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The interviewees' description of their entrepreneurial strategic direction and the implementation of policies and adjustment of practices to achieve them fits in entirely with the processual approach discussed both in the section on entrepreneurial strategy as process and again in the section of theories of effective practice in the discussion of Chinese strategic thought.
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In a study of 2 163 456 respondents from 8267 English primary care practices we show that case-mix adjustment of practice-level scores results in relatively few large adjustments (which were mainly positive), and many small adjustments (which were more often negative).
6 A particular strength of our study is the large sample size, enabling us to investigate the impact of case-mix adjustment on practices serving less typical patient populations.
Primary outcome was the impact of case-mix adjustment on practice-level means (adjusted minus unadjusted) and changes in practice percentile ranks for questions measuring patient experience in three domains of primary care: access; interpersonal care; anticipatory care planning, and overall satisfaction with primary care services.
Our aims are to quantify the impact of case-mix adjustment on practice-level scores in a national survey of patient experience, to identify why and when it may be useful to adjust for case mix, and to discuss unresolved policy issues regarding the use of case-mix adjustment in performance measurement in health care.
Table 2 shows the impact of case-mix adjustment on practice-level mean scores and practice ranks.
Our results show that the impact of case-mix adjustment on practice-level performance scores is modest for most practices but may meaningfully improve the measurement of performance for practices with less typical patient populations, discouraging practices from 'cream-skimming' by avoiding enrolling patients who could be seen as 'hard to treat'.
The impact of case-mix adjustment on practice-level means varied by patient experience domain, with a larger impact on anticipatory care planning items (questions 28 and 29) and a smaller impact for questions relating to access (getting through on the telephone; getting an urgent appointment; booking ahead; and evaluation of waiting time).
An example of immediate adjustment to practice involves observation of nursing staff, either pushing intravenous medications or running intravenous drips wide open, prior to receiving an educational lecture on drip rate calculations.
It is obvious that information on prevalence of T2DM related complications is important for the adjustment of policies and practices in diabetic care management to gain better control of T2DM.
Secondary analyses were also performed at the suggestion of the referees, with adjustment for practice as a covariate (that is, adjusting for confounding by practice) and also with practice as a cluster variable (that is, adjusting for clustering by practice).
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