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.

Introduction: special issue on advances in brand management

This special issue of the Journal of Business Research contains 13 articles presented at the Spring 2007 Thought Leaders International Conference on Brand Management. Following a blind reviewing process 69 papers were presented at the conference then authors were invited to revise their papers for inclusion consideration for this special issue. A further round of blind reviewing resulted in the selection of those 13 articles. This introduction presents a review of the research into brand management.

Expectation versus provision in the management and use of urban open space

This paper discusses the implications of the shifting cultural significance of public open space in urban areas. In particular, it focuses on the increasing dysfunction between people's expectations of that space and its actual provision and management. In doing so, the paper applies Lefebvre's ideas of spatiality to the evident paradigm shift from 'public' to 'private' culture, with its associated commodification of previously public space. While developing the construct of paradigm shift, the paper recognises that the former political notions inherent in the provision of public space remain in evidence. So whereas public parks were formerly seen as spaces of confrontation between the 'rationality' of public order as the 'irrationality' of individual leisure pursuits, they are now increasingly seen, particularly 'out of hours', as the domain of the dispossessed, to be defined and policed as 'dangerous'. Where once people were welcomed into public open spaces as a means of 'educating' them in good, acceptable, leisure practices, therefore, they are now increasingly excluded, but for the same ostensible reasons. Building on survey work undertaken in Reading, Berkshire, the paper illustrates how communities can become separated from 'their' space, leaving them with the overriding impression that they have been 'short-changed' in terms of both the provision and the management of urban open space. Rather than the intimacy of local space for local people, therefore, the paper argues that parks have become externalised places, increasingly responding to commercial definitions of culture and what is 'public'. Central urban open spaces are therefore increasingly becoming sites of stratification, signification of a consumer-constructed citizenship and valorisation of public life as a legitimate element of the market surface of town and city centres.

The role of the international cocoa germplasm database and the international cocoa quarantine centre in information management and distribution of cocoa genetic resources

A range of physiological parameters (canopy light transmission, canopy shape, leaf size, flowering and flushing intensity) were measured from the International Clone Trial, typically over the course of two years. Data were collected from six locations, these being: Brazil, Ecuador, Trinidad, Venezuela, Côte d’Ivoire and Ghana. Canopy shape varied significantly between clones, although it showed little variation between locations. Genotypic variation in leaf size was differentially affected by the growth location; such differences appeared to underlie a genotype by environment interaction in relation to canopy light transmission. Flushing data were recorded at monthly intervals over the course of a year. Within each location, a significant interaction was observed between genotype and time of year, suggesting that some genotypes respond to a greater extent than others to environmental stimuli. A similar interaction was observed for flowering data, where significant correlations were found between flowering intensity and temperature in Brazil and flowering intensity and rainfall in Côte d’Ivoire. The results demonstrate the need for local evaluation of cocoa clones and also suggest that the management practices for particular planting material may need to be fine-tuned to the location in which they are cultivated.

Soy products in the management of breast cancer

Purpose of review: Meta-analyses of epidemiological studies of soy consumption and breast cancer risk have demonstrated modest protective effects, usually attributed to isoflavones. Concern has been expressed, however, that the estrogenic activity of isoflavones may have adverse effects on breast cancer recurrence. Recent findings: The review covers epidemiological studies that have investigated the impact of soy consumption in breast cancer patients on recurrence and mortality. There are preliminary data to suggest that soy has differential effects on recurrence in human epidermal growth factor receptor-2 positive and human epidermal growth factor receptor-2 negative tumours. Recent studies on mechanisms of action of soy in breast cancer provide insights into epigenetic effects and the interaction of isoflavones with IGF-1 and with a number of polymorphisms of genes associated with breast cancer risk such as MDM2 and CYP1B1. Summary: Overall, these studies indicate that soy foods consumed at levels comparable to those in Asian populations have no detrimental effects on risk of breast cancer recurrence and in some cases significantly reduce the risk. Importantly, soy does not appear to interfere with tamoxifen or anastrozole therapy. Recent research suggests that women who are at increased risk of breast cancer due to polymorphisms in genes associated with the disease may especially benefit from high soy isoflavone intake.

Priority setting in healthcare: from arbitrariness to societal values

This paper develops an account of the normative basis of priority setting in health care as combining the values which a given society holds for the common good of its members, with the universal provided by a principle of common humanity. We discuss national differences in health basket in Europe and argue that health care decision-making in complex social and moral frameworks is best thought of as anchored in such a principle by drawing on the philosophy of need. We show that health care needs are ethically ‘thick’ needs whose psychological and social construction can best be understood in terms of David Wiggins's notion of vital need: a person's need is vital when failure to meet it leads to their harm and suffering. The moral dimension of priority setting which operates across different societies’ health care systems is located in the demands both of and on any society to avoid harm to its members.

Fenced in: Common property struggles in the management of communal rangelands in central Eastern Cape Province, South Africa

This paper takes as its starting point the assertion that current rangeland management in the central Eastern Cape Province (former Ciskei) of South Africa, is characterised primarily by an ‘open access’ approach. Empirical material drawn from three case-study communities in the region is used to examine the main barriers to management of rangeland as a ‘commons’. The general inability to define and enforce rights to particular grazing resourses in the face of competing claims from ‘outsiders’, as well as inadequate local institutions responsible for rangeland management are highlighted as being of key importance. These are often exacerbated by lack of available grazing land, diffuse user groups and local political and ethnic divisions. Many of these problems have a strong legacy in historical apartheid policies such as forced resettlement and betterment planning. On this basis it is argued that policy should focus on facilitating the emergence of effective, local institutions for rangeland management. Given the limited grazing available to many communities in the region, a critical aspect of this will be finding ways to legitimise current patterns of extensive resource use, which traverse existing ‘community’ boundaries. However, this runs counter to recent legislation, which strongly links community management with legal ownership of land within strict boundaries often defined through fencing. Finding ways to overcome this apparent disjuncture between theory and policy will be vital for the effective management of common pool grazing resources in the region.

BIM: innovation in design management, influence and challenges of implementation

The construction industry is widely being criticised as a fragmented industry. There are mounting calls for the industry to change. The espoused change calls for collaboration as well as embracing innovation in the process of design, construction and across the supply chain. Innovation and the application of emerging technologies are seen as enablers for integrating the processes ‘integrating the team’ such as building information modelling (BIM). A questionnaire survey was conducted to ascertain change in construction with regard to design management, innovation and the application of BIM as cutting edge pathways for collaboration. The respondents to the survey were from an array of designations across the construction industry such as construction managers, designers, engineers, design coordinators, design managers, architects, architectural technologists and surveyors. There was a general agreement by most respondents that the design team was responsible for design management in their organisation. There is a perception that the design manager and the client are the catalyst for advancing innovation. The current state of industry in terms of incorporating BIM technologies is posing a challenge as well as providing an opportunity for accomplishment. BIM technologies provide a new paradigm shift in the way buildings are designed, constructed and maintained. This paradigm shift calls for rethinking the curriculum for educating building professionals, collectively.

Information and efficiency: goal arrival in soccer betting

An efficient market incorporates news into prices immediately and fully. Tests for efficiency in financial markets have been undermined by information leakage. We test for efficiency in sports betting markets – real-world markets where news breaks remarkably cleanly. Applying a novel identification to high-frequency data, we investigate the reaction of prices to goals scored on the ‘cusp’ of half-time. This strategy allows us to separate the market's response to major news (a goal), from its reaction to the continual flow of minor game-time news. On our evidence, prices update swiftly and fully.