Reducing inappropriate hypnotic prescribing using a quality improvement initiative in a rural practice

Context This improvement project was set in a single general practice in rural Lincolnshire, East Midlands, UK. All doctors and practice staff were actively engaged in reducing inappropriate long term prescribing of hypnotic drugs in the practice population as part of a Quality Improvement Collaborative (QIC). Problem Hypnotic drugs are only licensed for short term use but inappropriate long-term prescribing of hypnotics is common. Evidence from previous studies shows that hypnotics have limited therapeutic value and potential for significant adverse cognitive and psychiatric effects. Although there is evidence for hypnotic drug withdrawal programmes there have been few improvement projects showing whether and how this might work in practice. Assessment of problem and analysis of its causes Baseline rates of hypnotic prescribing were analysed and charted using statistical process control (SPC) methods. Patients on repeat prescriptions of hypnotic drugs were identified from the practice database. Causes, solutions and barriers were determined using surveys and focus groups of patients and staff. A withdrawal programme was implemented for all patients on long term hypnotics by writing to patients, arranging a consultation, making a detailed assessment and using techniques such as tapering doses of drugs and using cognitive behavioural therapy for insomnia (CBTi) during general practice consultations. The improvement was supported by a QIC called REST (Resources for Effective Sleep Treatment) which supported the practice team to implement sleep assessment and management tools using plan-do-study-act cycles, process mapping and new protocols. Strategy for change The change was coordinated in the practice over six months, with each practitioner maintaining an agreed and consistent approach for managing sleep problems. All staff including doctors, nurses, administrative staff and practice manager took part. Patients were informed of the planned alteration to their treatment for their sleeping problem via a letter detailing exactly how the new regime would be implemented alongside the reasons for this. Patients were offered an appointment to discuss the proposed changes with their GP and all did so. Measurement of improvement We measured improvement by analysing prescribing rates using statistical process control charts. We also surveyed patients and conducted a focus group to explore the patients’ personal experiences of the new service the support they received during the withdrawal programme and how they manage their sleep now. Effects of changes There was a significant reduction in hypnotic prescribing of benzodiazepines (664.9 to 62.0 ADQ per 1000-STAR-PU) and Z drugs (2156.7 to 120.1A ADQ per STAR-PU) in the practice over the six months of the project and this improvement has been sustained since the initiative. Some patients were initially unhappy about being taken off sleeping tablets but with the approach described were successfully withdrawn. No patients are now prescribed long term benzodiazepines or Z drugs for sleep difficulties in the practice. Psychological treatments for the management of sleep problems are used first-line instead of hypnotics. The transition from hypnotics to psychological treatments is evidence of improvement in patient care. Lessons learnt It is possible to implement a hypnotic withdrawal programme over a relatively short period of time in general practice using a carefully constructed programme applied consistently by staff comprising a letter to patients, tapering of drugs and CBTi supported through education of practitioners in sleep management and quality improvement methods. Message for others Key factors for success in this improvement project were a motivated practice team, a range of solutions which could be adapted locally, expert support on sleep management and quality improvement methods and feedback of results. We will present further data on the experience of patients in this improvement project

Using The Jeopardy Game To Enhance Student Understanding Of Accounting Information Systems (AIS) Exam Material

Accounting research has included many suggestions for increasing active learning in the classroom. These include journal writing, role-playing and playing games (Haywood, McMullen, and Wygal 2004). The use of games in class is an effective tool to stimulate interest, reduce boredom, and enhance learning among the students. The popular TV game show “Jeopardy!” was employed to review students for an undergraduate accounting information systems (AIS) exam. Pre/post test results reflect a significant increase in the students’ understanding of AIS exam material that was covered. Overall the students agreed that the game was enjoyable and requested that they be able to review for other exams in a similar manner

The War On Fraud: Reducing Cheating In The Classroom

The purpose of this article is to alert and inform the reader of the rampant amount of fraud (cheating) that is taking place in the classrooms across the country and to provide some measures that can be employed to reduce the likelihood of it happening in your classroom. Cheating is analyzed and diagnosed utilizing the components of the fraud triangle (pressure, opportunity, and rationalization). Activities to promote ethical behavior and making it more difficult to rationalize cheating are proposed. Strategies for reducing the opportunity to cheat are also included. “In the broadest sense, fraud can encompass any crime for gain that uses deception as its principal modus operandi” (Wells, 2005

Multi-view Temporal Ensemble for Classification of Non-Stationary Signals

In the classification of non-stationary time series data such as sounds, it is often tedious and expensive to get a training set that is representative of the target concept. To alleviate this problem, the proposed method treats the outputs of a number of deep learning sub-models as the views of the same target concept that can be linearly combined according to their complementarity. It is proposed that the view’s complementarity be the contribution of the view to the global view, chosen in this work to be the Laplacian eigenmap of the combined data. Complementarity is computed by alternate optimization, a process that involves the cost function of the Laplacian eigenmap and the weights of the linear combination. By blending the views in this way, a more complete view of the underlying phenomenon can be made available to the final classifier. Better generalization is obtained, as the consensus between the views reduces the variance while the increase in the discriminatory information reduces the bias. Data experiment with artificial views of environment sounds formed by deep learning structures of different configurations shows that the proposed method can improve the classification performance

Patient experiences of a quality improvement initiative to reduce inappropriate long term hypnotic prescribing in a rural practice

Introduction Insomnia is common affecting up to 40% of adults. About a half of sufferers seek help from primary care, usually receiving sleep hygiene advice or hypnotic medication. Hypnotics are licensed short term, have limited therapeutic value and significant potential adverse effects, but many patients continue to receive them long term inappropriately. An innovative sleep management programme to reduce inappropriate prescribing of hypnotics was implemented by a single general practice in rural Lincolnshire as part of a quality improvement collaborative. This involved gradual withdrawal of hypnotic drugs supported by sleep assessment and treatment using cognitive behavioural therapy for insomnia. Little is known about patients’ experience of this type of withdrawal programme. We aimed to investigate patients’ experiences. Method We used a focus group interview to investigate patients’ experiences of the programme, inviting patients who had undergone the programme by letter. The focus group was moderated by two independent non-clinical researchers using a topic guide. Data were recorded, transcribed and analysed using a constant comparative approach using MAXQDA 2007. Results A single focus group was held with four patients. Key themes that emerged included current feelings about sleeping tablets, attitudes towards the process, access to GP support, perceived usefulness of sleep management, (re)attribution of sleep difficulty and current quality of patients’ sleep. Although patients were initially ambivalent they followed the programme because of trust in their doctor and a clear and consistent approach from the practice. Patients expressed a need for more face-to-face sleep advice during the process and greater recognition afterwards. They were generally positive about the benefits of hypnotic withdrawal despite variable effects on sleep. Discussion Patients were positive about the benefits of withdrawing from long term hypnotic drugs. They made recommendations about future programmes. Sleep education should be delivered during a consultation and a formal end to the process, recognising the patients’ success, should be incorporated. The main limitation was that the focus group was conducted over a year after the sleep management programme was conducted which may have affected participation. Focus groups can provide a useful method of evaluating patients’ experience which is an important aspect of quality of care

Signal processing and analytics of multimodal biosignals

Ph. D. ThesisBiosignals have been extensively studied by researchers for applications in diagnosis, therapy, and monitoring. As these signals are complex, they have to be crafted as features for machine learning to work. This begs the question of how to extract features that are relevant and yet invariant to uncontrolled extraneous factors. In the last decade or so, deep learning has been used to extract features from the raw signals automatically. Furthermore, with the proliferation of sensors, more raw signals are now available, making it possible to use multi-view learning to improve on the predictive performance of deep learning. The purpose of this work is to develop an effective deep learning model of the biosignals and make use of the multi-view information in the sequential data. This thesis describes two proposed methods, namely: (1) The use of a deep temporal convolution network to provide the temporal context of the signals to the deeper layers of a deep belief net. (2) The use of multi-view spectral embedding to blend the complementary data in an ensemble. This work uses several annotated biosignal data sets that are available in the open domain. They are non-stationary, noisy and non-linear signals. Using these signals in their raw form without feature engineering will yield poor results with the traditional machine learning techniques. By passing abstractions that are more useful through the deep belief net and blending the complementary data in an ensemble, there will be improvement in performance in terms of accuracy and variance, as shown by the results of 10-fold validations.Nanyang Polytechni

Interacting with a gaze-aware virtual character

In this paper, we present the user’s attentive state interpreted through eye gaze while interacting with a virtual character. The underlying narrative in which the approach was tested is based on a classical XIX th century psychological novel: Madame Bovary, by Flaubert. We connected a remote eye tracker with a dynamic 3D world. An empirical study revealed individual user experiences and behavioral patterns. In particular, we identified two different groups of users: one that was showing natural eye gaze behaviors with rhythmic eye gaze shifts between the characters ’ eyes, face and the scene and another one permanently staring at the character. Interestingly, the group with more natural behaviors towards the character also rated the experience with the system more positively

Psychotherapy mediated by remote communication technologies: a meta-analytic review

Reproduced with permission of the publisher. © 2008 Bee et al; licensee BioMed Central Ltd. The electronic version of this article is the complete one and can be found online at: http://www.biomedcentral.com/1471-244X/8/60. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Background Access to psychotherapy is limited by psychopathology (e.g. agoraphobia), physical disability, occupational or social constraints and/or residency in under-served areas. For these populations, interventions delivered via remote communication technologies (e.g. telephone, internet) may be more appropriate. However, there are concerns that such delivery may influence the therapeutic relationship and thus reduce therapy effectiveness. This review aimed to determine the clinical effectiveness of remotely communicated, therapist-delivered psychotherapy. Methods Systematic review (including electronic database searching and correspondence with authors) of randomised trials of individual remote psychotherapy. Electronic databases searched included MEDLINE (1966–2006), PsycInfo (1967–2006), EMBASE (1980–2006) and CINAHL databases (1982–2006). The Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDAN-CTR). All searches were conducted to include studies with a publication date to July 2006. Results Thirteen studies were identified, ten assessing psychotherapy by telephone, two by internet and one by videoconference. Pooled effect sizes for remote therapy versus control conditions were 0.44 for depression (95%CI 0.29 to 0.59, 7 comparisons, n = 726) and 1.15 for anxiety-related disorders (95%CI 0.81 to 1.49, 3 comparisons, n = 168). There were few comparisons of remote versus face-to-face psychotherapy. Conclusion Remote therapy has the potential to overcome some of the barriers to conventional psychological therapy services. Telephone-based interventions are a particularly popular research focus and as a means of therapeutic communication may confer specific advantages in terms of their widespread availability and ease of operation. However, the available evidence is limited in quantity and quality. More rigorous trials are required to confirm these preliminary estimates of effectiveness. Future research priorities should include overcoming the methodological shortcomings of published work by conducting large-scale trials that incorporate both clinical outcome and more process-orientated measures