Embedding effective depression care: using theory for primary care organisational and systems change

Background: depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting.Methods: we used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development.Results: five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences.Conclusions: ideas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depressio

The assertive cardiac care trial: A randomised controlled trial of a coproduced assertive cardiac care intervention to reduce absolute cardiovascular disease risk in people with severe mental illness in the primary care setting

BACKGROUND: Cardiovascular disease (CVD) accounts for 40% of the excess mortality identified in people with severe mental illness (SMI). Modifiable CVD risk factors are higher and can be exacerbated by the cardiometabolic impact of psychotropic medications. People with SMI frequently attend primary care presenting a valuable opportunity for early identification, prevention and management of cardiovascular health. The ACCT Healthy Hearts Study will test a coproduced, nurse-led intervention delivered with general practitioners to reduce absolute CVD risk (ACVDR) at 12 months compared with an active control group. METHODS/DESIGN: ACCT is a two group (intervention/active control) individually randomised (1:1) controlled trial (RCT). Assessments will be completed baseline (pre-randomisation), 6 months, and 12 months. The primary outcome is 5-year ACVDR measured at 12 months. Secondary outcomes include 6-month ACVDR; and blood pressure, lipids, HbA1c, BMI, quality of life, physical activity, motivation to change health behaviour, medication adherence, alcohol use and hospitalisation at 6 and 12 months. Linear mixed-effects regression will estimate mean difference between groups for primary and secondary continuous outcomes. Economic cost-consequences analysis will be conducted using quality of life and health resource use information and routinely collected government health service use and medication data. A parallel process evaluation will investigate implementation of the intervention, uptake and outcomes. DISCUSSION: ACCT will deliver a coproduced and person-centred, guideline level cardiovascular primary care intervention to a high need population with SMI. If successful, the intervention could lead to the reduction of the mortality gap and increase opportunities for meaningful social and economic participation. Trial registration ANZCTR Trial number: ACTRN12619001112156

Patient satisfaction with healthcare provided by family doctors: primary dimensions and an attempt at typology

<p>Abstract</p> <p>Background</p> <p>Patient satisfaction is a complex and difficult concept to measure, thus precluding the use of exclusively quantitative methods for its description. The purpose of this survey was firstly to identify particular healthcare dimensions that determine a patient's satisfaction or dissatisfaction; and secondly to attempt to typologise the patients' responses based on their evaluation of healthcare.</p> <p>Methods</p> <p>Using a qualitative research design, thirty-six in-depth interviews with patients of family physicians were conducted: four patients from each of 9 family practices in different regions of Poland were interviewed. The main outcome measure was factors associated with patient satisfaction/dissatisfaction.</p> <p>Results</p> <p>In their evaluations of their contacts with family doctors, the patients cited mostly issues concerning interpersonal relationships with the doctor. Nearly 40% of the statements referred to this aspect of healthcare, with nearly equal proportions of positive and negative comments. The second most frequent category of responses concerned contextual factors (21%) that related to conditions of medical service, with two-thirds of the evaluations being negative. Statements concerning the doctor's competencies (12.9%) and personal qualities (10.5%) were less common.</p> <p>Conclusion</p> <p>To improve the quality of healthcare, family doctors should take special care to ensure the quality of their interactions with patients.</p

The assertive cardiac care trial: a randomised controlled trial of a coproduced assertive cardiac care intervention to reduce absolute cardiovascular disease risk in people with severe mental illness in the primary care setting

Background: Cardiovascular disease (CVD) accounts for 40% of the excess mortality identified in people with severe mental illness (SMI). Modifiable CVD risk factors are higher and can be exacerbated by the cardiometabolic impact of psychotropic medications. People with SMI frequently attend primary care presenting a valuable opportunity for early identification, prevention and management of cardiovascular health. The ACCT Healthy Hearts Study will test a coproduced, nurse-led intervention delivered with general practitioners to reduce absolute CVD risk (ACVDR) at 12 months compared with an active control group. Methods/design: ACCT is a two group (intervention/active control) individually randomised (1:1) controlled trial (RCT). Assessments will be completed baseline (pre-randomisation), 6 months, and 12 months. The primary outcome is 5-year ACVDR measured at 12 months. Secondary outcomes include 6-month ACVDR; and blood pressure, lipids, HbA1c, BMI, quality of life, physical activity, motivation to change health behaviour, medication adherence, alcohol use and hospitalisation at 6 and 12 months. Linear mixed-effects regression will estimate mean difference between groups for primary and secondary continuous outcomes. Economic cost-consequences analysis will be conducted using quality of life and health resource use information and routinely collected government health service use and medication data. A parallel process evaluation will investigate implementation of the intervention, uptake and outcomes. Discussion: ACCT will deliver a coproduced and person-centred, guideline level cardiovascular primary care intervention to a high need population with SMI. If successful, the intervention could lead to the reduction of the mortality gap and increase opportunities for meaningful social and economic participation

The association between intimate partner violence, alcohol and depression in family practice

Background: Depressive symptoms, intimate partner violence and hazardous drinking are common among patients attending general practice. Despite the high prevalence of these three problems; the relationship between them remains relatively unexplored. Methods: This paper explores the association between depressive symptoms, ever being afraid of a partner and hazardous drinking using cross-sectional screening data from 7667 randomly selected patients from a large primary care cohort study of 30 metropolitan and rural general practices in Victoria, Australia. The screening postal survey included the Center for Epidemiological Studies Depression Scale, the Fast Alcohol Screening Test and a screening question from the Composite Abuse Scale on ever being afraid of any intimate partner. Results: 23.9% met criteria for depressive symptoms. A higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95%CI 2.5 to 4.0) and a lower proportion of females (12%) than males (25%) were hazardous drinkers (OR 0.4; 95%CI 0.4 to 0.5); and a higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95%CI 2.5 to 4.0). Men and women who had ever been afraid of a partner or who were hazardous drinkers had on average higher depressive symptom scores than those who had never been afraid or who were not hazardous drinkers. There was a stronger association between depressive symptoms and ever been afraid of a partner compared to hazardous drinking for both males (ever afraid of partner; Diff 6.87; 95% CI 5.42, 8.33; p < 0.001 vs. hazardous drinking in last year; Diff 1.07, 95% CI 0.21, 1.94; p = 0.015) and females (ever afraid of partner; Diff 5.26; 95% CI 4.55, 5.97; p < 0.001 vs. hazardous drinking in last year; Diff 2.23, 95% CI 1.35, 3.11; p < 0.001), even after adjusting for age group, income, employment status, marital status, living alone and education level. Conclusions: Strategies to assist primary care doctors to recognise and manage intimate partner violence and hazardous drinking in patients with depression may lead to better outcomes from management of depression in primary care

Multi-objective optimization of a permanent magnet motor for marine propulsion

156 σ.Η παρούσα εργασία, πραγματεύεται μια ολοκληρωμένη προσέγγιση σχεδιασμού και βελτιστοποίησης, κινητήρων μόνιμων μαγνητών, για χρήση σε εφαρμογές ηλεκτρικής πρόωσης και εν προκειμένω, ιστιοφόρου σκάφους. Αρχικά, έλαβε χώρα μια εκτενής βιβλιογραφική αναζήτηση επί των υφιστάμενων θερμικών κινητήρων, των συστημάτων μετάδοσης, των συστημάτων πρόωσης και των τοπολογιών των. Επίσης, πραγματοποιήθηκε μια αναζήτηση επί των ιδιαίτερων χαρακτηριστικών των ιστιοφόρων γαστρών και των τυχόντων διαφορετικών αναγκών που εκπορεύονται αυτών. Συμπληρωματικά, αναζητήθηκε στη σχετική βιβλιογραφία, η υδροδυναμική συμπεριφορά των συστημάτων πρόωσης και οι απαιτήσεις των τόσο μέσω της σχετικής θεωρίας όσο και μέσω εξειδικευμένου προγράμματος υδροδυναμικής ανάλυσης (Free!ship). Επόμενο βήμα, ήταν η μελέτη των ήδη υπάρχοντων ηλεκτρικών συστημάτων πρόωσης, των κινητήρων, των συστημάτων οδήγησης, μπαταριών και γενικά της συνολικής ηλεκτρικής εγκατάστασης. Ιδιαίτερη προσοχή δόθηκε στις υπάρχουσες τοπολογίες καθώς και στις νέες τάσεις. Απόρροια των παραπάνω, ήταν οι βασικές προδιαγραφές του κινητήρα προς σχεδίαση. Εν συνεχεία, βάσει των παραπάνω προδιαγραφών, αναζητήθηκαν στη σχετική βιβλιογραφία οι πιθανές εναλλακτικές λύσεις σχεδίασης κινητήρα (τύπος κινητήρα, τυλίγματος κοκ). Η επιλεχθείσα τοπολογία ήταν σύγχρονος κινητήρας επιφανειακών μόνιμων μαγνητών, με συγκεντρωμένο τύλιγμα, διπλής στρώσης, κλασματικού βήματος. Κατόπιν, έλαβε χώρα η προκαταρκτική σχεδίαση θεωρώντας τυπικές τιμές ηλεκτρικών και μαγνητικών φορτίσεων. Επιπρόσθετα, δημιουργήθηκε η απαραίτητη για την συνέχεια παραμετρική σχεδίαση του κινητήρα, όπου δύναται να μεταβληθεί το σύνολο των γεωμετρικών χαρακτηριστικών του κινητήρα. Ταυτόχρονα υπολογίζονται και όλα τα απαραίτητα μεγέθη για την αξιολόγηση του κινητήρα (όπως ροπή, κυμάτωση ροπής, αναπτυσσόμενη αντί-ηλεκτρεγερτική δύναμη (ΗΕΔ), αρμονική παραμόρφωση αντί-ΗΕΔ, απώλειες). Ακολούθως, κατόπιν βιβλιογραφικής αναζήτησης των διάφορων μεθόδων βελτιστοποίησης, επιλέχθηκε ο εξελικτικός αλγόριθμος ισχύος Pareto (SPEA-Strength Pareto Evolutionary Algorithm). Πρόκειται για πολυκριτηριακή μέθοδο βελτιστοποίησης. που ανήκει στην κατηγορία των εξελικτικών αλγορίθμων και προτιμήθηκε για την ικανότητα σύγκλισης, και για το εύρος λύσεων που προσφέρει. Ο αλγόριθμος υλοποιήθηκε σε προγραμματιστικό περιβάλλον MATLAB. Βάσει των επιθυμητών χαρακτηριστικών επίδοσης και απόδοσης του κινητήρα, δημιουργήθηκαν οι κατάλληλες αντικειμενικές συναρτήσεις και μέσω της διεπαφής MATLAB-FEMM έλαβε χώρα η βελτιστοποίηση του κινητήρα, από όπου λάβαμε το μέτωπο Pareto. Από αυτές μέσω επιπρόσθετων κριτηρίων λήφθηκε η καλύτερα συμβιβαστική λύση και η τελική γεωμετρία. Η επιλεχθείσα γεωμετρία αναλύθηκε ηλεκτρικά και θερμικά και καθορίστηκαν τα εκτιμώμενα, βασικά ηλεκτρικά και μηχανικά μεγέθη καθώς και ο τύπος ψύξης του κινητήρα.The present diploma thesis undertakes a complete approach for designing and optimizing, permanent magnet motors, for electric propulsion applications, and in particular for sailboats. Initially, an extensive bibliographical research, on existing heat engines, transmission systems, propulsion systems and topologies was conducted. A research was also performed for special characteristics of sailboat hulls and as a consequence, special demands. Additionally, the hydrodynamic behavior of hulls and propulsion systems was sought, via both theoretical analysis based on annotated bibliography and specialized software for hydrodynamic calculations (Free!ship). As a next step, the existing electric propulsion systems, motors, motor drive systems, batteries and in general the electrical installation were thoroughly studied. Moreover, current topologies and future trends were given additional attention. As a result, the basic motor specifications were determined. Based on the specifications, the alternative motor configurations (in terms of winding configuration, motor type etc.) were investigated. The selected configuration was the permanent magnet synchronous motor, with fractional slot concentrated double layer winding. Afterwards, a preliminary design of the machine was conducted, taking into consideration typical electric and magnetic loadings. Additionally, a parameterized motor design script was implemented, through which we can alter the motor geometry in its entity. Simultaneously, the values needed for the motor performance and efficiency evaluation (such as torque, torque ripple, back-EMF, THD of back-EMF, losses) are calculated. Following, after an extensive bibliographical research on the optimization methods, SPEA (Strength Pareto Evolutionary Algorithm) was selected. SPEA is a multi-objective evolutionary algorithm, and was chosen due to the convergence capability and the diversity of the solutions acquired. The algorithm was implemented in MATLAB. Based on the desired motor performance and efficiency characteristic, suitable objective functions were created, and via MATLAB-FEMM interface, the optimization took place and the Pareto front was acquired. After the addition of extra criteria, the best compromise solution and consequently motor geometry was selected. The final geometry was analyzed electrically and thermally and the basic electrical and mechanical parameters, along with the motor`s cooling system were defined.Γεώργιος Μ. Ποτηριάδη