The fulcrum effect has a major detrimental influence on acquisition of endoscopic skills. Further work is required to investigate the role of image inversion in clinical endoscopic training.

Objectives: Synthesizing qualitative research is an important means of ensuring the needs, preferences, and experiences of patients are taken into account by service providers and policy makers, but the range of methods available can appear confusing. This study presents the methods for synthesizing qualitative research most used in health research to-date and, specifically those with a potential role in health technology assessment. Methods: To identify reviews conducted using the eight main methods for synthesizing qualitative studies, nine electronic databases were searched using key terms including meta-ethnography and synthesis. A summary table groups the identified reviews by their use of the eight methods, highlighting the methods used most generally and specifically in relation to health technology assessment topics. Results: Although there is debate about how best to identify and quality appraise qualitative research for synthesis, 107 reviews were identified using one of the eight main methods. Four methods (meta-ethnography, meta-study, meta-summary, and thematic synthesis) have been most widely used and have a role within health technology assessment. Meta-ethnography is the leading method for synthesizing qualitative health research. Thematic synthesis is also useful for integrating qualitative and quantitative findings. Four other methods (critical interpretive synthesis, grounded theory synthesis, meta-interpretation, and cross-case analysis) have been under-used in health research and their potential in health technology assessments is currently under-developed. Conclusions: Synthesizing individual qualitative studies has becoming increasingly common in recent years. Although this is still an emerging research discipline such an approach is one means of promoting the patient-centeredness of health technology assessments.Keywords: Qualitative research, Patient-centered care, Review literature, Health technology assessment, SynthesisAll authors attest that (1) Each named author contributed to both the conception/design and/or analysis/interpretation of the project and the writing of the paper; (2) Each has approved the version being submitted; and (3) The content has not been published nor is being considered for publication elsewhere (although a longer report by the authors on the same topic has been published by NHS Quality Improvement Scotland). We acknowledge input from staff at NHS Quality Improvement Scotland (NHS QIS) (now Healthcare Improvement Scotland) and the University of Aberdeen who contributed to the full report on which this study is based. This work was funded by Healthcare Improvement Scotland including a consultancy fee to N.R. and R.J. to author the full report (18). K.R. is employed by Healthcare Improvement Scotland.

BackgroundClinical practice guidelines are typically written for healthcare providers but there is increasing interest in producing versions for the public, patients and carers. The main objective of this review is to identify and synthesise evidence of the public’s attitudes towards clinical practice guidelines and evidence-based recommendations written for providers or the public, together with their awareness of guidelines.MethodsWe included quantitative and qualitative studies of any design reporting on public, patient (and their carers) attitudes and awareness of guidelines written for providers or patients/public. We searched electronic databases including MEDLINE, PSYCHINFO, ERIC, ASSIA and the Cochrane Library from 2000 to 2012. We also searched relevant websites, reviewed citations and contacted experts in the field. At least two authors independently screened, abstracted data and assessed the quality of studies. We conducted a thematic analysis of first and second order themes and performed a separate narrative synthesis of patient and public awareness of guidelines.ResultsWe reviewed 5415 records and included 26 studies (10 qualitative studies, 13 cross sectional and 3 randomised controlled trials) involving 24 887 individuals. Studies were mostly good to fair quality. The thematic analysis resulted in four overarching themes: Applicability of guidelines; Purpose of guidelines for patient; Purpose of guidelines for health care system and physician; and Properties of guidelines. Overall, participants had mixed attitudes towards guidelines; some participants found them empowering but many saw them as a way of rationing care. Patients were also concerned that the information may not apply to their own health care situations. Awareness of guidelines ranged from 0-79%, with greater awareness in participants surveyed on national guideline websites.ConclusionThere are many factors, not only formatting, that may affect the uptake and use of guideline-derived material by the public. Producers need to make clear how the information is relevant to the reader and how it can be used to make healthcare improvements although there were problems with data quality. Awareness of guidelines is generally low and guideline producers cannot assume that the public has a more positive perception of their material than of alternative sources of health information.

Objective To present a first and second trimester Down syndrome screening strategy, whereby second‐trimester marker determination is contingent on the first‐trimester results. Unlike non‐disclosure sequential screening (‘the Integrated test’), which requires all women to have markers in both trimesters, this allows a large proportion of the women to complete screening in the first trimester. Methods Two first‐trimester risk cut‐offs defined three types of results: positive and referred for early diagnosis; negative with screening complete; and intermediate, needing second‐trimester markers. Multivariate Gaussian modelling with Monte Carlo simulation was used to estimate the false‐positive rate for a fixed 85% detection rate. The false‐positive rate was evaluated for various early detection rates and early test completion rates. Model parameters were taken from the SURUSS trial. Results Completion of screening in the first trimester for 75% of women resulted in a 30% early detection rate and a 55% second trimester detected rate (net 85%) with a false‐positive rate only 0.1% above that achievable by the Integrated test. The screen‐positive rate was 0.1% in the first trimester and 4.7% for those continuing to be tested in the second trimester. If the early detection rate were to be increased to 45% or the early completion rate were to be increased to 80%, there would be a further 0.1% increase in the false‐positive rate. Conclusion Contingent screening can achieve results comparable with the Integrated test but with earlier completion of screening for most women. Both strategies need to be evaluated in large‐scale prospective studies particularly in relation to psychological impact and practicability. Copyright © 2004 John Wiley & Sons, Ltd.