Investigating the mechanism of impact of the quality premium initiative on antibiotic prescribing in primary care practices in England: a study protocol

Introduction The persistent development and spread of resistance to antibiotics remains an important public health concern in the UK and globally. About 74% of antibiotics prescribed in England in 2016 was in primary care. The Quality Premium (QP) initiative that rewards Clinical Commissioning Groups (CCGs) financially based on the quality of specific health services commissioned is one of the National Health Service (NHS) England interventions to reduce antimicrobial resistance through reduced prescribing. Emerging evidence suggests a reduction in antibiotic prescribing in primary care practices in the UK following QP initiative. This study aims to investigate the mechanism of impact of this high-cost health-system level intervention on antibiotic prescribing in primary care practices in England. Methods and analysis The study will constitute secondary analyses of antibiotic prescribing data for almost all primary care practices in England from the NHS England Antibiotic Quality Premium Monitoring Dashboard and OpenPrescribing covering the period 2013 to 2018. The primary outcome is the number of antibiotic items per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR-PU) prescribed monthly in each practice or CCG. We will first conduct an interrupted time series using Ordinary Least Square regression method to examine whether antibiotic prescribing rate in England has changed over time, and how such changes, if any, are associated with QP implementation. Single and sequential multiple-mediator models using a unified approach for the natural direct and indirect effects will be conducted to investigate the relationship between QP initiative, the potential mediators and antibiotic prescribing rate with adjustment for practice and CCG characteristics. Ethics and dissemination This study will use secondary data that are anonymised and obtained from studies that have either undergone ethical review or generated data from routine collection systems. Multiple channels will be used in disseminating the findings from this study to academic and non-academic audiences. Strengths and Limitations of this study • This study will be the first to evaluate the mechanism of the impact of a financial incentive initiative involving Clinical Commissioning Groups to improve antibiotic prescribing in primary care practices in England. • The investigation of multiple mediators in this study will help to identify the contributions of multiple strategies in translating the effects of QP while unpacking the extent of the effect of specific mediators. • Due to the limited data on practice-level interventions or strategies that might potentially mediate the effect of the QP on antibiotic prescribing, we will not be able to extensively investigate the mechanism of QP impact at the practice level. • Nevertheless, extensive investigations will be conducted at CCG level where the Quality Premium initiative is implemented, and rewards paid out

Views and uses of sepsis digital alerts in national health service trusts in England: qualitative study with health care professionals

Background: Sepsis is a common cause of serious illness and death. Sepsis management remains challenging and suboptimal. To support rapid sepsis diagnosis and treatment, screening tools have been embedded into hospital digital systems to appear as digital alerts. The implementation of digital alerts to improve the management of sepsis and deterioration is a complex intervention that has to fit with team workflow and the views and practices of hospital staff. Despite the importance of human decision-making and behavior in optimal implementation, there are limited qualitative studies that explore the views and experiences of health care professionals regarding digital alerts as sepsis or deterioration computerized clinician decision support systems (CCDSSs). Objective: This study aims to explore the views and experiences of health care professionals on the use of sepsis or deterioration CCDSSs and to identify barriers and facilitators to their implementation and use in National Health Service (NHS) hospitals. Methods: We conducted a qualitative, multisite study with unstructured observations and semistructured interviews with health care professionals from emergency departments, outreach teams, and intensive or acute units in 3 NHS hospital trusts in England. Data from both interviews and observations were analyzed together inductively using thematic analysis. Results: A total of 22 health care professionals were interviewed, and 12 observation sessions were undertaken. A total of four themes regarding digital alerts were identified: (1) support decision-making as nested in electronic health records, but never substitute professionals’ knowledge and experience; (2) remind to take action according to the context, such as the hospital unit and the job role; (3) improve the alerts and their introduction, by making them more accessible, easy to use, not intrusive, more accurate, as well as integrated across the whole health care system; and (4) contextual factors affecting views and use of alerts in the NHS trusts. Digital alerts are more optimally used in general hospital units with a lower senior decision maker:patient ratio and by health care professionals with experience of a similar technology. Better use of the alerts was associated with quality improvement initiatives and continuous sepsis training. The trusts’ features, such as the presence of a 24/7 emergency outreach team, good technological resources, and staffing and teamwork, favored a more optimal use. Conclusions: Trust implementation of sepsis or deterioration CCDSSs requires support on multiple levels and at all phases of the intervention, starting from a prego-live analysis addressing organizational needs and readiness. Advancements toward minimally disruptive and smart digital alerts as sepsis or deterioration CCDSSs, which are more accurate and specific but at the same time scalable and accessible, require policy changes and investments in multidisciplinary research

Internal charge behaviour of nanocomposites

The incorporation of 23 nm titanium dioxide nanoparticles into an epoxy matrix to form a nanocomposite structure is described. It is shown that the use of nanometric particles results in a substantial change in the behaviour of the composite, which can be traced to the mitigation of internal charge when a comparison is made with conventional TiO2 fillers. A variety of diagnostic techniques (including dielectric spectroscopy, electroluminescence, thermally stimulated current, photoluminescence) have been used to augment pulsed electro-acoustic space charge measurement to provide a basis for understanding the underlying physics of the phenomenon. It would appear that, when the size of the inclusions becomes small enough, they act co-operatively with the host structure and cease to exhibit interfacial properties leading to Maxwell-Wagner polarization. It is postulated that the particles are surrounded by high charge concentrations in the Gouy-Chapman-Stern layer. Since nanoparticles have very high specific areas, these regions allow limited charge percolation through nano-filled dielectrics. The practical consequences of this have also been explored in terms of the electric strength exhibited. It would appear that there was a window in which real advantages accrue from the nano-formulated material. An optimum loading of about 10% (by weight) is indicated