Enhanced diabetes care to patients of south Asian ethnic origin (the United Kingdom Asian Diabetes Study):a cluster randomised controlled trial

Background - Delivery of high-quality, evidence-based health care to deprived sectors of the community is a major goal for society. We investigated the effectiveness of a culturally sensitive, enhanced care package in UK general practices for improvement of cardiovascular risk factors in patients of south Asian origin with type 2 diabetes. Methods - In this cluster randomised controlled trial, 21 inner-city practices in the UK were assigned by simple randomisation to intervention (enhanced care including additional time with practice nurse and support from a link worker and diabetes-specialist nurse [nine practices; n=868]) or control (standard care [12 practices; n=618]) groups. All adult patients of south Asian origin with type 2 diabetes were eligible. Prescribing algorithms with clearly defined targets were provided for all practices. Primary outcomes were changes in blood pressure, total cholesterol, and glycaemic control (haemoglobin A1c) after 2 years. Analysis was by intention to treat. This trial is registered, number ISRCTN 38297969. Findings - We recorded significant differences between treatment groups in diastolic blood pressure (1·91 [95% CI -2·88 to -0·94] mm?Hg, p=0·0001) and mean arterial pressure (1·36 [-2·49 to -0·23] mm?Hg, p=0·0180), after adjustment for confounders and clustering. We noted no significant differences between groups for total cholesterol (0·03 [-0·04 to 0·11] mmol/L), systolic blood pressure (-0·33 [-2·41 to 1·75] mm?Hg), or HbA1c (-0·15% [-0·33 to 0·03]). Economic analysis suggests that the nurse-led intervention was not cost effective (incremental cost-effectiveness ratio £28?933 per QALY gained). Across the whole study population over the 2 years of the trial, systolic blood pressure, diastolic blood pressure, and cholesterol decreased significantly by 4·9 (95% CI 4·0–5·9) mm?Hg, 3·8 (3·2–4·4) mm?Hg, and 0·45 (0·40–0·51) mmol/L, respectively, and we recorded a small and non-significant increase for haemoglobin A1c (0·04% [-0·04 to 0·13]), p=0·290). Interpretation - We recorded additional, although small, benefits from our culturally tailored care package that were greater than the secular changes achieved in the UK in recent years. Stricter targets in general practice and further measures to motivate patients are needed to achieve best possible health-care outcomes in south Asian patients with diabetes. Funding - Pfizer, Sanofi-Aventis, Servier Laboratories UK, Merck Sharp & Dohme/Schering-Plough, Takeda UK, Roche, Merck Pharma, Daiichi-Sankyo UK, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Bristol-Myers Squibb, Solvay Health Care, and Assurance Medical Society UK.

'Why don't you try it again?' A comparison of parent led, home based interventions aimed at increasing children's consumption of a disliked vegetable

Previous research suggests that the use of modelling and non-food rewards may be effective at increasing tasting, and consequential liking and acceptance, of a previously disliked food. Although successful school-based interventions have been developed, there is a lack of research into home-based interventions using these methods. This study aimed to develop and investigate the efficacy of a parent led home-based intervention for increasing children's acceptance of a disliked vegetable. A total of 115 children aged 2-4 years were allocated to one of four intervention groups or to a no-treatment control. The four intervention conditions were: repeated exposure; modelling and repeated exposure; rewards and repeated exposure; or modelling, rewards and repeated exposure. Children in all of the intervention conditions were exposed by a parent to daily offerings of a disliked vegetable for 14 days. Liking and consumption of the vegetable were measured pre and post-intervention. Significant increases in post-intervention consumption were seen in the modelling, rewards and repeated exposure condition and the rewards and repeated exposure condition, compared to the control group. Significant post-intervention differences in liking were also found between the experimental groups. Liking was highest (>60%) in the modelling, rewards and repeated exposure group and the rewards and repeated exposure group, intermediate (>26%) in the modelling and repeated exposure and repeated exposure groups, and lowest in the control group (10%). Parent led interventions based around modelling and offering incentives may present cost efficient ways to increase children's vegetable consumption.

Developing a framework to evaluate business networks:the case of Ireland's industry-led network initiative

Business networks have been described as cooperative arrangements between independent business organisations that vary from contractual joint ventures to informal exchanges of information. This collaboration has become recognised as an innovative and efficient tool for organising interdependent activities, with benefits accruing to both firms and the local economy. For a number of years, resources have been devoted to supporting Irish networking policies. One recent example of such support is the Irish government's target of €20 million per annum for five years to support the creation of enterprise-led networks. It is imperative that a clear rationale for such interventions is established, as the opportunity cost of public funds is high. This article, therefore, develops an evaluation framework for such networking interventions. This framework will facilitate effective programme planning, implementation and evaluation. It will potentially show how a chain of cause-and-effect at both micro and macro-levels for networking interventions can be established.

Families 'at risk' and the family nurse partnership:the intrusion of risk into social exclusion policy

This article considers why the family nurse partnership (FNP) has been promoted as a means of tackling social exclusion in the UK. The FNP consists in a programme of visits by nurses to low-income first-time mothers, both while the mothers are pregnant and for the first two years following birth. The FNP is focused on both teaching parenthood and encouraging mothers back into education and/or into employment. Although the FNP marks a considerable discontinuity with previous approaches to family health, it is congruent with an emerging new approach to social exclusion. This new approach maintains that the most important task of social policy is to identify quickly the most 'at-risk' households, individuals and children so that interventions can be targeted more effectively at those 'at risk', either to themselves or to others. The article illustrates this new approach by analysing a succession of reports by the Social Exclusion Unit. It indicates that there is a considerable amount of ambiguity about the relationship between specific risk-factors and being 'at risk of social exclusion'. Nonetheless, this new approach helps to explain why British policy-makers may have chosen to promote the new FNP now. © 2009 Cambridge University Press.

Successful development and testing of a Method for Aggregating The Reporting of Interventions in Complex Studies (MATRICS)

Objectives: To develop a tool for the accurate reporting and aggregation of findings from each of the multiple methods used in a complex evaluation in an unbiased way. Study Design and Setting: We developed a Method for Aggregating The Reporting of Interventions in Complex Studies (MATRICS) within a gastroenterology study [Evaluating New Innovations in (the delivery and organisation of) Gastrointestinal (GI) endoscopy services by the NHS Modernisation Agency (ENIGMA)]. We subsequently tested it on a different gastroenterology trial [Multi-Institutional Nurse Endoscopy Trial (MINuET)]. We created three layers to define the effects, methods, and findings from ENIGMA. We assigned numbers to each effect in layer 1 and letters to each method in layer 2. We used an alphanumeric code based on layers 1 and 2 to every finding in layer 3 to link the aims, methods, and findings. We illustrated analogous findings by assigning more than one alphanumeric code to a finding. We also showed that more than one effect or method could report the same finding. We presented contradictory findings by listing them in adjacent rows of the MATRICS. Results: MATRICS was useful for the effective synthesis and presentation of findings of the multiple methods from ENIGMA. We subsequently successfully tested it by applying it to the MINuET trial. Conclusion: MATRICS is effective for synthesizing the findings of complex, multiple-method studies.

Interventions for nurses caring for a child who has an unexpected acute life threatening event (ALTE) in hospital

Introduction: Caring for a child who has an unexpected ALTE in hospital can be stressful. An ALTE may include a cardiac arrest, respiratory arrest or call for immediate assistance. An international survey of practice was conducted to identify any existing interventions to inform a PhD program of work aimed at reducing the stress from these events through preparation and support. Purpose: The purpose of the survey was threefold: (1) Describe ‘normal’ practice when it comes to preparing staff or providing psychological support after caring for a child who has had an ALTE. (2) Determine if there are any interventions to prepare clinical staff for potential psychological effects of caring for a child who has an ALTE. (3) Determine if there are any interventions to provide support for clinical staff after caring for a child who has an ALTE. Material - Methods: An 18 item semi structured questionnaire was designed for the study to allow respondent to describe practices within their institution and outline their opinions and professional experiences. Clinicians from selected children’s and adult hospitals in Australia, Canada, New Zealand, United Kingdom and the United States of America were contacted by telephone. Following consent they were given the option to complete the survey via the telephone, by post or online. Results: Of the 61 hospitals approached 44 (72%) clinicians responded. Eighteen (41%) respondents identified interventions in place to prepare nurses for an ALTE ranging from (but not limited to) ad hoc discussions during life support training through to structured simulation training. Thirty-six (82%) respondents identified that they had interventions in place to support nurses after an ALTE ranging from (but not limited to) debriefing through to structured case reviews. Conclusions: Interventions varied across institutions, with no outcome or evaluation data for the interventions published to date.

A telephone survey to determine the experiences of children and their parents/carers, following the initiation of a new medicine

Objective: To determine what issues are experienced during the first few weeks of therapy by patients, and their parents/carers, when a child/young person has been prescribed a new medicine. Method: One hundred patients aged ≤18 years of age prescribed a new medicine for ≥6 weeks were recruited from a single UK National Health Service specialist paediatric hospital outpatient pharmacy. Six weeks after the first dispensing of their new medicine the patient or their parent/carer received telephone follow-up by a researcher and verbally completed a questionnaire containing both open and closed questions. Patient or parent/carer experiences were identified and analysed using thematic analysis and descriptive statistics. Results: Eighty-six participants were available for telephone follow-up. Six (7%) had not started their medicine. Paediatric patients and their parents/carers experienced a range of issues during the first few weeks after starting a new medicine. These included additional concerns/questions (24/80, 30%), administration issues (21/80, 26.3%), adverse effects (29/80, 36.3%) and obtaining repeat supplies (12/80, 15%). The Morisky Medication Adherence Scale indicated that 34/78 (43.6%) participants had a high adherence rating, 35/78 (44.9%) medium and 9/78 (11.5%) a low rating. Conclusions: Paediatric patients and their parents/carers experience a range of issues during the first few weeks after starting a new medicine. Further research is required to determine the type of interventions that may further support medicines use in this group of patients.