Perceptions of a service redesign by adults living with type 2 diabetes

<b>Aim:</b> This article is a report of a study conducted to explore the perceptions of adults with type 2 diabetes towards the service redesign. <b>Background:</b> Diabetes is reaching epidemic proportions and the management of this chronic illness is changing in response to this challenge. In the United Kingdom, there is ongoing restructuring of healthcare services for people with chronic illnesses to ensure that their general health and clinical needs are met predominantly in primary care. <b>Method:</b> An explorative qualitative approach was used. Eight focus groups were conducted with 35 people with type 2 diabetes in one urban location between 2003 and 2004. Five focus groups were conducted with people who had recently experienced the restructured service and three groups with people who had up to 2 years' experience of the new service. Concurrent data collection and thematic analysis were conducted by three researchers and credibility and verification sought by feedback to participants. <b>Findings:</b> Five main themes were identified: impact of living with diabetes; understanding diabetes; drivers for organizational change; care in context and individual concerns. Participants identified issues for ongoing development of the service. <b>Conclusion:</b> People with type 2 diabetes appreciate their care management within the primary care setting where there has been investment in staff to deliver this care. Healthcare resources are required to support the development of staff and the necessary infrastructure to undertake management in primary care. Policy makers need to address the balance of resources between primary and secondary care

Leadership development for micro-communities : developing leaders in United Methodist micro-communities

https://place.asburyseminary.edu/ecommonsatsdissertations/2414/thumbnail.jp

The Use of Limited Field Observation in Remedial Design

As a consequence of a slope failure, an investigation was carried out to determine the present and future stability of a gold tailings dam in the Orange Free State, South Africa. Recommendations were also required concerning the type of remedial measure(s) necessary in order to permit continued deposition of the tailings waste product on the dam. The field and laboratory investigation involved sampling of the tailings and foundation soils and installation of piezometers at various locations around the dam. The paper describes how, using data obtained from a limited monitoring period, evaluation of in-situ parameters enabled prediction of future phreatic surface variations under differing operating and climatic conditions

Stabilization of a Tailings Dam by De-Watering

The failure of the outer slope of one of the paddocks of a tailings dam, resulted in a significant decrease in the area available for tailings deposition. Overloading of the remaining five paddocks resulted. To maintain the stability of the existing dam whilst construction of new disposal facilities was in progress, three techniques were investigated; horizontal, push-in drains at the dam toe, a rock buttress around the operational paddocks, and vertical de-watering wells installed on the first terrace, or ‘step-back’ of the dam. De-watering wells proved most effective, and 165 wells were installed. A monitoring programme included regular determination of the water level in each well, and the installation of piezometers at selected locations around the dam. These observations were used to optimise the use of the five remaining paddocks, thus ensuring stability of the dam during the transfer of deposition operations to two new tailings dams

Shades of Grey: Ethical Dilemmas

No abstract available

Measures of promptness of cancer diagnosis in primary care: Secondary analysis of national audit data on patients with 18 common and rarer cancers

Background: Evidence is needed about the promptness of cancer diagnosis and associations between its measures. Methods: We analysed data from the National Audit of Cancer Diagnosis in Primary Care 2009–10 exploring the association between the interval from first symptomatic presentation to specialist referral (the primary care interval, or ‘interval’ hereafter) and the number of pre-referral consultations. Results: Among 13 035 patients with any of 18 different cancers, most (82%) were referred after 1 (58%) or 2 (25%) consultations (median intervals 0 and 15 days, respectively) while 9%, 4% and 5% patients required 3, 4 or 5 þ consultations (median intervals 34, 47 and 97 days, respectively) (Spearman’s r ¼ 0.70). The association was at least moderate for any cancer (Spearman’s r range: 0.55 (prostate) 0.77 (brain)). Patients with cancers with a higher proportion of three or more pre-referral consultations typically also had longer median intervals (e.g., multiple myeloma) and vice versa (e.g., breast cancer). Conclusion: The number of pre-referral consultations has construct validity as a measure of the primary care interval. Developing interventions to reduce the number of pre-referral consultations can help improve the timeliness of cancer diagnosis, and constitutes a priority for early diagnosis initiatives and research

Gender inequalities in the promptness of diagnosis of bladder and renal cancer after symptomatic presentation: evidence from secondary analysis of an English primary care audit survey

Objectives: To explore whether women experience greater delays in the diagnosis of bladder and renal cancer when first presenting to a general practitioner with symptoms caused by those cancers and potential reasons for such gender inequalities. Design: Prospective national audit survey of cancer diagnosis. Setting: English primary care (2009–2010). Participants: 920 patients with bladder and 398 patients with renal cancer (252 (27%) and 165 (42%), respectively, were women). Primary and secondary outcome measures: Proportion of patients with three or more pre-referral consultations; number of days from first presentation to referral; proportion of patients who presented with haematuria and proportion of patients investigated in primary care. Results: Women required three or more prereferral consultations more often than men (27% (95% CI 21% to 33%) vs 11% (9% to 14%) for bladder (p<0.001); and 30% (22% to 39%) vs 18% (13% to 25%) for renal cancer (p=0.025)) and had a greater number of days from presentation to referral. In multivariable analysis (adjusting for age, haematuria status and use of primary care-led investigations), being a woman was independently associated with higher odds of three or more pre-referral consultations (OR=3.29 (2.06 to 5.25, p<0.001) for bladder cancer; and OR=1.90 (1.06 to 3.42, p=0.031) for renal cancer). Although presentation with haematuria was associated with more timely diagnosis of bladder cancer, gender inequalities did not vary by haematuria status for either cancer (p=0.18 for bladder and p=0.27 for renal). Each year in the UK, approximately 700 women with either bladder or renal cancer experience a delayed diagnosis because of their gender, of whom more than a quarter (197, or 28%) present with haematuria. Conclusions: There are notable gender inequalities in the timeliness of diagnosis of urological cancers. There is a need to both reinforce existing guidelines on haematuria investigation and develop new diagnostic decision aids and tests for patients who present without haematuria

The frequency, nature and impact of GP-assessed avoidable delays in a population-based cohort of cancer patients

Background: There is a growing emphasis on the speed of diagnosis as an aspect of cancer prognosis. While epidemiological data in the last decade have quantified diagnostic timeliness and its variation, whether and how often prolonged diagnostic intervals can be considered avoidable is unknown. // Methods: We used data from the English National Cancer Diagnosis Audit (NCDA) on 17,042 patients diagnosed with cancer in 2014. Participating primary care physicians were asked to identify delays in diagnosis that they deemed avoidable, together with the ‘setting’ of the avoidable delay and key attributable factors. We used descriptive analysis and regression frameworks to assess validity and examine variation in the frequency and nature of avoidable delays. // Results: Among 14,259 patients, 24% were deemed to have had an avoidable delay to their diagnosis. Patients with a reported avoidable delay had a longer median diagnostic interval (92 days) than those without (30 days). Of all avoidable delays, 13% were deemed to have occurred pre-consultation, 49% within primary care, and 38% within secondary care. Avoidable delays were mostly attributed to the test request/performance phase (25%). Multimorbidity was associated with greater odds of avoidable delay (OR for 3+ vs no comorbidity: 1.43 (95% CI 1.25–1.63)), with heterogeneous associations with cancer site. // Conclusion: We have shown that GP-identified instances of avoidable delay have construct validity. Whilst the causes of avoidable diagnostic delays are multi-factorial and occur in different settings and phases of the diagnostic process, their analysis can guide improvement initiatives and enable the examination of any prognostic implications

Reply: Timeliness, risk communication and patient preferences for investigations or referral

This is the final version. Available from the publisher via the DOI in this record.Letter to the Edito