Nurse telephone triage for same day appointments in general practice: multiple interrupted time series trial of effect on workload and costs

OBJECTIVE: To compare the workloads of general practitioners and nurses and costs of patient care for nurse telephone triage and standard management of requests for same day appointments in routine primary care. DESIGN: Multiple interrupted time series using sequential introduction of experimental triage system in different sites with repeated measures taken one week in every month for 12 months. SETTING: Three primary care sites in York. Participants: 4685 patients: 1233 in standard management, 3452 in the triage system. All patients requesting same day appointments during study weeks were included in the trial. MAIN OUTCOME MEASURES: Type of consultation (telephone, appointment, or visit), time taken for consultation, presenting complaints, use of services during the month after same day contact, and costs of drugs and same day, follow up, and emergency care. RESULTS: The triage system reduced appointments with general practitioner by 29-44%. Compared with standard management, the triage system had a relative risk (95% confidence interval) of 0.85 (0.72 to 1.00) for home visits, 2.41 (2.08 to 2.80) for telephone care, and 3.79 (3.21 to 4.48) for nurse care. Mean overall time in the triage system was 1.70 minutes longer, but mean general practitioner time was reduced by 2.45 minutes. Routine appointments and nursing time increased, as did out of hours and accident and emergency attendance. Costs did not differ significantly between standard management and triage: mean difference £1.48 more per patient for triage (95% confidence interval -0.19 to 3.15). CONCLUSIONS: Triage reduced the number of same day appointments with general practitioners but resulted in busier routine surgeries, increased nursing time, and a small but significant increase in out of hours and accident and emergency attendance. Consequently, triage does not reduce overall costs per patient for managing same day appointments

No Evidence Supporting Flare Driven High-Frequency Global Oscillations

The underlying physics that generates the excitations in the global low-frequency, < 5.3 mHz, solar acoustic power spectrum is a well known process that is attributed to solar convection; However, a definitive explanation as to what causes excitations in the high-frequency regime, > 5.3 mHz, has yet to be found. Karoff and Kjeldsen (Astrophys. J. 678, 73-76, 2008) concluded that there is a correlation between solar flares and the global high-frequency solar acoustic waves. We have used the Global Oscillations Network Group (GONG) helioseismic data in an attempt to verify Karoff and Kjeldsen (2008) results as well as compare the post-flare acoustic power spectrum to the pre-flare acoustic power spectrum for 31 solar flares. Among the 31 flares analyzed, we observe that a decrease in acoustic power after the solar flare is just as likely as an increase. Furthermore, while we do observe variations in acoustic power that are most likely associated with the usual p-modes associated with solar convection, these variations do not show any significant temporal association with flares. We find no evidence that consistently supports flare driven high-frequency waves.Comment: 20 pages, 9 figures, Accepted for publication in Solar Physic

Accessing elite nurses for research: reflections on the theoretical and practical issues of telephone interviewing

Elite groups are interesting as they frequently are powerful (in terms of position, knowledge and influence) and enjoy considerable authority. It is important, therefore, to involve them in research concerned with understanding social contexts and processes. This is particularly pertinent in healthcare, where considerable strategic development and change are features of everyday practice that may be guided or perceived as being guided, by elites. This paper evolved from a study investigating the availability and role of nurses whose remit involved leading nursing research and development within acute NHS Trusts in two health regions in Southern England. The study design included telephone interviews with Directors of Nursing Services during which time the researchers engaged in a reflective analysis of their experiences of conducting research with an `elite' group. Important issues identified were the role of gatekeepers, engagement with elites and the use of the telephone interview method in this context. The paper examines these issues and makes a case for involving executive nurses in further research. The paper also offers strategies to help researchers design and implement telephone interview studies successfully to maximise access to the views and experiences of `hard to reach groups', such as elites, while minimising the associated disruption

Recent Developments of NEMO: Detection of Solar Eruptions Characteristics

The recent developments in space instrumentation for solar observations and telemetry have caused the necessity of advanced pattern recognition tools for the different classes of solar events. The Extreme ultraviolet Imaging Telescope (EIT) of solar corona on-board SOHO spacecraft has uncovered a new class of eruptive events which are often identified as signatures of Coronal Mass Ejection (CME) initiations on solar disk. It is evident that a crucial task is the development of an automatic detection tool of CMEs precursors. The Novel EIT wave Machine Observing (NEMO) (http://sidc.be/nemo) code is an operational tool that detects automatically solar eruptions using EIT image sequences. NEMO applies techniques based on the general statistical properties of the underlying physical mechanisms of eruptive events on the solar disc. In this work, the most recent updates of NEMO code - that have resulted to the increase of the recognition efficiency of solar eruptions linked to CMEs - are presented. These updates provide calculations of the surface of the dimming region, implement novel clustering technique for the dimmings and set new criteria to flag the eruptive dimmings based on their complex characteristics. The efficiency of NEMO has been increased significantly resulting to the extraction of dimmings observed near the solar limb and to the detection of small-scale events as well. As a consequence, the detection efficiency of CMEs precursors and the forecasts of CMEs have been drastically improved. Furthermore, the catalogues of solar eruptive events that can be constructed by NEMO may include larger number of physical parameters associated to the dimming regions.Comment: 12 Pages, 5 figures, submitted to Solar Physic

Discrete molecular dynamics simulations of peptide aggregation

We study the aggregation of peptides using the discrete molecular dynamics simulations. At temperatures above the alpha-helix melting temperature of a single peptide, the model peptides aggregate into a multi-layer parallel beta-sheet structure. This structure has an inter-strand distance of 0.48 nm and an inter-sheet distance of 1.0 nm, which agree with experimental observations. In this model, the hydrogen bond interactions give rise to the inter-strand spacing in beta-sheets, while the Go interactions among side chains make beta-strands parallel to each other and allow beta-sheets to pack into layers. The aggregates also contain free edges which may allow for further aggregation of model peptides to form elongated fibrils.Comment: 15 pages, 8 figure

Association between Reimbursement Incentives and Physician Practice in Oncology: A Systematic Review

Importance: Significant controversy exists regarding whether physicians factor personal financial considerations into their clinical decision making. Within oncology, several reimbursement policies may incentivize physicians to increase health care use. Objective: To evaluate whether the financial incentives presented by oncology reimbursement policies affect physician practice patterns. Evidence Review: Studies evaluating an association between reimbursement incentives and changes in reimbursement policy on oncology care delivery were reviewed. Articles were identified systematically by searching PubMed/MEDLINE, Web of Science, Proquest Health Management, Econlit, and Business Source Premier. English-language articles focused on the US health care system that made empirical estimates of the association between a measurement of physician reimbursement/compensation and a measurement of delivery of cancer treatment services were included. The Risk of Bias in Non-Randomized Studies of Interventions tool was used to assess risk of bias. There were no date restrictions on the publications, and literature searches were finalized on February 14, 2018. Findings: Eighteen studies were included. All were observational cohort studies, and most had a moderate risk of bias. Heterogeneity of reimbursement policies and outcomes precluded meta-analysis; therefore, a qualitative synthesis was performed. Most studies (15 of 18 [83%]) reported an association between reimbursement and care delivery consistent with physician responsiveness to financial incentives, although such an association was not identified in all studies. Findings consistently suggested that self-referral arrangements may increase use of radiotherapy and that profitability of systemic anticancer agents may affect physicians' choice of drug. Findings were less conclusive as to whether profitability of systemic anticancer therapy affects the decision of whether to use any systemic therapy. Conclusions and Relevance: To date, this study is the first systematic review of reimbursement policy and clinical care delivery in oncology. The findings suggest that some oncologists may, in certain circumstances, alter treatment recommendations based on personal revenue considerations. An implication of this finding is that value-based reimbursement policies may be a useful tool to better align physician incentives with patient need and increase the value of oncology care

The Saffman-Taylor problem on a sphere

The Saffman-Taylor problem addresses the morphological instability of an interface separating two immiscible, viscous fluids when they move in a narrow gap between two flat parallel plates (Hele-Shaw cell). In this work, we extend the classic Saffman-Taylor situation, by considering the flow between two curved, closely spaced, concentric spheres (spherical Hele-Shaw cell). We derive the mode-coupling differential equation for the interface perturbation amplitudes and study both linear and nonlinear flow regimes. The effect of the spherical cell (positive) spatial curvature on the shape of the interfacial patterns is investigated. We show that stability properties of the fluid-fluid interface are sensitive to the curvature of the surface. In particular, it is found that positive spatial curvature inhibits finger tip-splitting. Hele-Shaw flow on weakly negative, curved surfaces is briefly discussed.Comment: 26 pages, 4 figures, RevTex, accepted for publication in Phys. Rev.

Expansion in perfect groups

Let Ga be a subgroup of GL_d(Q) generated by a finite symmetric set S. For an integer q, denote by Ga_q the subgroup of Ga consisting of the elements that project to the unit element mod q. We prove that the Cayley graphs of Ga/Ga_q with respect to the generating set S form a family of expanders when q ranges over square-free integers with large prime divisors if and only if the connected component of the Zariski-closure of Ga is perfect.Comment: 62 pages, no figures, revision based on referee's comments: new ideas are explained in more details in the introduction, typos corrected, results and proofs unchange