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Subjective wellbeing (SWB) is a broad category of phenomena that includes people’s emotional responses, domain satisfactions (e.g., health or work), and global judgements of life satisfaction. Measures of SWB offer a means to gauge the impact of events in the lives of individuals. This article examines for the first time the ways in which measures of SWB can be used within a healthcare setting, which brings a new perspective to the way that SWB is considered and applied in determining health policy. The research uses methods for SWB data collection developed through innovative empirical work. The study is a cross sectional survey of the adult inpatient population of an NHS hospital and the nurses caring for the patients, which was undertaken at two time points: summer and winter. This work on the SWB of the staff and inpatients of an acute NHS hospital generated new data sets in clinical populations. The SWB of patients was shown to be significantly affected by severe levels of EQ5D states. When considering the data on a ward-by-ward basis, it was shown that nurses health and job satisfaction were important determinants of patient SWB. We discuss the implications of this research and explain how, when and where SWB measures, when used in healthcare, can be used in health policy. We offer a novel perspective that ensures a greater focus is placed on the way that patients experience health interventions when developing health policy.

Effective sharing of clinical information between care providers is a critical component of a safe, efficient health system. National data-sharing systems may be costly, politically contentious and do not reflect local patterns of care delivery. This study examines hospital attendances in England from 2013 to 2015 to identify instances of patient sharing between hospitals. Of 19.6 million patients receiving care from 155 hospital care providers, 130 million presentations were identified. On 14.7 million occasions (12%), patients attended a different hospital to the one they attended on their previous interaction. A network of hospitals was constructed based on the frequency of patient sharing between hospitals which was partitioned using the Louvain algorithm into ten distinct data-sharing communities, improving the continuity of data sharing in such instances from 0 to 65–95%. Locally implemented data-sharing communities of hospitals may achieve effective accessibility of clinical information without a large-scale national interoperable information system.

Effective sharing of clinical information between care providers is a critical component of a safe, efficient health system. National data-sharing systems may be costly, politically contentious and do not reflect local patterns of care delivery. This study examines hospital attendances in England from 2013 to 2015 to identify instances of patient sharing between hospitals. Of 19.6 million patients receiving care from 155 hospital care providers, 130 million presentations were identified. On 14.7 million occasions (12%), patients attended a different hospital to the one they attended on their previous interaction. A network of hospitals was constructed based on the frequency of patient sharing between hospitals which was partitioned using the Louvain algorithm into ten distinct data-sharing communities, improving the continuity of data sharing in such instances from 0 to 65–95%. Locally implemented data-sharing communities of hospitals may achieve effective accessibility of clinical information without a large-scale national interoperable information system.

Background— In the United Kingdom, cardiothoracic surgeons have led the outcome reporting revolution seen over the last 20 years. The objective of this survey was to assess cardiothoracic surgeons’ opinions on the topic, with the aim of guiding future debate and policy making for all subspecialties. Methods and Results— A questionnaire was developed using interviews with experts in the field. In January 2015, the survey was sent out to all consultant cardiothoracic surgeons in the United Kingdom (n=361). Logistic regression, bivariate correlation, and the χ 2 test were used to assess whether there was a relationship between answers and demographic variables. Free-text responses were analyzed using the grounded theory approach. The response rate was 73% (n=264). The majority of respondents (58.1% oppose, 34.1% favor, and 7.8% neither) oppose the public release of surgeon-specific mortality data and associate it with several adverse consequences. These include risk-averse behavior, gaming of data, and misinterpretation of data by the public. Despite this, the majority overwhelmingly supports publication of team-based measures of outcome. The free-text responses suggest that this is because most believe that quality of care is multifactorial and not represented by an individual’s mortality rate. Conclusions— There is evident opposition to surgeon-specific mortality data among UK cardiothoracic surgeons who associate this with several unintended consequences. Policy makers should refine their strategy behind publication of surgeon-specific mortality data and possibly consider shift toward team-based results for which there will be the required support. Stakeholder feedback and inclusive strategy should be completed before introducing major initiatives to avoid unforeseen consequences and disagreements.

High fidelity simulations within the operating theatre (OT) require physical infrastructure and a full OT team. Such teams place heavy demands on clinical service. Research and training programmes in our surgical department were often compromised by the late cancellation of anaesthetists.This paper describes and evaluates a training programme in which actors were trained as simulated anaesthetists.The training programme was developed, piloted and implemented in a surgical education programme. Evaluation consisted of interviews with actors after the series of simulations. Surgical participants were not informed that the anaesthetist was an actor until after the simulation when they completed an interview and a 10-point authenticity scale (1 = not at all to 10 = highly authentic).Three actors played the role of anaesthetists in 34 scenarios with 17 surgeons in simulations of carotid endarterectomy. Although initially anxious about their role, actors found the training programme valuable and came to feel confident. Mean ratings of anaesthetist authenticity was 8.1 (Range 2-10). Surgeons' comments showed that in most scenarios they found the anaesthetist's performance highly authentic.Although this study demonstrates the feasibility of using actors as anaesthetists in high fidelity surgical simulations, there are also limitations. Factors contributing to success included: selective actor recruitment; written training materials; formal OT orientation, audio link between the control room and the actor; the opportunity to rehearse; and, structured observations.

• To explore whether risk-adjusted funnel plots are a useful adjunct to analyse volume-outcome data and to further facilitate our understanding of institutional performance data by combining funnel-plot methodology with an incremental statistical modelling approach.• Risk-adjusted funnel plots were generated for mortality and re-intervention rates after elective radical cystectomy using administrative data from NHS Hospital Trusts between 2000/01 and 2006/07. Trusts were divided into volume tertiles based on their average annual cystectomy rate. • A funnel plot was produced for each of the following four incremental statistical models: model one (no adjustment), model two (adjusted for patient case mix variables), model three (case mix and 'clustering' of patients) and model four (additional adjustment for institutional structural and process-of-care variables).• In the final complex model (model four), no Trusts had abnormally high mortality or re-intervention rates. • Comparison of the funnel plots showed the importance of adjusting for certain confounding factors, such as the surgeon, at the institutional level, before they could be labelled as having truly outlying performance.• Risk-adjusted funnel plots have a useful role to play as a component of a methodological framework for investigating the volume-outcome relationship at the institutional level. They can act as a complementary method of validating data by displaying disaggregated outcomes at provider level and account for unmeasured confounders, so reducing the opportunity for spurious labelling of outliers.

•To evaluate the volume-outcome relationship for radical cystectomy in England using outcomes other than mortality.•Patients undergoing an elective radical cystectomy were extracted from administrative hospital data for financial years 2000/1 to 2006/7. •Institutional and surgeon volume was assessed against postoperative re-intervention, postoperative complications and emergency readmission within 28 days, using a set of models accounting for patient case-mix, the 'clustered' nature of the data and structural and process of care measures.•In the final model, the odds of re-intervention within 14 and 30 days of operation for medium-volume institutions compared to low-volume institutions were found to be 63% (odds ratio, OR, 1.63; 95% CI 1.15-2.32; P= 0.01) and 52% (OR, 1.52; 95% CI, 1.13-2.04; P= 0.01) higher, respectively. •In the summary of adjusted probabilities, low-volume institutions appeared to have a lower re-intervention rate than both medium- and high-volume institutions. •By contrast, high-volume surgeons were associated with a reduced odds (OR, 0.68; 95% CI, 0.51-0.91; P= 0.01) of early re-intervention (within 14 days) compared to low-volume surgeons. •This surgeon volume-outcome effect became apparent only after adjusting for the influence of the institution and structural and process of care confounders. •There was no statistically significant relationship between volume and complication or readmission rates.•Radical cystectomy measures of re-intervention rates can be used as outcome measures to discern differences across institutional or surgeon volume providers when the institutional and surgeon volume are co-examined and adjustment for structural and process of care confounders is performed. •The finding of a lower risk of re-intervention in low-volume institutions needs to be explored further.

This chapter gives a demonstration of the practical aspects of diagnostic meta-analysis, with emphasis on data entry and manipulation, allocation of variables and code formation, and ensuring the appropriate outcome measures are produced at the end of the analysis. SAS is used to show the manipulation of data in this process. Graphical representation of data and results is shown using Review Manager.

Evidence synthesis is a term applied to a group of assessment techniques that integrate the data from variable evidence sources. These techniques are used to provide best evidence in healthcare. Evidence synthesis has several advantages when compared to single studies and traditional data integration through meta-analysis. The complexities of combining heterogeneous data sources such as the amalgamation of both qualitative and quantitative data sources can be successfully overcome by applying these techniques. Evidence synthesis can summarise data by classifying each individual source according to its quality whilst it can also quantify the degree of uncertainty in synthesis results. In this chapter, we discuss current evidence synthesis methods and consider their application for medical practitioners, scientists and policymakers. We identify the future trends and increased importance of utilising evidence synthesis for evidence-based medicine. The versatility of evidence synthesis renders it a powerful tool in attaining the ultimate goal of improved health outcomes, innovation and enhanced quality of patient care.

Novel robotic technologies utilised in surgery need assessment for their effects on the user as well as on technical performance. In this paper, the evolution in 'cognitive burden' across visuomotor learning is quantified using a combination of functional near infrared spectroscopy (fNIRS) and graph theory. The results demonstrate escalating costs within the activated cortical network during the intermediate phase of learning which is manifest as an increase in cognitive burden. This innovative application of graph theory and fNIRS enables the economic evaluation of brain behaviour underpinning task execution and how this may be impacted by novel technology and learning. Consequently, this may shed light on how robotic technologies improve human-machine interaction and augment minimally invasive surgical skills acquisition. This work has significant implications for the development and assessment of emergent robotic technologies at cortical level and in elucidating learning-related plasticity in terms of inter-regional cortical connectivity.

Peritoneal metastases frequently occur in different gastrointestinal cancers and have a poor prognosis. It is known that surgical injury promotes tumor growth and local recurrence rates and also the degree of surgical trauma correlated with the amount of tumor implantation into the peritoneum. The mechanism that mediates tumor cell adhesion to the mesothelium is not fully understood. This study investigates the role of ICAM-1, an important mediator of trans-mesothelial leucocyte migration, in tumor-mesothelial interactions as the initial step in the development of peritoneal recurrence using an in vitro model incorporating mesothelial cell monolayer derived from omental samples. We also investigate how the cytokines interleukins 6 (IL-6) and tumor necrosis factor alpha (TNF-alpha) modulate this process. We demonstrate that ICAM-1 blockade reduces the ability of both pancreatic and colonic cancer cell lines to adhere to the mesothelium. Preincubation of the mesothelial cell monolayer with either IL-6 or TNF-alpha enhances tumor cell adhesion, and this is associated with an increased expression of ICAM-1. Mesothelial CD44 expression, which has previously been implicated in this process, was unaffected by these cytokines. The use of an inhibitory monoclonal antibody against ICAM-1 attenuated the enhanced adhesion mediated by IL-6 or TNF-alpha. This study suggests that mesothelial ICAM-1 plays a role in the adhesion of tumor cells to the peritoneum in the development of peritoneal metastases.

Introduction The development of peritoneal metastases is a significant clinical issue in the treatment of abdominal cancers and is associated with poor prognosis. We have previously shown that ICAM-1-CD43 interaction plays a significant role in tumor adhesion. However, an invasive phenotype is critical to establish tumor progression via cell associated and secreted proteases including matrix metalloproteinases. High metalloproteinases level significantly enhanced metastasis phenotype on tumors, a detrimental effect on surgical outcome. We investigated the role of direct and indirect signaling between the mesothelium and the tumor cells in enhancing tumor invasion and possible therapeutic intervention. Methods Mesothelial cells were enzymatically derived from human omental tissue and implanted in 24 wells plates. Colorectal cancer cells were then introduced and allowed a direct and an indirect contact with the mesothelial layer. Anti-ICAM antibodies, anti-CD43 antibodies, and heparin were used to block MMP production. Gelatin zymography was performed on the supernatant to detect MMPs activity. Results MMP production was observed in mesothelial and tumor cells. Direct contact between cell types enhanced MMP9 and 2 (p < 0.05). Indirect contact also stimulate MMPs but at a lower degree. ICAM-1 blocking antibodies attenuated MMP production in direct contact to that observed in the indirect. Heparin introduction achieved a similar outcome. Conclusions ICAM-1-CD43 interaction plays a vital role in tumor cells-peritoneum adhesion and invasion, which is manifested by the increased production of MMPs leading to tumor invasion and peritoneal loco-regional. Blocking this interaction with heparin can provide a new therapeutic option.