Implementation of behaviour change training in practice amongst pharmacy professionals in primary care settings: Analysis using the COM-B model.

BACKGROUND: The Pharmacy Integration Fund (PhIF) was established in England in 2016, with funded learning programmes or 'pathways' designed to support the development of clinical pharmacy practice in a range of settings. Despite pharmacy staff being well positioned to provide more clinical work, limited research has investigated behaviour change training targeted at widespread practice transformation. OBJECTIVE(S): To investigate implementation of PhIF learning in practice, using the COM-B model of behaviour change. METHODS: An online survey distributed in February and October 2020 included questions on motivations for learning, confidence in target behaviours and impact of PhIF training on behaviour. The October 2020 survey also included questions exploring the effect of the COVID-19 pandemic. Quantitative data were analysed in SPSS. v.27 (IBM). Inferential statistics were used to compare between the pathways (Primary care pathways [PCP], Post-registration pathway [PRP] and Accuracy Checking Pharmacy Technician [ACPT] pathway). Free text comments were categorised and themed. RESULTS: Three-hundred and eighty-three responses were received (49% PRP learners, 39% PCP learners and 12% ACPT learners). Learners generally had the capacity and opportunities to apply learning, and were strongly motivated to implement behaviours in practice, although learners based in community pharmacy (those on the PRP) were less likely to report receiving employer support. Enhanced knowledge/skills (capacity) were more commonly reported than change to patient-facing activities, leading clinical services and conducting medication reviews with patients with complex needs (clinical practice behaviours targeted by the pathways). The COVID-19 pandemic heightened barriers to implementing practice change. CONCLUSIONS: Implementation of a range of clinical practice behaviours following at scale training appears to have been largely successful. Despite this, the community pharmacy context, where funded service opportunities may be lacking, continues to present challenges to workforce transformation plans. More work is needed to understand how training can be implemented to promote practice change for pharmacy professionals in all settings.

Three-Dimensional Dosimetry of a Beta-Emitting Radionuclide Using PRESAGE Dosimeters.

Three-dimensional dose distributions from liquid brachytherapy were measured using PRESAGE(®) dosimeters. The dosimeters were exposed to Y-90 for 5.75 days and read by optical tomography. The distributions are consistent with estimates from beta dose kernels.

Immunochemical studies of an insulin-like material in the parotid gland of diabetic BB rats.

Immunocytochemical and radioimmunoassay studies were performed on pancreatic and parotid tissues from diabetic BB and control Wistar rats. Compared with those of normoglycemic controls, the pancreata of diabetic BB rats generally lacked insulin-containing B-cells. Extracts from the parotid glands of diabetic rats contained less immunoassayable insulin-like material than was present in parotid extracts of controls. However, the parotid glands of both groups of animals contained numerous cells displaying insulin-like immunoreactivity. These insulin-immunoreactive cells, located mainly in the intercalated portion of the duct system, were comparable to those we reported recently in the parotid glands of normal and streptozocin-diabetic Sprague-Dawley rats. The presence of an insulin-like material in the parotid salivary gland of two types of diabetic animals suggests that such cells may be spared, in part, from the effects of both chemical and hereditary diabetogenic factors.

Life-history correlates of evolution under high and low adult mortality.

Life-history theory predicts evolutionary changes in reproductive traits and intrinsic mortality rates in response to differences in extrinsic mortality rates. Trade-offs between life- history traits play a pivotal role in these predictions, and such trade-offs are mediated, at least in part, by physiological allocations. To gain insight into these trade-offs, we have been performing a long-term experiment in which we allow fruitflies, Drosophila melanogaster, to evolve in response to high (HAM) and low (LAM) adult mortality rates. Here we analyze the physiological correlates of the life-history trade-offs. In addition to changing development time and early fecundity in the direction predicted, high adult mortality affected three traits expressed early in life-body size, growth rate, and ovariole number-but had little or no effect on body composition (relative fat content), viability, metabolic rate, activity, starvation resistance, or desiccation resistance. Correlations among lines revealed trade-offs between early fecundity, late fecundity, and starvation resistance, which appear to be mediated by differential allocation of lipids.

Decline in offspring viability as a manifestation of aging in Drosophila melianogaster.

The evolutionary explanation of senescence proposes that selection against alleles with deleterious effects manifested only late in life is weak because most individuals die earlier for extrinsic reasons. This argument also applies to alleles whose deleterious effects are nongenetically transmitted from mother to progeny, that is, that affect the performance of progeny produced at late ages rather than of the aging individuals themselves. We studied the effect of maternal age on offspring viability (egg hatching success and larva-to-adult survival) in two sets of Drosophila melanogaster lines (HAM/LAM and YOUNG/OLD), originating from two long-term selection experiments. In each set, some lines (HAM and YOUNG, respectively) have been selected for early reproduction, whereas later reproduction was favored in their counterparts (LAM and OLD). In the HAM and LAM lines, both egg hatching success and larval viability declined with mother's age and did so with accelerating rates. The hatching success declined significantly faster with maternal age in HAM than in LAM lines, according to one of two statistical approaches used. Egg hatching success also declined with maternal age in YOUNG and OLD lines, with no difference between the selection regimes. However, the relationship between mother's age and offspring larva-to-adult viability differed significantly between these two selection regimes: a decline of larval viability with maternal age occurred in YOUNG lines but not in OLD lines. This suggests that the rate with which offspring viability declines with mother's age responded to selection for early versus late reproduction. We suggest broadening the evolutionary concept of senescence to include intrinsically caused declines in offspring quality with maternal age.

Diagnosing senescence: inferring evolutionary causes from phenotypic patterns can be misleading.

Based on the predictions of two theories for the evolution of senescence, the 'antagonistic pleiotropy' and the 'mutation accumulation' theory, an age-specific increase in mortality and a decrease in fecundity are widely used criteria to diagnose senescence in natural, and laboratory populations. In this study we question the reliability of these criteria. Using a simple model we show that similar phenotypic patterns result from optimal life histories without senescence. With a tradeoff between reproduction and period survival, optimal life histories produce patterns of increasing mortality and decreasing fecundity as organisms age, even if the tradeoff does not deteriorate with age, so that we are not forced to invoke genetic effects such as antagonistic pleiotropy or accumulation of deleterious mutations to explain such patterns. Furthermore, if optimal life history theory is applied to senescent organisms, phenotypic patterns can result that are usually not associated with senescence. We conclude that the reliability of a diagnosis of senescence based on phenotypic patterns and the comprehension of the phenomenon senescence depends critically on understanding to what extent tradeoffs are determined by the effects of segregating genes.

The experimental evolution of aging in fruitflies.

The evolutionary theory of aging suggests that the level of repair will evolve to an intermediate optimum that permits the accumulation of random damage to cells. This, in turn, causes a decline in essential functions during the life span of an organism. The central claim of the life history theory of aging is that intrinsic mortality rates evolve in response to changes in extrinsic mortality rates. To prove this central claim, it must be evaluated experimentally. Experimental evolution is an approach that has been yielding interesting results from both a variety of questions posed and organisms examined. In this article the organism chosen for study is the fruitfly (Drosophilia melanogaster) in which the evolutionary effects of high and low adult mortality rates are compared. It has been found that higher extrinsic mortality rates lead to the evolution of higher intrinsic mortality rates and a shorter life span. This is the first clear experimental demonstration of the central claim of the evolutionary theory of aging.

Psychosocial and educational outcomes associated with home- and clinic-based pretest education and cystic fibrosis carrier testing among a population of at-risk relatives.

We report on the psychosocial and knowledge outcomes of two different approaches to cystic fibrosis (CF) gene pretest education and carrier testing offered to 288 proactively recruited first-, second-, and third-degree relatives of people with CF. One group received pretest education and gene testing in a clinical setting from a certified genetic counselor. The other group received pretest education in their homes from a specially prepared pamphlet and were asked to send in a buccal cell sample for genotyping. No statistically significant differences between groups were noted on measures of CF knowledge, anxiety, and positive or negative affect, either while waiting for their test results or within a few weeks after they had learned their results. At both measurement points, participants who had received home education and testing reported that the testing was more convenient, but that they had received less information than they would have liked, and they were more likely to report being confused by the testing, although their level of CF knowledge was comparable to that of people who had been seen by a genetic counselor. In light of the increasing interest in home-based medical testing of all kinds, this study suggests that CF carrier testing in the home warrants further consideration as one possible approach to facilitating access to testing.

Immunoreactive hormones in human breast tissues.

Samples of breast tissue obtained at biopsy or mastectomy from women with benign breast disease and infiltrating duct or anaplastic carcinoma were maintained for 2 weeks in organ culture synthetic medium 199 without additional serum or hormones. Media were changed every 48 hours. Media withdrawn from the tissues were assayed for insulin, prolactin (Prl), and parathyroid hormone (PTH). In addition, tissue explants were extracted in acid-alcohol and assayed for insulin by standard radioimmunoassay (RIA) procedures. At day 0 portions of breast tissue from patients with malignant or benign disease were fixed in Bouin solution; they were then embedded in paraffin; and serial sections were obtained for histologic and immunocytochemical examination. The dissection media assayed for insulin and PTH by RIA showed that the hormones were present in media from patients with benign as well as malignant disease. However, there was no significant difference between the two groups of women. Only traces of Prl were detected in media. The amount of insulin present in certain tissue explants appeared to increase with time in culture. Immunocytochemical studies showed that insulin-like or PTH-like immunostaining appeared most often in malignant tumor tissue and was observed infrequently or not at all in patients with benign disease. Prl-positive cells were rare. These data suggest that breast tissues contain and may synthesize significant amounts of certain hormones that may influence the growth and proliferation of breast cells.

State risk pools and mental health care use.

State risk pools provide an opportunity for persons with mental health and substance abuse (MH/SA) problems to purchase health insurance. This study uses data from eight risk pools during the period 1988-1991 to analyze the utilization and enrollment experience for persons who submit claims for MH/SA treatment. Special consideration is given to the effect of variation in inpatient benefits across risk pools. The experience of Connecticut's risk pool differs markedly from that of the other risk pools. Given that two states (Connecticut and Florida) have restricted MH/SA benefits over time, we discuss the ability of risk pools to maintain comprehensive MH/SA benefits.

Do physicians cost shift?

This study analyzes whether physicians charge their privately insured patients more-a practice known as cost shifting-in response to Medicare payment reductions. As part of congressional legislation in 1989 and 1990, Medicare reduced its payment rates for selected procedures by as much as 30 percent. Here we examine whether reductions in Medicare rates increase how much physicians charge privately insured patients. Our data provide no evidence that physicians respond to Medicare payment reductions by shifting costs to their privately insured patients.

Systematic review of the clinical effectiveness and cost-effectiveness of tension-free vaginal tape for treatment of urinary stress incontinence.

OBJECTIVES: To evaluate the effectiveness and cost-effectiveness of tension-free vaginal tape (TVT) in comparison with the standard surgical interventions currently used. DATA SOURCES: Literature searches were carried out on electronic databases and websites for data covering the period 1966--2002. Other sources included references lists of relevant articles; selected experts in the field; abstracts of a limited number of conference proceedings titles; and the Internet. REVIEW METHODS: A systematic review of studies including comparisons of TVT with any of the comparators was conducted. Alternative treatments considered were abdominal retropubic colposuspension (including both open and laparoscopic colposuspension), traditional suburethral sling procedures and injectable agents (periurethral bulking agents). The identified studies were critically appraised and their results summarised. A Markov model comparing TVT with the comparators was developed using the results of the review of effectiveness and data on resource use and costs from previously conducted studies. The Markov model was used to estimate costs and quality-adjusted life-years for up to 10 years following surgery and it incorporated a probabilistic analysis and also sensitivity analysis around key assumptions of the model. RESULTS: Based on limited data from direct comparisons with TVT and from systematic reviews, laparoscopic colposuspension and traditional slings have broadly similar cure rates to TVT and open colposuspension, whereas injectable agents appear to have lower cure rates. TVT is less invasive than colposuspension and traditional sling procedures, and is also usually performed under regional or local anaesthesia. The principal operative complication is bladder perforation. There are currently no randomised controlled trial (RCT) data beyond 2 years post-surgery, and long-term effects are therefore currently not known reliably. TVT was more likely to be considered cost-effective compared with the other surgical procedures. Increasing the absolute probability of cure following TVT reduced the likelihood that TVT would be considered cost-effective. CONCLUSIONS: The long-term performance of TVT in terms of both continence and unanticipated adverse effects is not known reliably at the moment. Despite relatively few robust comparative data, it appears that in the short to medium term TVT's effectiveness approaches that of alternative procedures currently available, and is of lower cost. As TVT is a less invasive procedure, it is possible that some women who would currently be managed non-surgically will be considered eligible for TVT. Increased adoption of TVT will require additional surgeons proficient in the technique. It is likely that some of the higher rates of complications, e.g. bladder perforation, reported for TVT are associated with a 'learning curve'. Appropriate training will therefore be needed for surgeons new to the operation, in respect of both the technical aspects of the procedure and the choice of women suitable for the operation. Further research suggestions include unbiased assessments of longer term performance from follow-up of controlled trials or population-based registries; more data from methodologically sound RCTs using standard outcome measures; a surveillance system to detect longer term complications, if any, associated with the use of tape; and rigorous evaluation before extending the use of TVT to women who are currently managed non-surgically.

Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement.

OBJECTIVES: To undertake a systematic review of the long-term effects of obesity treatments on body weight, risk factors for disease, and disease. METHODS: The study encompassed three systematic reviews that examined different aspects of obesity treatments. (1) A systematic review of obesity treatments in adults where the methods of the Cochrane Collaboration were applied and randomised controlled trials (RCTs) with a follow-up of at least 1 year were evaluated. (2) A systematic epidemiological review, where studies were sought on long-term effects of weight loss on morbidity and/or mortality, and examined through epidemiological modelling. (3) A systematic economic review that sought reports with both costs and outcomes of treatment, including recent reports that assessed the cost-effectiveness of pharmaceutical and surgical interventions. A Markov model was also adopted to examine the cost-effectiveness of a low-fat diet and exercise intervention in adults with obesity and impaired glucose tolerance. RESULTS: The addition of the drugs orlistat or sibutramine was associated with weight loss and generally improved risk factors, apart from diastolic blood pressure for sibutramine. Metformin was associated with decreased mortality after 10 years in obese people with type 2 diabetes. Low-fat diets were associated with continuing weight loss for 3 years and improvements in risk factors, as well as prevention of type 2 diabetes and improved control of hypertension. Insufficient evidence was available to demonstrate the benefits of low calorie or very low calorie diets. The addition of an exercise or behaviour programme to diet was associated with improved weight loss and risk factors for at least 1 year. Studies combining low-fat diets, exercise and behaviour therapy suggested improved hypertension and cardiovascular disease. Family therapy was associated with improved weight loss for 2 years compared to individual therapy. There was insufficient evidence to conclude that individual therapy was more beneficial than group therapy. Weight lost more quickly (within 1 year), from the epidemiology review, may be more beneficial with respect to the risk of mortality. The effects of intentional weight loss need further investigation. Weight loss from surgical and non-surgical interventions for people suffering from obesity was associated with decreased risk of development of diabetes, and a reduction in low-density lipoprotein cholesterol, total cholesterol and blood pressure, in the long term. Targeting high-risk individuals with drugs or surgery was likely to result in a cost per additional life-year or quality-adjusted life-year (QALY) of no more than 13,000 British pounds. There was also suggestive evidence of cost saving from treatment of people with type 2 diabetes with metformin. Targeting surgery on people with severe obesity and impaired glucose tolerance was likely to be more cost-effective at 2329 British pounds per additional life-year. Economic modelling over 6 years for diet and exercise for people with impaired glucose tolerance was associated with a high initial cost per additional QALY, but by the sixth year the cost per QALY was 13,389 British pounds. Results did not include cost savings from diseases other than diabetes, and therefore may be conservative. CONCLUSIONS: The drugs orlistat and sibutramine appear beneficial for the treatment of adults with obesity, and metformin for obese patients with type 2 diabetes. Exercise and/or behaviour therapy appear to improve weight loss when added to diet. Low-fat diets with exercise, or with exercise and behaviour therapy are associated with the prevention of type 2 diabetes and hypertension. Long-term weight loss in epidemiological studies was associated with reduced risk of type 2 diabetes, and may be beneficial for cardiovascular disease. Low-fat diets and exercise interventions in individuals at risk of obesity-related illness are of comparable cost to drug treatments. Long-term pragmatic RCTs of obesity treatments in populations with obesity-related illness or at high risk of developing such illness are needed (to include an evaluation of risk factors, morbidity, quality of life and economic evaluations). Drug trials that include dietary advice, plus exercise and/or behaviour therapy are also needed. Research exploring effective types of exercise, diet or behaviour and also interventions to prevent obesity in adults is required.

Competitive behavior in local physician markets.

Competition often is viewed as a mechanism for controlling cost. Competition may work well in urban areas with many providers; competition may not exist in rural areas with few providers. The authors use the empirical framework developed by Bresnahan and Reiss to analyze the entry behavior of physicians into local markets to determine the level of physician supply consistent with competitive behavior. The study estimates entry patterns for total and specialty physicians located in nonmetropolitan health service areas using longitudinal data. The authors find a surprising drop in the population increments necessary for entry by the second provider, possibly due to the unattractiveness of being the solo physician in an area. Subsequent population increments stabilize at three to five physicians. Since more than 93 percent of the U.S. population lives in areas that can support three to five physicians, competition between physicians through mechanisms such as managed care may be feasible.

Hospital discharge decisions, health outcomes, and the use of unobserved information on case-mix severity.

Although implementation of the Medicare prospective payment system has been accompanied by significant decreases in hospital length of stay, the early discharge of some patients may lead to worse health outcomes, particularly if sufficient aftercare services following hospitalization are not available. This article develops an empirical model of the relationship between the choice of length of stay and patient outcome. The model incorporates information on the severity of a patient's medical condition known by the physician who chooses length of stay for a patient but generally not known by a researcher interested in the factors that affect length of stay and health outcome. Joint estimation of equations for length of stay and health outcome controls for unmeasured aspects of case severity that affect both variables. The ratio of nursing home beds to Medicare enrollees in the county is included as an exogenous variable in both equations to assess whether variation in nursing home bed availability is correlated with length of stay or health outcome. The model is estimated using billing data for Medicare patients admitted with congestive heart failure to New Jersey hospitals during 1982 and 1983. Two measures of outcome are used: (1) a discrete measure of survival time following admission, and (2) a categorical measure of whether or not the patient was discharged dead or died within six months after discharge. Empirical results show no evidence that longer lengths of stay for congestive heart failure patients lead to lower postadmission mortality. However, greater availability of nursing home beds may reduce length of stay and may shift the provision of terminal care away from a hospital setting. Therefore, policies to expand the nursing home bed supply may enable further decreases in hospital length of stay without deleterious effect on patient outcome.

The effect of Channeling on in-home utilization and subsequent nursing home care: a simultaneous equation perspective.

OBJECTIVE: This study explored the relationship between participation in a home/community-based long-term care case management intervention (known as the Channeling demonstration), use of formal in-home care, and subsequent nursing home utilization. STUDY DESIGN: Structural analysis of the randomized Channeling intervention was conducted to decompose the total effects of Channeling on nursing home use into direct and indirect effects. DATA COLLECTION METHOD: Secondary data analysis of the National Long-Term Care Data Set. PRINCIPAL FINDINGS: The use of formal in-home care, which was increased by the Channeling intervention, was positively associated with nursing home utilization at 12 months. However, the negative direct effect of Channeling on nursing home use was of sufficient magnitude to offset this positive indirect effect, so that a small but significant negative total effect of Channeling on subsequent nursing home utilization was found. CONCLUSIONS: This study shows why Channeling did not have a large total impact on nursing home utilization. The analysis did not provide evidence of direct substitution of in-home care for nursing home care because the direct reductions in nursing home utilization due to other aspects of Channeling (including, but not limited to case management) were substantially offset by the indirect increases in nursing home utilization associated with additional home care use.

Risk indicators for hospitalization during the last year of life.

OBJECTIVE: High levels of hospital expenditures for older people during their last year of life are widely documented. However, evidence of the association between prospectively measured indicators and subsequent hospitalization is sparse. This article investigates the pattern of hospitalization for a sample of Medicare enrollees during their last year of life. DATA SOURCES: Data from the Longitudinal Study of Aging, a national study of persons age 70 and older, are used. Only data on decedents are used. STUDY DESIGN: We determine individual characteristics (including functional status, evidence of disease, living arrangement, and prior hospitalization) shortly before the last year of life. A distinction is made between terminal and nonterminal admissions. National estimates and regression analyses using survey weights are conducted. PRINCIPAL FINDINGS: The likelihood of any use is high regardless of age, functional status, or the presence of major diseases. Although only a few indicators are associated with having a terminal stay, a number of indicators are associated with nonterminal use. Nonterminal stays and total nights hospitalized are positively associated with prior evidence of disease, prior hospitalization, and age, although the probability of nonterminal use decreases with age for persons over 82 years old. The relationship between use and functional status depends on whether persons lived alone, were institutionalized, or had private health insurance. CONCLUSIONS: This study demonstrates that while it is difficult to predict who will be admitted to the hospital at the time of death, a number of characteristics existing before the last year of life are associated with nonterminal hospitalization and total nights hospitalized during the last year of life.

Immunocytochemical localization of insulin- and somatostatin-like material in human breast tumors.

Four types of human breast lesions and C3H mouse mammary adenocarcinomas (type A) were examined for the immunocytochemical localization of cells containing hormone-like substances. Insulin- or somatostatin-like immunoreactive material was observed in scattered single cells and nests of tumor cells in seven of eight infiltrating duct carcinomas, and in the majority of tumor cells from an anaplastic carcinoma. A few somatostatin-immunoreactive cells were observed in only one of seven fibroadenomas studied. No immunoreactive cells were observed in mouse adenocarcinomas or in human breast dysplasias. These results suggest that cells with hormone-like immunoreactivity may be a common feature in two types of malignant human breast tumors.