Measuring outcomes in primary care: a patient generated measure,MYMOP, compared with the SF-36 health survey.

OBJECTIVE--To assess the sensitivity to within person change over time of an outcome measure for practitioners in primary care that is applicable to a wide range of illness. DESIGN--Comparison of a new patient generated instrument, the measure yourself medical outcome profile (MYMOP), with the SF-36 health profile and a five point change score; all scales were completed during the consultation with'' practitioners and repeated after four weeks. 103 patients were followed up for 16 weeks and their results charted; seven practitioners were interviewed. SETTING--Established practice of the four NHS general practitioners and four of the private complementary practitioners working in one medical centre. SUBJECTS--Systematic sample of 218 patients from general practice and all 47 patients of complementary practitioners; patients had had symptoms for more than seven days. OUTCOME MEASURES--Standardised response mean and index of responsiveness; view of practitioners. RESULTS--The index of responsiveness, relating to the minimal clinically important difference, was high for MYMOP: 1.4 for the first symptom, 1.33 for activity, and 0.85 for the profile compared with < 0.45 for SF-36. MYMOP''s validity was supported by significant correlation between the change score and the change in the MYMOP score and the ability of this instrument to detect more improvement in acute than in chronic conditions. Practitioners found that MYMOP was practical and applicable to all patients with symptoms and that its use increased their awareness of patients'' priorities. CONCLUSION--MYMOP shows promise as an outcome measure for primary care and for complementary treatment. It is more sensitive to change than the SF-36 and has the added bonus of improving patient-practitioner communication.     

Ecologically-based strategies for conservation and development in the tropics

Tropical countries are endowed with a rich array of biotic and geophysical resources. Only in the past 30 years has the rate of their resource transformation been so rapid as to threaten the environment, largely because of the demands of a growing human population resulting from the demographic transition. While resource transformations have produced the goods and services necessary to meet the needs of the growing populations, they have also generated a variety of effects on the environment and the societies of these countries. The rapid pace of technological advances and social change seriously threaten the sustainability of natural assets and ecological processes in these countries, with global consequences. This threat is exacerbated (1) by inadequate capability in these tropical countries to manage degradations in natural resources and the environment arising from technological interventions affecting large-scale ecological processes; and (2) by the coincidence of down-turns in long-term cycles of unequal amplitudes, which concern elitism and administrations, dependency on fossil fuels for industrialisation and shifts in cultural periods, all of which threaten the global structure and continuity of prevailing social institutions, Both phenomena endanger the prospects for international investments in the transformation of natural resources and management of the environment for sustainable livelihoods, especially in developing countries. most tropical countries have developing economies, and have inadequate capacity to manage the impacts and trade-offs of technological insertions largely because of financial constraints, poor technical expertise and the international character of their economies. In spite of harsh socio-biological, technological and financial constraints, there is a pressing need for investing in human expertise in tropical countries because of their effects on the sustainability of global climate, resource and environmental heritage, cultural heritage and societal organisation. Assurance of this sustainability demands that investments in tropical countries must be founded on traditional knowledge, organisation and community participation; on comparative advantages in terms of resource endowments and technological skills; on strategies and actions promoting innovative futures; on the strengthening of institutional capacities for assessing impacts and trade-offs; on a universally-acceptable system for exchanging experiences about technological insertions with reference to spatial areas, levels of sophistication, assessment of impacts and standards; and on the attraction of various forms of international cooperation at professional, governmental and non-governmental levels, which has been recommended by the World Commission on Environment and Development (Bruntland Commission). This overall challenge for international development in the tropics amounts to advancing macro-ecological and-economic sciences of large-scale processes having local impacts, andvice versa, involving the dynamic interactions between culture and philosophy, politics, investment (economics), society, technology and environment at different spatial and temporal scales.     

Development of a core outcome set for clinical trials in rosacea: study protocol for a systematic review of the literature and identification of a core outcome set using a Delphi survey

BackgroundRosacea is a chronic inflammatory disorder affecting millions of individuals worldwide. Diagnosis is based on signs and symptoms with management and treatment aimed to suppress inflammatory lesions, erythema, and telangiectasia. While many clinical trials of rosacea exist, the lack of consensus in outcome reporting across all trials poses a concern. Proper evaluation and comparison of treatment modalities is challenging. In order to address the inconsistencies present, this project aims to determine a core set of outcomes which should be evaluated in all clinical trials of rosacea.Methods/designThis project will utilize a methodology similar to previous core outcome set research. A long list of outcomes will be extracted over four phases: (1) systematic literature review, (2) patient interviews, (3) other published sources, and (4) stakeholder involvement. Potential outcomes will be examined by the Steering Committee to provide further insight. The Delphi process will then be performed to prioritize and condense the list of outcomes generated. Two homogenous groups of physicians and patients will participate in two consecutive rounds of Delphi surveys. A consensus meeting, composed of physicians, patients, and stakeholders, will be conducted after the Delphi exercise to further select outcomes, taking into account participant scores. By the end of the meeting, members will vote and decide on a final recommended set of core outcomes. For the duration of the study, we will be in collaboration with both the Core Outcome Measures in Effectiveness Trials (COMET) and Cochrane Skin Group - Core Outcome Set Initiative (CSG-COUSIN).DiscussionThis study aims to develop a core outcome set to guide assessment in clinical trials of rosacea. The end-goal is to improve the reliability and consistency of outcome reporting, thereby allowing sufficient evaluation of treatment effectiveness and patient satisfaction.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1554-3) contains supplementary material, which is available to authorized users.     

Violence in the emergency department: a survey of health care workers

BACKGROUND: Violence in the workplace is an ill-defined and underreported concern for health care workers. The objectives of this study were to examine perceived levels of violence in the emergency department, to obtain health care workers'' definitions of violence, to determine the effect of violence on health care workers and to determine coping mechanisms and potential preventive strategies. METHODS: A retrospective written survey of all 163 emergency department employees working in 1996 at an urban inner-city tertiary care centre in Vancouver. The survey elicited demographic information, personal definition of violence, severity of violence, degree of stress as a result of violence and estimate of the number of encounters with violence in the workplace in 1996. The authors examined the effects of violence on job performance and job satisfaction, and reviewed coping and potential preventive strategies. RESULTS: Of the 163 staff, 106 (65%) completed the survey. A total of 68% (70/103) reported an increased frequency of violence over time, and 60% (64/106) reported an increased severity. Most of the respondents felt that violence included witnessing verbal abuse (76%) and witnessing physical threats or assaults (86%). Sixty respondents (57%) were physically assaulted in 1996. Overall, 51 respondents (48%) reported impaired job performance for the rest of the shift or the rest of the week after an incident of violence. Seventy-seven respondents (73%) were afraid of patients as a result of violence, almost half (49%) hid their identities from patients, and 78 (74%) had reduced job satisfaction. Over one-fourth of the respondents (27/101) took days off because of violence. Of the 18 respondents no longer working in the emergency department, 12 (67%) reported that they had left the job at least partly owing to violence. Twenty-four-hour security and a workshop on violence prevention strategies were felt to be the most useful potential interventions. Physical exercise, sleep and the company of family and friends were the most frequent coping strategies. INTERPRETATION: Violence in the emergency department is frequent and has a substantial effect on staff well-being and job satisfaction.     

New statistical potential for quality assessment of protein models and a survey of energy functions

Background  

Scoring functions, such as molecular mechanic forcefields and statistical potentials are fundamentally important tools in protein structure modeling and quality assessment.     

Cooperative recurrent modular neural networks for constrained optimization: a survey of models and applications

Constrained optimization problems arise in a wide variety of scientific and engineering applications. Since several single recurrent neural networks when applied to solve constrained optimization problems for real-time engineering applications have shown some limitations, cooperative recurrent neural network approaches have been developed to overcome drawbacks of these single recurrent neural networks. This paper surveys in details work on cooperative recurrent neural networks for solving constrained optimization problems and their engineering applications, and points out their standing models from viewpoint of both convergence to the optimal solution and model complexity. We provide examples and comparisons to shown advantages of these models in the given applications.     

Planning for the information age: a survey of microcomputer use in a faculty of health sciences.

Microcomputers can greatly enhance information processing by clinicians and improve the quality of health care. We surveyed 983 full- and part-time faculty members to assess the state of microcomputer use in the Faculty of Health Sciences at McMaster University, Hamilton, Ont. The ratio of faculty members to microcomputers was close to 1; however, 29% of the full-time and 52% of the part-time members who responded indicated that they did not use a computer. Among those who did, the range of applications was generally limited. There was no mention of more advanced uses such as diagnosis, treatment and patient records. Only about 30% of the respondents had taken a computer course, but all indicated a desire to take courses (on average, three of the seven listed in the questionnaire). Our results showed an extensive but unequal distribution of microcomputers and revealed the need for planning and education to put them to optimal use.     

Nitrification and mineralization potentials in a limed Ultisol in the humid tropics

Summary We studied the effect of liming on the rates of mineralization and nitrification in a coarse-textured kaolinitic Ultisol. Soil samples were taken from field plots which received lime rates from 0 to 4mt/ha three years prior to the study. The pH of the soil samples varied from 4.2 to 6.1. Ammonification of soil organic N and added urea source proceeded readily and was not affected by lime rate. Nitrification occurred in both limed and unlimed soils but the rate of nitrification depended upon the rate of lime application. Soil pH, exchangeable Ca and exchangeable A1 were significantly correlated with the amount of NO₃-N accumulated at the end of the 65 days incubation period. Nitrification of NH₄-N from ammonium sulfate was absent in soils receiving lower rates of lime which gave pH values ranging from 4.2 to 4.8. Added ammonium source was nitrified readily after a 3-week delay period in the soil (pH 6.1) which received a higher rate of lime (4 mt/ha).     

Computerized clinical decision support systems for acute care management: A decision-maker-researcher partnership systematic review of effects on process of care and patient outcomes

Background

There is a need to find innovative approaches for translating best practices for chronic disease care into daily primary care practice routines. Primary care plays a crucial role in the prevention and management of cardiovascular disease. There is, however, a substantive care gap, and many challenges exist in implementing evidence-based care. The Improved Delivery of Cardiovascular Care (IDOCC) project is a pragmatic trial designed to improve the delivery of evidence-based care for the prevention and management of cardiovascular disease in primary care practices using practice outreach facilitation.

Methods

The IDOCC project is a stepped-wedge cluster randomized control trial in which Practice Outreach Facilitators work with primary care practices to improve cardiovascular disease prevention and management for patients at highest risk. Primary care practices in a large health region in Eastern Ontario, Canada, were eligible to participate. The intervention consists of regular monthly meetings with the Practice Outreach Facilitator over a one- to two-year period. Starting with audit and feedback, consensus building, and goal setting, the practices are supported in changing practice behavior by incorporating chronic care model elements. These elements include (a) evidence-based decision support for providers, (b) delivery system redesign for practices, (c) enhanced self-management support tools provided to practices to help them engage patients, and (d) increased community resource linkages for practices to enhance referral of patients. The primary outcome is a composite score measured at the level of the patient to represent each practice's adherence to evidence-based guidelines for cardiovascular care. Qualitative analysis of the Practice Outreach Facilitators' written narratives of their ongoing practice interactions will be done. These textual analyses will add further insight into understanding critical factors impacting project implementation.

Discussion

This pragmatic, stepped-wedge randomized controlled trial with both quantitative and process evaluations demonstrates innovative methods of implementing large-scale quality improvement and evidence-based approaches to care delivery. This is the first Canadian study to examine the impact of a large-scale multifaceted cardiovascular quality-improvement program in primary care. It is anticipated that through the evaluation of IDOCC, we will demonstrate an effective, practical, and sustainable means of improving the cardiovascular health of patients across Canada.

Trial Registration

ClinicalTrials.gov: NCT00574808