Quality improvement at scale: evaluation of the drivers and barriers to adoption and sustainability of an intervention to reduce late referral in chronic kidney disease

This quality improvement project aimed to drive large-scale and sustained change to reduce the burden of chronic kidney disease in the UK. The intervention is a software programme that extracts relevant biochemical data from laboratory databases which then generate graphs of estimated kidney function (eGFR) over time. Graphs showing progressive kidney disease are sent directly back to GPs to alert them to re-review patient care and if necessary, refer to renal services. The aim of this evaluation study was to explain the barriers and drivers to implementation and adoption of the eGFR graph intervention. This evaluation study involved five of the 20 renal units (sites) involved. A Developmental Evaluation approach was utilised. Methods included collection of descriptive data about graph reporting; GP surveys (n=68); focus groups (n=4) with Practices; face-to-face interviews with secondary care clinicians (n=10). Results showed the mean number of graphs reviewed per week per site was 230, taking one hour per week per site. Only 18.2 % graphs highlighted a concerning decline in kidney function. Important enablers to sustain the intervention were low cost, easy to understand, a sense of local ownership and perceived impact. Barriers included nephrologists’ perceived increase in new referrals. We concluded that developmental evaluation can explain the barriers/drivers to implementation of a national quality improvement project that involves a variety of different stakeholders. The intervention has the potential to slow down progression of kidney disease due to the eGFR prompts alerting GPs to review the patient record and take action, such as reviewing medications and referring to renal teams if progressive kidney disease had not been identified previously

A stepped wedge cluster randomized trial of graphical surveillance of kidney function data to reduce late presentation for kidney replacement therapy.

Late presentation for kidney replacement therapy (KRT) is an important cause of avoidable morbidity and mortality. Here, we evaluated the effect of a complex intervention of graphical estimated glomerular filtration rate (eGFR) surveillance across 15% of the United Kingdom population on the rate of late presentation using data routinely collected by the United Kingdom Renal Registry. A stepped wedge cluster randomized trial was established across 19 sites with eGFR graphs generated from all routine blood tests (community and hospital) across the population served by each site. Graphs were reviewed by trained laboratory or clinical staff and high-risk graphs reported to family doctors. Due to delays outside the control of clinicians and researchers few laboratories activated the intervention in their randomly assigned time period, so the trial was converted to a quasi-experimental design. We studied 6,100 kidney failure events at 20 laboratories served by 17 main kidney units. A total of 63,981 graphs were sent out. After adjustment for calendar time there was no significant reduction in the rate of presentation during the intervention period. Therefore, implementation of eGFR graph surveillance did not reduce the rate of late presentation for KRT after adjustment for secular trends. Thus, graphical surveillance is an intervention aimed at reducing late presentation, but more evidence is required before adoption of this strategy can be recommended. [Abstract copyright: Copyright © 2024. Published by Elsevier Inc.

The representation of the West-African Monsoon vertical cloud structure in the Met Office Unified Model: an evaluation with CloudSat

Weather and climate model simulations of the West African Monsoon (WAM) have generally poor representation of the rainfall distribution and monsoon circulation because key processes, such as clouds and convection, are poorly characterized. The vertical distribution of cloud and precipitation during the WAM are evaluated in Met Office Unified Model simulations against CloudSat observations. Simulations were run at 40-km and 12-km horizontal grid length using a convection parameterization scheme and at 12-km, 4-km, and 1.5-km grid length with the convection scheme effectively switched off, to study the impact of model resolution and convection parameterization scheme on the organisation of tropical convection. Radar reflectivity is forward-modelled from the model cloud fields using the CloudSat simulator to present a like-with-like comparison with the CloudSat radar observations. The representation of cloud and precipitation at 12-km horizontal grid length improves dramatically when the convection parameterization is switched off, primarily because of a reduction in daytime (moist) convection. Further improvement is obtained when reducing model grid length to 4 km or 1.5 km, especially in the representation of thin anvil and mid-level cloud, but three issues remain in all model configurations. Firstly, all simulations underestimate the fraction of anvils with cloud top height above 12 km, which can be attributed to too low ice water contents in the model compared to satellite retrievals. Secondly, the model consistently detrains mid-level cloud too close to the freezing level, compared to higher altitudes in CloudSat observations. Finally, there is too much low-level cloud cover in all simulations and this bias was not improved when adjusting the rainfall parameters in the microphysics scheme. To improve model simulations of the WAM, more detailed and in-situ observations of the dynamics and microphysics targeting these non-precipitating cloud types are required

Validity and worth in the science curriculum: learning school science outside the laboratory

It is widely acknowledged that there are problems with school science in many developed countries of the world. Such problems manifest themselves in a progressive decline in pupil enthusiasm for school science across the secondary age range and the fact that fewer students are choosing to study the physical sciences at higher levels and as careers. Responses to these developments have included proposals to reform the curriculum, pedagogy and the nature of pupil discussion in science lessons. We support such changes but argue from a consideration of the aims of science education that secondary school science is too rooted in the science laboratory; substantially greater use needs to be made of out-of-school sites for the teaching of science. Such usage should result in a school science education that is more valid and more motivating and is better at fulfilling defensible aims of school science education. Our contention is that laboratory-based school science teaching needs to be complemented by out-of-school science learning that draws on the actual world (e.g. through fieldtrips), the presented world (e.g. in science centres, botanic gardens, zoos and science museums) and the virtual worlds that are increasingly available through information and communications technologies (ICT)

Virtual reality, ultrasound-guided liver biopsy simulator: Development and performance discrimination

Objectives: The aim of this article was to identify and prospectively investigate simulated ultrasound-guided targeted liver biopsy performance metrics as differentiators between levels of expertise in interventional radiology. Methods: Task analysis produced detailed procedural step documentation allowing identification of critical procedure steps and performance metrics for use in a virtual reality ultrasound-guided targeted liver biopsy procedure. Consultant (n=14; male=11, female=3) and trainee (n=26; male=19, female=7) scores on the performance metrics were compared. Ethical approval was granted by the Liverpool Research Ethics Committee (UK). Independent t-tests and analysis of variance (ANOVA) investigated differences between groups. Results: Independent t-tests revealed significant differences between trainees and consultants on three performance metrics: targeting, p=0.018, t=22.487 (22.040 to 20.207); probe usage time, p=0.040, t=2.132 (11.064 to 427.983); mean needle length in beam, p=0.029, t=22.272 (20.028 to 20.002). ANOVA reported significant differences across years of experience (0–1, 1–2, 3+ years) on seven performance metrics: no-go area touched, p=0.012; targeting, p=0.025; length of session, p=0.024; probe usage time, p=0.025; total needle distance moved, p=0.038; number of skin contacts, p<0.001; total time in no-go area, p=0.008. More experienced participants consistently received better performance scores on all 19 performance metrics. Conclusion: It is possible to measure and monitor performance using simulation, with performance metrics providing feedback on skill level and differentiating levels of expertise. However, a transfer of training study is required

Representation of the Scandinavia-Greenland pattern and its relationship with the polar vortex in S2S forecast models

The strength of the stratospheric polar vortex is a key contributor to subseasonal prediction during boreal winter. Anomalously weak polar vortex events can be induced by enhanced vertically propagating Rossby waves from the troposphere, driven by blocking and wave breaking. Here, we analyse a tropospheric pattern – the Scandinavia-Greenland (S-G) pattern – associated with both processes. The S-G pattern is defined as the second empirical orthogonal function (EOF) of mean sea-level pressure in the northeast Atlantic. The first EOF is a zonal pattern resembling the North Atlantic Oscillation. We show that the S-G pattern is associated with a transient amplification of planetary wavenumber2 and meridional eddy heat flux, followed by the onset of a weakened polar vortex which persists for the next 2 months. We then analyse 10 different models from the S2S database, finding that while all models represent the structure of the S-G pattern well, some models have a zonal bias with more than the observed variability in their first EOF, and accordingly less in their second EOF. This bias is largest in models with the lowest resolution. Skill in predicting the S-G pattern is not high beyond week 2 in any model, in contrast to the zonal pattern. We find that the relationship between the S-G pattern and enhanced eddy heat flux and a weakened polar vortex is initially well-represented but significantly decays with lead time in most S2S models. Our results motivate improved representation of the S-G pattern and its stratospheric response at longer lead-times for improved subseasonal prediction of the stratospheric polar vortex

The sub-seasonal to seasonal prediction (S2S) project database

A database containing sub-seasonal to seasonal forecasts from 11 operational centres is available to the research community and will help advance our understanding of the sub-seasonal to seasonal time range. Demands are growing rapidly in the operational prediction and applications communities for forecasts that fill the gap between medium-range weather and long-range or seasonal forecasts. Based on the potential for improved forecast skill at the sub-seasonal to seasonal time range, a sub-seasonal prediction (S2S) research project has been established by the World Weather Research Program/World Climate Research Program. A main deliverable of this project is the establishment of an extensive database, containing sub-seasonal (up to 60 days) forecasts, 3-weeks behind real-time, and reforecasts from 11 operational centers, modelled in part on the THORPEX Interactive Grand Global Ensemble (TIGGE) database for medium range forecasts (up to 15 days). The S2S database, available to the research community since May 2015, represents an important tool to advance our understanding of the sub-seasonal to seasonal time range that has been considered for a long time as a “desert of predictability”. In particular, this database will help identify common successes and shortcomings in the model simulation and prediction of sources of sub-seasonal to seasonal predictability. For instance, a preliminary study suggests that the S2S models underestimate significantly the amplitude of the Madden Julian Oscillation (MJO) teleconnections over the Euro-Atlantic sector. The S2S database represents also an important tool for case studies of extreme events. For instance, a multi-model combination of S2S models displays higher probability of a landfall over Vanuatu islands 2 to 3 weeks before tropical cyclone Pam devastated the islands in March 2015

Unintended learning in primary school practical science lessons from Polanyi’s perspective of intellectual passion

This study explored, from the perspective of intellectual passion developed by Michael Polanyi, the unintended learning that occurred in primary practical science lessons. We use the term ‘unintended’ learning to distinguish it from ‘intended’ learning that appears in teachers’ learning objectives. Data were collected using video and audio recordings of a sample of twenty-four whole class practical science lessons, taught by five teachers, in Korean primary schools with 10- to 12-year-old students. In addition, video and audio recordings were made for each small group of students working together in order to capture their activities and intra-group discourse. Pre-lesson interviews with the teachers were undertaken and audio-recorded to ascertain their intended learning objectives. Selected key vignettes, including unintended learning, were analysed from the perspective of intellectual passion developed by Polanyi. What we found in this study is that unintended learning could occur when students got interested in something in the first place and could maintain their interest. In addition, students could get conceptual knowledge when they tried to connect their experience to their related prior knowledge. It was also found that the processes of intended learning and of unintended learning were different. Intended learning was characterized by having been planned by the teacher who then sought to generate students’ interest in it. In contrast, unintended learning originated from students’ spontaneous interest and curiosity as a result of unplanned opportunities. Whilst teachers’ persuasive passion comes first in the process of intended learning, students’ heuristic passion comes first in the process of unintended learning. Based on these findings, we argue that teachers need to be more aware that unintended learning, on the part of individual students, can occur during their lesson and to be able to better use this opportunity so that this unintended learning can be shared by the whole class. Furthermore, we argue that teachers’ deliberate action and a more interactive classroom culture are necessary in order to allow students to develop, in addition to heuristic passion, persuasive passion towards their unintended learning

Does it look safe? An eye tracking study into the visual aspects of fear of crime

Studies of fear of crime often focus on demographic and social factors, but these can be difficult to change. Studies of visual aspects have suggested that features reflecting incivilities, such as litter, graffiti, and vandalism increase fear of crime, but methods often rely on participants actively mentioning such aspects, and more subtle, less conscious aspects may be overlooked. To address these concerns, the present study examined people’s eye movements while they judged scenes for safety. Forty current and former university students were asked to rate images of day-time and night-time scenes of Lincoln, UK (where they studied) and Egham, UK (unfamiliar location) for safety, maintenance and familiarity, while their eye movements were recorded. Another twenty-five observers not from Lincoln or Egham rated the same images in an internet survey. Ratings showed a strong association between safety and maintenance and lower safety ratings for night-time scenes for both groups, in agreement with earlier findings. Eye movements of the Lincoln participants showed increased dwell times on buildings, houses, and vehicles during safety judgments, and increased dwell times on streets, pavements, and markers of incivilities for maintenance. Results confirm that maintenance plays an important role in perceptions of safety, but eye movements suggest that observers also look for indicators of current or recent presence of people