A case study approach to understand how quality improvement methods led to improvements in primary care for insomnia

Context: The Resources for Effective Sleep Treatment (REST) project was conducted in Lincolnshire, UK from 2007-2010. Its aim was to develop and evaluate new approaches to implementing sleep assessment methods and non-pharmacological treatments for insomnia into routine general practice. Problem: Sleep problems are common affecting 30% of the population in the previous year. Many insomnia sufferers present to general practice but patients and clinicians feel that primary care management should be improved. For example, there is considerable evidence of underuse of sleep assessment tools and psychological treatments such as cognitive behavioural therapy for insomnia (CBTi), continuing evidence of inappropriate long term prescribing of hypnotics and a perception of poor practice among patients and practitioners. Assessment of problem and analysis of its causes: Multiple mixed methods including surveys, qualitative analysis (of focus groups, interviews, practice visits and collaborative meetings) and analysis of prescribing data were used to understand the problem of sleep management and how to improve it. Intervention: We used a series of collaboratives to develop and spread the intervention. The initial modelling collaborative was used to develop a multidisciplinary model for management of sleep problems in primary care: ‘problem focused therapy’. This uses careful assessment using sleep diaries and sleep assessment tools and treatment using modified CBTi for insomnia. A subsequent collaborative was used to spread the intervention more widely. Study design: We used a multiple case study approach to develop an explanatory model of why and how GPs engaged to improve sleep management in the ‘modelling’ and ‘spread’ collaboratives. Using practices as the units of analysis we describe how clinicians (re)framed the problem, developed solutions and saw the impact of these on changing practice. Strategy for change: We used a range of multidisciplinary team approaches to understand the need for and receptiveness to change, how change could be introduced and how these changes in management of sleep problems could be spread more widely during the project and beyond. Measurement of improvement: We used qualitative and time series methods to show changes in care over time. We gathered evidence on what care patients currently received and what they needed, how practitioners responded and how they could change practice and how practice teams redesigned processes of care and the impact of these changes on quality of care and prescribing for sleep problems. Effects of changes: within two years, over one third of practices (36/102) in the county had participated in the quality improvement project with evidence of change in clinical routines, benefits to patients’ experiences of care and significant reductions in prescribing in some practices. Lessons learnt: Quality improvement projects which require introduction of new health technologies require different collaborative approaches to developing new models of care, compared to projects which are trying to improve the reliability of care or to spread knowledge. Message for others: Case study methods provided an invaluable way to understand the complex ‘black box’ of quality improvement to show how patients and practitioners adopted and benefited from improved systems of care for insomnia

Designing an intervention for improving primary care management of sleep problems (REST: Resources for Effective Sleep Treatment)

Brief outline of context An improvement project was begun in a Primary Care Trust in Lincolnshire a large rural county in the East Midlands of the United Kingdom comprising almost 700,000 patients. The projects included patients, general practitioners and their primary care teams, pharmacists and research and audit teams. Brief outline of problem Hypnotic prescribing rates from general practice Prescribing Analysis and Cost Data was identified by the executive as high in Lincolnshire compared to the rest of the East Midlands and the United Kingdom. Published research has shown that the clinical benefits of hypnotic drugs are small with significant risks of complications from adverse cognitive, psychiatric or psychomotor effects which may persist for several months after stopping the drug. The extent of the problem, its nature and the barriers to improvement were not well understood given that previous attempts to improve prescribing rates in this area of practice had failed. Assessment of problem and analysis of its causes Previous efforts to improve this aspect of quality and safety in healthcare in Lincolnshire and nationally have been hampered because of practitioner and patient attitudes, lack of organisational support or systems for change and an emphasis on other areas of healthcare. To understand the barriers to improving prescribing more fully we used questionnaires to general practitioners and patients and measured variation in prescribing rates across practices. Unforeseen and hitherto invisible problems were revealed by the responses. In addition, the views of patients prescribed hypnotics in the previous six months exposed high rates of inappropriate long term prescribing (94.9%had taken benzodiazepine or Z drug hypnotics for four weeks or more), side effects (41.8%reported at least one side effect), a wish to stop taking drugs (Z-drugs vs. benzodiazepines: 22.7 vs. 12.3%; p=0.001) and previous attempts by patients to come off medication (Z-drugs vs. benzodiazepines: 52.4% vs. 41.0%; p=0.001). Potential barriers to improvement included attitudes of general practitioners which supported prescribing of newer (Z drug) hypnotics for the majority of indications. More positively, practitioners were aware of their practice prescribing rates to the extent that they were able to identify whether they were in a high, intermediate or low prescribing practice. Most doctors held a negative perception of hypnotics and were positive to the idea of reducing prescribing in this area. Practitioners’ favoured methods for reducing prescribing helped inform potential strategies for change and will be presented. On the basis of these results it was felt that systematic efforts at implementation and improvement were likely to be successful given appropriate organisational support from the Primary Care Trust. Strategy for change: How did you implement the proposed change? What staff or other groups were involved? How did you disseminate the results of your analysis and your plans for change to the groups involved with/affected by the planned change? What was the timetable for change? A change project was developed, Resources for Effective Sleep Treatment (REST), with a number of stakeholders including partner organisation and patients. The aims of this project are to produce measurable improvements in the management of insomnia, specifically to: a. Reduce rate and (costs) of z-drug prescribing by 50% in 3 years b. Reduce the rate (costs) of benzodiazepine hypnotic prescribing by 25% in 3 years c. Increase use of recorded non-pharmacological measures in insomnia by at least 100% in 3 years. d. Improve the user experience of management of insomnia. We will use evidence based methods to develop an effective spread and adoption strategy to effect a sustained and sustainable change in practice in relation to management of insomnia. We will initially work with 10 pilot practices (10% of the total) using rapid experimentation (plan, do, study, act) cycles. We plan to work with these willing adopter practices and practitioners to develop a network of good practice, measurement and improvement tools, opinion leaders and champions for good practice using rapid cycle of change. We will also undertake focus groups with prescribing practitioners and patients to help understand more fully the barriers and facilitators, to identify good practice and to design appropriate improvement methods and interventions in this area of practice. Tailored interventions for practices involving clinician, pharmacy, secondary care and administrative support could help bring about change in clinical management. Measurement of improvement We will gather and analyse prescribing and improvement data from all practices in the county to enable systematic spread and adoption of improvements in prescribing and improvement methods more generally in the county. Lessons learned This project has emphasised the importance of gathering data at the onset of quality improvement initiatives to understand invisible barriers or facilitators for change and of involvement of patients and practitioners in their initial and ongoing development. Message for others Quality improvement projects benefit from research as well as quality improvement expertise in order to analyse, present and utilise information for their appropriate design

Hemp a war crop for Iowa

Hemp is an annual crop grown for the production of fiber. It is sown in the spring like small grain and produces a thick stand of slender unbranched stalks, growing usually to a height of 6 to 10 feet. The fiber is found extending the length of the stalk, between the thin bark on the outside and the woody central pith on the inside. To obtain, the fiber the stalks are retted (partially decomposed) and then put through machines that separate the fiber from the rest of the stalk. Although hemp has been grown in the United States since early colonial days the acreage of this crop has not been very extensive. Due primarily to competition from cotton, jute, sisal and abaca (Manila fiber) domestic hemp production declined until a low of 1,200 acres was reached in 1933. Since 1939, because of the stimulation of an increased demand due to war conditions, production has again increased. In 1942 there were about 7,500 acres grown for fiber in Wisconsin, 5,000 in Kentucky, 600 in Minnesota and 500 in Illinois

Effectiveness of an educational intervention for general practice teams to deliver problem focused therapy for insomnia: pilot cluster randomised trial

Introduction Sleep problems are common leading to physical and psychosocial morbidity and impaired quality of life. Sufferers often seek help from primary care and receive advice or hypnotic drugs which are ineffective long term. Cognitive behavioural therapy for insomnia (CBTi) is effective but is not widely used in general practice. We conducted a pilot study to test procedures and collect information in preparation for a larger definitive trial to measure effectiveness and cost-effectiveness of an educational intervention for general practitioners and primary care nurses a to deliver problem focused therapy to adults Methods This was a pilot cluster randomised controlled trial. General practices were randomised to an educational intervention (2x2 hours) for problem focused therapy which comprised assessment (of secondary causes, severity and using sleep diaries) and modified CBTi compared with usual care (sleep hygiene advice and hypnotic drugs). We recruited patients with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety and Pittsburgh Sleep Quality Index (PSQI≥4). The primary outcome was PSQI and secondary outcomes including Insomnia Severity Index (ISI), Epworth Sleepiness Scale, Beck Depression Inventory and PSYCHLOPS were measured at 0, 4, 8 and 13 weeks. Intervention fidelity was evaluated using telephone interviews of participating practitioners and patients. Results Out of 64 participants recruited, 37 completed the trial. Analysis was conducted masked to treatment allocation. We used a mixed effects model to test for overall change and whether the intervention affected the rate of change over time. There was significant dropout during the pilot study, mainly due to delays in recruitment. We detected neither an overall change over time (PSQI score increase per week 0.06 (95%CI -0.03 to 0.16) nor differential change between intervention and control groups 0.10 (-0.03 to 0.23) although the study was not powered to detect such a change. Conclusion This pilot study confirmed that it was feasible to undertake a trial of education for primary care clinicians to deliver problem focused therapy for insomnia in general practice but also exposed problems with study recruitment, dropout, and intervention fidelity which should be addressed in the design of a full trial

How to Grow Corn

A lot of things can make the difference between a good and poor corn crop. Some you can control - others you can\u27t. Here\u27s a roundup of present know-how about the factors you can\u27t control

Engineered Carrier with a Long Time of Flight (TOF) to Improve Drug Delivery From Dry Powder Inhalation Aerosols

A lactose carrier with long TOF was engineered to improve drug deposition from DPIs. The particles were engineered by contacting spray-dried particles with a solvent in which these have a poor solubility. The process increased the particles hollow volume without affecting their original shape. The long TOF was demonstrated by carrier deposition in the lower stage of the TSI, which was up to 9 -fold higher compared to the conventional lactose. The highest deposition of the long TOF carrier was obtained at the lowest inhalation flow rate (24 L/min). The % Fine Particle Fraction of salbutamol sulphate was up to 50% when long TOF carrier was used. Importantly, this study has shown that adhesion drug/carrier has no negative effect on drug deposition, when a long TOF carrier is used

Effectiveness and cost-effectiveness of an educational intervention for practice teams to deliver problem focused therapy for insomnia: rationale and design of a pilot cluster randomised trial

Background: Sleep problems are common, affecting over a third of adults in the United Kingdom and leading to reduced productivity and impaired health-related quality of life. Many of those whose lives are affected seek medical help from primary care. Drug treatment is ineffective long term. Psychological methods for managing sleep problems, including cognitive behavioural therapy for insomnia (CBTi) have been shown to be effective and cost effective but have not been widely implemented or evaluated in a general practice setting where they are most likely to be needed and most appropriately delivered. This paper outlines the protocol for a pilot study designed to evaluate the effectiveness and cost-effectiveness of an educational intervention for general practitioners, primary care nurses and other members of the primary care team to deliver problem focused therapy to adult patients presenting with sleep problems due to lifestyle causes, pain or mild to moderate depression or anxiety. Methods and design: This will be a pilot cluster randomised controlled trial of a complex intervention. General practices will be randomised to an educational intervention for problem focused therapy which includes a consultation approach comprising careful assessment (using assessment of secondary causes, sleep diaries and severity) and use of modified CBTi for insomnia in the consultation compared with usual care (general advice on sleep hygiene and pharmacotherapy with hypnotic drugs). Clinicians randomised to the intervention will receive an educational intervention (2 × 2 hours) to implement a complex intervention of problem focused therapy. Clinicians randomised to the control group will receive reinforcement of usual care with sleep hygiene advice. Outcomes will be assessed via self-completion questionnaires and telephone interviews of patients and staff as well as clinical records for interventions and prescribing. Discussion: Previous studies in adults have shown that psychological treatments for insomnia administered by specialist nurses to groups of patients can be effective within a primary care setting. This will be a pilot study to determine whether an educational intervention aimed at primary care teams to deliver problem focused therapy for insomnia can improve sleep management and outcomes for individual adult patients presenting to general practice. The study will also test procedures and collect information in preparation for a larger definitive cluster-randomised trial. The study is funded by The Health Foundation

USP22 promotes HER2-driven mammary carcinoma aggressiveness by suppressing the unfolded protein response.

The Ubiquitin-Specific Protease 22 (USP22) is a deubiquitinating subunit of the mammalian SAGA transcriptional co-activating complex. USP22 was identified as a member of the so-called "death-from-cancer" signature predicting therapy failure in cancer patients. However, the importance and functional role of USP22 in different types and subtypes of cancer remain largely unknown. In the present study, we leveraged human cell lines and genetic mouse models to investigate the role of USP22 in HER2-driven breast cancer (HER2+-BC) and demonstrate for the first time that USP22 is required for the tumorigenic properties in murine and human HER2+-BC models. To get insight into the underlying mechanisms, we performed transcriptome-wide gene expression analyses and identified the Unfolded Protein Response (UPR) as a pathway deregulated upon USP22 loss. The UPR is normally induced upon extrinsic or intrinsic stresses that can promote cell survival and recovery if shortly activated or programmed cell death if activated for an extended period. Strikingly, we found that USP22 actively suppresses UPR induction in HER2+-BC cells by stabilizing the major endoplasmic reticulum (ER) chaperone HSPA5. Consistently, loss of USP22 renders tumor cells more sensitive to apoptosis and significantly increases the efficiency of therapies targeting the ER folding capacity. Together, our data suggest that therapeutic strategies targeting USP22 activity may sensitize tumor cells to UPR induction and could provide a novel, effective approach to treat HER2+-BC

Cloud-Scale Molecular Gas Properties in 15 Nearby Galaxies

We measure the velocity dispersion, $\sigma$, and surface density, $\Sigma$, of the molecular gas in nearby galaxies from CO spectral line cubes with spatial resolution $45$-$120$ pc, matched to the size of individual giant molecular clouds. Combining $11$ galaxies from the PHANGS-ALMA survey with $4$ targets from the literature, we characterize ${\sim}30,000$ independent sightlines where CO is detected at good significance. $\Sigma$ and $\sigma$ show a strong positive correlation, with the best-fit power law slope close to the expected value for resolved, self-gravitating clouds. This indicates only weak variation in the virial parameter $\alpha_\mathrm{vir}\propto\sigma^2/\Sigma$, which is ${\sim}1.5$-$3.0$ for most galaxies. We do, however, observe enormous variation in the internal turbulent pressure $P_\mathrm{turb}\propto\Sigma\,\sigma^2$, which spans ${\sim}5\rm\;dex$ across our sample. We find $\Sigma$, $\sigma$, and $P_\mathrm{turb}$ to be systematically larger in more massive galaxies. The same quantities appear enhanced in the central kpc of strongly barred galaxies relative to their disks. Based on sensitive maps of M31 and M33, the slope of the $\sigma$-$\Sigma$ relation flattens at $\Sigma\lesssim10\rm\;M_\odot\,pc^{-2}$, leading to high $\sigma$ for a given $\Sigma$ and high apparent $\alpha_\mathrm{vir}$. This echoes results found in the Milky Way, and likely originates from a combination of lower beam filling factors and a stronger influence of local environment on the dynamical state of molecular gas in the low density regime.Comment: Accepted for publication in ApJ. 45 pages, 11 figures, 8 tables, 4 Appendices; key results summarized in Figure 10. Machine-readable table can be downloaded at http://www.astronomy.ohio-state.edu/~sun.1608/datafile3.txt prior to publication. For a brief video describing the main results of this paper, please see https://www.youtube.com/watch?v=-_eL7t1PVq8&