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.

Contested H2O: science, policy and politics in water resources management in Chile

This paper critically explores the politics that mediate the use of environmental science assessments as the basis of resource management policy. Drawing on recent literature in the political ecology tradition that has emphasised the politicised nature of the production and use of scientific knowledge in environmental management, the paper analyses a hydrological assessment in a small river basin in Chile, undertaken in response to concerns over the possible overexploitation of groundwater resources. The case study illustrates the limitations of an approach based predominantly on hydrogeological modelling to ascertain the effects of increased groundwater abstraction. In particular, it identifies the subjective ways in which the assessment was interpreted and used by the state water resources agency to underpin water allocation decisions in accordance with its own interests, and the role that a desocialised assessment played in reproducing unequal patterns of resource use and configuring uneven waterscapes. Nevertheless, as Chile’s ‘neoliberal’ political-economic framework privileges the role of science and technocracy, producing other forms of environmental knowledge to complement environmental science is likely to be contentious. In conclusion, the paper considers the potential of mobilising the concept of the hydrosocial cycle to further critically engage with environmental science.

Re-thinking stakeholder management in construction: theory & research

From its roots in strategic management theory, stakeholder management has been adopted by the construction management academic community and applied as a valid paradigm around which research work has been generated aiming to improve project effi ciencies and effectiveness. However, academics have argued that stakeholder management should move away from purely theoretical discussions and engage more with the realities of construction project work. This paper re-appraises the stakeholder management concept for the construction domain by re-thinking some of the fundamental principles and ideals present within the more general stakeholder theory literature. It engages with issues which researchers have arguably failed to acknowledge and calls for a re-evaluation of construction stakeholder management research by presenting a review around four distinctive themes: the moral obligations of engaging with stakeholders against the business and efficiency driven imperatives of construction organisations; the contrast between theoretical abstractions and empirically grounded research; the tensions between theoretical convergence versus calls for multiple and divergent perspectives on stakeholder management and the practicalities of conducting stakeholder management in the construction domain. Such a critical re-appraisal of stakeholder management thinking both generates new lines of enquiry and promises to help inform and shape current and future industry practice.

Corporate real estate management in the retail sector: a study of the relationship between the management of the corporate real estate and corporate performance

Retail organisations have often been cited as being at the forefront of corporate real estate management. This research found that the retail sector can be characterised by diversity both in terms of the degree to which organisations are vertically integrated and in terms of the range of modes of retailing they engage in. This in turn led to highly diverse real estate portfolios. Given this diversity it may be surprising that the over riding strategy which the vast majority of sample firms adopted was focused on supporting the core retail activity. However the way in which they implement this strategy, again reflected the diversity in the sector. In terms of the future, the senior real estate managers were focusing on the medium term particularly looking at the way change would impact their functional strategy. This study provides a snap-shot of current practice and contributes to the debate however it also recognised that there is a need to answer the more fundamental questions.

The domestication of water: water management in the ancient world and its prehistoric origins in the Jordan Valley

The ancient civilizations were dependent upon sophisticated systems of water management. The hydraulic engineering works found in ancient Angkor (ninth to thirteenth century AD), the Aztec city of Tenochtitlan (thirteenth to fifteenth century AD), Byzantine Constantinople (fourth to sixth century AD) and Nabatean Petra (sixth century BC to AD 106) are particularly striking because each of these is in localities of the world that are once again facing a water crisis. Without water management, such ancient cities would never have emerged, nor would the urban communities and towns from which they developed. Indeed, the ‘domestication’ of water marked a key turning point in the cultural trajectory of each region of the world where state societies developed. This is illustrated by examining the prehistory of water management in the Jordan Valley, identifying the later Neolithic (approx. 8300–6500 years ago) as a key period when significant investment in water management occurred, laying the foundation for the development of the first urban communities of the Early Bronze Age.

The implications of improved communications for participatory forest management in Tanzania

Following the 1998 National Forest Policy and Forest Act of 2002, participatory forest management (PFM) is being introduced in Tanzania. PFM has two key objectives: to reduce forest degradation thereby increasing ecosystem services, and to improve the livelihoods of local villagers. A unique data set collected in 2006 suggests that significant challenges remain with respect to communicating the new forest policies if the objectives of PFM are to be achieved. First, villagers as a group are much less well informed than other stakeholders, and their knowledge is often inaccurate. Second, women are less likely than men to have heard of the changes. Third, how PFM will contribute to poverty reduction (a key objective of PFM) is not always clear. Fourth, environmental degradation may not be reduced as much as anticipated – without alternatives sources, villagers often continue to cut trees for charcoal and firewood in the protected forests. Finally, several mismatches in perceptions are identified that could lead to difficulties in implementing PFM.

Hypothesis management in situation assessment

A situation assessment uses reports from sensors to produce hypotheses about a situation at a level of aggregation that is of direct interest to a military commander. A low level of aggregation could mean forming tracks from reports, which is well documented in the tracking literature as track initiation and data association. In this paper there is also discussion on higher level aggregation; assessing the membership of tracks to larger groups. Ideas used in joint tracking and identification are extended, using multi-entity Bayesian networks to model a number of static variables, of which the identity of a target is one. For higher level aggregation a scheme for hypothesis management is required. It is shown how an offline clustering of vehicles can be reduced to an assignment problem.

Farmers’ attitudes to disease risk management in England: a comparative analysis of sheep and pig farmers

The UK Department for Environment, Food and Rural Affairs (Defra) identified practices to reduce the risk of animal disease outbreaks. We report on the response of sheep and pig farmers in England to promotion of these practices. A conceptual framework was established from research on factors influencing adoption of animal health practices, linking knowledge, attitudes, social influences and perceived constraints to the implementation of specific practices. Qualitative data were collected from nine sheep and six pig enterprises in 2011. Thematic analysis explored attitudes and responses to the proposed practices, and factors influencing the likelihood of implementation. Most feel they are doing all they can reasonably do to minimise disease risk and that practices not being implemented are either not relevant or ineffective. There is little awareness and concern about risk from unseen threats. Pig farmers place more emphasis than sheep farmers on controlling wildlife, staff and visitor management and staff training. The main factors that influence livestock farmers’ decision on whether or not to implement a specific disease risk measure are: attitudes to, and perceptions of, disease risk; attitudes towards the specific measure and its efficacy; characteristics of the enterprise which they perceive as making a measure impractical; previous experience of a disease or of the measure; and the credibility of information and advice. Great importance is placed on access to authoritative information with most seeing vets as the prime source to interpret generic advice from national bodies in the local context. Uptake of disease risk measures could be increased by: improved risk communication through the farming press and vets to encourage farmers to recognise hidden threats; dissemination of credible early warning information to sharpen farmers’ assessment of risk; and targeted information through training events, farming press, vets and other advisers, and farmer groups, tailored to the different categories of livestock farmer.