Assessing patients' experience of integrated care: a survey of patient views in the North West London Integrated Care Pilot

Despite the importance of continuity of care and patient engagement, few studies have captured patients' views on integrated care. This study assesses patient experience in the Integrated Care Pilot in North West London with the aim to help clinicians and policymakers understand patients' acceptability of integrated care and design future initiatives

Multidisciplinary group performance—measuring integration intensity in the context of the North West London Integrated Care Pilot

Introduction: Multidisciplinary Group meetings (MDGs) are seen as key facilitators of integration, moving from individual to multidisciplinary decision-making, and from a focus on individual patients to a focus on patient groups. We have developed a method for coding MDG transcripts to identify whether they are or are not vehicles for delivering the anticipated efficiency improvements across various providers and apply it to a test case in the North West London Integrated Care Pilot. Methods: We defined ‘integrating’ as the process within the MDG meeting that enables or promotes an improved collaboration, improved understanding, and improved awareness of self and others within the local healthcare economy such that efficiency improvements could be identified and action taken. Utterances within the MDGs are coded according to three distinct domains grounded in concepts from communication, group decision-making, and integrated care literatures—the Valence, the Focus, and the Level. Standardized weighted integrative intensity scores are calculated across ten time deciles in the Case Discussion providing a graphical representation of its integrative intensity. Results: Intra- and Inter-rater reliability of the coding scheme was very good as measured by the Prevalence and Bias-adjusted Kappa Score. Standardized Weighted Integrative Intensity graph mirrored closely the verbatim transcript and is a convenient representation of complex communication dynamics. Trend in integrative intensity can be calculated and the characteristics of the MDG can be pragmatically described. Conclusion: This is a novel and potentially useful method for researchers, managers and practitioners to better understand MDG dynamics and to identify whether participants are integrating. The degree to which participants use MDG meetings to develop an integrated way of working is likely to require management, leadership and shared values

Forecasting project schedule performance using probabilistic and deterministic models

AbstractEarned value management (EVM) was originally developed for cost management and has not widely been used for forecasting project duration. In addition, EVM based formulas for cost or schedule forecasting are still deterministic and do not provide any information about the range of possible outcomes and the probability of meeting the project objectives. The objective of this paper is to develop three models to forecast the estimated duration at completion. Two of these models are deterministic; earned value (EV) and earned schedule (ES) models. The third model is a probabilistic model and developed based on Kalman filter algorithm and earned schedule management. Hence, the accuracies of the EV, ES and Kalman Filter Forecasting Model (KFFM) through the different project periods will be assessed and compared with the other forecasting methods such as the Critical Path Method (CPM), which makes the time forecast at activity level by revising the actual reporting data for each activity at a certain data date. A case study project is used to validate the results of the three models. Hence, the best model is selected based on the lowest average percentage of error. The results showed that the KFFM developed in this study provides probabilistic prediction bounds of project duration at completion and can be applied through the different project periods with smaller errors than those observed in EV and ES forecasting models

Determination and Distribution Map for Radionuclides in Soil Samples from Different Location by Gamma Spectrometry Using Software Analysis

The fundamental goal of the current study is to determine the mean activity concentrations of natural and artificial radionuclides of 226Ra, 232Th, 40K, and 137Cs using gamma spectrometry for three locations, in Egypt, Saudi Arabia, and Iraq, which are significant and vital countries in the Middle East. The mean absorbed dose rate equals 22.35, 28.96, and 43.34 nGy h-1 for Egypt, Saudi Arabia, and Iraq. The results are consistent with international reports. The dose contribution percentages for investigated locations are 24 %, 30 %, and 46 % for Egypt, Saudi Arabia, and Iraq, respectively. The obtained results were clarified by statistical measurements using one-way ANOVA test to determine the distribution and differences between the averages of the three groups under study, as they may be influenced by geological variations and human intervention. It was found that the Iraq samples followed a symmetrical, standard normal distribution, while samples from Egypt and Saudi Arabia did not. Statistically significant differences were found between the data from the three countries

Evaluation of complex integrated care programmes: the approach in North West London

Background: Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect. Study design: We present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and focus groups with patients and professionals, to understand participant experiences and to understand the pilot within the national policy context. Theory and discussion: This study considers the complexity of evaluating a large, multi-organisational intervention in a changing healthcare economy. We locate the evaluation within the theory of evaluation of complex interventions. We present the specific challenges faced by evaluating an intervention of this sort, and the responses made to mitigate against them. Conclusions: We hope this broad, dynamic and responsive evaluation will allow us to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar interventions. Because of the priority given to the integrated agenda by governments internationally, the need to develop and improve strong evaluation methodologies remains strikingly important

Transtheoretical model stages of change for dietary and physical exercise modification in weight loss management for overweight and obese adults.

BACKGROUND: Obesity is a global public health threat. The transtheoretical stages of change (TTM SOC) model has long been considered a useful interventional approach in lifestyle modification programmes, but its effectiveness in producing sustainable weight loss in overweight and obese individuals has been found to vary considerably.  OBJECTIVES: To assess the effectiveness of dietary intervention or physical activity interventions, or both, and other interventions based on the transtheoretical model (TTM) stages of change (SOC) to produce sustainable (one year and longer) weight loss in overweight and obese adults. SEARCH METHODS: Studies were obtained from searches of multiple electronic bibliographic databases. We searched The Cochrane Library, MEDLINE, EMBASE and PsycINFO. The date of the last search, for all databases, was 17 December 2013. SELECTION CRITERIA: Trials were included if they fulfilled the criteria of randomised controlled clinical trials (RCTs) using the TTM SOC as a model, that is a theoretical framework or guideline in designing lifestyle modification strategies, mainly dietary and physical activity interventions, versus a comparison intervention of usual care; one of the outcome measures of the study was weight loss, measured as change in weight or body mass index (BMI); participants were overweight or obese adults only; and the intervention was delivered by healthcare professionals or trained lay people at the hospital and community level, including at home. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the data, assessed studies for risk of bias and evaluated overall study quality according to GRADE (Grading of Recommendations Assessment, Development and Evaluation). We resolved disagreements by discussion or consultation with a third party. A narrative, descriptive analysis was conducted for the systematic review. MAIN RESULTS: A total of three studies met the inclusion criteria, allocating 2971 participants to the intervention and control groups. The total number of participants randomised to the intervention groups was 1467, whilst 1504 were randomised to the control groups. The length of intervention was 9, 12 and 24 months in the different trials. The use of TTM SOC in combination with diet or physical activity, or both, and other interventions in the included studies produced inconclusive evidence that TTM SOC interventions led to sustained weight loss (the mean difference between intervention and control groups varied from 2.1 kg to 0.2 kg at 24 months; 2971 participants; 3 trials; low quality evidence). Following application of TTM SOC there were improvements in physical activity and dietary habits, such as increased exercise duration and frequency, reduced dietary fat intake and increased fruit and vegetable consumption (very low quality evidence). Weight gain was reported as an adverse event in one of the included trials. None of the trials reported health-related quality of life, morbidity, or economic costs as outcomes. The small number of studies and their variable methodological quality limit the applicability of the findings to clinical practice. The main limitations include inadequate reporting of outcomes and the methods for allocation, randomisation and blinding; extensive use of self-reported measures to estimate the effects of interventions on a number of outcomes, including weight loss, dietary consumption and physical activity levels; and insufficient assessment of sustainability due to lack of post-intervention assessments. AUTHORS' CONCLUSIONS: The evidence to support the use of TTM SOC in weight loss interventions is limited by risk of bias and imprecision, not allowing firm conclusions to be drawn. When combined with diet or physical activity, or both, and other interventions we found very low quality evidence that it might lead to better dietary and physical activity habits. This systematic review highlights the need for well-designed RCTs that apply the principles of the TTM SOC appropriately to produce conclusive evidence about the effect of TTM SOC lifestyle interventions on weight loss and other health outcomes

Cystic artery pseudo-aneurysm: a complication of xanthogranulomatous cholecystitis

A 54-year-old man presented for radiology with pain and a feeling of fullness in the upper abdomen and an epigastric mass. Ultrasound revealed a large cystic mass with internal echoes, lying posterior and inferior to left lobe of the liver. The gallbladder was thick-walled and contracted, and contained a calculus and echogenic sludge. A cystic structure that produced swirling flow signals on colour Doppler was demonstrated within the gallbladder. The CT scan showed a thickened gallbladder with adjacent inflammation and a 2-cm pseudo-aneurysm in its wall. High-density material was present in the gallbladder lumen, in the extra-hepatic bile ducts and around the gastrohepatic ligament. A thick haemorrhagic pus, from which Escherichia coli was cultured, was drained from the gastrohepatic collection. An elective coeliac angiogram demonstrated a solitary pseudo-aneurysm of the medial branch of the cystic artery. Selective catheterisation of this artery with a micro-catheter enabled complete exclusion of the pseudo-aneurysm by a single micro-coil. Histological examination of the gallbladder, which was ultimately removed at open cholecystectomy, demonstrated xanthogranulomatous cholecystitis

The sedimentology of the Lower Permian Dandot Formation: a component of the Gondwana deglaciation sequence of the Salt Range, Pakistan

The Dandot Formation is a part of the Lower Permian, dominantly continental, Gondwanan Nilawahan Group in the Salt Range, Pakistan. The formation conformably overlies the glacio-fluvial Tobra Formation and has a sharp conformable contact with the overlying fluvio-continental Warchha Sandstone. Sedimentary analyses show that the Dandot Formation consists of 1: bioturbated sandstone lithofacies (L1), 2: dark green mudstone/shale lithofacies (L2), 3: flaser bedded sandstone lithofacies (L3), 4: rippled sandstone lithofacies (L4), 5: cross-bedded sandstone lithofacies (L5), and 6: planar sandstone lithofacies (L6). These can be grouped into shoreface, inner shelf, and tidal flat and estuarine facies associations, deposited in shallow marine to intertidal environments. The upper part of the Tobra Formation at the Choa-Khewra road section, where it conformably underlies the Dandot Formation, contains palynomorphs assignable to the earliest Permian 2141B Biozone. In south Oman, the 2141B Biozone is closely associated with the Rahab Shale Member, a widespread shale unit which is considered to represent part of a Permian deglaciation sequence which culminates in the marine beds of the Lower Gharif Member, interpreted as due to post glacial marine transgression. Thus, the Tobra Formation and the overlying marine Dandot Formation may form part of a similar deglaciation sequence

Stevens Johnson syndrome in Pakistan: a ten-year survey

Objective: A pre-tested questionnaire-based, retrospective study to highlight the causative factors, mode of presentation, complications and outcome of patients with Stevens Johnson syndrome.SETTING: Aga Khan University Hospital over a 10 year period.Methods: All case records with a diagnosis of Steven Johnson Syndrome in the period 1990 to 2000 were retrospectively reviewed. Data was retrieved on a comprehensive questionnaire. The demographic variatbles and drugs taken within the previous 21 days were noted. Date analysis was done by Epi-Info Version 6.0.Results: Of the 101 studied patient files, the most common offender was found to be the Penicillins as a group and Sulfadoxine-Pyrimethamine (Fansidar) when considering all drugs individually. Most common complications included electrolyte disturbances (13.9%) and congestive heart failure (6.9%). Mortality rate was high at 10.1%.CONCLUSION: SJS was found to be a rare condition but having a mortality rate of 10.1%. As it can be induced by a large number of drugs, caution should be practiced while prescribing

Woodlot farming by smallholder farmers in Ganderbal district of Kashmir, India

Forest degradation and deforestation are serious threats to resource conservation, subsistence livelihoods and rural income diversification. Woodlot farming on farms has been established as a potential option to increase forest resources from agricultural landscapes and remove human pressure from forests. The study investigated the land-use and landholding pattern, woodlots types and species preference and extent of spatial distribution, land allocation and growing stock of woodlots in the Ganderbal district of Kashmir. Multistage random sampling technique was employed to select 349 farm woodlots from 12 sample villages. Secondary sources were used to collect village-level data on land-use and landholding pattern. Primary data concerning the trees were collected through farm woodlot inventories. The data were analyzed using simple descriptive statistics. Results revealed that the total land area in the sample villages is 888.60 ha; 521.60 ha (58.70%) is cultivated land, which is mostly (80.78%) occupied by 1244 marginal farmers. The prevalent woodlots established were plantations of Populus, Salix, Robinia or mixed species. The farm woodlots (61.59 ha) contributed 11.81% of cultivated land and 6.93% of the total geographical area. The average growing stocks of woodlots were estimated to be 204.05 m3/ha for Populus, 191.77 m3/ha for Salix, 109.51 m3/ha for Robinia and 62.31 m3/ha for Mixed. The findings suggested that woodlot farming is the key alternative for forest resource production, livelihood resilience and socioeconomic improvement; hence, the policy must be implicated towards the promotion of woodlot farming by re-orienting the land use through farmer’s motivation and technical, financial and farming input assistance