Cost-effectiveness of a patient-centred approach to managing multimorbidity in primary care:a pragmatic cluster randomised controlled trial

Objective Patients with multiple chronic health conditions are often managed in a disjointed fashion in primary care, with annual review clinic appointments offered separately for each condition. This study aimed to determine the cost-effectiveness of the 3D intervention, which was developed to improve the system of care. Design Economic evaluation conducted alongside a pragmatic cluster-randomised trial. Setting General practices in three centres in England and Scotland. Participants 797 adults with three or more chronic conditions were randomised to the 3D intervention, while 749 participants were randomised to receive usual care. Intervention The 3D approach: comprehensive 6-monthly general practitioner consultations, supported by medication reviews and nurse appointments. Primary and secondary outcome measures The primary economic evaluation assessed the cost per quality-adjusted life year (QALY) gained from the perspective of the National Health Service (NHS) and personal social services (PSS). Costs were related to changes in a range of secondary outcomes (QALYs accrued by both participants and carers, and deaths) in a cost-consequences analysis from the perspectives of the NHS/PSS, patients/carers and productivity losses. Results Very small increases were found in both QALYs (adjusted mean difference 0.007 (-0.009 to 0.023)) and costs (adjusted mean difference 126 pound (-739 pound to 991)) pound in the intervention arm compared with usual care after 15 months. The incremental cost-effectiveness ratio was 18 pound 499, with a 50.8% chance of being cost-effective at a willingness-to-pay threshold of 20 pound 000 per QALY (55.8% at 30 pound 000 per QALY). Conclusions The small differences in costs and outcomes were consistent with chance, and the uncertainty was substantial; therefore, the evidence for the cost-effectiveness of the 3D approach from the NHS/PSS perspective should be considered equivocal

The foundations framework for developing and reporting new models of care for multimorbidity

PURPOSE Multimorbidity challenges health systems globally. New models of care are urgently needed to better manage patients with multimorbidity; however, there is no agreed framework for designing and reporting models of care for multimorbidity and their evaluation. METHODS Based on findings from a literature search to identify models of care for multimorbidity, we developed a framework to describe these models. We illustrate the application of the framework by identifying the focus and gaps in current models of care, and by describing the evolution of models over time. RESULTS Our framework describes each model in terms of its theoretical basis and target population (the foundations of the model) and of the elements of care implemented to deliver the model. We categorized elements of care into 3 types: (1) clinical focus, (2) organization of care, (3) support for model delivery. Application of the framework identified a limited use of theory in model design and a strong focus on some patient groups (elderly, high users) more than others (younger patients, deprived populations). We found changes in elements with time, with a decrease in models implementing home care and an increase in models offering extended appointments. CONCLUSIONS By encouraging greater clarity about the underpinning theory and target population, and by categorizing the wide range of potentially important elements of an intervention to improve care for patients with multimorbidity, the framework may be useful in designing and reporting models of care and help advance the currently limited evidence base

Biomarkers of Rehabilitation Therapy Vary According To Stroke Severity

Biomarkers that capture treatment effects could improve the precision of clinical decision making for restorative therapies. We examined the performance of candidate structural, functional,and angiogenesis-related MRI biomarkers before and after a 3-week course of standardized robotic therapy in 18 patients with chronic stroke and hypothesized that results vary significantly according to stroke severity. Patients were 4.1 ± 1 months poststroke, with baseline arm Fugl-Meyer scores of 20–60. When all patients were examined together, no imaging measure changed over time in a manner that correlated with treatment-induced motor gains. However, when also considering the interaction with baseline motor status, treatment-induced motor gains were significantly related to change in three functional connectivity measures: ipsilesional motor cortex connectivity with (1) contralesional motor cortex (p = 0 003), (2) contralesional dorsal premotor cortex (p = 0 005), and (3) ipsilesional dorsal premotor cortex (p = 0 004). In more impaired patients, larger treatment gains were associated with greater increases in functional connectivity, whereas in less impaired patients larger treatment gains were associated with greater decreases in functional connectivity. Functional connectivity measures performed best as biomarkers of treatment effects after stroke. The relationship between changes in functional connectivity and treatment gains varied according to baseline stroke severity. Biomarkers of restorative therapy effects are not one-size-fits-all after stroke

Mapping Local Climate Zones for a Worldwide Database of the Form and Function of Cities

Progress in urban climate science is severely restricted by the lack of useful information that describes aspects of the form and function of cities at a detailed spatial resolution. To overcome this shortcoming we are initiating an international effort to develop the World Urban Database and Access Portal Tools (WUDAPT) to gather and disseminate this information in a consistent manner for urban areas worldwide. The first step in developing WUDAPT is a description of cities based on the Local Climate Zone (LCZ) scheme, which classifies natural and urban landscapes into categories based on climate-relevant surface properties. This methodology provides a culturally-neutral framework for collecting information about the internal physical structure of cities. Moreover, studies have shown that remote sensing data can be used for supervised LCZ mapping. Mapping of LCZs is complicated because similar LCZs in different regions have dissimilar spectral properties due to differences in vegetation, building materials and other variations in cultural and physical environmental factors. The WUDAPT protocol developed here provides an easy to understand workflow; uses freely available data and software; and can be applied by someone without specialist knowledge in spatial analysis or urban climate science. The paper also provides an example use of the WUDAPT project results

Role of Corpus Callosum Integrity in Arm Function Differs Based on Motor Severity After Stroke

While the corpus callosum (CC) is important to normal sensorimotor function, its role in motor function after stroke is less well understood. This study examined the relationship between structural integrity of the motor and sensory sections of the CC, as reflected by fractional anisotropy (FA), and motor function in individuals with a range of motor impairment level due to stroke. Fifty-five individuals with chronic stroke (Fugl-Meyer motor score range 14 to 61) and 18 healthy controls underwent diffusion tensor imaging and a set of motor behavior tests. Mean FA from the motor and sensory regions of the CC and from corticospinal tract (CST) were extracted and relationships with behavioral measures evaluated. Across all participants, FA in both CC regions was significantly decreased after stroke (p \u3c 0.001) and showed a significant, positive correlation with level of motor function. However, these relationships varied based on degree of motor impairment: in individuals with relatively less motor impairment (Fugl-Meyer motor score \u3e 39), motor status correlated with FA in the CC but not the CST, while in individuals with relatively greater motor impairment (Fugl-Meyer motor score ≤ 39), motor status correlated with FA in the CST but not the CC. The role interhemispheric motor connections play in motor function after stroke may differ based on level of motor impairment. These findings emphasize the heterogeneity of stroke, and suggest that biomarkers and treatment approaches targeting separate subgroups may be warranted

Hyperbolic formulations and numerical relativity II: Asymptotically constrained systems of the Einstein equations

We study asymptotically constrained systems for numerical integration of the Einstein equations, which are intended to be robust against perturbative errors for the free evolution of the initial data. First, we examine the previously proposed "$\lambda$-system", which introduces artificial flows to constraint surfaces based on the symmetric hyperbolic formulation. We show that this system works as expected for the wave propagation problem in the Maxwell system and in general relativity using Ashtekar's connection formulation. Second, we propose a new mechanism to control the stability, which we call the ``adjusted system". This is simply obtained by adding constraint terms in the dynamical equations and adjusting its multipliers. We explain why a particular choice of multiplier reduces the numerical errors from non-positive or pure-imaginary eigenvalues of the adjusted constraint propagation equations. This ``adjusted system" is also tested in the Maxwell system and in the Ashtekar's system. This mechanism affects more than the system's symmetric hyperbolicity.Comment: 16 pages, RevTeX, 9 eps figures, added Appendix B and minor changes, to appear in Class. Quant. Gra