age adults.
Objectives: To understand why mortality increased in England and Wales in 2015. Design: Iterative demographic analysis. Setting: England and Wales Participants: Population of England and Wales. Main outcome measures: Causes and ages at death contributing to life expectancy changes between 2013 and 2015. Results: The long-term decline in age-standardised mortality in England and Wales was reversed in 2011. Although there was a small fall in mortality rates between 2013 and 2014, in 2015 we then saw one of the largest increases in deaths in the post-war period. Nonetheless, mortality in 2015 was higher than in any year since 2008. A small decline in life expectancy at birth between 2013 and 2015 was not significant but declines in life expectancy at ages over 60 were. The largest contributors to the observed changes in life expectancy were in those aged over 85 years, with dementias making the greatest contributions in both sexes. However, changes in coding practices and diagnosis of dementia demands caution in interpreting this finding. Conclusions: The long-term decline in mortality in England and Wales has reversed, with approximately 30,000 extra deaths compared to what would be expected if the average age-specific death rates in 2006- 2014 had continued. These excess deaths are largely in the older population, who are most dependent on health and social care. The major contributor, based on reported causes of death, was dementia but caution was advised in this interpretation. The role of the health and social care system is explored in an accompanying paper.
Objectives: To quantify population-level bias in self-reported weight and height as a function of age, sex, and the mode of self-report, and to estimate unbiased trends in national and state level obesity in the USA. Design: Statistical analysis of repeated cross-sectional health examination surveys (the National Health and Nutrition Examination Survey [NHANES]) and health surveys (the Behavioral Risk Factor Surveillance System [BRFSS]) in the USA. Setting: The 50 states of the USA and the District of Columbia. Results: In the USA, on average, women underreported their weight, but men did not. Young and middle-aged (< 65 years) adult men over-reported their height more than women of the same age. In older age groups, over-reporting of height was similar in men and women. Population-level bias in self-reported weight was larger in telephone interviews (BRFSS) than in-person interviews (NHANES). Except in older adults, height was over-reported more often in telephone interviews than in-person interviews. Using corrected weight and height in the year 2000, Mississippi (31%) and Texas (30%) had the highest prevalence of obesity for men; Texas (37%), Louisiana (37%), Mississippi (37%), District of Columbia (37%), Alabama (37%), and South Carolina (36%) for women. Conclusions: Population-level bias in self-reported weight and height is larger in telephone interviews than in-person interviews. Telephone interviews are a low-cost method for regular, nationally- and sub-nationally representative monitoring of obesity. It is possible to obtain corrected estimates of trends and geographical distributions of obesity from telephone interviews by using systematic analysis which measure weight and height from an independent sample of the same population,
Background Practitioners who enhance how they express empathy and create positive expectations of benefit could improve patient outcomes. However, the evidence in this area has not been recently synthesised. Objective To estimate the effects of empathy and expectations interventions for any clinical condition. Design Systematic review and meta-analysis of randomised trials. Data sources Six databases from inception to August 2017. Study selection Randomised trials of empathy or expectations interventions in any clinical setting with patients aged 12 years or older. Review methods Two reviewers independently screened citations, extracted data, assessed risk of bias and graded quality of evidence using GRADE. Random effects model was used for meta-analysis. Results We identified 28 eligible (n = 6017). In seven trials, empathic consultations improved pain, anxiety and satisfaction by a small amount (standardised mean difference −0.18 [95% confidence interval −0.32 to −0.03]). Twenty-two trials tested the effects of positive expectations. Eighteen of these (n = 2014) reported psychological outcomes (mostly pain) and showed a modest benefit (standardised mean difference −0.43 [95% confidence interval −0.65 to −0.21]); 11 (n = 1790) reported physical outcomes (including bronchial function/ length of hospital stay) and showed a small benefit (standardised mean difference −0.18 [95% confidence interval −0.32 to −0.05]). Within 11 trials (n = 2706) assessing harms, there was no evidence of adverse effects (odds ratio 1.04; 95% confidence interval 0.67 to 1.63). The risk of bias was low. The main limitations were difficulties in blinding and high heterogeneity for some comparisons. Conclusions Greater practitioner empathy or communication of positive messages can have small patient benefits for a range of clinical conditions, especially pain. Protocol registration Cochrane Database of Systematic Reviews (protocol) DOI: 10.1002/14651858.CD011934.pub2.
Summary Objectives Adverse drug reactions (ADR) are an important cause of morbidity and mortality. We analysed trends in hospital admissions associated with ADRs in English hospitals between 1999 and 2008. Design Data from the Hospital Episode Statistics database were examined for all English hospital admissions (1999–2008) with a primary or secondary diagnosis of an ADR recorded. Setting All NHS (public) hospitals in England. Main outcome measures The number of admissions and in-hospital mortality rate with a primary (codes including ‘adverse drug reaction’, ‘drug-induced’, ‘due to drug’, ‘due to medicament’ or ‘drug allergy’) or secondary diagnosis of ADR (ICD-10 Y40-59) were obtained and analysed. Further analysis for the year 2008–2009 was performed with regard to age, gender, proportion aged >65 yrs and total bed-days. Results Between 1999 and 2008, there were 557,978 ADR-associated admissions, representing 0.9% of total hospital admissions. Over this period the annual number of ADRs increased by 76.8% (from 42,453 to 75,076), and in-hospital mortality rate increased by 10% (from 4.3% to 4.7%). In 2008, there were 6,830,067 emergency admissions of which 75,076 (1.1%) were drug-related. Systemic agents were most commonly implicated (19.2%), followed by analgesics (13.3%) and cardiovascular drugs (12.9%).There has been a near two-fold increase in nephropathy and cardiovascular consequences secondary to drugs and a 6.8% fall in mental and behavioural disorders due to drugs. Conclusions ADRs have a major impact on public health. Our data suggest the number of ADR admissions has increased at a greater rate than the increase in total hospital admissions; some of this may be due to improved diagnostic coding. However, in-hospital mortality due to ADR admissions also increased during the period. Our findings should prompt policymakers to implement further measures to reduce ADR incidence and their associated in-hospital mortality, and methods to improve the recording of ADRs.