User redesign, testing and evaluation of the Monitoring Risk and Improving System Safety (MoRISS) checklist for the general practice work environment.

BACKGROUND: Inadequate checking of safety-critical issues can compromise care quality in general practice (GP) work settings. Adopting a systemic, methodical approach may lead to improved standardisation of processes and reliability of task performance, strengthening the safety systems concerned. This study aimed to revise, modify and test the content and relevance of a previously validated safety checklist to the current GP context. METHODS: A multimethod study was undertaken in Scottish GP involving: consensus building workshops with users and 'experts' to revise checklist content; regional testing of the modified checklist and follow-up usability evaluation survey of users. Quantitative data underwent descriptive statistical analyses and selected survey free-text comments are presented. RESULTS: A redesigned checklist tool consisting of eight themes (eg, medication safety) and 61 items (eg, out-of-date stock is appropriately disposed) was agreed by 53 users/experts with items reclassified as: mandatory (n=25), essential (n=24) and advisory (n=12). Totally 42/55 GPs tested the tool and submitted checklist data (76.4%). The mean aggregated results demonstrated 92.0% compliance with all 61 checklist items (range: 83.0%-98.0%) and 25/42 GP managers responded to the survey (59.5%) and reported high mean levels of agreement on the usefulness of the checklist (77.0%), ease of use (89.0%), learnability (94.0%) and satisfaction (78.4%). CONCLUSIONS: The checklist was comprehensively redesigned as a practical safety monitoring and improvement tool for potential implementation in Scottish GP. Testing and evaluation demonstrated high levels of checklist content compliance and strong usability feedback, but some variation was evident indicating room for improvement in current safety-critical checking processes. The checklist should be of interest in similar GP settings internationally and to other areas of primary care practice.

Genetic basis for skin youthfulness.

Aging skin is a consequence of both intrinsic factors, including genetics, and extrinsic factors, including environmental exposures such as ultraviolet (UV) radiation and smoking. This contribution focuses on intrinsic factors that promote aging skin. Specifically, in this contribution we review the literature describing how single nucleotide polymorphisms, epigenetic changes, variable gene expression, microRNA, and mitochondrial depletion relate to skin aging. Investigations studying intrinsic factors associated with skin aging are important as they promote a better understanding of the underlying pathophysiology of aging skin. This contribution also describes potential avenues for future genetic research in skin aging. Molecular mechanisms that may be therapeutically intervened upon are of particular interest given the cultural value placed on youthful appearing skin. Future research efforts will hopefully reveal a means upon which to intercede on the skin aging process.

Feasibility and reliability of clinical coding surveillance for the routine monitoring of adverse drug events in New Zealand hospitals.

AIM: To explore the feasibility and reliability of Clinical Coding Surveillance (CCS) for the routine monitoring of Adverse Drug Events (ADE) and describe the characteristics of harm identified through this approach in a large district health board (DHB). METHOD: All hospital admissions at Waitemata DHB from 2015 to 2016 with an ADE-related ICD10-AM code of Y40-Y59, X40-X49 or T36-T50 were extracted from clinical coded data. The data was analysed using descriptive statistics, statistical process control and Pareto charts. Two clinicians assessed a random sample of 140 ADEs for their accuracy against what was clinically documented in medical records. RESULTS: A total of 11,999 ADEs were identified in 244,992 admissions (4.9 ADEs per 100 admissions). ADEs were more prevalent in older adults and associated with longer average length of stays and medicines such as analgesics, antibiotics, anticoagulants and diuretics. Only 2,164 (18%) of ADEs were classified as originating within hospital. Of ADEs originating outside of the hospital, the main causes were poisoning by psychotropics, anti-epileptics and anti-parkinsonism agents and non-opioid analgesics. Clinicians agreed that 91% of ADE positive admissions were accurately classified as per clinical documentation. CONCLUSION: CCS is a feasible and reliable approach for the routine monitoring of ADEs in hospitals.

Age-induced and photoinduced changes in gene expression profiles in facial skin of Caucasian females across 6 decades of age.

BACKGROUND: Intrinsic and extrinsic factors, including ultraviolet irradiation, lead to visible signs of skin aging. OBJECTIVE: We evaluated molecular changes occurring in photoexposed and photoprotected skin of white women 20 to 74 years of age, some of whom appeared substantially younger than their chronologic age. METHODS: Histologic and transcriptomics profiling were conducted on skin biopsy samples of photoexposed (face and dorsal forearm) or photoprotected (buttocks) body sites from 158 women. 23andMe genotyping determined genetic ancestry. RESULTS: Gene expression and ontologic analysis revealed progressive changes from the 20s to the 70s in pathways related to oxidative stress, energy metabolism, senescence, and epidermal barrier; these changes were accelerated in the 60s and 70s. The gene expression patterns from the subset of women who were younger-appearing were similar to those in women who were actually younger. LIMITATIONS: Broader application of these findings (eg, across races and Fitzpatrick skin types) will require further studies. CONCLUSIONS: This study demonstrates a wide range of molecular processes in skin affected by aging, providing relevant targets for improving the condition of aging skin at different life stages and defining a molecular pattern of epidermal gene expression in women who appear younger than their chronologic age.

Evaluation of a complex intervention to improve primary care prescribing: a phase IV segmented regression interrupted time series analysis.

BACKGROUND: It is uncertain whether improvements in primary care high-risk prescribing seen in research trials can be realised in the real-world setting. AIM: To evaluate the impact of a 1-year system-wide phase IV prescribing safety improvement initiative, which included education, feedback, support to identify patients to review, and small financial incentives. DESIGN AND SETTING: An interrupted time series analysis of targeted high-risk prescribing in all 56 general practices in NHS Forth Valley, Scotland, was performed. In 2013-2014, this focused on high-risk non-steroidal anti-inflammatory drugs (NSAIDs) in older people and NSAIDs with oral anticoagulants; in 2014-2015, it focused on antipsychotics in older people. METHOD: The primary analysis used segmented regression analysis to estimate impact at the end of the intervention, and 12 months later. The secondary analysis used difference-in-difference methods to compare Forth Valley changes with those in NHS Greater Glasgow and Clyde (GGC). RESULTS: In the primary analysis, downward trends for all three NSAID measures that were existent before the intervention statistically significantly steepened following implementation of the intervention. At the end of the intervention period, 1221 fewer patients than expected were prescribed a high-risk NSAID. In contrast, antipsychotic prescribing in older people increased slowly over time, with no intervention-associated change. In the secondary analysis, reductions at the end of the intervention period in all three NSAID measures were statistically significantly greater in NHS Forth Valley than in NHS GGC, but only significantly greater for two of these measures 12 months after the intervention finished. CONCLUSION: There were substantial and sustained reductions in the high-risk prescribing of NSAIDs, although with some waning of effect 12 months after the intervention ceased. The same intervention had no effect on antipsychotic prescribing in older people.

A Preliminary, Open Label, Single-arm Study of Calcipotriene/Betamethasone Topical Suspension as a Supplement to Non-biologic Systemic Therapy for Psoriasis.

BACKGROUND: Calcipotriene/betamethasone topical suspension is a topical therapy that is often used as monotherapy as a first-line treatment for plaque psoriasis. The objective of this preliminary, open label, single arm study was to determine the efficacy of adding a topical suspension to a traditional systemic therapy for psoriasis, either methotrexate or acitretin. METHODS: In this exploratory study, eight patients with chronic plaque psoriasis who were on stable methotrexate or acitretin treatment without clearance were treated with once-daily calcipotriene/betamethasone topical suspension. Subjects completed five study visits over 12 weeks. Primary outcome measure was improvement of two or more points in Investigator Global Assessment. Secondary endpoints included change in Body Surface Area, Dermatology Life Quality Index, and Patient's Global Assessment from baseline to Week 12. RESULTS: Overall, the median decrease in Investigator Global Assessment over 12 weeks was 1.5 points, with 50 percent of subjects experiencing a drop of two or more points in Investigator Global Assessment. All eight subjects had a reduction in Body Surface Area and Patient's Global Assessment. There was a mean decrease in Dermatology Life Quality Index score of 78.9 percent, showing improved patient quality of life. In addition, all patients tolerated the treatment well and 6 of 8 patients had improved satisfaction level with their treatment by the end of the study. CONCLUSION: The topical suspension was effective and well-tolerated in conjunction with stable methotrexate or acitretin treatment in all eight patients in this study. These results support the feasibility of a larger scale study to further investigate the efficacy of these treatment combinations. The trial is registered at ClinicalTrials.gov, number NCT01761019.

Qualitative evaluation of the Safety and Improvement in Primary Care (SIPC) pilot collaborative in Scotland: perceptions and experiences of participating care teams.

OBJECTIVES: To explore general practitioner (GP) team perceptions and experiences of participating in a large-scale safety and improvement pilot programme to develop and test a range of interventions that were largely new to this setting. DESIGN: Qualitative study using semistructured interviews. Data were analysed thematically. SUBJECTS AND SETTING: Purposive sample of multiprofessional study participants from 11 GP teams based in 3 Scottish National Health Service (NHS) Boards. RESULTS: 27 participants were interviewed. 3 themes were generated: (1) programme experiences and benefits, for example, a majority of participants referred to gaining new theoretical and experiential safety knowledge (such as how unreliable evidence-based care can be) and skills (such as how to search electronic records for undetected risks) related to the programme interventions; (2) improvements to patient care systems, for example, improvements in care systems reliability using care bundles were reported by many, but this was an evolving process strongly dependent on closer working arrangements between clinical and administrative staff; (3) the utility of the programme improvement interventions, for example, mixed views and experiences of participating in the safety climate survey and meeting to reflect on the feedback report provided were apparent. Initial theories on the utilisation and potential impact of some interventions were refined based on evidence. CONCLUSIONS: The pilot was positively received with many practices reporting improvements in safety systems, team working and communications with colleagues and patients. Barriers and facilitators were identified related to how interventions were used as the programme evolved, while other challenges around spreading implementation beyond this pilot were highlighted.

Single blind, randomized, controlled trial of a lightening product with and without iontophoresis versus tretinoin and vehicle for hyperpigmentation.

BACKGROUND: Hyperpigmentation is a common concern and has many causes including lentigines and melasma. Currently available topical products for hyperpigmentation are limited by their potential for irritation, lack of demonstrated efficacy or regulatory concerns. OBJECTIVE: To compare the efficacy of a new skin lightening product with and without iontophoresis to a known effective product (tretinoin) and placebo on hyperpigmentation caused by lentigines and/or melasma. Secondary objectives included an assessment of the product's effects on the appearance of rhytides and roughness. METHODS AND MATERIALS: Eighty subjects were randomized into one of four treatment groups: proprietary lightening product, proprietary lightening product with iontophoresis, tretinoin 0.05% cream, or vehicle control. Seventy-four subjects completed all study visits. Blinded assessments of subjects were performed at each visit under ambient and Wood's light. RESULTS: The proprietary skin lightening product improved facial hyperpigmentation versus placebo under ambient light (P= 0.05) and Wood's lamp (P= 0.01) examination. Tretinoin also improved facial hyperpigmentation versus placebo under Wood's lamp (P= 0.01). The proprietary product was better tolerated than tretinoin, with fewer subject reported side effects. CONCLUSION: The investigational product was effective and may be better tolerated than tretinoin cream.