Towards an Implementation-STakeholder Engagement Model (I-STEM) for improving health and social care services

BACKGROUND

The implementation science literature acknowledges a need for engagement of key stakeholders when designing, delivering and evaluating implementation work. To date, the literature reports minimal or focused stakeholder engagement, where stakeholders are engaged in either barrier identification and/or barrier prioritisation. This paper begins to answer calls from the literature for the development of tools and guidance to support comprehensive stakeholder engagement in implementation research and practice. The paper describes the systematic development of the Implementation-STakeholder Engagement Model (I-STEM) in the context of an international, large-scale empirical implementation study (ImpleMentAll) aimed at evaluating the effectiveness of a tailored implementation toolkit. The I-STEM is a sensitising tool that defines key considerations and activities for undertaking stakeholder engagement activities across an implementation process.

METHODS

In-depth, semistructured interviews and observations were conducted with implementers who were tailoring implementation strategies to integrate and embed internet-based cognitive behavioural therapy (iCBT) services in 12 routine mental health care organisations in nine countries in Europe and Australia. The analytical process was informed by principles of first- and third-generation Grounded Theory, including constant comparative method.

RESULTS

We conducted 55 interviews and observed 19 implementation-related activities (e.g., team meetings and technical support calls). The final outcome of our analysis is expressed in an initial version of the I-STEM, consisting of five interrelated concepts: engagement objectives, stakeholder mapping, engagement approaches, engagement qualities and engagement outcomes. Engagement objectives are goals that implementers plan to achieve by working with stakeholders in the implementation process. Stakeholder mapping involves identifying a range of organisations, groups or people who may be instrumental in achieving the engagement objectives. Engagement approaches define the type of work that is undertaken with stakeholders to achieve the engagement objectives. Engagement qualities define the logistics of the engagement approach. Lastly, every engagement activity may result in a range of engagement outcomes.

CONCLUSION

The I-STEM represents potential avenues for substantial stakeholder engagement activity across key phases of an implementation process. It provides a conceptual model for the planning, delivery, evaluation and reporting of stakeholder engagement activities. The I-STEM is nonprescriptive and highlights the importance of a flexible, iterative approach to stakeholder engagement. It is developmental and will require application and validation across a range of implementation activities.

PATIENT OR PUBLIC CONTRIBUTION

Patient contribution to ImpleMentAll trial was facilitated by GAMIAN-Europe at all stages-from grant development to dissemination. GAMIAN-Europe brings together a wide variety of patient representation organisations (local, regional and national) from almost all European countries. GAMIAN-Europe was involved in pilot testing the ItFits-toolkit and provided their views on the various aspects, including stakeholder engagement. Patients were also represented in the external advisory board providing support and advice on the design, conduct and interpretation of the wider project, including the development of the ItFits-toolkit.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03652883. Retrospectively registered on 29 August 2018.

The Catalytic Reactivity of Alloys; Ethanol and Formic Acid Decomposition on Cu-Pd(110)

The effect of alloying Cu and Pd on the reactivity pattern for formic acid and for ethanol has been examined. The electronic structure of the material is strongly affected by the alloying, with the d-band lowered in energy and filled, compared with Pd alone. Hence the reactivity would be expected to be strongly affected by the alloying. This appears to be the case for formic acid decomposition, whose decomposition temperature in temperature-programmed desorption is shifted by alloying and is between the temperatures for the individual components (at 350 K, compared with 250 and 470 K for Pd and Cu, respectively). However, when a different molecule is chosen as the probe of surface reactivity, namely, ethanol, we come to a very different conclusion. Here the individual reactivity patterns for the two elemental components of the alloy are seen, namely, dehydrogenation on the Cu (to produce acetaldehyde) and decarbonylation on Pd (to methane and CO). There are effects of alloying on destabilizing the former pathway and stabilizing the latter, but the major conclusion from this work is that it is not average electronic structure that dictates reactivity but the individual atomic nature of the surface components. Only monodentate adsorbates truly probe this behavior.

Life is a rollercoaster: an exploration of a support group for parents and carers of those with children and young people with mental health difficulties

NHS Digital reported that one in eight children aged 5 to 19-year-old in England were identified with a mental illness, the most prevalent being emotional disorders. A diagnosis of a mental illness has a clear impact on children or young people and can also impact the health and wellbeing of family members, in particular parents and carers. We will share and discuss findings from a co-produced evaluation of a nationally recognized support group, Rollercoaster, a well-established and popular parent support group in the UK, for carers of children and young people with mental health difficulties. We will illustrate “what works” in setting up and running a support group for parents in the UK and more widely. The audience will learn what matters to the parents and carers regarding support and in terms of offering support, and how to effectively run a successful support group. Specifically, the evaluation focused on what principles could be drawn from Rollercoaster, given the wide gap in local services offering targeted support for carers. We therefore created a framework to aid in the development of other, unique support groups designed to meet the needs of their local populations. We carried out a parent/carer survey; interviews with parents/carers, support group workers and wider stakeholders; and observations of support group activities. Applying a “lesson drawing” method, we grouped what participants said around the following areas: 1) specific activities offered by Rollercoaster; 2) people who set up and run a parent/carer support group; 3) how to make a parent/carer support group successful. Engaging a wide range of parents/carers and stakeholders at every stage in the design of activities was seen as paramount. A range of skills are required by different people at various points in setting up and running the group. Success rests on constantly adapting to internal and external developments and having a bedrock of being parent led and professionally supported.

Air Pollution Exposure Monitoring among Pregnant Women with and without Asthma

Background: We monitored exposure to fine particulates (PM_2.5), ozone, nitrogen dioxide (NO₂), and ambient temperature for pregnant women with and without asthma. Methods: Women (n = 40) from the Breathe—Well-Being, Environment, Lifestyle, and Lung Function Study (2015–2018) were enrolled during pregnancy and monitored for 2–4 days. Daily pollutants were measured using personal air monitors, indoor air monitors, and nearest Environmental Protection Agency’s stationary monitors based on GPS tracking and home address. Results: Personal-monitor measurements of PM_2.5, ozone, and NO₂ did not vary by asthma status but exposure profiles significantly differed by assessment methods. EPA stationary monitor-based methods appeared to underestimate PM_2.5 and temperature exposure and overestimate ozone and NO₂ exposure. Higher indoor-monitored PM_2.5 exposures were associated with smoking and the use of gas appliances. The proportion of waking-time during which personal monitors were worn was ~56%. Lower compliance was associated with exercise, smoking, being around a smoker, and the use of a prescription drug. Conclusions: Exposure did not vary by asthma status but was influenced by daily activities and assessment methods. Personal monitors may better capture exposures but non-compliance merits attention. Meanwhile, larger monitoring studies are warranted to further understand exposure profiles and the health effects of air pollution during pregnancy.

Vital Status Ascertainment for a Historic Diverse Cohort of U.S. Women

BACKGROUND

Studies linking large pregnancy cohorts with mortality data can address critical questions about long-term implications of gravid health, yet relevant US data are scant. We examined the feasibility of linking the Collaborative Perinatal Project, a large multiracial U.S. cohort study of pregnant women (n = 48,197; 1959-1966), to death records.

METHODS

We abstracted essential National Death Index (NDI) (1979-2016) (n = 46,428). We performed a linkage to the Social Security Administration Death Master File through 2016 (n = 46,450). Genealogists manually searched vital status in 2016 for a random sample of women (n = 1,249). We conducted agreement analyses for women with abstracted data among the three sources. As proof of concept, we calculated adjusted associations between mortality and smoking and other sociodemographic factors using Cox proportional hazards regression.

RESULTS

We successfully abstracted identifying information for most of the cohort (97%). National Death Index identified the greatest proportion of participants deceased (35%), followed by genealogists (31%) and Death Master File (23%). Estimates of agreement (κ [95% confidence interval]) between National Death Index and Death Master File were lower (0.52 [0.51, 0.53]) than for National Death Index and genealogist (0.66 [0.61, 0.70]). As expected, compared with nonsmokers, smoking ≥1 pack per day was associated with elevated mortality for all vital sources and was strongest for National Death Index.

CONCLUSIONS

Linking this historic cohort with mortality records was feasible and agreed reasonably on vital status when compared with other data sources. Such linkage enables future examination of pregnancy conditions in relation to mortality in a diverse U.S. cohort.

Partnership or insanity: why do health partnerships do the same thing over and over again and expect a different result?

Objectives

The paper reports on an empirical study of Health and Wellbeing Boards (HWBs) in England. Established by the Health and Social Care Act 2012, HWBs act as place-based hubs for leaders in health, social care, local government and other sectors to come together to address health improvement and the wider determinants of health.

Methods

We conducted a three-year study of HWBs (2015–2017) in five localities across England. This involved collecting qualitative data from semi-structured interviews with key actors in the HWBs at strategic and operational levels, and focus group sessions with voluntary-sector participants at each HWB.

Results

HWBs have largely followed the path of previous partnerships in terms of a lack of clear aims and objectives, lack of ownership and accountability by partners, and an absence of any significant impact on health outcomes.

Conclusions

Many of the features of unsuccessful partnership working were largely displayed by HWBs. Boards require more executive power and ownership from the bottom up if they are to have any real impact.

Preconception Marijuana Use and Pregnancy Outcomes (P18-033-19)

Objectives

Marijuana is the most widely used and fastest growing drug in the United States, with legislation currently broadening legalization for both medical and recreational use. However, there are limited data evaluating associations with fecundity and adverse pregnancy outcomes. A few studies evaluating self-reported use suggest marijuana may not be harmful for pregnancy, yet there is a concern for underreporting due to stigma as marijuana is not universally legalized. Our aim was to examine the association between preconception marijuana use, using both self-reported and urinary levels of tetrahydrocannabinol (THC), and fecundability, live birth, and pregnancy loss.

Methods

Women aged 18–40 years old (n = 1212) enrolled in the EAGeR trial were screened for urinary THC at up to 2 time points during preconception using a homogenous enzyme immunoassay from Randox Laboratories, and asked at baseline to report any marijuana use during the past year. Women were followed for up to 6 months while attempting pregnancy. Cox proportional hazard regression was used to calculate fecundability odds ratios (FOR), and log-binomial regression to estimate risk ratios (RR) for live birth and pregnancy loss adjusting for age, race, BMI, education, smoking, alcohol, and detectable levels of opioids.

Results

33 (2.7%) women screened positive for THC during the preconception period, of which 14 also self-reported use during the past year. 62 women (5.1%) either screened positive or self-reported use. Women who screened positive for preconception THC had reduced fecundability (FOR 0.50; 95% CI 0.25, 1.00), as well as women who self-reported marijuana use (FOR 0.54; 95% CI 0.31, 0.94), or who were positive using either urinary or self-report (FOR 0.53, 95% CI 0.33, 0.86). No associations were observed between marijuana use and live birth (RR 0.71; 95% CI 0.41, 1.22) and pregnancy loss (RR 0.78; 95% CI 0.28, 2.18).

Conclusions

Women who screened positive for THC during preconception, or self-reported use during the past year had reduced fecundability, though no associations were observed with live birth or pregnancy loss. Further investigations are needed to determine what duration and dose of marijuana may negatively impact fecundability.

Funding Sources

Intramural Research Program, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development.

Preconception Vitamin D Status and Offspring Sex Ratio Among Women with Prior Pregnancy Loss (OR17-05-19)

Objectives

Experimental data indicate that maternal exposure to factors known to alter inflammatory milieu may be specifically harmful to the conception or survival of male fetuses. Indeed, in a recent clinical trial, preconception administration of low dose aspirin versus placebo restored the skewed sex ratio at birth among women with elevated inflammation, providing direct evidence of this phenomenon in humans. However, it is unknown whether other factors associated with inflammation, such as vitamin D status, are associated with offspring sex ratio at birth. Our objective was thus to evaluate the association of preconception serum 25-hydroxyvitamin D levels [25(OH)D] and male live birth among 1228 reproductive-age women with a history of 1–2 prior losses who were enrolled in the Effects of Aspirin in Gestation and Reproduction trial between 2007–2011.

Methods

We estimated RRs and 95% CIs for male live birth according to 25(OH)D sufficiency (≥75 vs. <75 nmol/L) using generalized estimating equations of log-binomial regression with robust standard errors.

Results

Among the 1086 women who completed follow-up, the proportion of live-born males was 24% (n = 136) and 30% (n = 156) in the 25(OH)D insufficient and sufficient groups, respectively. After adjustment for age, race/ethnicity, and other factors, women in the 25(OH)D sufficient group were 23% (95% CI: 1.01, 1.49) more likely to have a live-born male infant compared to the insufficient group. Associations were stronger among women with elevated versus low levels of high sensitivity C-reactive protein (>1.95 ng/mL: RR: 1.41; 95% CI: 0.99, 2.00 versus ≤1.95 ng/mL RR: 1.11; 95% CI: 0.88, 1.41), a marker of systemic low-grade inflammation.

Conclusions

Preconception vitamin D status was associated with male live birth, particularly among women with low-grade inflammation. These data suggest that maternal vitamin D sufficiency may mitigate maternal inflammation that would otherwise be detrimental to male fetal survival.

Funding Sources

Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD.

Vitamin D and Premenstrual Syndrome in Healthy Women with Regular Cycles (P18-056-19)

Objectives

Vitamin D levels have been associated with premenstrual syndrome (PMS) and symptom severity, but data are mixed. Our aim was to assess the relationship between serum vitamin D and PMS in women with regular menstrual cycles.

Methods

We looked at vitamin D and PMS using two cohorts of healthy women with regular cycles. BioCycle followed 76 women, for up to 2 menstrual cycles prospectively and EAGeR followed 1191 women with 1–2 prior pregnancy losses. 25(OH)D was measured in serum at baseline in both cohorts, with PMS assessed via questionnaire evaluating the presence and severity of 14 psychological and physical menstrual symptoms the week before and after menses. EAGeR assessed symptoms over the past year, and BioCycle assessed symptoms prospectively over the next cycle. We used status and PMS associations adjusting for age, BMI, race, smoking, income, physical activity, and season of blood draw.

Results

54% and 47% of women had sufficient 25(OH)D (≥30 ng/mL) and 33% and 40% exhibited PMS in BioCycle and EAGeR, respectively. Vitamin D status was not associated with risk of PMS in either cohort (BioCycle: D insufficiency was associated with risk of breast fullness/tenderness (RR 1.27, 95% CI 1.03, 1.55) and generalized aches and pains (RR 1.33, 95% CI 1.01, 1.78), compared to women with vitamin D sufficiency. Similar associations were observed in BioCycle though confidence intervals were wide. No associations were observed between vitamin D status and psychological symptoms.

Conclusions

Among women with regular menses, 25(OH)D was not associated with PMS, though it may be associated with individual symptoms. Additional studies are needed to understand these relationships in women with irregular menstrual.

Funding Sources

Intramural Research Program, Division of Population Health Research, NICHD. NIH Medical Research Scholars Program. Doris Duke Charitable Foundation.

Caffeinated Beverage Intake and Serum Caffeine Metabolites and Risk of Pregnancy Loss (OR17-04-19)

Objectives

The association between caffeine and pregnancy loss remains controversial due to limitations of prior studies such as relying on self-reported intake only, exposure measurement after clinical confirmation of pregnancy, and potential time-varying confounding by nausea/vomiting and lifestyle factors, which may be affected by prior caffeine exposure. Thus, our aim was to evaluate associations of preconception and early pregnancy serum caffeine, paraxanthine, and theobromine, self-reported intake of caffeinated beverages, and risk of pregnancy loss among 1228 reproductive-age women attempting pregnancy in the EAGeR trial during 2007–2011.

Methods

We estimated HRs and 95% CIs for any pregnancy loss, hCG loss (prior to ultrasound confirmation), and clinical loss (after ultrasound confirmation) according to caffeinated beverage intake and caffeine biomarkers measured at preconception and the 8th week of gestation using weighted adjusted Cox proportional hazards models.

Results

At preconception, 67%, 28%, and 9% of women reported any intake of caffeinated sodas, coffee, and tea, respectively. Preconception total caffeinated beverage intake of ≥3 vs. 0 cups/day was associated with 85% (95% CI: 1.18, 2.94) higher risk of any pregnancy loss, driven primarily by associations for hCG loss (HR: 2.88 (95% CI: 1.20, 6.91)). Caffeinated soda intake was associated with hCG loss (≥2 vs. <2 cups/day HR: 2.11 (95% CI: 1.14, 3.89)), whereas caffeinated coffee intake was associated with clinical loss (≥2 vs. <2 cups/day HR: 1.27 (95% CI: 1.02, 2.90)). Likewise, any detectable level of serum caffeine (>0.2 vs. ≤0.2 ng/mL) at preconception was strongly associated with hCG loss (HR: 4.51 (95% CI: 1.36, 14.91)). Serum caffeine, paraxanthine, and theobromine measured at the 8th week of gestation were not associated with risk of loss.

Conclusions

Collectively, these data suggest that caffeine intake prior to pregnancy may increase risk of pregnancy loss, particularly in early gestation.

Funding Sources

Intramural Research Program of the Eunice Kennedy Shriver National Institute of Child Health and Human Development, NIH, Bethesda, MD.

Total intravenous anaesthesia with ketamine, medetomidine and guaifenesin compared with ketamine, medetomidine and midazolam in young horses anaesthetised for computerised tomography

BACKGROUND

There is no information directly comparing midazolam with guaifenesin when used in combination with an alpha-2 agonist and ketamine to maintain anaesthesia via i.v. infusion in horses.

OBJECTIVES

To compare ketamine-medetomidine-guaifenesin with ketamine-medetomidine-midazolam for total intravenous anaesthesia (TIVA) in young horses anaesthetised for computerised tomography.

STUDY DESIGN

Prospective, randomised, blinded, crossover trial.

METHODS

Fourteen weanlings received medetomidine 7 μg/kg bwt i.v. and anaesthesia was induced with ketamine 2.2 mg/kg bwt i.v. On two separate occasions horses each received infusions of ketamine 3 mg/kg bwt/h, medetomidine 5 μg/kg bwt/h, guaifenesin 100 mg/kg bwt/h (KMG) or ketamine 3 mg/kg bwt/h, medetomidine 5 μg/kg bwt/h, midazolam 0.1 mg/kg bwt/h (KMM) for 50 min. Cardiorespiratory variables and anaesthetic depth were assessed every 5-10 min. Recovery times after the infusions ceased were recorded and recovery quality was assessed using a composite score system (CSS), simple descriptive scale (SDS) and visual analogue scale (VAS). Multivariable models were used to generate mean recovery scores for each treatment and each recovery score system and provide P-values comparing treatment groups.

RESULTS

Anaesthesia was uneventful with no difference in additional anaesthetic requirements and little clinically relevant differences in cardiopulmonary variables between groups. All horses recovered without incident with no significant difference in recovery times. Quality of the anaesthetic recovery was significantly better for the KMM group compared with the KMG group using the CSS (P<0.001), SDS (P<0.001) and VAS (P<0.001).

MAIN LIMITATIONS

No surgical stimulus was applied and study animals may not represent general horse population.

CONCLUSION

Midazolam is a suitable alternative to guaifenesin when co-infused with ketamine and medetomidine for anaesthesia in young horses undergoing noninvasive procedures. Both infusions produce a clinically comparable quality of anaesthesia; however, recovery from anaesthesia is of a better quality following an infusion of ketamine-medetomidine-midazolam.

Commissioning for health improvement following the 2012 health and social care reforms in England: what has changed?

Background

The wide-ranging program of reforms brought about by the Health and Social Care Act (2012) in England fundamentally changed the operation of the public health system, moving responsibility for the commissioning and delivery of services from the National Health Service to locally elected councils and a new national public health agency. This paper explores the ways in which the reforms have altered public health commissioning.

Methods

We conducted multi-methods research over 33 months, incorporating national surveys of Directors of Public Health and local council elected members at two time-points, and in-depth case studies in five purposively selected geographical areas.

Results

Public health commissioning responsibilities have changed and become more fragmented, being split amongst a range of different organisations, most of which were newly created in 2013. There is much change in the way public health commissioning is done, in who is doing it, and in what is commissioned, since the reforms. There is wider consultation on decisions in the local council setting than in the NHS, and elected members now have a strong influence on public health prioritisation. There is more (and different) scrutiny being applied to public health contracts, and most councils have embarked on wide-ranging changes to the health improvement services they commission. Public health money is being used in different ways as councils are adapting to increasing financial constraint.

Conclusions

Our findings suggest that, while some of the intended opportunities to improve population health and create a more joined-up system with clearer leadership have been achieved, fragmentation, dispersed decision-making and uncertainties regarding funding remain significant challenges. There have been profound changes in commissioning processes, with consequences for what health improvement services are ultimately commissioned. Time (and further research) will tell if any of these changes lead to improved population health outcomes and reduced health inequalities, but many of the opportunities brought about by the reforms are threatened by the continued flux in the system.

Commissioning through competition and cooperation in the English NHS under the Health and Social Care Act 2012: evidence from a qualitative study of four clinical commissioning groups

OBJECTIVE

The Health and Social Care Act 2012 ('HSCA 2012') introduced a new, statutory, form of regulation of competition into the National Health Service (NHS), while at the same time recognising that cooperation was necessary. NHS England's policy document, The Five Year Forward View ('5YFV') of 2014 placed less emphasis on competition without altering the legislation. We explored how commissioners and providers understand the complex regulatory framework, and how they behave in relation to competition and cooperation.

DESIGN

We carried out detailed case studies in four clinical commissioning groups, using interviews and documentary analysis to explore the commissioners' and providers' understanding and experience of competition and cooperation.

SETTING/PARTICIPANTS

We conducted 42 interviews with senior managers in commissioning organisations and senior managers in NHS and independent provider organisations (acute and community services).

RESULTS

Neither commissioners nor providers fully understand the regulatory regime in respect of competition in the NHS, and have not found that the regulatory authorities have provided adequate guidance. Despite the HSCA 2012 promoting competition, commissioners chose mainly to use collaborative strategies to effect major service reconfigurations, which is endorsed as a suitable approach by providers. Nevertheless, commissioners are using competitive tendering in respect of more peripheral services in order to improve quality of care and value for money.

CONCLUSIONS

Commissioners regard the use of competition and cooperation as appropriate in the NHS currently, although collaborative strategies appear more helpful in respect of large-scale changes. However, the current regulatory framework contained in the HSCA 2012, particularly since the publication of the 5YFV, is not clear. Better guidance should be issued by the regulatory authorities.

Integration, influence and change in public health: findings from a survey of Directors of Public Health in England

BACKGROUND

Following the Health and Social Care Act in England, public health teams were formally transferred from the NHS to local authorities in April 2013.

METHODS

Online survey of Directors of Public Health (DsPH) in local authorities in England (n = 152) to investigate their experience within local government 1 year on. Tests of association were used to explore relationships between the perceived integration and influence of public health, and changes in how the public health budget was being spent.

RESULTS

The organization of and managerial arrangements for public health within councils varied. Most DsPH felt that good relationships had been established within the council, and the move had made them more able to influence priorities for health improvement, even though most felt their influence was limited. Changes in commissioning using the public health budget were already widespread and included the de-commissioning of services.

CONCLUSIONS

There was a widespread feeling amongst DsPH that they had greater influence since the reforms, and that this went across the local authority and beyond. Public health's influence was most apparent when the transfer of staff to local government had gone well, when collaborative working relationships had developed, and when local partnership groups were seen as being effective.

Engaging GPs in commissioning: realist evaluation of the early experiences of Clinical Commissioning Groups in the English NHS

Objectives To explore the 'added value' that general practitioners (GPs) bring to commissioning in the English NHS. We describe the experience of Clinical Commissioning Groups (CCGs) in the context of previous clinically led commissioning policy initiatives. Methods Realist evaluation. We identified the programme theories underlying the claims made about GP 'added value' in commissioning from interviews with key informants. We tested these theories against observational data from four case study sites to explore whether and how these claims were borne out in practice. Results The complexity of CCG structures means CCGs are quite different from one another with different distributions of responsibilities between the various committees. This makes it difficult to compare CCGs with one another. Greater GP involvement was important but it was not clear where and how GPs could add most value. We identified some of the mechanisms and conditions which enable CCGs to maximize the 'added value' that GPs bring to commissioning. Conclusion To maximize the value of clinical input, CCGs need to invest time and effort in preparing those involved, ensuring that they systematically gather evidence about service gaps and problems from their members, and engaging members in debate about the future shape of services.

Complexity in the new NHS: longitudinal case studies of CCGs in England

OBJECTIVE

The reform in the English National Health Services (NHS) under the Health and Social Care Act 2012 is unlike previous NHS reorganisations. The establishment of clinical commissioning groups (CCGs) was intended to be 'bottom up' with no central blueprint. This paper sets out to offer evidence about how this process has played out in practice and examines the implications of the complexity and variation which emerged.

DESIGN

Detailed case studies in CCGs across England, using interviews, observation and documentary analysis. Using realist framework, we unpacked the complexity of CCG structures.

SETTING/PARTICIPANTS

In phase 1 of the study (January 2011 to September 2012), we conducted 96 interviews, 439 h of observation in a wide variety of meetings, 2 online surveys and 38 follow-up telephone interviews. In phase 2 (April 2013 to March 2015), we conducted 42 interviews with general practitioners (GPs) and managers and observation of 48 different types of meetings.

RESULTS

Our study has highlighted the complexity inherent in CCGs, arising out of the relatively permissive environment in which they developed. Not only are they very different from one another in size, but also in structure, functions between different bodies and the roles played by GPs.

CONCLUSIONS

The complexity and lack of uniformity of CCGs is important as it makes it difficult for those who must engage with CCGs to know who to approach at what level. This is of increasing importance as CCGs are moving towards greater integration across health and social care. Our study also suggests that there is little consensus as to what being a 'membership' organisation means and how it should operate. The lack of uniformity in CCG structure and lack of clarity over the meaning of 'membership' raises questions over accountability, which becomes of greater importance as CCG is taking over responsibility for primary care co-commissioning.

Epidemiology of vaginal prolapse in mixed-age ewes in New Zealand

AIMS

Identify environmental, animal, and management factors associated with risk of vaginal prolapse in ewes, to enable farmers and advisors to make pragmatic decisions based on empirical observations for control of the condition.

METHODS

Two longitudinal studies conducted over 2 years to identify factors associated with incidence of prolapse in (i) cohorts of 200 individually identified mixed-age (MA) ewes, and (ii) all MA ewes, on voluntarily participating sheep-breeding farms in Hawkes Bay (HB) and Southland regions of New Zealand.

RESULTS

The overall annual incidences of prolapse on 113 farms in 2000 and 88 in 2001 were 1.21 and 0.82 per 100 MA ewes, respectively, and 1.05 for both years combined. A total of 406 prolapses were recorded among 36,695 individually identified cohort ewes. Individual farm incidences for both years varied from 0-5.9 (mean=1.56, median=1.39) on Southland and 0-3.9 (mean=0.75, median=0.54) per 100 ewes on HB farms. The crude relative risk of a prolapse occurring in a MA ewe was 5.31 times higher for ewes carrying twins and 11.3 times higher for ewes carrying triplets, than single lambs. Flocks made up of predominantly pure or crossbred Perendale ewes appeared to be at lower risk than flocks with other breeds. Shearing in the 3 months leading up to mating appeared to be protective, as was shearing in the second half of pregnancy. The risk was higher on farms with moderate to steep terrain than on farms with flat terrain. The identified risk factors in the individually identified cohorts were: access to salt and feeding of swedes in the latter part of pregnancy, moderate to steep lambing paddocks, multiple lambs detected at scanning, and weight gain between start of mating and scanning. The condition recurred in 2001 in six (35%) of 17 study ewes that had prolapsed during 2000. Culling policies for female offspring of affected ewes did not influence incidence at the farm level; nor did feeding hay or grain in late pregnancy. Furthermore, there was no association between incidence and body condition scores measured prior to and after mating, at scanning, or at time of set stocking.

CLINICAL SIGNIFICANCE

Vaginal prolapse is an inevitable consequence of sheep reproduction and its incidence is expected to increase as reproductive rates increase. This study provides some firm leads as to the relative importance of risk factors and gives guidance for risk reduction, e.g. by identification and separate management of ewes carrying twins or triplets, using flat paddocks for lambing, and guarding against gain in weight between the start of mating and scanning.

Endothelial-cell FAK targeting sensitizes tumours to DNA-damaging therapy

Chemoresistance is a serious limitation of cancer treatment. Until recently, almost all the work done to study this limitation has been restricted to tumour cells. Here we identify a novel molecular mechanism by which endothelial cells regulate chemosensitivity. We establish that specific targeting of focal adhesion kinase (FAK; also known as PTK2) in endothelial cells is sufficient to induce tumour-cell sensitization to DNA-damaging therapies and thus inhibit tumour growth in mice. The clinical relevance of this work is supported by our observations that low blood vessel FAK expression is associated with complete remission in human lymphoma. Our study shows that deletion of FAK in endothelial cells has no apparent effect on blood vessel function per se, but induces increased apoptosis and decreased proliferation within perivascular tumour-cell compartments of doxorubicin- and radiotherapy-treated mice. Mechanistically, we demonstrate that endothelial-cell FAK is required for DNA-damage-induced NF-κB activation in vivo and in vitro, and the production of cytokines from endothelial cells. Moreover, loss of endothelial-cell FAK reduces DNA-damage-induced cytokine production, thus enhancing chemosensitization of tumour cells to DNA-damaging therapies in vitro and in vivo. Overall, our data identify endothelial-cell FAK as a regulator of tumour chemosensitivity. Furthermore, we anticipate that this proof-of-principle data will be a starting point for the development of new possible strategies to regulate chemosensitization by targeting endothelial-cell FAK specifically.

Evaluation of observation-fused regional air quality model results for population air pollution exposure estimation

In this study, Community Multiscale Air Quality (CMAQ) model was applied to predict ambient gaseous and particulate concentrations during 2001 to 2010 in 15 hospital referral regions (HRRs) using a 36-km horizontal resolution domain. An inverse distance weighting based method was applied to produce exposure estimates based on observation-fused regional pollutant concentration fields using the differences between observations and predictions at grid cells where air quality monitors were located. Although the raw CMAQ model is capable of producing satisfying results for O3 and PM2.5 based on EPA guidelines, using the observation data fusing technique to correct CMAQ predictions leads to significant improvement of model performance for all gaseous and particulate pollutants. Regional average concentrations were calculated using five different methods: 1) inverse distance weighting of observation data alone, 2) raw CMAQ results, 3) observation-fused CMAQ results, 4) population-averaged raw CMAQ results and 5) population-averaged fused CMAQ results. It shows that while O3 (as well as NOx) monitoring networks in the HRRs are dense enough to provide consistent regional average exposure estimation based on monitoring data alone, PM2.5 observation sites (as well as monitors for CO, SO2, PM10 and PM2.5 components) are usually sparse and the difference between the average concentrations estimated by the inverse distance interpolated observations, raw CMAQ and fused CMAQ results can be significantly different. Population-weighted average should be used to account for spatial variation in pollutant concentration and population density. Using raw CMAQ results or observations alone might lead to significant biases in health outcome analyses.

Effectiveness of a vegetable dental chew on periodontal disease parameters in toy breed dogs

Sixteen toy breed dogs completed a parallel, 70-day two-period, cross-over design clinical study to determine the effect of a vegetable dental chew on gingivitis, halitosis, plaque, and calculus accumulations. The dogs were randomly assigned into two groups. During one study period the dogs were fed a non-dental dry diet only and during the second study period were fed the same dry diet supplemented by the daily addition of a vegetable dental chew. Daily administration of the dental chew was shown to reduce halitosis, as well as, significantly reduce gingivitis, plaque and calculus accumulation and therefore may play a significant role in the improvement of canine oral health over the long-term.

Partnership Working in Public Health: The Implications for Governance of a Systems Approach

Objectives

Most of the research on partnerships has centred on health and social care, and while many of the findings remain relevant, public health partnerships concerned with ‘wicked issues’ give rise to a different and more complex set of issues which merit exploration. The study aimed to identify those factors promoting effective partnership working for health improvement; to assess the extent to which partnership governance and incentive arrangements were commensurate with the complexities of the problem; and to explore how far local partnerships contributed to better outcomes for individuals and populations.

Methods

A three-year study of public health partnerships (2007-10) in nine localities across England involving semi-structured interviews at strategic and operational levels.

Results

Successful partnerships shared a number of characteristics:they were clear about goals and purpose; they were aware of partners' roles and responsibilities; and they had a clear strategic overview of performance through robust monitoring and evaluation. In many cases, partnerships were facades with a ‘silo mentality’ prevailing - there was an unwillingness to share information or resources, or to accord partnership working sufficient priority or support. Despite enthusiasm for partnerships and an insistence that they were essential, it was impossible to establish evidence of their impact on health outcomes. While the focus on partnerships tends to be on structures, relational factors, including high levels of trust and goodwill, were important ingredients of a well-functioning partnership. Less formal and more organic, operational partnerships were more effective than more formal, strategic level ones which were driven by targets. Finally, partnerships were, in part, shaped by the national policy context, with constant policy and organizational churn making it difficult to sustain long-term relationships.

Conclusions

Future partnerships might be undertaken differently, adopting a complex adaptive systems perspective. This advocates an approach to partnership working that is less focused on rigid structures and much more on relational factors like trust and goodwill.

Influence of C, N and O Ion-Implantation on Yellow Luminescence

Influence of C, N and O ion-implantation on the yellow luminescence (YL) of halide vapor phase epitaxy (HVPE) and metal-organic vapor phase epitaxy (MOVPE) grown GaN has been studied by photoluminescence (PL) spectroscopy. For the HVPE-grown samples, only C implantation produces a significant enhancement of YL while its corresponding overall PL integrated intensity is only ˜72% of its original value. Implantation of O or N do not appreciably change the YL but decrease the BE integrated intensities by a factor of ten. The full-width-halfmaximum (FWHM) of the BE band expanded to about 1.4 × of the original value in all three cases. These results indicate that one source of the YL is strongly correlated to incorporation of C into the GaN film. The C-induced defect complexes in GaN are optically active while O or N does not lead to any new luminescence features. The variable-temperature PL measurements on the C-implanted HVPE-grown GaN reveal that the FWHM of the YL band increases linearly and the peak energy of the YL changes very little with the increasing measurement temperature, while the integrated intensity of the YL band decreases monotonically. This trend of the YL FWHM and peak energy with the measurement temperature can be explained by a two-channel transition model. For MOVPE-grown GaN films., all ion-implanted samples exhibit a significant loss of both the YL and overall integrated PL intensity. Residual C contamination in the MOVPE samples could be large compared to the additional ion-implanted carbon leading to a reduced impact of the ion-implanted carbon.

p53-dependent repression of polo-like kinase-1 (PLK1)

PLK1 is a critical mediator of G₂/M cell cycle transition that is inactivated and depleted as part of the DNA damage-induced G₂/M checkpoint. Here we show that downregulation of PLK1 expression occurs through a transcriptional repression mechanism and that p53 is both necessary and sufficient to mediate this effect. Repression of PLK1 by p53 occurs independently of p21 and of arrest at G₁/S where PLK1 levels are normally repressed in a cell cycle-dependent manner through a CDE/CHR element. Chromatin immunoprecipitation analysis indicates that p53 is present on the PLK1 promoter at two distinct sites termed p53RE1 and p53RE2. Recruitment of p53 to p53RE2, but not to p53RE1, is stimulated in response to DNA damage and/or p53 activation and is coincident with repression-associated changes in the chromatin. Downregulation of PLK1 expression by p53 is relieved by the histone deacetylase inhibitor, trichostatin A, and involves recruitment of histone deacetylase to the vicinity of p53RE2, further supporting a transcriptional repression mechanism. Additionally, wild type, but not mutant, p53 represses expression of the PLK1 promoter when fused upstream of a reporter gene. Silencing of PLK1 expression by RNAi interferes with cell cycle progression consistent with a role in the p53-mediated checkpoint. These data establish PLK1 as a direct transcriptional target of p53, independently of p21, that is required for efficient G₂/M arrest.

Use of multiple assays subject to detection limits with regression modeling in assessing the relationship between exposure and outcome

BACKGROUND

The goal of many studies in environmental epidemiology is to assess the relationship between chemical exposure and disease outcome. Often various assays can be used to measure a particular environmental exposure, with some assays being more invasive or expensive than others.

METHODS

We consider the situation in which 2 assays can be used to measure an environmental exposure. The first assay has measurement error and is subject to a lower detection limit (LOD), and the second assay has less measurement error and is not subject to a lower LOD. In this situation, the first assay is less invasive or less expensive and is measured in all study participants, whereas the second assay is more invasive or more expensive and is only measured in a subset of individuals. We develop a flexible class of regression models that incorporates both sets of assay measurements and allows for continuous or binary outcomes. We explore different design strategies for selecting the subset of patients in whom to measure the second assay. One design strategy is to measure the second more invasive or expensive assay only when the first assay is below LOD. We compare these designs with a simple design in which the second assay is measured in a random subset of patients without regard to the results of the first assay.

RESULTS

We develop estimation approaches for these regression models. We demonstrate through simulations that there are efficiency advantages of measuring the second assay in at least a fraction of cases in which the first assay is above LOD. We illustrate the methodology by using data from a study examining the effect of environmental polychlorinated biphenyl exposure on the risk of endometriosis.

CONCLUSION

The proposed methodology has good statistical properties and will be a useful methodological technique for studying the effect of exposure on outcome when exposure assays are subject to LOD.