Improving care for older people with long-term conditions and social care needs in Salford : the CLASSIC mixed-methods study, including RCT

BackgroundThe Salford Integrated Care Programme (SICP) was a large-scale transformation project to improve care for older people with long-term conditions and social care needs. We report an evaluation of the ability of the SICP to deliver an enhanced experience of care, improved quality of life, reduced costs of care and improved cost-effectiveness.ObjectivesTo explore the process of implementation of the SICP and the impact on patient outcomes and costs.DesignQualitative methods (interviews and observations) to explore implementation, a cohort multiple randomised controlled trial to assess patient outcomes through quasi-experiments and a formal trial, and an analysis of routine data sets and appropriate comparators using non-randomised methodologies.SettingSalford in the north-west of England.ParticipantsOlder people aged ≥ 65 years, carers, and health and social care professionals.InterventionsA large-scale integrated care project with three core mechanisms of integration (community assets, multidisciplinary groups and an ‘integrated contact centre’).Main outcome measuresPatient self-management, care experience and quality of life, and health-care utilisation and costs.Data sourcesProfessional and patient interviews, patient self-report measures, and routine quantitative data on service utilisation.ResultsThe SICP and subsequent developments have been sustained by strong partnerships between organisations. The SICP achieved ‘functional integration’ through the pooling of health and social care budgets, the development of the Alliance Agreement between four organisations and the development of the shared care record. ‘Service-level’ integration was slow and engagement with general practice was a challenge. We saw only minor changes in patient experience measures over the period of the evaluation (both improvements and reductions), with some increase in the use of community assets and care plans. Compared with other sites, the difference in the rates of admissions showed an increase in emergency admissions. Patient experience of health coaching was largely positive, although the effects of health coaching on activation and depression were not statistically significant. Economic analyses suggested that coaching was likely to be cost-effective, generating improvements in quality of life [mean incremental quality-adjusted life-year gain of 0.019, 95% confidence interval (CI) –0.006 to 0.043] at increased cost (mean incremental total cost increase of £150.58, 95% CI –£470.611 to £711.776).LimitationsThe Comprehensive Longitudinal Assessment of Salford Integrated Care study represents a single site evaluation, with consequent limits on external validity. Patient response rates to the cohort survey were ConclusionsThe SICP has been implemented in a way that is consistent with the original vision. However, there has been more rapid success in establishing new integrated structures (such as a formal integrated care organisation), rather than in delivering mechanisms of integration at sufficient scale to have a large impact on patient outcomes.Future workFurther research could focus on each of the mechanisms of integration. The multidisciplinary groups may require improved targeting of patients or disease subgroups to demonstrate effectiveness. Development of a proven model of health coaching that can be implemented at scale is required, especially one that would provide cost savings for commissioners or providers. Similarly, further exploration is required to assess the longer-term benefits of community assets and whether or not health impacts translate to reductions in care use.Trial registrationCurrent Controlled Trials ISRCTN12286422.FundingThis project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 6, No. 31. See the NIHR Journals Library website for further project information

Process Evaluation for Technology Enabled Atrial Fibrillation Screening after a Stroke in Scotland

Diagnosis of Atrial Fibrillation (AF) after stroke is a national priority. AF-related strokes typically cost twice as much to manage as non-AF related strokes (Miller et al, 2005). If diagnosed with AF, further stroke can be reduced by 60% by taking medications such as anticoagulants. Because AF can be paroxysmal- that is the heart can go in and out of AF- it is not always detected during hospitalisation for stroke. If there is a reasonable suspicion that stroke may have resulted from undetected AF, guidelines recommend screening with a Holter monitor - an ambulatory electrocardiogram (ECG) applied in a hospital clinic for 72 hours. A ‘Test of Change’ within one local hospital in Scotland (NHS Lanarkshire) was conducted during 2019 where a new managed service involving devices (applied to n=64 patients) were considered for AF screening that would allow for up to 14 days of continuous monitoring in the home setting. This new technology enabled service also included reporting conducted by the company providing the service as a proposed alternative to clinicians inside the NHS doing all the report reading and analysis. Clinicians and other key implementers involved in the planning, set up, delivery, and evaluation of this service innovation were interviewed throughout the project to gather qualitative data on the potential barriers and facilitators to this type of service working longer term locally for them and or potentially scaling nationally. Patient experience was also captured through interviews with a sample of patients who received the new service (8/64; 12.5%) to capture acceptability of the new device and resulting service within this NHS setting. Findings revealed that patients found the new monitoring device acceptable. Stroke clinicians and nurses invested additional time in training (4 half days) to use the software, apply the devices and in home-visits to apply devices but also highly valued the availability of 14 days of continuous data. For further adoption of this type of service, it is critical to explore whether clinicians would adopt a system or service that produces the reports for them or whether they would prefer to have the reports generated by NHS staff (trust and control versus cost and capacity for reporting). It is anticipated that this report will benefit policy makers in government, operational managers, clinical leads, service managers and digital and IT managers and leads and many others by providing key barriers and facilitators and therefore a realistic checklist of what must be considered in planning for implementation of new technology enabled services to monitor for intermittent AF within a care pathway

Process Evaluation for Technology Enabled Atrial Fibrillation Screening after a Stroke in Scotland

Diagnosis of Atrial Fibrillation (AF) after stroke is a national priority. AF-related strokes typically cost twice as much to manage as non-AF related strokes (Miller et al, 2005). If diagnosed with AF, further stroke can be reduced by 60% by taking medications such as anticoagulants. Because AF can be paroxysmal- that is the heart can go in and out of AF- it is not always detected during hospitalisation for stroke. If there is a reasonable suspicion that stroke may have resulted from undetected AF, guidelines recommend screening with a Holter monitor - an ambulatory electrocardiogram (ECG) applied in a hospital clinic for 72 hours. A ‘Test of Change’ within one local hospital in Scotland (NHS Lanarkshire) was conducted during 2019 where a new managed service involving devices (applied to n=64 patients) were considered for AF screening that would allow for up to 14 days of continuous monitoring in the home setting. This new technology enabled service also included reporting conducted by the company providing the service as a proposed alternative to clinicians inside the NHS doing all the report reading and analysis. Clinicians and other key implementers involved in the planning, set up, delivery, and evaluation of this service innovation were interviewed throughout the project to gather qualitative data on the potential barriers and facilitators to this type of service working longer term locally for them and or potentially scaling nationally. Patient experience was also captured through interviews with a sample of patients who received the new service (8/64; 12.5%) to capture acceptability of the new device and resulting service within this NHS setting. Findings revealed that patients found the new monitoring device acceptable. Stroke clinicians and nurses invested additional time in training (4 half days) to use the software, apply the devices and in home-visits to apply devices but also highly valued the availability of 14 days of continuous data. For further adoption of this type of service, it is critical to explore whether clinicians would adopt a system or service that produces the reports for them or whether they would prefer to have the reports generated by NHS staff (trust and control versus cost and capacity for reporting). It is anticipated that this report will benefit policy makers in government, operational managers, clinical leads, service managers and digital and IT managers and leads and many others by providing key barriers and facilitators and therefore a realistic checklist of what must be considered in planning for implementation of new technology enabled services to monitor for intermittent AF within a care pathway

Deep Underground Neutrino Experiment (DUNE) Near Detector Conceptual Design Report

International audienceThe Deep Underground Neutrino Experiment (DUNE) is an international, world-class experiment aimed at exploring fundamental questions about the universe that are at the forefront of astrophysics and particle physics research. DUNE will study questions pertaining to the preponderance of matter over antimatter in the early universe, the dynamics of supernovae, the subtleties of neutrino interaction physics, and a number of beyond the Standard Model topics accessible in a powerful neutrino beam. A critical component of the DUNE physics program involves the study of changes in a powerful beam of neutrinos, i.e., neutrino oscillations, as the neutrinos propagate a long distance. The experiment consists of a near detector, sited close to the source of the beam, and a far detector, sited along the beam at a large distance. This document, the DUNE Near Detector Conceptual Design Report (CDR), describes the design of the DUNE near detector and the science program that drives the design and technology choices. The goals and requirements underlying the design, along with projected performance are given. It serves as a starting point for a more detailed design that will be described in future documents

Reconstruction of interactions in the ProtoDUNE-SP detector with Pandora

International audienceThe Pandora Software Development Kit and algorithm libraries provide pattern-recognition logic essential to the reconstruction of particle interactions in liquid argon time projection chamber detectors. Pandora is the primary event reconstruction software used at ProtoDUNE-SP, a prototype for the Deep Underground Neutrino Experiment far detector. ProtoDUNE-SP, located at CERN, is exposed to a charged-particle test beam. This paper gives an overview of the Pandora reconstruction algorithms and how they have been tailored for use at ProtoDUNE-SP. In complex events with numerous cosmic-ray and beam background particles, the simulated reconstruction and identification efficiency for triggered test-beam particles is above 80% for the majority of particle type and beam momentum combinations. Specifically, simulated 1 GeV/$c$ charged pions and protons are correctly reconstructed and identified with efficiencies of 86.1$\pm0.6$% and 84.1$\pm0.6$%, respectively. The efficiencies measured for test-beam data are shown to be within 5% of those predicted by the simulation

Separation of track- and shower-like energy deposits in ProtoDUNE-SP using a convolutional neural network

International audienceLiquid argon time projection chamber detector technology provides high spatial and calorimetric resolutions on the charged particles traversing liquid argon. As a result, the technology has been used in a number of recent neutrino experiments, and is the technology of choice for the Deep Underground Neutrino Experiment (DUNE). In order to perform high precision measurements of neutrinos in the detector, final state particles need to be effectively identified, and their energy accurately reconstructed. This article proposes an algorithm based on a convolutional neural network to perform the classification of energy deposits and reconstructed particles as track-like or arising from electromagnetic cascades. Results from testing the algorithm on experimental data from ProtoDUNE-SP, a prototype of the DUNE far detector, are presented. The network identifies track- and shower-like particles, as well as Michel electrons, with high efficiency. The performance of the algorithm is consistent between experimental data and simulation

Highly-parallelized simulation of a pixelated LArTPC on a GPU

The rapid development of general-purpose computing on graphics processing units (GPGPU) is allowing the implementation of highly-parallelized Monte Carlo simulation chains for particle physics experiments. This technique is particularly suitable for the simulation of a pixelated charge readout for time projection chambers, given the large number of channels that this technology employs. Here we present the first implementation of a full microphysical simulator of a liquid argon time projection chamber (LArTPC) equipped with light readout and pixelated charge readout, developed for the DUNE Near Detector. The software is implemented with an end-to-end set of GPU-optimized algorithms. The algorithms have been written in Python and translated into CUDA kernels using Numba, a just-in-time compiler for a subset of Python and NumPy instructions. The GPU implementation achieves a speed up of four orders of magnitude compared with the equivalent CPU version. The simulation of the current induced on $10^3$ pixels takes around 1 ms on the GPU, compared with approximately 10 s on the CPU. The results of the simulation are compared against data from a pixel-readout LArTPC prototype

Reconstruction of interactions in the ProtoDUNE-SP detector with Pandora

International audienceThe Pandora Software Development Kit and algorithm libraries provide pattern-recognition logic essential to the reconstruction of particle interactions in liquid argon time projection chamber detectors. Pandora is the primary event reconstruction software used at ProtoDUNE-SP, a prototype for the Deep Underground Neutrino Experiment far detector. ProtoDUNE-SP, located at CERN, is exposed to a charged-particle test beam. This paper gives an overview of the Pandora reconstruction algorithms and how they have been tailored for use at ProtoDUNE-SP. In complex events with numerous cosmic-ray and beam background particles, the simulated reconstruction and identification efficiency for triggered test-beam particles is above 80% for the majority of particle type and beam momentum combinations. Specifically, simulated 1 GeV/$c$ charged pions and protons are correctly reconstructed and identified with efficiencies of 86.1$\pm0.6$% and 84.1$\pm0.6$%, respectively. The efficiencies measured for test-beam data are shown to be within 5% of those predicted by the simulation

The DUNE Far Detector Vertical Drift Technology, Technical Design Report

International audienceDUNE is an international experiment dedicated to addressing some of the questions at the forefront of particle physics and astrophysics, including the mystifying preponderance of matter over antimatter in the early universe. The dual-site experiment will employ an intense neutrino beam focused on a near and a far detector as it aims to determine the neutrino mass hierarchy and to make high-precision measurements of the PMNS matrix parameters, including the CP-violating phase. It will also stand ready to observe supernova neutrino bursts, and seeks to observe nucleon decay as a signature of a grand unified theory underlying the standard model. The DUNE far detector implements liquid argon time-projection chamber (LArTPC) technology, and combines the many tens-of-kiloton fiducial mass necessary for rare event searches with the sub-centimeter spatial resolution required to image those events with high precision. The addition of a photon detection system enhances physics capabilities for all DUNE physics drivers and opens prospects for further physics explorations. Given its size, the far detector will be implemented as a set of modules, with LArTPC designs that differ from one another as newer technologies arise. In the vertical drift LArTPC design, a horizontal cathode bisects the detector, creating two stacked drift volumes in which ionization charges drift towards anodes at either the top or bottom. The anodes are composed of perforated PCB layers with conductive strips, enabling reconstruction in 3D. Light-trap-style photon detection modules are placed both on the cryostat's side walls and on the central cathode where they are optically powered. This Technical Design Report describes in detail the technical implementations of each subsystem of this LArTPC that, together with the other far detector modules and the near detector, will enable DUNE to achieve its physics goals