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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.
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.
Comorbid post-traumatic stress disorder (PTSD) is associated with poorer outcomes of other disorders, but is treatable.
To estimate the frequency of clinically undetected PTSD in secondary care.
A systematic review of studies that screened for PTSD and reported on PTSD documentation in clinical records. Frequency of undetected PTSD was estimated, and reasons for heterogeneity explored.
The median proportion of participants with undetected PTSD (29 studies) was 28.6% (interquartile range 18.2–38.6%). There was substantial heterogeneity, with studies conducted in the USA and those with the highest proportions of in-patients and patients with psychotic disorder reporting higher frequencies of undetected PTSD.
Undetected PTSD is common in secondary care, even if the true value is at the lower limit of the estimates reported here. Trials examining the impact of routine screening for PTSD are required to determine whether such programmes should be standard procedure for all mental health services.
Anxiety disorders are prevalent yet under-recognized in late life. We examined the prevalence of anxiety disorders in a representative sample of community dwelling older adults in Hong Kong.
Data on 1,158 non-demented respondents aged 60–75 years were extracted from the Hong Kong Mental Morbidity survey (HKMMS). Anxiety was assessed with the revised Clinical Interview Schedule (CIS-R).
One hundred and thirty-seven respondents (11.9%, 95% CI = 10–13.7%) had common mental disorders with a CIS-R score of 12 or above. 8% (95% CI = 6.5–9.6%) had anxiety, 2.2% (95% CI = 1.3–3%) had an anxiety disorder comorbid with depressive disorder, and 1.7% (95% CI = 1–2.5%) had depression. Anxious individuals were more likely to be females (χ2 = 25.3, p < 0.001), had higher chronic physical burden (t = −9.3, p < 0.001), lower SF-12 physical functioning score (t = 9.2, p < 0.001), and poorer delayed recall (t = 2.3, p = 0.022). The risk of anxiety was higher for females (OR 2.8, 95% C.I. 1.7–4.6, p < 0.001) and those with physical illnesses (OR 1.4, 95% C.I. 1.3–1.6, p < 0.001). The risk of anxiety disorders increased in those with disorders of cardiovascular (OR 1.9, 95% C.I. 1.2–2.9, p = 0.003), musculoskeletal (OR 2.0, 95% C.I. 1.5–2.7, p < 0.001), and genitourinary system (OR 2.0, 95% C.I. 1.3–3.2, p = 0.002).
The prevalence of anxiety disorders in Hong Kong older population was 8%. Female gender and those with poor physical health were at a greater risk of developing anxiety disorders. Our findings also suggested potential risk for early sign of memory impairment in cognitively healthy individuals with anxiety disorders.
We describe a versatile infrared camera/spectrograph, IRIS, designed and constructed at the Anglo-Australian Observatory for use on the Anglo-Australian Telescope. A variety of optical configurations can be selected under remote control to provide several direct image scales and a few low-resolution spectroscopic formats. Two cross-dispersed transmission echelles are of novel design, as is the use of a modified Bowen-Burch system to provide a fast f/ratio in the widest-field option. The drive electronics includes a choice of readout schemes for versatility, and continuous display when the array is not taking data, to facilitate field acquisition and focusing.
The linearity of the detector has been studied in detail. Although outwardly good, slight nonlinearities prevent removal of fixed-pattern noise from the data without application of a cubic linearising function.
Specific control and data-reduction software has been written. We describe also a scanning mode developed for spectroscopic imaging.
It has been argued that the routine use of patient-reported outcome measures (PROMs) should be encouraged in order to improve the quality of services and even to determine payment. Clinician-rated outcome measures (CROMs), patient-reported experience measures (PREMs) and process measures also should be considered in evaluating healthcare quality. We discuss difficulties that the routine use of outcome measures might pose for psychiatric services. When outcome and experience measures are used to evaluate services they are difficult to interpret because of differences in case mix and regression to the mean. We conclude that PROMs and CROMs could be useful for monitoring the progress of individuals and that clinical audit still has an important role to play in improving the quality of services.
Understand the difference between process measurement and outcome measurement.
Understand the limitation of using outcome measures to assess and promote quality of services.
Understand the difficulties in assessing the psychometric properties and validity of outcome measures.
Excavations at Hengistbury Head Site 6 (Dragonfly Ponds) in 1984–5 uncovered a rare sequence of cultivation features, with pre-Late Iron Age to Romano-British period spade marks and an associated cultivation soil underlying proposed Romano-British furrows and another cultivation soil (Chadburn & Gardiner 1985; Chadburn 1987). Keyhole excavations for soil micromorphological study of these features and soils were conducted in 1997 as part of a larger project on identifying and characterising prehistoric cultivation from soil indicators in the field and in thin section (Lewis 1998). Profile inversion indicators identified within the implement marks suggest that the spade-mark horizon may show ‘double-digging’, and that the furrows were probably created by post-Roman mouldboard ploughing. Excavation and soil micromorphology results are presented here, and the importance of the remains at Hengistbury Head to the study of ancient agricultural land use is discussed in terms of methodological issues.
A combination of on- and off-site palaeo-environmental and archaeological investigations of the upper Allen valley of Dorset conducted in 1998–2000 has begun to reveal a different model of landscape development than those previously put forward. A combination of off-site geoarchaeological and aerial photographic survey and palynological analyses of two relict palaeochannel systems, and sample investigations of four Bronze Age round barrows and a Neolithic enclosure, have been combined with inter-regional summaries of the archaeological and molluscan records to re-examine the prehistoric landscape dynamics in the study area. Preliminary results suggest that woodland development in the earlier Holocene appears to have been more patchy than the presumed model of full climax deciduous woodland. With open areas still present in the Mesolithic, the area witnessed its first exploitation of the chalk downs, thus slowing and altering soil development of the downlands. Consequently, many areas perhaps never developed thick, well structured, clay-enriched soils (or argillic brown earths), but rather thin brown earths. By the later Neolithic these under-developed soils had become thin rendzinas, largely as a consequence of human exploitation. The presence of thinner and less well-developed soils over large areas of downland removes the necessity for envisaging extensive soil erosion and thick aggraded deposits in the valley bottom in later prehistory. The investigations have suggested that, if there were major changes in vegetation and soil complexes, these had already occurred by the Neolithic rather than in the Bronze Age as suggested by previous researchers, and the area has remained relatively stable since.
The paper describes the initial results from renewed investigations at Niah Cave in Sarawak on the island of Borneo, famous for the discovery in 1958 of the c. 40,000–year old ‘Deep Skull’. The archaeological sequences from the West Mouth and the other entrances of the cave complex investigated by Tom and Barbara Harrisson and other researchers have potential implications for three major debates regarding the prehistory of south-east Asia: the timing of initial settlement by anatomically modern humans; the means by which they subsisted in the late Pleistocene and early Holocene; and the timing, nature, and causation of the transition from foraging to farming. The new project is informing on all three debates. The critical importance of the Niah stratigraphies was commonly identified – including by Tom Harrisson himself – as because the site provided a continuous sequence of occupation over the past 40,000 years. The present project indicates that Niah was first used at least 45,000 years ago, and probably earlier; that the subsequent Pleistocene and Holocene occupations were highly variable in intensity and character; and that in some periods, perhaps of significant duration, the caves may have been more or less abandoned. The cultural sequence that is emerging from the new investigations may be more typical of cave use in tropical rainforests in south-east Asia than the Harrisson model.
Background: Substantial epidemiological research has shown that psychotic experiences are more common in densely populated areas. Many patients with persecutory delusions find it difficult to enter busy social urban settings. The stress and anxiety caused by being outside lead many patients to remain in-doors. We therefore developed a brief CBT intervention, based upon a formulation of the way urban environments cause stress and anxiety, to help patients with paranoid thoughts to feel less distressed when outside in busy streets. Aims: The aim was to pilot the new intervention for feasibility and acceptability and gather preliminary outcome data. Method: Fifteen patients with persecutory delusions in the context of a schizophrenia diagnosis took part. All patients first went outside to test their reactions, received the intervention, and then went outside again. Results: The intervention was considered useful by the patients. There was evidence that going outside after the intervention led to less paranoid responses than the initial exposure, but this was only statistically significant for levels of distress. Conclusions: Initial evidence was obtained that a brief CBT module specifically focused on helping patients with paranoia go outside is feasible, acceptable, and may have clinical benefits. However, it could not be determined from this small feasibility study that any observed improvements were due to the CBT intervention. Challenges in this area and future work required are outlined.
Interventions to reduce treatment delay in first-episode psychosis have met with mixed results. Systematic reviews highlight the need for greater understanding of delays within the care pathway if successful strategies are to be developed.
To document the care-pathway components of duration of untreated psychosis (DUP) and their link with delays in accessing specialised early intervention services (EIS). To model the likely impact on efforts to reduce DUP of targeted changes in the care pathway.
Data for 343 individuals from the Birmingham, UK, lead site of the National EDEN cohort study were analysed.
A third of the cohort had a DUP exceeding 6 months. The greatest contribution to DUP for the whole cohort came from delays within mental health services, followed by help-seeking delays. It was found that delay in reaching EIS was strongly correlated with longer DUP.
Community education and awareness campaigns to reduce DUP may be constrained by later delays within mental health services, especially access to EIS. Our methodology, based on analysis of care pathways, will have international application when devising strategies to reduce DUP.
All archives need to install certain safeguards against threats, both to the records themselves and to the people working in the building, both public and staff. This chapter looks at the main threats and ways of mitigating them; they include:
• security provision
• fire prevention, detection and suppression
• water detection.
Security is ‘the very essence of a repository’ (Kitching, 1993, 33) and must be taken very seriously. Breaches of security are potential threats to the validity of the documents stored in an archive, since loss of custody could jeopardize authenticity. But physical security installations are not enough. They must go hand in hand with good security procedures to ensure the maximum protection possible, always bearing in mind the need for access to the building by the public. A balance must be struck between fortress-like security and permitting rights of access to information. Not all security precautions need apply to the whole building and where archives form only a section of a building this must be recognized. Selecting the appropriate level of security for each part is important, as overprovision results in irritation and delay, as well as possible reliance on installations where better or tighter procedures might provide a preferable solution. To ensure that the measures are appropriate a risk assessment must be carried out; no two archives will face exactly the same problems. A major issue, common to all archives, libraries and museums, is that staff are a greater risk to the organization and its holdings than members of the public. This is an uncomfortable truth, but one which must be taken into account when considering appropriate security measures and procedures.
Questions for security risk assessment
The following questions might form the basis for a risk assessment but will be supplemented by others relating to particular circumstances.
• Are any roof lights or basement openings planned?
• What kind of external lighting/security lighting is planned?
• What kind of planting is planned round the building?
One of the key impacts on the success of collection care programmes is the availability of resources – these will vary considerably from institution to institution. Financial resources are becoming increasingly tight for heritage institutions and this presents many additional pressures and challenges. The preservation manager must continue to explore alternative means of addressing the significant needs of the collections. One particular resource that is vital to all elements of preservation is the people to carry out the activities, especially those who can physically process and/or package collections.
Two options are available:
• to extend the activities, capabilities and skills of all members of staff
• to develop programmes and systems to enable the use of volunteers.
In this chapter these two choices are addressed to ensure that they both may become integral elements of preservation planning.
What options for preservation training are available?
The manager has a number of different options for developing staff preservation skills and awareness. Most organizations will identify training needs via a staff appraisal process, but it will also require some knowledge of what is available, especially if specialist needs are identified. Alongside this commitment will be existing responsibilities for specific preservation activities among staff (not necessarily specialist) which might include pest management or environmental monitoring. These activities would ideally be included in individual job descriptions, which in turn presents a stronger imperative to provide training, and consequently to carry out the activity. This training may be provided in the following ways:
• Staff attend subject-specific external seminars and training events.
• Staff attend professional conferences (in the UK and abroad).
• Staff attend training at another organization, one-to-one with another professional.
• Staff who have attended a subject-specific or one-to-one training event provide cascade training for other staff within the organization.
• External trainers are commissioned to provide subject-specific training events.
• Staff attend subject-specific training provided by other specialist members of staff within the organization; this may be as part of a wider induction programme or as part of the preparation for a specific project.
Moving all or part of an archive is a daunting experience and one which needs to be approached in a very organized way. It is highly likely that many archivists will have to organize a move at some point in their careers. A successful move will ensure that:
• the material is undamaged by either the move or the new surroundings into which it is put
• access to the materials is interrupted for as little time as possible.
That said, any move is a serious risk which needs to be minimized as far as possible by good planning and efficient execution. This chapter looks at:
• the risks involved in moving archives
• managing the move
• briefing a removal firm
• the equipment required
• preparing for the move
• the move itself.
What are the risks?
Listing the preservation risks offers a good way to identify those which can be reduced and those which will have to be monitored throughout the process. Any of the following might be a problem:
• If there is a lack of clarity about the scope and purpose of the move it will be very difficult to retain control over the operation. Both scope and purpose should be spelt out in detail to inform those who are involved and clarify their roles.
• The parent organization – e.g. business, university or local authority – may not fully understand the requirements of the archive for moving.
• A complete move of an archive involves many factors and requires logistical expertise which may not be available in- house. Even a small move within an archive is complicated.
• The decision to move may not leave sufficient time or budget for the operation to be undertaken in the optimum way. Skimping on time for planning will affect the success of the outcome and introduces additional hazards. Poor budgeting will lead to risks that essential preservation procedures, such as boxing and wrapping, are not undertaken or too few staff are involved to guarantee the safety of the archive.
• If the material is in poor condition or is not adequately protected it risks additional damage in transit, and subsequent inaccessibility to readers.
Preserving Archives is a guide for all those with a responsibility for archival or special collections on the issues to be dealt with in developing successful preservation policies and strategies. While the chapters build up to implementation, they can also be read individually if required. Some archives will need advice on specific problems, others will require assistance with developing more general programmes. The reader can pick and choose as necessary; the notes and references, example boxes in the text and bibliography present further guidance for those who require more specific details.
The text is based on lectures given to successive cohorts of postgrad uate archive students in the UK, from those who have recently taken their first degree to those who are acquiring a professional qualification at a later stage in their careers. Preserving Archivesis intended to act as an aide-mémoire for them and their successors as students, as well as others who may need assistance in a particular situation. The book can be used as an overall guide or as a reference source for a particular area of practice. And it is not only for archivists: librarians and museum curators are also often faced with difficult decisions to make on preservation and much of what is included applies to paper-based materials held in other organizations. National and international examples are given and referred to, making comparisons possible and introducing the reader to a wider picture than just the UK. While there will clearly be national differences, many of the baseline and guiding principles will be evident in all forms of collection management and it is for the individual users to refer to their own national standards where appropriate.
The importance of understanding more traditional archival materials is underlined by its prime place at the beginning of the book, followed by the equally important topic of preserving digital material. The crucial role played by archival buildings, the security within them and the importance of good storage conditions for the archival materials are central to the text, followed by an emphasis on developing strategies to mitigate disasters. Clear guidance is given on how to manage and develop policies for the use of surrogates in both analogue and digital formats.
Why put irreplaceable material at risk? The main answer to this is that exhibitions are a major way of promoting access to archival material and involving the public and staff in a topic of mutual interest. All the activities connected with exhibitions, such as the publication of catalogues, production of facsimiles for sale, group visits and publicity, are major concerns of those involved with outreach. For those involved with preservation the essential requirement is to match these needs with adequate security and preservation standards, while not inhibiting or dampening the enthusiasm and talent of colleagues. The crucial factors are collaboration and understanding; exhibitions involve planning and co-operating, compromise and change. Once others understand the concerns of all, the process becomes easier but communication in the first instance is vital. If the parameters relating to standards of exhibition are laid out at the very beginning much less can go wrong. This chapter covers:
• minimizing the associated risks
• policies, standards and guidelines for exhibitions
• managing the care of documents in exhibitions
• planning and preparing for an exhibition.
How can the overall risk be minimized?
The easiest way of minimizing the risk is to set out an exhibition policy and procedure with which everyone agrees. This may involve not only a simple statement of aims for internal use but also a more detailed policy and set of procedures for external loans. The organization will benefit from being very clear about what it will and will not display, outside borrowers will understand the limits of what can be borrowed and why, and staff will appreciate the concerns of other colleagues. Drawing up such a document may take some time, but plenty of examples are available to suggest the main headings. It is very unwise to wait until an exhibition is suggested; policies developed in a hurry under the pressure of a particular project are never satisfactory. Consider:
• the purposes of exhibiting archival material and the authority by which the archive does so
• the scope of exhibitions and the capacity of the organization to mount them
• whether the policy of the organization is to display originals or facsimiles
• the location – whether on the premises or elsewhere.
Records and archives are important resources for individuals, organizations and the wider community. Records are created in the course of the functions and activities of organizations and the personal lives of individuals, and are preserved and maintained to support business and accountability and for cultural use. They provide evidence of, and information about, the actions of their creators and the environment in which those actions occurred. They extend and corroborate human and corporate memory and play a critical role in maintaining awareness of how the present is shaped by the past. Records are kept by almost everyone, but their management (and especially their medium-term and long-term management) is a professional discipline with its own distinctive body of knowledge. Within the discipline, ‘records’ and ‘archives’ are sometimes used as synonyms, but in English-speaking countries ‘archives’ usually denotes records which have been recognized as having long-term value. The term ‘archives’ can also be used more widely, to refer to collections of historical materials maintained by organizations, individuals, families or community groups, or to the locations where such materials are held.
The series Principles and Practice in Records Management and Archives aims both to disseminate and to add to the body of professional knowledge and understanding. Each text in the series is intended to offer a detailed overview of one or more key topics. The archives and records management discipline is experiencing rapid changes – not least as a result of the digital revolution – and the series will fully ref lect the new technological context as well as the societal changes and governmental initiatives in many countries that are placing new emphases on compliance, accountability, access to information and community relations. Some volumes in the series will address theoretical and strategic issues relating to the creation, management and interpretation of records and archives or their role in society; others will give practical guidance for those seeking successful and effective ways of managing them and presenting them to users. The authors come from many countries worldwide and are recognized experts in the field.
This volume provides a practical introduction to the preservation of archives.