Quasi-experimental evaluation of a nationwide diabetes prevention programme.

Diabetes is a leading cause of morbidity, mortality and cost of illness1,2. Health behaviours, particularly those related to nutrition and physical activity, play a key role in the development of type 2 diabetes mellitus3. Whereas behaviour change programmes (also known as lifestyle interventions or similar) have been found efficacious in controlled clinical trials4,5, there remains controversy about whether targeting health behaviours at the individual level is an effective preventive strategy for type 2 diabetes mellitus6 and doubt among clinicians that lifestyle advice and counselling provided in the routine health system can achieve improvements in health7-9. Here we show that being referred to the largest behaviour change programme for prediabetes globally (the English Diabetes Prevention Programme) is effective in improving key cardiovascular risk factors, including glycated haemoglobin (HbA1c), excess body weight and serum lipid levels. We do so by using a regression discontinuity design10, which uses the eligibility threshold in HbA1c for referral to the behaviour change programme, in electronic health data from about one-fifth of all primary care practices in England. We confirm our main finding, the improvement of HbA1c, using two other quasi-experimental approaches: difference-in-differences analysis exploiting the phased roll-out of the programme and instrumental variable estimation exploiting regional variation in programme coverage. This analysis provides causal, rather than associational, evidence that lifestyle advice and counselling implemented at scale in a national health system can achieve important health improvements.

Factors influencing care-seeking behaviour for mental illness in India: a situational analysis in Tamil Nadu.

BACKGROUND: The contribution of mental illness to the total burden of disease in India nearly doubled from 1990 to 2017, increasing from 2.5% of the total disability-adjusted life years in 1990 to 4.7% in 2017. Despite efforts by the Indian government, a treatment gap of 75-85%, with heterogeneity across multiple dimensions, exists across India. We conducted a qualitative study in Tamil Nadu, India, to better understand the contextual factors affecting the care-seeking behaviour for mental illness. METHODS: Qualitative methods, including semi-structured interviews and focus groups (FGs), were conducted with stakeholders involved in the mental health care pathway in Tamil Nadu. Ten semi-structured interviews and five FGs were conducted and analysed using an inductive approach to identify codes, using Dedoose v7, related to the emerging themes and categories. RESULTS: Our analyses identified three key areas that influence care-seeking: views on what causes and/or constitutes mental illness, stigma and discrimination associated with mental illness and broader factors influencing decision-making. CONCLUSIONS: The specific contextual factors identified by our study can be used to design and implement approaches that can help to address some of the issues that influence the care-seeking behaviour and manifest in the treatment gaps seen in Tamil Nadu and in India, more generally.

Is administered competition suitable for dealing with a public health emergency? Lessons from the local healthcare system at the centre of early COVID-19 outbreak in Italy.

OBJECTIVES: The Lombardy Region, Italy, was the most severely affected by the COVID-19 outbreak. In absence of effective treatments and with basic hygiene measures made mandatory, Lombardy response to COVID-19 relied on its healthcare system characteristics, the administered competition or "quasi-market" model. The aim of the study was to review the strengths and weaknesses of Lombardy's response during the first wave of the COVID-19 epidemic, to explore whether the healthcare model influenced crisis management and describe which policies could help to contain future outbreaks. The results are expected to provide similar healthcare systems with lessons to avoid mistakes and learn from best practice. METHODS: Data for quantitative analyses on the performance of the Lombardy and Veneto Regions healthcare systems were derived from existing government sources including the Italian Civil Protection Agency and the Ministry of Health. RESULTS: Lombardian quasi-market model, traditionally characterized by a strong hospital network, was held responsible for many suboptimal outcomes. According to critics, years of disinvestments in community care resulted in a hospital overload. However, the same model was responsible for other positive outcomes which have been substantially neglected, such as the opportunity to test for effective containment treatments in a safe environment and rapidly extend the number of beds. CONCLUSIONS: The performance of a quasi-market model against public health emergencies largely depends on integration between policy-makers and balance between healthcare providers, which require clear regulation. Reducing institutional fragmentation between levels of governance, improving the coordination of healthcare facilities and adopting telemedicine technologies are means by which healthcare networks could strengthen their resilience against future outbreaks.

Using an Ontology to Facilitate More Accurate Coding of Social Prescriptions Addressing Social Determinants of Health: Feasibility Study.

BACKGROUND: National Health Service (NHS) England supports social prescribing in order to address social determinants of health, which account for approximately 80% of all health outcomes. Nevertheless, data on ongoing social prescribing activities are lacking. Although NHS England has attempted to overcome this problem by recommending 3 standardized primary care codes, these codes do not capture the social prescribing activity to a level of granularity that would allow for fair attribution of outcomes to social prescribing. OBJECTIVE: In this study, we explored whether an alternative approach to coding social prescribing activity, specifically through a social prescribing ontology, can be used to capture the social prescriptions used in primary care in greater detail. METHODS: The social prescribing ontology, implemented according to the Web Ontology Language, was designed to cover several key concepts encompassing social determinants of health. Readv2 and Clinical Terms Version 3 codes were identified using the NHS Terms Browser. The Royal College of General Practitioners Research Surveillance Centre, a sentinel network of over 1000 primary care practices across England covering a population of more than 4,000,000 registered patients, was used for data analyses for a defined period (ie, January 2011 to December 2019). RESULTS: In all, 668 codes capturing social prescriptions addressing different social determinants of health were identified for the social prescribing ontology. For the study period, social prescribing ontology codes were used 5,504,037 times by primary care practices of the Royal College of General Practitioners Research Surveillance Centre as compared to 29,606 instances of use of social prescribing codes, including NHS England's recommended codes. CONCLUSIONS: A social prescribing ontology provides a powerful alternative to the codes currently recommended by NHS England to capture detailed social prescribing activity in England. The more detailed information thus obtained will allow for explorations about whether outputs or outcomes of care delivery can be attributed to social prescriptions, which is essential for demonstrating the overall value that social prescribing can deliver to the NHS and health care systems.

Value based maternal and newborn care requires alignment of adequate resources with high value activities.

BACKGROUND: Evidence based practice has been associated with better quality of care in many situations, but it has not been able to address increasing need and demand in healthcare globally and stagnant or decreasing healthcare resources. Implementation of value-based healthcare could address many important challenges in health care systems worldwide. Scaling up exemplary high value care practices offers the potential to ensure values-driven maternal and newborn care for all women and babies. DISCUSSION: Increased use of healthcare interventions over the last century have been associated with reductions in maternal and newborn mortality and morbidity. However, over an optimum threshold, these are associated with increases in adverse effects and inappropriate use of scarce resources. The Quality Maternal and Newborn Care framework provides an example of what value based maternity care might look like. To deliver value based maternal and newborn care, a system-level shift is needed, 'from fragmented care focused on identification and treatment of pathology for the minority to skilled care for all'. Ideally, resources would be allocated at population and individual level to ensure care is woman-centred instead of institution/ profession centred but oftentimes, the drivers for spending resources are 'the demands and beliefs of the acute sector'. We argue that decisions to allocate resources to high value activities, such as continuity of carer, need to be made at the macro level in the knowledge that these investments will relieve pressure on acute services while also ensuring the delivery of appropriate and high value care in the long run. To ensure that high value preventive and supportive care can be delivered, it is important that separate staff and money are allocated to, for example, models of continuity of carer to prevent shortages of resources due to rising demands of the acute services. To achieve value based maternal and newborn care, mechanisms are needed to ensure adequate resource allocation to high value maternity care activities that should be separate from the resource demands of acute maternity services. Funding arrangements should support, where wanted and needed, seamless movement of women and neonates between systems of care.

Value-based genomic screening: exploring genomic screening for chronic diseases using triple value principles.

BACKGROUND: Genomic screening has unique challenges which makes it difficult to easily implement on a wide scale. If the costs, benefits and tradeoffs of investing in genomic screening are not evaluated properly, there is a risk of wasting finite healthcare resources and also causing avoidable harm. MAIN TEXT: If healthcare professionals - including policy makers, payers and providers - wish to incorporate genomic screening into healthcare while minimizing waste, maximizing benefits, and considering results that matter to patients, using the principles of triple value (allocative, technical, and personal value) could help them to evaluate tough decisions and tradeoffs. Allocative value focuses on the optimal distribution of limited healthcare resources to maximize the health benefits to the entire population while also accounting for all the costs of care delivery. Technical value ensures that for any given condition, the right intervention is chosen and delivered in the right way. Various methods (e.g. ACCE, HTA, and Wilson and Jungner screening criteria) exist that can help identify appropriate genomic applications. Personal value incorporates preference based informed decision making to ensure that patients are informed about the benefits and harms of the choices available to them and to ensure they make choices based on their values and preferences. CONCLUSIONS: Using triple value principles can help healthcare professionals make reasoned and tough judgements about benefits and tradeoffs when they are exploring the role genomic screening for chronic diseases could play in improving the health of their patients and populations.

BRG1-mediated immune tolerance: facilitation of Treg activation and partial independence of chromatin remodelling.

Treg activation in response to environmental cues is necessary for regulatory T cells (Tregs) to suppress inflammation, but little is known about the transcription mechanisms controlling Treg activation. We report that despite the known proinflammatory role of the chromatin-remodelling factor BRG1 in CD4 cells, deleting Brg1 in all αß T cell lineages led to fatal inflammation, which reflected essential roles of BRG1 in Tregs. Brg1 deletion impaired Treg activation, concomitant with the onset of the inflammation. Remarkably, as the inflammation progressed, Tregs became increasingly activated, but the activation levels could not catch up with the severity of inflammation. In vitro assays indicate that BRG1 regulates a subset of TCR target genes including multiple chemokine receptor genes. Finally, using a method that can create littermates bearing either a tissue-specific point mutation or deletion, we found the BRG1 ATPase activity partially dispensable for BRG1 function. Collectively, these data suggest that BRG1 acts in part via remodelling-independent functions to sensitize Tregs to inflammatory cues, thus allowing Tregs to promptly and effectively suppress autoimmunity.

HIF prolyl hydroxylase inhibition prior to transient focal cerebral ischaemia is neuroprotective in mice.

This study investigated the effects of 2-(1-chloro-4-hydroxyisoquinoline-3-carboxamido) acetic acid (IOX3), a selective small molecule inhibitor of hypoxia-inducible factor (HIF) prolyl hydroxylases, on mouse brains subject to transient focal cerebral ischaemia. Male, 8- to 12-week-old C57/B6 mice were subjected to 45 min of middle cerebral artery occlusion (MCAO) either immediately or 24 h after receiving IOX3. Mice receiving IOX3 at 20 mg/kg 24 h prior to the MCAO had better neuroscores and smaller blood-brain barrier (BBB) disruption and infarct volumes than mice receiving the vehicle, whereas those having IOX3 at 60 mg/kg showed no significant changes. IOX3 treatment immediately before MCAO was not neuroprotective. IOX3 up-regulated HIF-1α, and increased EPO expression in mouse brains. In an in vitro BBB model (RBE4 cell line), IOX3 up-regulated HIF-1α and delocalized ZO-1. Pre-treating IOX3 on RBE4 cells 24 h before oxygen-glucose deprivation had a protective effect on endothelial barrier preservation with ZO-1 being better localized, while immediate IOX3 treatment did not. Our study suggests that HIF stabilization with IOX3 before cerebral ischaemia is neuroprotective partially because of BBB protection, while immediate application could be detrimental. These results provide information for studies aimed at the therapeutic activation of HIF pathway for neurovascular protection from cerebral ischaemia. We show that IOX3, a selective small molecule (280.66 Da) HIF prolyl hydroxylase inhibitor, could up-regulate HIF-1α and increase erythropoietin expression in mice. We further demonstrate that HIF stabilization with IOX3 before cerebral ischaemia is neuroprotective partially because of blood-brain barrier (BBB) protection, while immediate application is detrimental both in vivo and in vitro. These findings provide new insights into the role of HIF stabilization in ischaemic stroke.

Strategies to reduce variation in the use of surgery.

Provision rates for surgery vary widely in relation to identifiable need, suggesting that reduction of this variation might be appropriate. The definition of unwarranted variation is difficult because the boundaries of acceptable practice are wide, and information about patient preference is lacking. Very little direct research evidence exists on the modification of variations in surgery rates, so inferences must be drawn from research on the alteration of overall rates. The available evidence has large gaps, which suggests that some proposed strategies produce only marginal change. Micro-level interventions target decision making that affects individuals, whereas macro-level interventions target health-care systems with the use of financial, regulatory, or incentivisation strategies. Financial and regulatory changes can have major effects on provision rates, but these effects are often complex and can include unintended adverse effects. The net effects of micro-level strategies (such as improvement of evidence and dissemination of evidence, and support for shared decision making) can be smaller, but better directed. Further research is needed to identify what level of variation in surgery rates is appropriate in a specific context, and how variation can be reduced where desirable.

Achieving behavior change at scale: Causal evidence from a national lifestyle intervention program for pre-diabetes in the UK.

There remains widespread doubt among clinicians that mere lifestyle advice and counseling provided in routine care can achieve improvements in health. We aimed to determine the health effects of the largest behavior change program for pre-diabetes globally (the English Diabetes Prevention Programme) when implemented at scale in routine care. We exploited the threshold in glycated hemoglobin (HbA1c) used to decide on program eligibility by applying a regression discontinuity design, one of the most credible quasi-experimental strategies for causal inference, to electronic health data from approximately one-fifth of all primary care practices in England. Program referral led to significant improvements in patients' HbA1c and body mass index. This analysis provides causal, rather than associational, evidence that lifestyle advice and counseling implemented in a national health system can achieve important health improvements.

Promoting the Success and Sustainability of Coordinated Specialty Care Teams in Ohio.

Recent COVID-19-related federal legislation has resulted in time-limited increases in Mental Health Block Grant (MHBG) set-aside dollars for coordinated specialty care (CSC) throughout the United States. The state of Ohio has opted to apply these funds to establish a learning health network of Ohio CSC teams, promote efforts to expand access to CSC, and quantify the operating costs and rates of reimbursement from private and public payers for these CSC teams. These efforts may provide other states with a model through which they can apply increased MHBG funds to support the success of their own CSC programs.

Survey of young women's state of knowledge and perceptions about oral contraceptives in Germany.

BACKGROUND: In Germany, we see a decline in the use of the oral contraceptive pill. Although there have been studies showing a lack of knowledge about the mode of action of the pill and alternative methods, the number of German women who feel well informed about the pill increased over recent years. At the same time, a trend to increasingly cover negative aspects of oral contraception has emerged in German journalism and social media. OBJECTIVE: This study aimed to consider the relationship between the source of information about the pill, subjective and objective knowledge, and how their interaction influences perceptions of the pill. STUDY DESIGN: An online survey was conducted of 18- to 29-year-old women to test their objective and subjective knowledge, their perception of oral contraceptives, and their trust in gynecologists. The recruitment took place online and in gynecologic practices. The survey opened in September 2020 and closed in April 2021. RESULTS: A total of 2470 women completed the survey. The most common sources of information were the internet (80%), the gynecologist (47%), and friends and family (47%). Women reporting the internet as a source of information were more likely to have lower perception and trust rates, and less likely to overestimate their own knowledge. The findings suggest that school or university as a source of information has a positive effect on decision-making and general attitude toward information received by gynecologists about oral contraceptives. Those with higher confidence in their knowledge are likely to have a more positive attitude and higher levels of trust. CONCLUSION: A feeling of uncertainty, instead of fixed assumptions gathered from unsophisticated sources, affects perception regarding oral contraceptives and trust toward gynecologists negatively. Gynecologists and educators should hence increase efforts to meet potential needs for discussing uncertainties to prevent further loss of confidence.

Use of lifestyle interventions in primary care for individuals with newly diagnosed hypertension, hyperlipidaemia or obesity: a retrospective cohort study.

OBJECTIVE: Lifestyle interventions can be efficacious in reducing cardiovascular disease risk factors and are recommended as first-line interventions in England. However, recent information on the use of these interventions in primary care is lacking. We investigated for how many patients with newly diagnosed hypertension, hyperlipidaemia or obesity, lifestyle interventions were recorded in their primary care electronic health record. DESIGN: A retrospective cohort study. SETTING: English primary care, using UK Clinical Practice Research Datalink. PARTICIPANTS: A total of 770,711 patients who were aged 18 years or older and received a new diagnosis of hypertension, hyperlipidaemia or obesity between 2010 and 2019. MAIN OUTCOME MEASURES: Record of lifestyle intervention and/or medication in 12 months before to 12 months after initial diagnosis (2-year timeframe). RESULTS: Analyses show varying results across conditions: While 55.6% (95% CI 54.9-56.4) of individuals with an initial diagnosis of hypertension were recorded as having lifestyle support (lifestyle intervention or signposting) within the 2-year timeframe, this number was reduced to 45.2% (95% CI 43.8-46.6) for hyperlipidaemia and 52.6% (95% CI 51.1-54.1) for obesity. For substantial proportions of individuals neither lifestyle support nor medication (hypertension: 12.2%, 95% CI 11.9-12.5; hyperlipidaemia: 32.2%, 95% CI 31.2-33.3; obesity: 43.9%, 95% CI 42.3-45.4) were recorded. Sensitivity analyses confirm that limited proportions of patients had lifestyle support recorded in their electronic health record before they were first prescribed medication (diagnosed and undiagnosed), ranging from 12.1% for hypertension to 19.7% for hyperlipidaemia, and 19.5% for obesity (23.4% if restricted to Orlistat). CONCLUSIONS: Limited evidence of lifestyle support for individuals with cardiovascular risk factors (hypertension, hyperlipidaemia, obesity) recommended by national guidelines in England may stem from poor recording in electronic health records but may also represent missed opportunities. Given the link between progression to cardiovascular disease and modifiable lifestyle factors, early support for patients to manage their conditions through non-pharmaceutical interventions by establishing lifestyle modification as first-line treatment is crucial.

Internet of things-Enabled technologies as an intervention for childhood obesity: A systematic review.

Childhood obesity is one of the most serious public health challenges of the 21st century, with consequences lasting into adulthood. Internet of Things (IoT)-enabled devices have been studied and deployed for monitoring and tracking diet and physical activity of children and adolescents as well as a means of providing remote, ongoing support to children and their families. This review aimed to identify and understand current advances in the feasibility, system designs, and effectiveness of IoT-enabled devices to support weight management in children. We searched Medline, PubMed, Web of Science, Scopus, ProQuest Central and the IEEE Xplore Digital Library for studies published after 2010 using a combination of keywords and subject headings related to health activity tracking, weight management, youth and Internet of Things. The screening process and risk of bias assessment were conducted in accordance with a previously published protocol. Quantitative analysis was conducted for IoT-architecture related findings and qualitative analysis was conducted for effectiveness-related measures. Twenty-three full studies are included in this systematic review. The most used devices were smartphone/mobile apps (78.3%) and physical activity data (65.2%) from accelerometers (56.5%) were the most commonly tracked data. Only one study embarked on machine learning and deep learning methods in the service layer. Adherence to IoT-based approaches was low but game-based IoT solutions have shown better effectiveness and could play a pivotal role in childhood obesity interventions. Researcher-reported effectiveness measures vary greatly amongst studies, highlighting the importance for improved development and use of standardised digital health evaluation frameworks.

Broadening the concept of patient safety culture through value-based healthcare.

PURPOSE: Decision-makers are looking for innovative approaches to improve patient experience and outcomes with the finite resources available in healthcare. The concept of value-based healthcare has been proposed as one such approach. Since unsafe care hinders patient experience and contributes to waste, the purpose of this paper is to investigate how the value-based approach can help broaden the existing concept of patient safety culture and thus, improve patient safety and healthcare value. DESIGN/METHODOLOGY/APPROACH: In the arguments, the authors use the triple value model which consists of personal, technical and allocative value. These three aspects together promote healthcare in which the experience of care is improved through the involvement of patients, while also considering the optimal utilisation and allocation of finite healthcare resources. FINDINGS: While the idea that patient involvement should be integrated into patient safety culture has already been suggested, there is a lack of emphasis that economic considerations can play an important role as well. Patient safety should be perceived as an investment, thus, relevant questions need to be addressed such as how much resources should be invested into patient safety, how the finite resources should be allocated to maximise health benefits at a population level and how resources should be utilised to get the best cost-benefit ratio. ORIGINALITY/VALUE: Thus far, both the importance of patient safety culture and value-based healthcare have been advocated; this paper emphasizes the need to consider these two approaches together.

Molecular basis of CD4 repression by the Swi/Snf-like BAF chromatin remodeling complex.

The Brg1/Brm-associated factor (BAF) chromatin remodeling complex directly binds the CD4 silencer and is essential for CD4 repression during T-cell development, because deletion of the ATPase subunit Brg1 or a dominant negative mutant of BAF57 each impairs CD4 repression in early thymocytes. Paradoxically, BAF57 is dispensable for remodeling nucleosomes in vitro or for binding of the BAF complex to the CD4 silencer in vivo. Thus, it is unclear whether BAF57-dependent CD4 repression involves chromatin remodeling and, if so, how the remodeling translates into CD4 repression. Here we show that nucleosomes at the CD4 silencer occupy multiple translational frames. BAF57 dominant negative mutant does not alter these frames, but reduces the accessibility of the entire silencer without affecting the flanking regions, concomitant with localized accumulation of linker histone H1 and eviction of Runx1, a key repressor of CD4 transcription that directly binds the CD4 silencer. Our data indicate that precise nucleosome positioning is not critical for the CD4 silencer function and that BAF57 participates in remodeling H1-containing chromatin at the CD4 silencer, which enables Runx1 to access the silencer and repress CD4. In addition to BAF57, multiple other subunits in the BAF complex are also dispensable for chromatin remodelling in vitro. Our data suggest that these subunits could also help remodel chromatin at a step after the recruitment of the BAF complex to target genes.

Use and impact of social prescribing: a mixed-methods feasibility study protocol.

INTRODUCTION: Social prescribing aims to address social determinants of health, which account for 80%-90% of health outcomes, but the evidence base behind it is limited due to a lack of data linkingsocial prescribing activity and outcomes. METHODS AND ANALYSIS: The objective of the quantitative component of this feasibility studyisto identify the characteristics of individuals who receive social prescriptions and describe the use and estimate the impact of social prescribing; the latter will be done on a homeless subgroup. We will use the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care sentinel network, whose general practicescover a population of over 4 000 000 patients. Social prescribing data will be extracted onall recorded patients for 5 years up to 31 January 2020. The objective for the qualitative component of the study isto explore approaches to understand the contextual factors that will have influenced our quantitative findings to identify mechanisms to encourage adoption of social prescribing in primary care while improving data quality. Itwill comprise up to three 90-120 minute advisory group meetings for six to eight participants. Participants will be recruited based on their experience of delivering primary care within Oxfordshire and Surrey. The advisory group outputs will be analysed using framework analysis and will be used to create a survey instrument consisting of statements that surveyees, who will consist of primary care practitioners within the RCGP RSC, can agree or disagree with. ETHICS AND DISSEMINATION: All RCGP RSC data are pseudonymised at the point of data extraction. No personally identifiable data are required for this investigation. This protocol follows the Good Reporting of a Mixed Methods Study checklist. The study results will be published in a peer-reviewed journal and the dataset will be available to other researchers.

The use of PROMs and shared decision-making in medical encounters with patients: An opportunity to deliver value-based health care to patients.

BACKGROUND: The recent emphasis on value-based health care (VBHC) is thought to provide new opportunities for shared decision-making (SDM) in the Netherlands, especially when using patient-reported outcome measures (PROMs) in routine medical encounters. It is still largely unclear about how PROMs could be linked to SDM and what we expect from clinicians in this respect. AIM: To describe approaches and lessons learned in the fields of SDM and VBHC implementation that converge in using PROMs in medical encounters. APPROACH: Based on input from three Dutch forerunner case examples and available evidence about SDM and VBHC, we describe barriers and facilitators regarding the use of PROMs and SDM in the medical encounter. Barriers and facilitators were structured according to a conversational model that included monitoring and managing, team talk, option talk, choice talk, and decision talk. Key lessons learned and recommendations were synthesized. RESULTS: The use of individual, N = 1 PROMs scores in the medical encounter has been largely achieved in the forerunner projects. Conversation on monitoring and managing is relatively well implemented, and option talk to some extent, unlike team talk, and decision talk. Aggregated PROMs information describing outcomes of treatment options seemed to be scarcely used. Experienced barriers largely corresponded to what is known from the literature, eg, perceived lack of time and lack of tools summarizing the options. Some concerns were identified about increasing health care consumption as a result of using PROMs and SDM in the medical encounter. CONCLUSION: Successful implementation of SDM within VBHC initiatives may not be self-evident, even though individual, N = 1 PROMs scores are being used in the medical encounter. Education and staff resources on meso and macro levels may facilitate the more time-consuming SDM aspects. It seems fruitful to especially target team talk and choice talk in redesigning clinical pathways.