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.

Non-standard working time: an international and comparative analysis

This paper uses the large-scale Cranet data to explore the extent of non-standard working time (NSWT) across Europe and to highlight the contrasts and similarities between two different varieties of capitalism (coordinated market economies and liberal market economies). We explore variations in the extent of different forms of NSWT (overtime, shift working and weekend working) within these two different forms of capitalism, controlling for firm size, sector and the extent of employee voice. Overall, there was no strong link between the variety of capitalism and the use of overtime and weekend working though shift working showed a clear distinction between the two varieties of capitalism. Usage of NSWT in some service sectors was particularly high under both forms of capitalism and service sector activities had a particularly marked influence on the use of overtime in liberal market economies. Surprisingly, strong employee voice was associated with greater use of NSWT.

Spatial and temporal modeling of community non-timber forest extraction

This paper examines the interaction of spatial and dynamic aspects of resource extraction from forests by local people. Highly cyclical and varied across space and time, the patterns of resource extraction resulting from the spatial–temporal model bear little resemblance to the patterns drawn from focusing either on spatial or temporal aspects of extraction alone. Ignoring this variability inaccurately depicts villagers’ dependence on different parts of the forest and could result in inappropriate policies. Similarly, the spatial links in extraction decisions imply that policies imposed in one area can have unintended consequences in other areas. Combining the spatial–temporal model with a measure of success in community forest management—the ability to avoid open-access resource degradation—characterizes the impact of incomplete property rights on patterns of resource extraction and stocks.

Are property prices non-linear? An investigation of the behaviour of US REITs and UK property company shares

Linear models of market performance may be misspecified if the market is subdivided into distinct regimes exhibiting different behaviour. Price movements in the US Real Estate Investment Trusts and UK Property Companies Markets are explored using a Threshold Autoregressive (TAR) model with regimes defined by the real rate of interest. In both US and UK markets, distinctive behaviour emerges, with the TAR model offering better predictive power than a more conventional linear autoregressive model. The research points to the possibility of developing trading rules to exploit the systematically different behaviour across regimes.

The effectiveness of non-executive directors in Chinese state-owned enterprises

Purpose – The primary aim of this paper is to examine whether boards of directors with independent members function as effective corporate governance mechanisms in Chinese State-Owned Enterprises(SOEs), by analysing four characteristics of non-executive directors (NEDs) that impact on their effectiveness, namely their degree of independence, information, incentive, and competence. Design/methodology/approach – Being exploratory in nature, the research uses qualitative methods for data collection. It is based on an interpretivist perspective of social sciences, analysing and explaining the factors that influence the effectiveness of NEDs. Findings – The findings indicate that the NED system is weak in China as a result of the concentrated ownership structure, unique business culture, intervention of controlling shareholders and the lack of understanding of the benefits brought by NEDs. Research limitations/implications – The paper examines the salient features of and challenges to the system of NEDs of SOEs in present-day China. It provides an understanding of how the various perceptions of the board, gathered from in-depth interviews of corporate directors, leads to new interpretations of board effectiveness. The research, however, is limited owing to a relatively small sample size and the sensitive nature of the information collected. Originality/value – The study aims to fill gaps in the literature and contribute to it by assessing the “real” views and perceptions of NEDs in China in an institutional environment significantly different from that of the USA, the UK and other western economies.

Communities of practice in UK large contracting firms: contrasting application and non-utilized merits

The idea of a community of practice (CoP) has been offered as the engine to unlock the potential of organizational resources, mainly knowledge and people, to achieve the strategic goal of sustained competitiveness. The relevance and application of CoPs in large UK contracting companies was investigated using two case studies. Contrasting variations in the understanding of the concept between the two contracting companies were observed. While a CoP was applied in one company with strategic intent, the concept was not fully understood in the other. In one company, only a third of CoP members surveyed agreed that CoPs were a vehicle for driving best practice and innovation throughout the business; this compared with more than 60% in agreement in the other contracting firm. The higher agreement and satisfaction of CoP members in the latter case study was the result of the management's understanding and commitment. CoPs require time and organizational support to mature. The strategic inception and management support of CoP application is vital for their maturation and progress. Although the construction industry change discourses portray CoPs as fostering an environment of trust, and hence serving as innovation and competiveness enablers, their potential contribution to contracting firms does not provide a compelling case and hence merits further research studies.

Understanding lake and catchment history as a tool for integrated lake management

Sustainable lake management for nutrient-enriched lakes must be underpinned by an understanding of both the functioning of the lake, and the origins of changes in nutrient loading from the catchment. To date, limnologists have tended to focus on studying the impact of nutrient enrichment on the lake biota, and the dynamics of nutrient cycling between the water column, biota and sediments within the lake. Relatively less attention has been paid to understanding the specific origins of nutrient loading from the catchment and nutrient transport pathways linking the lake to its catchment. As such, when devising catchment management strategies to reduce nutrient loading on enriched lakes, assumptions have been made regarding the relative significance of non-point versus point sources in the catchment. These are not always supported by research conducted on catchment nutrient dynamics in other fields of freshwater science. Studies on nutrient enrichment in lakes need to take account of the history of catchment use and management specific to each lake in order to devise targeted and sustainable management strategies to reduce nutrient loading to enriched lakes. Here a modelling approach which allows quantification of the relative contribution of nutrients from each specific point and non-point catchment source over the course of catchment history is presented. The approach has been applied to three contrasting catchments in the U.K. for the period 1931 to present. These are the catchment of Slapton Ley in south Devon, the River Esk in Cumbria and the Deben Estuary in Suffolk. Each catchment showed marked variations in the nature and intensity of land use and management. The model output quantifies the relative importance of point source versus non-point livestock and land use sources in each of the catchments, and demonstrates the necessity for an understanding of site-specific catchment history in devising suitable management strategies for the reduction of nutrient loading on enriched lakes.

Phosphorus loss from agricultural catchments: pathways and implications for management

The contribution non-point P sources make to the total P loading on water bodies in agricultural catchments has not been fully appreciated. Using data derived from plot scale experimental studies, and modelling approaches developed to simulate system behaviour under differing management scenarios, a fuller understanding of the processes controlling P export and transformations along non-point transport pathways can be achieved. One modelling approach which has been successfully applied to large UK catchments (50-350km2 in area) is applied here to a small, 1.5 km2 experimental catchment. The importance of scaling is discussed in the context of how such approaches can extrapolate the results from plot-scale experimental studies to full catchment scale. However, the scope of such models is limited, since they do not at present directly simulate the processes controlling P transport and transformation dynamics. As such, they can only simulate total P export on an annual basis, and are not capable of prediction over shorter time scales. The need for development of process-based models to help answer these questions, and for more comprehensive UK experimental studies is highlighted as a pre-requisite for the development of suitable and sustainable management strategies to reduce non-point P loading on water bodies in agricultural catchments.

Discerning policy and drivers for sustainable facilities management practice

Due to the changing nature of the facilities management (FM) profession, facilities managers are increasingly engaged with the evolving sustainability agenda in the UK and the development or uptake of sustainability policies within their organisations. This study investigates how facilities managers are engaging with the sustainability agenda and the drivers, policy issues and information they use to improve their sustainability performance management. A web based self-administered questionnaire survey of facilities managers in the UK was conducted to identify drivers and issues that influence and support good sustainable practices. A total of 268 facilities managers responded. The results indicate that legislation is the most important driver for the implementation of sustainable practices. Corporate image and Organisational ethos are also recognised. However demand for efficient monitoring, management and reporting on environmental impact is not highly rated even though the top three issues of sustainability managed by facilities managers are energy management, waste and recycling management and carbon footprint. In addition, facilities managers are expected to take ownership of activities assigned to the reduction of carbon emission. Government industries and organisation with high turnover are more likely to have a sustainability policy. Financial constraints are the main barriers while legislations are the main driver for implementing sustainability. For non-profit organisations and the charitable sector, financial constraints are no hindrance to implementing a sustainability policy. The conclusion drawn is that sustainability agendas continue to be influenced by regulated environmental issues rather than a balanced approach which takes into consideration the wider social and economic aspects of sustainability. While this scenario is far from ideal, the expectation is that the organisation will trust FM to take a vital role in delivering a comprehensive sustainability policy due to the rising tide of legislation, public scrutiny, as well as the needed business case for genuinely embracing sustainability. However, as the integration of sustainability with core business strategies is continuously evolving the emphasis on different drivers will vary from organisation to organisation as well as the responsibilities of facilities managers.

Factors influencing adoption of improved grassland management by small-scale dairy farmers in central Mexico and the implications for future research on smallholder adoption in developing countries

There have been limited recent advances in understanding of what influences uptake of innovations despite the current international focus on smallholder agriculture as a means of achieving food security and rural development. This paper provides a rigorous study of factors influencing adoption by smallholders in central Mexico and builds on findings to identify a broad approach to significantly improve research on and understanding of factors influencing adoption by smallholders in developing countries. Small-scale dairy systems play an important role in providing income, employment and nutrition in the highlands of central Mexico. A wide variety of practices and technologies have been promoted by the government public services to increase milk production and economic efficiency, but there have been very low levels of uptake of most innovations, with the exception of improving grassland through introduction of grass varieties together with management practices. A detailed study was conducted with 80 farmers who are already engaged with the use of this innovation to better understand the process of adoption and identify socioeconomic and farm variables, cognitive (beliefs), and social–psychological (social norms) factors associated with farmers' use of improved grassland. The Theory of Reasoned Action (TRA) was used as a theoretical framework and Spearman Rank Order correlation was conducted to analyse the data. Most farmers (92.5%) revealed strong intention to continue to use improved grassland (which requires active management and investment of resources) for the next 12 months; whereas 7.5% of farmers were undecided and showed weak intention, which was associated with farmers whose main income was from non-farm activities as well as with farmers who had only recently started using improved grassland. Despite farmers' experience of using improved grassland (mean of 18 years) farmers' intentions to continue to adopt it was influenced almost as much by salient referents (mainly male relatives) as by their own attitudes. The hitherto unnoticed longevity of the role social referents play in adoption decisions is an important finding and has implications for further research and for the design of extension approaches. The study demonstrates the value and importance of using TRA or TPB approaches to understand social cognitive (beliefs) and social–psychological (social norms) factors in the study of adoption. However, other factors influencing adoption processes need to be included to provide fuller understanding. An approach that would enable this, and the development of more generalisable findings than from location specific case studies, and contribute to broader conceptualisation, is proposed.

Integrated clinical pathway management for medical quality improvement-based on a semiotically inspired systems architecture

Clinical pathway is an approach to standardise care processes to support the implementations of clinical guidelines and protocols. It is designed to support the management of treatment processes including clinical and non-clinical activities, resources and also financial aspects. It provides detailed guidance for each stage in the management of a patient with the aim of improving the continuity and coordination of care across different disciplines and sectors. However, in the practical treatment process, the lack of knowledge sharing and information accuracy of paper-based clinical pathways burden health-care staff with a large amount of paper work. This will often result in medical errors, inefficient treatment process and thus poor quality medical services. This paper first presents a theoretical underpinning and a co-design research methodology for integrated pathway management by drawing input from organisational semiotics. An approach to integrated clinical pathway management is then proposed, which aims to embed pathway knowledge into treatment processes and existing hospital information systems. The capability of this approach has been demonstrated through the case study in one of the largest hospitals in China. The outcome reveals that medical quality can be improved significantly by the classified clinical pathway knowledge and seamless integration with hospital information systems.