Exploring the scope for Normalisation Process Theory to help evaluate and understand the processes involved when scaling up integrated models of care: a case study of the scaling up of the Gnosall Memory Service

Purpose: The scaling up of promising, innovative integration projects presents challenges to social and health care systems. Evidence that a new service provides (cost) effective care in a (pilot) locality can often leave us some way from understanding how the innovation worked and what was crucial about the context to achieve the goals evidenced when applied to other localities. Even unpacking the “black box” of the innovation can still leave gaps in understanding with regard to scaling it up. Theory-led approaches are increasingly proposed as a means of helping to address this knowledge gap in understanding implementation. Our particular interest here is exploring the potential use of theory to help with understanding scaling up integration models across sites. The theory under consideration is Normalisation Process Theory (NPT). Design/methodology/approach: The article draws on a natural experiment providing a range of data from two sites working to scale up a well-thought-of, innovative integrated, primary care-based dementia service to other primary care sites. This provided an opportunity to use NPT as a means of framing understanding to explore what the theory adds to considering issues contributing to the success or failure of such a scaling up project. Findings: NPT offers a framework to potentially develop greater consistency in understanding the roll out of models of integrated care. The knowledge gained here and through further application of NPT could be applied to inform evaluation and planning of scaling-up programmes in the future. Research limitations/implications: The research was limited in the data collected from the case study; nevertheless, in the context of an exploration of the use of the theory, the observations provided a practical context in which to begin to examine the usefulness of NPT prior to embarking on its use in more expensive, larger-scale studies. Practical implications: NPT provides a promising framework to better understand the detail of integrated service models from the point of view of what may contribute to their successful scaling up. Social implications: NPT potentially provides a helpful framework to understand and manage efforts to have new integrated service models more widely adopted in practice and to help ensure that models which are effective in the small scale develop effectively when scaled up. Originality/value: This paper examines the use of NPT as a theory to guide understanding of scaling up promising innovative integration service models

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

Psychometric Properties of the Dutch Contextual Assessment of Social Skills (CASS):An Independent Observational Outcome Measure of Social Skills in Autistic Adolescents

The goal of this study was to translate and adapt the original 9-item of the Contextual Assessment of Social Skills (CASS) to a Dutch version and assess its psychometric qualities. Autistic adolescents aged 12 to 18 years (n = 99) took part in a randomized controlled trial. In this study, pre-intervention data were utilized. The original CASS was adapted to ensure cultural relevance and the content validity was assessed. Data was used to assess reliability and structural validity, using confirmatory factor analysis. 4-item were added to the CASS during the adaptation to better align with the objectives of the experimental intervention. The original 9-item had inter-item correlations between.01 and.70. The Cronbach’s alpha for the original 4-item total score was moderate (α =.69), while for a 7-item total score, it was high (α =.86). This 7-item total score had a sufficient model fit (Comparative Fit Index =.90). This total score had a significant correlation with the Assertion subscale of the Social Skills Improvement System-Adolescent (SSIS-A) (r = 0.26, p &lt;.01), and the Social Responsiveness Scale-2 (SRS-2) total score (r = − .21, p =.04) indicating sufficient convergent validity. The CASS total score was not correlated with the Repetitive and Restricted Behavior scale of the SRS-2 (r = − .08, p =.43), indicating sufficient divergent validity. The Dutch CASS can be considered a conceptually sound and reliable observational instrument for assessing social conversational skills in Dutch autistic youth. Further evaluation of its feasibility when implemented in practice, outside of clinical research, is needed. Trial registration: Dutch trail register NTR6255 (NL6117) 08/02/2017 https://www.trialregister.nl/trial/6117.</p

Unique Co‐Catalytic Behavior of Protic Ionic Liquids as Multifunctional Electrolytes for Water Splitting

Hydrogen production from water splitting holds great promise for solving today’s energy crisis but it is challenging to have high efficiency and low cost. For the first time, a protic ionic liquid (PIL), diethylammonium formate (DEAF) was used as a multifunctional electrolyte in water splitting, demonstrating a unique role of co‐catalyst for the hydrogen evolution reaction (HER) with the highest current density (21 mA cm−2 at −0.5 V) and the most positive onset potential (−0.002 V) in comparison to aprotic ILs and commonly used inorganic salts. Moreover, the concentration of PIL and temperature of electrolyte solution were optimized. The possible mechanism for the multifunctionality and high performance for water splitting using this PIL was proposed using X‐ray photoelectron spectroscopy (XPS). The high performance for HER, simplicity and low cost for synthesis, and unique properties make DEAF highly promising as an electrolyte toward water splitting.DEAFening: For the first time, a protic ionic liquid, diethylammonium format, is used as a multifunctional electrolyte in a water‐splitting cell, demonstrating a unique role as co‐catalyst.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137194/1/celc201500458.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137194/2/celc201500458-sup-0001-misc_information.pd

Genome-wide mouse embryonic stem cell regulatory network self-organisation : a big data CoSMoS computational modelling approach.

The principal barrier to gaining understanding of embryonic stem (ES) cell regulatory networks is their complexity. Reductionist approaches overlook much of the complexity inherent in these networks and treat the ES cell regulatory system as more or less equivalent to the sum of its component parts, studying them in relative isolation. However, as we learn more about regulatory components it becomes increasingly difficult to integrate complex layers of knowledge and to develop more refined understanding. We seek better control of the complexity inherent in non-equilibrium ES cell regulatory networks undergoing lineage specification by developing computer simulations of self-organisation using the CoSMoS approach. Simulation, together with the hypothesis that lineage computation occurs at the edge of chaos, should allow us to investigate the driving of gradual accumulation of network complexity 'from the bottom up'. Here, we present the first step in this design process: use of the CoSMoS approach to develop a highly abstracted model and simulation of regulatory network activity driven by just single pluripotent transcription factors (TF), but at genome-wide scales. We investigate three TFs in isolation: Oct4, Nanog and Sox2, central elements of the core pluripotent network of mouse embryonic stem cells. This provides a suitable basis for future modelling of multiple interacting TFs

Review of evidence for the alignment of guidelines on Aboriginal and Torres Strait Islander absolute cardiovascular disease risk: A report prepared for the Australian Government Department of Health

Policy context: Cardiovascular disease (CVD) is highly preventable. CVD continues to be the largest contributor to mortality within the Aboriginal and Torres Strait Islander population and rates of CVD are disproportionately higher within the Australian Aboriginal and Torres Strait Islander population compared to the non-Indigenous population. Improving uptake of current evidence based solutions such as the absolute risk approach to CVD within the Aboriginal and Torres Strait Islander population is important to address this disparity. Although there are several tools available supporting an absolute CVD risk approach, clinical uptake is limited due to a number of factors including an outdated continued reliance on the ‘single risk factor’ approach to prevention, diagnosis and treatment of CVD. A major barrier to uptake is inconsistent messages in the current clinical practice guidelines. Key messages: There are three main guidelines on the absolute CVD risk approach for Aboriginal and Torres Strait Islander peoples in Australia: The NVDPA Guidelines for the Management of Absolute Cardiovascular Disease Risk; The Central Australian Rural Practitioners Association Standard Treatment Manual; and the RACGP National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People. There is considerable alignment between the existing guidelines, including the need for an absolute risk approach, conditions conferring automatic high risk, use of the Framingham risk equation as the basis of calculating absolute risk, and the need to treat people at a greater than 15% risk of a primary CVD event over the next five years. The guidelines diverge materially in relation to four recommendations: 1) the age at which to commence absolute CVD risk assessment; 2) whether or not calculated risk scores should be adjusted upward by 5%; 3) how often CVD risk should be assessed; and 4) treatment targets for blood pressure. Available evidence indicates that CVD events and high absolute CVD risk occurs earlier in Aboriginal and Torres Strait Islander peoples, and that prevention of CVD should also start early. The proportion of Aboriginal and Torres Strait Islander peoples at high absolute CVD risk at the ages of 18-34 years broadly corresponds to the proportion at high risk among the general population aged 45-54 years. Limited evidence suggests that the current risk scores are likely to underestimate risk in Aboriginal and Torres Strait Islander peoples. Specific data on the extent of underestimation and alternative validated risk scores in this population are lacking. There is no primary data on adjusting risk scores upwards by 5% in Aboriginal and Torres Strait Islander people. Frequency of CVD risk assessment should be based on initial level of risk but the optimal interval for risk reassessment at each level of risk is not clear. There is general agreement between the guidelines to lower blood pressure as tolerated but there are inconsistencies in the exact blood pressure target. Evidence suggests that reductions in systolic blood pressure result in proportional reductions in CVD events and all-cause mortality. CVD guidelines could be kept up to date by adopting a ‘living’ guidelines model, but consideration needs to be given to how to identify relevant updated evidence and how to integrate the updates into electronic decision support tools.This research was supported by a grant from the Australian Government Department of Health

Lessons learned from recruiting socioeconomically disadvantaged smokers into a pilot randomized controlled trial to explore the role of Exercise Assisted Reduction then Stop (EARS) smoking

Background: Research is needed on what influences recruitment to smoking reduction trials, and how to increase their reach. The present study aimed to i) assess the feasibility of recruiting a disadvantaged population, ii) examine the effects of recruitment methods on participant characteristics, iii) identify resource requirements for different recruitment methods, and iv) to qualitatively assess the acceptability of recruitment. This was done as part of a pilot two-arm trial of the effectiveness of a novel behavioral support intervention focused on increasing physical activity and reducing smoking, among disadvantaged smokers not wishing to quit.&nbsp; Methods: Smokers were recruited through mailed invitations from three primary care practices (62 participants) and one National Health Stop Smoking Service (SSS) database (31 participants). Six other participants were recruited via a variety of other community-based approaches. Data were collected through questionnaires, field notes, work sampling, and databases. Chi-squared and t-tests were used to compare baseline characteristics of participants.&nbsp; Results: We randomized between 5.1 and 11.1% of those invited through primary care and SSS, with associated researcher time to recruit one participant varying from 18 to 157 minutes depending on time and intensity invested. Only six participants were recruited through a wide variety of other community-based approaches, with an associated researcher time of 469 minutes to recruit one participant. Targets for recruiting a disadvantaged population were met, with 91% of the sample in social classes C2 to E (NRS social grades, UK), and 41% indicating mental health problems. Those recruited from SSS were more likely to respond to an initial letter, had used cessation aids before, and had attempted to quit in the past year. Overall, initial responders were more likely to be physically active than those who were recruited via follow-up telephone calls. No other demographics or behaviour characteristics were associated with recruitment approach or intensity of effort. Qualitative feedback indicated that participants had been attracted by the prospect of support that focused on smoking reduction rather than abrupt quitting.&nbsp; Conclusions: Mailed invitations, and follow-up, from health professionals was an effective method of recruiting disadvantaged smokers into a trial of an exercise intervention to aid smoking reduction. Recruitment via community outreach approaches was largely ineffective.&nbsp; Trial registration: ISRCTN identifier: 13837944, registered on 6 July 201

Do engagement and behavioural mechanisms underpin the effectiveness of the Drink Less app?

This is a process evaluation of a large UK-based randomised controlled trial (RCT) (n = 5602) evaluating the effectiveness of recommending an alcohol reduction app, Drink Less, compared with usual digital care in reducing alcohol consumption in increasing and higher risk drinkers. The aim was to understand whether participants’ engagement (‘self-reported adherence’) and behavioural characteristics were mechanisms of action underpinning the effectiveness of Drink Less. Self-reported adherence with both digital tools was over 70% (Drink Less: 78.0%, 95% CI = 77.6–78.4; usual digital care: 71.5%, 95% CI = 71.0–71.9). Self-reported adherence to the intervention (average causal mediation effect [ACME] = −0.250, 95% CI = −0.42, −0.11) and self-monitoring behaviour (ACME = −0.235, 95% CI = −0.44, −0.03) both partially mediated the effect of the intervention (versus comparator) on alcohol reduction. Following the recommendation (self-reported adherence) and the tracking (self-monitoring behaviour) feature of the Drink Less app appear to be important mechanisms of action for alcohol reduction among increasing and higher risk drinkers

Do engagement and behavioural mechanisms underpin the effectiveness of the Drink Less app?

This is a process evaluation of a large UK-based randomised controlled trial (RCT) (n = 5602) evaluating the effectiveness of recommending an alcohol reduction app, Drink Less, compared with usual digital care in reducing alcohol consumption in increasing and higher risk drinkers. The aim was to understand whether participants’ engagement (‘self-reported adherence’) and behavioural characteristics were mechanisms of action underpinning the effectiveness of Drink Less. Self-reported adherence with both digital tools was over 70% (Drink Less: 78.0%, 95% CI = 77.6–78.4; usual digital care: 71.5%, 95% CI = 71.0–71.9). Self-reported adherence to the intervention (average causal mediation effect [ACME] = −0.250, 95% CI = −0.42, −0.11) and self-monitoring behaviour (ACME = −0.235, 95% CI = −0.44, −0.03) both partially mediated the effect of the intervention (versus comparator) on alcohol reduction. Following the recommendation (self-reported adherence) and the tracking (self-monitoring behaviour) feature of the Drink Less app appear to be important mechanisms of action for alcohol reduction among increasing and higher risk drinkers

Distinctive genotypes in infants with T-cell acute lymphoblastic leukaemia

Infant T-cell acute lymphoblastic leukaemia (iT-ALL) is a very rare and poorly defined entity with a poor prognosis. We assembled a unique series of 13 infants with T-ALL, which allowed us to identify genotypic abnormalities and to investigate prenatal origins. Matched samples (diagnosis/remission) were analysed by single nucleotide polymorphism-array to identify genomic losses and gains. In three cases, we identified a recurrent somatic deletion on chromosome 3. These losses result in the complete deletion of MLF1 and have not previously been described in T-ALL. We observed two cases with an 11p13 deletion (LMO2-related), one of which also harboured a deletion of RB1. Another case presented a large 11q14·1-11q23·2 deletion that included ATM and only five patients (38%) showed deletions of CDKN2A/B. Four cases showed NOTCH1 mutations; in one case FBXW7 was the sole mutation and three cases showed alterations in PTEN. KMT2A rearrangements (KMT2A-r) were detected in three out of 13 cases. For three patients, mutations and copy number alterations (including deletion of PTEN) could be backtracked to birth using neonatal blood spot DNA, demonstrating an in utero origin. Overall, our data indicates that iT-ALL has a diverse but distinctive profile of genotypic abnormalities when compared to T-ALL in older children and adults