Room for improvement? Leadership,innovation culture and uptake of quality improvement methods in general practice

Background Leadership and innovation are currently seen as essential elements for the development and maintenance of high‐quality care. Little is known about the relationship between leadership and culture of innovation and the extent to which quality improvement methods are used in general practice. This study aimed to assess the relationship between leadership behaviour, culture of innovation and adoption of quality improvement methods in general practice. Method Self‐administered postal questionnaires were sent to general practitioner quality improvement leads in one county in the UK between June and December 2007. The questionnaire consisted of background information, a 12‐item scale to assess leadership behaviour, a seven‐dimension self‐rating scale for culture of innovation and questions on current use of quality improvement tools and techniques. Results Sixty‐three completed questionnaires (62%) were returned. Leadership behaviours were not commonly reported. Most practices reported a positive culture of innovation, featuring relationship most strongly, followed by targets and information but rated lower on other dimensions of rewards, risk and resources. There was a significant positive correlation between leadership behaviour and the culture of innovation (r = 0.57; P < 0.001). Apart from clinical audit and significant event analysis, quality improvement methods were not adopted by most participating practices. Conclusions Leadership behaviours were infrequently reported and this was associated with a limited culture of innovation in participating general practices. There was little use of quality improvement methods beyond clinical and significant event audit. Practices need support to enhance leadership skills, encourage innovation and develop quality improvement skills if improvements in health care are to accelerate.     

Patient and clinician factors associated with prehospital pain treatment and outcomes: cross sectional study

Objective

We aimed to identify how patient (age, sex, condition) and paramedic factors (sex, role) affected prehospital analgesic administration and pain alleviation.

Performance and views of examiners in the Applied Knowledge Test for the nMRCGP licensing examination

Background

A new computer-based Applied Knowledge Test (AKT) has been developed for the licensing examination for general practice administered by the Royal College of General Practitioners.

Aim

The aim of this evaluation was to assess the acceptability, feasibility, and validity of the test as well as its transfer to a computerised format at local test centres.

Design of study

Computer-based test and postal questionnaire.

Participants and setting

Panel of examiners, Membership of the Royal College of General Practitioners (MRCGP) examination, UK.

Method

Self-administered postal questionnaires were sent to examiners not involved with the development of the test after completing it. Their performance scores were compared with those of candidates.

Results

The majority of participants (80.9%) were satisfied with the new computer-based test. Responses relating to content and attitudes to the test were also positive overall, but some problems with content were highlighted. Fewer examiners (61.9%) were positive about the physical comfort of the test centre, including seating, heating, and lighting. Examiners had significantly higher scores (mean 83.3%, range 69 to 93%, 95% confidence interval [CI] = 81.9 to 84.7%) than ‘real’ candidates (mean 75.0%, range 45 to 94%, 95% CI = 74.6 to 75.5%), who subsequently took an identical test.

Conclusion

The new computer-based licensing test (the AKT) was found to be acceptable to the majority of examiners. The pass–fail standard, determined by routine methods including an Angoff procedure, was supported by the higher success rate of examiners compared with candidates. The use of selected groups to assess high-stakes (licensing) examinations can be useful for assessing test validity.     

Isoleucine and leucine independently regulate mTOR signaling and protein synthesis in MAC-T cells and bovine mammary tissue slices

Understanding the regulatory effects of individual amino acids (AA) on milk protein synthesis rates is important for improving protein and AA requirement models for lactation. The objective of this study was to examine the effects of individual essential AA (EAA) on cellular signaling and fractional protein synthesis rates (FSR) in bovine mammary cells. Omission of L-arginine, L-isoleucine, L-leucine, or all EAA reduced (P < 0.05) mammalian target of rapamycin (mTOR; Ser2448) and ribosomal protein S6 (rpS6; Ser235/236) phosphorylation in MAC-T cells. Phosphorylation of mTOR and rpS6 kinase 1 (S6K1; Thr389) decreased (P < 0.05) in the absence of L-isoleucine, L-leucine, or all EAA in lactogenic mammary tissue slices. Omission of L-tryptophan also reduced S6K1 phosphorylation (P = 0.01). Supplementation of L-leucine to media depleted of EAA increased mTOR and rpS6 and decreased eukaryotic elongation factor 2 (Thr56) phosphorylation (P < 0.05) in MAC-T cells. Supplementation of L-isoleucine increased mTOR, S6K1, and rpS6 phosphorylation (P < 0.05). No single EAA considerably affected eukaryotic initiation factor 2-α (eIF2α; Ser51) phosphorylation, but phosphorylation was reduced in response to provision of all EAA (P < 0.04). FSR declined when L-isoleucine (P = 0.01), L-leucine (P = 0.01), L-methionine (P = 0.02), or L-threonine (P = 0.07) was depleted in media and was positively correlated (R = 0.64, P < 0.01) with phosphorylation of mTOR and negatively correlated (R = -0.42, P = 0.01) with phosphorylation of eIF2α. Such regulation of protein synthesis will result in variable efficiency of transfer of absorbed EAA to milk protein and is incompatible with the assumption that a single nutrient limits protein synthesis that is encoded in current diet formulation strategies.     

Microscopy, culture, and sensitive management of uncomplicated urinary tract infections in adults in the primary care setting

The high prevalence of urinary tract infections (UTIs) places a significant burden on healthcare systems. Clinicians may over-manage the issue, and there is great variability in practice, with economic- and resource- implications. Up to 40% of patients with a suspected UTI do not have an infection. Using PubMed (Medline) to shortlist relevant papers in English from the last 30 years, and further sub-selection to include only uncomplicated UTIs in adults in primary care, we reviewed the literature pertaining to uncomplicated UTIs, and how it should be managed efficiently in the primary care setting. In general practice, there is no advantage to routinely request microscopy and culture of urine samples in the presence of an appropriate history and urinalysis reagent-strip testing. If antibiotics are required, then a 3-day course shall suffice. Larger epidemiological studies focusing on more susceptible sub-populations may provide better guidance for discriminatory factors to produce an algorithm for treatment.