To be successfully and sustainably adopted, policy-makers, service managers and practitioners want public programmes to be affordable and cost-effective, as well as effective. While the realist evaluation question is often summarised as what works for whom, under what circumstances, we believe the approach can be as salient to answering questions about resource use, costs and cost-effectiveness – the traditional domain of economic evaluation methods. This paper first describes the key similarities and differences between economic evaluation and realist evaluation. It summarises what health economists see as the challenges of evaluating complex interventions, and their suggested solutions. We then use examples of programme theory from a recent realist review of shared care for chronic conditions to illustrate two ways in which realist evaluations might better capture the resource requirements and resource consequences of programmes, and thereby produce explanations of how they are linked to outcomes (i.e. explanations of cost-effectiveness).
IntroductionValue-based healthcare delivery models have emerged to address the unprecedented pressure on long-term health system performance and sustainability and to respond to the changing needs and expectations of patients. Implementing and scaling the benefits from these care delivery models to achieve large-system transformation are challenging and require consideration of complexity and context. Realist studies enable researchers to explore factors beyond ‘what works’ towards more nuanced understanding of ‘what tends to work for whom under which circumstances’. This research proposes a realist study of the implementation approach for seven large-system, value-based healthcare initiatives in New South Wales, Australia, to elucidate how different implementation strategies and processes stimulate the uptake, adoption, fidelity and adherence of initiatives to achieve sustainable impacts across a variety of contexts.Methods and analysisThis exploratory, sequential, mixed methods realist study followed RAMESES II (Realist And Meta-narrative Evidence Syntheses: Evolving Standards) reporting standards for realist studies. Stage 1 will formulate initial programme theories from review of existing literature, analysis of programme documents and qualitative interviews with programme designers, implementation support staff and evaluators. Stage 2 envisages testing and refining these hypothesised programme theories through qualitative interviews with local hospital network staff running initiatives, and analyses of quantitative data from the programme evaluation, hospital administrative systems and an implementation outcome survey. Stage 3 proposes to produce generalisable middle-range theories by synthesising data from context–mechanism–outcome configurations across initiatives. Qualitative data will be analysed retroductively and quantitative data will be analysed to identify relationships between the implementation strategies and processes, and implementation and programme outcomes. Mixed methods triangulation will be performed.Ethics and disseminationEthical approval has been granted by Macquarie University (Project ID 23816) and Hunter New England (Project ID 2020/ETH02186) Human Research Ethics Committees. The findings will be published in peer-reviewed journals. Results will be fed back to partner organisations and roundtable discussions with other health jurisdictions will be held, to share learnings.
BackgroundThird sector organisations (TSOs) are a well-established component of health care provision in the UK’s NHS and other health systems, but little is known about how they use research and other forms of knowledge in their work. There is an emerging body of evidence exploring these issues but there is no review of this literature. This scoping review summarises what is known about how health and social care TSOs use research and other forms of knowledge in their work.MethodsA systematic search of electronic databases was carried out with initial exploratory searching of knowledge mobilisation websites, contacting authors, and hand searching of journals. The literature was narratively summarised to describe how TSOs use knowledge in decision making.ResultsTen qualitative and mixed methods studies were retrieved. They show that TSOs wish to be “evidence-informed” in their decision making, and organisational context influences the kinds of research and knowledge they prefer, as well as how they use it. Barriers to research use include time, staff skill, resources and the acontextual nature of some academic research. Appropriate approaches to knowledge mobilisation may include using research intermediaries, involving TSOs in research, and better description of interventions and contexts in academic publications to aid applying it in the multi-disciplinary contexts of TSOs. TSOs identified specific benefits of using research, such as confidence that services were good quality, ability to negotiate with stakeholders and funders, and saving time and resources through implementing interventions shown to be effective. The small number of included studies means the findings need further confirmation through primary research.ConclusionsAs the contribution of health and social care TSOs to service delivery is growing, the need to understand how they mobilise research and other forms of knowledge will continue. The research community could 1) develop relationships with TSOs to support the design and development of research projects, 2) use a range of methods to evaluate interventions to facilitate TSOs applying them to their organisational contexts and 3) improve our understanding of how TSOs use knowledge, through the use of complementary research methods, such as a realist review or ethnography.Electronic supplementary materialThe online version of this article (doi:10.1186/s13012-015-0265-6) contains supplementary material, which is available to authorized users.
BackgroundShared care (an enhanced information exchange over and above routine outpatient letters) is commonly used to improve care coordination and communication between a specialist and primary care services for people with long-term conditions. Evidence of the effectiveness and cost-effectiveness of shared care is mixed. Informed decision-making for targeting shared care requires a greater understanding of how it works, for whom it works, in what contexts and why. This protocol outlines how realist review methods can be used to synthesise evidence on shared care for long-term conditions.A further aim of the review is to explore economic evaluations of shared care. Economic evaluations are difficult to synthesise due to problems in accounting for contextual differences that impact on resource use and opportunity costs. Realist review methods have been suggested as a way to overcome some of these issues, so this review will also assess whether realist review methods are amenable to synthesising economic evidence.Methods/DesignDatabase and web searching will be carried out in order to find relevant evidence to develop and test programme theories about how shared care works. The review will have two phases. Phase 1 will concentrate on the contextual conditions and mechanisms that influence how shared care works, in order to develop programme theories, which partially explain how it works. Phase 2 will focus on testing these programme theories. A Project Reference Group made up of health service professionals and people with actual experience of long-term conditions will be used to ground the study in real-life experience. Review findings will be disseminated through local and sub-national networks for integrated care and long-term conditions.DiscussionThis realist review will explore why and for whom shared care works, in order to support decision-makers working to improve the effectiveness of care for people outside hospital. The development of realist review methods to take into account cost and cost-effectiveness evidence is particularly innovative and challenging, and if successful will offer a new approach to synthesising economic evidence. This systematic review protocol is registered on the PROSPERO database (registration number: CRD42012002842).
DesignRealist synthesis.Study backgroundLarge-scale hospital improvement initiatives can standardise healthcare across multiple sites but results are contingent on the implementation strategies that complement them. The benefits of these implemented interventions are rarely able to be replicated in different contexts. Realist studies explore this phenomenon in depth by identifying underlying context–mechanism–outcome interactions.ObjectivesTo review implementation strategies used in large-scale hospital initiatives and hypothesise initial programme theories for how they worked across different contexts.MethodsAn iterative, four-step process was applied. Step 1 explored the concepts inherent in large-scale interventions using database searches and snowballing. Step 2 identified strategies used in their implementation. Step 3 identified potential initial programme theories that may explain strategies’ mechanisms. Step 4 focused on one strategy-theory pairing to develop and test context–mechanism–outcome hypotheses. Data was drawn from searches (March–May 2020) of MEDLINE, Embase, PubMed and CINAHL, snowballed from key papers, implementation support websites and the expertise of the research team and experts. Inclusion criteria: reported implementation of a large-scale, multisite hospital intervention. RAMESES reporting standards were followed.ResultsConcepts were identified from 51 of 381 articles. Large-scale hospital interventions were characterised by a top–down approach, external and internal support and use of evidence-based interventions. We found 302 reports of 28 different implementation strategies from 31 reviews (from a total of 585). Formal theories proposed for the implementation strategies included Diffusion of Innovation, and Organisational Readiness Theory. Twenty-three context–mechanism–outcome statements for implementation strategies associated with planning and assessment activities were proposed. Evidence from the published literature supported the hypothesised programme theories and were consistent with Organisational Readiness Theory’s tenets.ConclusionThis paper adds to the literature exploring why large-scale hospital interventions are not always successfully implemented and suggests 24 causative mechanisms and contextual factors that may drive outcomes in the planning and assessment stage.
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