Implementing integrated care: a synthesis of experiences in three European countries

Many countries are experimenting with new models to better integrate care; yet, innovative care models are often implemented as time-limited, localised projects with limited impact on service delivery more broadly. This paper seeks to understand the processes behind successful projects that achieved some form of ‘routinisation’ and informed system-wide integrated care strategies. It draws on detailed case studies of three integrated care experiments: the ‘Integrated effort for people living with chronic diseases’ project in Denmark; the Gesundes Kinzigtal network in Germany; and Zio, a care group in the Maastricht region in the Netherlands. It explores how they were developed, implemented and sustained, and how they impacted the wider system context. All three models implicitly or explicitly adopted processes shown to be conducive to the dissemination of innovations, including dedicated time and resources, support and advocacy, leadership and management, stakeholder involvement, communication and networks, adaptation to local context and feedback. Each showed robust evidence of improvements on a number of service and patient outcomes and these findings were central to their wider impacts, shaping country-wide integrated care polices. However, the wider dissemination of projects occurred in an incremental and somewhat haphazard way. To further redesign health and social care a more formal strategy, alongside resources, may thus be needed to provide funders and providers with genuine incentives to invest in new business models of care. There remains a crucial need for better understanding of specific local conditions that influence implementation and sustainability to enable translation to other contexts and settings

Discrete Model of Ideological Struggle Accounting for Migration

A discrete in time model of ideological competition is formulated taking into account population migration. The model is based on interactions between global populations of non-believers and followers of different ideologies. The complex dynamics of the attracting manifolds is investigated. Conversion from one ideology to another by means of (i) mass media influence and (ii) interpersonal relations is considered. Moreover a different birth rate is assumed for different ideologies, the rate being assumed to be positive for the reference population, made of initially non-believers. Ideological competition can happen in one or several regions in space. In the latter case, migration of non-believers and adepts is allowed; this leads to an enrichment of the ideological dynamics. Finally, the current ideological situation in the Arab countries and China is commented upon from the point of view of the presently developed mathematical model. The massive forced conversion by Ottoman Turks in the Balkans is briefly discussed.Comment: 24 pages, with 5 figures and 52 refs.; prepared for a Special issue of Advances in Complex System

Daily mood, partner support, sexual interest, and sexual activity among adolescent women

This is a post print version of the article. The official published version can be accessed from the link below.Objective: to examine day-to-day associations of coitus, sexual interest, partner emotional support, negative mood and positive mood among adolescent women. Methods: Women (ages 14 – 17 at enrollment; N=146) enrolled from one of three adolescent primary care clinics completed up to five 84-day diaries over a 27-month period. The diaries assessed partner interactions, sexual activity, substance use and mood. Partner-specific measures assessed on each day included partner emotional support (4 items; alpha = 0.94), argument with a partner (no/yes) and coitus (no/yes). Within-day measures assessed marijuana use (no/yes), Positive Mood (3-items; alpha = 0. 86); Negative Mood (3-items; alpha = 0.82) and Sexual Interest (1-item). Lagged measures of mood and sexual activity were included in multivariate models to control for recent mood and sexual behavior effects on current day mood and coitus. Two main analyses were conducted: coitus as a predictor of positive and negative mood; and the role of positive and negative mood as predictors of coitus. Analyses were conducted by multivariate mixed effect regression and mixed effect logistic regression models. Results: Data represent 28,376 days from 146 participants. The average number of diary days was 194 days per participant. Sexual activity was reported on 8.3% of days, with condoms used for 27.0% of these coital events. Marijuana was used on 11% of days. Significant predictors of positive mood on a given day included partner support, marijuana use, and coitus. Negative mood was associated with having an argument with a partner and with prior day coitus. Predictors of coitus on a given day included age (Odds ratio = 1.22), increased coital frequency in previous week (OR = 1.49), coitus on the previous day (1.21), increased same-day sexual interest (OR = 2.8) and decreased same-day negative mood (OR = 0.92). Conclusions: The data demonstrate complex associations of sexual interest, mood, partner interactions and sexual activity

Antiferromagnetic 4-d O(4) Model

We study the phase diagram of the four dimensional O(4) model with first (beta1) and second (beta2) neighbor couplings, specially in the beta2 < 0 region, where we find a line of transitions which seems to be second order. We also compute the critical exponents on this line at the point beta1 =0 (F4 lattice) by Finite Size Scaling techniques up to a lattice size of 24, being these exponents different from the Mean Field ones.Comment: 26 pages LaTeX2e, 7 figures. The possibility of logarithmic corrections has been considered, new figures and tables added. Accepted for publication in Physical Review

Incommensurate Charge Density Waves in the adiabatic Hubbard-Holstein model

The adiabatic, Holstein-Hubbard model describes electrons on a chain with step $a$ interacting with themselves (with coupling $U$) and with a classical phonon field \f_x (with coupling \l). There is Peierls instability if the electronic ground state energy F(\f) as a functional of \f_x has a minimum which corresponds to a periodic function with period ${\pi\over p_F}$, where $p_F$ is the Fermi momentum. We consider ${p_F\over\pi a}$ irrational so that the CDW is {\it incommensurate} with the chain. We prove in a rigorous way in the spinless case, when \l,U are small and {U\over\l} large, that a)when the electronic interaction is attractive $U<0$ there is no Peierls instability b)when the interaction is repulsive $U>0$ there is Peierls instability in the sense that our convergent expansion for F(\f), truncated at the second order, has a minimum which corresponds to an analytical and ${\pi\over p_F}$ periodic \f_x. Such a minimum is found solving an infinite set of coupled self-consistent equations, one for each of the infinite Fourier modes of \f_x.Comment: 16 pages, 1 picture. To appear Phys. Rev.

The U(1)-Higgs Model: Critical Behaviour in the Confinig-Higgs region

We study numerically the critical properties of the U(1)-Higgs lattice model, with fixed Higgs modulus, in the region of small gauge coupling where the Higgs and Confining phases merge. We find evidence of a first order transition line that ends in a second order point. By means of a rotation in parameter space we introduce thermodynamic magnitudes and critical exponents in close resemblance with simple models that show analogous critical behaviour. The measured data allow us to fit the critical exponents finding values in agreement with the mean field prediction. The location of the critical point and the slope of the first order line are accurately given.Comment: 21 text pages. 12 postscript figures available on reques

Low innate production of interleukin-1beta and interleukin-6 is associated with the absence of osteoarthritis in old age

OBJECTIVE We investigated whether innate differences in cytokine response were associated with the absence of osteoarthritis (OA) in old age. DESIGN In 82 participants from a cross-sectional birth cohort, radiographs of hands, hips and knees were taken at the age of 90 years. OA was defined as a Kellgren-Lawrence score of at least two. "Free from OA" was defined at patient level as absence of hip and knee OA, and presence of OA in maximally two hand joints. The innate cytokine response was determined in whole-blood samples upon stimulation with lipopolysaccharide. Logistic regression analyses were used to investigate associations between absence of OA in relation to tertiles of interleukin (IL)-1beta, IL-6, tumor necrosis factor (TNF)-alpha, IL-1 receptor antagonist (RA) and IL-10. Adjustments were made for gender and body mass index. RESULTS Sixteen percent of the participants were "free from OA". Subjects in the lowest tertile of Il-1beta production had a 11-fold increased chance to be free of OA [odds ratio (OR) 11.3, confidence intervals (CI) 95% 1.1-115.9], subjects in the lowest tertile of IL-6 production had an almost 7-fold increased chance to be free of OA (OR 6.7, 95% CI 1.1-41.2). Absence of hand OA was associated with low innate production of IL-6 and IL-1RA, absence of hip OA was associated with low innate IL-1beta production. No associations were found for TNF-alpha and IL-10. CONCLUSIONS Low innate capacity to produce the pro-inflammatory cytokines IL-1beta and IL-6 is associated with the absence of OA in old age.Pathophysiology and treatment of rheumatic disease

Summing Divergent Perturbative Series in a Strong Coupling Limit. The Gell-Mann - Low Function of the \phi^4 Theory

An algorithm is proposed for determining asymptotics of the sum of a perturbative series in the strong coupling limit using given values of the expansion coefficients. Operation of the algorithm is illustrated by test examples, method for estimating errors is developed, and an optimization procedure is described. Application of the algorithm to the $\phi^4$ theory gives a behavior $\beta(g)\approx 7.4 g^{0.96}$ at large $g$ for its Gell-Mann -- Low function. The fact that the exponent is close to unity can be interpreted as a manifestation of the logarithmic branching of the type $\beta(g)\sim g (\ln g)^{-\gamma}$ (with $\gamma\approx 0.14$), which is confirmed by independent evidence. In any case, the $\phi^4$ theory is internally consistent. The procedure of summing perturbartive series with arbitrary values of expansion parameter is discussed.Comment: 23 pages, PD

Identification of the factors associated with outcomes in a condition management programme

&lt;p&gt;Background: A requirement of the Government’s Pathways to Work (PtW) agenda was to introduce a Condition Management Programme (CMP). The aim of the present study was to identify the differences between those who engaged and made progress in this telephone-based biopsychosocial intervention, in terms of their health, and those who did not and to determine the client and practitioner characteristics and programme elements associated with success in a programme aimed at improving health.&lt;/p&gt; &lt;p&gt;Methods: Data were obtained from the CMP electronic spreadsheets and clients paper-based case records. CMP standard practice was that questionnaires were administered during the pre- and post-assessment phases over the telephone. Each client’s record contains their socio-demographic data, their primary health condition, as well as the pre- and post-intervention scores of the health assessment tool administered. Univariate and multivariate statistical analysis was used to investigate the relationships between the database variables. Clients were included in the study if their records were available for analysis from July 2006 to December 2007.&lt;/p&gt; &lt;p&gt; Results: On average there were 112 referrals per month, totalling 2016 referrals during the evaluation period. The majority (62.8%) of clients had a mental-health condition. Successful completion of the programme was 28.5% (575 “completers”; 144 “discharges”). Several factors, such as age, health condition, mode of contact, and practitioner characteristics, were significant determinants of participation and completion of the programme. The results showed that completion of the CMP was associated with a better mental-health status, by reducing the number of clients that were either anxious, depressed or both, before undertaking the programme, from 74% to 32.5%.&lt;/p&gt; &lt;p&gt;Conclusions: Our findings showed that an individual's characteristics are associated with success in the programme, defined as completing the intervention and demonstrating an improved health status. This study provides some evidence that the systematic evaluation of such programmes and interventions could identify ways in which they could be improved.&lt;/p&gt