UK experience of professional registration in radiation protection.

The UK Radiation Protection Council (RPC) was established in 2019, under the Royal Charter of the Society for Radiological Protection. The RPC holds the registers for three grades of professional registration-Chartered, Incorporated and Technical Radiation Protection Professional. Individual radiation protection practitioners may apply for registration through any society or organisation that has been accepted as a Licensee of the RPC. This paper will give an overview of the criteria used for registration at each level, along with the benefits of professional registration to individuals, employers, the radiation protection profession and the public. We will discuss the operation of the RPC and share the experience of its establishment, identifying key issues and potential pitfalls for other Societies wishing to go down this route. Future expectations for professional registration will be considered.

Advances and innovations in methods for collecting egocentric network data.

This article reviews recent methodological research that bears on the collection of egocentric network data. It begins with background on setting egocentric network boundaries and principal types of instruments that obtain information about such networks. It then discusses innovations in data collection and studies of data quality. The bulk of these address questions about "name generator" instruments that obtain information about the alters and relationships in a subject's network. Among topics receiving substantial attention in recent research are mitigation of respondent burden, interviewer effects, survey mode, and the performance of name generators in longitudinal studies. Potentially fruitful innovations supplement conventional question-and-answer surveys with visual elements that promise to better engage respondents and reduce the demands that name generator-based data collection poses. We close by highlighting both accomplishments of this body of research and some open issues.

Beyond the clot: perfusion imaging of the pulmonary vasculature after COVID-19.

A compelling body of evidence points to pulmonary thrombosis and thromboembolism as a key feature of COVID-19. As the pandemic spread across the globe over the past few months, a timely call to arms was issued by a team of clinicians to consider the prospect of long-lasting pulmonary fibrotic damage and plan for structured follow-up. However, the component of post-thrombotic sequelae has been less widely considered. Although the long-term outcomes of COVID-19 are not known, should pulmonary vascular sequelae prove to be clinically significant, these have the potential to become a public health problem. In this Personal View, we propose a proactive follow-up strategy to evaluate residual clot burden, small vessel injury, and potential haemodynamic sequelae. A nuanced and physiological approach to follow-up imaging that looks beyond the clot, at the state of perfusion of lung tissue, is proposed as a key triage tool, with the potential to inform therapeutic strategies.

Work Values in the United States: Age, Period, and Generational Differences.

This article examines how processes of aging, generational shifts, and changes over historical time periods shape differences in work values in the United States. Our analyses of data from the General Social Surveys and the International Social Survey Program show that changes over historical time periods are most consistently responsible for temporal differences in work values. In particular, during recent periods Americans tend to place greater importance on jobs that provide security, high income and opportunities for advancement; this is consistent with a narrative that these job rewards have become more difficult to attain recently and are thus more problematic for workers. Some differences in work values are also attributable to aging or life course processes, especially the greater importance placed on high income during the mid-life years when family responsibilities are generally greatest. By contrast, we find few differences in work values among members of different generations or cohorts. We also find that people from less advantaged social origins and those with greater labor market resources are more likely to value economic rewards.

Changing work values in the United States, 1973-2006.

This article examines changes in workers' work values for the period 1973-2006 using General Social Survey data. We assess the relative importance that workers assign to high income, as opposed to security, advancement, short hours and "importance and sense of accomplishment." The latter ranked highest throughout this period, but the relative priority placed on income and job security generally increased. We suggest that the rising relative rankings of earnings and job security reflect growing job, employability, and economic insecurity that workers generally experienced during this period, making these job characteristics generally more difficult to attain. Groups most vulnerable to job, employability, and economic insecurity-such as less educated workers and blacks-were most apt to place high importance on income and security. Differences in rankings between men and women, blacks and nonblacks, and college and high school graduates remained fairly stable over this period.

An efficient didehydroxylation method for the biomass-derived polyols glycerol and erythritol. Mechanistic studies of a formic acid-mediated deoxygenation.

An efficient 1,2-deoxygenation method, involving an unexpected mechanism, was found for simple diols and for biomass-derived polyols (glycerol and erythritol) that results in the conversion of the 1,2-dihydroxy group to a carbon-carbon double bond.

Gender differences in the relationships of cardiovascular symptoms and somatosensory amplification to mortality.

Symptoms of angina and dyspnea predict coronary artery disease and death less well in women than in men. Greater somatosensory amplification - a psychosocial propensity to report symptoms of physical discomfort - may lead women to report relatively high levels of angina and dyspnea for reasons unrelated to coronary disease, reducing their associations with mortality. We assessed this hypothesis in a nationally representative survey of U.S. adults. When stratified by gender, angina and dyspnea significantly predicted mortality among men, but predicted it less well among women. After adjusting for amplification, cardiovascular symptoms did not predict mortality among women, but amplification was positively associated with mortality among older women.

Meeting report: risk assessment of tamiflu use under pandemic conditions.

On 3 October 2007, 40 participants with diverse expertise attended the workshop Tamiflu and the Environment: Implications of Use under Pandemic Conditions to assess the potential human health impact and environmental hazards associated with use of Tamiflu during an influenza pandemic. Based on the identification and risk-ranking of knowledge gaps, the consensus was that oseltamivir ethylester-phosphate (OE-P) and oseltamivir carboxylate (OC) were unlikely to pose an ecotoxicologic hazard to freshwater organisms. OC in river water might hasten the generation of OC-resistance in wildfowl, but this possibility seems less likely than the potential disruption that could be posed by OC and other pharmaceuticals to the operation of sewage treatment plants. The work-group members agreed on the following research priorities: a) available data on the ecotoxicology of OE-P and OC should be published; b) risk should be assessed for OC-contaminated river water generating OC-resistant viruses in wildfowl; c) sewage treatment plant functioning due to microbial inhibition by neuraminidase inhibitors and other antimicrobials used during a pandemic should be investigated; and d) realistic worst-case exposure scenarios should be developed. Additional modeling would be useful to identify localized areas within river catchments that might be prone to high pharmaceutical concentrations in sewage treatment plant effluent. Ongoing seasonal use of Tamiflu in Japan offers opportunities for researchers to assess how much OC enters and persists in the aquatic environment.

The effect of care team composition on the quality of HIV care.

Compared to single-clinician care, care provided by multiple clinicians might result in higher-quality care, especially if some of them have condition-specific expertise and complementary knowledge, skills, and roles. Individual physician continuity, which has been shown to be associated with care quality, necessarily decreases when care is provided by multiple clinicians. This study uses data from the HIV Cost and Services Utilization Study to assess the effect of care team composition on the quality of HIV care. In adjusted analyses, care teams composed of three or more clinicians were associated with more consistent prescribing of pneumocystis carinii pneumonia prophylaxis when medically indicated ( p < .01). Patients with multiple physicians generally reported worse care coordination, however, and had more inappropriate use of emergency services. These findings indicate both advantages and disadvantages to having multiple clinicians. More effort should be devoted to facilitating coordination when multiple clinicians provide care.

The Analysis of Social Networks.

Many questions about the social organization of medicine and health services involve interdependencies among social actors that may be depicted by networks of relationships. Social network studies have been pursued for some time in social science disciplines, where numerous descriptive methods for analyzing them have been proposed. More recently, interest in the analysis of social network data has grown among statisticians, who have developed more elaborate models and methods for fitting them to network data. This article reviews fundamentals of, and recent innovations in, social network analysis using a physician influence network as an example. After introducing forms of network data, basic network statistics, and common descriptive measures, it describes two distinct types of statistical models for network data: individual-outcome models in which networks enter the construction of explanatory variables, and relational models in which the network itself is a multivariate dependent variable. Complexities in estimating both types of models arise due to the complex correlation structures among outcome measures.

Correlations among measures of quality in HIV care in the United States: cross sectional study.

OBJECTIVE: To determine whether a selected set of indicators can represent a single overall quality construct. DESIGN: Cross sectional study of data abstracted during an evaluation of an initiative to improve quality of care for people with HIV. SETTING: 69 sites in 30 states. DATA SOURCES: Medical records of 9020 patients. MAIN OUTCOME MEASURES: Adjusted performance rates at site level for eight measures of quality of care specific to HIV and a site level summary performance score (the number of measures for which the site was in the top quarter of the distribution). RESULTS: Of 28 site level correlations between measures, two were greater than 0.40, two were between 0.30 and 0.39, four were between 0.20 and 0.29, and the 20 remaining were all less than 0.20. One site was in the top quarter for seven measures, but no sites were in the top quarter for six or eight of the measures. Across the eight quality measures, sites were in the top quarter no more often than predicted by a chance (binomial) distribution. CONCLUSIONS: The quality suggested by one measured indicator cannot necessarily be generalised to unmeasured indicators, even if this might be expected for clinical or other reasons.

Factors affecting influential discussions among physicians: a social network analysis of a primary care practice.

BACKGROUND: Physicians often rely on colleagues for new information and advice about the care of their patients. OBJECTIVE: Evaluate the network of influential discussions among primary care physicians in a hospital-based academic practice. DESIGN: Survey of physicians about influential discussions with their colleagues regarding women's health issues. We used social network analysis to describe the network of discussions and examined factors predictive of a physician's location in the network. SUBJECTS: All 38 primary care physicians in a hospital-based academic practice. MEASUREMENTS: Location of physician within the influential discussion network and relationship with other physicians in the network. RESULTS: Of 33 responding physicians (response rate = 87%), the 5 reporting expertise in women's health were more likely than others to be cited as sources of influential information (odds ratio [OR] 6.81, 95% Bayesian confidence interval [CI] 2.25-23.81). Physicians caring for more women were also more often cited (OR 1.03, 95% CI 1.01-1.05 for a 1 percentage-point increase in the proportion of women patients). Influential discussions were more frequent among physicians practicing in the same clinic within the practice than among those in different clinics (OR 5.03, 95% CI 3.10-8.33) and with physicians having more weekly clinical sessions (OR 1.33, 95% CI 1.15 to 1.54 for each additional session). CONCLUSIONS: In the primary care practice studied, physicians obtained information from colleagues with greater expertise and experience as well as colleagues who were accessible based on location and schedule. It may be possible to organize practices to promote more rapid dissemination of high-quality evidence-based medicine.

The impact of a quality improvement program on systems, processes, and structures in medical clinics.

OBJECTIVE: We sought to assess whether participation in a quality-improvement collaborative changed care processes, systems, and organization of outpatient human immunodeficiency virus (HIV) clinics. METHODS: We surveyed clinicians, medical directors, and HIV program administrators before and after an 18-month quality improvement collaborative at 54 intervention and 37 control clinics providing HIV care. Surveys assessed clinic structures, processes, systems, and culture. During the collaborative, a clinician-administrator team from each intervention clinic attended 4 2-day sessions on quality improvement techniques. Conference calls, a website, and an e-mail list provided support and facilitated communication among collaborative participants. RESULTS: Survey response rates were 85% or greater. Six of 54 organizational measures differed significantly between baseline and follow-up. Intervention clinicians reported greater computer availability (82% vs. 67%, P = 0.03) and use (3.13 vs. 2.68, P = 0.02; 4-point scale), attended more local (14.2 vs. 8.6, P < 0.01) and national (4.1 vs. 2.9, P = 0.01) conferences, and rated leaders' ability to implement quality improvement higher (3.8 vs. 3.4, P = 0.01; 5-point scale). Intervention directors were more likely to compare quality data to other clinics (79% vs. 54%, P = 0.04). For the set of 54 measures, intervention clinics were more likely to have higher post-intervention scores than controls (sign test, mean = 14.5, P < 0.0001). CONCLUSIONS: A quality-improvement collaborative for HIV clinics resulted in modest organizational changes. Achieving greater change may require more focused and/or intensive interventions, greater resources for participating clinics, and better developed information technology.

Voluntary physician switching by human immunodeficiency virus-infected individuals: a national study of patient, physician, and organizational factors.

OBJECTIVE: We sought to assess which patient, physician, and organizational factors are related to voluntary physician switching among human immunodeficiency virus (HIV)-infected patients. DESIGN: We analyzed the results from a 3-wave survey of patients conducted by the HIV Cost and Services Utilization Study (HCSUS), a longitudinal study of a nationally representative sample of noninstitutionalized HIV-infected individuals receiving care in the contiguous United States. Physicians providing care and care site directors were surveyed once. Relationships of interpersonal aspects of care, access and continuity, technical quality of care, and physician and site characteristics to voluntary switching were analyzed using multilevel logistic regression models that nested repeated observations within patients, patients within clinicians, and clinicians within region. RESULTS: Approximately 15% of patients voluntarily changed their usual clinicians during the 2-year study period. In a multivariate model, lower voluntary switching was predicted by patient trust (odds ratio [OR]=0.74; 95% confidence interval [95% CI]=0.61-0.90), physician antiretroviral knowledge (OR=0.26; 95% CI 0.13-0.53), moderate (rather than low or high) HIV patient volume at a care site (OR=0.09; 95% CI=0.03-0.31), and Ryan White Care Act funding (OR=0.27, 95% CI=0.14-0.52). CONCLUSIONS: Patients with chronic illnesses may use several markers of specialization and technical quality to make decisions about their care. These results challenge the notion that patients cannot assess the quality of care they receive.

Gender differences in quality of HIV care in Ryan White CARE Act-funded clinics.

BACKGROUND: Women with HIV infection have lagged behind men in receipt of critical health care, but it is not known if those disparities are due in part to where women receive care. We examined differences in care received by HIV-infected women and men in a national sample of Ryan White CARE Act-funded clinics and explored the influence of clinic characteristics on care quality. METHODS: Record review was done on a sample of 9,015 patients who received care at 69 CARE Act-funded HIV primary care clinics that participated in a quality improvement study. Outcome measures studied were highly active antiretroviral therapy (HAART) use, HIV viral suppression, Pneumocystis jiroveci pneumonia (PCP) prophylaxis, screening, and other disease prevention efforts. RESULTS: Women were less likely than men to receive HAART (78% versus 82%, p < .001), receive PCP prophylaxis (65% versus 75%, p < .0001), or have their hepatitis C virus status known (87% versus 88%, p = .02) despite being seen more regularly (69% versus 66%, p = .04). Sites serving high percentages of women delivered similar or better care for both men and women than other sites. Although sites serving a higher percent of women had more support services such as case management and onsite obstetrician-gynecologists and provided Pap smears at higher rates, women at such sites remained less likely than men to receive important HIV care including HAART and PCP prophylaxis. CONCLUSIONS: The gap in the quality of care provided to HIV-infected men and women in critical areas persists, and is not explained by the types of sites where men and women receive care.

The reliability of survey assessments of characteristics of medical clinics.

OBJECTIVE: To assess the reliability of survey measures of organizational characteristics based on reports of single and multiple informants. DATA SOURCE: Survey of 330 informants in 91 medical clinics providing care to HIV-infected persons under Title III of the Ryan White CARE Act. STUDY DESIGN: Cross-sectional survey. DATA COLLECTION METHODS: Surveys of clinicians and medical directors measured the implementation of quality improvement initiatives, priorities assigned to aspects of HIV care, barriers to providing high-quality HIV care, and quality improvement activities. Reliability of measures was assessed using generalizability coefficients. Components of variance and clinician-director differences were estimated using hierarchical regression models with survey items and informants nested within organizations. PRINCIPAL FINDINGS: There is substantial item- and informant-related variability in clinic assessments that results in modest or low clinic-level reliability for many measures. Directors occasionally gave more optimistic assessments of clinics than did clinicians. CONCLUSIONS: For most measures studied, obtaining adequate reliability requires multiple informants. Using multiple-item scales or multiple informants can improve the psychometric performance of measures of organizational characteristics. Studies of such characteristics should report the organizational level reliability of the measures used.

Quality of HIV care provided by nurse practitioners, physician assistants, and physicians.

BACKGROUND: Nurse practitioners (NPs) and physician assistants (PAs) are primary care providers for patients with HIV in some clinics, but little is known about the quality of care that they provide. OBJECTIVE: To compare the quality of care provided by NPs and PAs with that provided by physicians. DESIGN: Cross-sectional analysis. SETTING: 68 HIV care sites, funded by Ryan White Comprehensive AIDS Resources Emergency (CARE) Act Title III, in 30 different states. PARTICIPANTS: The authors surveyed 243 clinicians (177 physicians and 66 NPs and PAs) and reviewed medical records of 6651 persons with HIV or AIDS. MEASUREMENTS: 8 quality-of-care measures assessed by medical record review. RESULTS: After adjustments for patient characteristics, 6 of the 8 quality measures did not statistically significantly differ between NPs and PAs and either infectious disease specialists or generalist HIV experts. Adjusted rates of purified protein derivative testing and Papanicolaou smears were statistically significantly higher for NPs and PAs (0.63 and 0.71, respectively) than for infectious disease specialists (0.53 [P = 0.007] and 0.56 [P = 0.001], respectively) or generalist HIV experts (0.47 [P < 0.001] and 0.62 [P = 0.025], respectively). Nurse practitioners and PAs had statistically significantly higher performance scores than generalist non-HIV experts on 6 of the 8 quality measures. LIMITATIONS: These results may not be generalizable to care settings where on-site physician HIV experts are not accessible or to measures of more complex clinical processes. CONCLUSIONS: For the measures examined, the quality of HIV care provided by NPs and PAs was similar to that of physician HIV experts and generally better than physician non-HIV experts. Nurse practitioners and PAs can provide high-quality care for persons with HIV. Preconditions for this level of performance include high levels of experience, focus on a single condition, and either participation in teams or other easy access to physicians and other clinicians with HIV expertise.

Physician specialization and the quality of care for human immunodeficiency virus infection.

BACKGROUND: There is debate over the types of physicians who should treat patients with complex chronic medical conditions such as human immunodeficiency virus (HIV) infection. We sought to assess the relationship between specialty training and expertise and the quality of care delivered to patients with HIV infection. METHODS: We selected random samples of HIV-infected patients receiving care at 64 Ryan White CARE (Comprehensive AIDS Resources Emergency) Act-funded clinics throughout the country and their primary HIV physicians for an observational cohort study in which quality-of-care measures were assessed by medical record review. RESULTS: We studied 5247 patients linked to 177 physicians who responded to a survey. Fifty-eight percent of the physicians were general medicine physicians ("generalists") and 42% were infectious diseases specialists. Sixty-three percent of the generalists (37% overall) considered themselves expert in HIV care. In hierarchical logistic regression models that controlled for patient characteristics, infectious diseases physicians and expert generalists had similar performance. In contrast, nonexpert generalists delivered lower quality care. More than 80% of the appropriate patients being cared for by infectious diseases physicians and expert generalists were receiving highly active antiretroviral therapy, compared with 73% of appropriate patients of nonexpert generalists (P<.001). Physicians with fewer than 20 patients with active HIV had fewer appropriate patients on highly active antiretroviral therapy (73% vs 82% of physicians with >/=20 such patients, P = .04) and saw patients less frequently. CONCLUSION: These findings extend previous work by examining a range of quality-of-care measures and suggest that generalists with appropriate experience and expertise in HIV care can provide high-quality care to patients with this complex chronic illness.

Effects of a quality improvement collaborative on the outcome of care of patients with HIV infection: the EQHIV study.

BACKGROUND: Multi-institution collaborative quality improvement programs are a well-established and broadly applicable quality improvement strategy, but there is little systematic assessment their effectiveness. OBJECTIVE: To evaluate the effectiveness of a quality improvement collaborative in improving the quality of care for HIV-infected patients. DESIGN: Controlled pre- and postintervention study. SETTING: Clinics receiving funding from the Ryan White Comprehensive AIDS Resources Emergency Act. PARTICIPANTS: 44 intervention clinics and 25 control clinics matched by location (urban or rural), region, size, and clinic type. MEASUREMENTS: Changes in quality-of-care measures abstracted from medical records of pre- and postintervention samples of patients at each study clinic. Measures examined included use and effectiveness of antiretroviral therapy, screening and prophylaxis, and access to care. INTERVENTION: A multi-institutional quality improvement collaborative (the "Breakthrough Series"). RESULTS: 9986 patients were studied. Clinical and sociodemographic characteristics of the intervention and control patients were similar (P > 0.05). Differences in changes in the quality of care were not statistically significant. The proportion of patients with a suppressed viral load increased by 11 percentage points (from 40.1% to 51.1%) in the intervention group compared with 5.3 percentage points (from 43.6% to 48.8%) in the control group, but this difference was not statistically significant (P = 0.18). In addition, rates of appropriate screening tests and prophylaxis did not differ between intervention and control sites. LIMITATIONS: It was not possible to perform a pure randomized trial of the intervention or to assess other measures of quality, such as adherence and satisfaction. CONCLUSIONS: This prospective, matched study of almost 10 000 patients found that a quality improvement collaborative did not significantly affect the quality of care. Additional research is needed to improve methods of teaching and implementing quality improvement programs to achieve better results.