Improving diabetes care in a large health care system: an enhanced primary care approach

OBJECTIVE: The objective of this study was to evaluate the impact of a multifaceted improvement strategy on diabetes quality of care in a defined population of patients. STUDY DESIGN: A multifaceted improvement strategy to enhance diabetes care was deployed to 18 primary care clinics serving 170,000 adults. Interventions empowered patient self-management, supported care team decision making, redesigned office systems, and maximized use of available information technology. Specific goals were to improve glycemic control and reduce cardiovascular risk in all adult diabetes patients. DATA SOURCE AND COLLECTION: Diabetes was identified through pharmacy and diagnostic data (estimated sensitivity 0.91, positive predictive value 0.94), and the target population ranged from 6,542 to 7,037 members over time. Trends in glycosylated hemoglobin (HbA1c) and low-density lipid LDL-cholesterol were analyzed monthly throughout 1999 in both cohorts and serial cross-sections. RESULTS: During 12 months, mean HbA1c improved from 7.86% to 7.47%, and the proportion of patients with HbA1c levels < 8% rose from 60.5% to 68.3%, and the proportion with HbA1c > 10% fell from 10.3% to 7.2%. The LDL test rate rose from 47.4% to 57.4%, and mean LDL fell from 120 mg/dl to 116 mg/dl. The proportion with acceptable lipid control (LDL < 130 mg/dl, or < 100 mg/dl with coronary artery disease) rose from 48.9% to 57.7%. All changes were significant at p < 0.01 or less. CONCLUSION: Clinically significant population-based improvements in diabetes care were observed during a 1-year period using a multifaceted "enhanced primary care" strategy.     

Exploring the possibility of a common structural model measuring associations between safety climate factors and safety behaviour in health care and the petroleum sectors

The aim of the present study was to explore the possibility of identifying general safety climate concepts in health care and petroleum sectors, as well as develop and test the possibility of a common cross-industrial structural model. Self-completion questionnaire surveys were administered in two organisations and sectors: (1) a large regional hospital in Norway that offers a wide range of hospital services, and (2) a large petroleum company that produces oil and gas worldwide. In total, 1919 and 1806 questionnaires were returned from the hospital and petroleum organisation, with response rates of 55 percent and 52 percent, respectively. Using a split sample procedure principal factor analysis and confirmatory factor analysis revealed six identical cross-industrial measurement concepts in independent samples—five measures of safety climate and one of safety behaviour. The factors’ psychometric properties were explored with satisfactory internal consistency and concept validity. Thus, a common cross-industrial structural model was developed and tested using structural equation modelling (SEM). SEM revealed that a cross-industrial structural model could be identified among health care workers and offshore workers in the North Sea. The most significant contributing variables in the model testing stemmed from organisational management support for safety and supervisor/manager expectations and actions promoting safety. These variables indirectly enhanced safety behaviour (stop working in dangerous situations) through transitions and teamwork across units, and teamwork within units as well as learning, feedback, and improvement. Two new safety climate instruments were validated as part of the study: (1) Short Safety Climate Survey (SSCS) and (2) Hospital Survey on Patient Safety Culture-short (HSOPSC-short). Based on development of measurements and structural model assessment, this study supports the possibility of a common safety climate structural model across health care and the offshore petroleum industry.     

Therapeutic nanoreactors: combining chemistry and biology in a novel triblock copolymer drug delivery system

Triblock copolymeric nanoreactors are introduced as an alternative for liposomes as encapsulating carrier for prodrug activating enzymes. Inosine-adenosine-guanosine preferring nucleoside hydrolase of Trypanosoma vivax, a potential prodrug activating enzyme, was encapsulated in nanometer-sized vesicles constructed of poly(2-methyloxazoline)-block-poly(dimethylsiloxane)-block-(2-methyloxazoline) triblock copolymers. The nanoreactor is functionalized by incorporation of bacterial porins, OmpF or Tsx, in the reactor wall. Efficient cleavage of three natural substrates and one prodrug, 2-fluoroadenosine, by the nanoreactors was demonstrated.     

Coaching and leadership for the diffusion of innovation in health care: a different type of multi-organization improvement collaborative

BACKGROUND: Health care organizations have suffered a steady decrease in operating margins in recent years while facing increased competition and pressure to provide ever-higher levels of customer service, quality of care, and innovation in delivery methodologies. The ability to rapidly find and implement changes that will lead to strategic improvement is critical. To assist member organizations in dealing with these issues, VHA Upper Midwest launched the Coaching and Leadership Initiative (VHA-CLI) in January 1999. The initiative was intended to develop new methods of collaborating for organizational learning of best practices, with a focus on generalizable change and deliberate leadership supports for deployment, diffusion, and sustainability. The emphasis was on the spread of ideas for improvement into all relevant corners of the organization. STRUCTURE AND PROCESS OF THE COLLABORATIVE: The structure of the VHA-CLI collaborative involved four waves of demonstration teams during 2 years. Each meeting of the collaborative included an executive session, team learning sessions (concepts applied to their improvement projects), and planning for the 6-month action period following the meeting. An important feature of the collaborative is the way in which teams in the various waves overlapped. For example, the Wave 1 team for a given organization came to a learning session in January 1999. At the second collaborative meeting in June 1999, the Wave 1 teams reported on the progress in their pilot sites. This meeting was also the kick-off session for the Wave 2 teams, which could learn about organizational culture and the improvement model from the efforts of their colleagues on Wave 1. Wave 1 teams also learned about and planned for spreading their efforts to other sites beyond the pilot. The pattern of multiple teams stretching across two waves of activity was repeated at every meeting of the collaborative. SUCCESS: Each organization in the collaborative has achieved improved outcomes around its selected clinical topics. In total, 26 teams have made significant improvement in 17 different topic areas. In addition, each organization has been able to successfully spread tested improvements to other individuals, teams, or locations, and the improvement work has become easier and more rapid with each successive cycle. CONCLUSIONS: The learning process initiated by this project will continue for at least another year in the VHA Upper Midwest region and will be expanded as participating organizations in other regions enroll in the VHA's national effort.     

The effects on safety, time consumption and environment of large scale use of roundabouts in an urban area: a case study

An experiment with small roundabouts-as speed reducing measures-was carried out in a Swedish city. The purpose of the study was to test the large scale and long term effects of the roundabouts. The results showed that the roundabouts reduced the speed considerably at the junctions and on links between roundabouts. The lateral displacement the roundabout forces the driver to has a great importance for the speed of approaching cars to a roundabout. The speed-reducing effect is large already at a 2 m deflection. A larger deflection does not result in a larger effect. Conflict studies indicated an overall decrease in accident risk by 44%. Vulnerable road-users' risk was reduced significantly, while there was no reduction for car occupants. There is a relation between the reduction of approach speed and the reduction of injury accident risk. The time consumption at a time operated signal was reduced heavily by the instalment of a roundabout at a signalised intersection. On average, emissions (CO and NOx) at roundabouts replacing non-signalised junctions increased by between 4 and 6%, while a roundabout replacing a signalised intersection led to a reduction by between 20 and 29%. The noise level was reduced at junctions that were provided with roundabout. Car drivers were less positive to the roundabouts than bicyclists. In the long term, the unchanged roundabouts worked almost as good as they did shortly after the rebuilding. The study showed that details in the design are of decisive importance for road-users' safety. Special attention has to be paid to the situation of bicyclists. The transition between the cycle path/lane and the junction has to be designed with care-the bicyclists should be integrated with motorised traffic before they enter the roundabout. There should be only one car lane both on the approach, in the circulating area and on the exit. The size of the roundabout shall be as small as possible.     

Integration of occupational health and safety in the facility layout planning,part II: design of the kitchen of a hospital

Facility layout design has an important effect on the performance of manufacturing systems. It intends to determine relative location of departments and machines within a plant. A good layout design must ensure that a set of criteria and objectives are met and optimised, e.g. area requirements, cost, communication and safety. The most common objective used in facility planning methods is to minimise the transportation cost. However, factors such as the plant safety, flexibility for future design changes, noise and aesthetics must be considered as well. In this paper, a case study is carried out to investigate the safety concerns in facility layout design. In this regard, a facility layout planning methodology, integrating occupational health and safety (OHS) is presented. This methodology considers transportation cost as well as safety in the facility design. By this means, OHS issues are considered at the design stage of the facility. In other words, this research demonstrates the improvements in the layout design by integrating safety aspects.     

Bioactive borate glass scaffolds: in vitro and in vivo evaluation for use as a drug delivery system in the treatment of bone infection

The objective of this work was to evaluate borate bioactive glass scaffolds (with a composition in the system Na₂O–K₂O–MgO–CaO–B₂O₃–P₂O₅) as devices for the release of the drug Vancomycin in the treatment of bone infection. A solution of ammonium phosphate, with or without dissolved Vancomycin, was used to bond borate glass particles into the shape of pellets. The in vitro degradation of the pellets and their conversion to a hydroxyapatite-type material in a simulated body fluid (SBF) were investigated using weight loss measurements, chemical analysis, X-ray diffraction, and scanning electron microscopy. The results showed that greater than 90% of the glass in the scaffolds degraded within 1 week, to form poorly crystallized hydroxyapatite (HA). Pellets loaded with Vancomycin provided controlled release of the drug over 4 days. Vancomycin-loaded scaffolds were implanted into the right tibiae of rabbits infected with osteomyelitis. The efficacy of the treatment was assessed using microbiological examination and histology. The HA formed in the scaffolds in vivo, resulting from the conversion of the glass, served as structure to support the growth of new bone and blood vessels. The results in this work indicate that bioactive borate glass could provide a promising biodegradable and bioactive material for use as both a drug delivery system and a scaffold for bone repair.     

Acrylic resins as rate-controlling membranes in novel formulation of a nine-day 17beta-estradiol transdermal delivery system: in vitro and release modifier effect evaluation.

The feasibility of transdermal controlled delivery system of 17beta-estradiol was investigated by conducting in vitro release studies. Several new 17beta-estradiol unilaminate adhesive devices capable of releasing 17beta-estradiol in a controlled fashion over a 24-h, 36-h, 96-h, 104-h, 168-h, and 216-h period have been developed using acrylic resins (Eudragits E100, RSPO, and RLPO) as adhesive and rate-controlling polymers. The in vitro release profiles of 17beta-estradiol from various TDS unilaminate devices were characterized in a new developed dissolution tester vessel (total volume 200 ml), using a new paddle. The release of drug from different formulations was measured by a sensitive high-performance liquid chromatographic (HPLC) method. The release of drug from all prepared adhesive devices seems to obey zero-order kinetics (r > 0.98). The effect of two different plasticizers (acetyltriburyl citrate [ATBC] and triethyl citrate [TEC]) on the release patterns of 17beta-estradiol from TDS formulations was studied, and they were almost identical. The effect of two different release modifiers, propylene glycol (PG) and myristic acid (MA), on the release pattern of 17beta-estradiol from prepared unilaminate devices was evaluated. It was shown that the use of these release modifiers significantly increased the release of 17beta-estradiol from a TDS unilaminate patch. Furthermore, these data clearly demonstrated that the acrylic resins are suitable polymers for the preparation of 17beta-estradiol TDS adhesive devices.     

The Strength and Compaction of Millispheres: The design of a controlled-release drug delivery system for ibuprofen in the form of a tablet comprising compacted polymer-coated millispheres

Abstract

This paper reviews a case study of the design of a controlled-release drug delivery system for ibuprofen in the form of a tablet comprising compacted polymer-coated millispheres (multiparticulate pellets). The particular challenge was to prepare coated millispheres of ibuprofen (a high-dose drug) with the addition of minimal excipients so that the drug-release retarding polymeric membrane surrounding the millispheres remains intact during and after tablet compression, disintegration and release of the millispheres. The study included (a) the design of the uncoated core and its manufacture by wet massing, extrusion, spheronization and drying; (b) the coating of these millispheres with a range of possibly suitable polymers; (c) an assessment of the drug release profiles from these pellets; (d) the quantification by indentation rheology of the mechanical properties of the polymer films used to coat the spheres; (e) the measurement of the mechanical properties of individual uncoated and coated millispheres and f. the design, manufacture and evaluation of compressed tablets containing coated millispheres

The matching of millisphere and polymer mechanical properties was found to be essential in order to ensure minimal damage to the millispheres and the release of virtually intact coated spheres without destruction of their retarded drug-release characteristics. Aqueous polymeric dispersions which formed a film with similar elastic and tensile properties to the uncoated millisphere formulation resulted in the most satisfactory film coating for application to spherical particles which must withstand compaction. Those polymeric films exhibiting significantly greater resilience than the uncoated cores were inappropriate for the film coating of millispheres for compaction into tablets     

The Strength and Compaction of Millispheres: The design of a controlled-release drug delivery system for ibuprofen in the form of a tablet comprising compacted polymer-coated millispheres

This paper reviews a case study of the design of a controlled-release drug delivery system for ibuprofen in the form of a tablet comprising compacted polymer-coated millispheres (multiparticulate pellets). The particular challenge was to prepare coated millispheres of ibuprofen (a high-dose drug) with the addition of minimal excipients so that the drug-release retarding polymeric membrane surrounding the millispheres remains intact during and after tablet compression, disintegration and release of the millispheres. The study included (a) the design of the uncoated core and its manufacture by wet massing, extrusion, spheronization and drying; (b) the coating of these millispheres with a range of possibly suitable polymers; (c) an assessment of the drug release profiles from these pellets; (d) the quantification by indentation rheology of the mechanical properties of the polymer films used to coat the spheres; (e) the measurement of the mechanical properties of individual uncoated and coated millispheres and f. the design, manufacture and evaluation of compressed tablets containing coated millispheres

The matching of millisphere and polymer mechanical properties was found to be essential in order to ensure minimal damage to the millispheres and the release of virtually intact coated spheres without destruction of their retarded drug-release characteristics. Aqueous polymeric dispersions which formed a film with similar elastic and tensile properties to the uncoated millisphere formulation resulted in the most satisfactory film coating for application to spherical particles which must withstand compaction. Those polymeric films exhibiting significantly greater resilience than the uncoated cores were inappropriate for the film coating of millispheres for compaction into tablets     

The development of a naturalistic data collection system to perform critical incident analysis: an investigation of safety and fatigue issues in long-haul trucking

Traditionally, both epidemiological and empirical methods have been used to assess driving safety. This paper describes an alternative, hybrid, naturalistic approach to data collection that shares advantages with each traditional approach. Though this naturalistic approach draws on elements of several safety techniques that have been developed in the past, including the Hazard Analysis Technique, instrumented vehicle studies, and fleet studies of driving safety interventions, it has a number of unique elements. Sophisticated instrumented vehicles collected over 400,000 km of commercial vehicle data to address the long-haul trucking application described in this paper. The development of this data collection and analysis method and data collection instrumentation has resulted in a set of valuable tools to advance the current state-of-the-practice in driving safety assessment. An application of this unique approach to a study of long-haul truck driver performance, behavior, and fatigue is described herein.     

Comparison of simple Eudragit microparticles loaded with prednisolone and Eudragit-coated chitosan-succinyl-prednisolone conjugate microparticles: Part I. Particle characteristics and in vitro evaluation as a colonic delivery system

Objective: Simple Eudragit microparticles loaded with prednisolone and chitosan-succinyl-prednisolone conjugate microparticles coated with Eudragit were prepared and characterized in vitro in order to obtain their basic features as a colonic delivery system.

Materials and methods: Both types of microparticles were prepared by the emulsification-solvent evaporation modified somewhat from the previous one. Their particle size, shape and their drug content were investigated, and in vitro release profiles were examined using JP-15 1st fluid (pH 1.2), JP-15 2nd fluid (pH 6.8) and PBS (pH 7.4) as release media. Furthermore, the regeneration of conjugate microparticles from Eudragit-coated microparticles was investigated under the same incubation conditions.

Results: Simple Eudragit S100 (EuS) microparticles (ES-M) were almost spherical, ca. 1.2 μm diameter, and PD content ca. 3.7% (w/w). Conjugate microparticles (CS-M1) and EuS-coated conjugate microparticles (CS-M1/S) had particle sizes of ca. 2.8 and 15.3 μm, respectively, and PD contents of 5.4 and 2.1% (w/w), respectively. ES-M exhibited suppressed release at pH 1.2, gradual release at pH 6.8 and rapid release at pH 7.4. CS-M1 showed no release at pH 1.2, and very slow release at pH 6.8 and 7.4. CS-M1 regenerated poorly from CS-M1/S at pH 6.8.

Conclusions: Simple Eudragit micrparticles and Eudragit-caoted conjugate microparticles, prepared by the present methods, were found in vitro to be possibly useful as the delivery systems of PD to the lower intestine, although there were differences in their release rate and morphological features.