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.

The Clean Development Mechanism as ethical development? Reconciling emissions trading and local development

This paper examines the ethics of the Clean Development Mechanism (CDM) in its architecture, processes and outcomes and its potential to allocate resources to the poor as ‘ethical development’. Two specific examples of CDM projects help us to explore some of the quandaries that seem to be quickly defining operating procedure for the CDM in its efforts to bring entitlementsto the poor. The paper concludes with reflections on the normative and social complications of the CDM and closes with three key areas of further investigation.

Exploring social barriers to adaptation: insights from Western Nepal

As the challenges and opportunities posed by climate change become increasingly apparent, the need for facilitating successful adaptation and enhancing adaptive capacity within the context of sustainable development is clear. With adaptation high on the agenda, the notion of limits and barriers to adaptation has recently received much attention within both academic and policymaking spheres. While emerging literature has been quick to depict limits and barriers in terms of natural, financial, or technologic processes, there is a clear shortfall in acknowledging social barriers to adaptation. It is against such a backdrop that this paper sets out to expose and explore some of the underlying features of social barriers to adaptation, drawing on insights from two case studies in the Western Nepal. This paper exposes the significant role of cognitive, normative and institutional factors in both influencing and prescribing adaptation. It explores how restrictive social environments can limit adaptation actions and influence adaptive capacity at the local level, particularly for the marginalised and socially excluded. The findings suggest a need for greater recognition of the diversity and complexity of social barriers, strategic planning and incorporation at national and local levels, as well as an emphasis on tackling the underlying drivers of vulnerability and social exclusion.

Societal choice for climate change futures: trees, biotechnology and clean development

The rate and magnitude of predicted climate change require that we urgently mitigate emissions or sequester carbon on a substantial scale in order to avoid runaway climate change. Geo- and bioengineering solutions are increasingly proposed as viable and practical strategies for tackling global warming. Biotechnology companies are already developing transgenic “super carbon-absorbing” trees, which are sold as a cost-effective and relatively low-risk means of sequestering carbon. The question posed in this article is, Do super carbon trees provide real benefits or are they merely a fanciful illusion? It remains unclear whether growing these trees makes sense in terms of the carbon cost of production and the actual storage of carbon. In particular, it is widely acknowledged that “carbon-eating” trees fail to sequester as much carbon as they oxidize and return to the atmosphere; moreover, there are concerns about the biodiversity impacts of large-scale monoculture plantations. The potential social and ecological risks and opportunities presented by such controversial solutions warrant a societal dialogue.

Resilient responses to climate change: exploring organisational learning in networked development organisations

Drawing from the organisational learning and governance literature, this paper assesses four internationally networked governmental and non‐governmental organisations in the UK addressing climate change. We analyse how those concerned understand the climate change crisis, what mechanisms are put in place to address information flows, and what evidence there is of learning through sharing information between the organisational headquarters and their regional offices. The most striking finding is the evidence of learning that largely depends on ad‐hoc informal processes and shadow networks.

Protecting degraded rainforests: enhancement of forest carbon stocks under REDD+

The likely Reducing Emissions from Deforestation and Degradation (REDD+) mechanism includes strategies for the enhancement of forest carbon stocks. Recent concerns have been expressed that such enhancement, or restoration, of forest carbon could be counterproductive to biodiversity conservation, because forests are managed as “carbon farms” with the application of intensive silvicultural management that could homogenize diverse degraded rainforests. Restoration increases regeneration rates in degraded forest compared to naturally regenerating forest, and thus could yield significant financial returns for carbon sequestered. Here, we argue that such forest restoration projects are, in fact, likely to provide a number of benefits to biodiversity conservation including the retention of biodiversity, the prevention of forest conversion to agriculture, and employment opportunities for poor local communities. As with other forms of forest-based carbon offsets, there are possible moral hazard and leakage problems with restoration. However, due to the multiple benefits, we urge that enhancement of forest carbon stocks be detailed as a major component in the future negotiations of REDD+.

Using learning networks to understand complex systems: a case study of biological, geophysical and social research in the Amazon

Developing high-quality scientific research will be most effective if research communities with diverse skills and interests are able to share information and knowledge, are aware of the major challenges across disciplines, and can exploit economies of scale to provide robust answers and better inform policy. We evaluate opportunities and challenges facing the development of a more interactive research environment by developing an interdisciplinary synthesis of research on a single geographic region. We focus on the Amazon as it is of enormous regional and global environmental importance and faces a highly uncertain future. To take stock of existing knowledge and provide a framework for analysis we present a set of mini-reviews from fourteen different areas of research, encompassing taxonomy, biodiversity, biogeography, vegetation dynamics, landscape ecology, earth-atmosphere interactions, ecosystem processes, fire, deforestation dynamics, hydrology, hunting, conservation planning, livelihoods, and payments for ecosystem services. Each review highlights the current state of knowledge and identifies research priorities, including major challenges and opportunities. We show that while substantial progress is being made across many areas of scientific research, our understanding of specific issues is often dependent on knowledge from other disciplines. Accelerating the acquisition of reliable and contextualized knowledge about the fate of complex pristine and modified ecosystems is partly dependent on our ability to exploit economies of scale in shared resources and technical expertise, recognise and make explicit interconnections and feedbacks among sub-disciplines, increase the temporal and spatial scale of existing studies, and improve the dissemination of scientific findings to policy makers and society at large. Enhancing interaction among research efforts is vital if we are to make the most of limited funds and overcome the challenges posed by addressing large-scale interdisciplinary questions. Bringing together a diverse scientific community with a single geographic focus can help increase awareness of research questions both within and among disciplines, and reveal the opportunities that may exist for advancing acquisition of reliable knowledge. This approach could be useful for a variety of globally important scientific questions.