PINCER trial: a cluster randomised trial comparing the effectiveness and cost-effectiveness of a pharmacist-led IT-based intervention with simple feedback in reducing rates of clinically important errors in medicines management in general practices

Background: Medication errors in general practice are an important source of potentially preventable morbidity and mortality. Building on previous descriptive, qualitative and pilot work, we sought to investigate the effectiveness, cost-effectiveness and likely generalisability of a complex pharm acist-led IT-based intervention aiming to improve prescribing safety in general practice. Objectives: We sought to: • Test the hypothesis that a pharmacist-led IT-based complex intervention using educational outreach and practical support is more effective than simple feedback in reducing the proportion of patients at risk from errors in prescribing and medicines management in general practice. • Conduct an economic evaluation of the cost per error avoided, from the perspective of the National Health Service (NHS). • Analyse data recorded by pharmacists, summarising the proportions of patients judged to be at clinical risk, the actions recommended by pharmacists, and actions completed in the practices. • Explore the views and experiences of healthcare professionals and NHS managers concerning the intervention; investigate potential explanations for the observed effects, and inform decisions on the future roll-out of the pharmacist-led intervention • Examine secular trends in the outcome measures of interest allowing for informal comparison between trial practices and practices that did not participate in the trial contributing to the QRESEARCH database. Methods Two-arm cluster randomised controlled trial of 72 English general practices with embedded economic analysis and longitudinal descriptive and qualitative analysis. Informal comparison of the trial findings with a national descriptive study investigating secular trends undertaken using data from practices contributing to the QRESEARCH database. The main outcomes of interest were prescribing errors and medication monitoring errors at six- and 12-months following the intervention. Results: Participants in the pharmacist intervention arm practices were significantly less likely to have been prescribed a non-selective NSAID without a proton pump inhibitor (PPI) if they had a history of peptic ulcer (OR 0.58, 95%CI 0.38, 0.89), to have been prescribed a beta-blocker if they had asthma (OR 0.73, 95% CI 0.58, 0.91) or (in those aged 75 years and older) to have been prescribed an ACE inhibitor or diuretic without a measurement of urea and electrolytes in the last 15 months (OR 0.51, 95% CI 0.34, 0.78). The economic analysis suggests that the PINCER pharmacist intervention has 95% probability of being cost effective if the decision-maker’s ceiling willingness to pay reaches £75 (6 months) or £85 (12 months) per error avoided. The intervention addressed an issue that was important to professionals and their teams and was delivered in a way that was acceptable to practices with minimum disruption of normal work processes. Comparison of the trial findings with changes seen in QRESEARCH practices indicated that any reductions achieved in the simple feedback arm were likely, in the main, to have been related to secular trends rather than the intervention. Conclusions Compared with simple feedback, the pharmacist-led intervention resulted in reductions in proportions of patients at risk of prescribing and monitoring errors for the primary outcome measures and the composite secondary outcome measures at six-months and (with the exception of the NSAID/peptic ulcer outcome measure) 12-months post-intervention. The intervention is acceptable to pharmacists and practices, and is likely to be seen as costeffective by decision makers.

Practicing sustainability in PFI project management

This paper investigates the relationship of the project management in Private Finance Initiative (PFI) and sustainability. A live PFI project is selected as a case study, where contract review and monitoring on project management are carried out to evaluate the sustainability of project management. The PFI procurement shows great advantages in increased contractual responsibilities of the contractor in sustainable construction, and also in practicing sustainability in project management. Six main sustainable attributes of the project management are selected to evaluate the sustainability of project management in the PFI project. The project management process in the case study is closely monitored in order to verify how the PFI project promotes sustainability in practice. The project management in the different stages of the PFI project, including tendering, design, construction and operation, contributes to the six sustainable attributes in different ways. The project management in PFI project paid more attention in sustainable development during its whole process. As the private sector is responsible to the whole life of the building project, the project manager has to consider the long-term benefits during the management process. The government should take advantages of PFI project management in practicing sustainability therefore to promote sustainable development of the national infrastructure services.

Cloud banding and winds in intense European cyclones: results from the DIAMET project

The DIAMET (DIAbatic influences on Mesoscale structures in ExTratropical storms) project aims to improve forecasts of high-impact weather in extratropical cyclones through field measurements, high-resolution numerical modeling, and improved design of ensemble forecasting and data assimilation systems. This article introduces DIAMET and presents some of the first results. Four field campaigns were conducted by the project, one of which, in late 2011, coincided with an exceptionally stormy period marked by an unusually strong, zonal North Atlantic jet stream and a succession of severe windstorms in northwest Europe. As a result, December 2011 had the highest monthly North Atlantic Oscillation index (2.52) of any December in the last 60 years. Detailed observations of several of these storms were gathered using the UK’s BAe146 research aircraft and extensive ground-based measurements. As an example of the results obtained during the campaign, observations are presented of cyclone Friedhelm on 8 December 2011, when surface winds with gusts exceeding 30 m s-1 crossed central Scotland, leading to widespread disruption to transportation and electricity supply. Friedhelm deepened 44 hPa in 24 hours and developed a pronounced bent-back front wrapping around the storm center. The strongest winds at 850 hPa and the surface occurred in the southern quadrant of the storm, and detailed measurements showed these to be most intense in clear air between bands of showers. High-resolution ensemble forecasts from the Met Office showed similar features, with the strongest winds aligned in linear swaths between the bands, suggesting that there is potential for improved skill in forecasts of damaging winds.

The DACCIWA project: dynamics-aerosol-chemistry-cloud interactions in West Africa

Massive economic and population growth, and urbanization are expected to lead to a tripling of anthropogenic emissions in southern West Africa (SWA) between 2000 and 2030. However, the impacts of this on human health, ecosystems, food security, and the regional climate are largely unknown. An integrated assessment is challenging due to (a) a superposition of regional effects with global climate change, (b) a strong dependence on the variable West African monsoon, (c) incomplete scientific understanding of interactions between emissions, clouds, radiation, precipitation, and regional circulations, and (d) a lack of observations. This article provides an overview of the DACCIWA (Dynamics-Aerosol-Chemistry-Cloud Interactions in West Africa) project. DACCIWA will conduct extensive fieldwork in SWA to collect high-quality observations, spanning the entire process chain from surface-based natural and anthropogenic emissions to impacts on health, ecosystems, and climate. Combining the resulting benchmark dataset with a wide range of modeling activities will allow (a) assessment of relevant physical, chemical, and biological processes, (b) improvement of the monitoring of climate and atmospheric composition from space, and (c) development of the next generation of weather and climate models capable of representing coupled cloud-aerosol interactions. The latter will ultimately contribute to reduce uncertainties in climate predictions. DACCIWA collaborates closely with operational centers, international programs, policy-makers, and users to actively guide sustainable future planning for West Africa. It is hoped that some of DACCIWA’s scientific findings and technical developments will be applicable to other monsoon regions.