Multidisciplinary group performance—measuring integration intensity in the context of the North West London Integrated Care Pilot

Introduction: Multidisciplinary Group meetings (MDGs) are seen as key facilitators of integration, moving from individual to multidisciplinary decision-making, and from a focus on individual patients to a focus on patient groups. We have developed a method for coding MDG transcripts to identify whether they are or are not vehicles for delivering the anticipated efficiency improvements across various providers and apply it to a test case in the North West London Integrated Care Pilot. Methods: We defined ‘integrating’ as the process within the MDG meeting that enables or promotes an improved collaboration, improved understanding, and improved awareness of self and others within the local healthcare economy such that efficiency improvements could be identified and action taken. Utterances within the MDGs are coded according to three distinct domains grounded in concepts from communication, group decision-making, and integrated care literatures—the Valence, the Focus, and the Level. Standardized weighted integrative intensity scores are calculated across ten time deciles in the Case Discussion providing a graphical representation of its integrative intensity. Results: Intra- and Inter-rater reliability of the coding scheme was very good as measured by the Prevalence and Bias-adjusted Kappa Score. Standardized Weighted Integrative Intensity graph mirrored closely the verbatim transcript and is a convenient representation of complex communication dynamics. Trend in integrative intensity can be calculated and the characteristics of the MDG can be pragmatically described. Conclusion: This is a novel and potentially useful method for researchers, managers and practitioners to better understand MDG dynamics and to identify whether participants are integrating. The degree to which participants use MDG meetings to develop an integrated way of working is likely to require management, leadership and shared values

‘Concerned not only with relief’: UNRRA’s work rehabilitating the Displaced Persons in the American zone of occupation in Germany, 1945-1947

The purpose of the dissertation is to further our knowledge of the process of normalization in the displaced person (DP) camps in the American zone of occupation in Germany after the Second World War. The United Nations Relief and Rehabilitation Administration (UNRRA) welfare workers brought with them their years of education and training in the United States, primarily as professional social workers, to their work in these camps. They believed that their task was not only to feed and clothe the DPs, but to provide rehabilitation as well. They continually emphasized the importance of reinstituting prewar social norms as the key element in rehabilitating the DPs. However, once they entered the DP camps in Germany, they soon discovered that the DPs had very different understandings of what constituted “normal life.” As a result, rehabilitation included not only reinstituting prewar social norms, but also introducing the DPs to new ones. UNRRA focused their rehabilitation efforts on six aspects of DP care: housing, cleanliness, education, work, and respect for civil and criminal law. While the DP camps were administered by UNRRA, they existed next to German communities who governed by Military Government and in the midst of their own reconstruction efforts. Given the immense wartime destruction, widespread shortages and the arrival of large numbers of German refugees, resources for all groups were at a premium. As a result, there were numerous opportunities for creative and broad-minded people to work at solving problems in unconventional ways. While UNRRA planning had provided some direction for its welfare workers, staff working in field came to play an important role in defining UNRRA’s policies. At the same time, their competing goals of rehabilitation and repatriation, as well as their at-times difficult relationship with the military, worked to constrain their efforts. Nevertheless, when UNRRA’s tenure as administrator of the DP camps ended in the summer of 1947, they left behind a legacy which highlighted the importance of the successful integration of refugees into their societies, and which made rehabilitation as central as relief in all future humanitarian responses

Evaluation of complex integrated care programmes: the approach in North West London

Background: Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect. Study design: We present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and focus groups with patients and professionals, to understand participant experiences and to understand the pilot within the national policy context. Theory and discussion: This study considers the complexity of evaluating a large, multi-organisational intervention in a changing healthcare economy. We locate the evaluation within the theory of evaluation of complex interventions. We present the specific challenges faced by evaluating an intervention of this sort, and the responses made to mitigate against them. Conclusions: We hope this broad, dynamic and responsive evaluation will allow us to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar interventions. Because of the priority given to the integrated agenda by governments internationally, the need to develop and improve strong evaluation methodologies remains strikingly important

Multidisciplinary integration in the context of integrated care - results from the North West London Integrated Care Pilot

Background: In the context of integrated care, Multidisciplinary Group meetings involve participants from diverse professional groups and organisations and are potential vehicles to advance efficiency improvements within the local health economy. We advance a novel method to characterise the communication within Multidisciplinary Group meetings measuring the extent to which participants integrate and whether this integration leads to improved working. Methods: We purposively selected four Multidisciplinary Group meetings and conducted a content analysis of audio-recorded and transcribed Case Discussions. Two coders independently coded utterances according to their 'integrative intensity' which was defined against three a-priori independent domains - the Level (i.e. Individual, Collective and Systems); the Valence (Problem, Information and Solution); the Focus (Concrete and Abstract). Inter- and intra-rater reliability was tested with Kappa scores on one randomly selected Case Discussion. Standardised weighted mean integration scores were calculated for Case Discussions across utterance deciles, indicating how integrative intensity changed during the conversations. Results: Twenty-three Case Discussions in four different Multidisciplinary Groups were transcribed and coded. Inter- and intra-rater reliability was good as shown by the Prevalence and Bias-Adjusted Kappa Scores for one randomly selected Case Discussion. There were differences in the proportion of utterances per participant type (Consultant 14.6%; presenting general practitioner 38.75%; Chair 7.8%; nonpresenting general practitioner 2.25%; Allied Health Professional 4.8%). Utterances were predominantly coded at low levels of integrative intensity; however, there was a gradual increase (R = 0.71) in integrative intensity during the Case Discussions. Based on the analysis of the minutes and action points arising from the Case Discussions, this improved integration did not translate into actions moving forward. Interpretation: We characterise the Multidisciplinary Groups as having consultative characteristics with some trend towards collaboration, but that best resemble Community-Based Ward Rounds. Although integration scores do increase from the beginning to the end of the Case Discussions, this does not tend to translate into actions for the groups to take forward. The role of the Chair and the improved participation of non-presenting general practitioners and Allied Health Professionals seems important, particularly as the latter contribute well to higher integrative scores. Traditional communication patterns of medical dominance seem to be being perpetuated in the Multidisciplinary Groups. This suggests that more could be done to sensitise participants to the value of full participation from all the members of the group. The method we have developed could be used for ongoing and future evaluations of integrated care projects

Mitochondrial DNA changes in pedunculopontine cholinergic neurons in Parkinson’s disease

In Parkinson’s disease (PD), mitochondrial dysfunction associates with nigral dopaminergic neuronal loss. Cholinergic neuronal loss co-occurs, particularly within a brainstem structure, the pedunculopontine nucleus (PPN). We isolated single cholinergic neurons from post-mortem PPNs of aged controls and PD patients. Mitochondrial DNA (mtDNA) copy number and mtDNA deletions were increased significantly in PD patients compared to controls. Furthermore, compared to controls the PD patients had significantly more PPN cholinergic neurons containing mtDNA deletion levels exceeding 60%, a level associated with deleterious effects on oxidative phosphorylation. The current results differ from studies reporting mtDNA depletion in nigral dopaminergic neurons of PD patients

Differential physiological responses to environmental change promote woody shrub expansion

Direct and indirect effects of warming are increasingly modifying the carbon-rich vegetation and soils of the Arctic tundra, with important implications for the terrestrial carbon cycle. Understanding the biological and environmental influences on the pr

Resolved Debris Discs Around A Stars in the Herschel DEBRIS Survey

The majority of debris discs discovered so far have only been detected through infrared excess emission above stellar photospheres. While disc properties can be inferred from unresolved photometry alone under various assumptions for the physical properties of dust grains, there is a degeneracy between disc radius and dust temperature that depends on the grain size distribution and optical properties. By resolving the disc we can measure the actual location of the dust. The launch of Herschel, with an angular resolution superior to previous far-infrared telescopes, allows us to spatially resolve more discs and locate the dust directly. Here we present the nine resolved discs around A stars between 20 and 40 pc observed by the DEBRIS survey. We use these data to investigate the disc radii by fitting narrow ring models to images at 70, 100 and 160 {\mu}m and by fitting blackbodies to full spectral energy distributions. We do this with the aim of finding an improved way of estimating disc radii for unresolved systems. The ratio between the resolved and blackbody radii varies between 1 and 2.5. This ratio is inversely correlated with luminosity and any remaining discrepancies are most likely explained by differences to the minimum size of grain in the size distribution or differences in composition. We find that three of the systems are well fit by a narrow ring, two systems are borderline cases and the other four likely require wider or multiple rings to fully explain the observations, reflecting the diversity of planetary systems.Comment: 19 pages, 13 figures, 6 tables. Accepted for publication in MNRA

Differential physiological responses to environmental change promote woody shrub expansion

© The Author(s), 2013. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Ecology and Evolution 3 (2013): 1149–1162, doi:10.1002/ece3.525.Direct and indirect effects of warming are increasingly modifying the carbon-rich vegetation and soils of the Arctic tundra, with important implications for the terrestrial carbon cycle. Understanding the biological and environmental influences on the processes that regulate foliar carbon cycling in tundra species is essential for predicting the future terrestrial carbon balance in this region. To determine the effect of climate change impacts on gas exchange in tundra, we quantified foliar photosynthesis (Anet), respiration in the dark and light (RD and RL, determined using the Kok method), photorespiration (PR), carbon gain efficiency (CGE, the ratio of photosynthetic CO2 uptake to total CO2 exchange of photosynthesis, PR, and respiration), and leaf traits of three dominant species – Betula nana, a woody shrub; Eriophorum vaginatum, a graminoid; and Rubus chamaemorus, a forb – grown under long-term warming and fertilization treatments since 1989 at Toolik Lake, Alaska. Under warming, B. nana exhibited the highest rates of Anet and strongest light inhibition of respiration, increasing CGE nearly 50% compared with leaves grown in ambient conditions, which corresponded to a 52% increase in relative abundance. Gas exchange did not shift under fertilization in B. nana despite increases in leaf N and P and near-complete dominance at the community scale, suggesting a morphological rather than physiological response. Rubus chamaemorus, exhibited minimal shifts in foliar gas exchange, and responded similarly to B. nana under treatment conditions. By contrast, E. vaginatum, did not significantly alter its gas exchange physiology under treatments and exhibited dramatic decreases in relative cover (warming: −19.7%; fertilization: −79.7%; warming with fertilization: −91.1%). Our findings suggest a foliar physiological advantage in the woody shrub B. nana that is further mediated by warming and increased soil nutrient availability, which may facilitate shrub expansion and in turn alter the terrestrial carbon cycle in future tundra environments.This study was supported by the National Science Foundation #0732664; Australian Research Council DP0986823; and Marsden Fund of the Royal Society of New Zealand

A High-Power 4 × 4:Crystallographic and Electrochemical Insights into a Novel Wadsley-Roth Anode Nb₉Ti_1.5W_1.5O₃₀

A novel 4 x 4 Wadsley-Roth block phase, Nb9Ti1.5W1.5O30, has been prepared and its structure determined through Neutron and X-ray diffraction studies. Electrochemical testing indicate excellent high rate performance, with a returned delithiation capacity of 184 (4) mA h g-1 at a current of 2 A g-1