Improving the effectiveness and efficiency of outpatient services: A scoping review of interventions at the primary-secondary care interface

This is the final published version. Available from SAGE Publications via the DOI in this record.Objectives: Variation in patterns of referral from primary care can lead to inappropriate overuse or underuse of specialist resources. Our aim was to review the literature on strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services. Methods: A scoping review to update a review published in 2006. We conducted a systematic literature search and qualitative evidence synthesis of studies across five intervention domains: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary care practitioners and specialists; interventions to change the referral behaviour of primary care practitioners and interventions to change patient behaviour. Results: The 183 studies published since 2005, taken with the findings of the previous review, suggest that transfer of services from secondary to primary care and strategies aimed at changing referral behaviour of primary care clinicians can be effective in reducing outpatient referrals and in increasing the appropriateness of referrals. Availability of specialist advice to primary care practitioners by email or phone and use of store-and-forward telemedicine also show potential for reducing outpatient referrals and hence reducing costs. There was little evidence of a beneficial effect of relocation of specialists to primary care, or joint primary/secondary care management of patients on outpatient referrals. Across all intervention categories there was little evidence available on cost-effectiveness. Conclusions: There are a number of promising interventions which may improve the effectiveness and efficiency of outpatient services, including making it easier for primary care clinicians and specialists to discuss patients by email or phone. There remain substantial gaps in the evidence, particularly on cost-effectiveness, and new interventions should continue to be evaluated as they are implemented more widely. A move for specialists to work in the community is unlikely to be cost-effective without enhancing primary care clinicians’skills through education or joint consultations with complex patients.National Institute for Health Research (NIHR

Organisational interventions to reduce length of stay in hospital: a rapid evidence assessment

This is the final version of the report. Available from the publisher via the DOI in this record.BACKGROUND: Available evidence on effective interventions to reduce length of stay in hospital is wide-ranging and complex, with underlying factors including those acting at the health system, organisational and patient levels, and the interface between these. There is a need to better understand the diverse literature on reducing the length of hospital stay. OBJECTIVES: This study sought to (i) describe the nature of interventions that have been used to reduce length of stay in acute care hospitals; (ii) identify the factors that are known to influence length of stay; and (iii) assess the impact of interventions on patient outcomes, service outcomes and costs. DATA SOURCES: We searched MEDLINE (Ovid), EMBASE, the Health Management Information Consortium and System for Information on Grey Literature in Europe for the period January 1995 to January 2013 with no limitation of publication type. METHODS: We conducted a rapid evidence synthesis of the peer-reviewed literature on organisational interventions set in or initiated from acute hospitals. We considered evidence published between 2003 and 2013. Data were analysed drawing on the principles of narrative synthesis. We also carried out interviews with eight NHS managers and clinical leads in four sites in England. Results: A total of 53 studies met our inclusion criteria, including 19 systematic reviews and 34 primary studies. Although the overall evidence base was varied and frequently lacked a robust study design, we identified a range of interventions that showed potential to reduce length of stay. These were multidisciplinary team working, for example some forms of organised stroke care; improved discharge planning; early supported discharge programmes; and care pathways. Nursing-led inpatient units were associated with improved outcomes but, if anything, increased length of stay. Factors influencing the impact of interventions on length of stay included contextual factors and the population targeted. The evidence was mixed with regard to the extent to which interventions seeking to reduce length of stay were associated with cost savings. LIMITATIONS: We only considered assessments of interventions which provided a quantitative estimate of the impact of the given organisational intervention on length of hospital stay. There was a general lack of robust evidence and poor reporting, weakening the conclusions that can be drawn from the review. CONCLUSIONS: The design and implementation of an intervention seeking to reduce (directly or indirectly) the length of stay in hospital should be informed by local context and needs. This involves understanding how the intervention is seeking to change processes and behaviours that are anticipated, based on the available evidence, to achieve desired outcomes (‘theory of change’). It will also involve assessing the organisational structures and processes that will need to be put in place to ensure that staff who are expected to deliver the intervention are appropriately prepared and supported. With regard to future research, greater attention should be given to the theoretical underpinning of the design, implementation and evaluation of interventions or programmes. There is a need for further research using appropriate methodology to assess the effectiveness of different types of interventions in different settings. Different evaluation approaches may be useful, and closer relationships between researchers and NHS organisations would enable more formative evaluation. Full economic costing should be undertaken where possible, including considering the cost implications for the wider local health economyThe National Institute for Health Research Health Services and Delivery Research programme

Outpatient services and primary care: scoping review, substudies and international comparisons

This is the final version of the report. Available from the publisher via the DOI in this record.AIM: This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B. Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services. FINDINGS FROM THE SCOPING REVIEW: Evidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals. FINDINGS FROM THE SUBSTUDIES: Because of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS. CONCLUSIONS: For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.The NIHR Health Services and Delivery Research programme

Pre-operative diagnosis of an unusual complication of abdominal aortic aneurysm on multidetector computed tomography: a case report

Spontaneous fistulation of an abdominal aortic aneurysm (AAA) into the inferior vena cava (IVC) is an unusual and infrequently encountered complication in clinical practice. In the majority of cases, it is a diagnosis made on the operating table, during surgical repair of AAA. We report a patient with an aortocaval fistula diagnosed preoperatively on multidetector computed tomography (MDCT). Preoperative diagnosis of this rare complication is important as it allows appropriate anaesthetic and surgical planning thereby reducing morbidity and mortality

Chlorine Dioxide Degradation Issues on Metal and Plastic Water Pipes Tested in Parallel in a Semi-Closed System

Chlorine dioxide (ClO2) has been widely used as a disinfectant in drinking water in the past but its effects on water pipes have not been investigated deeply, mainly due to the difficult experimental set-up required to simulate real-life water pipe conditions. In the present paper, four different kinds of water pipes, two based on plastics, namely random polypropylene (PPR) and polyethylene of raised temperature (PERT/aluminum multilayer), and two made of metals, i.e., copper and galvanized steel, were put in a semi-closed system where ClO2 was dosed continuously. The semi-closed system allowed for the simulation of real ClO2 concentrations in common water distribution systems and to simulate the presence of pipes made with different materials from the source of water to the tap. Results show that ClO2 has a deep effect on all the materials tested (plastics and metals) and that severe damage occurs due to its strong oxidizing power in terms of surface chemical modification of metals and progressive cracking of plastics. These phenomena could in turn become an issue for the health and safety of drinking water due to progressive leakage of degraded products in the water

Semi-empirical model for shear strength of RC interior beam-column joints subjected to cyclic loads

This paper proposes an extension to RC interior beam-column joints of a model for the shear strength prediction of exterior joints under seismic actions, already presented in the literature and based, for certain assumptions, on a previous work of Park and Mosalam. The necessary changes, due to the joints\u2019 different physical configurations, only one beam converging in exterior joints and two beams converging in interior ones, are introduced. In the proposed model, on the basis of mechanical considerations, a direct formula for interior joint shear strength accounting for the resisting contributions of three inclined concrete struts and of joint reinforcements, the column horizontal stirrups and intermediate vertical bars, is derived. In comparison to the model for exterior joints, three struts are considered instead of two and the influenced of the upper column axial load on the inclination of the concrete struts is taken into account. The coefficients of the contributions of the struts and reinforcements are calibrated using 69 test data sets available in the literature, selecting only cyclic tests showing joint shear failure. For the validation of the proposed model, the shear strength predictions obtained using the proposed expression are compared with those obtained from Kassem\u2019s model, Wang et al.\u2019s formula and Kim and LaFave\u2019s formula, on a set of 28 specimens. It is also proposed a design formula, whose predictions are compared to those of Eurocode 8 and ACI Code

Evidence for RNA transport in rat optic nerve

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/66066/1/j.1471-4159.1969.tb08995.x.pd

Sub-3mm spatial resolution from a large monolithic LaBr3 (Ce) scintillator

Abstract A Compton camera prototype for ion beam range monitoring via prompt (< 1 ns) gamma detection in hadron therapy is being developed and characterized at the Medical Physics Department of LMU Munich. The system consists of a large (50x50x30 mm3) monolithic LaBr3(Ce) scintillation crystal as absorber component to detect the multi-MeV Compton scattered photons, together with a stack of 6 double-sided silicon strip detectors (DSSSD) acting as scatterer component. Key ingredient of the γ-source reconstruction is the determination of the γ-ray interaction position in the scintillator, which is read out by a 256-fold segmented multi-anode photomultiplier tube (PMT). From simulations an angular resolution of about 1.5o for the photon source reconstruction can be expected for the energy range around 3 – 5 MeV, provided that a spatial resolution of 3 mm can be reached in the absorbing scintillator [1]. Therefore, particular effort was dedicated to characterize this latter property as a function of the γ-ray energy. Intense, tightly collimated 137Cs and 60Co photon sources were used for 2D irradiation scans (step size 0.5 mm) as prerequisite for studying the performance of the "k-Nearest-Neighbors" algorithm developed at TU Delft [2] (together with its variant "Categorical Average Pattern", CAP) and extending its applicability into the energy range beyond the original 511 keV. In this paper we present our most recent interaction position analysis in the absorbing scintillator, leading to a considerably improved value for the spatial resolution: systematic studies were performed as a function of the k-NN parameters and the PMT segmentation. A trend of improving spatial resolution with increasing photon energy was confirmed, resulting in the realization of the presently optimum spatial resolution of 2.9(1) mm @1.3 MeV, thus reaching the design specifications of the Compton camera absorber. The specification goal was reached also for a reduced PMT segmentation of 8x8 anode segments (each with 6x6 mm2 active area), thus allowing to reduce the complexity of the signal processing while preserving the performance

Characterization of Large Volume 3.5″ x 8″ LaBr3:Ce Detectors for the HECTOR+ array

A selection of the properties of large volume, cylindrical 3.5" x 8" LaBr 3 :Ce scintillation detectors coupled to a 3.5" PMT (model R10233-1000SEL from HAMAMATSU) and a special designed Voltage Divider (LABRVD) will be discussed. A number of 10 of such detectors constitute the HECTOR + array which, in fall 2012, measured at GSI coupled to the AGATA DEMOSTRATOR at the PRESPEC experimental setup. These crystals are among the largest ever produced and needed to be characterized. We have performed several tests and here we discuss, in particular, the energy resolution measured using monochromatic γ −ray sources and in-beam reactions producing γ −rays up to 22.6 MeV. As already measured in two previous works a saturation in the energy resolution was observed in case of high energy gamma rays. Crystal non-homogeneities and PMT gain drifts can affect the resolution of measurements especially in case of high energy γ −rays

Genome Sequences of Rare Human Enterovirus Genotypes Recovered from Clinical Respiratory Samples in Bern, Switzerland.

We report on genomic sequences of human enteroviruses (EVs) that were identified in respiratory samples in Bern, Switzerland, in 2018 and 2019. Besides providing sequences for coxsackievirus A2, echovirus 11, and echovirus 30, we determined the sequences of rare EV-D68 and EV-C105 genotypes circulating in Switzerland