Patient reported measures of continuity of care and health outcomes: a systematic review.

BACKGROUND: There is a considerable amount of research showing an association between continuity of care and improved health outcomes. However, the methods used in most studies examine only the pattern of interactions between patients and clinicians through administrative measures of continuity. The patient experience of continuity can also be measured by using patient reported experience measures. Unlike administrative measures, these can allow elements of continuity such as the presence of information or how joined up care is between providers to be measured. Patient experienced continuity is a marker of healthcare quality in its own right. However, it is unclear if, like administrative measures, patient reported continuity is also linked to positive health outcomes. METHODS: Cohort and interventional studies that examined the relationship between patient reported continuity of care and a health outcome were eligible for inclusion. Medline, EMBASE, CINAHL and the Cochrane Library were searched in April 2021. Citation searching of published continuity measures was also performed. QUIP and Cochrane risk of bias tools were used to assess study quality. A box-score method was used for study synthesis. RESULTS: Nineteen studies were eligible for inclusion. 15 studies measured continuity using a validated, multifactorial questionnaire or the continuity/co-ordination subscale of another instrument. Two studies placed patients into discrete groups of continuity based on pre-defined questions, one used a bespoke questionnaire, one calculated an administrative measure of continuity using patient reported data. Outcome measures examined were quality of life (n = 11), self-reported health status (n = 8), emergency department use or hospitalisation (n = 7), indicators of function or wellbeing (n = 6), mortality (n = 4) and physiological measures (n = 2). Analysis was limited by the relatively small number of hetrogenous studies. The majority of studies showed a link between at least one measure of continuity and one health outcome. CONCLUSION: Whilst there is emerging evidence of a link between patient reported continuity and several outcomes, the evidence is not as strong as that for administrative measures of continuity. This may be because administrative measures record something different to patient reported measures, or that studies using patient reported measures are smaller and less able to detect smaller effects. Future research should use larger sample sizes to clarify if a link does exist and what the potential mechanisms underlying such a link could be. When measuring continuity, researchers and health system administrators should carefully consider what type of continuity measure is most appropriate.

Trajectories of cognitive flexibility through kindergarten and first grade: Implications for externalizing and internalizing behavior problems in the second grade.

Developmental delays in cognitive flexibility early in elementary school can potentially increase vulnerability for subsequent externalizing and internalizing psychopathology. The first goal of the current study was to identify latent subgroups of children characterized by different developmental trajectories of cognitive flexibility throughout kindergarten and first grade using data from the Early Childhood Longitudinal Study, Kindergarten Class of 2010-2011 dataset. The second goal was to examine whether identified longitudinal developmental trajectories of cognitive flexibility could be associated with internalizing and externalizing behaviors in the second grade, while accounting for background child (age, gender, and Spanish-speaking) and family (family income and mother's education) covariates. The analytic sample consisted of 15,827 kindergarteners (51.20% male; 48.50% White, 13.5% Black/African American, 24.3% Hispanic/Latino, 7.60% Asian, and 6.1% other), who were approximately 5.62 years old (SD = 4.48 months) at the study's outset. Most children lived in households with medium family income of approximately $50,000-$55,000. Using a growth mixture modeling approach, our analyses identified normative (91.05%; 50.4% male) and delayed (8.95%; 59.4% male) cognitive flexibility groups and demonstrated that delayed developers have higher levels of externalizing and internalizing behaviors in the second grade, even after adjusting for background covariates. Our findings, in conjunction with research on cognitive flexibility training, suggest that caregivers may lower the risk for externalizing and internalizing behaviors in delayed developers by correcting inflexible thinking, encouraging alternative solutions, and providing emotional support when children face challenging problems. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Second generation readout for large format photon counting microwave kinetic inductance detectors.

We present the development of a second generation digital readout system for photon counting microwave kinetic inductance detector (MKID) arrays operating in the optical and near-infrared wavelength bands. Our system retains much of the core signal processing architecture from the first generation system but with a significantly higher bandwidth, enabling the readout of kilopixel MKID arrays. Each set of readout boards is capable of reading out 1024 MKID pixels multiplexed over 2 GHz of bandwidth; two such units can be placed in parallel to read out a full 2048 pixel microwave feedline over a 4 GHz-8 GHz band. As in the first generation readout, our system is capable of identifying, analyzing, and recording photon detection events in real time with a time resolution of order a few microseconds. Here, we describe the hardware and firmware, and present an analysis of the noise properties of the system. We also present a novel algorithm for efficiently suppressing IQ mixer sidebands to below -30 dBc.

Negotiating refusal in primary care consultations: a qualitative study.

BACKGROUND: How GPs negotiate patient requests is vital to their gatekeeper role but also a source of potential conflict, practitioner stress and patient dissatisfaction. Difficulties may arise when demands of shared decision-making conflict with resource allocation, which may be exacerbated by new commissioning arrangements, with GPs responsible for available services. OBJECTIVES: To explore GPs' accounts of negotiating refusal of patient requests and their negotiation strategies. METHODS: A qualitative design was employed with two focus groups of GPs and GP registrars followed by 20 semi-structured interviews. Participants were sampled by gender, experience, training/non-training, principal versus salaried or locum. Thematic content analysis proceeded in parallel with interviews and further sampling. The setting was GP practices within an English urban primary care trust. RESULTS: Sickness certification, antibiotics and benzodiazepines were cited most frequently as problematic patient requests. GP trainees reported more conflict within interactions than experienced GPs. Negotiation strategies, such as blaming distant third parties such as the primary care organization, were designed to prevent conflict and preserve the doctor-patient relationship. GPs reported patients' expectations being strongly influenced by previous encounters with other health care professionals. CONCLUSIONS: The findings reiterate the prominence of the doctor-patient relationship in GPs' accounts. GPs' relationships with colleagues and the wider National Health Service (NHS) are particular of relevance in light of provisions in the Health and Social Care Bill for clinical commissioning consortia. The ability of GPs to offset blame for rationing decisions to third parties will be undermined if the same GPs commission services.

Comparing a discrete and continuum model of the intestinal crypt.

The integration of processes at different scales is a key problem in the modelling of cell populations. Owing to increased computational resources and the accumulation of data at the cellular and subcellular scales, the use of discrete, cell-level models, which are typically solved using numerical simulations, has become prominent. One of the merits of this approach is that important biological factors, such as cell heterogeneity and noise, can be easily incorporated. However, it can be difficult to efficiently draw generalizations from the simulation results, as, often, many simulation runs are required to investigate model behaviour in typically large parameter spaces. In some cases, discrete cell-level models can be coarse-grained, yielding continuum models whose analysis can lead to the development of insight into the underlying simulations. In this paper we apply such an approach to the case of a discrete model of cell dynamics in the intestinal crypt. An analysis of the resulting continuum model demonstrates that there is a limited region of parameter space within which steady-state (and hence biologically realistic) solutions exist. Continuum model predictions show good agreement with corresponding results from the underlying simulations and experimental data taken from murine intestinal crypts.

Professional values and reported behaviours of doctors in the USA and UK: quantitative survey.

BACKGROUND The authors aimed to determine US and UK doctors' professional values and reported behaviours, and the extent to which these vary with the context of care. METHOD 1891 US and 1078 UK doctors completed the survey (64.4% and 40.3% response rate respectively). Multivariate logistic regression was used to compare responses to identical questions in the two surveys. RESULTS UK doctors were more likely to have developed practice guidelines (82.8% UK vs 49.6% US, p<0.001) and to have taken part in a formal medical error-reduction programme (70.9% UK vs 55.7% US, p<0.001). US doctors were more likely to agree about the need for periodic recertification (completely agree 23.4% UK vs 53.9% US, p<0.001). Nearly a fifth of doctors had direct experience of an impaired or incompetent colleague in the previous 3 years. Where the doctor had not reported the colleague to relevant authorities, reasons included thinking that someone else was taking care of the problem, believing that nothing would happen as a result, or fear of retribution. UK doctors were more likely than US doctors to agree that significant medical errors should always be disclosed to patients. More US doctors reported that they had not disclosed an error to a patient because they were afraid of being sued. DISCUSSION The context of care may influence both how professional values are expressed and the extent to which behaviours are in line with stated values. Doctors have an important responsibility to develop their healthcare systems in ways which will support good professional behaviour.

How should trainees be taught to open a clinical interview?

AIM: To characterise the opening of secondary care consultations. METHOD: We audio-taped 17 first consultations in medical clinics, transcribed them verbatim, and analysed verbal interactions from when the doctor called the patient into the consulting room to when she or he asked clarifying questions. RESULTS: The interviews did not open with the sequence, reported by previous researchers, of 'doctor's soliciting question, patient's opening statement, interruption by the doctor'. Doctors (1) called the patient to the consultation; (2) greeted them; (3) introduced themselves; (4) made a transition to clinical talk; and (5) framed the consultation. They used a referral letter, the case notes, computer records and their prior knowledge of the patient to help frame the consultation, and did so informally and with humour. CONCLUSION: These 5 steps could help trainees create a context for active listening that is less prone to interruption.