Dempster–Shafer evidence theory is widely used in many fields of information fusion. However, the counter-intuitive results may be obtained when combining with highly conflicting evidence. To deal with such a problem, we put forward a new method based on the distance of evidence and the uncertainty measure. First, based on the distance of evidence, the evidence is divided into two parts, the credible evidence and the incredible evidence. Then, a novel belief entropy is applied to measure the information volume of the evidence. Finally, the weight of each evidence is obtained and used to modify the evidence before using the Dempster’s combination rule. Numerical examples show that the proposed method can effectively handle conflicting evidence with better convergence. In practical applications, the information collected from the sensors is often imprecise and uncertain. How to deal with the uncertain information effectively is still an open issue. To address the uncertain information, many math tools are presented such as fuzzy sets theory Zadeh , evidencDempster–Shafer evidence theory Dempster  D–S evi. HoweverAmong these two methods to solve the counter-intuitive results, according to the first type of methodology, the counter-intuitive behaviors are imputed to the combination rule. However, modifying combination rule usually destroys the good properties such as commutativity and associativity. What’s more, modifying the evidence combination rule is blamed to be unreasonable if the counter-intuitive results are caused by sensor failure. Based on the analysis above, researchers prefer to modify data model, in other words, through pre-process evidence to solve the problem of highly conflicting evidence.As to the method of pre-processing evidence, the weight vector is difficult to determine. At present, most of the researchers are limited to basing on the relationship among evidence or the evidence itself to generate the weight, instead of considering these two aspects. Murphy’s method Murphy  is just In this paper, a method of modifying the evidence is used to solve the combination problem of conflicting evidence. By considering the difference among evidence and the effect of evidence itself on weight, a combination method based on the distance of evidence   is defined as follows:Suppose that d Kennes .Recently, a novel belief entropy, named as Deng entropy, is applied to measure the information volume of the evidence. This entropy is the generalization of Shannon entropy Shannon . It is am, and Deng entropy is defined as follows:Specially, this entropy can definitely degenerate to the Shannon entropy if the belief is only assigned to single element. Namely,In addition, the belief entropy has been used in Jiang et al.  and Yuann evidence Suppose that there are m denotes the weighted averaging evidence of the original n evidence. The n evidence are weighted average according to all the available focal elements, respectively. But how to get the appropriate weight? We argue that both the distance of evidence and the uncertainty should be used to generate the appropriate weight of evidence.In Eq. , each \dThe uncertainty ::7):\docuThe novel belief entropy: From an intuitive point of view, In order to get the appropriate weight, the novel entropy is used to measure the uncertainty of the evidence, and a new combination method is proposed based on the entropy and the distance of evidence. Meanwhile, some definitions are presented below.n mutually exclusive evidence.If the Jousselme distance between one evidence and other evidence is small, namely, the evidence is supported by other evidence, then the evidence is considered as credible evidence;If the Jousselme distance between one evidence and other evidence is great, namely, the evidence is not supported by other evidence, then the evidence is considered as incredible evidence.Suppose there are For a credible evidence, the smaller the entropy, the smaller the uncertainty, then the clearer the evidence and it is favorable to making decision. So, the greater weight should be assigned to the evidence. On the contrary, for a incredible evidence, the smaller the entropy, the smaller the uncertainty, then the clearer the evidence. However, since there is a great conflict between the incredible evidence and other evidence, and in order to weaken its negative effects, the smaller weight should be assigned to the evidence. Based on this idea, a reward function and a penalty function are defined to generate weight.A reward function is defined as:This presented reward function meets the following properties:The reward function is always positive, i.e.,According to the mathematic properties of the exp-function, we can get that The reward function is a monotone decreasing function.According to the mathematic properties of the exp-function, we can get that this reward function is a monotone decreasing function. Thus, it can achieve that the smaller the entropy, the greater the weight. In the method, the reward function is used to generate the weight for the credible evidence.A penalty function is defined as:This presented penalty function meets the following properties:The penalty function is always positive, i.e., According to the mathematic properties of the exp-function, we can get that The penalty function is a monotone increasing function.Arbitrary take variables SinceBased on the mathematic properties of the exp-function, we can get that:HenceNamely, the penalty function is a monotone increasing function. So it can achieve that the smaller the entropy, the smaller the weight. In the method, the penalty function is used to generate the weight for the incredible evidence.n evidence Assume there are Step 1 Obtain the Jousselme distances DM is given as follows:j by Eq. . The disStep 2 Calculate the average evidence distance Step 3 Calculate the global evidence distance d.Step 4 The evidence set is divided into two parts: the credible evidence and the incredible evidence.If If Step 5 Calculate the belief entropy Step 6 Obtain the corresponding initial weight For the credible evidence, the reward function is used to generate the initial weight g to Eq. ;For the incredible evidence, the penalty function is used to generate the initial weight g to Eq. .Step 7 The final weight According to Eq. , we can It should be pointed out that, if there are only two BPAs, the Jousselme distance loses efficacy, the building steps of weight are given as follows:Step 1 Calculate the belief entropy t by Eq. .Step 2 The weight Step 3 The weight Step 4 A average weight Step 5 The final weight d by Eq. .In this section, a simple example is given to show the efficiency of the new method.In a multisensor-based target recognition system, there are totally three types of targets: DM can be obtained as follows:Firstly, according to Eq. , the JouThen, adopt Eq.  to calcud can be obtained by Eq. \documentAccording to Eq. , the finObviously, we can obtain that there is a highly conflict between the evidence Finally, use the weight to modify the evidence, the results are:After combine for 4 times by Dempster’s combination rule, the final results are given below:The fusing results derived based on different combination rules are listed in Table Dempster’s combination rule will generate counter-intuitive results when dealing with highly conflicting evidence. In the past, more attention was paid to the relationship among the evidence in information fusion, and the research on the evidence itself is ignored. In the presented method, a novel belief entropy is taken as the uncertainty measure, and it is more accurate than the AM. Furthermore, the new method can efficiently handle conflicting evidence with better performance of convergence by jointly using the distance of evidence and the uncertainty measure.In the future work, more factors will be analyzed and used in establishing the weight to construct more powerful evidence combination methods.


Evidence-based practice (EBP) gaps are widespread across health disciplines. Understanding factors supporting the uptake of evidence can inform the design of strategies to narrow these EBP gaps. Although research utilization (RU) and the factors associated with EBP have been reported in several health disciplines, to date this area has not been reviewed comprehensively in the chiropractic profession. The purpose of this review was to report on the current state of knowledge on EBP, RU, and knowledge translation (KT) in chiropractic.A scoping review using the Arksey and O’Malley framework was used to systematically select and summarize existing literature. Searches were conducted using a combination of keywords and MeSH terms from the earliest date available in each database to May 2015. Quantitative and thematic analyses of the selected literature were conducted.Nearly 85 % (56/67) of the included studies were conducted in Canada, USA, UK or Australia. Thematic analysis for the three categories  revealed two themes related to EBP , three related to RU , and three related to KT . EBP gaps were noted in the areas of assessment of activity limitation, determination of psychosocial factors influencing pain, general health indicators, establishing a prognosis, and exercise prescription. While most practitioners believed EBP and research to be important and a few studies suggested that traditional and online educational strategies could improve patient care, use of EBP and guideline adherence varied widely.Findings suggest that the majority of chiropractors hold favourable attitudes and beliefs toward EBP. However, much remains to be done for chiropractors to routinely apply evidence into clinical practice. Educational strategies aimed at practicing chiropractors can lead to more EBP and improved patient care. The chiropractic profession requires more robust dissemination and implementation research to improve guideline adherence and patient health outcomes.The online version of this article (doi:10.1186/s12906-016-1175-0) contains supplementary material, which is available to authorized users. Evidence-based practice (EBP), research utilization (RU), and knowledge translation (KT) are interrelated concepts that pertain to the identification, utilization and application of knowledge from research sources to clinical practice. EBP has been defined as “the integration of clinical expertise, patient values, and the best research evidence into the decision making process for patient care” . RU is aA number of articles have been published on EBP and determinants associated with the use of evidence in different healthcare professions, including medicine –7, nursiThe purpose of this scoping review was to identify studies reporting on RU, KT, and EBP in chiropractic in order to provide a synthesis of information about barriers and enablers to the uptake of evidence into chiropractic practice, and inform a KT research programme to help close the ‘research-practice gap’ . SpecifiDue to the uncertain volume of existing literature on evidence-based practice (EBP), research utilization (RU), and knowledge translation (KT), a scoping review methodology was preferred considering it is a flexible yet comprehensive approach to examining these topics. This methodology is optimal for answering our research question given that the breadth of information on the topic is unknown, and may arise from disparate sources and levels of evidence. In addition, scoping reviews set the scene for a future research agenda by documenting what is already known, and by using a critical analysis of gaps in knowledge to help refine research questions, concepts and theories , 21. We What is known about EBP, RU, and KT in chiropractic practice? . Multilevel strategies involving professional chiropractic leaders, teaching institutions, researchers and other stakeholders are needed to help transform the culture of chiropractic toward one that is guided by EBP principles [Leaders in the profession and clinicians alike need to be aware of a moderate to strong association between HCPs’ attitudes and beliefs and their influence on the attitudes and beliefs, clinical management, and outcomes of patients with low back pain . This isinciples .Studies included in the current review found that chiropractors generally held positive attitudes towards EBP, and were interested in improving their EBP skills –40. Howehttp://www.wfcsuggestedreadinglist.com/#download). Other important resources on EBP can be found on the Canadian Chiropractic Guideline Initiative (CCGI) website with links to Cochrane reviews relevant to the scope of practice (www.chiroguidelines.org).While guideline compliance for managing acute whiplash  and low https://clinicaltrials.gov/, NCT02483091, registered 17 June 2015). Future dissemination and implementation efforts should aim to address knowledge-practice gaps identified in our review, including risk factors for scoliosis progression [Although effect sizes were small to moderate, included studies evaluating the effect of educational interventions on process of care –87 and pgression , establigression , routinegression , 65, thegression  and patigression –69.http://www.chiroguideines.org and http://www.acorn-arccim.com/).Knowledge gained from this review provides a deeper insight on ways in which we can help end users engage in group discussions. For clinicians, strategies aimed at closing the evidence-practice gap can reduce inappropriate practice variations and improve process of care and patient outcomes. Chiropractors recognize the important of research to raise the credibility of the profession , 39 and Interprofessional collaboration is an essential component for moving toward integrated health care , 117. FiChiropractic teaching institutions play a crucial role in promoting EBP/RU/KT with their students and alumni , 119. ToConsortium for Evidence-Informed Practice Educators (http://www.cameducatorsforeip.org/) and the Academic Collaborative for Integrative Health (http://www.accahc.org/) are examples of initiatives respectively aimed at providing leadership, training, and support to CAM educators in the principles, practice and teaching of Evidence-Informed Practice (EIP) and in cultivating partnerships and advancing interprofessional education and collaborative practice. Other important initiatives to promote the application of EBP include the development and dissemination of clinical practice guidelines and related tools by the Council on Chiropractic Guidelines and Practice Parameters  and the CCGI (http://www.chiroguidelines.org). Together, these initiatives should facilitate the shift of the chiropractic profession toward EBP, which ultimately may translate in the delivery of safer and more effective patient centered care [To increase the likelihood of successful change however, faculty members could benefit from continuing professional development; not only on the EBP process itself, but on how to teach and evaluate EBP . The red care .This review complies with key steps outlined in the Joanna Briggs Institute manual for conducting scoping reviews,  includinFindings from this review suggest that the majority of chiropractors hold favourable attitudes towards, and beliefs about, EBP. However, much remains to be done for chiropractors to routinely apply evidence into clinical practice. Continuing education programmes should seek to increase chiropractors’ EBP skills. Clinicians are encouraged to consider newer resources aimed at facilitating the uptake of best practice and guidelines. Additional research is needed to identify determinants of, and barriers to, EBP and knowledge use among chiropractors and to test tailored dissemination and implementation strategies to increase adherence to best practice and guidelines and to improve patient health outcomes.CAM, complementary and alternative medicine; CCA, Canadian Chiropractic Association; CCGI, Canadian Chiropractic Guideline Initiative; DC, Doctor of Chiropractic; EBP, evidence-based practice; HCP, Heath Care Professional; KT, knowledge translation; RU, Research Utilization.


Valid and reliable instruments are required to measure the effect of educational interventions to improve evidence-based practice (EBP) knowledge and skills in occupational therapy. The aims of this paper are to: 1) describe amendments to the Adapted Fresno Test of Competence in EBP (AFT), and 2) report the psychometric properties of the modified instrument when used with South African occupational therapists.n = 58). Therapists were randomised in matched pairs to one of two educational interventions (interactive or didactic), and completed the modified AFT at baseline and 12 weeks after the intervention. An intention-to-treat analysis was performed. Data were not normally distributed, thus non-parametric statistics were used.The clinical utility of the AFT was evaluated for use with South African occupational therapists and modifications made. The modified AFT was used in two studies to assess its reliability and validity. In Study 1 a convenience sample of 26 occupational therapists in private practice or government-funded health facilities in a South African province were recruited to complete the modified AFT on two occasions 1 week apart. Completed questionnaires were scored independently by two raters. Inter-rater, test-retest reliability and internal consistency were determined. Study 2 was a pragmatic randomised controlled trial involving occupational therapists in four Western Cape Department of Health district municipalities  with a moderate effect size (r = 0.55).In Study 1, 21 of 26 participants completed the questionnaire twice. Test-retest  and inter-rater reliability  were excellent for total scores. Internal consistency based on time 1 scores was satisfactory (α = 0.70). In Study 2, 28 participants received an interactive educational intervention and completed the modified AFT at baseline and 12 weeks later. Median total SAFT scores increased significantly from baseline to 12-weeks (The modified AFT has demonstrated validity for detecting differences in EBP knowledge between two groups. It also has excellent test-retest and inter-rater reliability. The instrument is recommended for contexts where EBP is an emerging approach and time is at a premium.PACTR201201000346141. Registered 31 January 2012.Pan African Controlled Trials Register NCT01512823. Registered 1 February 2012.Clinical Trials DOH2710093067. Registered 27 October 2009.South African National Clinical Trial Register  The obligation for health professionals to base their practice on solid evidence requires a certain level of knowledge and skills in evidence-based practice (EBP). Educational interventions are commonly used to equip health professionals with the tools for EBP, but valid and reliable instruments are required to measure the effects of such interventions in improving knowledge and skills , 2. At t AND  AND (“evidence-based practice” OR “evidence based practice” OR EBP OR “evidence-based-medicine” OR evidence-based) AND (knowledge OR awareness OR skills OR attitudes OR perceptions OR behaviour OR practice OR ability OR uptake OR implementation OR “research use” OR “research utilisation” OR “research utilization”).To identify existing instruments to measure changes in EBP knowledge and skills specifically within occupational therapy, searches were conducted in Pubmed and EBSCOHost  from their inception until May 2008. The search terms used were:Terms were searched individually and results sets combined. No limits were set and no attempt was made to identify unpublished materials. Reference lists of included studies were checked for articles that may have been missed. Articles identified in the searches were screened and those that included instruments measuring EBP knowledge and/or skills in occupational therapists were selected and examined to identify those with evaluative properties.n = 7). Contact with two occupational therapists involved in EBP research revealed one further instrument  and d = 0.6) . QuestioRemoval of four of the AFT items is likely to have influenced the content validity of the SAFT as it measures only the first two steps of the EBP process. However, the AFT does not measure the entire EBP process either having been critiqued for its inability to measure the apply step . It has The time-consuming nature of completion and scoring has been identified as a short-coming of both the original Fresno Test  and the A strength of this study is the use of the SAFT in a RCT. Few studies have employed a comparison group to contribute validation data to EBP measurement instruments . FurtherA limitation of this study is the small sample size and the inclusion of only occupational therapists in the public health sector in one area of South Africa. It is therefore unclear whether the findings apply to occupational therapists working in other sectors  and provinces in South Africa. It is furthermore unclear to what extent the findings may be generalised to occupational therapists in other low- and middle-income countries or to other health professional groups.There is a paucity of research on instruments to measure EBP knowledge and skills in contexts where health professionals have had limited or no exposure to EBP training. Instruments such as the AFT, intended for novice evidence-based practitioners, are too advanced and time intensive. The content of EBP measurement instruments needs to match the knowledge and skill levels of the target group and the outcomes of the training to be provided. This requires a consensus process to establish the levels of knowledge and skill required by professionals from those with no previous EBP training right up to those who are more advanced. Future research should test the SAFT with a wider population of occupational therapists and other health professions to evaluate transferability. Investigation into valid and reliable instruments in contexts where EBP is in its early stages would build the limited current evidence base in these settings, and inform the development of additional instruments to test all five steps of the EBP process.The SAFT demonstrated its validity for detecting differences between two groups in EBP knowledge related to the first two steps of the EBP process. It also has excellent IRR and test-retest reliability. Its psychometric properties compare favourably with the AFT suggesting that it offers another option for researchers conducting studies in contexts where EBP is less advanced. As an instrument that is also quick and easy to complete and score, it may be a useful research tool in contexts where EBP knowledge levels are low and time is limited.


To assess the validity of a predictive model of health literacy, and to examine the relationship between derived health literacy estimates and 30-day hospital readmissions for acute myocardial infarction (AMI).Retrospective cohort study.A National Institute of Aging (NIA) study cohort of 696 adult, English-speaking primary care patients, aged 55–74 years, was used to assess the validity of derived health literacy estimates. Claims from 7733 Medicare beneficiaries hospitalised for AMI in 2008 in North Carolina and Illinois were used to investigate the association between health literacy estimates and 30-day hospital readmissions.The NIA cohort was administered 3 common health literacy assessments . Health literacy estimates at the census block group level were derived via a predictive model. 30-day readmissions were measured from Medicare claims data using a validated algorithm.Fair agreement was found between derived estimates and in-person literacy assessments . Medicare enrollees with above basic literacy according to derived health literacy estimates had an 18% lower risk of a 30-day readmission  and 21% lower incidence rate of 30-day readmission  than patients with basic or below basic literacy. After adjusting for demographic and clinical characteristics, the risk of 30-day readmission was 12% lower (p=0.03), and the incidence rate 16% lower (p<0.01) for patients with above basic literacy.Health literacy, as measured by a predictive model, was found to be a significant, independent predictor of 30-day readmissions. As a modifiable risk factor with evidence-based solutions, health literacy should be considered in readmission reduction efforts. To the best of our knowledge, this is the first study investigating the association between health literacy and 30-day hospital readmission on a population level, albeit through the use of predictive modelling.Results indicate that derived health literacy estimates can be used as basic surrogates of test-based measures to conduct health literacy research on a larger scale than previously possible with direct measures. Conclusions must be tempered, however, due to the use of estimates from a predictive model.Agreement between the derived health literacy estimates and individual, test-based measures was fair. Derived health literacy estimates rely on aggregate socioeconomic and demographic characteristics, and are therefore less than ideal.Nearly 20% of Medicare beneficiaries are readmitted within 30 days of hospital discharge, at a cost approaching US$17.4 billion annually.below basic or basic literacy skills, and are likely to have difficulty communicating with providers, interpreting medication instructions, engaging in self-care activities and navigating health systems.modifiable characteristic.Health literacy, or one's ability to obtain, process and understand the health information needed to make informed health decisions, is theorised to influence hospital admission and readmissions.To date, the primary obstacle limiting the study of health literacy for many epidemiological and health services phenomena has been measurement. Current, validated literacy assessments are often time-intensive and logistically challenging, with most requiring in-person administration.In this study, we utilised a unique opportunity to further validate this predictive model as a measure of health literacy. To demonstrate the potential for such a measure, we also sought to investigate the relationship between health literacy and hospital readmissions on a population level. To achieve these aims, we first determined the validity of derived health literacy estimates by examining their association with three commonly used, test-based literacy assessments among a cohort of older patients. We then examined the relationship between the derived health literacy estimates and 30-day hospital readmissions among Medicare enrollees discharged from a hospital stay for AMI in 2008 in Illinois and North Carolina, USA.We conducted a retrospective cohort study utilising data from a National Institute of Aging study entitled ‘Health Literacy and Cognitive Function among Older Adults’ ,The LitCog cohort was used to assess the construct validity of the derived health literacy estimates by examining their association with three individual health literacy measures. This cohort included English-speaking adults, aged 55–74 years, who were enrolled in the study after receiving medical care at a participating academic general internal medicine clinic or federally qualified health centre in Chicago, Illinois, USA. A full description of the cohort and LitCog study methodology has been previously published.A Medicare claims-based cohort was then used to assess the association between derived health literacy estimates and 30-day readmission. This cohort included all Medicare beneficiaries who were: (1) ≥65 years old; (2) continuously enrolled in the Medicare fee-for-service and prescription Part D programmes at least 12 months before and until the end of the study period after an index AMI hospitalisation; (3) hospitalised for the index AMI between 1 January 2008 and 31 December 2008, and survived at least 30 days after discharge in Illinois and North Carolina, USA; and (4) were discharged to non-acute care settings. Hospitalisation with AMI was defined as having international classification of diseases (ICD) 9 codes of 410.x1 as the primary or secondary discharge codes in Medicare inpatient claims. The first AMI hospitalisation in the study period was defined as the index hospitalisation for each subject. Data for this cohort were from Medicare service claims and files from the CMS Medicare Chronic Condition Data Warehouse (CCW) from 2007 to 2009.Three literacy assessments were administered to patients in the LitCog study during structured, in-person interviews.28et al used linear regression and data from the 2003 NAAL and 2000 US Census to predict the mean health literacy score of individuals living in a US census tract. The model uses the following predictor variables: gender, age, race/ethnicity, language spoken at home, income, education, marital status, time in the US, and metropolitan statistical area. The mean health literacy scores generated by the model are linked to categories used in the health literacy component of the 2003 NAAL. Specifically, NAAL health literacy scores range from 0 to 500, and are categorised as below basic (0–184), basic (185–225), intermediate (226–309), or proficient (310–500). According to the NAAL, individuals with below basic or basic skills can perform only rudimentary health tasks, such as locating and circling the date on an appointment slip or understanding basic information provided in a health brochure, respectively. Those with intermediate skills are able to perform more advanced tasks, such as determining when and how a prescription drug should be taken. Finally, individuals with proficient health literacy skills are able to understand more complex and abstract information and perform more complicated health tasks, such as determining health insurance coverage and calculating out-of-pocket costs. More detailed information on both the NAAL and the Martin and colleagues predictive model has been published elsewhere.22–24Health literacy estimates were derived for each census block group in Illinois and North Carolina using the predictive model developed by Martin and colleagues.et alWhile the original model by Martin above basic (score >225) or basic/below basic (score ≤225) in accordance with published NAAL categorisation.Patients were linked to health literacy estimates by geocoding their residential address and assigning each to a 2010 census block group. The LitCog cohort was geocoded by their complete residential address, and the AMI cohort by their 9-digit, residential ZIP code. For patients who could not be matched to a census block group, we identified their nearest 9-digit ZIP code in our geographic information database by straight-line distance, and assigned the census block group of the nearest 9-digit ZIP code to that subject. Geographic mapping and geocoding was implemented using ArcGIS software . Patient literacy estimates were categorised as score >22 or basicHospital readmission is defined as any admission, for any cause, to any hospital, within 30 days after discharge from an index AMI hospitalisation. To measure readmission, we used the same criteria utilised by CMS to evaluate hospital performance.For the LitCog cohort, patients’ basic sociodemographic information was collected during in-person interviews.29–32Pearson product-moment and Spearman correlations statistics (literacy measured continuously) and κ agreement tests  were calculated to examine the association between derived health literacy estimates and test-based, individual literacy assessments. Spearman correlation statistics were used for analyses involving the NVS (score range 0–6), while Pearson product-moment correlation statistics were calculated for analyses involving the REALM and TOFHLA .To examine the association between the derived health literacy estimates and 30-day hospital readmission, we first investigated whether the derived health literacy estimate was associated with having a readmission. A multivariable log-binomial regression model was applied to assess the relative risk (RR) of readmission within 30 days (yes vs no) between patients with above basic literacy level and patients with basic/below basic literacy.A total of 696 patients were included in the LitCog cohort . OverallAll LitCog patients were matched to a census block group, and a health literacy estimate derived by the predictive model. Using this approach, 31.2% of LitCog patients were estimated to have basic/below basic literacy skills. The results from the regression models are shown in Our results indicate that derived health literacy estimates can be used as proxies for test-based measures to conduct health literacy research on a larger scale than previously feasible with direct assessments. Using derived health literacy estimates at the census block group level, our findings suggest that health literacy is a significant, independent predictor of having a readmission within 30-days of discharge from a hospital stay for AMI; it is also predictive of the number of readmissions experienced by a patient within this timeframe. To our knowledge, this is the first study investigating the association between health literacy, albeit a derived estimate, and 30-day hospital readmission on a population level.Agreement between the derived health literacy estimates and individual, test-based measures was fair, but less than ideal. This is understandable, as the estimates are based on a neighbourhood average and not individual performance. Interestingly, the levels of agreement between the three individual-level measures of health literacy were comparable with those between the individual measures and the predictive model. This suggests that even among accepted, widely used health literacy measures, variation and measurement challenges exist. While these methods will not be suitable for all health literacy studies, a neighbourhood-based estimate is appropriate for the hypotheses we tested and is the only feasible approach at this time. Other alternatives, such as directly assessing the relationship between hospital readmissions and demographic and socioeconomic factors using Medicare data, is implausible, as claims data often lacks key variables ; furthermore, sociodemographic variables that are available can be inaccurate .22It is necessary to note, however, that using a derived health literacy estimate is not without its limitations. Socioeconomic and demographic characteristics that were included in the derived estimate have been shown in prior studies to be independently associated with readmissions, and are also well known to be strongly associated with existing, objective measures of health literacy. Yet, the relationship between socioeconomic and demographic factors and health literacy is so strong—and is the reason for their summative inclusion in the derived variable—that it has not been possible to untangle these factors from health literacy itself. As the Institute of Medicine, WHO, and many other professional societies to date have reiterated, low health literacy is, in fact, often the result of low education, poor opportunity, and limited healthcare access.24Despite these limitations, our study offers some novel insights worth further examination. Our results are particularly timely given recent attention placed on hospital readmissions as a patient safety and healthcare quality concern.Finally, our findings have implications for CMS policies. Currently, adjusted rates used by CMS to determine financial penalties include only medical comorbidity and age.Our study has several limitations beyond those associated with our derived health literacy estimates. First, the NIA study cohort used to assess the validity of the health literacy predictive model consisted of older, English-speaking adults in the Chicago metropolitan area who were predominately Caucasian or African-American. Therefore, our results may not be generalisable to younger populations, to individuals who do not speak English, to other racial/ethnic minority groups, or to those living in non-urban areas. Similarly, our analyses of the relationship between derived health literacy estimates and hospital admission were conducted among elderly Medicare beneficiaries, so results may not be generalisable to younger populations. While future research can extend our methods to younger populations, the elderly carry a disproportionate burden for hospitalisation and readmission and is the appropriate focus of this research. Second, the effects of health literacy on readmissions may vary for conditions other than AMI. Future research is necessary to examine effects of health literacy on other conditions such as heart failure and pneumonia. Third, we used Medicare medical service claims to assemble our study cohort and measure baseline clinical risk factors. It remains possible that not all diagnoses were captured in these data. To address those limitations, we applied validated algorithms to identify AMI and medical adjustment variables.41–43These methods open the door to mapping health literacy on a population level. Further, by applying this approach to the outcome of 30-day readmissions, we provide an example of how such data can be used to inform an active target for policy and health services research. Our results indicate that health literacy as measured by a predictive model is an independent predictor for both the risk and incidence rate of readmission after AMI. Future research is warranted to evaluate the generalisability of these findings to younger patients, other diagnoses, and other states in the USA, as well as to evaluate the efficacy of interventions to ameliorate the impact of health literacy.


N.M. Wulffraat and MW Heijstek, Department of pediatric rheumatology, UMC Utrecht, The NetherlandsIn order to develop evidence-based recommendations for vaccination of pediatric patients with auto-immune and/or auto-inflammatory diseases, a EULAR task force performed a systematic literature review. Available evidence was critically appraised using a customary scoring system for the level of evidence. The strength of each recommendation was determined.The majority of papers considered influenza (44) or pneumococcal (20) vaccination. Very few studies were found for the live-attenuated vaccines. Considering composite vaccines, it is recommended to adhere to national guidelines for the meningococcal serogroup C conjugate, Hib, pneumococcal, hepatitis A and B, DTaP, HPV, Japanese encephalitis, tick-borne encephalitis, typhoid fever, rabies and cholera vaccination (Grade C-D). Seasonal influenza vaccination is recommended (Grade D). Patients on anti-CD20 therapy must receive tetanus specific immunoglobulines when indicated, since rituximab lowers responses to tetanus toxoid (Grade D).Since the publication of these recommendations, we concluded a randomised controlled trial for the effects of booster MMR in 139 children  with JIA in the age of 4 to 9 years. Disease activity measured by the JADAS 27 did not differ between the revaccinated and the non-vaccinated groups. As expected seroprotection rates were higher in the revaccinated group. Methotrexate and biologicals did not affect humoral responses, but low numbers precluded definite conclusions.N. Wulfraat Consultant for: Pfizer, Novartis, Roche, AbbVie.


Effective use of a patient decision aid (PtDA) can be affected by the user’s health literacy and the PtDA’s characteristics. Systematic reviews of the relevant literature can guide PtDA developers to attend to the health literacy needs of patients. The reviews reported here aimed to assess:1. a) the effects of health literacy / numeracy on selected decision-making outcomes, and b) the effects of interventions designed to mitigate the influence of lower health literacy on decision-making outcomes, and2. the extent to which existing PtDAs a) account for health literacy, and b) are tested in lower health literacy populations.We reviewed literature for evidence relevant to these two aims. When high-quality systematic reviews existed, we summarized their evidence. When reviews were unavailable, we conducted our own systematic reviews.per se, but in 2 lower health literacy was related to higher decisional uncertainty and regret. Lower health literacy was associated with less desire for involvement in 3 studies, less question-asking in 2, and less patient-centered communication in 4 studies; its effects on other measures of patient involvement were mixed. Only one study assessed the effects of a health literacy intervention on outcomes; it showed that using video to improve the salience of health states reduced decisional uncertainty. Aim 2: In our review of 97 trials, only 3 PtDAs overtly addressed the needs of lower health literacy users. In 90% of trials, user health literacy and readability of the PtDA were not reported. However, increases in knowledge and informed choice were reported in those studies in which health literacy needs were addressed.Aim 1: In an existing systematic review of PtDA trials, lower health literacy was associated with lower patient health knowledge (14 of 16 eligible studies). Fourteen studies reported practical design strategies to improve knowledge for lower health literacy patients. In our own systematic review, no studies reported on values clarity Lower health literacy affects key decision-making outcomes, but few existing PtDAs have addressed the needs of lower health literacy users. The specific effects of PtDAs designed to mitigate the influence of low health literacy are unknown. More attention to the needs of patients with lower health literacy is indicated, to ensure that PtDAs are appropriate for lower as well as higher health literacy patients. A person’s health literacy status affects their ability to utilise health information and services, and their health outcomes . It is t“the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions” ..83]].3. Recruit, where possible, adequate numbers of low health literacy / numeracy individuals to evaluate effectiveness in this population. If full inclusion is not possible, report results of pilot studies among lower health literacy patients.4. In conjunction with point 3, assess literacy / health literacy and/or numeracy levels in study samples by directly measuring functional health literacy and/or numeracy among a representative sample of the target sample of patients, using a recognized measure such as TOFHLA, REALM, or Newest Vital Signs (NVS).5. Assess outcomes that have been shown to be or are postulated to be of specific concern for lower literacy patients.Important research gaps in the field include a) the role of health literacy in the process of values clarification, b) the need to identify the characteristics of PtDAs that are universally acceptable and helpful, and c) the need to identify those characteristics that are particularly effective at enhancing shared decision making among people with lower health literacy/numeracy. Ultimately, this future research will contribute in important ways towards understanding the effects of PtDAs on health inequalities and towards ensuring that lower literacy/numeracy groups are not disadvantaged.There are a number of limitations to our reviews of the decision-making literature. The decision for inclusion/exclusion was based on only a single assessment of each article. Although the articles closest in subject to our reviews’ purposes were assessed by two reviewers, it is possible that some relevant studies were missed. Other limitations include the inherent potential for publication bias, the diversity of measures used for similar outcomes, and the small number of physicians (despite adequate numbers of patients) that were included in studies of health literacy and communication. Indeed, many of the reviewed studies had small samples and larger studies are needed in future research. We also acknowledge there may be confounding and lack of control of relevant variables in some of the papers included in our reviews; however, we have presented the quality rating of our reviewed studies and indicated those with adjusted analyses. Although not a specific limitation of our reviews, one additional issue is that we excluded studies stratifying analyses by education. We made this choice because our search was not designed to pick up education as a proxy for literacy and we likely would have missed many relevant studies. It should be noted, however, that important information may be learned from such studies ,86. FurtIn our reviews of the PtDA literature, health literacy was not directly measured in any study. Proxy measures were used in three studies that reported having recruited individuals with unspecified deficits in education and health literacy. A limitation of our reviews is that we have not included the background articles that describe the development of PtDAs tested in the trials. Adding these may provide greater insight into how literacy was addressed. It does not, however, address the lack of attention to literacy in the trials and in identification of research questions. A related limitation is that we included only RCTs. Other studies of PtDAs that used different research designs may have included PtDAs that addressed low health literacy. We also note that there is now mixed evidence regarding the benefit of alternate media on improving outcomes for lower literacy patients, and so review criteria may need to be revised for future reviews .Because lower health literacy groups have lower levels of knowledge and involvement in health care, and some of the poorest health outcomes, they may be considered a priority group for better support in health decision making. Yet little attention has been given to this group in the PtDA literature. To enable more equitable access to PtDA resources and shared decision making, developers of PtDAs need to ensure that tools are accessible to lower as well as higher health literacy patients, and that lower health literacy groups are better equipped and supported to utilize PtDAs. Evidence is available to improve written information for lower health literacy patients; this evidence needs to be used more widely in PtDA development. However, there is little evidence to guide values clarification and increasing patient involvement in the consultation for this group of patients. More research is needed in these domains, in particular, to facilitate shared decision making among patients from varying health literacy backgrounds.NVS: Newest Vital Signs; PtDA: patient decision aid; RCTs: randomized controlled trials; REALM: Rapid Estimate of Adult Literacy in Medicine; SAM: Suitability Assessment of Materials; SMOG: Simple Measure Of Gobbledegook; TOFHLA: Test of Functional Health Literacy in Adultshttp://www.informedmedicaldecisions.org). The Foundation develops content for patient education programs. The Foundation has an arrangement with a for-profit company, Health Dialog, to co-produce these programs. The programs are used as part of the decision support and disease management services Health Dialog provides to consumers through health care organizations and employers.Kirsten McCaffery and Marla Clayman have received research funding from the Informed Medical Decisions Foundation, a not-for-profit (501 (c)3) private foundation (All other authors have no competing interests to declare.KM and SLS drafted the manuscript with comments from MHR, DR, SKS and DN. All authors contributed to the drafting of the chapter on which the paper was based. SLS led the decision making review which involved MC, KM, SKS and MW. MHR and DR led the DA RCT review with input from KKB. DN, SKS and KM contributed to the theoretical framework for the paper. All authors read and approved the final manuscript.Appendix 1: Review I: Overview of included studiesClick here for fileAppendix 2: Review I: Relationships between Health Literacy and Values Clarity/Decision ConfidenceClick here for fileAppendix 3: Review I: Relationship between Health Literacy and Selected Patient-Physician Communication VariablesClick here for fileAppendix 4: Review I: Effect of Health Literacy Interventions on Decision-Making OutcomesClick here for fileAppendix 5: Review II: Further Details about Procedures and Coding of PtDA TrialsClick here for file


N = 72) of the original papers and their corresponding replication attempts. In our computation, we take into account the likely scenario that publication bias had distorted the originally published results. Overall, 75% of studies gave qualitatively similar results in terms of the amount of evidence provided. However, the evidence was often weak . The majority of the studies (64%) did not provide strong evidence for either the null or the alternative hypothesis in either the original or the replication, and no replication attempts provided strong evidence in favor of the null. In all cases where the original paper provided strong evidence but the replication did not (15%), the sample size in the replication was smaller than the original. Where the replication provided strong evidence but the original did not (10%), the replication sample size was larger. We conclude that the apparent failure of the Reproducibility Project to replicate many target effects can be adequately explained by overestimation of effect sizes (or overestimation of evidence against the null hypothesis) due to small sample sizes and publication bias in the psychological literature. We further conclude that traditional sample sizes are insufficient and that a more widespread adoption of Bayesian methods is desirable.We revisit the results of the recent Reproducibility Project: Psychology by the Open Science Collaboration. We compute Bayes factors—a quantity that can be used to express comparative evidence for an hypothesis but also for the null hypothesis—for a large subset ( Nevertheless, the paper reports a.51 correlation between original and replication effect sizes, indicating some degree of robustness of results .The summer of 2015 saw the first published results of the long-awaited Reproducibility Project: Psychology by the Open Science Collaboration [Much like the results of the project, the reactions in media and social media have been mixed. In a first wave of reactions, headlines ranged from the dryly descriptive “Scientists replicated 100 psychology studies, and fewer than half got the same results”  and “MorIn addition to the unresolved possibility of hidden moderators, there is the issue of lacking statistical power. The statistical power of an experiment is the frequency with which it will yield a statistically significant effect in repeated sampling, assuming that the underlying effect is of a given size. All other things—such as the design of the study and the true size of the effect—being equal, statistical power is determined by an experiment’s sample size. Low-powered research designs undermine the credibility of statistically significant results in addition to increasing the probability of nonsignificant ones  in all replications, this estimate was based on the observed effect size in the original studies. In the likely event that these observed effect sizes were inflated (see next section), the sample size recommendations from prospective power analysis will have been underestimates, and thus replication studies will tend to find mostly weak evidence as well.Reviewers and editors in psychology journals are known to put a premium on ‘positive’ results. That is, they prefer studies in which a statistically significant result is used to support the existence of an effect. Nearly six decades ago, Sterling  noted thpublication bias, and is recognized as one cause of the current crisis of confidence in psychology [Moreover, it is a truism that studies published in the psychology literature are only a subset of the studies psychologists conduct, and various criteria are used to determine if a study should be published in a given journal. Studies that do not meet the criteria are relegated to lab file drawers . A selecychology .p-values to make it through to publication. Studies with smaller, non-significant effects are rarely published, driving up the average effect size [When journals selectively publish only those studies that achieve statistical significance, average published effect sizes inevitably inflate because the significance threshold acts as a filter; only the studies with the largest effect sizes have sufficiently low ect size . Readersect size  (p. 427)ect size . For theect size  and detaBayes factors [B) is a tool from Bayesian statistics that expresses how much a data set shifts the balance of evidence from one hypothesis .δ = 0) over the alternative model that uses the sequential prior because the replication result poorly fits the predictions made by the original posterior distribution, whereas small-to-medium effects will yield less forceful evidence in favor of Other analysts could reasonably choose different prior distributions when assessing these data, and it is possible they would come to different conclusions. For example, in the case of a replication study specifically, a reasonable choice for the prior distribution of  effects . Using tamount of evidence gathered in an original study compares to that found in an independent replication attempt. This question is uniquely addressed by computing Bayes factors on two data sets, using identical priors. Compared to the sequential prior, the unit information prior we have chosen for our analysis is somewhat conservative, meaning that it requires more evidence before strongly favoring There are two main reasons why, in the present paper, we choose to use the unit information prior over this sequential prior. First, our goal is not to evaluate how well empirical results reproduce, but rather to see how the t author  suggest Jeffreys  famouslyA second reason we do not use the sequential prior in this report is that it does not take into account publication bias. Assuming that publication bias has a greater effect on the original studies than it did on the  replications, the observed effect sizes in original and replicate studies are not expected to be equal. Using the original posterior distribution as a prior in the replication study would penalize bias in the original result; since the replication attempts will nearly always show smaller effect sizes than the biased originals, it will be more common to ‘fail to replicate’ these original findings , a Bayes factor of 3 in favor of the alternative will change their odds to 3:1 or a posterior probability of .75 for Jeffreys ). FinallIt is important to keep in mind that the Bayes factor as a measure of evidence must always be interpreted in the light of the substantive issue at hand: For extraordinary claims, we may reasonably require more evidence, while for certain situations—when data collection is very hard or the stakes are low—we may satisfy ourselves with smaller amounts of evidence. For our purposes, we will only consider Bayes factors of 10 or more as evidential—a value that would take an uninvested reader from equipoise to a 91% confidence level . The second, an extreme-bias model, indexes a process where non-significant results are never published. This model assigns nonzero density only to regions where significant results occur  and nowhere else. The third, a constant-bias model, indexes a process where non-significant results are published at a rate that is some constant π (0 ≤ π ≤ 1) times the rate at which significant results are published. These distributions look like typical t distributions but with the central (non-significant) region weighted down, creating large spikes in density over critical regions in the t-distribution. The fourth, an exponential-bias model, indexes a process where the probability that non-significant results are published decreases exponentially as (p − α) increases . These distributions have spikes in density around critical t-values. t values under each of the four possible censoring functions, with and without a true effect.Guan and Vandekerckhove  define fmitigated Bayes factor (BM) that takes into account that a biased process may have led to the published effect. The procedure essentially serves to raise the evidentiary bar for published studies if publication bias was not somehow prevented . A unique feature of this method  is thatBM, we first define a likelihood function in which the t distribution is multiplied by a weighting function w, so thatx is the reported t-value, n stands for the associated degrees of freedom, δ is the effect size parameter of the noncentral t distribution, and w is one of the four censoring functions which has optional parameters θ : t distribution reduces to the central t, and these four models together form the null hypothesis To calculate marginal likelihoods of these models , and they can be conveniently approximated with Gaussian quadrature methods [Second, we obtain the Bayesian evidences  methods .w and the null or alternative hypothesis; see Pr(w) is the prior probability of censoring function w and BM. Full details and MATLAB/Octave code to implement the procedure can be found here: http://bit.ly/1Nph9xQ.Finally, the posterior probability of each hypothesis can be calculated by (1) multiplying each evidence value with the corresponding model prior . No studies provide strong evidence for the null hypothesis. The remaining 57% provide only weak evidence one way or the other.For the original studies, we first computed “face value” Bayes factors that do not take into account the possibility of a biased publication process. By this measure, we find that 31 of the original studies (43%) provide strong support for the alternative hypothesis . A sizable majority of studies  provide only ambiguous or weak information, with none finding strong evidence in favor of the null.When we apply the statistical mitigation method of Guan and Vandekerckhove , the eviBR ≥ 10) and none strongly support the null. Twenty-seven (38%) provide only ambiguous information, and another 25 (35%) provide weak evidence for the null hypothesis.The set of replication studies was entirely preregistered, with all data sets fully in the open and no opportunity for publication bias to muddy the results. Hence, no mitigation of bias is called for. Of the 72 replication studies, 15 (21%) strongly support the alternative hypothesis (B ≥ 10). In only 8 cases (11%) did both the original study and the replication strongly support the alternative hypothesis. In 11 cases (15%) the original study strongly supported the alternative but the replication did not, and in 7 cases (10%) the replication provided strong evidence for the alternative whereas the original did not. The frequencies of these Bayes factor transitions are given in One of the stated goals of the Reproducibility Project: Psychology was to test whether previously found effects would obtain in an identical replication of a published study. Focusing on Bayesian evidence, we can now evaluate whether similar studies support similar conclusions. In 46 cases (64%), neither the original study nor the replication attempt yielded strong evidence  differences in sample size. The apparent discrepancy between the original set of results and the outcome of the Reproducibility Project can be adequately explained by the combination of deleterious publication practices and weak standards of evidence, without recourse to hypothetical hidden moderators.The Reproducibility Project: Psychology is a monumental effort whose preliminary results are already transforming the field. We conclude with the simple recommendation that, whenever possible, empirical investigations in psychology should increase their planned replication sample sizes beyond what is implied by power analyses based on effect sizes in the literature. Our analysis in that sense echoes that of Fraley and Vazire .p <.05), only 43% met our criteria for strong evidence, with that number shrinking further to 26% when we took publication bias into account. Furthermore, publication bias inflates published effect sizes. If this inflationary bias is ignored in prospective power calculations then replication attempts will systematically tend to be underpowered, and subsequently will systematically obtain only weak or ambiguous evidence. This appears to have been the case in the Reproducibility Project: Psychology.Decades of reliance on orthodox statistical inference—which is known to overstate the evidence against a null hypothesis –32—have A major selling point of Bayesian statistical methods is that sample sizes need not be determined in advance , which aThis is the first of several retrospective analyses of the Reproducibility Project data. We have focused on a subset of the reproduced studies that are based on univariate tests in order to account for publication bias. Other retrospectives include those that focus on Bayes factors and Bayesian effect size estimates .S1 TableInferential statistics for each of the 72 studies and their replicates.(PDF)Click here for additional data file.


Designing and implementing high-quality health care services and interventions requires robustly synthesised evidence. Syntheses of qualitative research studies can provide evidence of patients’ experiences of health conditions; intervention feasibility, appropriateness and acceptability to patients; and advance understanding of health care issues. The unique, interpretive, theory-based meta-ethnography synthesis approach is suited to conveying patients’ views and developing theory to inform service design and delivery. However, meta-ethnography reporting is often poor quality, which discourages trust in, and use of, meta-ethnography findings. Users of evidence syntheses require reports that clearly articulate analytical processes and findings. Tailored research reporting guidelines can raise reporting standards but none exists for meta-ethnography. This study aims to create an evidence-based meta-ethnography reporting guideline articulating the methodological standards and depth of reporting required to improve reporting quality.http://www.stir.ac.uk/emerge/) follows good practice in research reporting guideline development comprising: (1) a methodological systematic review (PROSPERO registration: CRD42015024709) to identify recommendations and guidance in conducting/reporting meta-ethnography; (2) a review and audit of published meta-ethnographies to identify good practice principles and develop standards in conduct/reporting; (3) an online workshop and Delphi studies to agree guideline content with 45 international qualitative synthesis experts and 45 other stakeholders including patients; (4) development and wide dissemination of the guideline and its accompanying detailed explanatory document, a report template for National Institute of Health Research commissioned meta-ethnographies, and training materials on guideline use.The mixed-methods design of this National Institute of Health Research-funded study (Meta-ethnography, devised in the field of education, is now used widely in other disciplines. Methodological advances relevant to meta-ethnography conduct exist. The extent of discipline-specific adaptations of meta-ethnography and the fit of any adaptions with the underpinning philosophy of meta-ethnography require investigation. Well-reported meta-ethnography findings could inform clinical decision-making. A bespoke meta-ethnography reporting guideline is needed to improve reporting quality, but to be effective potential users must know it exists, trust it and use it. Therefore, a rigorous study has been designed to develop and promote a guideline. By raising reporting quality, the guideline will maximise the likelihood that high-quality meta-ethnographies will contribute robust evidence to improve health care and patient outcomes. Because of the large amount of research evidence available, both types of evidence need to be robustly synthesised . Electronic reminders will be sent automatically to participants two weeks after the commencement of each round, and also shortly before the end of the round to individuals who have not yet completed the round. These reminders state the final date by which the current round must be completed.In each round a set of provisional items (agreed in Stage 3.1) will be presented on the eDelphi website. Each participant will be asked to rate how important they consider it to be  that the item should appear in the guideline. Participants will have the option to state that they have no expertise related to any item listed. In round 2 participants will have the option to add items which they consider important that are not already listed in round 1. No qualitative data will be collected, other than suggestions for additional guideline items.either of the eDelphi studies (i.e. items considered important by a majority of either group) will appear in the guideline [one of the participant groups then it will appear in the guideline. We will produce the final version of the meta-ethnography reporting guideline standards and items (the ‘guideline statement’) which will be fed back to the panels via email.Inter-round data collation is completed automatically and fed back to participants during the subsequent round, as described already. Following completion of round 3 , descriptive statistics of the ordinal data (frequencies/ percentage of responses) showing the level of consensus for each item for each study will be prepared. There will be two final sets of consensus ratings from the two parallel Delphi studies. Non-parametric inferential statistics (the Wilcoxon Signed Ranks Test) will be used to assess whether there is a statistically significant increase in consensus for item importance between rounds for each study. Items with a final consensus level of ≥70 % (for very important/important response categories) in uideline , 41. An Stages 1 and 2 of the study are deemed exempt from the need for ethical approval . Ethical approval for Stage 3 of the project has been granted by the School of Health Sciences Research Ethics Committee at the University of Stirling (SREC 14/15 – Paper No 31 – Version 1). In Stage 3 all potential participants will be given a letter of study invitation and a study information sheet. They will have the opportunity to ask questions about the study before deciding whether to take part. Participants will agree at the outset how their intellectual contribution to the study will be recognised in project outputs such as publications.Participation in the online workshop and eDelphi studies will be taken as participants’ implicit consent. Participants will be informed in the information sheet and verbally at the start of the workshop that it will be audio-recorded and detailed minutes taken, that we might use anonymised verbatim quotations in project publications (unless they prefer to be identified), and that they can choose not to participate if they do not want to be recorded. Participants will be told that they can retract their contributions to the workshop and can withdraw from the study at any time and that this will not affect their work or health care.It is unlikely that the research topic will cause emotional distress to participants or researchers. There is a slight possibility that participants and researchers with experience of a health issue might become upset if the study causes them to reflect on their experience of any health issues that affect them or people close to them. We will provide participants with a list of potential sources of support and offer them the option to take a break from or discontinue their participation. Researchers will receive regular supervision and debrief sessions.A detailed explanatory document, drawing on findings from Stages 1 to 3, will be produced to accompany the guideline statement. The explanatory document will provide detailed rationales and evidence for all of the guideline items and standards. For each item, the document will include (a) an example of good reporting from a published article, and (b) the scientific background and rationale for including that information in a published article. The document will be published simultaneously along with the guideline statement. The document will be circulated to the expert and stakeholder panels for comments and feedback prior to journal submission.Based on the contents of the reporting guideline and explanatory document an NIHR report template for commissioned meta-ethnographies will be developed. The current NIHR template for evidence syntheses and systematic reviews is designed for syntheses of quantitative studies, such as systematic reviews of intervention effectiveness. Online training resources supporting use of the guideline will also be created and a workshop about the guideline run for professional users of qualitative evidence syntheses. Other dissemination activities are described in Fig. Meta-ethnography was originally developed in the 1980s by Noblit and Hare  to synthSince 1988 when Noblit and Hare published their book on meta-ethnography there have been relevant methodological advances. For instance, Noblit and Hare gave no detail on how to implement the synthesis process  and no gWell-conducted, well-reported meta-ethnographies can provide valuable evidence to improve patient experiences, public health, and health services for any health condition, issue or service. To realise the high potential value of meta-ethnography requires high quality, transparent reporting that clearly conveys the methodology, analysis and findings. Current poor reporting , 18 is ahttp://www.equator-network.org/). The project has also been awarded DECIPHer  affiliated status and the team will report project performance and impact to them annually. The methodological systematic review to be conducted in Stage 1 has been registered with the PROSPERO international database (http://www.crd.york.ac.uk/PROSPERO/). Furthermore, we will negotiate with and ask editors of journals that publish meta-ethnographies to promote the guideline by making a clear statement of how the journal expects authors to use the guideline, what level of adherence is required, to consider asking authors to state how their article meets the guideline items and by asking peer-reviewers to use them as part of their review. Journal editors will be asked to notify us when they endorse the reporting guideline to help us to document and track all endorsements. The project team will continue to gather user feedback on use of the guideline to inform its future refinement.To be effective, a reporting guideline must be used. For this to happen, the intended users of the reporting guideline must be aware of the existence, and must trust in the quality, of the guideline and how it was developed. To engender trust in the guideline, it will be created through a rigorous study that follows good practice in reporting guideline development. The content of the guideline will be the culmination of learning from comprehensive literature reviews and debate with and the consensus of academic experts and other stakeholders. The project team will ensure that an audit trail of decisions made at each stage in the study is documented so that the decision-making process can be scrutinised. To raise awareness of the existence of the guideline we have registered our intent to produce these, and will register the final guideline, with the EQUATOR  international network and comprehensive database of reporting guidelines (www.jiscmail.ac.uk/META-ETHNOGRAPHY. The project website is available at http://www.stir.ac.uk/emerge/.The consensus study will start in May 2016 with an online workshop followed by the eDelphi studies in August 2016 and an article describing the guidelines will be submitted by May 2017. We have established an online discussion forum for anyone with an interest in meta-ethnography which can be found at:


Modern health care in the field of Medicine, Dentistry and Nursing is grounded in fundamental philosophy and epistemology of translational science. Recently in the U.S major national initiatives have been implemented in the hope of closing the gaps that sometimes exist between the two fundamental components of translational science, the translational research and translational effectiveness. Subsequent to these initiatives, many improvements have been made; however, important bioethical issues and limitations do still exist that need to be addressed. One such issue is the stakeholder engagement and its assessment and validation. Federal, state and local organizations such as PCORI and AHRQ concur that the key to a better understanding of the relationship between translational research and translational effectiveness is the assessment of the extent to which stakeholders are actively engaged in the translational process of healthcare. The stakeholder engagement analysis identifies who the stakeholders are, maps their contribution and involvement, evaluates their priorities and opinions, and accesses their current knowledge base. This analysis however requires conceptualization and validation from the bioethics standpoint. Here, we examine the bioethical dilemma of stakeholder engagement analysis in the context of the person-environment fit (PE-fit) theoretical model. This model is an approach to quantifying stakeholder engagement analysis for the design of patient-targeted interventions. In our previous studies of Alzheimer patients, we have developed, validated and used a simple instrument based on the PE-fit model that can be adapted and utilized in a much less studied pathology as a clinical model that has a wide range of symptoms and manifestations, the temporomandibular joint disorders (TMD). The temporomandibular joint (TMJ) is the jaw joint endowed with sensory and motor innervations that project from within the central nervous system and its dysfunction can be manifested systemically in forms of movement disorders, and related pathological symptomatologies.Currently, there is limited reliable evidence available to fully understand the complexity of the various domains of translational effectiveness, particularly in the context of stakeholder engagement and its assessment, validation as well as the bioethical implications as they pertain to evidence-based, effectivness-focused and patient-centered care. The Patient Protection and Affordable Care Act PPACA-2010) [0 [1] seeThe temporomandibular joints are ginglymo-arthrodial bilateral articulations of the mandible with the maxillary bone of the frontal aspect of the skull, with a hinge-type ginglymal and a sliding arthrodial component. Encapsulated by a fibrous tissue, each joint consists of the condylar process of the mandible below, and the glenoid fossa of the temporal bone above. Between these bone surfaces lies the articular meniscal disc, held by tight fibers from below and looser fibers from the temporal bone superiorly, which creates an upper and a lower capsular space. A synovial membrane lines the inner facet of the capsules, and secretes the temporomandibular synovium that fills and lubricates the upper and lower spaces . When adThe trigeminal nerve, the largest of the twelve cranial nerves is responsible for sensation in the head and neck. Of its three branches, the mandibular branch innervates the lower face and the temporomandibular joint. It projects somatic afferent fibers, and motor innervation to the masticatory musculature  . The triDisorders of the temporomandibular joint encompass a spectrum of diverse conditions, and the term TMD describes a group of conditions with similar signs and symptoms that affect the termporomandibular joints, the muscles of mastication, or both. TMD is often characterized by aching of the muscles of mastication, pain and clicking or popping sounds upon opening and closing the jaw, and severely restricted jaw movement. In our previous studies, we showed that TMD contributes to the development and exacerbation of cervical dystonia and other movement disorders, most likely via neuritis of the auriculotemporal branch of the trigeminal nerve that feeds into the pontine region and controls head and body posture . In thosTranslational medicine rests on the fundamental principles of stakeholder engagement . StakehoPrimary stakeholders: those individuals ultimately and directly affected, either positively or negatively, by the healthcare outcomes ,Key stakeholders: individuals who may or may not be primary stakeholders, but have a significant influence on the decision-making process ,Secondary stakeholders: individuals indirectly affected by the outcomes, or indirectly involved in the patient’s care process,Allied stakeholders: individuals who are involved in the patient’s care, but are indirectly affected by the healthcare outcome .Stakeholder theory originally defined stakeholders as those individuals without whose support and feedback an organization, or a project within an organization cannot subsist . In the de facto (in practice but not necessarily ordained by law) as stakeholders raising issues of liability and protection of the confidentiality and security of health care information. Incontrovertible evidence establishes that stakeholder engagement is rarely uniform: not all stakeholders have the same roles and degree of involvement in the healthcare process. Therefore, assessing stakeholder engagement  actions and position; 2) ability and intent to influence implementation; (3) motivation to participate; and (4) capability to change and adapt as the care situation evolves, and calls for adaptive management  ability -18. ReliIn order to assess the reliability of these novel instruments, the analyses of inter-rater reliability and coefficient of agreement , as wellIn our preliminary studies (data not included) we have examined the criteria and processes necessary to improve stakeholder engagement by raising their health literacy. We were able to demonstrate that bioethically sound training in communication skills could significantly improve physicians-patient relationship, reduce inappropriate use of medical information, and raise stakeholder engagement .To best examine the role and fit of stakeholders in the context of patient-targeted interventions in translational medicine, we considered the well-established and validated theoretical PE fit model. PE-fit establishes the degree to which a person is compatible with the environment, and determines the extent to which someone’s personality and set of skills are adaptable with the environmental demands. It defines the degree to which an individual can successfully adjust to the imperatives of the surrounding. The model arose from the Personality-Job Fit theory, which states in brief that a person’s personality, training and skills determine one’s adaptability and synergy in an organization and a work environment. A perceived  or real  misfit between the person and environment leads to impaired outcomes on specific tasks, job performance, satisfaction and quality of professional and personal life. From an analytical standpoint, the model offers a framework for establishing and predicting how the person’s real and perceived characteristics and skills will fit and adapt to the real and perceived requisites and demands of the work environment. Because the perception of fit of an individual within a given environment is dependent upon one’s ability to discern between perception and reality, the model reveals preventive intervention toward improving the person’s well-being, should it be sub-optimal due to constraining factors in the environment ,21-23.The model evolved to address outcomes of ill-health, consequential to the psycho-emotional stress associated with a perceived or real lack of fit, between an individual and the environment. Further evolution rendered the model more widely applicable across a variety of settings in translational medicine, including our study of evidence-based health care for caregivers  of patients with Alzheimer’s disease ,25.The principal subjective caregiver-environment fit: fit between the subjective perception of the caregiver and his/her perceived responsibilities;The secondary objective caregiver-environment fit: fit between the objective abilities of caregiver in the face of the objective demands of the caregiving responsibilities;The reality contact: correspondence between the subjective perception of the responsibilities of caregiving and the objective reality posed by these responsibilities; andThe accuracy, or accessibility, of the self: correspondence between the subjective views and objective reality of the caregiver’ abilities to face these demanding responsibilities.In that work, we constructed and validated a simple instrument (in-house questionnaire), based on the same criteria described in the literature , which cThe subjective person-environment fit (Fs) is the result of the interdependent relationship between the person’s subjective assessment of self (Ps) and his or her subjective evaluation of the environment (Es). In a parallel fashion, the objective environment (Eo) and the objectively assessed person’s abilities to meet its demands (Po) yield a quantification of the objective person-environment fit (Fo). These relationships can be summarized quantitatively as Fo = Eo-Po and Fs = Es-Ps, a can reflect the demand, or need on the part of the person (Np), or the environment (Ne) to actualize fit; and the given abilities of the person (Gp), or the given attributes of the environment (Ge) that facilitates fit. The objective person-environment fit (Fo) is a complex function of the difference  between the attributes of the environment (Ge) and the need on the part of the person (Np) or the environment (Ne) to actualize fit. In the same vein, subjective person-environment fit (Fs) is a function of the delta between the attributes of the person (Gp) and the need of the environment (Ne) to facilitate fit.The validity and the reliability of the instrument were tested in 200 subjects stratified, based on clinical exam among the groups of senile dementia of the Alzheimer’s type of stages 1–5 on the Global Assessment Scale (age range: 55–70), and of age-matched non-Alzheimer’s type dementias that included vascular dementias, Parkinson’s dementia, and dementia with Lewy bodies. We also included control subjects with no signs of dementia and of the same age range. Taken together, the inferences derived from this simple instrument provided a critical element to ensure optimal utilization of caregivers in the patient-targeted evidence-based clinical intervention for patients with Alzheimer’s disease .Currently we are in the process of developing a new instrument (questioner) in order to incorporate bioethical issues in the assessment of the stakeholder engagement for patients with TMD. Ongoing studies are validating a revision and expansion of the original instrument, based in part on the ethical dialectics proposed in the literature and above . Some ofPatient objective – Evidence objective – Provider Objective: optimal translational medicinePatient objective – Evidence objective – Provider Subjective: sub-optimal translational medicine, with potential bias on the part of the providerPatient objective – Evidence subjective – Provider subjective: health care based on the evidence, with added concern of potentially biased providerPatient Objective – Evidence subjective – Provider objective: health care based on the evidence, provider unbiasedPatient subjective – Evidence Objective – Provider subjective: although the best available evidence is used, caveat of bias due subjective patient and providerPatient subjective – Evidence subjective – Provider subjective: evidence-based of the evidence, with all possible drawbacks of subjective assessmentsPatient subjective – Evidence objective – Provider objective: attempt is made for translational medicine, but patient is biased with pre-conceived notions: provider must help patient “un”learn the misguided information before the best available evidence can be givenPatient subjective – Evidence subjective – Provider objective: provider needs to be taught how to gain access to the best available evidence in order to carry out translational medicine effectively .To further establish the applicability of the PE fit approach to bioethical concerns in translational medicine, we propose the person-environment fit model to a patient-evidence-provider best-fit model that is grounded on the same principles outlined above . In thisPrimary areas of bioethical concern subsist in the context of patient-targeted intervention in translational medicine. They are: (1) selection bias in the sampling process, (2) invasiveness of the screening and treatment protocols, (3) infraction to the fundamental principles of human rights and human dignity, and (4) reliable process of research synthesis for obtaining the best available evidence for patient-targeted intervention, and unbiased dissemination and utilization in specific clinical settings. The latter pertains to the domain of translational effectiveness, which we have discussed previously , and inv


This is the 5th edition of the UK Multi-Disciplinary Guidelines for Head and Neck Cancer, endorsed by seven national specialty associations involved in head and neck cancer care. Our aim is to provide a document can be used as a ready reference for multidisciplinary teams and a concise easy read for trainees. All evidence based recommendations in this edition are indicated by ‘(R)’ and where the multidisciplinary team of authors consider a recommendation to be based on clinical experience, it is denoted by ‘(G)’ as a good practice point. It is an enormous privilege and a great pleasure to introduce the 5th edition of the UK Multi-Disciplinary Guidelines for Head and Neck Cancer. Akin to the 4th edition,Our aim was to produce multidisciplinary consensus recommendations on the management of Head and Neck cancer based on the expertise and experience invested within the UK-based international experts and their appraisal of the current evidence. The remit of these guidelines is to provide evidence-based recommendations that will help identify an optimal management strategy. It should be appreciated that the ultimate decision for the management should rest with the multidisciplinary team, which takes into account all clinical data pertaining to the patient and his or her own social circumstances and individual preferences.In contrast to the 4th edition, we have migrated away from the Scottish Intercollegiate Guidelines Network (SIGN) grading of recommendations. In 2013, SIGN abandoned its ABCD grading methodThe 5th edition will again provide a robust clinical document, which can be used as a ready reference. and a concise easy read for trainees and all involved in Head and Neck cancer care. In conjunction with the upper aerodigestive tract cancer guidelines published recently by the National Institute for Health and Care Excellence,