Measuring quality in the therapeutic relationship-Part 2: subjective approaches

Publisher version: http://qualitysafety.bmj.com/content/19/6/479.ful

Risk models and scores for type 2 diabetes: Systematic review

This article is published under a Creative Commons Attribution Non Commercial (CC BY-NC 3.0) licence that allows reuse subject only to the use being non-commercial and to the article being fully attributed (http://creativecommons.org/licenses/by-nc/3.0).Objective - To evaluate current risk models and scores for type 2 diabetes and inform selection and implementation of these in practice. Design - Systematic review using standard (quantitative) and realist (mainly qualitative) methodology. Inclusion - criteria Papers in any language describing the development or external validation, or both, of models and scores to predict the risk of an adult developing type 2 diabetes. Data sources - Medline, PreMedline, Embase, and Cochrane databases were searched. Included studies were citation tracked in Google Scholar to identify follow-on studies of usability or impact. Data extraction - Data were extracted on statistical properties of models, details of internal or external validation, and use of risk scores beyond the studies that developed them. Quantitative data were tabulated to compare model components and statistical properties. Qualitative data were analysed thematically to identify mechanisms by which use of the risk model or score might improve patient outcomes. Results - 8864 titles were scanned, 115 full text papers considered, and 43 papers included in the final sample. These described the prospective development or validation, or both, of 145 risk prediction models and scores, 94 of which were studied in detail here. They had been tested on 6.88 million participants followed for up to 28 years. Heterogeneity of primary studies precluded meta-analysis. Some but not all risk models or scores had robust statistical properties (for example, good discrimination and calibration) and had been externally validated on a different population. Genetic markers added nothing to models over clinical and sociodemographic factors. Most authors described their score as “simple” or “easily implemented,” although few were specific about the intended users and under what circumstances. Ten mechanisms were identified by which measuring diabetes risk might improve outcomes. Follow-on studies that applied a risk score as part of an intervention aimed at reducing actual risk in people were sparse. Conclusion - Much work has been done to develop diabetes risk models and scores, but most are rarely used because they require tests not routinely available or they were developed without a specific user or clear use in mind. Encouragingly, recent research has begun to tackle usability and the impact of diabetes risk scores. Two promising areas for further research are interventions that prompt lay people to check their own diabetes risk and use of risk scores on population datasets to identify high risk “hotspots” for targeted public health interventions.Tower Hamlets, Newham, and City and Hackney primary care trusts and National Institute of Health Research

Effect on smoking quit rate of telling patients their lung age: the Step2quit randomised controlled trial

Objective To evaluate the impact of telling patients their estimated spirometric lung age as an incentive to quit smoking.Design Randomised controlled trial.Setting Five general practices in Hertfordshire, England.Participants 561 current smokers aged over 35.Intervention All participants were offered spirometric assessment of lung function. Participants in intervention group received their results in terms of "lung age" (the age of the average healthy individual who would perform similar to them on spirometry). Those in the control group received a raw figure for forced expiratory volume at one second (FEV1). Both groups were advised to quit and offered referral to local NHS smoking cessation services.Main outcome measures The primary outcome measure was verified cessation of smoking by salivary cotinine testing 12 months after recruitment. Secondary outcomes were reported changes in daily consumption of cigarettes and identification of new diagnoses of chronic obstructive lung disease.Results Follow-up was 89%. Independently verified quit rates at 12 months in the intervention and control groups, respectively, were 13.6% and 6.4% (difference 7.2%, P=0.005, 95% confidence interval 2.2% to 12.1%; number needed to treat 14). People with worse spirometric lung age were no more likely to have quit than those with normal lung age in either group. Cost per successful quitter was estimated at 280 pound ((euro) 365, $556). A new diagnosis of obstructive lung disease was made in 17% in the intervention group and 14% in the control group; a total of 16% (89/561) of participants.Conclusion Telling smokers their lung age significantly improves the likelihood of them quitting smoking, but the mechanism by which this intervention achieves its effect is unclear.Trial registration National Research Register N0096173751

Soft networks for bridging the gap between research and practice: illuminative evaluation of CHAIN

Objectives To explore the process of knowledge exchange in an informal email network for evidence based health care, to illuminate the value of the service and its critical success factors, and to identify areas for improvement.Design Illuminative evaluationSetting Targeted email and networking service for UK healthcare practitioners and researchers.Participants 2800 members of a networking service.Main outcome measures Tracking of email messages, interviews with core staff, and a qualitative analysis of messages, postings from focus groups, and invited and unsolicited feedback to the service.Results The informal email network helped to bridge the gap between research and practice by serving as a rich source of information, providing access to members' experiences, suggestions, and ideas, facilitating cross boundary collaboration, and enabling participation in networking at a variety of levels. Ad hoc groupings and communities of practice emerged spontaneously as members discovered common areas of interest.Conclusion This study illuminated how knowledge for evidence based health care can be targeted, personalised, and made meaningful through informal social processes. Critical success factors include a broad based membership from both the research and service communities; a loose and fluid network structure; fight targeting of messages based on members' interests; the presence of a strong network identity and culture of reciprocity; and the opportunity for new members to learn through passive participation

Adoption and non-adoption of a shared electronic summary record in England: a mixed-method case study

Publisher version: http://www.bmj.com/content/340/bmj.c3111.full?sid=fcb22308-64fe-4070-9067-15a172b3aea

Electric Potential and Fréchet Derivatives for a Uniform Anisotropic Medium with a Tilted Axis of Symmetry

In this paper we develop analytic solutions for the electric potential, current density and Fréchet derivatives at any interior point within a 3-D transversely isotropic medium having a tilted axis of symmetry. The current electrode is assumed to be on the surface of the Earth and the plane of stratification given arbitrary strike and dip. Profiles can be computed for any azimuth. The equipotentials exhibit an elliptical pattern and are not orthogonal to the current density vectors, which are strongly angle dependent. Current density reaches its maximum value in a direction parallel to the longitudinal conductivity direction. Illustrative examples of the Fréchet derivatives are given for the 2.5-D problem, in which the profile is taken perpendicular to strike. All three derivatives of the Green's function with respect to longitudinal conductivity, transverse resistivity and dip angle of the symmetry axis (dG/dσl, dG/dσt, dG/dθ0) show a strongly asymmetric pattern compared to the isotropic case. The patterns are aligned in the direction of the tilt angle. Such sensitivity patterns are useful in real-time experimental design as well as in the fast inversion of resistivity data collected over an anisotropic eart