Protocol for the effective feedback to improve primary care prescribing safety (EFIPPS) study : a cluster randomised controlled trial using ePrescribing data

High-risk prescribing in primary care is common and causes considerable harm. Feedback interventions to improve care are attractive because they are relatively cheap to widely implement. There is good evidence that feedback has small to moderate effects, but the most recent Cochrane review called for more high-quality, large trials that explicitly test different forms of feedback. The study is a three-arm cluster-randomised trial with general practices being randomised and outcomes measured at patient level. 262 practices in three Scottish Health Board areas have been randomised (94% of all possible practices). The two active arms receive different forms of prescribing safety data feedback, with rates of high-risk prescribing compared with a ‘usual care’ arm. Sample size estimation used baseline data from participating practices. With 85 practices randomised to each arm, then there is 93% power to detect a 25% difference in the percentage of high-risk prescribing (from 6.1% to 4.5%) between the usual care arm and each intervention arm. The primary outcome is a composite of six high-risk prescribing measures (antipsychotic prescribing to people aged ≥75 years; non-steroidal anti-inflammatory drug (NSAID) prescribing to people aged ≥75 without gastroprotection; NSAID prescribing to people prescribed aspirin/clopidogrel without gastroprotection; NSAID prescribing to people prescribed an ACE inhibitor/angiotensin receptor blocker and a diuretic; NSAID prescription to people prescribed an oral anticoagulant without gastroprotection; aspirin/clopidogrel prescription to people prescribed an oral anticoagulant without gastroprotection). The primary analysis will use multilevel modelling to account for repeated measurement of outcomes in patients clustered within practices. The study was reviewed and approved by the NHS Tayside Committee on Medical Research Ethics B (11/ES/0001). The study will be disseminated via a final report to the funder with a publicly available research summary, and peer reviewed publications

On the spectrum of hypergraphs

Here we study the spectral properties of an underlying weighted graph of a non-uniform hypergraph by introducing different connectivity matrices, such as adjacency, Laplacian and normalized Laplacian matrices. We show that different structural properties of a hypergrpah, can be well studied using spectral properties of these matrices. Connectivity of a hypergraph is also investigated by the eigenvalues of these operators. Spectral radii of the same are bounded by the degrees of a hypergraph. The diameter of a hypergraph is also bounded by the eigenvalues of its connectivity matrices. We characterize different properties of a regular hypergraph characterized by the spectrum. Strong (vertex) chromatic number of a hypergraph is bounded by the eigenvalues. Cheeger constant on a hypergraph is defined and we show that it can be bounded by the smallest nontrivial eigenvalues of Laplacian matrix and normalized Laplacian matrix, respectively, of a connected hypergraph. We also show an approach to study random walk on a (non-uniform) hypergraph that can be performed by analyzing the spectrum of transition probability operator which is defined on that hypergraph. Ricci curvature on hypergraphs is introduced in two different ways. We show that if the Laplace operator, $\Delta$, on a hypergraph satisfies a curvature-dimension type inequality $CD (\mathbf{m}, \mathbf{K})$ with $\mathbf{m}>1$ and $\mathbf{K}>0$ then any non-zero eigenvalue of $- \Delta$ can be bounded below by $\frac{ \mathbf{m} \mathbf{K}}{ \mathbf{m} -1 }$. Eigenvalues of a normalized Laplacian operator defined on a connected hypergraph can be bounded by the Ollivier's Ricci curvature of the hypergraph

Are there three main subgroups within the patellofemoral pain population? A detailed characterisation study of 127 patients to help develop targeted Intervention (TIPPs)

• Background Current multimodal approaches for the management of non-specific patellofemoral pain are not optimal, however, targeted intervention for subgroups could improve patient outcomes. This study explores whether subgrouping of non-specific patellofemoral pain patients, using a series of low cost simple clinical tests, is possible. • Method The exclusivity and clinical importance of potential subgroups was assessed by applying à priori test thresholds (1 SD) from seven clinical tests in a sample of adult patients with non-specific patellofemoral pain. Hierarchical clustering and latent profile analysis, were used to gain additional insights into subgroups using data from the same clinical tests. • Results One hundred and thirty participants were recruited, 127 had complete data: 84 (66%) female, mean age 26 years (SD 5.7) and mean BMI 25.4 (SD 5.83), median (IQR) time between onset of pain and assessment was 24 (7-60) months. Potential subgroups defined by the à priori test thresholds were not mutually exclusive and patients frequently fell into multiple subgroups. Using hierarchical clustering and latent profile analysis three subgroups were identified using 6 of the 7 clinical tests. These subgroups were given the following nomenclature: (i) ‘strong’, (ii) ‘weak and tighter’, and (iii) ‘weak and pronated foot’. • Conclusions We conclude that three subgroups of patellofemoral patients may exist based on the results of six clinical tests which are feasible to perform in routine clinical practice. Further research is needed to validate these findings in other datasets and, if supported by external validation, to see if targeted interventions for these subgroups improve patient outcomes

Data feedback and behavioural change intervention to improve primary care prescribing safety (EFIPPS):multicentre, three arm, cluster randomised controlled trial

Objective: To evaluate the effectiveness of feedback on safety of prescribing compared with moderately enhanced usual care. Design: Three arm, highly pragmatic cluster randomised trial. Setting and participants: 262/278 (94%) primary care practices in three Scottish health boards. Interventions: Practices were randomised to: "usual care," consisting of emailed educational material with support for searching to identify patients (88 practices at baseline, 86 analysed); usual care plus feedback on practice's high risk prescribing sent quarterly on five occasions (87 practices, 86 analysed); or usual care plus the same feedback incorporating a behavioural change component (87 practices, 86 analysed). Main outcome measures: The primary outcome was a patient level composite of six prescribing measures relating to high risk use of antipsychotics, non-steroidal anti-inflammatories, and antiplatelets. Secondary outcomes were the six individual measures. The primary analysis compared high risk prescribing in the two feedback arms against usual care at 15 months. Secondary analyses examined immediate change and change in trend of high risk prescribing associated with implementation of the intervention within each arm. Results: In the primary analysis, high risk prescribing as measured by the primary outcome fell from 6.0% (3332/55 896) to 5.1% (2845/55 872) in the usual care arm, compared with 5.9% (3341/56 194) to 4.6% (2587/56 478) in the feedback only arm (odds ratio 0.88 (95% confidence interval 0.80 to 0.96) compared with usual care; P=0.007) and 6.2% (3634/58 569) to 4.6% (2686/58 582) in the feedback plus behavioural change component arm (0.86 (0.78 to 0.95); P=0.002). In the pre-specified secondary analysis of change in trend within each arm, the usual care educational intervention had no effect on the existing declining trend in high risk prescribing. Both types of feedback were associated with significantly more rapid decline in high risk prescribing after the intervention compared with before. Conclusions: Feedback of prescribing safety data was effective at reducing high risk prescribing. The intervention would be feasible to implement at scale in contexts where electronic health records are in general use

The impact and effectiveness of pneumococcal vaccination in Scotland for those aged 65 and over during winter 2003/2004

For winter 2003/2004 in Scotland, it was recommended that all those aged 65 and over be eligible to receive 23-valent polysaccharide pneumococcal vaccine (23vPPV), which has been shown to be effective in reducing the risk of invasive pneumococcal disease (IPD). We assessed the success of the vaccination programme by examining the age specific incidence rates of IPD compared to four previous winter seasons and estimating vaccination effectiveness

Understanding official data sources: Final report for the low pay commission

The paper is split into three main sections: a review of existing data sources; an analysis of characteristics of the main reference datasets used for the production of research and official statistics; and an investigation into the imputation code used by the LPC to produce official statistics.The finding of the review of ASHE, LFS and BHPS is that the notion of rounding in wage setting and wage reporting is confirmed, and the sources of that rounding detailed. For employers, one suggestion is that rounding wages is a response to administrative burdens. For employees, rounding in survey reponses is largely unrelated to any characteristics of the respondent; this means that, although the LFS is clearly subject to measurement error, it can be assumed to be random for many statistical purposes. The report recommends that LPC should focus its attention on occupational differences in wages rather than industrial sector. On imputation, the study reviewed the current LPC code for addressing gaps in the data available for describing subsections of the community. The study found that while the code has a number of problems, the alternatives (no imputation, or using an alternative wage measure) seemed to less justified statistically. The report recommends that the LPC review and rewrite the code

MANAGEMENT AND CHALLENGES OF THE MOUNTAIN PINE BEETLE INFESTATION IN BRITISH COLUMBIA

Central British Columbia is currently subject to the largest outbreak of mountain pine beetle (Dendroctonus ponderosa) ever recorded in British Columbia. The massive expansion of this natural disturbance agent is a result of both natural and human-associated influences including milder winter weather and fire suppression policy. Resource managers are grappling with a response to the infestation that considers economic, social, and ecological factors. In British Columbia the response has moved from a control or sanitation phase, to an economic recovery or salvage phase. The condition of the landscape resulting from the insect and the management associated with each phase will impact wildlife populations. Distribution and abundance of certain species will either increase or decline in response to changes in the forest vegetation and hydrologic regime. Caribou (Rangifer tarandus caribou), fisher (Martes pennanti), marten (Martes americana), woodpeckers, and pygmy nuthatches (Sitta pygmaea) are considered species with high sensitivity to mortality of pine trees that will adversely affect their forage, cover, and nesting/denning habitat. Moose (Alces alces) will probably benefit in the short-term from increased forage resources, but may decline long-term from intensive forest management to recover mature forest stands. The impact of larger and more dispersed moose and wolf (Canis lupus) populations could harm the recovery and stability of threatened caribou populations in British Columbia

Enrichment of low-frequency functional variants revealed by whole-genome sequencing of multiple isolated European populations

The genetic features of isolated populations can boost power in complex-trait association studies, and an in-depth understanding of how their genetic variation has been shaped by their demographic history can help leverage these advantageous characteristics. Here, we perform a comprehensive investigation using 3,059 newly generated low-depth whole-genome sequences from eight European isolates and two matched general populations, together with published data from the 1000 Genomes Project and UK10K. Sequencing data give deeper and richer insights into population demography and genetic characteristics than genotype-chip data, distinguishing related populations more effectively and allowing their functional variants to be studied more fully. We demonstrate relaxation of purifying selection in the isolates, leading to enrichment of rare and low-frequency functional variants, using novel statistics, DVxy and SVxy. We also develop an isolation-index (Isx) that predicts the overall level of such key genetic characteristics and can thus help guide population choice in future complex-trait association studies.Peer reviewe