Protocol for the PINCER trial: a cluster randomised trial comparing the 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 are an important cause of morbidity and mortality in primary care. The aims of this study are to determine the effectiveness, cost effectiveness and acceptability of a pharmacist-led information-technology-based complex intervention compared with simple feedback in reducing proportions of patients at risk from potentially hazardous prescribing and medicines management in general (family) practice. Methods: Research subject group: "At-risk" patients registered with computerised general practices in two geographical regions in England. Design: Parallel group pragmatic cluster randomised trial. Interventions: Practices will be randomised to either: (i) Computer-generated feedback; or (ii) Pharmacist-led intervention comprising of computer-generated feedback, educational outreach and dedicated support. Primary outcome measures: The proportion of patients in each practice at six and 12 months post intervention: - with a computer-recorded history of peptic ulcer being prescribed non-selective non-steroidal anti-inflammatory drugs - with a computer-recorded diagnosis of asthma being prescribed beta-blockers - aged 75 years and older receiving long-term prescriptions for angiotensin converting enzyme inhibitors or loop diuretics without a recorded assessment of renal function and electrolytes in the preceding 15 months. Secondary outcome measures; These relate to a number of other examples of potentially hazardous prescribing and medicines management. Economic analysis: An economic evaluation will be done of the cost per error avoided, from the perspective of the UK National Health Service (NHS), comparing the pharmacist-led intervention with simple feedback. Qualitative analysis: A qualitative study will be conducted to explore the views and experiences of health care professionals and NHS managers concerning the interventions, and investigate possible reasons why the interventions prove effective, or conversely prove ineffective. Sample size: 34 practices in each of the two treatment arms would provide at least 80% power (two-tailed alpha of 0.05) to demonstrate a 50% reduction in error rates for each of the three primary outcome measures in the pharmacist-led intervention arm compared with a 11% reduction in the simple feedback arm. Discussion: At the time of submission of this article, 72 general practices have been recruited (36 in each arm of the trial) and the interventions have been delivered. Analysis has not yet been undertaken.

Information system evolvability, feedback and pattern languages

Information systems for business are frequently heavily reliant on software. Two important feedback-related effects of embedding software in a business process are identified. First, the system dynamics of the software maintenance process can become complex, particularly in the number and scope of the feedback loops. Secondly, responsiveness to feedback can have a big effect on the evolvability of the information system. Ways have been explored to provide an effective mechanism for improving the quality of feedback between stakeholders during software maintenance. Understanding can be improved by using representations of information systems that are both service-based and architectural in scope. The conflicting forces that encourage change or stability can be resolved using patterns and pattern languages. A morphology of information systems pattern languages has been described to facilitate the identification and reuse of patterns and pattern languages. The kind of planning process needed to achieve consensus on a system's evolution is also considered.

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.

ASSET: moving forward through feedback

Providing high quality and timely feedback to students is often a challenge for many staff in higher education as it can be both time-consuming and frustratingly repetitive. From the student perspective, feedback may sometimes be considered unhelpful, confusing and inconsistent and may not always be provided within a timeframe that is considered to be ‘useful’. The ASSET project, based at the University of Reading, addresses many of these inherent challenges by encouraging the provision of feedback that supports learning, i.e. feedback that contains elements of ‘feed-forward’, is of a high quality and is delivered in a timely manner. In particular, the project exploits the pedagogic benefits of video/audio media within a Web 2.0 context to provide a new, interactive resource, ‘ASSET’, to enhance the feedback experience for both students and staff. A preliminary analysis of both our quantitative and qualitative pedagogic data demonstrate that the ASSET project has instigated change in the ways in which both staff and students think about, deliver, and engage with feedback. For example, data from our online questionnaires and focus groups with staff and students indicate a positive response to the use of video as a medium for delivering feedback to students. In particular, the academic staff engaged in piloting the ASSET resource indicated that i) using video has made them think more, and in some cases differently, about the ways in which they deliver feedback to students and ii) they now see video as an effective means of making feedback more useful and engaging for students. Moreover, the majority of academic staff involved in the project have said they will continue to use video feedback. From the student perspective, 60% of those students whose lecturers used ASSET to provide video feedback said that “receiving video feedback encouraged me to take more notice of the feedback compared with normal methods” and 80% would like their lecturer to continue to use video as a method for providing feedback. An important aim of the project was for it to complement existing University-wide initiatives on feedback and for ASSET to become a ‘model’ resource for staff and students wishing to explore video as a medium for feedback provision. An institutional approach was therefore adopted and key members of Senior Management, academics, T&L support staff, IT support and Student Representatives were embedded within the project from the start. As with all initiatives of this kind, a major issue is the future sustainability of the ASSET resource and to have had both ‘top-down’ and ‘bottom-up’ support for the project has been extremely beneficial. In association with the project team the University is currently exploring the creation of an open-source, two-tiered video supply solution and a ‘framework’ (that other HEIs can adopt and/or adapt) to support staff in using video for feedback provision. In this way students and staff will have new opportunities to explore video and to exploit the benefits of this medium for supporting learning.

Energy consumption feedback in perspective: integrating Australian data to meta-analyses on in home displays

Providing homeowners with real-time feedback on their electricity consumption through a dedicated display device has been shown to reduce consumption by approximately 6-10%. However, recent advances in smart grid technology have enabled larger sample sizes and more representative sample selection and recruitment methods for display trials. By analyzing these factors using data from current studies, this paper argues that a realistic, large-scale conservation effect from feedback is in the range of 3-5%. Subsequent analysis shows that providing real-time feedback may not be a cost effective strategy for reducing carbon emissions in Australia, but that it may enable additional benefits such as customer retention and peak-load shift.

Providing persuasive feedback through interactive posters to motivate energy-saving behaviours

The behaviour of building occupants can have a significant impact on in-use energy performance. In these pilot studies, based on the Elaboration Likelihood Model, interactivity was incorporated in the design of behavioural interventions to assess its effectiveness in promoting energy-saving behaviours. An interactive poster and an interactive prompt were designed to ‘nudge’ occupants’ behaviours towards energy-saving. The poster was installed in an office building and was intended to encourage occupants to save energy by taking the stairs, rather than the lifts, by providing them with cumulative metaphorical feedback. The prompt was installed in student halls of residence and intended to act as a reminder to the occupants to turn the lights off by providing them with an immediate playful reward. The results showed that interactivity can ‘nudge’ occupants’ behaviours when it is combined with a clear message/feedback. The results also suggest that simple immediate feedback can be effective in encouraging energy-efficient behaviours.

The dependence of radiative forcing and feedback on evolving patterns of surface temperature change in climate models

Experiments with CO2 instantaneously quadrupled and then held constant are used to show that the relationship between the global-mean net heat input to the climate system and the global-mean surface-air-temperature change is nonlinear in Coupled Model Intercomparison Project phase 5 (CMIP5) Atmosphere-Ocean General Circulation Models (AOGCMs). The nonlinearity is shown to arise from a change in strength of climate feedbacks driven by an evolving pattern of surface warming. In 23 out of the 27 AOGCMs examined the climate feedback parameter becomes significantly (95% confidence) less negative – i.e. the effective climate sensitivity increases – as time passes. Cloud feedback parameters show the largest changes. In the AOGCM-mean approximately 60% of the change in feedback parameter comes from the topics (30N-30S). An important region involved is the tropical Pacific where the surface warming intensifies in the east after a few decades. The dependence of climate feedbacks on an evolving pattern of surface warming is confirmed using the HadGEM2 and HadCM3 atmosphere GCMs (AGCMs). With monthly evolving sea-surface-temperatures and sea-ice prescribed from its AOGCM counterpart each AGCM reproduces the time-varying feedbacks, but when a fixed pattern of warming is prescribed the radiative response is linear with global temperature change or nearly so. We also demonstrate that the regression and fixed-SST methods for evaluating effective radiative forcing are in principle different, because rapid SST adjustment when CO2 is changed can produce a pattern of surface temperature change with zero global mean but non-zero change in net radiation at the top of the atmosphere (~ -0.5 Wm-2 in HadCM3).

Promoting behaviour change through personalized energy feedback in offices

A body of research suggests that the provision of energy feedback information to building users can elicit significant energy reductions through behaviour change. However, most studies have focused on energy use in homes and the assessment of interventions and technologies, to the neglect of the non-domestic context and broader issues arising from the introduction of feedback technologies. To address this gap, a non-domestic case study explores the delivery of personalized energy feedback to office workers through a novel system utilizing wireless technologies. The research demonstrates advantages of monitoring occupancy and quantifying energy use from specific behaviours as a basis for effective energy feedback; this is particularly important where there are highly disaggregated forms of energy use and a range of locations for that activity to take place. Quantitative and qualitative data show that personalized feedback can help individuals identify energy reduction opportunities. However, the analysis also highlights important contextual barriers and issues that need to be addressed when utilizing feedback technologies in the workplace. If neglected, these issues may limit the effective take-up of feedback interventions.

A new feedback on climate change from the hydrological cycle

An intensification of the hydrological cycle is a likely consequence of global warming. But changes in the hydrological cycle could affect sea-surface temperature by modifying diffusive ocean heat transports. We investigate this mechanism by studying a coupled general circulation model sensitivity experiment in which the hydrological cycle is artificially amplified. We find that the amplified hydrological cycle depresses sea-surface temperature by enhancing ocean heat uptake in low latitudes. We estimate that a 10% increase in the hydrological cycle will contribute a basin-scale sea-surface temperature decrease of around 0.1°C away from high latitudes, with larger decreases locally. We conclude that an intensified hydrological cycle is likely to contribute a weak negative feedback to anthropogenic climate change.

How well do we understand and evaluate climate change feedback processes?

Processes in the climate system that can either amplify or dampen the climate response to an external perturbation are referred to as climate feedbacks. Climate sensitivity estimates depend critically on radiative feedbacks associated with water vapor, lapse rate, clouds, snow, and sea ice, and global estimates of these feedbacks differ among general circulation models. By reviewing recent observational, numerical, and theoretical studies, this paper shows that there has been progress since the Third Assessment Report of the Intergovernmental Panel on Climate Change in (i) the understanding of the physical mechanisms involved in these feedbacks, (ii) the interpretation of intermodel differences in global estimates of these feedbacks, and (iii) the development of methodologies of evaluation of these feedbacks (or of some components) using observations. This suggests that continuing developments in climate feedback research will progressively help make it possible to constrain the GCMs’ range of climate feedbacks and climate sensitivity through an ensemble of diagnostics based on physical understanding and observations.

A cost-effective high-throughput digital system for observation and acquisition of animal behavioral data

We have designed and implemented a low-cost digital system using closed-circuit television cameras coupled to a digital acquisition system for the recording of in vivo behavioral data in rodents and for allowing observation and recording of more than 10 animals simultaneously at a reduced cost, as compared with commercially available solutions. This system has been validated using two experimental rodent models: one involving chemically induced seizures and one assessing appetite and feeding. We present observational results showing comparable or improved levels of accuracy and observer consistency between this new system and traditional methods in these experimental models, discuss advantages of the presented system over conventional analog systems and commercially available digital systems, and propose possible extensions to the system and applications to nonrodent studies.

Diagnostic analysis of atmospheric moisture and clear-sky radiative feedback in the Hadley Centre and Geophysical Fluid Dynamics Laboratory (GFDL) climate models

The interannual variability of the hydrological cycle is diagnosed from the Hadley Centre and Geophysical Fluid Dynamics Laboratory (GFDL) climate models, both of which are forced by observed sea surface temperatures. The models produce a similar sensitivity of clear-sky outgoing longwave radiation to surface temperature of ∼2 W m−2 K−1, indicating a consistent and positive clear-sky radiative feedback. However, differences between changes in the temperature lapse-rate and the height dependence of moisture fluctuations suggest that contrasting mechanisms bring about this result. The GFDL model appears to give a weaker water vapor feedback (i.e., changes in specific humidity). This is counteracted by a smaller upper tropospheric temperature response to surface warming, which implies a compensating positive lapse-rate feedback.