Improving the effectiveness and efficiency of outpatient services: A scoping review of interventions at the primary-secondary care interface

This is the final published version. Available from SAGE Publications via the DOI in this record.Objectives: Variation in patterns of referral from primary care can lead to inappropriate overuse or underuse of specialist resources. Our aim was to review the literature on strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services. Methods: A scoping review to update a review published in 2006. We conducted a systematic literature search and qualitative evidence synthesis of studies across five intervention domains: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary care practitioners and specialists; interventions to change the referral behaviour of primary care practitioners and interventions to change patient behaviour. Results: The 183 studies published since 2005, taken with the findings of the previous review, suggest that transfer of services from secondary to primary care and strategies aimed at changing referral behaviour of primary care clinicians can be effective in reducing outpatient referrals and in increasing the appropriateness of referrals. Availability of specialist advice to primary care practitioners by email or phone and use of store-and-forward telemedicine also show potential for reducing outpatient referrals and hence reducing costs. There was little evidence of a beneficial effect of relocation of specialists to primary care, or joint primary/secondary care management of patients on outpatient referrals. Across all intervention categories there was little evidence available on cost-effectiveness. Conclusions: There are a number of promising interventions which may improve the effectiveness and efficiency of outpatient services, including making it easier for primary care clinicians and specialists to discuss patients by email or phone. There remain substantial gaps in the evidence, particularly on cost-effectiveness, and new interventions should continue to be evaluated as they are implemented more widely. A move for specialists to work in the community is unlikely to be cost-effective without enhancing primary care clinicians’skills through education or joint consultations with complex patients.National Institute for Health Research (NIHR

Spin dynamics of heterometallic Cr7M wheels (M = Mn, Zn, Ni) probed by inelastic neutron scattering

Inelastic neutron scattering has been applied to the study of the spin dynamics of Cr-based antiferromagnetic octanuclear rings where a finite total spin of the ground state is obtained by substituting one Cr(III) ion (s = 3/2) with Zn (s = 0), Mn (s = 5/2) or Ni (s = 1) di-cations. Energy and intensity measurements for several intra-multiplet and inter-multiplet magnetic excitations allow us to determine the spin wavefunctions of the investigated clusters. Effects due to the mixing of different spin multiplets have been considered. Such effects proved to be important to correctly reproduce the energy and intensity of magnetic excitations in the neutron spectra. On the contrary to what is observed for the parent homonuclear Cr8 ring, the symmetry of the first excited spin states is such that anticrossing conditions with the ground state can be realized in the presence of an external magnetic field. Heterometallic Cr7M wheels are therefore good candidates for macroscopic observations of quantum effects.Comment: 9 pages, 11 figures, submitted to Phys. Rev. B, corrected typos and added references, one sentence change

Outpatient services and primary care: scoping review, substudies and international comparisons

This is the final version of the report. Available from the publisher via the DOI in this record.AIM: This study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B. Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services. FINDINGS FROM THE SCOPING REVIEW: Evidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals. FINDINGS FROM THE SUBSTUDIES: Because of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS. CONCLUSIONS: For many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.The NIHR Health Services and Delivery Research programme

Oxo-centered carboxylate-bridged trinuclear complexes deposited on Au(111) by a mass-selective electrospray.

We developed an apparatus for nondestructive in vacuum deposition of mass-selected fragile Cr based metal trinuclear complexes, by modifying a commercial Mass Spectrometer containing an electrospray ionization source. Starting from a solution, this system creates a beam of ionized molecules which is then transferred into an evacuated region where the molecules can be mass selected before deposition. To verify the system efficiency, we deposited sub monolayers of oxo-centered carboxylate-bridged trinuclear complexes (Cr3 and Cr2Ni) on Au(111) surface. By XPS and STM we determined the deposited molecule stoichiometry and the surface coverage. The results show that this apparatus is works well for the in vacuum deposition of molecular nanomagnets and, thanks to its reduced dimensions, it is portable

NMR Study of Spin Dynamics in V\u3csub\u3e7\u3c/sub\u3eZn and V\u3csub\u3e7\u3c/sub\u3eNi Molecular Rings

We present a 1H NMR investigation of spin dynamics in to finite integer spin molecular nanomagnetic rings, namely V7Zn and V7Ni. This study could be put in correlation with the problem of Haldane gap in infinite integer spin chains. While V7Zn is an approximation of a homometallic broken chain due to the presence of s = 0 Zn2+ ion uncoupled from nearest neighbor V2+ s = 1 ions, the V7Ni compound constitutes an example of a closed periodical s = 1 heterometallic chain. From preliminary susceptibility measurements on single crystals and data analysis, the exchange coupling constant J/kB results in the order of few kelvin. At room temperature, the frequency behavior of the 1H NMR spin–lattice relaxation rate 1/T1 allowed to conclude that the spin–spin correlation function is similar to the one observed in semi-integer spin molecules, but with a smaller cutoff frequency. Thus, the high-T data can be interpreted in terms of, e.g., a Heisenberg model including spin diffusion. On the other hand, the behavior of 1/T1 vs temperature at different constant fields reveals a clear peak at temperature of the order of J/kB, qualitatively in agreement with the well-known Bloembergen–Purcell–Pound model and with previous results on semi-integer molecular spin systems. Consequently, one can suggest that for a small number N of interacting s = 1 ions (N = 8), the Haldane conjecture does not play a key role on spin dynamics, and the investigated rings still keep the quantum nature imposed mainly by the low number of magnetic centers, with no clear topological effect due to integer spins

Evaluation of telephone first approach to demand management in English general practice: observational study

Objective: To evaluate a “telephone first” approach, in which all patients wanting to see a general practitioner (GP) are asked to speak to a GP on the phone before being given an appointment for a face to face consultation. Design: Time series and cross sectional analysis of routine healthcare data, data from national surveys, and primary survey data. Participants: 147 general practices adopting the telephone first approach compared with a 10% random sample of other practices in England. Intervention: Management support for workload planning and introduction of the telephone first approach provided by two commercial companies. Main outcome measures: Number of consultations, total time consulting (59 telephone first practices, no controls). Patient experience (GP Patient Survey, telephone first practices plus controls). Use and costs of secondary care (hospital episode statistics, telephone first practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices thought to be closely following the companies’ protocols. Results: After the introduction of the telephone first approach, face to face consultations decreased considerably (adjusted change within practices −38%, 95% confidence interval −45% to −29%; P<0.001). An average practice experienced a 12-fold increase in telephone consultations (1204%, 633% to 2290%; P<0.001). The average duration of both telephone and face to face consultations decreased, but there was an overall increase of 8% in the mean time spent consulting by GPs, albeit with large uncertainty on this estimate (95% confidence interval −1% to 17%; P=0.088). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase. Compared with other English practices in the national GP Patient Survey, in practices using the telephone first approach there was a large (20.0 percentage points, 95% confidence interval 18.2 to 21.9; P<0.001) improvement in length of time to be seen. In contrast, other scores on the GP Patient Survey were slightly more negative. Introduction of the telephone first approach was followed by a small (2.0%) increase in hospital admissions (95% confidence interval 1% to 3%; P=0.006), no initial change in emergency department attendance, but a small (2% per year) decrease in the subsequent rate of rise of emergency department attendance (1% to 3%; P=0.005). There was a small net increase in secondary care costs. Conclusions: The telephone first approach shows that many problems in general practice can be dealt with over the phone. The approach does not suit all patients or practices and is not a panacea for meeting demand. There was no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care

How does the alcohol industry attempt to influence marketing regulations? A systematic review

Aim: To systematically review, using a qualitative, narrative synthesis approach, papers examining alcohol industry efforts to influence alcohol marketing policy, and compare with those used by the tobacco industry. Methods: Literature searches were conducted between April and July 2011, and updated in March 2013. Papers were included if they: made reference to alcohol industry efforts to influence (a) policy debates concerning marketing regulations, (b) new specific marketing policies or (c) broad alcohol policy which included marketing regulations; were written in English; and concerned the period 1990-2013. Alcohol industry political activity was categorized into strategies/tactics and frames/arguments. Data extraction was undertaken by the lead author and 100% of the papers were fully second-reviewed. Seventeen papers met the review criteria. Results: Five main political strategies and five main frames were identified. The alcohol industry argues against marketing regulation by emphasizing industry responsibility and the effectiveness of self-regulation, questioning the effectiveness of statutory regulation and by focusing on individual responsibility. Arguments relating to industry responsibility are often reinforced through corporate social responsibility activities. The industry primarily conveys its arguments through manipulating the evidence base and by promoting ineffective voluntary codes and non-regulatory initiatives. Conclusions: The alcohol industry's political activity is more varied than existing models of corporate political activity suggest. The industry's opposition to marketing regulation centres on claims that the industry is responsible and that self regulation is effective. There are considerable commonalities between tobacco and alcohol industry political activity, with differences due potentially to differences in policy contexts and perceived industry legitimacy

Modelling Conformational Flexibility in a Spectrally Addressable Molecular Multi-Qubit Model System

Dipolar coupled multi-spin systems have the potential to be used as molecular qubits. Herein we report the synthesis of a molecular multi-qubit model system with three individually addressable, weakly interacting, spin (Formula presented.) centres of differing g-values. We use pulsed Electron Paramagnetic Resonance (EPR) techniques to characterise and separately address the individual electron spin qubits; CuII, Cr7Ni ring and a nitroxide, to determine the strength of the inter-qubit dipolar interaction. Orientation selective Relaxation-Induced Dipolar Modulation Enhancement (os-RIDME) detecting across the CuII spectrum revealed a strongly correlated CuII-Cr7Ni ring relationship; detecting on the nitroxide resonance measured both the nitroxide and CuII or nitroxide and Cr7Ni ring correlations, with switchability of the interaction based on differing relaxation dynamics, indicating a handle for implementing EPR-based quantum information processing (QIP) algorithms

Entanglement in supramolecular spin systems of two weakly coupled antiferromagnetic rings (purple-Cr7Ni)

International audienceWe characterize supramolecular magnetic structures, consisting of two weakly coupled antiferromagnetic rings, by low-temperature specific heat, susceptibility, magnetization and electron paramagnetic resonance measurements. Intra- and inter-ring interactions are modeled through a microscopic spin-Hamiltonian approach that reproduces all the experimental data quantitatively and legitimates the use of an effective two-qubit picture. Spin entanglement between the rings is experimentally demonstrated through magnetic susceptibility below 50 mK and theoretically quantified by the concurrence

Spin dynamics of molecular nanomagnets fully unraveled by four-dimensional inelastic neutron scattering

Molecular nanomagnets are among the first examples of spin systems of finite size and have been test-beds for addressing a range of elusive but important phenomena in quantum dynamics. In fact, for short-enough timescales the spin wavefunctions evolve coherently according to the an appropriate cluster spin-Hamiltonian, whose structure can be tailored at the synthetic level to meet specific requirements. Unfortunately, to this point it has been impossible to determine the spin dynamics directly. If the molecule is sufficiently simple, the spin motion can be indirectly assessed by an approximate model Hamiltonian fitted to experimental measurements of various types. Here we show that recently-developed instrumentation yields the four-dimensional inelastic-neutron scattering function S(Q,E) in vast portions of reciprocal space and enables the spin dynamics to be determined with no need of any model Hamiltonian. We exploit the Cr8 antiferromagnetic ring as a benchmark to demonstrate the potential of this new approach. For the first time we extract a model-free picture of the quantum dynamics of a molecular nanomagnet. This allows us, for example, to examine how a quantum fluctuation propagates along the ring and to directly test the degree of validity of the N\'{e}el-vector-tunneling description of the spin dynamics