Improving the annual review of diabetic patients in primary care: an appreciative inquiry in the Cape Town District Health Services

Background: Diabetes in a common chronic disease in the Cape Town District Health Services and yet an audit of diabetic care demonstrated serious deficiencies in the quality of care. The Metro District Health Services (MDHS) decided to focus on improving the annual review of the diabetic patient. The MDHS provides primary care to the uninsured population of Cape Town through a network of 45 Community Health Centres (CHC). Methods: An appreciative inquiry was established amongst the staff responsible for diabetic care at the 15 CHCs that had newly appointed facility managers. The inquiry completed three cycles of action-reflection over a period of one year and included training in clinical skills as requested by the participants. At the end of the inquiry a consensus was reached on the learning of the group. Results: This consensus was expressed in the form of 11 key themes. CHCs that reported success with improving the annual review formed chronic care teams that met regularly to discuss their goals, roles and to plan improvements. These teams developed more structured and systematic approaches to care, which included the creation of special clubs, attention to the steps in patient flow and methods of summarising and accessing key information. These teams also appointed specific champions who would not rotate to other duties and who would provide continuity of leadership and organisation. These teams also supported continuity of relationships, clinical management and organisation of care. Teams involved the community and local non-profit organisations, particularly in the establishment of support groups that could disseminate medications and build health literacy and self-efficacy. Some teams emphasised the need to also care for the carers and to not just focus on workload and output indicators. More successful CHCs also grappled with balancing of the workload, quality of care and waiting times in a way that improved all three in an upward spiral. Patient satisfaction, staff satisfaction and clinical outcomes were seen as interlinked' There was a need to plan methods for empowering patients and build self-efficacy through a variety of facility- and community-based as well as individual- and group-orientated initiatives. Training in clinical skills was requested for foot and eye screening. Feedback was given to the MDHS on the need to improve referral pathways and access to preventative services such as dieticians, podiatrists and vascular surgery. Finally, the inquiry process itself together with the annual audit supported organisational learning and change at the facility level. Conclusion: Improving the annual review has more to do with the organisation of care than gaps in knowledge or skills that can be addressed through training. While such gaps do exist, as shown by the training around foot screening, the main focus was on issues of leadership, teamwork, systematic organisation, continuity, staff satisfaction, motivation and the balancing of quality care provided, quantity of care demanded and queuing required. The appreciative inquiry (Al) process supported decentralised organisational learning and, while key themes were shared, the specific solutions were localised

Improving the annual review of diabetic patients in primary care: an appreciative inquiry in the Cape Town District Health Services

Background: Diabetes in a common chronic disease in the Cape Town District Health Services and yet an audit of diabetic care demonstrated serious deficiencies in the quality of care. The Metro District Health Services (MDHS) decided to focus on improving the annual review of the diabetic patient. The MDHS provides primary care to the uninsured population of Cape Town through a network of 45 Community Health Centres (CHC). Methods: An appreciative inquiry was established amongst the staff responsible for diabetic care at the 15 CHCs that had newly appointed facility managers. The inquiry completed three cycles of action-reflection over a period of one year and included training in clinical skills as requested by the participants. At the end of the inquiry a consensus was reached on the learning of the group. Results: This consensus was expressed in the form of 11 key themes. CHCs that reported success with improving the annual review formed chronic care teams that met regularly to discuss their goals, roles and to plan improvements. These teams developed more structured and systematic approaches to care, which included the creation of special clubs, attention to the steps in patient flow and methods of summarising and accessing key information. These teams also appointed specific champions who would not rotate to other duties and who would provide continuity of leadership and organisation. These teams also supported continuity of relationships, clinical management and organisation of care. Teams involved the community and local non-profit organisations, particularly in the establishment of support groups that could disseminate medications and build health literacy and self-efficacy. Some teams emphasised the need to also care for the carers and to not just focus on workload and output indicators. More successful CHCs also grappled with balancing of the workload, quality of care and waiting times in a way that improved all three in an upward spiral. Patient satisfaction, staff satisfaction and clinical outcomes were seen as interlinked' There was a need to plan methods for empowering patients and build self-efficacy through a variety of facility- and community-based as well as individual- and group-orientated initiatives. Training in clinical skills was requested for foot and eye screening. Feedback was given to the MDHS on the need to improve referral pathways and access to preventative services such as dieticians, podiatrists and vascular surgery. Finally, the inquiry process itself together with the annual audit supported organisational learning and change at the facility level. Conclusion: Improving the annual review has more to do with the organisation of care than gaps in knowledge or skills that can be addressed through training. While such gaps do exist, as shown by the training around foot screening, the main focus was on issues of leadership, teamwork, systematic organisation, continuity, staff satisfaction, motivation and the balancing of quality care provided, quantity of care demanded and queuing required. The appreciative inquiry (Al) process supported decentralised organisational learning and, while key themes were shared, the specific solutions were localised

Screening for diabetic retinopathy in primary care with a mobile fundal camera – evaluation of a South African pilot

Background and aims. In South Africa diabetes makes a significant contribution to the burden of disease. Diabetic retinopathy is a leading cause of adult blindness, and screening can reduce the incidence. This project aimed to implement and evaluate a new service for retinal screening that uses a non-mydriatic mobile fundal camera in primary care. This is the first time such a service has been evaluated in an African primary care context. Methods. The service was implemented as an operational research study at three community health centres and data were collected to evaluate the operational issues, screening, reporting and referral of patients. Results. Out of 400 patients screened 84% had a significantly reduced visual acuity, 63% had retinopathy (22% severe nonproliferative, 6% proliferative and 15% maculopathy), 2% of eyes could not be screened and 14% of patients required dilatation. Referral was necessary in 27% of cases for cataracts, in 7% for laser treatment and in 4% for other specialist services. Repeat photography was needed in 8% and urgent follow-up in 12%. A SWOT analysis of the pilot project was completed and recommendations were made on how to integrate it into the district health system. Conclusion. Screening with a fundal camera improved the quality of care for diabetic patients and is feasible in the South African public sector, primary care setting. A single technician should be able to photograph almost 10 000 patients a year. South African Medical Journal Vol. 97 (12) 2007: pp. 1284-128

MRI Markers and Functional Performance in Patients With CIS and MS: A Cross-Sectional Study

Introduction: Brain atrophy is a widely accepted marker of disease severity with association to clinical disability in multiple sclerosis (MS). It is unclear to which extent this association reflects common age effects on both atrophy and function. Objective: To explore how functional performance in gait, upper extremities and cognition is associated with brain atrophy in patients with Clinically Isolated Syndrome (CIS) and relapsing-remitting MS (RRMS), controlling for effects of age and sex. Methods: In 27 patients with CIS, 59 with RRMS (EDSS <= 3) and 63 healthy controls (HC), 3T MRI were analyzed for T2 lesion count (T2C), volume (T2V) and brain volumes [normalized brain volume (NBV), gray matter volume (NGMV), white matter volume (NWMV), thalamic volume (NThaIV)]. Functional performance was measured with short maximum walking speed (SMSW speed), 9-hole peg test (9HPT) and symbol digit modalities test (SDMT). Linear regression models were created for functional variables with stepwise inclusion of age, sex and MR imaging markers. Results: CIS differed from HC only in T2C and T2V. RRMS differed from HC in NBV, NGMV and NThaIV, T2C and T2V, but not in NWMV. A strong association with age was seen in HC, CIS and RRMS groups for NBV (r = -0.5 to -0.6) and NGMV (r = -0.6 to -0.8). Associations with age were seen in HC and RRMS but not CIS for NThaIV (r = -0.3; r = -0.5), T2C (r(s) = 0.3; r(s) = 0.2) and T2V (r(s) = 0.3; r(s) = 0.3). No effect of age was seen on NWMV. Correlations of functional performance with age in RRMS were seen for SMSW speed, 9HPTand SDMT (r = -0.27 to -0.46). Regression analyses yielded significant models only in the RRMS group for 9HPT, SMSW speed and EDSS. These included NBV, NGMV, NThaIV, NWMV, logT2V, age and sex as predictors. NThalV was the only MRI variable predicting a functional measure (9HPT(r)) with a higher standardized beta than age and sex (R2 = 0.36, p < 1e-04). Conclusion: Thalamic atrophy was a stronger predictor of hand function (9HPT) in RRMS, than age and sex. This underlines the clinical relevance of thalamic atrophy and the relevance of hand function as a clinical marker even in mildly disabled patients

In-out charge exchange measurements and 3D modelling of diagnostic thermal neutrals to study edge poloidal impurity asymmetries

A new method was developed to model the neutral population produced by the gas puff based charge exchange recombination spectroscopy systems at ASDEX Upgrade (AUG). With this method, the edge impurity density on the high field side (HFS) and low field side (LFS) can be obtained without the need to apply a neutral beam injection system. The neutral penetration needed for the calculation of the impurity density is obtained with a new gas puff module implemented in the FIDASIM code. The LFS impurity density profile evaluated with the new gas puff module matches the impurity density calculated with standard beam-based charge exchange diagnostics. Impurity temperature, rotation and density profiles at the HFS and LFS of an AUG H-mode discharge are presented. Edge impurity toroidal and poloidal flows show asymmetric structures. The impurity density asymmetries obtained with the new gas puff module are consistent with the observed flow structure

Non-parametric inference of impurity transport coefficients in the ASDEX Upgrade tokamak

We present a non-parametric inference of impurity transport coefficients by using charge exchange recombination spectroscopy measurements of Ne X, Ne VIII, O VIII, and C VI lines. Due to their close atomic numbers, neon, oxygen and carbon impurity ions are assumed to have the same diffusion coefficient D and convection velocity v. Unlike conventional techniques that modulate or perturb the impurity contents, we employ a quasi-stationary plasma with static impurity profiles. Since the ratio of v to D only describes the equilibrated profile of the sum of all impurity charge states, steady-state measurements can still decouple D and v if different charge states are simultaneously observed. We have formulated a non-parametric analysis framework based on the Bayesian probability theory and conducted transport coefficient measurements for a Type III ELMy H-mode plasma at ASDEX Upgrade. The charge exchange reactions with the background neutrals, which are known to affect the impurity charge state balance, are taken into account by introducing additional free parameters. While D at the pedestal is close to the neoclassical level ( < 1 m s-2), a large diffusion coefficient and a strong outward convection are inferred right inside the pedestal top.This work has been carried out within the framework of the EUROfusion Consortium and has received funding from the Euratom research and training programme 2014–2018 and 2019–2020 under Grant Agreement No. 633053

Modeling Spatial Sustainability: Spatial Welfare Economics versus Ecological Footprint

A spatial welfare framework for the analysis of the spatial dimensions of sustainability is developed. It incorporates agglomeration effects, interregional trade, negative environmental externalities and various land use categories. The model is used to compare rankings of spatial configurations according to evaluations based on social welfare and ecological footprint indicators. Five spatial configurations are considered for this purpose. The exercise is operationalized with the help of a two-region model of the economy that is in line with the new economic geography. Various (counter) examples show that the footprint method is not consistent with an approach aimed at maximum social welfare

A Spatial Survey of Environmental Indicators for Kazakhstan: An Examination of Current Conditions and Future Needs

The Republic of Kazakhstan, located in Central Asia, has experienced many years of environmental degradation, largely as a result of the poor management of its significant natural resources. In this survey, data relating to different environmental factors are critically analysed in order to understand the state of the environment. It was found that: warming trends are seen in sensitive areas (e.g. the steppe and near glaciers); drying trends are seen where there is already water stress (e.g. the Aral Sea); air quality has been declining recently (following improvements on the decadal timescale) in major urban centres, particularly Almaty; water quality appears to be improving in some areas (e.g. important lakes in the Aktobe and Zhambyl regions); and levels of exposure to radioactivity are below internationally recommended levels (where data have been found). More generally, there is an issue with data availability and quality, which requires attention if Kazakhstan is going to make the best use of its increasing investment in environmental actions. Current policies are reviewed and recommendations are made for future interventions