Integration and Continuity of Primary Care: Polyclinics and Alternatives, a Patient-Centred Analysis of How Organisation Constrains Care Coordination

Background An ageing population, increasingly specialised of clinical services and diverse healthcare provider ownership make the coordination and continuity of complex care increasingly problematic. The way in which the provision of complex healthcare is coordinated produces – or fails to – six forms of continuity of care (cross-sectional, longitudinal, flexible, access, informational, relational). Care coordination is accomplished by a combination of activities by: patients themselves; provider organisations; care networks coordinating the separate provider organisations; and overall health system governance. This research examines how far organisational integration might promote care coordination at the clinical level. Objectives To examine: 1. What differences the organisational integration of primary care makes, compared with network governance, to horizontal and vertical coordination of care. 2. What difference provider ownership (corporate, partnership, public) makes. 3. How much scope either structure allows for managerial discretion and ‘performance’. 4. Differences between networked and hierarchical governance regarding the continuity and integration of primary care. 5. The implications of the above for managerial practice in primary care. Methods Multiple-methods design combining: 1. Assembly of an analytic framework by non-systematic review. 2. Framework analysis of patients’ experiences of the continuities of care. 3. Systematic comparison of organisational case studies made in the same study sites. 4. A cross-country comparison of care coordination mechanisms found in our NHS study sites with those in publicly owned and managed Swedish polyclinics. 5. Analysis and synthesis of data using an ‘inside-out’ analytic strategy. Study sites included professional partnership, corporate and publicly owned and managed primary care providers, and different configurations of organisational integration or separation of community health services, mental health services, social services and acute in-patient care. Results Starting from data about patients' experiences of the coordination or under-coordination of care we identified: 1. Five care coordination mechanisms present in both the integrated organisations and the care networks. 2. Four main obstacles to care coordination within the integrated organisations, of which two were also present in the care networks. 3. Seven main obstacles to care coordination that were specific to the care networks. 4. Nine care coordination mechanisms present in the integrated organisations. Taking everything into consideration, integrated organisations appeared more favourable to producing continuities of care than were care networks. Network structures demonstrated more flexibility in adding services for small care groups temporarily, but the expansion of integrated organisations had advantages when adding new services on a longer term and larger scale. Ownership differences affected the range of services to which patients had direct access; primary care doctors’ managerial responsibilities (relevant to care coordination because of its impact on GP workload); and the scope for doctors to develop special interests. We found little difference between integrated organisations and care networks in terms of managerial discretion and performance. Conclusions On balance, an integrated organisation seems more likely to favour the development of care coordination, and therefore continuities of care, than a system of care networks. At least four different variants of ownership and management of organisationally integrated primary care providers are practicable in NHS-like settings

Theoretical and experimental investigation of Raman modes, ferroelectric and dielectric properties of relaxor Na0.5Bi0.5TiO3

We use a combination of first-principles density functional theoretical analysis and experimental characterization to understand the lattice dynamics, dielectric and ferroelectric properties of lead-free relaxor ferroelectric Na0.5Bi0.5TiO3 (NBT) system. Vibrational spectrum determined through our calculations agrees well with the observed Raman spectrum, and allows assignment of symmetry labels to modes. The calculated Born effective charges reveal (a) two distinct types of Ti ions at the B-site with anomalous dynamical charges differing by up 1.6e, and (b) Na and Bi ions at the A-site exhibit disparate dynamical charges of about 1 and 5.5e, respectively. Thus, there exist hetero-polar activity at both A and B-sites in NBT, and disorder associated with these hetero-polar ions is responsible for its relaxor behaviour. Large dielectric response of NBT arises primarily from phonons, and specifically the modes involving Bi-O (109 cm-1) and Ti-O (246, 276 cm-1) vibrations, respectively

Integrating the voluntary sector in personalised care: mixed methods study of the outcomes from wellbeing co-ordination for adults with complex needs

PurposeThis integrated care study seeks to highlight how voluntary sector “wellbeing co-ordinators” co-located in a horizontally and vertically integrated, multidisciplinary community hub within one locality of an Integrated Care Organisation contribute to complex, person-centred, co-ordinated care.Design/methodology/approachThis is a naturalistic, mixed method and mixed data study. It is complementing a before-and-after study with a sub-group analysis of people receiving input from the wider hub (including Wellbeing Co-ordination and Enhanced Intermediate Care), qualitative case studies, interviews, and observations co-produced with embedded researchers-in-residence.FindingsThe cross-case analysis uses trajectories and outcome patterns across six client groups to illustrate the bio-psycho-social complexity of each group across the life course, corresponding with the range of inputs offered by the hub.Research limitations/implicationsTo consider the effectiveness and mechanisms of complex system-wide interventions operating at horizontal and vertical interfaces and researching this applying co-produced, embedded, naturalistic and mixed methods approaches.Practical implicationsHow a bio-psycho-social approach by a wellbeing co-ordinator can contribute to improved person reported outcomes from a range of preventive, rehabilitation, palliative care and bereavement services in the community.Social implicationsTo combine knowledge about individuals held in the community to align the respective inputs, and expectations about outcomes while considering networked pathways based on functional status, above diagnostic pathways, and along a life-continuum.Originality/valueThe hub as a whole seems to (1) Enhance engagement through relationship, trust and activation, (2) Exchanging knowledge to co-create a shared bio-psycho-social understanding of each individual’s situation and goals, (3) Personalising care planning by utilising the range of available resources to ensure needs are met, and (4) Enhancing co-ordination and ongoing care through multi-disciplinary working between practitioners, across teams and sectors.</jats:sec

Influence of Interfacial Reactions on the Fiber-Matrix Interfacial Shear-Strength in Sapphire Fiber-Reinforced Nial(Yb) Composites

The influence of microstructure of the fiber-matrix interface on the interfacial shear strength, measured using a fiber-pushout technique, has been examined in a sapphire-fiber-reinforced NiAl(Yb) matrix composite under the following conditions: (1) as-fabricated powder metallurgy (PM) composites, (2) PM composites after solid-state heat treatment (HT), and (3) PM composites after directional solidification (DS). The fiber-pushout stress-displacement behavior consisted of an initial \u27\u27pseudoelastic\u27\u27 region, wherein the stress increased linearly with displacement, followed by an \u27\u27inelastic\u27\u27 region, where the slope of the stress-displacement plot decreased until a maximum stress was reached, and the subsequent gradual stress decreased to a \u27\u27frictional\u27\u27 stress. Energy-dispersive spectroscopy (EDS) and X-ray analyses showed that the interfacial region in the PM NiAl(Yb) composites was comprised of Yb2O3, O-rich NiAl and some spinel oxide (Yb3Al5O12), whereas the interfacial region in the HT and DS composites was comprised mainly of Yb3Al5O12. A reaction mechanism has been proposed to explain the presence of interfacial species observed in the sapphire-NiAl(Yb) composite. The extent of inter facial chemical reactions and severity of fiber surface degradation increased progressively in this order: PM \u3c HT \u3c DS. Chemical interactions between the fiber and the NiAl(Yb) matrix resulted in chemical bonding and higher interfacial shear strength compared to sapphire-NiAl composites without Yb. Unlike the sapphire-NiAl system, the frictional shear stress in the sapphire-NiAl(Yb) composites was strongly dependent on the processing conditions

Label-free quantitative comparison of cerebrospinal fluid glycoproteins and endogenous peptides in subjects with Alzheimer's disease, mild cognitive impairment, and healthy individuals

PURPOSE: The goal of this study is to investigate putative molecular dynamic changes in cerebrospinal fluids (CSFs) collected from individuals with mild cognitive impairment (MCI) and Alzheimer's disease (AD) as compared to healthy controls. EXPERIMENTAL DESIGN: The CSF samples from 12 subjects comprised of four cognitively normal individuals and eight patients with MCI and AD, respectively. Two aliquots of each CSF samples (total 1 mL) of each participant are used for this study. Endogenous peptide separations are performed using 10 000 molecular weight cut-off filters followed by LC-MS/MS identification and quantitation while lectin-enrichment chromatography is used to enrich glycoproteins in CSF followed by trypsin digestion and subsequent LC-MS/MS for shotgun identification and label-free quantitation. RESULTS: Using an optimized submicrogram peptide separation with molecular weight cut-off filtration and an in house-constructed database, 645 peptides are identified. Glycoproteins are enriched by lectin affinity chromatography, resulting in 795 identified proteins. The discovery and alterations of proSAAS-derived peptides and transthyretin are described and their roles in AD are discussed. CONCLUSIONS AND CLINICAL RELEVANCE: Comprehensive identification of endogenous CSF peptidome is achieved. Fifteen proteins are found to be differentially expressed among the three groups. The dynamic changes of transthyretin are reported for the first time

Synthesis and Characterisation of Bis-azido Methyl Oxetane and its Polymer and Copolymer with Tetrahydrofuran

Bis-azido methyl oxetane (BAMO) was synthesised from pentaerythritol in two steps. Pentaerythritol was chlorinated to yield a mixture of mono, di, tri and tetra chloro compounds. The trichloro compound on ring closure gives bis-chloro methyl oxetane (BCMO). It was reacted with sodium azide in aqueous medium to obtain BAMO. The latter was polymerised using BF3 etherate catalyst and 1,4-butanediol initiator. Similarly, the BAMO- THF copolymer was also synthesised. All the monomers and polymers were characterised by IR, 1H-NMR, 13C-NMR, and refractive index. The polymers were also characterised for molecular weight, hydroxyl value, etc. Thermal analysis showed that both polymers degrade exothermically with T max of 237 °C for poly BAMO and 241°C for BAMO- THF copolymer with activation energy of 39 kcal/mol and 40 kcal/mol, respectively. Explosive properties like impact and friction sensitivity of BAMO and the other polymers were also determined

Glycidyl Azide Polymer-based Enhanced Energy LOVA Gun Propellant

In this study, cyclotrimethylene trinitramine propellants with triacetin (TA)-plasticisedcellulose acetate (CA) and nitrocellulose (NC) combination as binders were evaluated for lowvulnerable ammunition (LOVA). Triacetin was replaced by energetic plasticiser; glycidyl azidepolymer (GAP) in increments to enhance the performance in terms of force constant . In additionto ballistics, parameters like vulnerability, mechanical and thermal properties of GAP-basedpropellants in comparison to those of TA-based propellants, were also determined. The studybrings out that the incorporation of 2-6 per cent GAP in place of TA resulted in the enhancementof force constant by 22-70 J/g and improved overall combustion characteristics. DSC revealedthat thermal decomposition of GAP-LOVA propellants evolved more energy than TA-LOVApropellants. GAP-based LOVA propellant similar to TA-plasticised LOVA propellant, was foundsuperior to NQ propellant in vulnerability tests as well as in hot fragment conductive ignition(HFCI) studies. As regards mechanical properties, incorporation of GAP resulted in improvedcompression strength

Risk-Averse Matchings over Uncertain Graph Databases

A large number of applications such as querying sensor networks, and analyzing protein-protein interaction (PPI) networks, rely on mining uncertain graph and hypergraph databases. In this work we study the following problem: given an uncertain, weighted (hyper)graph, how can we efficiently find a (hyper)matching with high expected reward, and low risk? This problem naturally arises in the context of several important applications, such as online dating, kidney exchanges, and team formation. We introduce a novel formulation for finding matchings with maximum expected reward and bounded risk under a general model of uncertain weighted (hyper)graphs that we introduce in this work. Our model generalizes probabilistic models used in prior work, and captures both continuous and discrete probability distributions, thus allowing to handle privacy related applications that inject appropriately distributed noise to (hyper)edge weights. Given that our optimization problem is NP-hard, we turn our attention to designing efficient approximation algorithms. For the case of uncertain weighted graphs, we provide a $\frac{1}{3}$-approximation algorithm, and a $\frac{1}{5}$-approximation algorithm with near optimal run time. For the case of uncertain weighted hypergraphs, we provide a $\Omega(\frac{1}{k})$-approximation algorithm, where $k$ is the rank of the hypergraph (i.e., any hyperedge includes at most $k$ nodes), that runs in almost (modulo log factors) linear time. We complement our theoretical results by testing our approximation algorithms on a wide variety of synthetic experiments, where we observe in a controlled setting interesting findings on the trade-off between reward, and risk. We also provide an application of our formulation for providing recommendations of teams that are likely to collaborate, and have high impact.Comment: 25 page