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New approaches are needed to safely reduce emergency admissions to hospital by targeting interventions effectively in primary care. A predictive risk stratification tool (PRISM) identifies each registered patient's risk of an emergency admission in the following year, allowing practitioners to identify and manage those at higher risk. We evaluated the introduction of PRISM in primary care in one area of the United Kingdom, assessing its impact on emergency admissions and other service use.
We conducted a randomized stepped wedge trial with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. PRISM was implemented in eleven primary care practice clusters (total thirty-two practices) over a year from March 2013. We analyzed routine linked data outcomes for 18 months.
We included outcomes for 230,099 registered patients, assigned to ranked risk groups.
Overall, the rate of emergency admissions was higher in the intervention phase than in the control phase: adjusted difference in number of emergency admissions per participant per year at risk, delta = .011 (95 percent Confidence Interval, CI .010, .013). Patients in the intervention phase spent more days in hospital per year: adjusted delta = .029 (95 percent CI .026, .031). Both effects were consistent across risk groups.
Primary care activity increased in the intervention phase overall delta = .011 (95 percent CI .007, .014), except for the two highest risk groups which showed a decrease in the number of days with recorded activity.
Introduction of a predictive risk model in primary care was associated with increased emergency episodes across the general practice population and at each risk level, in contrast to the intended purpose of the model. Future evaluation work could assess the impact of targeting of different services to patients across different levels of risk, rather than the current policy focus on those at highest risk.
Emergency admissions to hospital are a major financial burden on health services. In one area of the United Kingdom (UK), we evaluated a predictive risk stratification tool (PRISM) designed to support primary care practitioners to identify and manage patients at high risk of admission. We assessed the costs of implementing PRISM and its impact on health services costs. At the same time as the study, but independent of it, an incentive payment (‘QOF’) was introduced to encourage primary care practitioners to identify high risk patients and manage their care.
We conducted a randomized stepped wedge trial in thirty-two practices, with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. We analysed routine linked data on patient outcomes for 18 months (February 2013 – September 2014). We assigned standard unit costs in pound sterling to the resources utilized by each patient. Cost differences between the two study phases were used in conjunction with differences in the primary outcome (emergency admissions) to undertake a cost-effectiveness analysis.
We included outcomes for 230,099 registered patients. We estimated a PRISM implementation cost of GBP0.12 per patient per year.
Costs of emergency department attendances, outpatient visits, emergency and elective admissions to hospital, and general practice activity were higher per patient per year in the intervention phase than control phase (adjusted δ = GBP76, 95 percent Confidence Interval, CI GBP46, GBP106), an effect that was consistent and generally increased with risk level.
Despite low reported use of PRISM, it was associated with increased healthcare expenditure. This effect was unexpected and in the opposite direction to that intended. We cannot disentangle the effects of introducing the PRISM tool from those of imposing the QOF targets; however, since across the UK predictive risk stratification tools for emergency admissions have been introduced alongside incentives to focus on patients at risk, we believe that our findings are generalizable.
A predictive risk stratification tool (PRISM) to estimate a patient's risk of an emergency hospital admission in the following year was trialled in general practice in an area of the United Kingdom. PRISM's introduction coincided with a new incentive payment (‘QOF’) in the regional contract for family doctors to identify and manage the care of people at high risk of emergency hospital admission.
Alongside the trial, we carried out a complementary qualitative study of processes of change associated with PRISM's implementation. We aimed to describe how PRISM was understood, communicated, adopted, and used by practitioners, managers, local commissioners and policy makers. We gathered data through focus groups, interviews and questionnaires at three time points (baseline, mid-trial and end-trial). We analyzed data thematically, informed by Normalisation Process Theory (1).
All groups showed high awareness of PRISM, but raised concerns about whether it could identify patients not yet known, and about whether there were sufficient community-based services to respond to care needs identified. All practices reported using PRISM to fulfil their QOF targets, but after the QOF reporting period ended, only two practices continued to use it. Family doctors said PRISM changed their awareness of patients and focused them on targeting the highest-risk patients, though they were uncertain about the potential for positive impact on this group.
Though external factors supported its uptake in the short term, with a focus on the highest risk patients, PRISM did not become a sustained part of normal practice for primary care practitioners.
Depression is a prevalent long-term condition that is associated with substantial resource use. Telehealth may offer a cost-effective means of supporting the management of people with depression.
To investigate the cost-effectiveness of a telehealth intervention (‘Healthlines’) for patients with depression.
A prospective patient-level economic evaluation conducted alongside a randomised controlled trial. Patients were recruited through primary care, and the intervention was delivered via a telehealth service. Participants with a confirmed diagnosis of depression and PHQ-9 score ≥10 were recruited from 43 English general practices. A series of up to 10 scripted, theory-led, telephone encounters with health information advisers supported participants to effect a behaviour change, use online resources, optimise medication and improve adherence. The intervention was delivered alongside usual care and was designed to support rather than duplicate primary care. Cost-effectiveness from a combined health and social care perspective was measured by net monetary benefit at the end of 12 months of follow-up, calculated from incremental cost and incremental quality-adjusted life years (QALYs). Cost–consequence analysis included cost of lost productivity, participant out-of-pocket expenditure and the clinical outcome.
A total of 609 participants were randomised – 307 to receive the Healthlines intervention plus usual care and 302 to receive usual care alone. Forty-five per cent of participants had missing quality of life data, 41% had missing cost data and 51% of participants had missing data on either cost or utility, or both. Multiple imputation was used for the base-case analysis. The intervention was associated with incremental mean per-patient National Health Service/personal social services cost of £168 (95% CI £43 to £294) and an incremental QALY gain of 0.001 (95% CI −0.023 to 0.026). The incremental cost-effectiveness ratio was £132 630. Net monetary benefit at a cost-effectiveness threshold of £20 000 was –£143 (95% CI –£164 to –£122) and the probability of the intervention being cost-effective at this threshold value was 0.30. Productivity costs were higher in the intervention arm, but out-of-pocket expenses were lower.
The Healthlines service was acceptable to patients as a means of condition management, and response to treatment after 4 months was higher for participants randomised to the intervention. However, the positive average intervention effect size was modest, and incremental costs were high relative to a small incremental QALY gain at 12 months. The intervention is not likely to be cost-effective in its current form.
Acting on harmful command hallucinations is a major clinical concern. Our COMMAND CBT trial approximately halved the rate of harmful compliance (OR = 0.45, 95% CI 0.23–0.88, p = 0.021). The focus of the therapy was a single mechanism, the power dimension of voice appraisal, was also significantly reduced. We hypothesised that voice power differential (between voice and voice hearer) was the mediator of the treatment effect.
The trial sample (n = 197) was used. A logistic regression model predicting 18-month compliance was used to identify predictors, and an exploratory principal component analysis (PCA) of baseline variables used as potential predictors (confounders) in their own right. Stata's paramed command used to obtain estimates of the direct, indirect and total effects of treatment.
Voice omnipotence was the best predictor although the PCA identified a highly predictive cognitive-affective dimension comprising: voices’ power, childhood trauma, depression and self-harm. In the mediation analysis, the indirect effect of treatment was fully explained by its effect on the hypothesised mediator: voice power differential.
Voice power and treatment allocation were the best predictors of harmful compliance up to 18 months; post-treatment, voice power differential measured at nine months was the mediator of the effect of treatment on compliance at 18 months.
The peculiar motions for spiral galaxies and elliptical galaxies within V = 3500 km/s are compared to the model predictions of the mass concentration (MC) velocity field model of Lynden-Bell et al. The large-scale motions defined by over 600 galaxies from three independent sets of data (Aaronson et al.; de Vaucouleurs and Peters and elliptical galaxies) are in substantial agreement with this model.
Motions of nearby elliptical galaxies reveal a large-scale velocity flow relative to cosmic rest towards the point 1=307±10, b = 9±10. The data are fit best by a two-component flow model. The smaller component is due to Virgo, which induces a velocity at the Local Group of 250 km/s. The main flow is due to a more massive concentration located a distance of 4350±350 km/s towards 1=307, b=9, which induces a local velocity here of 570±60 km/s. This larger component falls off away from the mass concentration roughly as r−1. The Centaurus double cluster and its neighbors are in the direction of the mass concentration but are in the foreground and are falling into it. Galaxy counts, radial velocity surveys, and the motions of nearby spirals are consistent with the above model. The IRAS dipole results are less clear but may also be consistent. There is evidence that the distant mass concentration is non-spherical, with the Centaurus cloud a substantial sub-condensation in the foreground. The formal agreement of the large-scale flow with biased (b=2) cold dark matter is low, but the simple methods used so far to assess this are uncertain. The main weakness of the present data in comparing to theory is the fact that they do not penetrate far enough to show the velocity field on all sides of the mass concentration. Sphericity and total extent of the flow are therefore still unknown.
Conservation planning often relies on measures such as species richness and abundance to prioritize areas for protection. Nonetheless, alternative metrics such as functional traits have recently been shown to be useful complementary measures for detecting biological change. Timely conservation planning often precludes the collection of such detailed biological data relying instead on remotely-sensed habitat mapping as a surrogate for diversity. While there is evidence that habitat maps may predict taxonomic species richness and diversity in some coastal ecosystems, it is unknown whether similar strong relationships exist for functional traits and functional multimetrics. We compared the performance of physical habitat structural complexity obtained from high definition swath mapping in explaining variation in traditional taxonomic metrics as well as functional traits (e.g., maximum length, trophic level, gregariousness) and functional multimetrics (e.g., functional richness, dispersion) of fish assemblages. Reef complexity measures were good surrogates for fish species richness and abundance but not for functional traits or multimetrics, except functional richness at the scale of 1 m. Remotely sensed habitat maps may not be a good surrogate for predicting functional traits and multimetrics of fish assemblages, and must be used with caution when maximizing such aspects of assemblages is a priority for conservation planning.
We have used a new distance estimator for elliptical galaxies to determine the peculiar velocities, with respect to a uniform Hubble flow, of approximately 400 galaxies. The relative distances of five clusters in common with those of Aaronson et al. (1981, 1986), based on the infrared Tully-Fisher relation for spirals, are in good agreement.
We do not see the reflex of the Local Group motion with respect to the microwave background out to recession velocities of 6000 km s−1. Rather, the frame of elliptical galaxies appears to be moving with respect to the microwave background with a velocity of 600 km s−1 towards 1 = 312°, b = +6°. This motion is consistent with a re-analysis of the Rubin et al. (1976) data on the magnitude-diameter relation for ScI galaxies and with the nearby and cluster samples of Aaronson et al. (1982, 1986).
Evaluate antimicrobial stewardship interventions targeted to reduce highly active antiretroviral therapy (HAART)– or opportunistic infection (Ol)–related medication errors and increase error resolution.
Retrospective before-after study.
Academic medical center.
Inpatients who were prescribed antiretroviral therapy before the intervention (January 1, 2011, to October 31, 2011) and after the intervention (July 1, 2012, to December 31, 2012). Patients treated with lamivudine or tenofovir monotherapy for hepatitis B were excluded.
Antimicrobial stewardship interventions included education, modification of electronic medication records, collaboration with the infectious diseases (ID) department, and prospective audit and review of HAART and OI regimens by an ID clinical pharmacist.
Data for 162 admissions from the preintervention period and 110 admissions from the postintervention period were included. The number of admissions with a medication error was significantly reduced after the intervention (81 [50%] of 162 admissions vs 37 (34%) of 110 admissions; P < .00)1. A total of 124 errors occurred in the preintervention group (mean no. of errors, 1.5 per admission), and 43 errors occurred in the postintervention group (mean no. of errors, 1.2 per admission). The most common error types were major drug interactions and dosing in the preintervention group and renal adjustment and OI-related errors in the postintervention group. A significantly higher error resolution rate was observed in the postintervention group (36% vs 74%; P < .001). After adjustment for potential confounders with logistic regression, admission in the postintervention group was independently associated with fewer medication errors (odds ratio, 0.4 [95% confidence interval, 0.24-0.77]; P = .005). Overall, presence of an ID consultant demonstrated a higher error resolution rate (32% without a consultation vs 68% with a consultation; P = .002).
Multifaceted, multidisciplinary stewardship efforts reduced the rate and increased the overall resolution of HAART-related medication errors.
To identify factors associated with the presence and severity of food insecurity among a sample of Honduran caregivers of young children.
Cross-sectional study in which the dependent variable, household food insecurity, was measured using a fourteen-item questionnaire developed and validated in a population of similar cultural context. A predictive modelling strategy used backwards elimination in logistic regression and multinomial logit regression models to compute odds ratios and 95 % confidence intervals for food insecurity.
Rural Honduras in the department of Intibucá, between March and April 2009.
Two-hundred and ninety-eight Honduran caregivers of children aged 6–18 months.
Ninety-three per cent of households were classified as having some degree of food insecurity (mild, moderate or severe). After controlling for caregiver age and marital status, compared with caregivers with more than primary-school education, those with less than primary-school education had 3·47 (95 % CI 1·34, 8·99) times the odds of severe food insecurity and 2·29 (95 % CI 1·00, 5·25) times the odds of moderate food insecurity. Our results also found that child anthropometric status was not associated with the presence or severity of food insecurity.
These results show that among the sociodemographic factors assessed, food insecurity in rural Honduras is associated with maternal education. Understanding key factors associated with food insecurity that are unique to Honduras can inform the design of interventions to effectively mitigate the negative impact of food insecurity on children.