Repeat prescribing of medications: a system-centred risk management model for primary care organisations

Rationale, aims and objectives: Reducing preventable harm from repeat medication prescriptions is a patient safety priority worldwide. In the United Kingdom, repeat prescriptions items issued has doubled in the last 20 years from 5.8 to 13.3 items per patient per annum. This has significant resource implications and consequences for avoidable patient harms. Consequently, we aimed to test a risk management model to identify, measure, and reduce repeat prescribing system risks in primary care. Methods: All 48 general medical practices in National Health Service (NHS) Lambeth Clinical Commissioning Group (an inner city area of south London in England) were recruited. Multiple interventions were implemented, including educational workshops, a web-based risk monitoring system, and external reviews of repeat prescribing system risks by clinicians. Data were collected via documentation reviews and interviews and subject to basic thematic and descriptive statistical analyses. Results: Across the 48 participating general practices, 62 unique repeat prescribing risks were identified on 505 occasions (eg, practices frequently experiencing difficulty interpreting medication changes on hospital discharge summaries), equating to a mean of 8.1 risks per practice (range: 1-33; SD = 7.13). Seven hundred sixty-seven system improvement actions were recommended across 96 categories (eg, alerting hospitals to illegible writing and delays with discharge summaries) with a mean of 15.6 actions per practice (range: 0-34; SD = 8.0). Conclusions: The risk management model tested uncovered important safety concerns and facilitated the development and communication of related improvement recommendations. System-wide information on hazardous repeat prescribing and how this could be mitigated is very limited. The approach reported may have potential to close this gap and improve the reliability of general practice systems and patient safety, which should be of high interest to primary care organisations internationally

Progress in the development of an 88-mm bore 10 Tn3Sn dipole magnet

A 10 T, 2-layer cos(&thetas;)-dipole model magnet with an 88 mm clear bore utilizing an advanced powder-in-tube Nb3Sn conductor is being developed for the LHC. A dedicated conductor development program has resulted in a well performing Rutherford cable containing strands that uniquely exhibit both an overall current density of 600 A/mm2 @ 11 T and filaments with a diameter of 20 ¿m. The resistance between crossing strands amounts to 30-70 ¿¿ by insertion of a stainless steel core. After being exposed to a transverse pressure of 200 MPa identical cables show negligible permanent degradation of the critical current. The mechanical support structure is further optimized in order to reduce the peak stress in the mid-plane to below 130 MPa at full excitation and to control the pre-stress build-up during system assembly. Prior to the manufacturing of the final coils a dummy 2-layer pole is wound, heat-treated at 675°C and vacuum resin impregnated. This paper presents the current status of the magnet development program and highlights in particular the successful conductor developmen

The impact of three evidence-based programmes delivered in public systems in Birmingham, UK

The Birmingham Brighter Futures strategy was informed by epidemiological data on child well-being and evidence on “what works,” and included the implementation and evaluation of three evidence-based programmes in regular children’s services systems, as well as an integrated prospective cost-effectiveness analysis (reported elsewhere). A randomised controlled trial (RCT) of the Incredible Years BASIC parenting programme involved 161 children aged three and four at risk of a social-emotional or behavioural disorder. An RCT of the universal PATHS social-emotional learning curriculum involved children aged four–six years in 56 primary schools. An RCT of the Level 4 Group Triple-P parenting programme involved parents of 146 children aged four–nine years with potential social-emotional or behavioural disorders. All three studies used validated standardised measures. Both parenting programme trials used parentcompleted measures of child and parenting behaviour. The school-based trial used teacher reports of children’s behaviour, emotions, and social competence. Incredible Years yielded reductions in negative parenting behaviours among parents, reductions in child behaviour problems, and improvements in children’s relationships. In the PATHS trial, modest improvements in emotional health and behavioural development after one year disappeared by the end of year two. There were no effects for Triple-P. Much can be learned from the strengths and limitations of the Birmingham experience

Participation and representation in ATSIC elections: a ten-year perspective

This paper examines participation and representation in Aboriginal and Torres Strait Islander Commission (ATSIC) elections over the ten-year period since its inception in 1990. It attempts to identify patterns of participation that seem to be emerging and what these might suggest about ATSIC's operation. By examining numbers of nominees compared to positions available, the paper suggests that ATSIC elected office has fairly keenly and consistently sought and competed for by Indigenous people, though there may have been some slight initial reticence in the 1990 elections. By examining voter numbers and voter turnout, the paper suggests that voter participation nation-wide rose slightly from 1990 to 1996 and then largely stabilised in 1999. It also suggests that there have been significant variations from this national pattern at State and Territory levels and it explores some reasons for this, such as change in postal voting procedures. The paper also examines voter numbers and voter turnout at the ATSIC regional level since 1993 and finds that there has been a much higher voter turnout in the sparsely settled regions of northern Australia and much lower voter turnout in the southern and urban areas. This is explained in terms of ATSIC program and expenditure priorities and in terms of polling place access. The final two sections of the paper examine the representation of women and Torres Strait Islanders among ATSIC elected representatives. Both are seen as significant issues, which should be of some ongoing concern within ATSIC, alongside the issue of the southern/northern difference in voter participation

Fidelity in complex behaviour change interventions : a standardised approach to evaluate intervention integrity

Objectives: The aim of this study was to (1) demonstrate the development and testing of tools and procedures designed to monitor and assess the integrity of a complex intervention for chronic pain (COping with persistent Pain, Effectiveness Research into Self-management (COPERS) course); and (2) make recommendations based on our experiences. Design: Fidelity assessment of a two-arm randomised controlled trial intervention, assessing the adherence and competence of the facilitators delivering the intervention. Setting: The intervention was delivered in the community in two centres in the UK: one inner city and one a mix of rural and urban locations. Participants: 403 people with chronic musculoskeletal pain were enrolled in the intervention arm and 300 attended the self-management course. Thirty lay and healthcare professionals were trained and 24 delivered the courses (2 per course). We ran 31 courses for up to 16 people per course and all were audio recorded. Interventions: The course was run over three and a half days; facilitators delivered a semistructured manualised course. Outcomes: We designed three measures to evaluate fidelity assessing adherence to the manual, competence and overall impression. Results: We evaluated a random sample of four components from each course (n=122). The evaluation forms were reliable and had good face validity. There were high levels of adherence in the delivery: overall adherence was two (maximum 2, IQR 1.67–2.00), facilitator competence exhibited more variability, and overall competence was 1.5 (maximum 2, IQR 1.25–2.00). Overall impression was three (maximum 4, IQR 2.00–3.00). Conclusions: Monitoring and assessing adherence and competence at the point of intervention delivery can be realised most efficiently by embedding the principles of fidelity measurement within the design stage of complex interventions and the training and assessment of those delivering the intervention. More work is necessary to ensure that more robust systems of fidelity evaluation accompany the growth of complex interventions

Conductor development for a wide bore 10 T Nb3Sn model dipole magnet

An 87.8 mm bore single aperture 10 T Nb3Sn model dipole magnet is under development as a next step in the realization of high-field Nb3Sn dipole magnets. The magnet is a 2 layer cos(&thetas;)-dipole model as an alternative for the proposed NbTi D1 beam separator magnets for the LHC. After completion of the general magnetic and mechanical design, all attention is focused on the manufacturing and cabling of a novel powder-in-tube Nb3Sn conductor. This Nb3Sn conductor is characterized by a high non-Cu Jc of 2680 A/mm2 at 10 T with an effective filament size of about 20 ¿m. Cabling should result in a Rutherford type of cable exhibiting a moderate Jc degradation due to the cabling process itself, a low transverse stress sensitivity and a controllable minimum value of Rc. The conductor development program is presented and the results are evaluated. Progress on the actual realization of the coils is briefly describe

Pain management for chronic musculoskeletal conditions : the development of an evidence-based and theory-informed pain self-management course

Objective: To devise and test a self-management course for chronic pain patients based on evidence and underpinned by theory using the Medical Research Council (MRC) framework for developing complex interventions. Design: We used a mixed method approach. We conducted a systematic review of the effectiveness of components and characteristics of pain management courses. We then interviewed chronic pain patients who had attended pain and self-management courses. Behavioural change theories were mapped onto our findings and used to design the intervention. We then conducted a feasibility study to test the intervention. Setting: Primary care in the inner city of London, UK. Participants: Adults (18 years or older) with chronic musculoskeletal pain. Outcomes: Related disability, quality of life, coping, depression, anxiety, social integration and healthcare resource use. Results: The systematic reviews indicated that group-based courses with joint lay and healthcare professional leadership and that included a psychological component of short duration (<8 weeks) showed considerable promise. The qualitative research indicated that participants liked relaxation, valued social interaction and course location, and that timing and good tutoring were important determinants of attendance. We used behavioural change theories (social learning theory and cognitive behaviour approaches (CBA)) to inform course content. The course addressed: understanding and accepting pain, mood and pain, unhelpful thoughts and behaviour, problem solving, goal setting, action planning, movement, relaxation and social integration/reactivation. Attendance was 85%; we modified the recruitment of patients, the course and the training of facilitators as a result of testing. Conclusions: The MRC guidelines were helpful in developing this intervention. It was possible to train both lay and non-psychologists to facilitate the courses and deliver CBA. The course was feasible and well received