Should measures of patient experience in primary care be adjusted for case mix? Evidence from the English General Practice Patient Survey.

OBJECTIVES: Uncertainties exist about when and how best to adjust performance measures for case mix. Our aims are to quantify the impact of case-mix adjustment on practice-level scores in a national survey of patient experience, to identify why and when it may be useful to adjust for case mix, and to discuss unresolved policy issues regarding the use of case-mix adjustment in performance measurement in health care. DESIGN/SETTING: Secondary analysis of the 2009 English General Practice Patient Survey. Responses from 2 163 456 patients registered with 8267 primary care practices. Linear mixed effects models were used with practice included as a random effect and five case-mix variables (gender, age, race/ethnicity, deprivation, and self-reported health) as fixed effects. MAIN OUTCOME MEASURES: Primary outcome was the impact of case-mix adjustment on practice-level means (adjusted minus unadjusted) and changes in practice percentile ranks for questions measuring patient experience in three domains of primary care: access; interpersonal care; anticipatory care planning, and overall satisfaction with primary care services. RESULTS: Depending on the survey measure selected, case-mix adjustment changed the rank of between 0.4% and 29.8% of practices by more than 10 percentile points. Adjusting for case-mix resulted in large increases in score for a small number of practices and small decreases in score for a larger number of practices. Practices with younger patients, more ethnic minority patients and patients living in more socio-economically deprived areas were more likely to gain from case-mix adjustment. Age and race/ethnicity were the most influential adjustors. CONCLUSIONS: While its effect is modest for most practices, case-mix adjustment corrects significant underestimation of scores for a small proportion of practices serving vulnerable patients and may reduce the risk that providers would 'cream-skim' by not enrolling patients from vulnerable socio-demographic groups.The study was funded by a grant from the UK Department of Healt

Emergent order in the kagome Ising magnet Dy3_3Mg2_2Sb3_3O14_{14}

The Ising model-in which degrees of freedom (spins) are binary valued (up/down)-is a cornerstone of statistical physics that shows rich behaviour when spins occupy a highly frustrated lattice such as kagome. Here we show that the layered Ising magnet Dy$_3$Mg$_2$Sb$_3$O$_{14}$ hosts an emergent order predicted theoretically for individual kagome layers of in-plane Ising spins. Neutron-scattering and bulk thermomagnetic measurements reveal a phase transition at ~0.3 K from a disordered spin-ice-like regime to an emergent charge ordered state, in which emergent magnetic charge degrees of freedom exhibit three-dimensional order while spins remain partially disordered. Monte Carlo simulations show that an interplay of inter-layer interactions, spin canting and chemical disorder stabilizes this state. Our results establish Dy$_3$Mg$_2$Sb$_3$O$_{14}$ as a tuneable system to study interacting emergent charges arising from kagome Ising frustration.Work at Cambridge was supported through the Winton Programme for the Physics of Sustainability. The work of J.A.M.P., X.B. and M.M. and facilities at Georgia Tech were supported by the College of Sciences through M.M. start-up funds. J.A.M.P. gratefully acknowledges Churchill College, Cambridge for the provision of a Junior Research Fellowship. H.S.O. acknowledges a Teaching Scholarship (Overseas) from the Ministry of Education, Singapore. J.O.H. is grateful to the Engineering and Physical Sciences Research Council (EPSRC) for funding. C.C. was supported by EPSRC Grant No. EP/G049394/1, and the EPSRC NetworkPlus on ‘Emergence and Physics far from Equilibrium’. Experiments at the ISIS Pulsed Neutron and Muon Source were supported by a beamtime allocation from the Science and Technology Facilities Council. This work utilized facilities at the NIST Center for Neutron Research. Monte Carlo simulations were performed using the Darwin Supercomputer of the University of Cambridge High Performance Computing Service (http://www.hpc.cam.ac.uk/) and the ARCHER UK National Supercomputing Service (http://www.archer.ac.uk/, for which access was provided by an ARCHER Instant Access scheme)

A robust system for RNA interference in the chicken using a modified microRNA operon

AbstractRNA interference (RNAi) provides an effective method to silence gene expression and investigate gene function. However, RNAi tools for the chicken embryo have largely been adapted from vectors designed for mammalian cells. Here we present plasmid and retroviral RNAi vectors specifically designed for optimal gene silencing in chicken cells. The vectors use a chicken U6 promoter to express RNAs modelled on microRNA30, which are embedded within chicken microRNA operon sequences to ensure optimal Drosha and Dicer processing of transcripts. The chicken U6 promoter works significantly better than promoters of mammalian origin and in combination with a microRNA operon expression cassette (MOEC), achieves up to 90% silencing of target genes. By using a MOEC, we show that it is also possible to simultaneously silence two genes with a single vector. The vectors express either RFP or GFP markers, allowing simple in vivo tracking of vector delivery. Using these plasmids, we demonstrate effective silencing of Pax3, Pax6, Nkx2.1, Nkx2.2, Notch1 and Shh in discrete regions of the chicken embryonic nervous system. The efficiency and ease of use of this RNAi system paves the way for large-scale genetic screens in the chicken embryo

“I Keep Hearing Reports on the News That it's a Real Problem at the Moment”: Public Health Nurses’ Understandings of Sexting Practices Among Young People

Over the past decade, the potential harms regarding young people's use of technology have attracted mounting political, media and research attention worldwide. One practice engaged in by many young people is that of “sexting” and the sharing of partially, or complete nude images (“selfies”). Such images are not always retained within private spaces and are prone to be shared, with significant psychosocial consequences for young people involved. A significant risk is the hidden nature of some online interactions, with potential for grooming and child sexual exploitation. As key professionals working with young people, public health nurses have potential to educate and explore the risks with them. Yet to date, to our knowledge there has been no research in relation to public health nurses’ understandings of the practices involved or their potential harms. A qualitative study was undertaken drawing theoretically on the common‐sense model (CSM) to frame the analysis. Eighteen semi‐structured interviews were conducted with public health nurses in a region of England in 2016. Data were analysed through thematic analysis, and mapped to the five domains of CSM. Public health nurses’ understandings of young people's sexting practices were shaped largely by media reports, rather than scientific, disciplinary knowledge. Sexting did not resonate with many public health nurses’ own experiences of being a young person and was therefore difficult to understand. All were able to express an opinion about the causes and consequences of sexting and we present these as a “perceived hierarchy of risk”. All public health nurses acknowledged the importance of their role in dealing with harm reduction associated with sexting among young people, but they need education and support to do this effectively and confidently. Findings can be transferred carefully to many contexts and countries because sexting is a practice among young people that transcends geographical boundaries

Are people with negative diabetes screening tests falsely reassured? Parallel group cohort study embedded in the ADDITION (Cambridge) randomised controlled trial

Objective To assess whether receiving a negative test result at primary care based stepwise diabetes screening results in false reassurance