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1.  Model-driven approach to data collection and reporting for quality improvement 
Graphical abstract
Highlights
•Addressing the challenge of the second translational gap is key to improving healthcare processes.•Data-driven methodologies improve likelihood of success.•We propose the Improvement Data Model (IDM) for data collection and reporting for local improvement.•WISH, a prototype software tool based on IDM is used by over 600 users in 50+ improvement projects.
Continuous data collection and analysis have been shown essential to achieving improvement in healthcare. However, the data required for local improvement initiatives are often not readily available from hospital Electronic Health Record (EHR) systems or not routinely collected. Furthermore, improvement teams are often restricted in time and funding thus requiring inexpensive and rapid tools to support their work. Hence, the informatics challenge in healthcare local improvement initiatives consists of providing a mechanism for rapid modelling of the local domain by non-informatics experts, including performance metric definitions, and grounded in established improvement techniques. We investigate the feasibility of a model-driven software approach to address this challenge, whereby an improvement model designed by a team is used to automatically generate required electronic data collection instruments and reporting tools. To that goal, we have designed a generic Improvement Data Model (IDM) to capture the data items and quality measures relevant to the project, and constructed Web Improvement Support in Healthcare (WISH), a prototype tool that takes user-generated IDM models and creates a data schema, data collection web interfaces, and a set of live reports, based on Statistical Process Control (SPC) for use by improvement teams. The software has been successfully used in over 50 improvement projects, with more than 700 users. We present in detail the experiences of one of those initiatives, Chronic Obstructive Pulmonary Disease project in Northwest London hospitals. The specific challenges of improvement in healthcare are analysed and the benefits and limitations of the approach are discussed.
doi:10.1016/j.jbi.2014.04.014
PMCID: PMC4266541  PMID: 24874182
D2.1 (Software engineering) requirements/specification J.3 (life and medical sciences): Health model-driven architectures; Healthcare analytics; Quality improvement; Data collection; Metrics; Performance analytics
2.  Improving mental health outcomes: achieving equity through quality improvement 
Objective
To investigate equity of patient outcomes in a psychological therapy service, following increased access achieved by a quality improvement (QI) initiative.
Design
Retrospective service evaluation of health outcomes; data analysed by ANOVA, chi-squared and Statistical Process Control.
Setting
A psychological therapy service in Westminster, London, UK.
Participants
People living in the Borough of Westminster, London, attending the service (from either healthcare professional or self-referral) between February 2009 and May 2012.
Intervention(s)
Social marketing interventions were used to increase referrals, including the promotion of the service through local media and through existing social networks.
Main Outcome Measure(s)
(i) Severity of depression on entry using Patient Health Questionnaire-9 (PHQ9). (ii) Changes to severity of depression following treatment (ΔPHQ9). (iii) Changes in attainment of a meaningful improvement in condition assessed by a key performance indicator.
Results
Patients from areas of high deprivation entered the service with more severe depression (M = 15.47, SD = 6.75), compared with patients from areas of low (M = 13.20, SD = 6.75) and medium (M = 14.44, SD = 6.64) deprivation. Patients in low, medium and high deprivation areas attained similar changes in depression score (ΔPHQ9: M = −6.60, SD = 6.41). Similar proportions of patients achieved the key performance indicator across initiative phase and deprivation categories.
Conclusions
QI methods improved access to mental health services; this paper finds no evidence for differences in clinical outcomes in patients, regardless of level of deprivation, interpreted as no evidence of inequity in the service with respect to this outcome.
doi:10.1093/intqhc/mzu005
PMCID: PMC3979278  PMID: 24521701
quality improvement; mental health; public health; inequalities; outcome assessment (health care)
3.  The diversity and biogeography of the Coleoptera of Churchill: insights from DNA barcoding 
BMC Ecology  2013;13:40.
Background
Coleoptera is the most diverse order of insects (>300,000 described species), but its richness diminishes at increasing latitudes (e.g., ca. 7400 species recorded in Canada), particularly of phytophagous and detritivorous species. However, incomplete sampling of northern habitats and a lack of taxonomic study of some families limits our understanding of biodiversity patterns in the Coleoptera. We conducted an intensive biodiversity survey from 2006–2010 at Churchill, Manitoba, Canada in order to quantify beetle species diversity in this model region, and to prepare a barcode library of beetles for sub-arctic biodiversity and ecological research. We employed DNA barcoding to provide estimates of provisional species diversity, including for families currently lacking taxonomic expertise, and to examine the guild structure, habitat distribution, and biogeography of beetles in the Churchill region.
Results
We obtained DNA barcodes from 3203 specimens representing 302 species or provisional species (the latter quantitatively defined on the basis of Molecular Operational Taxonomic Units, MOTUs) in 31 families of Coleoptera. Of the 184 taxa identified to the level of a Linnaean species name, 170 (92.4%) corresponded to a single MOTU, four (2.2%) represented closely related sibling species pairs within a single MOTU, and ten (5.4%) were divided into two or more MOTUs suggestive of cryptic species. The most diverse families were the Dytiscidae (63 spp.), Staphylinidae (54 spp.), and Carabidae (52 spp.), although the accumulation curve for Staphylinidae suggests that considerable additional diversity remains to be sampled in this family. Most of the species present are predatory, with phytophagous, mycophagous, and saprophagous guilds being represented by fewer species. Most named species of Carabidae and Dytiscidae showed a significant bias toward open habitats (wet or dry). Forest habitats, particularly dry boreal forest, although limited in extent in the region, were undersampled.
Conclusions
We present an updated species list for this region as well as a species-level DNA barcode reference library. This resource will facilitate future work, such as biomonitoring and the study of the ecology and distribution of larvae.
doi:10.1186/1472-6785-13-40
PMCID: PMC3819705  PMID: 24164967
Barcode library; Barcoding biotas; Boreal-arctic transition; COI; Cytochrome c oxidase subunit I; DNA barcoding; Freshwater; Terrestrial; Subarctic forest
4.  Making change last: applying the NHS institute for innovation and improvement sustainability model to healthcare improvement 
The implementation of evidence-based treatments to deliver high-quality care is essential to meet the healthcare demands of aging populations. However, the sustainable application of recommended practice is difficult to achieve and variable outcomes well recognised. The NHS Institute for Innovation and Improvement Sustainability Model (SM) was designed to help healthcare teams recognise determinants of sustainability and take action to embed new practice in routine care. This article describes a formative evaluation of the application of the SM by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for Northwest London (CLAHRC NWL).
Data from project teams’ responses to the SM and formal reviews was used to assess acceptability of the SM and the extent to which it prompted teams to take action. Projects were classified as ‘engaged,’ ‘partially engaged’ and ‘non-engaged.’ Quarterly survey feedback data was used to explore reasons for variation in engagement. Score patterns were compared against formal review data and a ‘diversity of opinion’ measure was derived to assess response variance over time.
Of the 19 teams, six were categorized as ‘engaged,’ six ‘partially engaged,’ and seven as ‘non-engaged.’ Twelve teams found the model acceptable to some extent. Diversity of opinion reduced over time. A minority of teams used the SM consistently to take action to promote sustainability but for the majority SM use was sporadic. Feedback from some team members indicates difficulty in understanding and applying the model and negative views regarding its usefulness.
The SM is an important attempt to enable teams to systematically consider determinants of sustainability, provide timely data to assess progress, and prompt action to create conditions for sustained practice. Tools such as these need to be tested in healthcare settings to assess strengths and weaknesses and findings disseminated to aid development. This study indicates the SM provides a potentially useful approach to measuring teams’ views on the likelihood of sustainability and prompting action. Securing engagement of teams with the SM was challenging and redesign of elements may need to be considered. Capacity building and facilitation appears necessary for teams to effectively deploy the SM.
doi:10.1186/1748-5908-8-127
PMCID: PMC3827618  PMID: 24160758
Sustainability; Implementation
5.  The Role of Markers of Inflammation in Traumatic Brain Injury 
Within minutes of a traumatic impact, a robust inflammatory response is elicited in the injured brain. The complexity of this post-traumatic squeal involves a cellular component, comprising the activation of resident glial cells, microglia, and astrocytes, and the infiltration of blood leukocytes. The second component regards the secretion immune mediators, which can be divided into the following sub-groups: the archetypal pro-inflammatory cytokines (Interleukin-1, Tumor Necrosis Factor, Interleukin-6), the anti-inflammatory cytokines (IL-4, Interleukin-10, and TGF-beta), and the chemotactic cytokines or chemokines, which specifically drive the accumulation of parenchymal and peripheral immune cells in the injured brain region. Such mechanisms have been demonstrated in animal models, mostly in rodents, as well as in human brain. Whilst the humoral immune response is particularly pronounced in the acute phase following Traumatic brain injury (TBI), the activation of glial cells seems to be a rather prolonged effect lasting for several months. The complex interaction of cytokines and cell types installs a network of events, which subsequently intersect with adjacent pathological cascades including oxidative stress, excitotoxicity, or reparative events including angiogenesis, scarring, and neurogenesis. It is well accepted that neuroinflammation is responsible of beneficial and detrimental effects, contributing to secondary brain damage but also facilitating neurorepair. Although such mediators are clear markers of immune activation, to what extent cytokines can be defined as diagnostic factors reflecting brain injury or as predictors of long term outcome needs to be further substantiated. In clinical studies some groups reported a proportional cytokine production in either the cerebrospinal fluid or intraparenchymal tissue with initial brain damage, mortality, or poor outcome scores. However, the validity of cytokines as biomarkers is not broadly accepted. This review article will discuss the evidence from both clinical and laboratory studies exploring the validity of immune markers as a correlate to classification and outcome following TBI.
doi:10.3389/fneur.2013.00018
PMCID: PMC3586682  PMID: 23459929
traumatic brain injury; biomarkers; inflammation; cytokines; chemokines
6.  DNA barcoding reveals diversity of Hymenoptera and the dominance of parasitoids in a sub-arctic environment 
BMC Ecology  2013;13:2.
Background
Insect diversity typically declines with increasing latitude, but previous studies have shown conflicting latitude-richness gradients for some hymenopteran parasitoids. However, historical estimates of insect diversity and species richness can be difficult to confirm or compare, because they may be based upon dissimilar methods. As a proxy for species identification, we used DNA barcoding to identify molecular operational taxonomic units (MOTUs) for 7870 Hymenoptera specimens collected near Churchill, Manitoba, from 2004 through 2010.
Results
We resolved 1630 MOTUs for this collection, of which 75% (1228) were ichneumonoids (Ichneumonidae + Braconidae) and 91% (1484) were parasitoids. We estimate the total number of Hymenoptera MOTUs in this region at 2624-2840.
Conclusions
The diversity of parasitoids in this sub-Arctic environment implies a high diversity of potential host species throughout the same range. We discuss these results in the contexts of resolving interspecific interactions that may include cryptic species, and developing reproducible methods to estimate and compare species richness across sites and between surveys, especially when morphological specialists are not available to identify every specimen.
doi:10.1186/1472-6785-13-2
PMCID: PMC3565895  PMID: 23351160
Barcoding biotas; Biodiversity; DNA barcoding; Hymenoptera; Sub-Arctic; Parasitoids; Canada
7.  Statistical process control for data without inherent order 
Background
The XmR chart is a powerful analytical tool in statistical process control (SPC) for detecting special causes of variation in a measure of quality. In this analysis a statistic called the average moving range is used as a measure of dispersion of the data. This approach is correct for data with natural underlying order, such as time series data. There is however conflict in the literature over the appropriateness of the XmR chart to analyse data without an inherent ordering.
Methods
We derive the maxima and minima for the average moving range in data without inherent ordering, and show how to calculate this for any data set. We permute a real world data set and calculate control limits based on these extrema.
Results
In the real world data set, permuting the order of the data affected an absolute difference of 109 percent in the width of the control limits.
Discussion
We prove quantitatively that XmR chart analysis is problematic for data without an inherent ordering, and using real-world data, demonstrate the problem this causes for calculating control limits. The resulting ambiguity in the analysis renders it unacceptable as an approach to making decisions based on data without inherent order.
Conclusion
The XmR chart should only be used for data endowed with an inherent ordering, such as a time series. To detect special causes of variation in data without an inherent ordering we suggest that one of the many well-established approaches to outlier analysis should be adopted. Furthermore we recommend that in all SPC analyses authors should consistently report the type of control chart used, including the measure of variation used in calculating control limits.
doi:10.1186/1472-6947-12-86
PMCID: PMC3464151  PMID: 22867269
Statistical process control (SPC); Individual and moving range (XmR); Ordering of data
8.  Designing and implementing a COPD discharge care bundle 
Thorax  2011;67(1):90-92.
National surveys have revealed significant differences in patient outcomes following admission to hospital with acute exacerbation of COPD which are likely to be due to variations in care. We developed a care bundle, comprising a short list of evidence-based practices to be implemented prior to discharge for all patients admitted with this condition, based on a review of national guidelines and other relevant literature, expert opinion and patient consultation. Implementation was then piloted using action research methodologies with patient input. Actively involving staff was vital to ensure that the changes introduced were understood and the process followed. Implementation of a care bundle has the potential to produce a dramatic improvement in compliance with optimum health care practice.
doi:10.1136/thoraxjnl-2011-200233
PMCID: PMC3240777  PMID: 21846790
Acute exacerbation; quality improvement; pulmonary rehabilitation; smoking cessation; COPD pathology; lung physiology; lung volume reduction surgery; respiratory measurement; respiratory muscles; asthma epidemiology; asthma in primary care; COPD epidemiology; COPD exacerbations; emphysema; pulmonary rehabilitation; non-invasive ventilation; pulmonary embolism; COPD mechanisms; asthma; asthma mechanisms; cough/mechanisms/pharmacology; empyema; mesothelioma; pleural disease

Results 1-8 (8)