Assessing patients' experience of integrated care: a survey of patient views in the North West London Integrated Care Pilot

Despite the importance of continuity of care and patient engagement, few studies have captured patients' views on integrated care. This study assesses patient experience in the Integrated Care Pilot in North West London with the aim to help clinicians and policymakers understand patients' acceptability of integrated care and design future initiatives

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

Infant Mortality Trends Among Georgia Residents, 1995-2003: Targeting Healthy People’s 2010 Goals

Population-based trends in infant mortality among Georgia Residents between 1995 and 2003 were assessed on characteristics such as race, birth weight, neonatal and post-neonatal periods, and cause of death. A statistical analysis was conducted to show that the Georgia infant mortality rate (IMR) remained constant throughout the study period and averaged 8.67 per 1,000 live births. The analysis revealed racial disparities, with an IMR ranging from 6.03 in white infants to 13.76 in black infants, with less than one percent (0.86%) change, on average, among the differences between black and white mortality rates across the nine-year period. The disparities were also evident in infants with low birth weight (LBW) and very low birth weight (VLBW). Black infants born with LBW (12.9%) and VLBW (9.98%) have more than twice the rate of infant mortality compared to white infants born with LBW (6.64%) and VLBW (1.12%). Mortality in the neonatal period accounted for more than half (67.96%) of all infant deaths and exhibited considerable ethnic differences. Among all groups, black male neonates (10.7) have the highest mortality rates. The average neonatal mortality rate across the entire study period is 5.89 (SD=0.20); the average postneonatal mortality rate across the entire study period is 2.78 (SD=0.22). The five leading causes of death among Georgian infants in descending order were: birth defects, prematurity and low birth weight, Sudden Unexplained Infant Deaths (SUID), other perinatal conditions and respiratory conditions with racial differences in the ordering

The impact of the Luton social prescribing programme on energy expenditure: a quantitative before-and-after study

The objective of this study was to assess the change in energy expenditure levels of service users after participation in the Luton social prescribing programme. Uncontrolled before-and-after study. This study was set in the East of England (Luton). Service users with complete covariate information and baseline measurements (n=146) were included in the analysis. Social prescribing, which is an initiative that aims to link patients in primary care with sources of support within the community sector to improve their health, well-being and care experience. Service users were referred to 12 sessions (free of charge), usually provided by third sector organisations. Energy expenditure measured as metabolic equivalent (MET) minutes per week. Using a Bayesian zero-inflated negative binomial model to account for a large number of observed zeros in the data, 95% posterior intervals show that energy expenditure from all levels of physical activities increased post intervention (walking 41.7% (40.31%, 43.11%); moderate 5.0% (2.94%, 7.09%); vigorous 107.3% (98.19%, 116.20%) and total 56.3% (54.77%, 57.69%)). The probability of engaging in physical activity post intervention increased, in three of four MET physical activity levels, for those individuals who were inactive at the start of the programme. Age has a negative effect on energy expenditure from any physical activity level. Similarly, working status has a negative effect on energy expenditure in all but one MET physical activity level. No consistent pattern was observed across physical activity levels in the association between gender and energy expenditure. This study shows that social prescribing may have the potential to increase the physical activity levels of service users and promote the uptake of physical activity in inactive patient groups. Results of this study can inform future research in the field, which could be of use for commissioners and policy makers

Transtheoretical model stages of change for dietary and physical exercise modification in weight loss management for overweight and obese adults.

BACKGROUND: Obesity is a global public health threat. The transtheoretical stages of change (TTM SOC) model has long been considered a useful interventional approach in lifestyle modification programmes, but its effectiveness in producing sustainable weight loss in overweight and obese individuals has been found to vary considerably.  OBJECTIVES: To assess the effectiveness of dietary intervention or physical activity interventions, or both, and other interventions based on the transtheoretical model (TTM) stages of change (SOC) to produce sustainable (one year and longer) weight loss in overweight and obese adults. SEARCH METHODS: Studies were obtained from searches of multiple electronic bibliographic databases. We searched The Cochrane Library, MEDLINE, EMBASE and PsycINFO. The date of the last search, for all databases, was 17 December 2013. SELECTION CRITERIA: Trials were included if they fulfilled the criteria of randomised controlled clinical trials (RCTs) using the TTM SOC as a model, that is a theoretical framework or guideline in designing lifestyle modification strategies, mainly dietary and physical activity interventions, versus a comparison intervention of usual care; one of the outcome measures of the study was weight loss, measured as change in weight or body mass index (BMI); participants were overweight or obese adults only; and the intervention was delivered by healthcare professionals or trained lay people at the hospital and community level, including at home. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the data, assessed studies for risk of bias and evaluated overall study quality according to GRADE (Grading of Recommendations Assessment, Development and Evaluation). We resolved disagreements by discussion or consultation with a third party. A narrative, descriptive analysis was conducted for the systematic review. MAIN RESULTS: A total of three studies met the inclusion criteria, allocating 2971 participants to the intervention and control groups. The total number of participants randomised to the intervention groups was 1467, whilst 1504 were randomised to the control groups. The length of intervention was 9, 12 and 24 months in the different trials. The use of TTM SOC in combination with diet or physical activity, or both, and other interventions in the included studies produced inconclusive evidence that TTM SOC interventions led to sustained weight loss (the mean difference between intervention and control groups varied from 2.1 kg to 0.2 kg at 24 months; 2971 participants; 3 trials; low quality evidence). Following application of TTM SOC there were improvements in physical activity and dietary habits, such as increased exercise duration and frequency, reduced dietary fat intake and increased fruit and vegetable consumption (very low quality evidence). Weight gain was reported as an adverse event in one of the included trials. None of the trials reported health-related quality of life, morbidity, or economic costs as outcomes. The small number of studies and their variable methodological quality limit the applicability of the findings to clinical practice. The main limitations include inadequate reporting of outcomes and the methods for allocation, randomisation and blinding; extensive use of self-reported measures to estimate the effects of interventions on a number of outcomes, including weight loss, dietary consumption and physical activity levels; and insufficient assessment of sustainability due to lack of post-intervention assessments. AUTHORS' CONCLUSIONS: The evidence to support the use of TTM SOC in weight loss interventions is limited by risk of bias and imprecision, not allowing firm conclusions to be drawn. When combined with diet or physical activity, or both, and other interventions we found very low quality evidence that it might lead to better dietary and physical activity habits. This systematic review highlights the need for well-designed RCTs that apply the principles of the TTM SOC appropriately to produce conclusive evidence about the effect of TTM SOC lifestyle interventions on weight loss and other health outcomes

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

Marble melancholy: using crossmodal correspondences of shapes, materials, and music to predict music-induced emotions

Introduction: Music is known to elicit strong emotions in listeners, and, if primed appropriately, can give rise to specific and observable crossmodal correspondences. This study aimed to assess two primary objectives: (1) identifying crossmodal correspondences emerging from music-induced emotions, and (2) examining the predictability of music-induced emotions based on the association of music with visual shapes and materials. Methods: To achieve this, 176 participants were asked to associate visual shapes and materials with the emotion classes of the Geneva Music-Induced Affect Checklist scale (GEMIAC) elicited by a set of musical excerpts in an online experiment. Results: Our findings reveal that music-induced emotions and their underlying core affect (i.e., valence and arousal) can be accurately predicted by the joint information of musical excerpt and features of visual shapes and materials associated with these music-induced emotions. Interestingly, valence and arousal induced by music have higher predictability than discrete GEMIAC emotions. Discussion: These results demonstrate the relevance of crossmodal correspondences in studying music-induced emotions. The potential applications of these findings in the fields of sensory interactions design, multisensory experiences and art, as well as digital and sensory marketing are briefly discussed.Peer Reviewe

Electrospray sample injection for single-particle imaging with x-ray lasers

The possibility of imaging single proteins constitutes an exciting challenge for x-ray lasers. Despite encouraging results on large particles, imaging small particles has proven to be difficult for two reasons: not quite high enough pulse intensity from currently available x-ray lasers and, as we demonstrate here, contamination of the aerosolized molecules by nonvolatile contaminants in the solution. The amount of contamination on the sample depends on the initial droplet size during aerosolization. Here, we show that, with our electrospray injector, we can decrease the size of aerosol droplets and demonstrate virtually contaminant-free sample delivery of organelles, small virions, and proteins. The results presented here, together with the increased performance of next-generation x-ray lasers, constitute an important stepping stone toward the ultimate goal of protein structure determination from imaging at room temperature and high temporal resolution. © 2019 The Authors

A Survey of z>5.7 Quasars in the Sloan Digital Sky Survey II: Discovery of Three Additional Quasars at z>6

We present the discovery of three new quasars at z>6 in 1300 deg^2 of SDSS imaging data, J114816.64+525150.3 (z=6.43), J104845.05+463718.3 (z=6.23) and J163033.90+401209.6 (z=6.05). The first two objects have weak Ly alpha emission lines; their redshifts are determined from the positions of the Lyman break. They are only accurate to 0.05 and could be affected by the presence of broad absorption line systems. The last object has a Ly alpha strength more typical of lower redshift quasars. Based on a sample of six quasars at z>5.7 that cover 2870 deg^2 presented in this paper and in Paper I, we estimate the comoving density of luminous quasars at z 6 and M_{1450} < -26.8 to be (8 +/- 3)x10^{-10} Mpc^{-3} (for H_0 = 50 km/s/Mpc, Omega = 1). HST imaging of two z>5.7 quasars and high-resolution ground-based images (seeing 0.4'') of three additional z>5.7 quasars show that none of them is gravitationally lensed. The luminosity distribution of the high-redshfit quasar sample suggests the bright end slope of the quasar luminosity function at z 6 is shallower than Psi L^{-3.5} (2-sigma), consistent with the absence of strongly lensed objects.Comment: AJ in press (Apr 2003), 26 pages, 9 figure

Is the SMART risk prediction model ready for real-world implementation?: A validation study in a routine care setting of approximately 380 000 individuals

AIMS: Reliably quantifying event rates in secondary prevention could aid clinical decision-making, including quantifying potential risk reductions of novel, and sometimes expensive, add-on therapies. We aimed to assess whether the SMART risk prediction model performs well in a real-world setting. METHODS AND RESULTS: We conducted a historical open cohort study using UK primary care data from the Clinical Practice Research Datalink (2000-2017) diagnosed with coronary, cerebrovascular, peripheral, and/or aortic atherosclerotic cardiovascular disease (ASCVD). Analyses were undertaken separately for cohorts with established (≥6 months) vs. newly diagnosed ASCVD. The outcome was first post-cohort entry occurrence of myocardial infarction, stroke, or cardiovascular death. Among the cohort with established ASCVD [n = 244 578, 62.1% male, median age 67.3 years, interquartile range (IQR) 59.2-74.0], the calibration and discrimination achieved by the SMART model was not dissimilar to performance at internal validation [Harrell's c-statistic = 0.639, 95% confidence interval (CI) 0.636-0.642, compared with 0.675, 0.642-0.708]. Decision curve analysis indicated that the model outperformed treat all and treat none strategies in the clinically relevant 20-60% predicted risk range. Consistent findings were observed in sensitivity analyses, including complete case analysis (n = 182 482; c = 0.624, 95% CI 0.620-0.627). Among the cohort with newly diagnosed ASCVD (n = 136 445; 61.0% male; median age 66.0 years, IQR 57.7-73.2), model performance was weaker with more exaggerated risk under-prediction and a c-statistic of 0.559, 95% CI 0.556-0.562. CONCLUSIONS: The performance of the SMART model in this validation cohort demonstrates its potential utility in routine healthcare settings in guiding both population and individual-level decision-making for secondary prevention patients