Evaluating and developing GP appraisal processes

EXECUTIVE SUMMARY: Introduction: This report details findings from a study undertaken by the School of Primary Care, Severn Deanery and the School of Health and Social Care, Faculty of Health and Life Sciences, University of the West of England, Bristol (UWE) between November 2008 and November 2009 to evaluate and develop GP appraisal processes in an area in the South West of England.A process of licensing for all doctors practising medicine in the UK is currently being implemented by the General Medical Council (GMC). All licensed doctors will need to demonstrate at regular intervals that their practice meets the generic standards set by the GMC, as described in Good Medical Practice (GMC 2006). Licensing will involve a process of revalidation for individual practitioners. It is planned to incorporate revalidation into the current appraisal processes for all medical professionals (GMC 2008).Although a statutory requirement, GP appraisal has until recently had primarily a formative, developmental purpose (DH 2002). Despite being obligatory, the uptake of GP appraisal has been problematic and inconsistent (Martin et al 2003). To date, only a limited amount of research or evaluation about GP appraisal has been published. However, there is recognised tension between the concept of appraisal as both a supportive developmental process and as a measure for judging fitness to practise.STUDY AIMA: This study set out to evaluate existing evidence submitted by GPs for the purposes of appraisal, and to explore how a model for appraisal could be developed that meets the needs of revalidation but also acts as a developmental process for individual GPs.METHODS: Both qualitative and quantitative methods were used for this study, in order to provide both breadth and depth to the evaluation. Quantitative data sources comprised all the appraisal evidence checklists used by appraisers in one Primary Care Trust (PCT) over the financial year April 2008 to May 2009 (n=123). The evidence checklist provides a basic template for recording the types of evidence a GP appraisee submits for appraisal purposes, and whether the evidence submitted relates to an individual’s personal practice, or to organisational practice within the GP practice as a whole. Data were analysed using descriptive statistics. Comparative analysis of types of evidence was conducted for appraiser, appraisee age and appraisee status.Qualitative data were collected through 5 focus groups held with 23 attendees at a GP appraisal stakeholder event hosted by the Deanery, and through interviews with all the appraisal leads for PCTs within the Deanery’s geographical area (n=7). Data were analysed thematically.The study was approved by a University research ethics sub-committee.MAIN FINDINGS AND POINTS FOR CONSIDERATION: Findings from this study raise particular points for consideration in relation to the appraiser role; the nature of evidence required for appraisal; the situation of sessional doctors; appraisee age; sharing expertise and experience; and the role of the Deanery in appraisal.Appraiser role: Most focus group and interview participants were adamant that appraisal should retain a strong developmental element. Clear definition of the role and appropriate national training were seen as essential factors contributing to the success of the process.Evidence required for appraisal: A notable feature of the focus group data was the confusion expressed by many participants about the nature and amount of evidence required for appraisal. Given the perception that appraisal for revalidation is extremely time-consuming for individual GPs, it was felt that having a clear brief about the evidence required is essential. The revised RCGP guidelines published after these data were collected (RCGP 2009, 2010) may go some way to ameliorating this problem, particularly with respect to the description of what constitutes audit for appraisal purposes.Sessional doctors: Many focus group participants and at least one appraisal lead were concerned that sessional doctors would have problems collecting the required evidence for appraisal. However, the data from this study also suggest that these problems can be addressed. The checklist data revealed very few substantive differences between principal and sessional doctors with regard to evidence submitted for appraisal. In particular, there was no statistically significant difference between the proportions of principal and sessional doctors who provided supporting information concerning their personal practice in relation to significant events, data or audit collection, multi-source feedback and complaints; this was notable, as these four areas have been identified as potentially problematic for sessional doctors (RCGP 2009, 2010). A number of the study participants were able to provide anecdotal evidence concerning innovative practice among sessional doctors with respect to the collection of evidence for appraisal, both at personal and collective levels. All these data, taken together, suggest that sessional doctors’ problems in this regard may be overstated, as long as appropriate support is provided by employing practices and PCTs.Appraisee age: The stereotype of the older GP, near retirement and not computer-literate, and not wishing to engage with appraisal, was present in the data. However, this was counterbalanced by examples of exceptions, and concern expressed about some younger, part-time GPs, whose personal circumstances do not support their involvement in appraisal. No differences were found in the checklist data between younger and older GPs with regard to the evidence they provided for appraisal. This applied to all GPs, and also only to locum GPs. It appears that difficulties encountered arise due to individuals’ particular circumstances or personalities, rather than because they belong to a defined category of appraisee.Sharing expertise and experience: A very strong feature of the qualitative data was the extent to which participants enthused about the benefits they experience when presented with opportunities for sharing expertise and experience. A number of suggestions concerning format were made, including both face to face and on-line media.The role of the Deanery in appraisal: There was no consistency with regard to participants’ opinions about the degree to which the Deanery should be involved in the co-ordination of the appraisal process. However, all the participants, both from the focus groups and the appraisal leads, were clear that the Deanery has a valuable role to play in training and preparation for appraisal for both appraisers and appraisees. They welcomed the idea that the Deanery could provide fora for sharing expertise and experience, as well as providing structured, dedicated preparation for appraisees. The Deanery was also thought to be well placed to help address any lack of consistency among appraisers through appropriate training.RECOMMENDATIONS:1. Change the organisational culture of practices and trusts to encourage access for sessional and locum doctors to Clinical Governance, Significant Event, Audit and Data Collection, through meetings and improved communication. This could be accelerated by including locum access as a quality criterion to be reviewed at practice inspections by PCTs or by the Care Quality Commission.2. Encourage, establish and facilitate fora and self directed groups for isolated locums and sessional GPs.3. Provide examples of innovative ways of collecting evidence for this group.4. Establish new tools designed specifically for this group, such as patient and colleague feedback

Effects of white matter microstructure on phase and susceptibility maps

Purpose: To investigate the effects on quantitative susceptibility mapping (QSM) and susceptibility tensor imaging (STI) of the frequency variation produced by the microstructure of white matter (WM). Methods: The frequency offsets in a WM tissue sample that are not explained by the effect of bulk isotropic or anisotropic magnetic susceptibility, but rather result from the local microstructure, were characterized for the first time. QSM and STI were then applied to simulated frequency maps that were calculated using a digitized whole-brain, WM model formed from anatomical and diffusion tensor imaging data acquired from a volunteer. In this model, the magnitudes of the frequency contributions due to anisotropy and microstructure were derived from the results of the tissue experiments. Results: The simulations suggest that the frequency contribution of microstructure is much larger than that due to bulk effects of anisotropic magnetic susceptibility. In QSM, the microstructure contribution introduced artificial WM heterogeneity. For the STI processing, the microstructure contribution caused the susceptibility anisotropy to be significantly overestimated. Conclusion: Microstructure-related phase offsets in WM yield artifacts in the calculated susceptibility maps. If susceptibility mapping is to become a robust MRI technique, further research should be carried out to reduce the confounding effects of microstructure-related frequency contribution

Effects of white matter microstructure on phase and susceptibility maps

Purpose: To investigate the effects on quantitative susceptibility mapping (QSM) and susceptibility tensor imaging (STI) of the frequency variation produced by the microstructure of white matter (WM). Methods: The frequency offsets in a WM tissue sample that are not explained by the effect of bulk isotropic or anisotropic magnetic susceptibility, but rather result from the local microstructure, were characterized for the first time. QSM and STI were then applied to simulated frequency maps that were calculated using a digitized whole-brain, WM model formed from anatomical and diffusion tensor imaging data acquired from a volunteer. In this model, the magnitudes of the frequency contributions due to anisotropy and microstructure were derived from the results of the tissue experiments. Results: The simulations suggest that the frequency contribution of microstructure is much larger than that due to bulk effects of anisotropic magnetic susceptibility. In QSM, the microstructure contribution introduced artificial WM heterogeneity. For the STI processing, the microstructure contribution caused the susceptibility anisotropy to be significantly overestimated. Conclusion: Microstructure-related phase offsets in WM yield artifacts in the calculated susceptibility maps. If susceptibility mapping is to become a robust MRI technique, further research should be carried out to reduce the confounding effects of microstructure-related frequency contribution

Compromise, learning and cognitive change as a function in induced cognitive conflict

LD2668 .T4 1966 W554Master of Scienc

Effects of white matter microstructure on phase and susceptibility maps

Purpose: To investigate the effects on quantitative susceptibility mapping (QSM) and susceptibility tensor imaging (STI) of the frequency variation produced by the microstructure of white matter (WM).Methods: The frequency offsets in a WM tissue sample that are not explained by the effect of bulk isotropic or anisotropic magnetic susceptibility, but rather result from the local microstructure, were characterized for the first time. QSM and STI were then applied to simulated frequency maps that were calculated using a digitized whole-brain, WM model formed from anatomical and diffusion tensor imaging data acquired from a volunteer. In this model, the magnitudes of the frequency contributions due to anisotropy and microstructure were derived from the results of the tissue experiments.Results: The simulations suggest that the frequency contribution of microstructure is much larger than that due to bulk effects of anisotropic magnetic susceptibility. In QSM, the microstructure contribution introduced artificial WM heterogeneity. For the STI processing, the microstructure contribution caused the susceptibility anisotropy to be significantly overestimated.Conclusion: Microstructure-related phase offsets in WM yield artifacts in the calculated susceptibility maps. If susceptibility mapping is to become a robust MRI technique, further research should be carried out to reduce the confounding effects of microstructure-related frequency contribution

Patient Compliance With Follow-Up After Open Reduction and Internal Fixation for Treating Malleolar Ankle Fractures: A Retrospective Review

Background: Compliance with follow-up after orthopaedic procedures is variable and does not always occur as recommended. Various factors such as medical, financial, cultural, and logistical reasons may contribute to this lack of compliance. The purpose of this study was to determine follow-up compliance of patients who had undergone open reduction and internal fixation (ORIF) for treating closed malleolar ankle fractures. Methods: Medical records of patients who underwent ORIF for treating closed malleolar ankle fractures by the senior author (RAM) were reviewed to evaluate compliance with postoperative follow-up (n = 267). Inclusion criteria were patients with isolated, acute, closed fractures (n = 229). Patients were considered to have followed up appropriately if they returned to clinic after a removable cast boot was issued at 4 to 8 weeks postoperatively. A 2-tailed t test was performed to analyze age and visual analogue scale score at the time of obtaining the removable cast boot. Chi-square testing was performed to analyze the other variables studied. Results: Of the 229 patients included, a total of 183 complied with follow-up whereas 46 did not. Younger age, male sex, and living greater than 160.9 km (100 mi) from the hospital were statistically significant variables associated with decreased compliance with follow-up. Conclusions: In our patient population, 80% of patients followed up in clinic as scheduled. The remaining 20% did not adhere with scheduled followup either before or after obtaining a removable cast boot. Younger age, male sex, and living greater than 100 miles from the hospital were associated with decreased compliance. Consideration should be paid to these factors when treating patients with ankle fractures

Global intravascular and local hyperoxia contrast phase-based blood oxygenation measurements

AbstractThe measurement of venous cerebral blood oxygenation (Yv) has potential applications in the study of patient groups where oxygen extraction and/or metabolism are compromised. It is also useful for fMRI studies to assess the stimulus-induced changes in Yv, particularly since basal Yv partially accounts for inter-subject variation in the haemodynamic response to a stimulus. A range of MRI-based methods of measuring Yv have been developed recently. Here, we use a method based on the change in phase in the MR image arising from the field perturbation caused by deoxygenated haemoglobin in veins. We build on the existing phase based approach (Method I), where Yv is measured in a large vein (such as the superior sagittal sinus) based on the field shift inside the vein with assumptions as to the vein's shape and orientation. We demonstrate two novel modifications which address limitations of this method. The first modification (Method II), maps the actual form of the vein, rather than assume a given shape and orientation. The second modification (Method III) uses the intra and perivascular phase change in response to a known change in Yv on hyperoxia to measure normoxic Yv in smaller veins. Method III can be applied to veins whose shape, size and orientation are not accurately known, thus allowing more localised measures of venous oxygenation. Results demonstrate that the use of an overly fine spatial filter caused an overestimation in Yv for Method I, whilst the measurement of Yv using Method II was less sensitive to this bias, giving Yv=0.62±0.03. Method III was applied to mapping of Yv in local veins across the brain, yielding a distribution of values with a mode of Yv=0.661±0.008

Insights into the pathological basis of dementia from population-based neuropathology studies

The epidemiological neuropathology perspective of population and community-based studies allows unbiased assessment of the prevalence of various pathologies and their relationships to late-life dementia. In addition, this approach provides complementary insights to conventional case–control studies, which tend to be more representative of a younger clinical cohort. The Cognitive Function and Ageing Study (CFAS) is a longitudinal study of cognitive impairment and frailty in the general United Kingdom population. In this review, we provide an overview of the major findings from CFAS, alongside other studies, which have demonstrated a high prevalence of pathology in the ageing brain, particularly Alzheimer's disease neuropathological change and vascular pathology. Increasing burdens of these pathologies are the major correlates of dementia, especially neurofibrillary tangles, but there is substantial overlap in pathology between those with and without dementia, particularly at intermediate burdens of pathology and also at the oldest ages. Furthermore, additional pathologies such as limbic-predominant age-related TDP-43 encephalopathy, ageing-related tau astrogliopathy and primary age-related tauopathies contribute to late-life dementia. Findings from ageing population-representative studies have implications for the understanding of dementia pathology in the community. The high prevalence of pathology and variable relationship to dementia status has implications for disease definition and indicate a role for modulating factors on cognitive outcome. The complexity of late-life dementia, with mixed pathologies, indicates a need for a better understanding of these processes across the life-course to direct the best research for reducing risk in later life of avoidable clinical dementia syndromes

Canonical Wnt signals combined with suppressed TGFβ/BMP pathways promote renewal of the native human colonic epithelium

Background: A defining characteristic of the human intestinal epithelium is that it is the most rapidly renewing tissue in the body. However, the processes underlying tissue renewal and the mechanisms that govern their coordination have proved difficult to study in the human gut. Objective: To investigate the regulation of stem cell-driven tissue renewal by canonical Wnt and TGFβ/bone morphogenetic protein (BMP) pathways in the native human colonic epithelium. Design: Intact human colonic crypts were isolated from mucosal tissue samples and placed into 3D culture conditions optimised for steady-state tissue renewal. High affinity mRNA in situ hybridisation and immunohistochemistry were complemented by functional genomic and bioimaging techniques. The effects of signalling pathway modulators on the status of intestinal stem cell biology, crypt cell proliferation, migration, differentiation and shedding were determined. Results: Native human colonic crypts exhibited distinct activation profiles for canonical Wnt, TGFβ and BMP pathways. A population of intestinal LGR5/OLFM4-positive stem/progenitor cells were interspersed between goblet-like cells within the crypt-base. Exogenous and crypt cell-autonomous canonical Wnt signals supported homeostatic intestinal stem/progenitor cell proliferation and were antagonised by TGFβ or BMP pathway activation. Reduced Wnt stimulation impeded crypt cell proliferation, but crypt cell migration and shedding from the crypt surface were unaffected and resulted in diminished crypts. Conclusions: Steady-state tissue renewal in the native human colonic epithelium is dependent on canonical Wnt signals combined with suppressed TGFβ/BMP pathways. Stem/progenitor cell proliferation is uncoupled from crypt cell migration and shedding, and is required to constantly replenish the crypt cell population