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.

Moving feedback forward: theory to practice

There is substantial research interest in tutor feedback and students’ perception and use of such feedback. This paper considers some of the major issues raised in relation to tutor feedback and student learning. We explore some of the current feedback drivers, most notably the need for feedback to move away from simply a monologue from a tutor to a student to a valuable tutor–student dialogue. In relation to moving feedback forward the notions of self regulation, dialogue and social learning are explored and then considered in relation to how such theory can translate into practice. The paper proposes a framework (GOALS) as a tool through which tutors can move theory into practice with the aim of improving student learning from feedback.

Modeling building semantics: providing feedback and sustainability

Even minor changes in user activity can bring about significant energy savings within built space. Many building performance assessment methods have been developed, however these often disregard the impact of user behavior (i.e. the social, cultural and organizational aspects of the building). Building users currently have limited means of determining how sustainable they are, in context of the specific building structure and/or when compared to other users performing similar activities, it is therefore easy for users to dismiss their energy use. To support sustainability, buildings must be able to monitor energy use, identify areas of potential change in the context of user activity and provide contextually relevant information to facilitate persuasion management. If the building is able to provide users with detailed information about how specific user activity that is wasteful, this should provide considerable motivation to implement positive change. This paper proposes using a dynamic and temporal semantic model, to populate information within a model of persuasion, to manage user change. By semantically mapping a building, and linking this to persuasion management we suggest that: i) building energy use can be monitored and analyzed over time; ii) persuasive management can be facilitated to move user activity towards sustainability.

The role of atmosphere feedbacks during ENSO in the CMIP3 models. Part II: using AMIP runs to understand the heat flux feedback mechanisms

Several studies using ocean–atmosphere general circulation models (GCMs) suggest that the atmospheric component plays a dominant role in the modelled El Niño-Southern Oscillation (ENSO). To help elucidate these findings, the two main atmosphere feedbacks relevant to ENSO, the Bjerknes positive feedback (μ) and the heat flux negative feedback (α), are here analysed in nine AMIP runs of the CMIP3 multimodel dataset. We find that these models generally have improved feedbacks compared to the coupled runs which were analysed in part I of this study. The Bjerknes feedback, μ, is increased in most AMIP runs compared to the coupled run counterparts, and exhibits both positive and negative biases with respect to ERA40. As in the coupled runs, the shortwave and latent heat flux feedbacks are the two dominant components of α in the AMIP runs. We investigate the mechanisms behind these two important feedbacks, in particular focusing on the strong 1997–1998 El Niño. Biases in the shortwave flux feedback, α SW, are the main source of model uncertainty in α. Most models do not successfully represent the negative αSW in the East Pacific, primarily due to an overly strong low-cloud positive feedback in the far eastern Pacific. Biases in the cloud response to dynamical changes dominate the modelled α SW biases, though errors in the large-scale circulation response to sea surface temperature (SST) forcing also play a role. Analysis of the cloud radiative forcing in the East Pacific reveals model biases in low cloud amount and optical thickness which may affect α SW. We further show that the negative latent heat flux feedback, α LH, exhibits less diversity than α SW and is primarily driven by variations in the near-surface specific humidity difference. However, biases in both the near-surface wind speed and humidity response to SST forcing can explain the inter-model αLH differences.

The relationship between the North American summer monsoon, the Rocky Mountains and the North Pacific subtropical anticyclone in HadAM3

In this study the relationship between the North American monsoon, the Californian sea surface temperature (SST) cold pool, the Rocky Mountains and the North Pacific subtropical anticyclone is investigated using the Hadley Centre's atmospheric climate model, HadAM3. In 1996 Hoskins hypothesized that heating in the North American monsoon might be important for the maintenance of the summertime North Pacific subtropical anticyclone, since the monsoon heating may induce descent to the north-west of the monsoon in the descending eastern flank of the subtropical anticyclone. This descent is further enhanced by radiative cooling and is associated with equatorward surface winds parallel to the western coast of North America. These equatorward winds induce oceanic upwelling of cold water and contribute to the formation of the Californian SST cold pool, which may feed back on the anticyclone by further suppressing convection and inducing descent. More recently, Rodwell and Hoskins also investigated the global summer monsoon–subtropical anticyclone relationship. They examined the role that mountains play in impeding the progress of the low-level mid-latitude westerlies, either deflecting the westerlies northwards where they ascend along the sloping mid-latitude isentropes or deflecting them southwards forcing them to descend along the isentropes. In particular, the introduction of the Rockies into a primitive-equation model adiabatically induces descent in the eastern descending flank of the North Pacific subtropical anticyclone. These hypothesized mechanisms have been investigated using HadAM3, focusing on the possible suppression of convection by the Californian SST cold pool, the response of the North Pacific subtropical anticyclone to the strength of the North American monsoon and the ‘blocking’ of the mid-latitude westerlies by the Rocky Mountains. The role of the Rockies is examined by integrating the model with modified orography for the Rocky Mountains. Changing the height of the Rockies alters the circulation in a way consistent with the mechanism outlined above. Higher Rocky mountains force the westerlies southwards, inducing descent in the eastern flank of the subtropical anticyclone as the air descends along the sloping isentropes. The relationship between the North American monsoon and the North Pacific subtropical anticyclone is investigated by suppressing the monsoon in HadAM3. The suppression of the monsoon is accomplished by increasing the surface albedo over Mexico, which induces anomalous ascent on the eastward flank of the subtropical anticyclone and anomalous polewards surface winds along the western coast of the North American continent, also providing support for the above hypothesis. The removal of the Californian SST cold pool, however, has a statistically insignificant effect on the model, suggesting that in this model the feedback of the SST cold pool on the eastern flank of the anticyclone is weak.

Occupants’ behavioural adaptation in workplaces with non-central heating and cooling systems

Occupants’ behaviour when improving the indoor environment plays a significant role in saving energy in buildings. Therefore the key step to reducing energy consumption and carbon emissions from buildings is to understand how occupants interact with the environment they are exposed to in terms of achieving thermal comfort and well-being; though such interaction is complex. This paper presents a dynamic process of occupant behaviours involving technological, personal and psychological adaptations in response to varied thermal conditions based on the data covering four seasons gathered from the field study in Chongqing, China. It demonstrates that occupants are active players in environmental control and their adaptive responses are driven strongly by ambient thermal stimuli and vary from season to season and from time to time, even on the same day. Positive, dynamic, behavioural adaptation will help save energy used in heating and cooling buildings. However, when environmental parameters cannot fully satisfy occupants’ requirements, negative behaviours could conflict with energy saving. The survey revealed that about 23% of windows are partly open for fresh air when air-conditioners are in operation in summer. This paper addresses the issues how the building and environmental systems should be designed, operated and managed in a way that meets the requirements of energy efficiency without compromising wellbeing and productivity.

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.

A robust controller design method for feedback substitution schemes using genetic algorithms

Controllers for feedback substitution schemes demonstrate a trade-off between noise power gain and normalized response time. Using as an example the design of a controller for a radiometric transduction process subjected to arbitrary noise power gain and robustness constraints, a Pareto-front of optimal controller solutions fulfilling a range of time-domain design objectives can be derived. In this work, we consider designs using a loop shaping design procedure (LSDP). The approach uses linear matrix inequalities to specify a range of objectives and a genetic algorithm (GA) to perform a multi-objective optimization for the controller weights (MOGA). A clonal selection algorithm is used to further provide a directed search of the GA towards the Pareto front. We demonstrate that with the proposed methodology, it is possible to design higher order controllers with superior performance in terms of response time, noise power gain and robustness.

Real-time application of a constrained predictive controller based on dynamic neural networks with feedback linearization

This paper describes an experimental application of constrained predictive control and feedback linearisation based on dynamic neural networks. It also verifies experimentally a method for handling input constraints, which are transformed by the feedback linearisation mappings. A performance comparison with a PID controller is also provided. The experimental system consists of a laboratory based single link manipulator arm, which is controlled in real time using MATLAB/SIMULINK together with data acquisition equipment.

From saccades to smooth pursuit: real-time gaze control using motion feedback

The authors present an active vision system which performs a surveillance task in everyday dynamic scenes. The system is based around simple, rapid motion processors and a control strategy which uses both position and velocity information. The surveillance task is defined in terms of two separate behavioral subsystems, saccade and smooth pursuit, which are demonstrated individually on the system. It is shown how these and other elementary responses to 2D motion can be built up into behavior sequences, and how judicious close cooperation between vision and control results in smooth transitions between the behaviors. These ideas are demonstrated by an implementation of a saccade to smooth pursuit surveillance system on a high-performance robotic hand/eye platform.

Feedback design for regularizing descriptor systems

This paper surveys numerical techniques for the regularization of descriptor (generalized state-space) systems by proportional and derivative feedback. We review generalizations of controllability and observability to descriptor systems along with definitions of regularity and index in terms of the Weierstraß canonical form. Three condensed forms display the controllability and observability properties of a descriptor system. The condensed forms are obtained through orthogonal equivalence transformations and rank decisions, so they may be computed by numerically stable algorithms. In addition, the condensed forms display whether a descriptor system is regularizable, i.e., when the system pencil can be made to be regular by derivative and/or proportional output feedback, and, if so, what index can be achieved. Also included is a a new characterization of descriptor systems that can be made to be regular with index 1 by proportional and derivative output feedback.

Robust pole assignment in linear state feedback

Numerical methods are described for determining robust, or well-conditioned, solutions to the problem of pole assignment by state feedback. The solutions obtained are such that the sensitivity of the assigned poles to perturbations in the system and gain matrices is minimized. It is shown that for these solutions, upper bounds on the norm of the feedback matrix and on the transient response are also minimized and a lower bound on the stability margin is maximized. A measure is derived which indicates the optimal conditioning that may be expected for a particular system with a given set of closed-loop poles, and hence the suitability of the given poles for assignment.