Study protocol: The Adherence and Intensification of Medications (AIM) study - a cluster randomized controlled effectiveness study

Abstract Background Many patients with diabetes have poor blood pressure (BP) control. Pharmacological therapy is the cornerstone of effective BP treatment, yet there are high rates both of poor medication adherence and failure to intensify medications. Successful medication management requires an effective partnership between providers who initiate and increase doses of effective medications and patients who adhere to the regimen. Methods In this cluster-randomized controlled effectiveness study, primary care teams within sites were randomized to a program led by a clinical pharmacist trained in motivational interviewing-based behavioral counseling approaches and authorized to make BP medication changes or to usual care. This study involved the collection of data during a 14-month intervention period in three Department of Veterans Affairs facilities and two Kaiser Permanente Northern California facilities. The clinical pharmacist was supported by clinical information systems that enabled proactive identification of, and outreach to, eligible patients identified on the basis of poor BP control and either medication refill gaps or lack of recent medication intensification. The primary outcome is the relative change in systolic blood pressure (SBP) measurements over time. Secondary outcomes are changes in Hemoglobin A1c, low-density lipoprotein cholesterol (LDL), medication adherence determined from pharmacy refill data, and medication intensification rates. Discussion Integration of the three intervention elements - proactive identification, adherence counseling and medication intensification - is essential to achieve optimal levels of control for high-risk patients. Testing the effectiveness of this intervention at the team level allows us to study the program as it would typically be implemented within a clinic setting, including how it integrates with other elements of care. Trial Registration The ClinicalTrials.gov registration number is NCT00495794.http://deepblue.lib.umich.edu/bitstream/2027.42/78258/1/1745-6215-11-95.xmlhttp://deepblue.lib.umich.edu/bitstream/2027.42/78258/2/1745-6215-11-95.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/78258/3/1745-6215-11-95-S1.DOCPeer Reviewe

Assessing investigative skills in history: a case study from Scotland

Recent changes in our history syllabi stress the importance of developing an investigative/enquiry method of learning involving the framing of questions, subsequent research and the presentation of findings. Scotland has made several attempts to assess not only the end result (the paper) but also the process itself and now uses an extended essay format in two important history courses that come at the end of secondary schooling. This article discusses how we experimented before we decided on these various approaches to assessing investigative skills and evaluates the extended essay solution with particular reference to the comments of students and teachers. This analysis expands a previous article on the assessment of investigative skills which appeared in this journal

Does the process map influence the outcome of quality improvement work? A comparison of a sequential flow diagram and a hierarchical task analysis diagram

Background: Many quality and safety improvement methods in healthcare rely on a complete and accurate map of the process. Process mapping in healthcare is often achieved using a sequential flow diagram, but there is little guidance available in the literature about the most effective type of process map to use. Moreover there is evidence that the organisation of information in an external representation affects reasoning and decision making. This exploratory study examined whether the type of process map - sequential or hierarchical - affects healthcare practitioners' judgments.Methods: A sequential and a hierarchical process map of a community-based anti coagulation clinic were produced based on data obtained from interviews, talk-throughs, attendance at a training session and examination of protocols and policies. Clinic practitioners were asked to specify the parts of the process that they judged to contain quality and safety concerns. The process maps were then shown to them in counter-balanced order and they were asked to circle on the diagrams the parts of the process where they had the greatest quality and safety concerns. A structured interview was then conducted, in which they were asked about various aspects of the diagrams.Results: Quality and safety concerns cited by practitioners differed depending on whether they were or were not looking at a process map, and whether they were looking at a sequential diagram or a hierarchical diagram. More concerns were identified using the hierarchical diagram compared with the sequential diagram and more concerns were identified in relation to clinical work than administrative work. Participants' preference for the sequential or hierarchical diagram depended on the context in which they would be using it. The difficulties of determining the boundaries for the analysis and the granularity required were highlighted.Conclusions: The results indicated that the layout of a process map does influence perceptions of quality and safety problems in a process. In quality improvement work it is important to carefully consider the type of process map to be used and to consider using more than one map to ensure that different aspects of the process are captured

Symbolic capital and the production discourse of The American Music Show: a microhistory of Atlanta cable access

The American Music Show, an Atlanta cable public access television show that ran from 1981 to 2005, is not only a forgotten piece of production history but also a fertile case study. This article—situated in both local Atlanta and national cable access contexts in which the show began—uses the tools of production studies to construct a microhistory of local cable access, analyzing the hopes, ideals, ethos, and actual production practices that surrounded the show. The producers of The American Music Show refl ect on their work in the initial years of the show as creatively avant-garde but ultimately limited within the commercial structures of television. It is that tension that has enabled them to claim part of the show’s symbolic capital.Published versio

Relying on storage or ICT? How to maintain low voltage grids' stability with an increasing feed-in of fluctuating renewable energy sources

Since the beginning of the new century our electricity system is changing rapidly. Distributed energy resources, such as wind or solar energies are becoming more and more important. These energies are producing fluctuating electricity, which is fed into low voltage distribution grids. The resulting volatility complicates the exact balancing of demand and supply. These changes can lead to distribution grid instabilities, damages of electronic devices or even power outages and might therefore end in deadweight losses affecting all electricity users. A concept to tackle this challenge is matching demand with supply in real-time, which is known as smart grids. In this study, we focus on two smart grids' key components: decentralized electricity storages and smart meters. The aim of this study is to provide new insights concerning the low diffusion of smart meters and decentralized electricity storages and to examine whether we are facing situations of positive externalities. During our study we conducted eight in-depth expert interviews. Our findings show that the diffusion of smart meters as well as decentralized electricity storages is widely seen as beneficial to society. This study identifies the most important stakeholders and various related private costs and benefits. As private benefits are numerous but widely distributed among distinct players, we argue that we face situations of positive externalities and thus societal desirable actions are omitted. We identify and discuss measures to foster diffusion of the two studied smart grid key components. Surprisingly, we find that direct interventions like subsidies are mostly not seen as appropriate even by experts from industries that would directly benefit from them. As the most important point, we identified well-designed and clearly defined regulatory and legal frameworks that are free of contradictions. --smart meter,decentralized electricity storage,smart grid,externality

Development of an empathy and clarity rating scale to measure the effect of medical improv on end-of-first-year OCSE performance: a pilot study

Patients want empathetic physicians who listen and understand. How do you teach and measure empathy? Medical educators, including those inspired by Alan Alda, have turned to theater to teach skills in empathetic communication. Improvisation-informedcurriculum (medical improv) draws upon foundational actors training: deep listening, emotional understanding, connections, authenticity. Arating scale to measure the impact of medical improv on empathetic and clear communication does not exist. Objective: To develop aframework and instrument, the Empathy and Clarity Rating Scale (ECRS), for measuring communication elements used by actors and physicians, and pilot ECRS to test effectiveness of medical improv on first-yearstudents' communication skills. Design: Four medical schools collaborated. USMLE Step 2 Communication and Interpersonal Skills (CIS) domains were used as framework for discussion among three focus groups, each with clinicians, actors, communication experts, and community members with patient experience. Audiotaped discussions were transcribed; open coding procedures located emerging themes. The initial coding scheme was compared with the Consultation and Relational Empathy (CARE) measure. ECRS content was aligned with CARE, CIS and focus group themes. Modified nominal processes were conducted to finalize the scale. We implemented procedures to establish content validity and interrater reliability. Final ECRS was used to study student performance across three levels of experience with medical improv. Results: The final ECRS was comprised of seven five-pointscale items. Narrative comments precede behaviorally anchored ratings: 5=desired, 1=ineffective, 2-4=developing based upon adjustment needed. Rater agreement across all items was 84%. There was asmall correlation between the ECRS and another measure interviewing (r=0.262, p=0.003). Students with advanced medical improv training outperformed those without (F=3.51, p=.042). Conclusion: Acommunication scale enlightened by experiences of actors, clinicians, scholars and patients has been developed. The ECRS has potential to detect the impact of medical improv on development of empathetic and clear communication

PhenDisco: phenotype discovery system for the database of genotypes and phenotypes.

The database of genotypes and phenotypes (dbGaP) developed by the National Center for Biotechnology Information (NCBI) is a resource that contains information on various genome-wide association studies (GWAS) and is currently available via NCBI's dbGaP Entrez interface. The database is an important resource, providing GWAS data that can be used for new exploratory research or cross-study validation by authorized users. However, finding studies relevant to a particular phenotype of interest is challenging, as phenotype information is presented in a non-standardized way. To address this issue, we developed PhenDisco (phenotype discoverer), a new information retrieval system for dbGaP. PhenDisco consists of two main components: (1) text processing tools that standardize phenotype variables and study metadata, and (2) information retrieval tools that support queries from users and return ranked results. In a preliminary comparison involving 18 search scenarios, PhenDisco showed promising performance for both unranked and ranked search comparisons with dbGaP's search engine Entrez. The system can be accessed at http://pfindr.net

Noncoercive human intelligence gathering

Despite widespread recognition that coercive methods for intelligence gathering are unethical and counterproductive, there is an absence of empirical evidence for effective alternatives. We compared two non-coercive methods - the Modified Cognitive Interview (MCI) and Controlled Cognitive Engagement (CCE), adapted for intelligence gathering by adding a moral frame to encourage interviewees to consciously consider sharing intelligence. Participants from the general population experienced an unexpected live event where equipment was damaged, and an argument ensued. Prior to interview, participants were incentivised to withhold information about a target individual implicated in the event. CCE yielded more target information, more frequently than MCI (67% vs. 36%). Similarly, framing yielded target information more often (65% vs. 39%). The effects of interview and framing appear to be additive rather than interactive. Our results indicate combining non-coercive interview methods with moral framing can enhance intelligence gain

Fright at the Improv: The Fear of Public Speaking as a Social Phobia

Clinically speaking, fear is a phobia and the medical field has identified more than 530 phobias that humans suffer from. The fear of public speaking has long been ranked as the number one fear of Americans, placing higher than the fear of sickness or death. Within the spectrum of public speaking, many experts believe that improvisational speaking is one of the most difficult styles of public presentation. Although anxiety caused by the fear of public speaking can diminish through tactics and training, this study attempts to demonstrate that a moderate-to-extreme fear of public speaking is linked to the condition of Social Phobia. Social Phobia, or Social Anxiety Disorder (SAD), is the irrational, yet intense fear of being judged, watched, or ridiculed by others. If an extreme fear of public speaking is a Social Phobia, tactics and training alone are not the best remedy for those who suffer from this condition. Therefore, the purpose of this study was to examine the relationship between the fear of public speaking and Social Phobia. The author surveyed 77 students from an introductory speech class at Grand Valley State University. The researcher found a moderate association between the average level of anxiety of public speaking and known symptoms of Social Phobia