Evaluation of the prescribing decision support system Synonyms in primary care : a mixed-method study

Background Primary care prescribers must cope with an increasing number and complexity of considerations. To assist prescribers, prescribing decision support systems (DSS) have been developed. The Drug Synonyms function (“Synonyms”) is a DSS inherent in the electronic medical record system EMIS, which has been further developed by the NHSGGC Central Prescribing Team to promote safe and cost-effective prescribing. By entering a disease short code (e.g. AST for asthma), prescribers are presented with appropriate prescribing choices based on local/national guidelines and NHSGGC formulary recommendations for the identified condition. Synonyms is therefore an innovative method of ensuring consistent clinical and cost-efficient prescribing. As the functionality of Synonyms does not enable usage data to be collected, there is no current knowledge regarding the uptake or effect of Synonyms. A quantitative and qualitative analysis of Synonyms uptake and usage was undertaken to determine the impact Synonyms has on primary care prescribing; this will inform the continued maintenance and/or future development of this prescribing DSS. Aim To determine the uptake of Synonyms and explore prescribers’ perceptions of its usefulness. Design and setting An exploratory sequential mixed-method observational study using quantitative questionnaires, followed by semi-structured interviews with primary care prescribers across NHSGGC. Method An electronic questionnaire (Questionnaire 1) accessible across 218 GP practices ascertained the uptake of Synonyms. Questionnaire 2 and interviews established its usefulness. Interviews were audio-recorded, transcribed verbatim and analysed thematically. Results Questionnaire 1 was completed by 201 prescribers from 43.1% of GP practices surveyed: 186 (92.5%) prescribers were aware of Synonyms, of whom 163 (87.6%) had used it and 155 (83.3%) continue to use it. Questionnaire 2 was completed by 104 prescribers: 90 (86.5%) indicated that Synonyms informs or influences their choice of drug prescribed; 94 (90.4%) reported that Synonyms changed their prescribing choice towards medication on NHSGGC formulary and 104 (100%) reported that they trust Synonyms. Six interviews generated suggestions for improvements, mainly extending the disease short code list and making Synonyms more easily identifiable. Conclusion Most respondents were aware of and continued to use Synonyms. Respondents perceived Synonyms to influence prescribing choices towards NHSGGC formulary medicines and improve adherence to local prescribing guidelines. This suggests that Synonyms is instrumental in standardising the quality of prescribing care within NHSGGC. Potentially, the NHSGGC Synonyms function could be utilised by other health boards with supportive clinical systems; such collaboration could standardise the appropriateness and effectiveness of primary care prescribing throughout the NHS in Scotland

Evaluation of the prescribing decision support system synonyms in a primary care setting : a mixed-method study

Background: Primary care prescribers must cope with an increasing number and complexity of considerations. Prescribing decision support systems (DSS) have therefore been developed to assist prescribers. Previous studies have shown that although there is wide variance in the different DSS available within primary care, barriers and facilitators to uptake remain. The Drug Synonyms function (‘Synonyms’) is a DSS inherent in the commercial electronic medical record system EMIS. Synonyms functionality has been further developed by the NHS Greater Glasgow and Clyde (GG&C) Central Prescribing Team to promote safe and cost-effective prescribing; however, it does not support the collection of usage data. As there is no knowledge on the uptake nor on the perceived effect of using Synonyms on prescribing, quantitative and qualitative analyses of Synonyms usage are required to ascertain the impact Synonyms has on primary care prescribers, which will influence the continued maintenance and/or future development of this prescribing DSS. Aim: To determine the uptake of Synonyms and explore users’ perceptions of its usefulness and future development. Design and setting: An exploratory sequential mixed-method observational study using quantitative questionnaires, followed by semi-structured interviews with primary care prescribers within NHS GG&C. Method: An electronic questionnaire (Questionnaire 1) accessible across 218 EMIS-compliant NHS GG&C GP practices ascertained Synonyms uptake by determining whether prescribers were aware of the DSS, whether they were aware of it and whether they used it. Prescribers who were aware of and used Synonyms were asked to opt in to participating further. This involved answering a second electronic questionnaire (Questionnaire 2), with the option of taking part in an additional one-to-one interview, to investigate their use and perceptions of Synonyms. Results: Questionnaire 1 was completed by 201 respondents from 43.1% of eligible GP practices: 186 (92.5%) respondents were aware of Synonyms, of whom 163 (87.6%) had used it and 155 (83.3%) continued to use it. Questionnaire 2 was completed by 104 respondents: 90 (86.5%) indicated that Synonyms informed or influenced their choice of drug prescribed; 94 (90.4%) reported that Synonyms changed their prescribing choice towards medication on NHS GG&C formulary, and 104 (100%) reported that they trust Synonyms. Six interviews generated suggestions for improvements, mainly extending the clinical conditions listed. Conclusion: Most respondents were aware of and continued to use Synonyms. Respondents perceived Synonyms to influence prescribing choices towards local formulary medicines and improve adherence to local prescribing guidelines. Respondents trusted the DSS, but there is potential to increase awareness and training amongst non-users to encourage usage. Potentially, the NHS GG&C Synonyms function could be utilised by other health boards with supportive clinical systems

Expanding Access to Parasite-based Malaria Diagnosis through Retail Drug shops in Tanzania: Evidence from a Randomized Trial and Implications for Treatment.

Tanzania has seen a reduction in the fraction of fevers caused by malaria, likely due in part to scale-up of control measures. While national guidelines require parasite-based diagnosis prior to treatment, it is estimated that more than half of suspected malaria treatment-seeking in Tanzania initiates in the private retail sector, where diagnosis by malaria rapid diagnostic test (RDT) or microscopy is illegal. This pilot study investigated whether the introduction of RDTs into Accredited Drug Dispensing Outlets (ADDOs) under realistic market conditions would improve case management practices.\ud Dispensers from ADDOs in two intervention districts in Tanzania were trained to stock and perform RDTs and monitored quarterly. Each district was assigned a different recommended retail price to evaluate the need for a subsidy. Malaria RDT and artemisinin-based combination therapy (ACT) uptake and availability were measured pre-intervention and 1 year post-intervention through structured surveys of ADDO owners and exiting customers in both intervention districts and one contiguous control district. Descriptive analysis and logistic regression were used to compare the three districts and identify predictive variables for testing. A total of 310 dispensers from 262 ADDOs were trained to stock and perform RDTs. RDT availability in intervention ADDOs increased from 1% (n = 172) to 73% (n = 163) during the study; ACT medicines were available in 75% of 260 pre-intervention and 68% of 254 post-intervention ADDOs. Pre-treatment testing performed within the ADDO increased from 0 to 65% of suspected malaria patients who visited a shop (95% CI 60.8-69.6%) with no difference between intervention districts. Overall parasite-based diagnosis increased from 19 to 74% in intervention districts and from 3 to 18% in the control district. Prior knowledge of RDT availability (aOR = 1.9, p = 0.03) and RDT experience (aOR = 1.9, p = 0.01) were predictors for testing. Adherence data indicated that 75% of malaria positives received ACT, while 3% of negatives received ACT. Trained and supervised ADDO dispensers in rural Tanzania performed and sold RDTs under real market conditions to two-thirds of suspected malaria patients during this one-year pilot. These results support the hypothesis that introducing RDTs into regulated private retail sector settings can improve malaria testing and treatment practices without an RDT subsidy. Trial registration ISRCTN ISRCTN14115509

Growth and neurodevelopment in low birth weight versus normal birth weight infants from birth to 24 months, born in an obstetric emergency hospital in Haiti, a prospective cohort study

Background Low birthweight (LBW) infants are at higher risk of mortality and morbidity (growth, chronic disease and neurological problems) during their life. Due to the high incidence of (pre-) eclampsia in Haiti, LBW infants are common. We assessed the anthropometric growth (weight and length) and neurodevelopmental delay in LBW and normal birthweight (NBW) infants born at an obstetric emergency hospital in Port au Prince, Haiti, between 2014 and 2017. Methods Infants were followed at discharge and 3, 6, 12, 15, 18, 21 and 24 months of corrected gestational age. At each visit they underwent a physical checkup (weight, length, physical abnormalities, identification of morbidities). At 6, 12, 18 and 24 months they underwent a neurodevelopmental assessment using the Bayley Scale III (motor, cognitive and communication skills). We modelled the trajectories between birth and 24 months of age of NBW compared to LBW infants for weight, length, and raw scores for Bayley III assessments using mixed linear models. Results In total 500 LBW and 210 NBW infants were recruited of which 333 (46.7%) were followed up for 24 months (127 NBW; 60.5% and 206 LBW; 41.2%) and 150 died (LBW = 137 and NBW = 13). LBW and NBW babies gained a mean 15.8 g and 11.4 g per kg of weight from discharge per day respectively. The speed of weight gain decreased rapidly after 3 months in both groups. Both groups grow rapidly up to 6 months of age. LBW grew more than the NBW group during this period (22.8 cm vs. 21.1 cm). Both groups had WHZ scores <− 2 up to 15 months. At 24 months NBW babies scored significantly higher on the Bayley scales for gross motor, cognitive and receptive and expressive communication skills. There was no difference between the groups for fine motor skills. Conclusion LBW babies that survive neonatal care in urban Haiti and live up to 24 months of age, perform similar to their NBW for weight, length and fine motor skills. LBW babies are delayed in gross motor, cognitive and communication skills development. Further research on the clinical significance of these findings and long term implications of this neurodevelopmental delay is needed

Collaborative innovation, new technologies and work redesign

Stakeholders agree on the need to promote innovation in work organization in public services. This article deploys the concept of collaborative innovation to discuss employees’ and managers’ experiences of a major technology-driven work redesign project within National Health Service (NHS) pharmacy services in Scotland. We draw on extant literature on New Public Management (NPM) and collaborative approaches to innovation to frame more than 40 in-depth interviews with managers and employees. We find that key components of collaborative innovation – related to joint problem-solving, inter-disciplinary working and mutual learning – were important to the success of the redesign project and to positive impacts on job quality for some employees. We argue that researchers and policymakers should look beyond NPM-driven models that have dominated some areas of the public innovation literature, to consider the potential added value of collaborative innovation to improving both work and service delivery in the public sector

Positive Selection Differs between Protein Secondary Structure Elements in Drosophila

Different protein secondary structure elements have different physicochemical properties and roles in the protein, which may determine their evolutionary flexibility. However, it is not clear to what extent protein structure affects the way Darwinian selection acts at the amino acid level. Using phylogeny-based likelihood tests for positive selection, we have examined the relationship between protein secondary structure and selection across six species of Drosophila. We find that amino acids that form disordered regions, such as random coils, are far more likely to be under positive selection than expected from their proportion in the proteins, and residues in helices and β-structures are subject to less positive selection than predicted. In addition, it appears that sites undergoing positive selection are more likely than expected to occur close to one another in the protein sequence. Finally, on a genome-wide scale, we have determined that positively selected sites are found more frequently toward the gene ends. Our results demonstrate that protein structures with a greater degree of organization and strong hydrophobicity, represented here as helices and β-structures, are less tolerant to molecular adaptation than disordered, hydrophilic regions, across a diverse set of proteins

Resilient Pedagogy: Practical Teaching Strategies to Overcome Distance, Disruption, and Distraction

Resilient Pedagogy offers a comprehensive collection on the topics and issues surrounding resilient pedagogy framed in the context of the COVID-19 pandemic and the social justice movements that have swept the globe. As a collection, Resilient Pedagogy is a multi-disciplinary and multi-perspective response to actions taken in different classrooms, across different institution types, and from individuals in different institutional roles with the purpose of allowing readers to explore the topics to improve their own teaching practice and support their own students through distance, disruption, and distraction

Factors affecting general practice collaboration with voluntary and community sector organisations.

Collaborative working between general practice (GP) and voluntary and community sector (VCS) organisations is increasingly championed as a means of primary care doing more with less and of addressing patients' "wicked problems". This paper aims to add to the knowledge base around collaborative practice between GPs and VCS organisations by examining the factors that aid or inhibit such collaboration. A case study design was used to examine the lived-experience of GPs and VCS organisations working collaboratively. Four cases, each consisting of a GP and a VCS organisation with whom they work collaboratively, were identified. Interviews (n = 18) and a focus group (n = 1) were conducted with staff within each organisation. Transcribed data were analysed thematically. Whilet there are similarities across cases in their use of, for example, Health Trainers and social prescribing, the form and function of GP-VCS collaborations were unique to their local context. The identified factors affecting GP-VCS collaboration reflect those found in previous service evaluations and the broader literature on partnership working; shared understanding, time and resources, trust, strong leadership, operational systems and governance and the "negotiation" of professional boundaries. While the current political environment may represent an opportunity for collaborations to develop, there are issues yet to be resolved before collaboration-especially more holistic and integrated approaches-becomes systematically embedded into practice

Productivity of Malaria Vectors from Different Habitat Types in the Western Kenya Highlands

BACKGROUND: Mosquito Larval Source Management (LSM) could be a valuable additional tool for integrated malaria vector control especially in areas with focal transmission like the highlands of western Kenya if it were not for the need to target all potential habitats at frequent intervals. The ability to determine the productivity of malaria vectors from identified habitats might be used to target LSM only at productive ones. METHODS: Each aquatic habitat within three highland sites in western Kenya was classified as natural swamp, cultivated swamp, river fringe, puddle, open drain or burrow pit. Three habitats of each type were selected in each site in order to study the weekly productivity of adult malaria vectors from February to May 2009 using a sweep-net and their habitat characteristics recorded. RESULTS: All surveyed habitat types produced adult malaria vectors. Mean adult productivity of Anopheles gambiae sensu lato in puddles (1.8/m(2)) was 11-900 times higher than in the other habitat types. However, puddles were the most unstable habitats having water at 43% of all sampling occasions and accounted for 5% of all habitats mapped in the study areas whereas open drains accounted for 72%. Densities of anopheline late instars larvae significantly increased with the presence of a biofilm but decreased with increasing surface area or when water was flowing. Taking stability and frequency of the habitat into account, puddles were still the most productive habitat types for malaria vectors but closely followed by open drains. CONCLUSION: Even though productivity of An. gambiae s.l. was greatest in small and unstable habitats, estimation of their overall productivity in an area needs to consider the more stable habitats over time and their surface extension. Therefore, targeting only the highly productive habitats is unlikely to provide sufficient reduction in malaria vector densities