Optimising the community-based approach to healthcare improvement: Comparative case studies of the clinical community model in practice

Community-based approaches to healthcare improvement are receiving increasing attention. Such approaches could offer an infrastructure for efficient knowledge-sharing and a potent means of influencing behaviours, but their potential is yet to be optimised. After briefly reviewing challenges to community-based approaches, we describe in detail the clinical community model. Through exploring clinical communities in practice, we seek to identify practical lessons for optimising this community-based approach to healthcare improvement. Through comparative case studies based on secondary analysis, we examine two contrasting examples of clinical communities in practice – the USA-based Michigan Keystone ICU programme, and the UK-based Improving Lung Cancer Outcomes Project. We focus on three main issues. First, both cases were successful in mobilising diverse communities: favourable starting conditions, core teams with personal credibility, reputable institutional backing and embeddedness in wider networks were important. Second, top-down input to organise regular meetings, minimise conflict and empower those at risk of marginalisation helped establish a strong sense of community and reciprocal ties, while intervention components and measures common to the whole community strengthened peer-norming effects. Third, to drive implementation, technical expertise and responsiveness from the core team were important, but so too were ‘hard tactics’ (e.g. strict limits on local customisation); these were more easily deployed where the intervention was standardised across the community and a strong evidence-base existed. Contrary to the idea of self-organising communities, our cases make clear that vertical and horizontal forces depend on each other synergistically for their effectiveness. We offer practical lessons for establishing an effective balance of horizontal and vertical influences, and for identifying the types of quality problems most amenable to community-based improvement.Emma-Louise Aveling's contribution was supported by funding from a Wellcome Trust Senior Investigator award [WT097899]. Graham Martin's contribution was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care East Midlands (CLAHRC EM). The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. Previous work with the Improving Lung Cancer Outcomes project was funded by the Health Foundation, registered charity 286967, as part of its evaluation of the Closing the Gap through Clinical Communities programme

Optimal Recharging Strategy for Battery-Switch Stations for Electric Vehicles in France

Most papers that study the recharging of electric vehicles focus on charging the batteries at home and at the work-place. The alternative is for owners to exchange the battery at a specially equipped battery switch station (BSS). This paper studies strategies for the BSS to buy and sell the electricity through the day-ahead market. We determine what the optimal strategies would have been for a large fleet of EVs in 2010 and 2011, for the V2G and the G2V cases. These give the amount that the BSS should offer to buy or sell each hour of the day. Given the size of the fleet, the quantities of electricity bought and sold will displace the market equilibrium. Using the aggregate offers to buy and the bids to sell on the day-ahead market, we compute what the new prices and volumes transacted would be. While buying electricity for the G2V case incurs a cost, it is possible to generate revenue in the V2G case, if the arrivals of the EVs are evenly spaced during the day. We compare the total cost of implementing the strategies proposed with the cost of buying the same quantity of electricity from EDF

Similarity measures for mid-surface quality evaluation

Mid-surface models are widely used in engineering analysis to simplify the analysis of thin-walled parts, but it can be difficult to ensure that the mid-surface model is representative of the solid part from which it was generated. This paper proposes two similarity measures that can be used to evaluate the quality of a mid-surface model by comparing it to a solid model of the same part. Two similarity measures are proposed; firstly a geometric similarity evaluation technique based on the Hausdorff distance and secondly a topological similarity evaluation method which uses geometry graph attributes as the basis for comparison. Both measures are able to provide local and global similarity evaluation for the models. The proposed methods have been implemented in a software demonstrator and tested on a selection of representative models. They have been found to be effective for identifying geometric and topological errors in mid-surface models and are applicable to a wide range of practical thin-walled designs

Stellar Nucleosynthesis in the Hyades Open Cluster

We report a comprehensive light element (Li, C, N, O, Na, Mg, and Al) abundance analysis of three solar-type main sequence (MS) dwarfs and three red giant branch (RGB) clump stars in the Hyades open cluster using high-resolution and high signal-to-noise spectroscopy. For each group (MS or RGB), the CNO abundances are found to be in excellent star-to-star agreement. Our results confirm that the giants have undergone the first dredge-up and that material processed by the CN cycle has been mixed to the surface layers. The observed abundances are compared to predictions of a standard stellar model based on the Clemson-American University of Beirut (CAUB) stellar evolution code. The model reproduces the observed evolution of the N and O abundances, as well as the previously derived 12C/13C ratio, but it fails to predict by a factor of 1.5 the observed level of 12C depletion. Li abundances are derived to determine if non-canonical extra mixing has occurred in the Hyades giants. The Li abundance of the giant gamma Tau is in good accord with the predicted level of surface Li dilution, but a ~0.35 dex spread in the giant Li abundances is found and cannot be explained by the stellar model. Possible sources of the spread are discussed; however, it is apparent that the differential mechanism responsible for the Li dispersion must be unrelated to the uniformly low 12C abundances of the giants. Na, Mg, and Al abundances are derived as an additional test of our stellar model. All three elements are found to be overabundant by 0.2-0.5 dex in the giants relative to the dwarfs. Such large enhancements of these elements are not predicted by the stellar model, and non-LTE effects significantly larger (and, in some cases, of opposite sign) than those implied by extant literature calculations are the most likely cause.Comment: 40 pages, 6 figures, 6 tables; accepted by Ap

Impact of disease severity on outcome of antiviral therapy for chronic hepatitis C: Lessons from the HALT-C trial

In patients with chronic hepatitis C, advanced fibrosis and cirrhosis are associated with lower rates of sustained virologic response (SVR) to interferon (IFN)-based therapy. In this study, we assessed virologic response to retreatment with peginterferon alfa-2a and ribavirin (RBV), as a function of the baseline fibrosis score (Ishak staging) and platelet count, in 1,046 patients enrolled in the Hepatitis C Antiviral Long-term Treatment against Cirrhosis (HALT-C) Trial. All patients had failed prior treatment with IFN or peginterferon ± RBV and had Ishak fibrosis scores ≥ 3. Four groups of patients with increasingly severe liver disease were compared: (A) bridging fibrosis (Ishak 3 and 4) with platelet counts >125,000/mm 3 (n = 559); (B) bridging fibrosis with platelet counts ≤125,000/mm 3 (n = 96); (C) cirrhosis (Ishak 5 and 6) with platelet counts >125,000/mm 3 (n = 198); and (D) cirrhosis with platelet counts ≤125,000/mm 3 (n = 193). SVR rates were 23%, 17%, 10%, and 9% in groups A, B, C, and D, respectively ( P < .0001 for trend). Reduction in SVR as a function of increasingly severe disease was independent of age, percent African American, HCV genotype, HCV level, and type of prior therapy. Dose reduction lowered SVR frequencies, but to a lesser extent than disease severity. By logistic regression, cirrhosis ( P < .0001) was the major determinant that impaired virologic response, independent of dose reduction or platelet count. In conclusion , disease severity is a major independent determinant of rate of SVR in patients with advanced chronic hepatitis C. New strategies are needed to optimize antiviral therapy in these “difficult-to-cure” patients. (H EPATOLOGY 2006;44:1675–1684.)Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/55880/1/21440_ftp.pd

Precision Measurement of the Neutron Twist-3 Matrix Element d(2)(n): Probing Color Forces

Double-spin asymmetries and absolute cross sections were measured at large Bjorken x (0.25 ≤ x ≤ 0.90), in both the deep-inelastic and resonance regions, by scattering longitudinally polarized electrons at beam energies of 4.7 and 5.9 GeV from a transversely and longitudinally polarized 3He target. In this dedicated experiment, the spin structure function g(2)(3He) was determined with precision at large x, and the neutron twist-3 matrix element d(2)(n) was measured at \u3c Q2\u3e of 3.21 and 4.32 GeV2/c2, with an absolute precision of about 10-5. Our results are found to be in agreement with lattice QCD calculations and resolve the disagreement found with previous data at \u3c Q2\u3e = 5 GeV2/c2. Combining d(2)(n) and a newly extracted twist-4 matrix element f(2)(n), the average neutron color electric and magnetic forces were extracted and found to be of opposite sign and about 30 MeV/fm in magnitude

Implementation Research Is Needed to Achieve International Health Goals

Sanders and Haines discuss the "knowledge-implementation gap" and identify key obstacles to correcting the gap