Accountability by Design: Moving Primary Care Reform Ahead in Alberta

Health-care reform is perennially popular in Alberta, but reality doesn’t match the rhetoric. Government has invested more than $700 million in Primary Care Networks — with little beyond anecdotal evidence of the value achieved with this investment. As the province redirects primary care to Family Care Clinics, the authors assert that simply tinkering with one part of the system is not the answer: health care must change on a system-wide basis. Drawing on the experiences of frontline staff and a rich body of literature, the authors present their vision for integrated team-based primary care, designed to be accountable to meet the needs of populations. This will require governance that makes primary care the hub of the system, and brings together government and health-services leadership to support the integration of primary and specialty care. There are shared accountabilities for achieving primary care that exhibits the attributes of high performing primary care systems, and these exist at multiple levels, from individuals seeking primary care, up to and including government. The authors make these accountabilities explicit, and outline strategies to secure their achievement that include system redesign, service delivery redesign and payment reform. All of this demands whole-system reform focused on primary care, and it won’t be easy. There are plenty of vested interests at stake, and a truly transformative vision requires buy-in at every level. However, Alberta’s rapidly growing and aging population makes it more urgent than ever to realize such a vision. This paper offers guidelines to spark the fresh thinking required

Online reflections : a constructivist tool?

vii, 74 leaves ; 29 cm. --The purpose of this study was to determine whether or not online reflections are effective in facilitating student learning, as measured by achievement on unit exams and instructional planning as reported by the instructor. This study followed an altematingtreatments design. The achievement of 22 students randomly divided into two groups of 11 students each (Group 1 and Group 2) was compared. The first group of students followed an A-B-A-B design and the second group of students from the same Biology class followed a B-A-B-A design. A refers to the condition where students completed higher order online reflections and B refers to the lower order word search condition. The word search condition in this study serves as a proxy control condition in this study. Achievement on unit exams was determined and compared for each student under treatment condition A and treatment condition B. Correlations between the average length of students' responses, the number of reflections and word searches completed and students' final marks were conducted to identify the degree of association between these variables. 5-10 minutes of class time was provided to students to complete their online reflections or word searches. Analysis of variance was used to compare the effect completing online reflections and word searches had on student achievement as measured by unit-exams marks. No significant differences in achievement were found between the two conditions. The number and average length of online reflections were positively and significantly correlated with a student's final mark (Pearson correlation = 0.556, .Q = 0.007; 0.463, .Q = 0.03). 50% (10/20) of students felt that online reflections helped them study. 45% (9/20) felt that they clarified their understanding of scientific concepts. Students identified the following benefits of online reflections: it helps you remember, improves understanding and helps you think. The most common suggestion made by students for improvement was to change the questions with each lesson so that they were more relevant. The instructor felt the questions asked by students in the online reflections were important as they provided insight into what students know and don't know. As a result of online reflections the instructor now incorporates regular and in depth reviews into his teaching. According to the instructor online reflections helped him and his class meet 8 technology outcomes (i.e. Students will compose, revise and edit text). Future studies should control for the Hawthorne effect by changing the reflection questions on a daily basis and control for the different academic abilities of students

CMOS ring oscillator delay cell performance: a comparative study

A common voltage-controlled oscillator (VCO) architecture used in the phase locked loop (PLL) is the ring oscillator (RO). RO consist of number of inverters cascaded together as the input of the first stage connected to the output of the last stage. It is important to design the RO to be work at desired frequency depend on application with low power consumption. This paper presents a review the performance evaluation of different delay cell topologies the implemented in the ring oscillator. The various topologies analyzed includes current starved delay cell, differential delay cell and current follower cell. Performance evaluation includes frequency range, frequency stability, phase noise and power consumption had been reviewed and comparison of different topologies has been discussed. It is observed that starved current delay cell have lower power consumption and the different of the frequency range is small as compared to other type of delay cell

Preparation of catalysts based on iron(III) porphyrins heterogenized on silica obtained by the Sol-Gel process for hydroxylation and epoxidation reactions

Solid catalysts have been prepared by chemical interaction of iron(III) porphyrins with the surface of the pores of a silica matrix obtained by the sol-gel method. The presence of the complexes in the silica matrix and the morphology of the obtained particles were studied by UV-Vis spectroscopy, powder X-ray diffractometry, infrared spectroscopy, transmission electron microscopy, electron paramagnetic resonance and thermogravimetric analysis. The catalytic activity of the immobilized iron(III) porphyrins in the oxidation of (Z)-cyclooctene, cyclohexene and cyclohexane was evaluated in dichloromethane/acetonitrile 1:1 solvent mixture (v/v) using iodosylbenzene as oxidant. Results were compared with those achieved with the homogeneous counterparts

Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries

Context: A key aim of reforms to primary health care (PHC) in many countries has been to enhance interprofessional teamwork. However, the impact of these changes on practitioners has not been well understood.Objective: To assess the impact of reform policies and interventions that have aimed to create or enhance teamwork on professional communication relationships, roles, and work satisfaction in PHC practices.Design: Collaborative synthesis of 12 mixed methods studies.Setting: Primary care practices undergoing transformational change in three countries: Australia, Canada, and the USA, including three Canadian provinces (Alberta, Ontario, and Quebec).Methods: We conducted a synthesis and secondary analysis of 12 qualitative and quantitative studies conducted by the authors in order to understand the impacts and how they were influenced by local context.Results: There was a diverse range of complex reforms seeking to foster interprofessional teamwork in the care of patients with chronic disease. The impact on communication and relationships between different professional groups, the roles of nursing and allied health services, and the expressed satisfaction of PHC providers with their work varied more within than between jurisdictions. These variations were associated with local contextual factors such as the size, power dynamics, leadership, and physical environment of the practice. Unintended consequences included deterioration of the work satisfaction of some team members and conflict between medical and nonmedical professional groups.Conclusion: The variation in impacts can be understood to have arisen from the complexity of interprofessional dynamics at the practice level. The same characteristic could have both positive and negative influence on different aspects (eg, larger practice may have less capacity for adoption but more capacity to support interprofessional practice). Thus, the impacts are not entirely predictable and need to be monitored, and so that interventions can be adapted at the local level

Safety of Levetiracetam in paediatrics: a systematic review

Objective To identify adverse events (AEs) associated with Levetiracetam (LEV) in children. Methods Databases EMBASE (1974-February 2015) and Medline (1946-February 2015) were searched for articles in which paediatric patients (≤18 years) received LEV treatment for epilepsy. All studies with reports on safety were included. Studies involving adults, mixed age population (i.e. children and adults) in which the paediatric subpopulation was not sufficiently described, were excluded. A meta-analysis of the RCTs was carried out and association between the commonly reported AEs or treatment discontinuation and the type of regimen (polytherapy or monotherapy) was determined using Chi2 analysis. Results Sixty seven articles involving 3,174 paediatric patients were identified. A total of 1,913 AEs were reported across studies. The most common AEs were behavioural problems and somnolence, which accounted for 10.9% and 8.4% of all AEs in prospective studies. 21 prospective studies involving 1120 children stated the number of children experiencing AEs. 47% of these children experienced AEs. Significantly more children experienced AEs with polytherapy (64%) than monotherapy (22%) (p<0.001). Levetiracetam was discontinued in 4.5% of all children on polytherapy and 0.9% on monotherapy (p<0.001), the majority were due to behavioural problems. Conclusion Behavioural problems and somnolence were the most prevalent adverse events to LEV and the most common causes of treatment discontinuation. Children on polytherapy have a greater risk of adverse events than those receiving monotherapy

Dimensions and intensity of inter-professional teamwork in primary care: Evidence from five international jurisdictions

Background. Inter-professional teamwork in primary care settings offers potential benefits for responding to the increasing complexity of patients' needs. While it is a central element in many reforms to primary care delivery, implementing inter-professional teamwork has proven to be more challenging than anticipated. Objective. The objective of this study was to better understand the dimensions and intensity of teamwork and the developmental process involved in creating fully integrated teams. Methods. Secondary analyses of qualitative and quantitative data from completed studies conducted in Australia, Canada and USA. Case studies and matrices were used, along with faceto- face group retreats, using a Collaborative Reflexive Deliberative Approach. Results. Four dimensions of teamwork were identified. The structural dimension relates to human resources and mechanisms implemented to create the foundations for teamwork. The operational dimension relates to the activities and programs conducted as part of the team's production of services. The relational dimension relates to the relationships and interactions occurring in the team. Finally, the functional dimension relates to definitions of roles and responsibilities aimed at coordinating the team's activities as well as to the shared vision, objectives and developmental activities aimed at ensuring the long-term cohesion of the team. There was a high degree of variation in the way the dimensions were addressed by reforms across the national contexts. Conclusion. The framework enables a clearer understanding of the incremental and iterative aspects that relate to higher achievement of teamwork. Future reforms of primary care need to address higher-level dimensions of teamwork to achieve its expected outcomes

In patients eligible for meniscal surgery who first receive physical therapy, multivariable prognostic models cannot predict who will eventually undergo surgery

Purpose Although physical therapy is the recommended treatment in patients over 45 years old with a degenerative meniscal tear, 24% still opt for meniscal surgery. The aim was to identify those patients with a degenerative meniscal tear who will undergo surgery following physical therapy. Methods The data for this study were generated in the physical therapy arm of the ESCAPE trial, a randomized clinical trial investigating the effectiveness of surgery versus physical therapy in patients of 45-70 years old, with a degenerative meniscal tear. At 6 and 24 months patients were divided into two groups: those who did not undergo surgery, and those who did undergo surgery. Two multivariable prognostic models were developed using candidate predictors that were selected from the list of the patients' baseline variables. A multivariable logistic regression analysis was performed with backward Wald selection and a cut-off of p < 0.157. For both models the performance was assessed and corrected for the models' optimism through an internal validation using bootstrapping technique with 500 repetitions. Results At 6 months, 32/153 patients (20.9%) underwent meniscal surgery following physical therapy. Based on the multivariable regression analysis, patients were more likely to opt for meniscal surgery within 6 months when they had worse knee function, lower education level and a better general physical health status at baseline. At 24 months, 43/153 patients (28.1%) underwent meniscal surgery following physical therapy. Patients were more likely to opt for meniscal surgery within 24 months when they had worse knee function and a lower level of education at baseline at baseline. Both models had a low explained variance (16 and 11%, respectively) and an insufficient predictive accuracy. Conclusion Not all patients with degenerative meniscal tears experience beneficial results following physical therapy. The non-responders to physical therapy could not accurately be predicted by our prognostic models.Orthopaedics, Trauma Surgery and Rehabilitatio