Education Reform for the Digital Era

Will the digital-learning movement repeat the mistakes of the charter-school movement? How much more successful might today's charter universe look if yesterday's proponents had focused on the policies and practices needed to ensure its quality, freedom, and resources over the long term? What mistakes might have been avoided? Damaging scandals forestalled? Missed opportunities seized

Conditional versus non-conditional incentives to maximise return of participant completed questionnaires in clinical trials: a cluster randomised study within a trial

Background High participant retention enhances the validity of clinical trials. A monetary incentive can increase retention, but it is not known if when it is provided and if it is conditional matters. We aimed to determine whether there was a difference in the number of follow-up trial questionnaires returned when a monetary (gift voucher) incentive was given to participants at recruitment (non-conditional), compared to informing participants at recruitment that the incentive would be given only once their 14-day daily diary (questionnaire) had been returned (conditional). Method A cluster randomised study within a trial embedded within the Antivirals for influenza-Like Illness, An rCt of Clinical and Cost effectiveness in primary CarE (ALIC4E) Trial. Matched site pairs (GP practices) were randomised using computer-generated random numbers, to either a non-conditional or conditional monetary voucher incentive (only once their 14-day daily diary (questionnaire) had been returned. Sites were matched on previous recruitment levels and practice list size. Analyses were conducted according to randomised groups irrespective of compliance with a two-sided 5% level statistical significance level. The main analysis of the primary outcome (site proportion of diaries returned) was linear regression accounting for site pair (using cluster-robust variance). Additional weighted, paired and non-parametric sensitivity analyses were conducted. Secondary outcomes were the site average number of completed pages, time to return diary, and cost related to the incentive (administration and postage). Results Of the 42 randomised sites (21 for each intervention), only 28 recruited at least one participant with only 10 practice pairs recruiting participants at both constituent sites. Raw diaries return proportions were 0.58 (127/220) and 0.73 (91/125) for non-conditional and conditional incentive groups. Regression analysis adjusted for site pair showed no significant difference in returns, − 0.09, (95% CI, − 0.29, 0.10, p = 0.34); when weighted, there was still no clear difference: 0.15 (95% CI, − 0.02, 0.31, p = 0.07). There was no clear statistical evidence of a difference in time taken to return questionnaires, nor the proportion of pages completed, by the intervention group in the main analyses (all p > 0.05). The conditional incentive was approximately £23 cheaper per diary returned based upon observed data. Conclusion There was no clear evidence of a statistically significant difference in the proportion of participant-completed diaries returned between conditional or non-conditional incentive groups. The time to questionnaire return and completeness of the returned questionnaires were similar in both groups. There was substantial statistical uncertainty in the findings. Some of the sensitivity analyses suggested that a meaningful benefit of a conditional incentive of a magnitude that would be meaningful was plausible. The conditional approach costs less in cash terms

The Preemptive Nature of Quality Early Child Education on Special Educational Needs in Children

Given the growth of scholarship in early child education (ECE), as well as the rapid emergence of the sector as an area of academic inquiry, a team of special education/mental health scholars opted to explore its preemptive nature. Despite long and distinguished careers in childhood special educational needs (SEN), ECE has never been an area of attention for them, and they proceeded with unbiased perspectives to answer: Does participation in quality ECE lessen SEN and insulate children against requiring supports later in their school experience? Inclusive education is now an international standard for all children and the recent Canadian bilateral agreements between the federal and provincial/territorial governments strive to increase access to ECE for all children, including those with diverse needs. How inclusive is ECE and will access lessen the amount of support required by children with identified SEN, allowing them a smoother school start and ensuring better educational outcomes? Particular attention was given to children with specific needs: those with autism spectrum disorder (ASD) who typically struggle with starting school and usually require intensive supports; and those with mental health concerns. An extensive review of the literature, with particular attention to longitudinal studies, was undertaken by the team. Additionally, the Effective Pre-school, Primary and Secondary Education Project study in the UK was re-examined by Dr. Edward Melhuish to track the SEN of children across their full school experience. Public data from a representative number of Canadian provinces was also examined to help answer the questions above and illuminate the nature of inclusion in ECE programs. Surprisingly, while the literature was rich on the preemptive nature of ECE, provincial/ territorial data on inclusion during the early years was scant. Poor and inconsistent data collection processes, and an absence of policy to mandate it, sabotages the sector and leads to uninformed public policy. While all regions report policies supporting inclusive ECE programs, the absence of data and inclusive practice creates an illusion of inclusion during the early years. What emerges is significant, especially for the discipline of special education which traditionally views early identification and intervention as beginning at age six. By examining the impact of quality ECE with a common lens, both the ECE sector and the K-12 system obtain startling findings that poses an opportunity to develop earlier identification and intervention to alter the trajectory of the lives of vulnerable children. A continuum of evidence, from multiple studies in multiple countries unanimously converge on the preemptive nature of ECE on SEN. Inclusive, high quality ECE reduces SEN in young children and improves developmental outcomes, especially for vulnerable children and those with complex needs. The need for intervention is both removed for some children and reduced for others. Front loading interventions during the early years is wise public policy. Educators, parents, policy makers and governments could benefit from these findings

Greenland Ice Sheet exports labile organic carbon to the Arctic oceans

Runoff from small glacier systems contains dissolved organic carbon (DOC) rich in protein-like, low molecular weight (LMW) compounds, designating glaciers as an important source of bioavailable carbon for downstream heterotrophic activity. Fluxes of DOC and particulate organic carbon (POC) exported from large Greenland catchments, however, remain unquantified, despite the Greenland Ice Sheet (GrIS) being the largest source of global glacial runoff (ca. 400 km3 yr−1). We report high and episodic fluxes of POC and DOC from a large (> 600 km2) GrIS catchment during contrasting melt seasons. POC dominates organic carbon (OC) export (70–89% on average), is sourced from the ice sheet bed, and contains a significant bioreactive component (9% carbohydrates). A major source of the “bioavailable” (free carbohydrate) LMW–DOC fraction is microbial activity on the ice sheet surface, with some further addition of LMW–DOC to meltwaters by biogeochemical processes at the ice sheet bed. The bioavailability of the exported DOC (26–53%) to downstream marine microorganisms is similar to that reported from other glacial watersheds. Annual fluxes of DOC and free carbohydrates during two melt seasons were similar, despite the approximately two-fold difference in runoff fluxes, suggesting production-limited DOC sources. POC fluxes were also insensitive to an increase in seasonal runoff volumes, indicating a supply limitation in suspended sediment in runoff. Scaled to the GrIS, the combined DOC (0.13–0.17 TgC yr−1 (±13 %)) and POC fluxes (mean = 0.36–1.52 TgC yr−1 (±14 %)) are of a similar order of magnitude to a large Arctic river system, and hence may represent an important OC source to the near-coastal North Atlantic, Greenland and Labrador seas

Let\u27s talk about antibiotics: A randomised trial of two interventions to reduce antibiotic misuse

BACKGROUND: Children with acute respiratory tract infections (ARTIs) receive ≈11.4 million unnecessary antibiotic prescriptions annually. A noted contributor is inadequate parent-clinician communication, however, efforts to reduce overprescribing have only indirectly targeted communication or been impractical. OBJECTIVES: Compare two feasible (higher vs lower intensity) interventions for enhancing parent-clinician communication on the rate of inappropriate antibiotic prescribing. DESIGN: Multisite, parallel group, cluster randomised comparative effectiveness trial. Data collected between March 2017 and March 2019. SETTING: Academic and private practice outpatient clinics. PARTICIPANTS: Clinicians (n=41, 85% of eligible approached) and 1599 parent-child dyads (ages 1-5 years with ARTI symptoms, 71% of eligible approached). INTERVENTIONS: All clinicians received 20 min ARTI diagnosis and treatment education. Higher intensity clinicians received an additional 50 min communication skills training. All parents viewed a 90 second antibiotic education video. MAIN OUTCOMES AND MEASURES: Inappropriate antibiotic treatment was assessed via blinded medical record review by study clinicians and a priori defined as prescriptions for the wrong diagnosis or use of the wrong agent. Secondary outcomes were revisits, adverse drug reactions (both assessed 2 weeks after the visit) and parent ratings of provider communication, shared decision-making and visit satisfaction (assessed at end of the visit on Likert-type scales). RESULTS: Most clinicians completed the study (n=38, 93%), were doctors (n=25, 66%), female (n=30, 78%) and averaged 8 years in practice. All parent-child dyad provided data for the main outcome (n=855 (54%) male, n=1043 (53%) CONCLUSIONS AND RELEVANCE: Rate of inappropriate prescribing was low in both arms. Clinician education coupled with parent education may be sufficient to yield low inappropriate antibiotic prescribing rates. The absence of a significant difference between groups indicates that communication principles previously thought to drive inappropriate prescribing may need to be re-examined or may not have as much of an impact in practices where prescribing has improved in recent years. TRIAL REGISTRATION NUMBER: NCT03037112

A trial like ALIC4E: why design a platform, response-adaptive, open, randomised controlled trial of antivirals for influenza-like illness?

ALIC4E is the first publicly funded, multicountry, pragmatic study determining whether antivirals should be routinely prescribed for influenza-like illness in primary care. The trial aims to go beyond determining the average treatment effect in a population to determining effects in patients with combinations of participant characteristics (age, symptom duration, illness severity, and comorbidities). It is one of the first platform, response-adaptive, open trial designs implemented in primary care, and this article aims to provide an accessible description of key aspects of the study design. 1) The platform design allows the study to remain relevant to evolving circumstances, with the ability to add treatment arms. 2) Response adaptation allows the proportion of participants with key characteristics allocated to study arms to be altered during the course of the trial according to emerging outcome data, so that participants' information will be most useful, and increasing their chances of receiving the trial intervention that will be most effective for them. 3) Because the possibility of taking placebos influences participant expectations about their treatment, and determining effects of the interventions on patient help seeking and adherence behaviour in real-world care is critical to estimates of cost-effectiveness, ALIC4E is an open-label trial

Characteristics associated with quality of life among people with drug-resistant epilepsy

Quality of Life (QoL) is the preferred outcome in non-pharmacological trials, but there is little UK population evidence of QoL in epilepsy. In advance of evaluating an epilepsy self-management course we aimed to describe, among UK participants, what clinical and psycho-social characteristics are associated with QoL. We recruited 404 adults attending specialist clinics, with at least two seizures in the prior year and measured their self-reported seizure frequency, co-morbidity, psychological distress, social characteristics, including self-mastery and stigma, and epilepsy-specific QoL (QOLIE-31-P). Mean age was 42 years, 54% were female, and 75% white. Median time since diagnosis was 18 years, and 69% experienced ≥10 seizures in the prior year. Nearly half (46%) reported additional medical or psychiatric conditions, 54% reported current anxiety and 28% reported current depression symptoms at borderline or case level, with 63% reporting felt stigma. While a maximum QOLIE-31-P score is 100, participants’ mean score was 66, with a wide range (25–99). In order of large to small magnitude: depression, low self-mastery, anxiety, felt stigma, a history of medical and psychiatric comorbidity, low self-reported medication adherence, and greater seizure frequency were associated with low QOLIE-31-P scores. Despite specialist care, UK people with epilepsy and persistent seizures experience low QoL. If QoL is the main outcome in epilepsy trials, developing and evaluating ways to reduce psychological and social disadvantage are likely to be of primary importance. Educational courses may not change QoL, but be one component supporting self-management for people with long-term conditions, like epilepsy

Point of care testing for urinary tract infection in primary care (POETIC): protocol for a randomised controlled trial of the clinical and cost effectiveness of FLEXICULT (TM) informed management of uncomplicated UTI in primary care

BACKGROUND: Urinary tract infections (UTI) are the most frequent bacterial infection affecting women and account for about 15% of antibiotics prescribed in primary care. However, some women with a UTI are not prescribed antibiotics or are prescribed the wrong antibiotics, while many women who do not have a microbiologically confirmed UTI are prescribed antibiotics. Inappropriate antibiotic prescribing unnecessarily increases the risk of side effects and the development of antibiotic resistance, and wastes resources. POETIC is a randomised controlled trial of a Point Of Care Test (POCT) (Flexicult™) guided UTI management strategy for use in primary care, which may help General Practitioners more effectively decide both whether or not to prescribe antibiotics, and if so, to select the most appropriate antibiotic. METHODS/DESIGN: 614 adult female patients will be recruited from four primary care research networks (Wales, England, Spain, the Netherlands) and individually randomised to either POCT guided care or the guideline-informed ‘standard care’ arm. Urine and stool samples (where possible) will be obtained at presentation (day 1) and two weeks later for microbiological analysis. All participants will be followed up on the course of their illness and their quality of life, using a 2 week self-completed symptom diary. At 3 months, a primary care notes review will be conducted for evidence of further evidence of treatment failures, recurrence, complications, hospitalisations and health service costs. The primary objective is to compare appropriate antibiotic use on day 3 between the POCT and standard care arms using multi-level logistic regression to produce an odds ratio and associated 95% confidence interval. Costs of the two management approaches will be assessed in terms of the primary outcome. DISCUSSION: Although the Flexicult™ POCT is used in some countries in routine primary care, it’s clinical and cost effectiveness has never been evaluated in a randomised clinical trial. If shown to be effective, the use of this POCT could benefit individual sufferers and provide evidence for health care authorities to develop evidence based policies to combat the spread and impact of the unprecedented rise of infections caused by antibiotic resistant bacteria in Europe. TRIAL REGISTRATION NUMBER: ISRCTN65200697 (Registered 10 September 2013)

Evaluation of a web-based intervention to reduce antibiotic prescribing for LRTI in six European countries: quantitative process analysis of the GRACE/INTRO randomised controlled trial.

To reduce the spread of antibiotic resistance, there is a pressing need for worldwide implementation of effective interventions to promote more prudent prescribing of antibiotics for acute LRTI. This study is a process analysis of the GRACE/INTRO trial of a multifactorial intervention that reduced antibiotic prescribing for acute LRTI in six European countries. The aim was to understand how the interventions were implemented and to examine effects of the interventions on general practitioners' (GPs') and patients' attitudes