Quality improvement at scale: evaluation of the drivers and barriers to adoption and sustainability of an intervention to reduce late referral in chronic kidney disease

This quality improvement project aimed to drive large-scale and sustained change to reduce the burden of chronic kidney disease in the UK. The intervention is a software programme that extracts relevant biochemical data from laboratory databases which then generate graphs of estimated kidney function (eGFR) over time. Graphs showing progressive kidney disease are sent directly back to GPs to alert them to re-review patient care and if necessary, refer to renal services. The aim of this evaluation study was to explain the barriers and drivers to implementation and adoption of the eGFR graph intervention. This evaluation study involved five of the 20 renal units (sites) involved. A Developmental Evaluation approach was utilised. Methods included collection of descriptive data about graph reporting; GP surveys (n=68); focus groups (n=4) with Practices; face-to-face interviews with secondary care clinicians (n=10). Results showed the mean number of graphs reviewed per week per site was 230, taking one hour per week per site. Only 18.2 % graphs highlighted a concerning decline in kidney function. Important enablers to sustain the intervention were low cost, easy to understand, a sense of local ownership and perceived impact. Barriers included nephrologists’ perceived increase in new referrals. We concluded that developmental evaluation can explain the barriers/drivers to implementation of a national quality improvement project that involves a variety of different stakeholders. The intervention has the potential to slow down progression of kidney disease due to the eGFR prompts alerting GPs to review the patient record and take action, such as reviewing medications and referring to renal teams if progressive kidney disease had not been identified previously

Non-equilibrium Landauer Transport Model for Hawking radiation from a Black Hole

We propose that the Hawking radiation energy and entropy flow rates from a black hole can be viewed as a one-dimensional (1D), non-equilibrium Landauer transport process. Support for this viewpoint comes from previous calculations invoking conformal symmetry in the near-horizon region, which give radiation rates that are identical to those of a single 1D quantum channel connected to a thermal reservoir at the Hawking temperature. The Landauer approach shows in a direct way the particle statistics independence of the energy and entropy fluxes of a black hole radiating into vacuum, as well as one near thermal equilibrium with its environment. As an application of the Landauer approach, we show that Hawking radiation gives a net entropy production that is 50% larger than that obtained assuming standard three-dimensional emission into vacuum.Comment: 14 pages, 2 figures, published versio

Relational lattices via duality

The natural join and the inner union combine in different ways tables of a relational database. Tropashko [18] observed that these two operations are the meet and join in a class of lattices-called the relational lattices- and proposed lattice theory as an alternative algebraic approach to databases. Aiming at query optimization, Litak et al. [12] initiated the study of the equational theory of these lattices. We carry on with this project, making use of the duality theory developed in [16]. The contributions of this paper are as follows. Let A be a set of column's names and D be a set of cell values; we characterize the dual space of the relational lattice R(D, A) by means of a generalized ultrametric space, whose elements are the functions from A to D, with the P (A)-valued distance being the Hamming one but lifted to subsets of A. We use the dual space to present an equational axiomatization of these lattices that reflects the combinatorial properties of these generalized ultrametric spaces: symmetry and pairwise completeness. Finally, we argue that these equations correspond to combinatorial properties of the dual spaces of lattices, in a technical sense analogous of correspondence theory in modal logic. In particular, this leads to an exact characterization of the finite lattices satisfying these equations.Comment: Coalgebraic Methods in Computer Science 2016, Apr 2016, Eindhoven, Netherland

A smart phone application for increasing fruit and vegetable knowledge and intakes: Development and inital testing

Abstract onl

Advance Care Planning in A Preoperative Clinic: A Retrospective Chart Review

Patients seen in preoperative testing clinics are at an increased risk of surgical complications and most are incapacitated for during anesthesia. Advance directives (ADs) are important to guide care in the event of emergencies when patients are unable to speak for themselves. The goal of this study was to determine the frequency with which ADs are completed for patients seen in preoperative clinics prior to elective surgery and identify demographic and clinical characteristics associated with having ADs available in the electronic medical record (EMR)

The QICKD study protocol: a cluster randomised trial to compare quality improvement interventions to lower systolic BP in chronic kidney disease (CKD) in primary care.

BACKGROUND: Chronic kidney disease (CKD) is a relatively newly recognised but common long-term condition affecting 5 to 10% of the population. Effective management of CKD, with emphasis on strict blood pressure (BP) control, reduces cardiovascular risk and slows the progression of CKD. There is currently an unprecedented rise in referral to specialist renal services, which are often located in tertiary centres, inconvenient for patients, and wasteful of resources. National and international CKD guidelines include quality targets for primary care. However, there have been no rigorous evaluations of strategies to implement these guidelines. This study aims to test whether quality improvement interventions improve primary care management of elevated BP in CKD, reduce cardiovascular risk, and slow renal disease progression DESIGN: Cluster randomised controlled trial (CRT) METHODS: This three-armed CRT compares two well-established quality improvement interventions with usual practice. The two interventions comprise: provision of clinical practice guidelines with prompts and audit-based education. The study population will be all individuals with CKD from general practices in eight localities across England. Randomisation will take place at the level of the general practices. The intended sample (three arms of 25 practices) powers the study to detect a 3 mmHg difference in systolic BP between the different quality improvement interventions. An additional 10 practices per arm will receive a questionnaire to measure any change in confidence in managing CKD. Follow up will take place over two years. Outcomes will be measured using anonymised routinely collected data extracted from practice computer systems. Our primary outcome measure will be reduction of systolic BP in people with CKD and hypertension at two years. Secondary outcomes will include biomedical outcomes and markers of quality, including practitioner confidence in managing CKD. A small group of practices (n = 4) will take part in an in-depth process evaluation. We will use time series data to examine the natural history of CKD in the community. Finally, we will conduct an economic evaluation based on a comparison of the cost effectiveness of each intervention. CLINICAL TRIALS REGISTRATION: ISRCTN56023731. ClinicalTrials.gov identifier

Operationalising and measuring language dominance

The paper offers a new way to measure language ability in bilinguals, based on measures of lexical richness. The validity of proposed approach is tested in a variety of ways

Stimulating uncertainty: Amplifying the quantum vacuum with superconducting circuits

The ability to generate particles from the quantum vacuum is one of the most profound consequences of Heisenberg's uncertainty principle. Although the significance of vacuum fluctuations can be seen throughout physics, the experimental realization of vacuum amplification effects has until now been limited to a few cases. Superconducting circuit devices, driven by the goal to achieve a viable quantum computer, have been used in the experimental demonstration of the dynamical Casimir effect, and may soon be able to realize the elusive verification of analogue Hawking radiation. This article describes several mechanisms for generating photons from the quantum vacuum and emphasizes their connection to the well-known parametric amplifier from quantum optics. Discussed in detail is the possible realization of each mechanism, or its analogue, in superconducting circuit systems. The ability to selectively engineer these circuit devices highlights the relationship between the various amplification mechanisms.Comment: 27 pages, 10 figures, version published in Rev. Mod. Phys. as a Colloquiu

A Comprehensive Profile of Decoding and Comprehension in Autism Spectrum Disorders

The present study examined intake data from 384 participants with autism spectrum disorders (ASD) and a comparison group of 100 participants with dyslexia on nine standardized measures of decoding and comprehension. Although diagnostic groups were based on parental reports and could not be verified independently, we were able to observe significant distinctions between subject groups. Overall findings confirm previous results of a disassociation between decoding and comprehension in ASD. Using a larger sample than previous studies and a greater variety of measures, a pattern of relatively intact decoding skills paired with low comprehension was found in autism, PDD-NOS, and Asperger’s. In contrast, the dyslexic group showed the opposite pattern of stronger comprehension and weaker decoding