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Freddie Stening shares the challenges he faced while coming to terms with his wife’s unexpected death

Back pain remains a challenge for primary care internationally. One model that has not been tested is stratification of the management according to the patient's prognosis (low, medium, or high risk). We compared the clinical effectiveness and cost-effectiveness of stratified primary care (intervention) with non-stratified current best practice (control). 1573 adults (aged ≥18 years) with back pain (with or without radiculopathy) consultations at ten general practices in England responded to invitations to attend an assessment clinic. Eligible participants were randomly assigned by use of computer-generated stratified blocks with a 2:1 ratio to intervention or control group. Primary outcome was the effect of treatment on the Roland Morris Disability Questionnaire (RMDQ) score at 12 months. In the economic evaluation, we focused on estimating incremental quality-adjusted life years (QALYs) and health-care costs related to back pain. Analysis was by intention to treat. This study is registered, number ISRCTN37113406. 851 patients were assigned to the intervention (n=568) and control groups (n=283). Overall, adjusted mean changes in RMDQ scores were significantly higher in the intervention group than in the control group at 4 months (4·7 [SD 5·9] vs 3·0 [5·9], between-group difference 1·81 [95% CI 1·06–2·57]) and at 12 months (4·3 [6·4] vs 3·3 [6·2], 1·06 [0·25–1·86]), equating to effect sizes of 0·32 (0·19–0·45) and 0·19 (0·04–0·33), respectively. At 12 months, stratified care was associated with a mean increase in generic health benefit (0·039 additional QALYs) and cost savings (£240·01 vs £274·40) compared with the control group. The results show that a stratified approach, by use of prognostic screening with matched pathways, will have important implications for the future management of back pain in primary care. Arthritis Research UK.

Objective To evaluate the effectiveness and costs of a multifaceted flexible educational programme aimed at reducing antibiotic dispensing at the practice level in primary care.Design Randomised controlled trial with general practices as the unit of randomisation and analysis. Clinicians and researchers were blinded to group allocation until after randomisation.Setting 68 general practices with about 480 000 patients in Wales, United Kingdom.Participants 34 practices were randomised to receive the educational programme and 34 practices to be controls. 139 clinicians from the intervention practices and 124 from control practices had agreed to participate before randomisation. Practice level data covering all the clinicians in the 68 practices were analysed.Interventions Intervention practices followed the Stemming the Tide of Antibiotic Resistance (STAR) educational programme, which included a practice based seminar reflecting on the practices’ own dispensing and resistance data, online educational elements, and practising consulting skills in routine care. Control practices provided usual care.Main outcome measures Total numbers of oral antibiotic items dispensed for all causes per 1000 practice patients in the year after the intervention, adjusted for the previous year’s dispensing. Secondary outcomes included reconsultations, admissions to hospital for selected causes, and costs.Results The rate of oral antibiotic dispensing (items per 1000 registered patients) decreased by 14.1 in the intervention group but increased by 12.1 in the control group, a net difference of 26.1. After adjustment for baseline dispensing rate, this amounted to a 4.2% (95% confidence interval 0.6% to 7.7%) reduction in total oral antibiotic dispensing for the year in the intervention group relative to the control group (P=0.02). Reductions were found for all classes of antibiotics other than penicillinase-resistant penicillins but were largest and significant individually for phenoxymethylpenicillins (penicillin V) (7.3%, 0.4% to 13.7%) and macrolides (7.7%, 1.1% to 13.8%). There were no significant differences between intervention and control practices in the number of admissions to hospital or in reconsultations for a respiratory tract infection within seven days of an index consultation. The mean cost of the programme was £2923 (€3491, $4572) per practice (SD £1187). There was a 5.5% reduction in the cost of dispensed antibiotics in the intervention group compared with the control group (−0.4% to 11.4%), equivalent to a reduction of about £830 a year for an average intervention practice.Conclusion The STAR educational programme led to reductions in all cause oral antibiotic dispensing over the subsequent year with no significant change in admissions to hospital, reconsultations, or costs.Trial registration ISRCT No 63355948.

In 2007, the Royal British Institute of Architects (RIBA) commissioned Jeremy Till’s now seminal essay, ‘Architectural Research: Three Myths and One Model’. Till’s essay called out ‘unnecessary antipathy’ between practitioners and academics, arguing for enhanced collaboration to enable a more ‘dynamic system’ of research. This paper presents a pilot study of five large architectural practices engaged in research that seeks to understand what is driving greater research engagement within contemporary architectural practice, what knowledge is being created for what purpose, and the relationship of practice-generated research to that produced within academia. Five semi-structured interviews and three written questionnaires were elicited from practices, each of whom have dedicated research staff or a demonstrated track record of research engagement and/or utilisation. Ultimately, it is suggested, a more honest discussion of the relational dynamics of collaborations between practice and academia is needed. Such discussion requires researchers from both to embrace ethnographic approaches, reporting not just the outcomes of their work together but also revealing the ‘mess’ involved in generating those outcomes.

A compact business education that strategically incorporates 500 keywords to lay the foundation and over 50 action items to initiate meaningful advances and excel in your eye care practice today. Medical training is a difficult journey with enormous amounts of information to absorb over a short time period. The intense time commitment required during this process leaves little opportunity to study any other discipline. However, even the most intelligent and well-intentioned provider cannot care for patients if the front door of the building is closed. Simply put: A fundamental background in business is required to effectively practice medicine. Eye care professionals, which includes their ophthalmic staff, can now fill the critical gap in their education with Essential Business Fundamentals for the Successful Eye Care Practice , providing them the necessary basic tools to make and execute winning practice management decisions. Writing in a high-density format that medical professionals will be familiar with, Dr. Savak Teymoorian combines his physician training and experience as a successful ophthalmologist at Harvard Eye Associates with the knowledge acquired earning his MBA. This unique perspective allows him to provide the proper theory and execution in the business of eye care and present it in an efficient manner like that used in medical education. Each chapter is dedicated to a different subject that would routinely be taught in a masters of business administration degree, tailored specifically for eye care professionals and distilled into the most critical information for a strong foundation. Each section is further enhanced with real life examples seen in ophthalmic care showing how to properly apply business strategies and tactics to obtain the best results. Chapter topics include: Marketing Leadership Negotiations Operations Finance Ophthalmologists, optometrists, and eye care staff will appreciate Essential Business Fundamentals for the Successful Eye Care Practice for its efficient and relevant information to running an eye care practice, whether they are currently in training and want to set themselves up for success or they are already practicing and want to fill in a deficiency in their knowledge.

The United States patent system has become sand rather than lubricant in the wheels of American progress. Such is the premise behind this provocative and timely book by two of the nation's leading experts on patents and economic innovation.

High-volume prescribing of antibiotics in primary care is a major driver of antibiotic resistance. Education of physicians and patients can lower prescribing levels, but it frequently relies on highly trained staff. We assessed whether internet-based training methods could alter prescribing practices in multiple health-care systems. After a baseline audit in October to December, 2010, primary-care practices in six European countries were cluster randomised to usual care, training in the use of a C-reactive protein (CRP) test at point of care, in enhanced communication skills, or in both CRP and enhanced communication. Patients were recruited from February to May, 2011. This trial is registered, number ISRCTN99871214. The baseline audit, done in 259 practices, provided data for 6771 patients with lower-respiratory-tract infections (3742 [55·3%]) and upper-respiratory-tract infections (1416 [20·9%]), of whom 5355 (79·1%) were prescribed antibiotics. After randomisation, 246 practices were included and 4264 patients were recruited. The antibiotic prescribing rate was lower with CRP training than without (33% vs 48%, adjusted risk ratio 0·54, 95% CI 0·42–0·69) and with enhanced-communication training than without (36% vs 45%, 0·69, 0·54–0·87). The combined intervention was associated with the greatest reduction in prescribing rate (CRP risk ratio 0·53, 95% CI 0·36–0·74, p<0·0001; enhanced communication 0·68, 0·50–0·89, p=0·003; combined 0·38, 0·25–0·55, p<0·0001). Internet training achieved important reductions in antibiotic prescribing for respiratory-tract infections across language and cultural boundaries. European Commission Framework Programme 6, National Institute for Health Research, Research Foundation Flanders.