Effects of an integrated medicines management program on medication appropriateness in hospitalized patients

Purpose. The effects of an integrated medicines management (IMM) program on medication appropriateness are discussed.

A qualitative study of the relationship between clinician attributes, organization, and patient characteristics on implementation of a disease management program

The purpose of this study was to examine the challenges of integrating an asthma disease management (DM) program into a primary care setting from the perspective of primary care practitioners. A second goal was to examine whether barriers differed between urban-based and nonurban-based practices. Using a qualitative design, data were gathered using focus groups in primary care pediatric practices. A purposeful sample included an equal number of urban and nonurban practices. Participants represented all levels in the practice setting. Important themes that emerged from the data were coded and categorized. A total of 151 individuals, including physicians, advanced practice clinicians, registered nurses, other medical staff, and nonmedical staff participated in 16 focus groups that included 8 urban and 8 nonurban practices. Content analyses identified 4 primary factors influencing the implementation of a DM program in a primary care setting. They were related to providers, the organization, patients, and characteristics of the DM program. This study illustrates the complexity of the primary care environment and the challenge of changing practice in these settings. The results of this study identified areas in a primary care setting that influence the adoption of a DM program. These findings can assist in identifying effective strategies to change clinical behavior in primary care practices. © 2008 Mary Ann Liebert, Inc.

Organizational Attributes of Practices Successful at a Disease Management Program

Objective: To assess the contribution of organizational factors to implementation of 3 asthma quality measures: enrollment in a disease management program, development of a written treatment plan, and prescription of severity-appropriate anti-inflammatory therapy. Study design: A total of 138 pediatric clinicians and 247 office staff in 13 urban clinics and 23 nonurban private practices completed questionnaires about their practice's organizational characteristics (eg, leadership, communication, perceived effectiveness, job satisfaction). Results: 94% of the clinicians and 92% of the office staff completed questionnaires. When adjusted for confounders, greater practice activity and perceived effectiveness in meeting family needs were associated with higher rates of enrollment in the Easy Breathing program, whereas higher scores for 3 organizational characteristics-communication timeliness, decision authority, and job satisfaction-were associated with both higher enrollment and a greater number of written treatment plans. None of the organizational characteristics was associated with greater use of anti-inflammatory therapy. Conclusions: Three organizational characteristics predicted 2 quality asthma measures: use of a disease management program and creation of a written asthma treatment plan. If these organizational characteristics were amenable to change, then our findings could help focus interventions in areas of effective and acceptable organizational change. © 2009 Mosby, Inc. All rights reserved.

Hierarchical energy management system for multi-source multi-product microgrids

This paper proposes a hierarchical energy management system for multi-source multi-product (MSMP) microgrids. Traditional energy hub based scheduling method is combined with a hierarchical control structure to incorporate transient characteristics of natural gas flow and dynamics of energy converters in microgrids. The hierarchical EMS includes a supervisory control layer, an optimizing control layer, and an execution control layer. In order to efficiently accommodate the systems multi time-scale characteristics, the optimizing control layer is decomposed into three sub-layers: slow, medium and fast. Thermal, gas and electrical management systems are integrated into the slow, medium, and fast control layer, respectively. Compared with wind energy, solar energy is easier to integrate and more suitable for the microgrid environment, therefore, potential impacts of the hierarchical EMS on MSMP microgrids is investigated based on a building energy system integrating photovoltaic and microturbines. Numerical studies indicate that by using a hierarchical EMS, MSMP microgrids can be economically operated. Also, interactions among thermal, gas, and electrical system can be effectively managed.

Automatic extraction of Reduced order models from CFD simulations for building energy modeling

Thermal comfort is defined as “that condition of mind which expresses satisfaction with the thermal environment’ [1] [2]. Field studies have been completed in order to establish the governing conditions for thermal comfort [3]. These studies showed that the internal climate of a room was the strongest factor in establishing thermal comfort. Direct manipulation of the internal climate is necessary to retain an acceptable level of thermal comfort. In order for Building Energy Management Systems (BEMS) strategies to be efficiently utilised it is necessary to have the ability to predict the effect that activating a heating/cooling source (radiators, windows and doors) will have on the room. The numerical modelling of the domain can be challenging due to necessity to capture temperature stratification and/or different heat sources (radiators, computers and human beings). Computational Fluid Dynamic (CFD) models are usually utilised for this function because they provide the level of details required. Although they provide the necessary level of accuracy these models tend to be highly computationally expensive especially when transient behaviour needs to be analysed. Consequently they cannot be integrated in BEMS. This paper presents and describes validation of a CFD-ROM method for real-time simulations of building thermal performance. The CFD-ROM method involves the automatic extraction and solution of reduced order models (ROMs) from validated CFD simulations. The test case used in this work is a room of the Environmental Research Institute (ERI) Building at the University College Cork (UCC). ROMs have shown that they are sufficiently accurate with a total error of less than 1% and successfully retain a satisfactory representation of the phenomena modelled. The number of zones in a ROM defines the size and complexity of that ROM. It has been observed that ROMs with a higher number of zones produce more accurate results. As each ROM has a time to solution of less than 20 seconds they can be integrated into the BEMS of a building which opens the potential to real time physics based building energy modelling.

Automatic extraction of reduced-order models from CFD simulations for building energy modelling

Accurate modelling of the internal climate of buildings is essential if Building Energy Management Systems (BEMS) are to efficiently maintain adequate thermal comfort. Computational fluid dynamics (CFD) models are usually utilised to predict internal climate. Nevertheless CFD models, although providing the necessary level of accuracy, are highly computationally expensive, and cannot practically be integrated in BEMS. This paper presents and describes validation of a CFD-ROM method for real-time simulations of building thermal performance. The CFD-ROM method involves the automatic extraction and solution of reduced order models (ROMs) from validated CFD simulations. ROMs are shown to be adequately accurate with a total error below 5% and to retain satisfactory representation of the phenomena modelled. Each ROM has a time to solution under 20seconds, which opens the potential of their integration with BEMS, giving real-time physics-based building energy modelling. A parameter study was conducted to investigate the applicability of the extracted ROM to initial boundary conditions different from those from which it was extracted. The results show that the ROMs retained satisfactory total errors when the initial conditions in the room were varied by ±5°C. This allows the production of a finite number of ROMs with the ability to rapidly model many possible scenarios.

Economical and coordinated dispatch of CHP based microgrid with renewable energy resources

The advantages of high energy efficiency and economic benefit promote the wide application of combined heat and power system (CHP) based microgrid. Firstly, a mathematical model of the CHP based microgrid is developed. Then, a cost function for the coordination of heat and electric load is proposed. Finally, an optimal dispatch model is developed to achieve the economical and coordinated operation of the CHP based microgrid system. Simulation results verify effectiveness of the proposed dispatch model, which is a powerful tool for the energy management of CHP based microgrid with renewable energy resources.

Development and Evaluation of a Computer-Based, Self-Management Tool for People Recently Diagnosed with Type 2 Diabetes

Aim. The purpose of this study was to develop and evaluate a computer-based, dietary, and physical activity self-management program for people recently diagnosed with type 2 diabetes. 
Methods. The computer-based program was developed in conjunction with the target group and evaluated in a 12-week randomised controlled trial (RCT). Participants were randomised to the intervention (computer-program) or control group (usual care). Primary outcomes were diabetes knowledge and goal setting (ADKnowl questionnaire, Diabetes Obstacles Questionnaire (DOQ)) measured at baseline and week 12. User feedback on the program was obtained via a questionnaire and focus groups. Results. Seventy participants completed the 12-week RCT (32 intervention, 38 control, mean age 59 (SD) years). After completion there was a significant between-group difference in the “knowledge and beliefs scale” of the DOQ. Two-thirds of the intervention group rated the program as either good or very good, 92% would recommend the program to others, and 96% agreed that the information within the program was clear and easy to understand. 
Conclusions. The computer-program resulted in a small but statistically significant improvement in diet-related knowledge and user satisfaction was high. With some further development, this computer-based educational tool may be a useful adjunct to diabetes self-management.

Retrospective assessment of dryland soil stability in relation to grazing and climate change

Accelerated soil erosion is an aspect of dryland degradation that is affected by repeated intense drought events and land management activities such as commercial livestock grazing. A soil stability index (SSI) that detects the erosion status and susceptibility of a landscape at the pixel level, i.e., stable, erosional, or depositional pixels, was derived from the spectral properties of an archived time series (from 1972 to 1997) of Landsat satellite data of a commercial ranch in northeastern Utah. The SSI was retrospectively validated with contemporary field measures of soil organic matter and erosion status that was surveyed by US federal land management agencies. Catastrophe theory provided the conceptual framework for retrospective assessment of the impact of commercial grazing and soil water availability on the SSI. The overall SSI trend was from an eroding landscape in the early drier 1970s towards stable conditions in the wetter mid-1980s and late 1990s. The landscape catastrophically shifted towards an extreme eroding state that was coincident with the “The Great North American Drought of 1988”. Periods of landscape stability and trajectories toward stability were coincident with extremely wet El Niño events. Commercial grazing had less correlation with soil stability than drought conditions. However, the landscape became more susceptible to erosion events under multiple droughts and grazing. Land managers now have nearly a year warning of El Niño and La Niña events and can adjust their management decisions according to predicted landscape erosion conditions.

Stable GeV Ion Beam Acceleration from Thin Foils by Circularly Polarized Laser Pulses

A stable relativistic ion acceleration regime for thin foils irradiated by circularly polarized laser pulses is suggested. In this regime, the "light-sail" stage of radiation pressure acceleration for ions is smoothly connected with the initial relativistic "hole-boring" stage, and a defined relationship between laser intensity I(0), foil density n(0), and thickness l(0) should be satisfied. For foils with a wide range of n(0), the required I(0) and l(0) for the regime are theoretically estimated and verified with the particle-in-cell code ILLUMINATION. It is shown for the first time by 2D simulations that high-density monoenergetic ion beams with energy above GeV/u and divergence of 10 degrees are produced by circularly polarized lasers at intensities of 10(22) W/cm(2), which are within reach of current laser systems.

Improving clinician self-efficacy does not increase asthma guideline use by primary care clinicians

Objective: The purpose of this study was to show the association between changes in clinician self-efficacy and readiness to change and implementation of an asthma management program (Easy Breathing). Methods: A 36 month randomized, controlled trial was conducted involving 24 pediatric practices (88 clinicians). Randomized clinicians received interventions designed to enhance clinician self-efficacy and readiness to change which were measured at baseline and 3 years. Interventions consisted of an educational toolbox, seminars, teleconferences, mini-fellowships, opinion leader visits, clinician-specific feedback, and pay for performance. The primary outcome was program utilization (number of children enrolled in Easy Breathing/year); secondary outcomes included development of a written treatment plan and severity-appropriate therapy. Results: At baseline, clinicians enrolled 149 ± 147 (mean ± SD) children/clinician/year; 84% of children had a written treatment plan and 77% of plans used severity-appropriate therapy. At baseline, higher self-efficacy scores were associated with greater program utilization (relative rate [RR], 1.34; 95% confidence interval [CI], 1.04-1.72; P =.04) but not treatment plan development (RR, 0.63; 95% CI, 0.29-1.35; P =.23) or anti-inflammatory use (RR, 1.76; 95% CI, 0.92-3.35; P =.09). Intervention clinicians participated in 17 interventions over 36 months. At study end, self-efficacy scores increased in intervention clinicians compared to control clinicians (P =.01) and more clinicians were in an action stage of change (P =.001) but these changes were not associated with changes in primary or secondary outcomes. Conclusions: Self-efficacy scores correlated with program use at baseline and increased in the intervention arm, but these increases were not associated with greater program-related activities. Self-efficacy may be necessary but not sufficient for behavior change. Copyright © 2012 by Academic Pediatric Association.

The buffering effect of hope on clinicians' behavior:A test in pediatric primary care

Although trait hope is thought to motivate goal-directed actions in the face of impediments, few studies have directly examined hope's role in overcoming obstacles, and none have done so while accounting for related goal constructs. We describe a study of 127 pediatric primary care providers who over the course of a year were asked to identify new cases of asthma and confirm previously diagnosed active disease by completing for each of their patients a brief survey validated for this purpose. These clinicians also completed measures of hope, self-efficacy, conscientiousness, and perceived obstacles to implementing a pediatric asthma management program. As predicted by hope theory, the agency component of hope buffered clinicians from perceived obstacles by facilitating the identification of asthma cases among high-hope clinicians in the face of obstacles. This buffering effect remained after controlling for self-efficacy and conscientiousness. We discuss the study findings in terms of current theories of goal-directed behavior and implications for delivering hope-related interventions, and we offer a testable hypothesis regarding when agency and pathways thinking facilitate goal-related behavior.

Implementation Experiences from Smart Grid Security Applications and Outlook on Future Research

Experiences from smart grid cyber-security incidents in the past decade have raised questions on the applicability and effectiveness of security measures and protection mechanisms applied to the grid. In this chapter we focus on the security measures applied under real circumstances in today’s smart grid systems. Beginning from real world example implementations, we first review cyber-security facts that affected the electrical grid, from US blackout incidents, to the Dragonfly cyber-espionage campaign currently focusing on US and European energy firms. Provided a real world setting, we give information related to energy management of a smart grid looking also in the optimization techniques that power control engineers perform into the grid components. We examine the application of various security tools in smart grid systems, such as intrusion detection systems, smart meter authentication and key management using Physical Unclonable Functions, security analytics and resilient control algorithms. Furthermore we present evaluation use cases of security tools applied on smart grid infrastructure test-beds that could be proved important prior to their application in the real grid, describing a smart grid intrusion detection system application and security analytics results. Anticipated experimental results from the use-cases and conclusions about the successful transitions of security measures to real world smart grid operations will be presented at the end of this chapter.