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.

Multiple hydrogen bonds induce formation of nanoparticles with internal microemulsion structure by an amphiphilic copolymer

A particulate microemulsion is generated in a simple two-component system comprising an amphiphilic copolymer (Pluronic P123) in mixtures with tannic acid. This is correlated to complexation between the poly(ethylene oxide) in the Pluronic copolymer and the multiple hydrogen bonding units in tannic acid which leads to the breakup of the ordered structure formed in gels of Pluronic copolymers, and the formation of dispersed nanospheres containing a bicontinuous internal structure. These novel nanoparticles termed ‘‘emulsomes’’ are self-stabilized by a coating layer of Pluronic copolymer. The microemulsion exhibits a pearlescent appearance due to selective light scattering from the emulsion droplets. This simple formulation based on a commercial copolymer and a biofunctional and biodegradable additive is expected to find applications in the fast moving consumer goods sector.

Internal rents and corporate property management: a study into the use of internal rents in UK corporate organisations

Research in the late 1980s showed that in many corporate real estates users were not fully aware of the full extent of their property holdings. In many cases, not only was the value of the holdings unknown, but there was uncertainty over the actual extent of ownership within the portfolio. This resulted in a large number of corporate occupiers reviewing their property holdings during the 1990s, initially to create a definitive asset register, but also to benefit from an more efficient use of space. Good management of corporately owned property assets is of equal importance as the management of other principal resources within the company. A comprehensive asset register can be seen as the first step towards a rational property audit. For the effective, efficient and economic delivery of services, it is vital that all property holdings are utilised to the best advantage. This requires that the property provider and the property user are both fully conversant with the value of the property holding and that an asset/internal rent/charge is made accordingly. The advantages of internal rent charging are twofold. Firstly, it requires the occupying department to “contribute” an amount to the business equivalent to the open market rental value of the space that it occupies. This prevents the treating of space as a free good and, as individual profit centres, each department will then rationalise its holdings to minimise its costs. The second advantage is from a strategic viewpoint. By charging an asset rent, the holding department can identify the performance of its real estate holdings. This can then be compared to an internal or external benchmark to help determine whether the company has adopted the most efficient tenure pattern for its properties. This paper investigates the use of internal rents by UK-based corporate businesses and explains internal rents as a form of transfer pricing in the context of management and responsibility accounting. The research finds that the majority of charging organisations introduced internal rents primarily to help calculate true profits at the business unit level. However, less than 10% of the charging organisations introduced internal rents primarily to capture the return on assets within the business. There was also a sizeable element of the market who had no plans to introduce internal rents. Here, it appears that, despite academic and professional views that internal rents are beneficial in improving the efficient use of property, opinion at the business and operational level has not universally accepted this proposition.

Moving feedback forward: theory to practice

There is substantial research interest in tutor feedback and students’ perception and use of such feedback. This paper considers some of the major issues raised in relation to tutor feedback and student learning. We explore some of the current feedback drivers, most notably the need for feedback to move away from simply a monologue from a tutor to a student to a valuable tutor–student dialogue. In relation to moving feedback forward the notions of self regulation, dialogue and social learning are explored and then considered in relation to how such theory can translate into practice. The paper proposes a framework (GOALS) as a tool through which tutors can move theory into practice with the aim of improving student learning from feedback.

Modeling building semantics: providing feedback and sustainability

Even minor changes in user activity can bring about significant energy savings within built space. Many building performance assessment methods have been developed, however these often disregard the impact of user behavior (i.e. the social, cultural and organizational aspects of the building). Building users currently have limited means of determining how sustainable they are, in context of the specific building structure and/or when compared to other users performing similar activities, it is therefore easy for users to dismiss their energy use. To support sustainability, buildings must be able to monitor energy use, identify areas of potential change in the context of user activity and provide contextually relevant information to facilitate persuasion management. If the building is able to provide users with detailed information about how specific user activity that is wasteful, this should provide considerable motivation to implement positive change. This paper proposes using a dynamic and temporal semantic model, to populate information within a model of persuasion, to manage user change. By semantically mapping a building, and linking this to persuasion management we suggest that: i) building energy use can be monitored and analyzed over time; ii) persuasive management can be facilitated to move user activity towards sustainability.

The role of atmosphere feedbacks during ENSO in the CMIP3 models. Part II: using AMIP runs to understand the heat flux feedback mechanisms

Several studies using ocean–atmosphere general circulation models (GCMs) suggest that the atmospheric component plays a dominant role in the modelled El Niño-Southern Oscillation (ENSO). To help elucidate these findings, the two main atmosphere feedbacks relevant to ENSO, the Bjerknes positive feedback (μ) and the heat flux negative feedback (α), are here analysed in nine AMIP runs of the CMIP3 multimodel dataset. We find that these models generally have improved feedbacks compared to the coupled runs which were analysed in part I of this study. The Bjerknes feedback, μ, is increased in most AMIP runs compared to the coupled run counterparts, and exhibits both positive and negative biases with respect to ERA40. As in the coupled runs, the shortwave and latent heat flux feedbacks are the two dominant components of α in the AMIP runs. We investigate the mechanisms behind these two important feedbacks, in particular focusing on the strong 1997–1998 El Niño. Biases in the shortwave flux feedback, α SW, are the main source of model uncertainty in α. Most models do not successfully represent the negative αSW in the East Pacific, primarily due to an overly strong low-cloud positive feedback in the far eastern Pacific. Biases in the cloud response to dynamical changes dominate the modelled α SW biases, though errors in the large-scale circulation response to sea surface temperature (SST) forcing also play a role. Analysis of the cloud radiative forcing in the East Pacific reveals model biases in low cloud amount and optical thickness which may affect α SW. We further show that the negative latent heat flux feedback, α LH, exhibits less diversity than α SW and is primarily driven by variations in the near-surface specific humidity difference. However, biases in both the near-surface wind speed and humidity response to SST forcing can explain the inter-model αLH differences.

Researching from within: external and internal ethical engagement

This article examines the superficial and deep ethical and moral dilemmas confronting ‘insider’ researchers which we term external and internal ethical engagement. External ethical engagement refers to the traditional, easily identifiable ethical issues that insider researchers attend to by submitting their application for ethical approval to their institution’s internal review board. Internal ethical engagement relates to the deeper level ethical and moral dilemmas that insider researchers have to deal with once ‘in the field’ linked to on-going personal and professional relationships with participants, insider knowledge, conflicting professional and researcher roles, and anonymity. By reviewing the literature in this area and drawing on the authors’ experiences of undertaking interpretive studies at institutions where they were members of staff, we explore these concepts and examine the implications for insider researchers. Keywords: insider research; ethics; professional relationships; anonymity; access

Internal doubts about Cohen's Rescue of Justice

G.A. Cohen's Rescuing Justice and Equality is the culmination of twenty years' work on Rawls's theory of justice. In this paper I distinguish three prongs of attack advanced by Cohen, and show how two of the prongs (the claim that egalitarianism includes productive demands and the claim that equality is best understood as 'luck egalitarianism') are incompatible.