The relationship of individual comorbid chronic conditions to diabetes care quality.

ObjectiveMultimorbidity affects 26 million persons with diabetes, and care for comorbid chronic conditions may impact diabetes care quality. The aim of this study was to determine which chronic conditions were related to lack of achievement or achievement of diabetes care quality goals to determine potential targets for future interventions.Research design and methodsThis is an exploratory retrospective analysis of electronic health record data for 23 430 adults, aged 18-75, with diabetes who were seen at seven Midwestern US health systems. The main outcome measures were achievement of six diabetes quality metrics in the reporting year, 2011 (glycated haemoglobin (HbA1c) control and testing, low-density lipoprotein control and testing, blood pressure control, kidney testing). Explanatory variables were 62 chronic condition indicators. Analyses were adjusted for baseline patient sociodemographic and healthcare utilization factors.ResultsThe 62 chronic conditions varied in their relationships to diabetes care goal achievement for specific care goals. Congestive heart failure was related to lack of achievement of cholesterol management goals. Obesity was related to lack of HbA1c and BP control. Mental health conditions were related to both lack of achievement and achievement of different care goals. Three conditions were related to lack of cholesterol testing, including congestive heart failure and substance-use disorders. Of 17 conditions related to achieving control goals, 16 were related to achieving HbA1c control. One-half of the comorbid conditions did not predict diabetes care quality.ConclusionsFuture interventions could target patients at risk for not achieving diabetes care for specific care goals based on their individual comorbidities

Human Resource Outsourcing: Long Term Operating Performance Effects From The Providers Perspective

Human resource (HR) outsourcing research has primarily focused on the client with little attention paid to the service provider. As an initial step in understanding this important stakeholder in the HR outsourcing relationship, this study focuses on the financial performance of HR service firms that publicly announce outsourcing contracts. From the provider’s perspective, we investigate firm performance changes subsequent to outsourcing contract announcements, using a sample of 94 publicly available press releases. Our tests show that in the long term, small HR service providers contracted by large client firms experience improvements in operating profitability and margins

Adjustments in end-effector trajectory and underlying joint angle synergies after a target switch:Order of adjustment is flexible

Goal-directed reaching adapts to meet changing task requirements after unexpected perturbations such as a sudden switch of target location. Literature on adaptive behavior using a target switch has primarily focused on adjustments of the end-effector trajectory, addressing proposed feedback and feedforward processes in planning adjusted actions. Starting from a dynamical systems approach to motor coordination, the current paper focusses on coordination of joint angles after a target switch, which has received little attention in the literature. We argue that joint angles are coordinated in synergies, temporary task-specific units emerging from interactions amongst task, organism, and environmental constraints. We asked whether after a target switch: i) joint angles were coordinated in synergies, ii) joint angles were coordinated in a different synergy than the synergy used when moving to the original target, and iii) synergies or end-effector trajectory was adjusted first. Participants (N = 12) performed manual reaching movements toward a target on a table (stationary target trials), where in some trials the target could unexpectedly switch to a new location (switch trials). Results showed that the end-effector curved to the switched target. Joint angles were synergistically organized as shown by the large extent of co-variation based on Uncontrolled Manifold analyses. At the end of the target switch movement, joint angle configurations differed from the joint angle configurations used to move to the original stationary target. Hence, we argue, a new synergy emerged after the target switch. The order of adjustment in the synergies and in the end-effector was flexible within participants, though most often synergies were adjusted first. These findings support the two-step framework of Kay (1988) to understand the coordination of abundant degrees of freedom and to explain adaptive actions. The flexibility in the order of adjustments of synergies suggests that the coordination of DOF emerges from self-organization

Community Experiences of Serious Organised Crime in Scotland

This summary sets out key findings from a research project that aimed to explore the community experiences of serious organised crime ( SOC) in Scotland. The study sought to answer the following questions: 1) What are the relationships that exist between SOC and communities in Scotland? 2) What are the experiences and perceptions of residents, stakeholders and organisations of the scope and nature of SOC within their local area? and 3) How does SOC impact on community wellbeing, and to what extent can the harms associated with SOC be mitigated? The work involved in-depth qualitative research, to understand both direct and indirect forms of harm. Key points pertaining to the research and its results are as follows: - The study involved the selection of three community case study sites based on a typology of ' SOC-affected' communities. These sites were based in varying urban and semi-urban settings. - The impact of SOC at a more 'diffuse' national level was explored via research in a range of smaller case study sites and via interviews with national stakeholders. This included a consideration of SOC impacts in rural and remote areas, and on populations that were not concentrated in any defined geographic community. - The case study areas were selected on the basis of pre-existing academic and policy literature, an initial set of interviews with key experts, and on the basis of aggregated and anonymised intelligence summaries provided by Police Scotland. - 188 individuals participated in the study, which mostly involved semi-structured qualitative interviews, but also a small number of focus groups, unstructured interviews and observational research. Interviews were conducted with residents, local businesses, service providers, community groups, and national organisations, as well as with a small number of individuals with lived experience of SOC. - Interviews comprised of questions about: the relationship between SOC and communities; the experiences and perceptions of residents and local service providers as to the nature and extent of SOC; and the impact of SOC on community wellbeing. - Preliminary findings were presented back to a sub-sample of 33 community residents and representatives, across three of the case study areas, through a feedback method called 'co-inquiry'. This involved the organisation of events designed to assess the integrity of the findings, and elicit reflections on the implications of the findings for potential actions

Primary Care Provider Perceptions of Colorectal Cancer Screening Barriers: Implications for Designing Quality Improvement Interventions

Aims. Colorectal cancer (CRC) screening is underutilized. Increasing CRC screening rates requires interventions targeting multiple barriers at each level of the healthcare organization (patient, provider, and system). We examined groups of primary care providers (PCPs) based on perceptions of screening barriers and the relationship to CRC screening rates to inform approaches for conducting barrier assessments prior to designing and implementing quality improvement interventions. Methods. We conducted a retrospective cohort study linking EHR and survey data. PCPs with complete survey responses for questions addressing CRC screening barriers were included (N=166 PCPs; 39,430 patients eligible for CRC screening). Cluster analysis identified groups of PCPs. Multivariate logistic regression estimated odds ratios and 95% confidence intervals for predictors of membership in one of the PCP groups. Results. We found two distinct groups: (1) PCPs identifying multiple barriers to CRC screening at patient, provider, and system levels (N=75) and (2) PCPs identifying no major barriers to screening (N=91). PCPs in the top half of CRC screening performance were more likely to identify multiple barriers than the bottom performers (OR, 4.14; 95% CI, 2.43–7.08). Conclusions. High-performing PCPs can more effectively identify CRC screening barriers. Targeting high-performers when conducting a barrier assessment is a novel approach to assist in designing quality improvement interventions for CRC screening

Chandra X-ray Observations of 12 Millisecond Pulsars in the Globular Cluster M28

We present a Chandra X-ray Observatory investigation of the millisecond pulsars (MSPs) in the globular cluster M28 (NGC 6626). In what is one of the deepest X-ray observations of a globular cluster, we firmly detect seven and possibly detect two of the twelve known M28 pulsars. With the exception of PSRs B1821-24 and J1824-2452H, the detected pulsars have relatively soft spectra, with X-ray luminosities 10^30-31 ergs s^-1 (0.3-8 keV),similar to most "recycled" pulsars in 47 Tucanae and the field of the Galaxy, implying thermal emission from the pulsar magnetic polar caps. We present the most detailed X-ray spectrum to date of the energetic PSR B1821-24. It is well described by a purely non-thermal spectrum with spectral photon index 1.23 and luminosity 1.4x10^33Theta(D/5.5 kpc)^2 ergs s^-1 (0.3-8 keV), where Theta is the fraction of the sky covered by the X-ray emission beam(s). We find no evidence for the previously reported line emission feature around 3.3 keV, most likely as a consequence of improvements in instrument calibration. The X-ray spectrum and pulse profile of PSR B1821--24 suggest that the bulk of unpulsed emission from this pulsar is not of thermal origin, and is likely due to low-level non-thermal magnetospheric radiation, an unresolved pulsar wind nebula, and/or small-angle scattering of the pulsed X-rays by interstellar dust grains. The peculiar binary PSR J1824-2452H shows a relatively hard X-ray spectrum and possible variability at the binary period, indicative of an intrabinary shock formed by interaction between the relativistic pulsar wind and matter from its non-degenerate companion star.Comment: 9 pages, 6 figures. Accepted for publication in the Astophysical Journa

Establishing chronic condition concordance and discordance with diabetes: a Delphi study

Background The vast majority of patients with diabetes have multiple chronic conditions, increasing complexity of care; however, clinical practice guidelines, interventions, and public reporting metrics do not adequately address the interaction of these multiple conditions. To advance the understanding of diabetes clinical care in the context of multiple chronic conditions, we must understand how care overlaps, or doesn’t, between diabetes and its co-occurring conditions. This study aimed to determine which chronic conditions are concordant (share care goals with diabetes) and discordant (do not share care goals) with diabetes care, according to primary care provider expert opinion. Methods Using the Delphi technique, we administered an iterative, two-round survey to 16 practicing primary care providers in an academic practice in the Midwestern USA. The expert panel determined which specific diabetes care goals were also care goals for other chronic conditions (concordant) and which were not (discordant). Our diabetes care goals were those commonly used in quality reporting, and the conditions were 62 ambulatory-relevant condition categories. Results Sixteen experts participated and all completed both rounds. Consensus was reached on the first round for 94% of the items. After the second round, 12 conditions were concordant with diabetes care and 50 were discordant. Of the concordant conditions, 6 overlapped in care for 4 of 5 diabetes care goals and 6 overlapped for 3 of 5 diabetes care goals. Thirty-one discordant conditions did not overlap with any of the diabetes care goals, and 19 overlapped with only 1 or 2 goals. Conclusions This study significantly adds to the number of conditions for which we have information on concordance and discordance for diabetes care. The results can be used for future studies to assess the impact of concordant and discordant conditions on diabetes care, and may prove useful in developing multimorbidity guidelines and interventions

Protocol for the development of guidance for stakeholder engagement in health and healthcare guideline development and implementation

Stakeholder engagement has become widely accepted as a necessary component of guideline development and implementation. While frameworks for developing guidelines express the need for those potentially affected by guideline recommendations to be involved in their development, there is a lack of consensus on how this should be done in practice. Further, there is a lack of guidance on how to equitably and meaningfully engage multiple stakeholders. We aim to develop guidance for the meaningful and equitable engagement of multiple stakeholders in guideline development and implementation. METHODS: This will be a multi-stage project. The first stage is to conduct a series of four systematic reviews. These will (1) describe existing guidance and methods for stakeholder engagement in guideline development and implementation, (2) characterize barriers and facilitators to stakeholder engagement in guideline development and implementation, (3) explore the impact of stakeholder engagement on guideline development and implementation, and (4) identify issues related to conflicts of interest when engaging multiple stakeholders in guideline development and implementation. DISCUSSION: We will collaborate with our multiple and diverse stakeholders to develop guidance for multi-stakeholder engagement in guideline development and implementation. We will use the results of the systematic reviews to develop a candidate list of draft guidance recommendations and will seek broad feedback on the draft guidance via an online survey of guideline developers and external stakeholders. An invited group of representatives from all stakeholder groups will discuss the results of the survey at a consensus meeting which will inform the development of the final guidance papers. Our overall goal is to improve the development of guidelines through meaningful and equitable multi-stakeholder engagement, and subsequently to improve health outcomes and reduce inequities in health

Enteric dysbiosis and fecal calprotectin expression in premature infants.

BackgroundPremature infants often develop enteric dysbiosis with a preponderance of Gammaproteobacteria, which has been related to adverse clinical outcomes. We investigated the relationship between increasing fecal Gammaproteobacteria and mucosal inflammation, measured by fecal calprotectin (FC).MethodsStool samples were collected from very-low-birth weight (VLBW) infants at ≤2, 3, and 4 weeks' postnatal age. Fecal microbiome was surveyed using polymerase chain reaction amplification of the V4 region of 16S ribosomal RNA, and FC was measured by enzyme immunoassay.ResultsWe enrolled 45 VLBW infants (gestation 27.9 ± 2.2 weeks, birth weight 1126 ± 208 g) and obtained stool samples at 9.9 ± 3, 20.7 ± 4.1, and 29.4 ± 4.9 days. FC was positively correlated with the genus Klebsiella (r = 0.207, p = 0.034) and its dominant amplicon sequence variant (r = 0.290, p = 0.003), but not with the relative abundance of total Gammaproteobacteria. Klebsiella colonized the gut in two distinct patterns: some infants started with low Klebsiella abundance and gained these bacteria over time, whereas others began with very high Klebsiella abundance.ConclusionIn premature infants, FC correlated with relative abundance of a specific pathobiont, Klebsiella, and not with that of the class Gammaproteobacteria. These findings indicate a need to define dysbiosis at genera or higher levels of resolution