'Explicit Learning: an Effort towards Human Scheduling Algorithms'

Abstract Scheduling problems are generally NP-hard combinatorial problems, and a lot of research has been done to solve these problems heuristically. However, most of the previous approaches are problem-specific and research into the development of a general scheduling algorithm is still in its infancy. Mimicking the natural evolutionary process of the survival of the fittest, Genetic Algorithms (GAs) have attracted much attention in solving difficult scheduling problems in recent years. Some obstacles exist when using GAs: there is no canonical mechanism to deal with constraints, which are commonly met in most real-world scheduling problems, and small changes to a solution are difficult. To overcome both difficulties, indirect approaches have been presented (in [1] and [2]) for nurse scheduling and driver scheduling, where GAs are used by mapping the solution space, and separate decoding routines then build solutions to the original problem. In our previous indirect GAs, learning is implicit and is restricted to the efficient adjustment of weights for a set of rules that are used to construct schedules. The major limitation of those approaches is that they learn in a non-human way: like most existing construction algorithms, once the best weight combination is found, the rules used in the construction process are fixed at each iteration. However, normally a long sequence of moves is needed to construct a schedule and using fixed rules at each move is thus unreasonable and not coherent with human learning processes. When a human scheduler is working, he normally builds a schedule step by step following a set of rules. After much practice, the scheduler gradually masters the knowledge of which solution parts go well with others. He can identify good parts and is aware of the solution quality even if the scheduling process is not completed yet, thus having the ability to finish a schedule by using flexible, rather than fixed, rules. In this research we intend to design more human-like scheduling algorithms, by using ideas derived from Bayesian Optimization Algorithms (BOA) and Learning Classifier Systems (LCS) to implement explicit learning from past solutions. BOA can be applied to learn to identify good partial solutions and to complete them by building a Bayesian network of the joint distribution of solutions [3]. A Bayesian network is a directed acyclic graph with each node corresponding to one variable, and each variable corresponding to individual rule by which a schedule will be constructed step by step. The conditional probabilities are computed according to an initial set of promising solutions. Subsequently, each new instance for each node is generated by using the corresponding conditional probabilities, until values for all nodes have been generated. Another set of rule strings will be generated in this way, some of which will replace previous strings based on fitness selection. If stopping conditions are not met, the Bayesian network is updated again using the current set of good rule strings. The algorithm thereby tries to explicitly identify and mix promising building blocks. It should be noted that for most scheduling problems the structure of the network model is known and all the variables are fully observed. In this case, the goal of learning is to find the rule values that maximize the likelihood of the training data. Thus learning can amount to 'counting' in the case of multinomial distributions. In the LCS approach, each rule has its strength showing its current usefulness in the system, and this strength is constantly assessed [4]. To implement sophisticated learning based on previous solutions, an improved LCS-based algorithm is designed, which consists of the following three steps. The initialization step is to assign each rule at each stage a constant initial strength. Then rules are selected by using the Roulette Wheel strategy. The next step is to reinforce the strengths of the rules used in the previous solution, keeping the strength of unused rules unchanged. The selection step is to select fitter rules for the next generation. It is envisaged that the LCS part of the algorithm will be used as a hill climber to the BOA algorithm. This is exciting and ambitious research, which might provide the stepping-stone for a new class of scheduling algorithms. Data sets from nurse scheduling and mall problems will be used as test-beds. It is envisaged that once the concept has been proven successful, it will be implemented into general scheduling algorithms. It is also hoped that this research will give some preliminary answers about how to include human-like learning into scheduling algorithms and may therefore be of interest to researchers and practitioners in areas of scheduling and evolutionary computation. References 1. Aickelin, U. and Dowsland, K. (2003) 'Indirect Genetic Algorithm for a Nurse Scheduling Problem', Computer & Operational Research (in print). 2. Li, J. and Kwan, R.S.K. (2003), 'Fuzzy Genetic Algorithm for Driver Scheduling', European Journal of Operational Research 147(2): 334-344. 3. Pelikan, M., Goldberg, D. and Cantu-Paz, E. (1999) 'BOA: The Bayesian Optimization Algorithm', IlliGAL Report No 99003, University of Illinois. 4. Wilson, S. (1994) 'ZCS: A Zeroth-level Classifier System', Evolutionary Computation 2(1), pp 1-18.

On the study of train-track dynamic interactions caused by rail welds on discrete supported rails

The paper studies the influence of rail weld dip on wheel-rail contact dynamics, with particular reference to freight trains where it is important to increase the operating speed and also the load transported. This has produced a very precise model, albeit simple and cost-effective, which has enabled train-track dynamic interactions over rail welds to be studied to make it possible to quantify the influence on dynamic forces and displacements of the welding geometry; of the position of the weld relative to the sleeper; of the vehicle's speed; and of the axle load and wheelset unsprung mass. It is a vertical model on the spatial domain and is drawn up in a simple fashion from vertical track receptances. For the type of track and vehicle used, the results obtained enable the quantification of increases in wheel-rail contact forces due to the new speed and load conditions.

Planar Odometry from a Radial Laser Scanner. A Range Flow-based Approach

In this paper we present a fast and precise method to estimate the planar motion of a lidar from consecutive range scans. For every scanned point we formulate the range flow constraint equation in terms of the sensor velocity, and minimize a robust function of the resulting geometric constraints to obtain the motion estimate. Conversely to traditional approaches, this method does not search for correspondences but performs dense scan alignment based on the scan gradients, in the fashion of dense 3D visual odometry. The minimization problem is solved in a coarse-to-fine scheme to cope with large displacements, and a smooth filter based on the covariance of the estimate is employed to handle uncertainty in unconstraint scenarios (e.g. corridors). Simulated and real experiments have been performed to compare our approach with two prominent scan matchers and with wheel odometry. Quantitative and qualitative results demonstrate the superior performance of our approach which, along with its very low computational cost (0.9 milliseconds on a single CPU core), makes it suitable for those robotic applications that require planar odometry. For this purpose, we also provide the code so that the robotics community can benefit from it.

Influência na qualidade final de metais retificados através da variação da velocidade de mergulho

A retificação, processo final de usinagem de uma peça, utiliza fluidos de corte com a finalidade de lubrificação, refrigeração e remoção de cavacos. No entanto, esses fluidos são extremamente agressivos com o meio. Com o avanço tecnológico a tendência mundial é produzir peças cada vez mais sofisticadas, com elevado grau de tolerância geométrica, dimensional, com bom acabamento superficial, com baixo custo e, principalmente, sem causar danos ao meio. Para tanto, ao processo de retificação está intrínseca a reciclagem do fluido de corte, que se destaca pelo seu custo. Através da variação da velocidade de avanço no processo de retificação cilíndrica externa do aço ABNT D6, racionalizando a aplicação de dois fluidos de corte e usando um rebolo superabrasivo de CBN (nitreto de boro cúbico) com ligante vitrificado, avaliaram-se os parâmetros de saída da força tangencial de corte, emissão acústica, rugosidade, circularidade, desgaste da ferramenta, tensão residual e a integridade superficial através da microscopia eletrônica de varredura (MEV) dos corpos-de-prova. Com a análise do desempenho do fluido, do rebolo e da velocidade de mergulho, encontraram-se as melhores condições de usinagem propiciando a diminuição do volume de fluido de corte e a diminuição do tempo de usinagem, sem prejudicar os parâmetros geométricos e dimensionais, o acabamento superficial e a integridade superficial dos componentes.

Influência da lubrirrefrigeração na qualidade superficial de metais retificados

Na fabricação de componentes mecânicos precisos, que necessitam de alta resistência mecânica e ao desgaste, utiliza-se o processo de retificação, para conferir o acabamento final desejado e, também, para eliminar as deformações ocorridas durante a têmpera do aço. No entanto, as condições de retificação devem ser adequadas, para que não sejam introduzidas falhas na peça. Novos conceitos de lubrificação e refrigeração, para o processo de retificação, estão sendo pesquisados, de forma a diminuir os custos e os danos ambientais causados pelos fluidos de corte. Nesse trabalho, é analisada a influência das técnicas de mínima quantidade de lubrificante (MQL), refrigeração otimizada e refrigeração convencional, com diferentes vazões e velocidade de aplicação do fluido de corte, na qualidade das peças produzidas com aço ABNT 4340 endurecido, no processo de retificação cilíndrica externa de mergulho com a utilização de rebolos de CBN. O Aço ABNT 4340 apresenta várias aplicações industriais, sendo considerado de uso aeronáutico devido, sua alta resistência mecânica sem aumentar o peso dos componentes que o utilizam. A análise da qualidade das peças foi realizada com a verficação das rugosidades e com a análise de microscopias eletrônicas de varredura. Verificou-se, ainda, a força tangencial de corte. em relação às diferentes formas de aplicação do fluido de corte, notou-se o melhor desempenho da aplicação otimizada, para maiores velocidades, mostrando a eficiência do bocal utilizado. O processo otimizado e o processo MQL foram capazes de manter a integridade superficial das peças produzidas. Exceção somente para a condição MQL com vazão de fluido de corte de 40ml/h, que produziu trincas e queima superficial. Rebolos com baixa concentração de CBN, conseqüentemente mais baratos, proporcionaram bons resultados, quando associados com técnicas mais eficientes de aplicação de fluido de corte apresentando desgaste reduzido.

Community reintegration and related factors in a Nigerian stroke sample.

Background: The goal of stroke rehabilitation has shifted from mere survival of a victim to how well a survivor can be effectively reintegrated back into the community. Objectives: The present study determined the level of satisfaction with community reintegration (CR) and related factors among Nigerian community-dwelling stroke survivors (CDSS). Methods: This was a cross-sectional survey of 71 volunteering CDSS (35 males, 36 females) from selected South-Eastern Nigerian communities. Reintegration to Normal Living Index was used to assess participants’ CR. Data was analysed using Spearman rank-order correlation, Kruskal-Wallis and Mann-Whitney U tests at p≤0.05. Results: Participants generally had deficits in CR which was either mild/moderate (52.1%) or severe (47.9%). Scores in the CR domains of distance mobility, performance of daily activities, recreational activities and family roles were particularly low (median scores ≤ 4). CR was significantly correlated with and influenced by age (r=-0.35; p=0.00) and presence/absence of diabetes mellitus (u=3.56.50; p=0.01), pre- (k=6.13; p=0.05) and post-stroke employment (k=18.26; p=0.00) status, type of assistive mobility device being used (AMD) (k=25.39; p=0.00) and support from the community (k=7.15; p=0.03) respectively. Conclusion: CR was generally poor for this CDSS sample. Survivors who are older, having diabetes as co-morbidity, using AMD (particularly wheel-chair) and without employment pre- and/or post-stroke may require keener attention. Rehabilitation focus may be targeted at enhancing mobility functions, vocational and social skills.

Análise de falhas em martelos oscilantes dos desfibradores da indústria sucroalcooleira da Região Norte-Nordeste

The failure of materials is always an unwelcome event for several reasons: human lives are put in danger, economic losses, and interference in the availability of products and services. Although the causes of failures and behaviour of materials can be known, the prevention of such a condition is difficult to be guaranteed. Among the failures, wear abrasion by the low voltage is the kind of failure that occurs in more equipment and parts industry. The Plants Sucroalcooleiras suffer significant losses because of such attrition, this fact that motivated their choice for the development of this work. For both, were considered failures in the swing hammers desfibradores stopped soon after the exchange provided in accordance with tonnage of cane processed, then were analyzed by the level of wear testing of rubber wheel defined by the standard ASTM G65-91.The failures were classified as to the origin of the cause and mechanism, moreover, were prepared with samples of welding procedures according to ASME code, sec. IX as well, using the technique of thermal spraying to analyze the performance of these materials produced in laboratories, and compares them with the solder used in the plant. It was observed that the bodies-of-proof prepared by the procedure described as welding, and the thermal spraying the results of losing weight have been minimized significantly compared to the preparations in the plant. This is because the use of techniques more appropriate and more controlled conditions of the parameters of welding. As for the thermal spraying, this technique has presented a satisfactory result, but requires the use of these coatings in the best condition for real affirmation of the results

Influence of Acute and Chronic Exercise on Markers of Hippocampal Plasticity

Exercise and physical activity are lifestyle behaviors associated with enriched mental health. Understanding the mechanisms by which exercise and physical activity improve mental health may provide insight for novel therapeutic approaches for numerous mental health disorders. This dissertation reports the findings from three studies investigating the influence of acute and chronic exercise on behavioral and mechanistic markers of hippocampal plasticity and delves into the potential role of noradrenergic signaling in the hippocampal adaptations with exercise. The first study assessed the effects of long-term voluntary wheel running on hippocampal expression of plasticity-associated genes and proteins in adult male and female C57BL/6J mice, highlighting sex differences in the adaptations to long-term voluntary wheel running. The second study examined the influence of acute exercise intensity on AMPA receptor phosphorylation, a mechanism essential for hippocampal plasticity, plasticity- associated gene expression, spatial learning and memory, and anxiety-like behavior. The unexpected finding that acute exercise increased anxiety-like behavior encouraged investigation into the role of central noradrenergic signaling in acute exercise-induced anxiety. The third study determined how previous exposure to voluntary wheel running modulates the response to an acute bout of exercise, focusing primarily on transcription of the important plasticity-promoting gene, brain-derived neurotrophic factor. Using a pharmacological approach to compromise the locus coeruleus noradrenergic system, a system that is implicated in age-related mental health disorders such as Alzheimer’s Disease, the third study also investigated the influence and interaction of the noradrenergic system and acute exercise on expression of multiple brain-derived neurotrophic factor transcripts. Together, this dissertation reports the findings from a series of experiments that explored similarities, differences, and interactions between the effects of acute and chronic exercise on markers of hippocampal plasticity and behavior. Further, this work provides insight into the role of the noradrenergic system in exercise-induced hippocampal plasticity.

Salivary cortisol level and uncooperative behavior in pediatric dental practice

Aim: To investigate the relation between uncooperative behavior and salivary cortisol level in children who underwent preventive dental care. Methods: The sample was composed by 10 children of both sexes aged 40 to 52 months, presenting uncooperative behavior during dental preventive treatments. The saliva collection was performed using a cotton wheel and an Eppendorf tube (Sarstedt Salivete®) in 3 different moments: a) at home, on a day without dental treatment and at the same time on the day of the sessions treatment; b) 30 min after the end of the session, when there was manifestation of uncooperative behavior; c) 30 min after the end of the session, when there was a cooperative behavior of the child. A sample of saliva was centrifuged for 5 minutes at 2400 rpm, 1 of mL of saliva was pipetted in an Eppendorf tube and stored in a freezer at -20 ° C. For the determination of the levels of salivary cortisol was used an Active® kit for cortisol enzyme immunoassay (EIA) DSL-10-67100, composed of specific rabbit antibody anti-cortisol. Data were analyzed statistically for the uncooperative behavior issued in the beginning and at the end of sessions, using the paired t test (p<0.05) and for cortisol levels in saliva samples at home, after the beginning and at the end of sessions, using repeated-measures ANOVA and Tukey’s test (p<0.05). Results: During expression of uncooperative behavior in preventive dental care sessions the salivary cortisol level was significantly higher (0.65 ± 0.25 μg/dL) compared with expression of collaborative behavior (0.24 ± 0.10 μg/dL). Conclusions: It is possible to conclude that, even under preventive intervention, the stress must be controlled in order to reduce dental anxiety and fear.

Activité physique et récompense : impact de la leptine et de la signalisation STAT3 dans les neurones dopaminergiques

La course d’endurance active le système de récompense (SR) et est reliée aux comportements de recherche alimentaire. L’influence de la leptine sur l’activité physique (AP) volontaire est bien documentée d’un point de vue physiologique, mais très peu en termes d’impact hédonique. La leptine inhibe l’effet récompensant lié à la consommation de nourriture et joue un rôle semblable pour d’autres types de stimuli. La leptine s’arrime à la forme longue du récepteur à la leptine (Leprb) situé sur les neurones à dopamine (DA) et GABA de l’aire tegmentale ventrale (ATV) dans le mésencéphale. Signal transducer and Activator of Transcription 3 (STAT3) est un facteur de transcription important de la cascade de signalisation de la leptine. La phosphorylation de STAT3 n’est détectée que dans une parcelle des neurones DA positifs pour le Leprb, conférant aux neurones DA STAT3-spécifiques des caractéristiques uniques. Nous avons généré un modèle murin invalidé pour STAT3 sélectivement dans les neurones DA (STAT3DAT-KO). La première expérience consistait à évaluer les paramètres métaboliques de base de notre modèle en utilisant les chambres métaboliques Comprehensive Lab Animal Monitoring System (CLAMS), incluant l’activité ambulatoire, le ratio d’échanges respiratoires (RER) et la production de chaleur. Les STAT3DAT-KO sont hyperactives, démontré par une activité locomotrice augmentée, mais aucune variation entre les deux groupes n’est observée pour le RER et la production de chaleur, en plus d’un gain de poids identique. Une stratégie de récupération ciblant la réinsertion de STAT3 dans les neurones DA du système mésolimbique normalise l’AP anciennement plus élevée des STAT3DAT-KO à celle des contrôles, suivant l’accès libre à une roue d’exercice (RE) pour une durée de 4 semaines, suivant l’accès libre à une roue d’exercice (RE) pour une durée de 4 semaines. L’injection d’un psychostimulant (agoniste du récepteur DA de type 1 (D1R), le Chloro-APB-Hydrobromide (SKF 82958)) reflète une fonction dopaminergique réduite chez les STAT3DAT-KO. Un test de recherche compulsive de nourriture révèle une suppression de la prise alimentaire chez les deux groupes expérimentaux. Nous démontrons pour la première fois que la motivation alliée à la course d’endurance, indépendamment de la régulation de la prise alimentaire par la leptine, est dépendant d’une signalisation leptine-STAT3 amoindrie dans les neurones DA du système mésolimbique, révélant STAT3 comme élément clé dans la régulation du tonus dopaminergique et des propriétés récompensantes de l’AP.

Factors Influencing the Implementation of Substance Use Prevention Programs in Elementary Schools

Prevention scientists have called for more research on the factors affecting the implementation of substance use prevention programs. Given the lack of literature in this area, coupled with evidence that children as early as elementary school engage in substance use, the purpose of this study was to identify the factors that influence the implementation of substance use prevention programs in elementary schools. This study involved a mixed methods approach comprised of a survey and in-person interviews. Sixty-five guidance counselors and teachers completed the survey, and 9 guidance counselors who completed the survey were interviewed individually. Correlation analyses and hierarchical multiple regression were conducted. Quantitative findings revealed ease of implementation most frequently influenced program implementation, followed by beliefs about the program’s effectiveness. Qualitative findings showed curriculum modification as an important theme, as well as difficulty of program implementation. The in-person interviews also shed light on three interrelated themes influencing program implementation – The Wheel, time, and scheduling. Results indicate the majority of program providers modified the curriculum in some way. Implications for research, policy, and practice are discussed, and areas for future research are suggested.

Effect of Pavement-Vehicle Interaction on Highway Fuel Consumption and Emission

Vehicle fuel consumption and emission are two important effectiveness measurements of sustainable transportation development. Pavement plays an essential role in goals of fuel economy improvement and greenhouse gas (GHG) emission reduction. The main objective of this dissertation study is to experimentally investigate the effect of pavement-vehicle interaction (PVI) on vehicle fuel consumption under highway driving conditions. The goal is to provide a better understanding on the role of pavement in the green transportation initiates. Four study phases are carried out. The first phase involves a preliminary field investigation to detect the fuel consumption differences between paired flexible-rigid pavement sections with repeat measurements. The second phase continues the field investigation by a more detailed and comprehensive experimental design and independently investigates the effect of pavement type on vehicle fuel consumption. The third study phase calibrates the HDM-IV fuel consumption model with data collected in the second field phase. The purpose is to understand how pavement deflection affects vehicle fuel consumption from a mechanistic approach. The last phase applies the calibrated HDM-IV model to Florida’s interstate network and estimates the total annual fuel consumption and CO2 emissions on different scenarios. The potential annual fuel savings and emission reductions are derived based on the estimation results. Statistical results from the two field studies both show fuel savings on rigid pavement compared to flexible pavement with the test conditions specified. The savings derived from the first phase are 2.50% for the passenger car at 112km/h, and 4.04% for 18-wheel tractor-trailer at 93km/h. The savings resulted from the second phase are 2.25% and 2.22% for passenger car at 93km/h and 112km/h, and 3.57% and 3.15% for the 6-wheel medium-duty truck at 89km/h and 105km/h. All savings are statistically significant at 95% Confidence Level (C.L.). From the calibrated HDM-IV model, one unit of pavement deflection (1mm) on flexible pavement can cause an excess fuel consumption by 0.234-0.311 L/100km for the passenger car and by 1.123-1.277 L/100km for the truck. The effect is more evident at lower highway speed than at higher highway speed. From the network level estimation, approximately 40 million gallons of fuel (combined gasoline and diesel) and 0.39 million tons of CO2 emission can be saved/reduced annually if all Florida’s interstate flexible pavement are converted to rigid pavement with the same roughness levels. Moreover, each 1-mile of flexible-rigid conversion can result in a reduction of 29 thousand gallons of fuel and 258 tons of CO2 emission yearly.

Effects of truck traffic on top-down fatigue cracking performance of flexible pavements using a new mechanics-based analysis framework

The mechanics-based analysis framework predicts top-down fatigue cracking initiation time in asphalt concrete pavements by utilising fracture mechanics and mixture morphology-based property. To reduce the level of complexity involved, traffic data were characterised and incorporated into the framework using the equivalent single axle load (ESAL) approach. There is a concern that this kind of simplistic traffic characterisation might result in erroneous performance predictions and pavement structural designs. This paper integrates axle load spectra and other traffic characterisation parameters into the mechanics-based analysis framework and studies the impact these traffic characterisation parameters have on predicted fatigue cracking performance. The traffic characterisation inputs studied are traffic growth rate, axle load spectra, lateral wheel wander and volume adjustment factors. For this purpose, a traffic integration approach which incorporates Monte Carlo simulation and representative traffic characterisation inputs was developed. The significance of these traffic characterisation parameters was established by evaluating a number of field pavement sections. It is evident from the results that all the traffic characterisation parameters except truck wheel wander have been observed to have significant influence on predicted top-down fatigue cracking performance.

Activité physique et récompense : impact de la leptine et de la signalisation STAT3 dans les neurones dopaminergiques

La course d’endurance active le système de récompense (SR) et est reliée aux comportements de recherche alimentaire. L’influence de la leptine sur l’activité physique (AP) volontaire est bien documentée d’un point de vue physiologique, mais très peu en termes d’impact hédonique. La leptine inhibe l’effet récompensant lié à la consommation de nourriture et joue un rôle semblable pour d’autres types de stimuli. La leptine s’arrime à la forme longue du récepteur à la leptine (Leprb) situé sur les neurones à dopamine (DA) et GABA de l’aire tegmentale ventrale (ATV) dans le mésencéphale. Signal transducer and Activator of Transcription 3 (STAT3) est un facteur de transcription important de la cascade de signalisation de la leptine. La phosphorylation de STAT3 n’est détectée que dans une parcelle des neurones DA positifs pour le Leprb, conférant aux neurones DA STAT3-spécifiques des caractéristiques uniques. Nous avons généré un modèle murin invalidé pour STAT3 sélectivement dans les neurones DA (STAT3DAT-KO). La première expérience consistait à évaluer les paramètres métaboliques de base de notre modèle en utilisant les chambres métaboliques Comprehensive Lab Animal Monitoring System (CLAMS), incluant l’activité ambulatoire, le ratio d’échanges respiratoires (RER) et la production de chaleur. Les STAT3DAT-KO sont hyperactives, démontré par une activité locomotrice augmentée, mais aucune variation entre les deux groupes n’est observée pour le RER et la production de chaleur, en plus d’un gain de poids identique. Une stratégie de récupération ciblant la réinsertion de STAT3 dans les neurones DA du système mésolimbique normalise l’AP anciennement plus élevée des STAT3DAT-KO à celle des contrôles, suivant l’accès libre à une roue d’exercice (RE) pour une durée de 4 semaines, suivant l’accès libre à une roue d’exercice (RE) pour une durée de 4 semaines. L’injection d’un psychostimulant (agoniste du récepteur DA de type 1 (D1R), le Chloro-APB-Hydrobromide (SKF 82958)) reflète une fonction dopaminergique réduite chez les STAT3DAT-KO. Un test de recherche compulsive de nourriture révèle une suppression de la prise alimentaire chez les deux groupes expérimentaux. Nous démontrons pour la première fois que la motivation alliée à la course d’endurance, indépendamment de la régulation de la prise alimentaire par la leptine, est dépendant d’une signalisation leptine-STAT3 amoindrie dans les neurones DA du système mésolimbique, révélant STAT3 comme élément clé dans la régulation du tonus dopaminergique et des propriétés récompensantes de l’AP.

Development of an intervention to support medication management in patients with multimorbidity in primary care

The overarching aim of this thesis was to develop an intervention to support patient-centred prescribing in the context of multimorbidity in primary care. Methods A range of research methods were used to address different components of the Medical Research Council, UK (MRC) guidance on the development and evaluation of complex interventions in health care. The existing evidence on GPs’ perceptions of the management of multimorbidity was systematically reviewed. In qualitative interviews, chart-stimulated recall was used to explore the challenges experienced by GPs when prescribing for multimorbid patients. In a cross-sectional study, the psychosocial issues that complicate the management of multimorbidity were examined. To develop the complex intervention, the Behaviour Change Wheel (BCW) was used to integrate behavioural theory with the findings of these three studies. A feasibility study of the new intervention was then conducted with GPs. Results The systematic review revealed four domains of clinical practice where GPs experienced difficulties in multimorbidity. The qualitative interview study showed that GPs responded to these difficulties by ‘satisficing’. In multimorbid patients perceived as stable, GPs preferred to ‘maintain the status quo’ rather than actively change medications. In the cross-sectional study, the significant association between multimorbidity and negative psychosocial factors was shown. These findings informed the development of the ‘Multimorbidity Collaborative Medication Review and Decision-making’ (MY COMRADE) intervention. The intervention involves peer support: two GPs review the medications prescribed to a complex multimorbid patient together. In the feasibility study, GPs reported that the intervention was appropriate for the context of general practice; was widely applicable to their patients with multimorbidity; and recommendations for optimising medications arose from all collaborative reviews. Conclusion Applying theory to empirical data has led to an intervention that is implementable in clinical practice, and has the potential to positively change GPs’ behaviour in the management of medications for patients with multimorbidity.