Factors associated with non-response in routine use of patient reported outcome measures after elective surgery in England

BACKGROUND: Patient-reported outcome measures are increasingly being used to compare providers. We studied whether non-response rates to post-operative questionnaires are associated with patients' characteristics and organisational features of providers. METHODS: 131,447 patients who underwent a hip or knee replacement, hernia repair or varicose vein surgery in 2009-10 in England. Multivariable logistic regression to calculate adjusted odds ratios of non-response for characteristics of the patients and organisational characteristics of providers. Multiple imputation was used for missing patient characteristics. Providers were included as random effects. RESULTS: Response rates to the post-operative questionnaire were 85.1% for hip replacement (n = 37 961), 85.3% for knee replacements (n = 44 422), 72.9% for hernia repair (n = 34 964), and 64.8% for varicose vein surgery (n = 14 100). Across the four procedures, there were higher levels of non-response in men (odds ratios 1.03 [95% CI 0.95-1.11] - 1.35 [1.25-1.46]), younger patients (those under 55 years 3.01 [2.72-3.32] - 6.05 [5.49-6.67]), non-white patients (1.24 [1.11-1.38] - 2.08 [1.89-2.31]), patients in the most deprived quintile of socio-economic status (1.47 [1.34-1,62] - 1.86 [1.71-2.03]), those who lived alone (1.11 [0.99-1.23] - 1.27 [1.18-1.36]) and those who had been assisted when completing their pre-operative questionnaire (1.26 [1.10-1.46] -1.67 [1.56-1.79]). Non-response rates were also higher in patients who had poorer pre-operative health (three or more comorbidities: 1.14 [0.96-1.35] - 1.45 [1.30-1.63]). Providers' patient recruitment rates before surgery and the timing of pre-operative questionnaire administration did not affect the rates of response to post-operative questionnaires. CONCLUSION: If non-response can be shown to be associated with outcome, then rates of non-response to post-operative questionnaires would need to be taken into account when these measures are being used to compare the performance of providers or to evaluate surgical procedures

Relationship between patient reported experience (PREMs) and patient reported outcomes (PROMs) in elective surgery.

OBJECTIVE: Our aim was to see if the reporting of better experiences by elective surgical patients was associated with better outcomes (effectiveness and safety). The objectives were to: describe the distribution of experience scores and any association with patients' characteristics; determine the relationship of experience with effectiveness and with safety; and explore the influence of patient characteristics, year and provider on the relationship between experience and effectiveness. METHODS: Patients undergoing one of three procedures from 2010 to 2012 in England who completed a patient reported outcome measure (PROM) questionnaire before and after surgery and a patient reported experience measure (PREM) questionnaire. Data on 4089 hip replacement patients, 4501 knee replacements and 1793 groin hernia repairs. Regression analysis was used to examine associations between disease-specific and generic PROMs and PREMs. RESULTS: There was a weak positive association between experience and effectiveness for all three procedures (correlation coefficient with disease-specific PROMs for hip and knee replacements 0.2 and with EQ-5D 0.1 for all three procedures). The aspect of experience most strongly associated with a better outcome was the level of communication with and trust in their doctor. A higher experience score of 1 SD (about 1.5 on a 10-point scale) was associated with about 30% less likelihood of the patient reporting a complication. There was no difference between the eight dimensions of experience. All the relationships observed were consistent over time, between different types of patients (age, sex, socioeconomic status) and between providers. CONCLUSIONS: Patients distinguish between the three domains of quality when reporting their experience and outcome. If the weak positive associations between domains were shown to be causal, there would be implications for maximising performance measures for providers

Differentiated, promoter-specific response of [4Fe-4S] NsrR DNA-binding to reaction with nitric oxide

NsrR is an iron-sulfur cluster protein that regulates the nitric oxide (NO) stress response of many bacteria. NsrR from Streptomyces coelicolor regulates its own expression and that of only two other genes, hmpA1 and hmpA2, which encode HmpA enzymes predicted to detoxify NO. NsrR binds promoter DNA with high affinity only when coordinating a [4Fe-4S] cluster. Here we show that reaction of [4Fe-4S] NsrR with NO affects DNA-binding differently depending on the gene promoter. Binding to the hmpA2 promoter was abolished at ~2 NO per cluster, while for the hmpA1 and nsrR promoters, ~4 and ~8 NO molecules, respectively, were required to abolish DNA binding. Spectroscopic and kinetic studies of the NO reaction revealed a rapid, multi-phase, non-concerted process involving up to 8 – 10 NO molecules per cluster, leading to the formation of several iron-nitrosyl species. A distinct intermediate was observed at ~2 NO per cluster, along with two further intermediates at ~4 and ~6 NO. The NsrR nitrosylation reaction was not significantly affected by DNA-binding. These results show that NsrR regulates different promoters in response to different concentrations of NO. Spectroscopic evidence indicates that this is achieved by different NO-FeS complexes

Do patient-reported outcomes offer a more sensitive method for comparing the outcomes of consultants than mortality? A multilevel analysis of routine data.

BACKGROUND: Patient-reported outcome measures (PROM) might be better for comparing consultant surgeons' outcomes than mortality. OBJECTIVES: To describe variation in outcomes between consultants, compare the number of outlying consultants according to different measures, explore the effect that the hospital in which a consultant works has on their outcomes and determine the scope for improving outcomes by reducing variation between consultants. METHOD: Consultants performing hip replacement (n=948), knee replacement (1130) and hernia repair (974) in National Health Service hospitals in England in 2009-2012; disease-specific and generic PROMs and complications; fixed-effects and multilevel models to assess consultant outcomes, were all compared. Influence of patient factors and hospital factors was assessed. RESULTS: Fixed-effects models showed that most consultants are 'as or better than expected'. However, unlike with mortality, some consultants are more than three SDs 'worse than expected' according to disease-specific PROMs (2.4% for hip and 1.2% for knee replacement), generic PROMs (1.2% and 1.0%) and incidence of complications (1.8% and 0.8%). The proportion of consultants worse than expected is less with random-effects models. Controlling for hospital factors reduced the proportion further. After controlling for known patient characteristics, consultants and hospitals contribute little towards variation in patient outcomes. CONCLUSIONS: PROMs offer a more appropriate and sensitive method for comparing consultants' outcomes. The influence of hospitals must be considered to ensure comparisons are meaningful. Improvements will be achieved by shifting the distribution of consultants rather than by reducing variation between them

NMR analysis of Nile Blue (C. I. Basic Blue 12) and Thionine (C. I. 52000) in solution

The dyes Nile Blue (C. I. Basic Blue 12, NB) and Thionine (C. I. 52000, TH) were examined in both ionic and neutral forms in different solvents using NMR and UV-visible Spectroscopy to firmly establish the structures of the molecules and to assess the nature and extent of their aggregating characteristics. 1H and 13C NMR assignments and chemical shift data were used along with (for NB) nuclear Overhauser effect information enabling a structure for self-assembly to be proposed. In both cases these data were supplemented with variable temperature, dilution and diffusion-based experimental results using 1H NMR spectroscopy thereby enabling the extended aggregate structures to be assessed in terms of the relative strength of self-association and the extent to which extended aggregates could form. Full and detailed solution phase NMR analysis of such dyes, especially the two studied in this context, have either not been widely reported or have not been studied to the depth presented here. The data and their interpretation form an important addition to the analysis of this class of dye compounds and provide additional insight into the effects of self-assembly on the behaviour of such molecules in various solution-phase environments

Retrieval cues fail to influence contextualized evaluations.

Initial evaluations generalise to new contexts, whereas counter-attitudinal evaluations are context-specific. Counter-attitudinal information may not change evaluations in new contexts because perceivers fail to retrieve counter-attitudinal cue-evaluation associations from memory outside the counter-attitudinal learning context. The current work examines whether an additional, counter-attitudinal retrieval cue can enhance the generalizability of counter-attitudinal evaluations. In four experiments, participants learned positive information about a target person, Bob, in one context, and then learned negative information about Bob in a different context. While learning the negative information, participants wore a wristband as a retrieval cue for counter-attitudinal Bob-negative associations. Participants then made speeded as well as deliberate evaluations of Bob while wearing or not wearing the wristband. Internal meta-analysis failed to find a reliable effect of the counter-attitudinal retrieval cue on speeded or deliberate evaluations, whereas the context cues influenced speeded and deliberate evaluations. Counter to predictions, counter-attitudinal retrieval cues did not disrupt the generalisation of first-learned evaluations or the context-specificity of second-learned evaluations (Experiments 2-4), but the counter-attitudinal retrieval cue did influence evaluations in the absence of context cues (Experiment 1). The current work provides initial evidence that additional counter-attitudinal retrieval cues fail to disrupt the renewal and generalizability of first-learned evaluations

Optimized magneto-optical isolator designs inspired by seedlayer-free terbium iron garnets with opposite chirality

Simulations demonstrate that undoped yttrium iron garnet (YIG) seedlayers cause reduced Faraday rotation in silicon-on-insulator (SOI) waveguides with Ce-doped YIG claddings. Undoped seedlayers are required for the crystallization of the magneto-optical Ce:YIG claddings, but they diminish the interaction of the Ce:YIG with the guided modes. Therefore new magneto-optical garnets, terbium iron garnet (TIG) and bismuth-doped TIG (Bi:TIG), are introduced that can be integrated directly on Si and quartz substrates without seedlayers. The Faraday rotations of TIG and Bi:TIG films at 1550nm were measured to be +500 and -500°/cm, respectively. Simulations show that these new garnets have the potential to significantly mitigate the negative impact of the seedlayers under Ce:YIG claddings. The successful growth of TIG and Bi:TIG on low-index fused quartz inspired novel garnet-core waveguide isolator designs, simulated using finite difference time domain (FDTD) methods. These designs use alternating segments of positive and negative Faraday rotation for push-pull quasi phase matching in order to overcome birefringence in waveguides with rectangular cross-sections

Estimating recruitment rates for routine use of patient reported outcome measures and the impact on provider comparisons.

BACKGROUND: The routine use of patient reported outcome measures (PROMs) aims to compare providers as regards the clinical need of their patients and their outcome. Simple methods of estimating recruitment rates based on aggregated data may be inaccurate. Our objectives were to: use patient-level linked data to evaluate these estimates; produce revised estimates of national and providers' recruitment rates; and explore whether or not recruitment bias exists. METHODS: Case study based on patients who were eligible to participate in the English National PROMs Programme for elective surgery (hip and knee replacement, groin hernia repair, varicose vein surgery) using data from pre-operative questionnaires and Hospital Episode Statistics. Data were linked to determine: the eligibility for including operations; eligibility of date of surgery; duplicate questionnaires; cancelled operations; correct assignment to provider. Influence of patient characteristics on recruitment rates were investigated. RESULTS: National recruitment rates based on aggregated data over-estimated the true rate because of the inclusion of ineligible operations (from 1.9% - 7.0% depending on operation) and operations being cancelled (1.9% - 3.6%). Estimates of national recruitment rates using inclusion criteria based on patient-level linked data were lower than those based on simple methods (eg hip replacement was 73% rather than 78%).Estimates of provider's recruitment rates based on aggregated data were also adversely affected by attributing patients to the wrong provider (2.4% - 4.9%). Use of linked data eliminated all estimates of over 100% recruitment, though providers still showed a wide range of rates.While the principal determinant of recruitment rates was the provider, some patients' socio-demographic characteristics had an influence on non-recruitment: non-white (Adjusted Odds Ratio 1.25-1.67, depending on operation); most deprived socio-economic group (OR 1.11-1.23); aged over 75 years (OR 1.28-1.79). However, there was no statistically significant association between providers' recruitment rates and patients' pre-operative clinical need. CONCLUSIONS: Accurate recruitment rates require the use of linked data to establish consistent inclusion criteria for numerators and denominators. Non-recruitment will bias comparisons of providers' pre-operative case-mix and may bias comparisons of outcomes if unmeasured confounders are not evenly distributed between providers. It is important, therefore, to strive for high recruitment rates

Quasi-phase-matched Faraday rotation in semiconductor waveguides with a magnetooptic cladding for monolithically integrated optical isolators

Strategies are developed for obtaining nonreciprocal polarization mode conversion, also known as Faraday rotation, in waveguides in a format consistent with silicon-on-insulator or III–V semiconductor photonic integrated circuits. Fabrication techniques are developed using liftoff lithography and sputtering to obtain garnet segments as upper claddings, which have an evanescent wave interaction with the guided light. A mode solver approach is used to determine the modal Stokes parameters for such structures, and design considerations indicate that quasi-phase-matched Faraday rotation for optical isolator applications could be obtained with devices on the millimeter length scale

Challenges to implementing the national programme for information technology (NPfIT): a qualitative study.

OBJECTIVES: To describe the context for implementing the national programme for information technology (NPfIT) in England, actual and perceived barriers, and opportunities to facilitate implementation. DESIGN: Case studies and in depth interviews, with themes identified using a framework developed from grounded theory. SETTING: Four acute NHS trusts in England. PARTICIPANTS: Senior trust managers and clinicians, including chief executives, directors of information technology, medical directors, and directors of nursing. RESULTS: The trusts varied in their circumstances, which may affect their ability to implement the NPfIT. The process of implementation has been suboptimal, leading to reports of low morale by the NHS staff responsible for implementation. The overall timetable is unrealistic, and trusts are uncertain about their implementation schedules. Short term benefits alone are unlikely to persuade NHS staff to adopt the national programme enthusiastically, and some may experience a loss of electronic functionality in the short term. CONCLUSIONS: The sociocultural challenges to implementing the NPfIT are as daunting as the technical and logistical ones. Senior NHS staff feel these have been neglected. We recommend that national programme managers prioritise strategies to improve communication with, and to gain the cooperation of, front line staff