Do the UK government's new Quality and Outcomes Framework (QOF) scores adequately measure primary care performance? A cross-sectional survey of routine healthcare data

BACKGROUND General practitioners' remuneration is now linked directly to the scores attained in the Quality and Outcomes Framework (QOF). The success of this approach depends in part on designing a robust and clinically meaningful set of indicators. The aim of this study was to assess the extent to which measures of health observed in practice populations are correlated with their QOF scores, after accounting for the established associations between health outcomes and socio-demographics. METHODS QOF data for the period April 2004 to March 2005 were obtained for all general practices in two English Primary Care Trusts. These data were linked to data for emergency hospital admissions (for asthma, cancer, chronic obstructive pulmonary disease, coronary hear disease, diabetes, stroke and all other conditions) and all cause mortality for the period September 2004 to August 2005. Multilevel logistic regression models explored the association between health outcomes (hospital admission and death) and practice QOF scores (clinical, additional services and organisational domains), age, sex and socio-economic deprivation. RESULTS Higher clinical domain scores were generally associated with lower admission rates and this was significant for cancer and other conditions in PCT 2. Higher scores in the additional services domain were associated with higher admission rates, significantly so for asthma, CHD, stroke and other conditions in PCT 1 and cancer in PCT 2. Little association was observed between the organisational domain scores and admissions. The relationship between the QOF variables and mortality was less clear. Being female was associated with fewer admissions for cancer and CHD and lower mortality rates. Increasing age was mainly associated with an increased number of events. Increasing deprivation was associated with higher admission rates for all conditions and with higher mortality rates. CONCLUSION The associations between QOF scores and emergency admissions and mortality were small and inconsistent, whilst the impact of socio-economic deprivation on the outcomes was much stronger. These results have implications for the use of target-based remuneration of general practitioners and emphasise the need to tackle inequalities and improve the health of disadvantaged groups and the population as a whole

Dynamics of Vortex Core Switching in Ferromagnetic Nanodisks

Dynamics of magnetic vortex core switching in nanometer-scale permalloy disk, having a single vortex ground state, was investigated by micromagnetic modeling. When an in-plane magnetic field pulse with an appropriate strength and duration is applied to the vortex structure, additional two vortices, i.e., a circular- and an anti-vortex, are created near the original vortex core. Sequentially, the vortex-antivortex pair annihilates. A spin wave is created at the annihilation point and propagated through the entire element; the relaxed state for the system is the single vortex state with a switched vortex core.Comment: to appear in Appl. Phys. Let

Interferon beta in multiple sclerosis: experience in a British specialist multiple sclerosis centre

Background: The efficacy of interferon beta (IFN beta) is well established in relapsing-remitting multiple sclerosis (MS). However, the use of this drug in clinical practice is complex, especially because it is only partially effective, its long term efficacy and side effects are unknown, its efficacy may be abrogated by the development of neutralising antibodies, compliance is variable, and its cost effectiveness is controversial. Objectives and Methods: Analysis of a prospectively followed up series of 101 MS patients treated with IFN beta was undertaken to: (1) monitor the outcome of IFN beta treatment in clinical practice; (2) compare the immunogenicity of the three commercial IFN beta preparations available; (3) assess the proportion of patients fulfilling the current guidelines of the Association of British Neurologists for stopping IFN beta therapy. Results: During a median treatment period of 26 months (range 2–85), the relapse rate decreased by 41%. Although the reduction in the relapse rate was similar for all three commercial products, none of the Avonex treated patients were relapse free, compared with 19% of the Betaferon treated and 27% of the Rebif treated patients (p=0.02). Neutralising antibodies were not detected in Avonex treated patients (0 of 18), compared with 12 of 32 (38%) Betaferon treated and 10 of 23 (44%) Rebif treated patients (p=0.02). Forty of 101 (40%) patients satisfied the current (2001) Association of British Neurologists criteria for stopping IFN beta treatment at some stage during their treatment. Conclusion: IFN beta is effective in reducing the relapse rate in patients with relapsing-remitting MS in routine clinical practice. However, after a median treatment duration of 26 months, 40% of initially relapsing-remitting MS patients seem to have ongoing disease activity, presenting as disabling relapses or insidious progression

Estimating fuel channel bore from fuel grab load trace data

Detailed measurements of the graphite core fuel channels are made by specialist inspection equipment during planned outages, typically every 18 months to 3 years. The bores of the graphite fuel bricks are obtained during these inspections and are used to provide important information about the health of the core. Additionally, less detailed online monitoring data is obtained much more frequently during refuelling events, called the fuel grab load trace (FGLT), which can be also used to infer the health of the graphite core. This paper describes the process of creating a model which isolates a component of the refuelling data and maps it directly to dimensional measurements of fuel channel bore. The model is created from a combination of the theoretical understanding of the physical interactions of the fuel stringer during refuelling events and several years of refuelling and inspection data to estimate suitable model parameters. Initially the model created was a coarse estimation of FGLT to fuel bore dimension but through refinements a much more accurate model has been created. An application of this model is shown through a case study of a recent outage where estimations were made on refuelling data and were compared to previously unseen inspection data

Which is more useful in predicting hospital mortality - dichotomised blood test results or actual test values? A retrospective study in two hospitals

Routine blood tests are an integral part of clinical medicine and in interpreting blood test results clinicians have two broad options. (1) Dichotomise the blood tests into normal/abnormal or (2) use the actual values and overlook the reference values. We refer to these as the "binary" and the "non-binary" strategy respectively. We investigate which strategy is better at predicting the risk of death in hospital based on seven routinely undertaken blood tests (albumin, creatinine, haemoglobin, potassium, sodium, urea, and white blood cell count) using tree models to implement the two strategies

Histopathological placental lesions in mild gestational hyperglycemic and diabetic women

Objective: To investigate and compare the incidence of histopathological placental lesions in mild gestational hyperglycemia, gestational diabetes and overt diabetes at term and preterm gestation.Research design and methods: One-hundred-and-thirty-one placental samples were collected from Diabetes mellitus (DM) positive screened patients. Two diagnostic tests, glycemic profile and 100 g oral glucose tolerance test (OGTT) in parallel identified 4 groups normoglycemic, mild gestational hyperglycemia (MGH), gestational DM (GDM) or overt DM (DM). Placental tissue specimens and sections from 4 groups were obtained by uniform random sampling and stained with hematoxylin-eosin.Results: Placentas from MGH group presented 17 types of histopathological change and higher rates of syncytial nodes and endarteritis. GDM placentas presented only nine types of histopathological change, high rates of dysmaturity, low rates of calcification and no syncytial nodes. Overt DM placentas showed 22 types of histopathological change, 21 of which were present in the preterm period. There were histopathological similarities between MGH and DM placentas, but the former exhibited a higher incidence of endarteritis, which has been described as a post-mortem phenomenon.Conclusion: Our results confirmed that the distinct placental changes associated with DM and MGH depend on gestational period during which the diabetic insult occurs. It may reasonably be inferred that subclinical maternal hyperglycemia during pregnancy, as showed in MGH group, is responsible for increased placental endarteritis, a postmortem lesion in the live fetus

A Pair Polarimeter for Linearly Polarized High Energy Photons

A high quality beam of linearly polarized photons of several GeV will become available with the coherent bremsstrahlung technique at JLab. We have developed a polarimeter which requires about two meters of the beam line, has an analyzing power of 20% and an efficiency of 0.02%. The layout and first results of a polarimeter test on the laser back-scattering photon beam at SPring-8/LEPS are presented

A possible bias on the estimate of Lbol/Ledd in AGN as a function of luminosity and redshift

The BH mass (and the related Eddington ratio) in broad line AGN is usually evaluated by combining estimates (often indirect) of the BLR radius and of the FWHM of the broad lines, under the assumption that the BLR clouds are in Keplerian motion around the BH. Such an evaluation depends on the geometry of the BLR. There are two major options for the BLR configuration: spherically symmetric or ``flattened''. In the latter case the inclination to the line of sight becomes a relevant parameter. This paper is devoted to evaluate the bias on the estimate of the Eddington ratio when a spherical geometry is assumed (more generally when inclination effects are ignored), while the actual configuration is ``flattened'', as some evidence suggests. This is done as a function of luminosity and redshift, on the basis of recent results which show the existence of a correlation between the fraction of obscured AGN and these two parameters up to at least z=2.5. The assumed BLR velocity field is akin to the ``generalized thick disk'' proposed by Collin et al. (2006). Assuming an isotropic orientation in the sky, the mean value of the bias is calculated as a function of luminosity and redshift. It is demonstrated that, on average, the Eddington ratio obtained assuming a spherical geometry is underestimated for high luminosities, and overestimated for low luminosities. This bias converges for all luminosities at z about 2.7, while nothing can be said on this bias at larger redshifts due to the lack of data. The effects of the bias, averaged over the luminosity function of broad line AGN, have been calculated. The results imply that the bias associated with the a-sphericity of the BLR make even worse the discrepancy between the observations and the predictions of evolutionary models.Comment: 6 pages, 3 figures, accepted for publication in A&

The pivotal position of \u27liaison people\u27: facilitating a research utilisation intervention in policy agencies

Externally designed and implemented organisational change interventions are thought to have a greater chance of success when they are supported by one or more internal staff members acting as facilitators (Greenhalgh, Robert, Macfarlane, Bate, & Kyriakidou, 2004). Such facilitators often manage the administrative tasks associated with an intervention and may be involved in recruitment, consent processes and/or data collection. More importantly, they are social mediators of the ideas and processes central to the intervention. This may involve formal activities such as presentations at staff meetings, but is likely to include ad hoc negotiation and interpretive communication with diverse colleagues and with those implementing the intervention. Thus facilitators are expected to function as persuasive advocates and mediators, using their interpersonal skills and institutional knowledge to deliver and, where necessary, reframe, interventions to maximise their success. In this paper we build on existing knowledge by describing the attributes, perceptions, contexts and associated behaviours of the facilitators—known as liaison people — of a novel complex trial that was designed to increase the use of research in health policy agencies (CIPHER Investigators, 2014). We demonstrate that the liaison people (LPs) functioned as critical mediators with profound impacts on how the intervention was shaped and received in each site. We develop propositions from our analysis that provide guidance about how to identify and support liaison people (or related functions) in similar interventions. But first, we present an overview of the key roles and characteristics of intervention facilitators in general, and then describe the intervention trial that our LPs were facilitating

Effect of physiological overload on pregnancy in women with mitral regurgitation

OBJECTIVES: to evaluate the structural and functional heart abnormalities in women with mitral regurgitation during pregnancy.INTRODUCTION: Women with mitral regurgitation progress well during pregnancy. However, the effects on the heart of the association between pregnancy and mitral regurgitation are not well established.METHODS: This is a case-control, longitudinal prospective study. Echocardiograms were performed in 18 women with mitral regurgitation at the 12th and 36th week of pregnancy and on the 45th day of the puerperium. Twelve age-matched healthy and pregnant women were included as controls and underwent the same evaluation as the study group.RESULTS: Compared with controls, women with mitral regurgitation presented increased left cardiac chambers in all evaluations. Increasing left atrium during pregnancy occurred only in the mitral regurgitation group. At the end of the puerperium, women with mitral regurgitation showed persistent enlargement of the left atrium compared with the beginning of pregnancy (5.0 +/- 1.1 cm vs 4.6 +/- 0.9 cm; p < 0.05). Reduced left ventricular relative wall thickness (0.13 +/- 0.02 vs 0.16 +/- 0.02; p < 0.05) and an increased peak of afterload (278 +/- 55 g/cm(2) vs 207 +/- 28 g/cm(2); p < 0.05) was still observed on the 45th day after delivery in the mitral regurgitation group compared with controls.CONCLUSIONS: Pregnancy causes unfavorable structural alterations in women with mitral regurgitation that are associated with an aggravation of the hemodynamic overload