Maluka, Stephen; Kamuzora, Peter; Sebastiån, Miguel San
care priorities in Mbarali district, Tanzania, and evaluates the descriptions against Accountability for Reasonableness. Key informant interviews were conducted with district health managers, local government officials and other stakeholders using a semi-structured interview guide. Relevant documents......Priority-setting has become one of the biggest challenges faced by health decision-makers worldwide. Fairness is a key goal of priority-setting and Accountability for Reasonableness has emerged as a guiding framework for fair priority-setting. This paper describes the processes of setting health...... not satisfy all four conditions of Accountability for Reasonableness; namely relevance, publicity, appeals and revision, and enforcement. This paper aims to make two important contributions to this problematic situation. First, it provides empirical analysis of priority-setting at the district level...
The Affordable Care Act (ACA) may be the most important health law statute in American history, yet much of the most prominent legal scholarship examining it has focused on the merits of the court challenges it has faced rather than delving into the details of its priority-setting provisions. In addition to providing an overview of the ACA's provisions concerning priority setting and their developing interpretations, this Article attempts to defend three substantive propositions. First, I argue that the ACA is neither uniformly hostile nor uniformly friendly to efforts to set priorities in ways that promote cost and quality. Second, I argue that the ACA does not take a single, unified approach to priority setting; rather, its guidance varies depending on the aspect of the healthcare system at issue (Patient Centered Outcomes Research Institute, Medicare, essential health benefits) and the factors being excluded from priority setting (age, disability, life expectancy). Third, I argue that cost-effectiveness can be achieved within the ACA's constraints, but that doing so will require adopting new approaches to cost-effectiveness and priority setting. By limiting the use of standard cost-effectiveness analysis, the ACA makes the need for workable rivals to cost-effectiveness analysis a pressing practical concern rather than a mere theoretical worry.
Defechereux, T.; Paolucci, F.; Mirelman, A.; Youngkong, S.; Botten, G.; Hagen, T.P.; Niessen, L.W.
BACKGROUND: Priority setting in population health is increasingly based on explicitly formulated values. The Patients Rights Act of the Norwegian tax-based health service guaranties all citizens health care in case of a severe illness, a proven health benefit, and proportionality between need and tr
Full Text Available Abstract Background Health organizations the world over are required to set priorities and allocate resources within the constraint of limited funding. However, decision makers may not be well equipped to make explicit rationing decisions and as such often rely on historical or political resource allocation processes. One economic approach to priority setting which has gained momentum in practice over the last three decades is program budgeting and marginal analysis (PBMA. Methods This paper presents a detailed step by step guide for carrying out a priority setting process based on the PBMA framework. This guide is based on the authors' experience in using this approach primarily in the UK and Canada, but as well draws on a growing literature of PBMA studies in various countries. Results At the core of the PBMA approach is an advisory panel charged with making recommendations for resource re-allocation. The process can be supported by a range of 'hard' and 'soft' evidence, and requires that decision making criteria are defined and weighted in an explicit manner. Evaluating the process of PBMA using an ethical framework, and noting important challenges to such activity including that of organizational behavior, are shown to be important aspects of developing a comprehensive approach to priority setting in health care. Conclusion Although not without challenges, international experience with PBMA over the last three decades would indicate that this approach has the potential to make substantial improvement on commonly relied upon historical and political decision making processes. In setting out a step by step guide for PBMA, as is done in this paper, implementation by decision makers should be facilitated.
Full Text Available Abstract Background Priority setting in population health is increasingly based on explicitly formulated values. The Patients Rights Act of the Norwegian tax-based health service guaranties all citizens health care in case of a severe illness, a proven health benefit, and proportionality between need and treatment. This study compares the values of the country's health policy makers with these three official principles. Methods In total 34 policy makers participated in a discrete choice experiment, weighting the relative value of six policy criteria. We used multi-variate logistic regression with selection as dependent valuable to derive odds ratios for each criterion. Next, we constructed a composite league table - based on the sum score for the probability of selection - to rank potential interventions in five major disease areas. Results The group considered cost effectiveness, large individual benefits and severity of disease as the most important criteria in decision making. Priority interventions are those related to cardiovascular diseases and respiratory diseases. Less attractive interventions rank those related to mental health. Conclusions Norwegian policy makers' values are in agreement with principles formulated in national health laws. Multi-criteria decision approaches may provide a tool to support explicit allocation decisions.
Norell, Margaretha; Ziegert, Kristina; Kihlgren, Annica
Common in Swedish elderly home care is that Registered Nurses work independently, and lead the care team without being a part of it. People involved in the care of the patient can be social services, physician, Registered Nurse (RN), nurses in inpatient care and family. In according to current model for nursing documentation RNs interventions is described as participation, information/education, support, environment, general care, training, observation/surveillance, special care drug administration and coordination. Time pressure is perceived as high, but the nurses have the opportunity to influence their daily work situation and make priorities. The purpose of this study was to investigate how RNs prioritise interventions in municipal elderly care settings. A quantitative descriptive method was used for the study. Data were collected during the months of April and October 2004 - 2008, using a web-based form. The nurses filled in patient's type of housing, performed interventions, and if the interventions were delegated. Interventions were described as keywords and were attributed a certain amount of time, calculated in previous time studies. The inclusion criteria were: all patients 80 years of age and older, in a municipality in south-western Sweden, who received some form of health care from a RN, or performed by non-certified staff by delegation. Results indicate that differences in priority could be observed, depending on the patient's gender, or whether the patient was living in independent or sheltered housing. Drug administration was prioritised for female patients, while coordination became a priority for patients living in ordinary housing. Support received the highest priority, regardless if the patient lived in ordinary or sheltered housing. However, it is not entirely clear what support signifies in municipal health care settings, and this issue would therefore require further investigation.
Full Text Available Health care systems are faced with the challenge of resource scarcity and have insufficient resources to respond to all health problems and target groups simultaneously. Hence, priority setting is an inevitable aspect of every health system. However, priority setting is complex and difficult because the process is frequently influenced by political, institutional and managerial factors that are not considered by conventional priority-setting tools. In a five-year EU-supported project, which started in 2006, ways of strengthening fairness and accountability in priority setting in district health management were studied. This review is based on a PhD thesis that aimed to analyse health care organisation and management systems, and explore the potential and challenges of implementing Accountability for Reasonableness (A4R approach to priority setting in Tanzania. A qualitative case study in Mbarali district formed the basis of exploring the sociopolitical and institutional contexts within which health care decision making takes place. The study also explores how the A4R intervention was shaped, enabled and constrained by the contexts. Key informant interviews were conducted. Relevant documents were also gathered and group priority-setting processes in the district were observed. The study revealed that, despite the obvious national rhetoric on decentralisation, actual practice in the district involved little community participation. The assumption that devolution to local government promotes transparency, accountability and community participation, is far from reality. The study also found that while the A4R approach was perceived to be helpful in strengthening transparency, accountability and stakeholder engagement, integrating the innovation into the district health system was challenging. This study underscores the idea that greater involvement and accountability among local actors may increase the legitimacy and fairness of priority-setting
Cornelissen, Evelyn; Mitton, Craig; Davidson, Alan; Reid, Colin; Hole, Rachelle; Visockas, Anne-Marie; Smith, Neale
Purpose - Program budgeting and marginal analysis (PBMA) is a priority setting approach that assists decision makers with allocating resources. Previous PBMA work establishes its efficacy and indicates that contextual factors complicate priority setting, which can hamper PBMA effectiveness. The purpose of this paper is to gain qualitative insight into PBMA effectiveness. Design/methodology/approach - A Canadian case study of PBMA implementation. Data consist of decision-maker interviews pre (n=20), post year-1 (n=12) and post year-2 (n=9) of PBMA to examine perceptions of baseline priority setting practice vis-à-vis desired practice, and perceptions of PBMA usability and acceptability. Findings - Fit emerged as a key theme in determining PBMA effectiveness. Fit herein refers to being of suitable quality and form to meet the intended purposes and needs of the end-users, and includes desirability, acceptability, and usability dimensions. Results confirm decision-maker desire for rational approaches like PBMA. However, most participants indicated that the timing of the exercise and the form in which PBMA was applied were not well-suited for this case study. Participant acceptance of and buy-in to PBMA changed during the study: a leadership change, limited organizational commitment, and concerns with organizational capacity were key barriers to PBMA adoption and thereby effectiveness. Practical implications - These findings suggest that a potential way-forward includes adding a contextual readiness/capacity assessment stage to PBMA, recognizing organizational complexity, and considering incremental adoption of PBMA's approach. Originality/value - These insights help us to better understand and work with priority setting conditions to advance evidence-informed decision making.
“Personalised medicine” is currently attracting considerable attention and raising high hopes and expectations in modern medicine. The term “personalised medicine” denotes the use of genetic or other biomarker information, and it does not focus on a more personal patient-doctor relationship. Furthermore, personalised medicine is associated with ethical problems like priority setting and opportunity costs in solidarity-based public health care systems. Personalised medicine provides modern,...
Weale, Albert; Kieslich, Katharina; Littlejohns, Peter; Tugendhaft, Aviva; Tumilty, Emma; Weerasuriya, Krisantha; Whitty, Jennifer A
Purpose - The purpose of this paper is to introduce the special issue on improving equitable access to health care through increased public and patient involvement (PPI) in prioritization decisions by discussing the conceptualization, scope and rationales of PPI in priority setting that inform the special issue. Design/methodology/approach - The paper employs a mixed-methods approach in that it provides a literature review and a conceptual discussion of the common themes emerging in the field of PPI and health priority setting. Findings - The special issue focuses on public participation that is collective in character, in the sense that the participation relates to a social, not personal, decision and is relevant to whole groups of people and not single individuals. It is aimed at influencing a decision on public policy or legal rules. The rationales for public participation can be found in democratic theory, especially as they relate to the social and political values of legitimacy and representation. Originality/value - The paper builds on previous definitions of public participation by underlining its collective character. In doing so, it develops the work by Parry, Moyser and Day by arguing that, in light of the empirical evidence presented in this issue, public participatory activities such as protests and demonstrations should no longer be labelled unconventional, but should instead be labelled as "contestatory participation". This is to better reflect a situation in which these modes of participation have become more conventional in many parts of the world.
Full Text Available Abstract Background The Health-sector Wide (HsW priority setting model is designed to shift the focus of priority setting away from 'program budgets' – that are typically defined by modality or disease-stage – and towards well-defined target populations with a particular disease/health problem. Methods The key features of the HsW model are i a disease/health problem framework, ii a sequential approach to covering the entire health sector, iii comprehensiveness of scope in identifying intervention options and iv the use of objective evidence. The HsW model redefines the unit of analysis over which priorities are set to include all mutually exclusive and complementary interventions for the prevention and treatment of each disease/health problem under consideration. The HsW model is therefore incompatible with the fragmented approach to priority setting across multiple program budgets that currently characterises allocation in many health systems. The HsW model employs standard cost-utility analyses and decision-rules with the aim of maximising QALYs contingent upon the global budget constraint for the set of diseases/health problems under consideration. It is recognised that the objective function may include non-health arguments that would imply a departure from simple QALY maximisation and that political constraints frequently limit degrees of freedom. In addressing these broader considerations, the HsW model can be modified to maximise value-weighted QALYs contingent upon the global budget constraint and any political constraints bearing upon allocation decisions. Results The HsW model has been applied in several contexts, recently to osteoarthritis, that has demonstrated both its practical application and its capacity to derive clear evidenced-based policy recommendations. Conclusion Comparisons with other approaches to priority setting, such as Programme Budgeting and Marginal Analysis (PBMA and modality-based cost
Rogge, Jana; Kittel, Bernhard
The principle of distributing health care according to medical need is being challenged by increasing costs. As a result, many countries have initiated a debate on the introduction of explicit priority regulations based on medical, economic and person-based criteria, or have already established such regulations. Previous research on individual attitudes towards setting health care priorities based on medical and economic criteria has revealed consistent results, whereas studies on the use of person-based criteria have generated controversial findings. This paper examines citizens' attitudes towards three person-based priority criteria, patients' smoking habits, age and being the parent of a young child. Using data from the ISSP Health Module (2011) in 28 countries, logistic regression analysis demonstrates that self-interest as well as socio-demographic predictors significantly influence respondents' attitudes towards the use of person-based criteria for health care prioritization. This study contributes to resolving the controversial findings on person-based criteria by using a larger country sample and by controlling for country-level differences with fixed effects models.
Bukachi, Salome A.; Onyango-Ouma, Washington; Siso, Jared Maaka
In resource-poor settings, the accountability for reasonableness (A4R) has been identified as an important advance in priority setting that helps to operationalize fair priority setting in specific contexts. The four conditions of A4R are backed by theory, not evidence, that conformance with them...... improves the priority setting decisions. This paper describes the healthcare priority setting processes in Malindi district, Kenya, prior to the implementation of A4R in 2008 and evaluates the process for its conformance with the conditions for A4R. In-depth interviews and focus group discussions with key...... players in the Malindi district health system and a review of key policy documents and national guidelines show that the priority setting process in the district relies heavily on guidelines from the national level, making it more of a vertical, top-down orientation. Multilateral and donor agencies...
(CCL), Center for Creative Leadership
To be a successful leader, you need to get results. To get results, you need to set priorities. This book can help you do a better job of setting priorities, recognizing the personal values that motivate your decision making, the probable trade-offs and consequences of your decisions, and the importance of aligning your priorities with your organization's expectations. In this way you can successfully meet organizational objectives and consistently produce results.
Hansson, Sven Ove; Rudén, Christina
Due to the large number of chemicals for which toxicological and ecotoxicological information is lacking, priority setting for data acquisition is a major concern in chemicals regulation. In the current European system, two administrative priority-setting criteria are used, namely novelty (i.e., time of market introduction) and production volume. In the proposed Registration, Evaluation, Authorisation and Restriction of Chemicals (REACH) system, the novelty criterion is no longer used, and production volume will be the main priority-setting criterion for testing requirements, supplemented in some cases with hazard indications obtained from QSAR modelling. This system for priority setting has severe weaknesses. In this paper we propose that a multicriteria system should be developed that includes at least three additional criteria: chemical properties, results from initial testing in a tiered system, and voluntary testing for which efficient incentives can be created. Toxicological and decision-theoretical research is needed to design testing systems with validated priority-setting mechanisms.
Full Text Available In Sweden, an expected growing gap between available resources and greater potential for medical treatment has brought evidence-based guidelines and priority setting into focus. There are problems, however, in areas where the evidence base is weak and underlying ethical values are controversial. Based on a specified definition of multiple-diseased elderly patients, the aims of this study are: (i to describe and quantify inpatient care utilisation and patient characteristics, particularly regarding cardiovascular disease and co-morbidity; and (ii to question the applicability of evidence-based guidelines for these patients with regard to the reported characteristics (i.e. age and co-morbidity, and to suggest some possible strategies in order to tackle the described problem and the probable presence of ageism. We used data from three sources: (a a literature review, (b a register study, based on a unique population-based register of inpatient care in Sweden, and (c a national cost per patient database. The results show that elderly patients with multiple co-morbidities constitute a large and growing population in Swedish inpatient hospital care. They have multiple and complex needs and a large majority have a cardiovascular disease. There is a relationship between reported characteristics, i.e. age and co-morbidity, and limited applicability of evidence-based guidelines, and this can cause an under-use as well as an over-use of medical interventions. As future clinical studies will be rare due to methodological and financial factors, we consider it necessary to condense existing practical-clinical experiences of individual experts into consensus-based guidelines concerning elderly with multi-morbidity. In such priority setting, it will be important to consider co-morbidity and different degrees of frailty.
Chalkidou, Kalipso; Glassman, Amanda; Marten, Robert; Vega, Jeanette; Teerawattananon, Yot; Tritasavit, Nattha; Gyansa-Lutterodt, Martha; Seiter, Andreas; Kieny, Marie Paule; Hofman, Karen; Culyer, Anthony J
Governments in low- and middle-income countries are legitimizing the implementation of universal health coverage (UHC), following a United Nation's resolution on UHC in 2012 and its reinforcement in the sustainable development goals set in 2015. UHC will differ in each country depending on country contexts and needs, as well as demand and supply in health care. Therefore, fundamental issues such as objectives, users and cost-effectiveness of UHC have been raised by policy-makers and stakeholders. While priority-setting is done on a daily basis by health authorities - implicitly or explicitly - it has not been made clear how priority-setting for UHC should be conducted. We provide justification for explicit health priority-setting and guidance to countries on how to set priorities for UHC.
Hansen, Kristian Schultz; Chapman, Glyn
estimates of the burden of disease, the present paper developed packages of health interventions using the estimated cost-effectiveness ratios. These packages could avert a quarter of the burden of disease at total costs corresponding to one tenth of the public health budget in the financial year 1997...... if more research resources were available. Conclusions: The present study showed that it was feasible to conduct cost-effectiveness analyses for a large number of health interventions in a developing country like Zimbabwe using a consistent methodology.......Background: This study aimed at providing information for priority setting in the health care sector of Zimbabwe as well as assessing the efficiency of resource use. A general approach proposed by the World Bank involving the estimation of the burden of disease measured in Disability-Adjusted Life...
Hansen, Kristian Schultz; Chapman, Glyn
estimates of the burden of disease, the present paper developed packages of health interventions using the estimated cost-effectiveness ratios. These packages could avert a quarter of the burden of disease at total costs corresponding to one tenth of the public health budget in the financial year 1997...... if more research resources were available. CONCLUSION: The present study showed that it was feasible to conduct cost-effectiveness analyses for a large number of health interventions in a developing country like Zimbabwe using a consistent methodology.......BACKGROUND: This study aimed at providing information for priority setting in the health care sector of Zimbabwe as well as assessing the efficiency of resource use. A general approach proposed by the World Bank involving the estimation of the burden of disease measured in Disability-Adjusted Life...
Game, Edward T; Kareiva, Peter; Possingham, Hugh P
A vast number of prioritization schemes have been developed to help conservation navigate tough decisions about the allocation of finite resources. However, the application of quantitative approaches to setting priorities in conservation frequently includes mistakes that can undermine their authors' intention to be more rigorous and scientific in the way priorities are established and resources allocated. Drawing on well-established principles of decision science, we highlight 6 mistakes commonly associated with setting priorities for conservation: not acknowledging conservation plans are prioritizations; trying to solve an ill-defined problem; not prioritizing actions; arbitrariness; hidden value judgments; and not acknowledging risk of failure. We explain these mistakes and offer a path to help conservation planners avoid making the same mistakes in future prioritizations.
Goddard, Maria; Hauck, Katharina; Smith, Peter C
Most countries face high demands on their health care systems and have limited resources with which to meet them. Priority setting seeks to address these problems by proposing rules to decide which groups of patients or disease areas should secure favoured access to limited health care resources. The economic approach towards priority setting, particularly in the form of cost-effectiveness analysis, is commonly advocated. However, despite many decades of refinement of the technical and methodological issues arising from the use of economic evaluation in priority setting, decision makers continue to diverge frequently from the principles of economic evaluation. Our approach in this paper is to highlight the potential contribution of models of political economy to understanding what constitutes rational behaviour when agents operate within political and institutional constraints. We argue that there may be potentially greater benefits to be gained from exploration and analysis of priority setting using models based on concepts such as median voter and competing interest groups, than from further efforts to refine the techniques of economic evaluation.
Glassman, Amanda; Giedion, Ursula; McQueston, Kate
The use of health technology assessment research in emerging economies is becoming an increasingly important tool to determine the uses of health spending. As low- and middle-income countries' gross domestic product grows, the funding available for health has increased in tandem. There is growing evidence that comparative effectiveness research and cost-effectiveness can be used to improve health outcomes within a predefined financial space. The use of these evaluation tools, combined with a systematized process of priority setting, can help inform national and global health payers. This review of country institutions for health technology assessment illustrates two points: the efforts underway to use research to inform priorities are widespread and not confined to wealthier countries; and many countries' efforts to create evidence-based policy are incomplete and more country-specific research will be needed. Further evidence shows that there is scope to reduce these gaps and opportunity to support better incorporation of data through better-defined priority-setting processes.
Priority setting in health care is generally not done well. This paper draws on ideas from Amartya Sen and Martha Nussbaum and adds some communitarian underpinnings to provide a way of improving on current uses of program budgeting and marginal analysis (PBMA) in priority setting. The paper suggests that shifting to a communitarian base for priority setting alters the distribution of property rights over health service decision making and increases the probability that recommendations from PBMA exercises will be implemented. The approach is built on a paradigm which departs from three tenets of welfarism as it is normally conceived: (i) individuals qua individuals seek to maximise their individual utility/well-being; (ii) individuals want to do this; and (iii) it is the values of individuals qua individuals that count. Some of the problems of PBMA, as it has been applied to date, are highlighted. It is argued that these are due largely to a lack of 'credible commitment'. Bringing in the community and communitarian values to PBMA priority setting exercises can help to overcome some of the barriers to getting PBMA recommendations implemented. The approach has the merit of reflecting Sen's concept of capabilities (but extending that to a community level). It avoids the often consequentialist base of a conventional welfarist framework, and it allows community values as opposed to individual values to come to the fore. How to elicit communitarian values is explored.
In this paper David Canning argues that interventions against 'neglected' tropical diseases should be thought of as investments in human capital and form an integral part of global poverty reduction. He argues that overall burden of disease should not be the criterion for priority setting; if the goal is to maximize health benefits from a fixed health budget then cost-effective interventions should be prioritized. Whilst many people find objectionable the assignment of a monetary value to health, a cost-benefit approach, combining health and economic benefits, would allow the health sector to present arguments to policy makers, based on the rate of return on investment. Since many health interventions in low-income countries have exceptionally high rankings in terms of cost-benefit ratios, this should result in large flows from other sectors to the health sector.
Game, Edward T; Kareiva, Peter; Possingham, Hugh P
Abstract A vast number of prioritization schemes have been developed to help conservation navigate tough decisions about the allocation of finite resources. However, the application of quantitative approaches to setting priorities in conservation frequently includes mistakes that can undermine their authors’ intention to be more rigorous and scientific in the way priorities are established and resources allocated. Drawing on well-established principles of decision science, we highlight 6 mistakes commonly associated with setting priorities for conservation: not acknowledging conservation plans are prioritizations; trying to solve an ill-defined problem; not prioritizing actions; arbitrariness; hidden value judgments; and not acknowledging risk of failure. We explain these mistakes and offer a path to help conservation planners avoid making the same mistakes in future prioritizations. Seis Errores Comunes en la Definición de Prioridades de Conservación Resumen Se ha desarrollado un vasto número de esquemas de priorización para ayudar a que la conservación navegue entre decisiones difíciles en cuanto a la asignación de recursos finitos. Sin embargo, la aplicación de métodos cuantitativos para la definición de prioridades en la conservación frecuentemente incluye errores que pueden socavar la intención de sus autores de ser más rigurosos y científicos en la manera en que se establecen las prioridades y se asignan los recursos. Con base en los bien establecidos principios de la ciencia de la decisión, resaltamos seis errores comúnmente asociados con la definición de prioridades para la conservación: no reconocer que los planes de conservación son priorizaciones; tratar de resolver un problema mal definido; no priorizar acciones; arbitrariedad; juicios de valor ocultos y no reconocer el riesgo de fracasar. Explicamos estos errores y ofrecemos un camino para que planificadores de la conservación no cometan los mismos errores en priorizaciones
Successful leaders get results. To get results, you need to set priorities. This book can help you do a better job of setting priorities, recognizing the personal values that motivate your decision making, the probable trade-offs and consequences of your decisions, and the importance of aligning your priorities with your organization's…
Haelst, A.G. van; Hansen, B.G.
One of the four steps within Council Regulation 793/93/EEC on the evaluation and control of existing chemicals is the priority setting step. The priority setting step is concerned with selecting high-priority substances from a large number of substances, initially starting with 2,474 high-production
Kamuzora, Peter; Maluka, Stephen; Ndawi, Benedict
Community participation in priority setting in health systems has gained importance all over the world, particularly in resource-poor settings where governments have often failed to provide adequate public-sector services for their citizens. Incorporation of public views into priority setting...... of implementing community participation and the challenges of promoting it in the context of resource-poor settings, weak organizations, and fragile democratic institutions....... is perceived as a means to restore trust, improve accountability, and secure cost-effective priorities within healthcare. However, few studies have reported empirical experiences of involving communities in priority setting in developing countries. The aim of this article is to provide the experience...
Pornak, S; Meyer, T; Raspe, H
Priority setting in medicine helps to achieve a fair and transparent distribution of health-care resources. The German discussion about priority setting is still in its infancy and may benefit from other countries' experiences. This paper aims to analyse the Danish priority setting debate in order to stimulate the German discussion. The methods used are a literature analysis and a document analysis as well as expert interviews. The Danish debate about priority setting in medicine began in the 1970s, when a government committee was constituted to evaluate health-care priorities at the national level. In the 1980s a broader debate arose in politics, ethics, medicine and health economy. The discussions reached a climax in the 1990s, when many local activities - always involving the public - were initiated. Some Danish counties tried to implement priority setting in the daily routine of health care. The Council of Ethics was a major player in the debate of the 1990s and published a detailed statement on priority setting in 1996. With the new century the debate about priority setting seemed to have come to an end, but in 2006 the Technology Council and the Danish Regions resumed the discussion. In 2009 the Medical Association called for a broad debate in order to achieve equity among all patients. The long lasting Danish debate on priority setting has entailed only very little practical consequences on health care. The main problems seem to have been the missing effort to bundle the various local initiatives on a national level and the lack of powerful players to put results of the discussion into practice. Nevertheless, today the attitude towards priority setting is predominantly positive and even politicians talk freely about it.
Pornak, S C; Raspe, H
In the last years, the Danish debate about priority setting in medicine has gained new strength. This paper shows the main focuses of the current discussion based on a research of Danish primary literature. For the first time since the 1990s the Danish Council of Ethics has been involved with priority setting in medicine in a project running from 2011 to 2013. The Council emphasises the importance of legitimate processes and calls for visible values and criteria. A focus of the debate is how to deal with new expensive drugs. Politicians, physicians, health economists and the Council of Ethics have called for a national institution for priority setting in medicine. They have mainly looked to the Norwegian National Council for Priority Setting in Health Care and the British National Institute for Health and Care Excellence for inspiration. The Danish Government considered establishing a national institute for priority setting, but the plans were not put into practice. In the year 2012 a new national project was launched to create clinical guidelines. Danish doctors welcome the guidelines as a good basis for priority setting. Just like in earlier Danish priority setting debates, a coordinating institution is lacking to bundle the discussion and keep it going. The debate seems to have come to an end once again. The fact that it was seriously considered to establish an institute for priority setting is a new development. It can be expected that the discussion will be resumed in the near future, possibly the idea of an institute for priority setting will be readopted. The general conditions for priority setting in health care have improved.
Bennett Sara C
Full Text Available Abstract Health policy and systems research (HPSR has been identified as critical to scaling-up interventions to achieve the millennium development goals, but research priority setting exercises often do not address HPSR well. This paper aims to (i assess current priority setting methods and the extent to which they adequately include HPSR and (ii draw lessons regarding how HPSR priority setting can be enhanced to promote relevant HPSR, and to strengthen developing country leadership of research agendas. Priority setting processes can be distinguished by the level at which they occur, their degree of comprehensiveness in terms of the topic addressed, the balance between technical versus interpretive approaches and the stakeholders involved. When HPSR is considered through technical, disease-driven priority setting processes it is systematically under-valued. More successful approaches for considering HPSR are typically nationally-driven, interpretive and engage a range of stakeholders. There is still a need however for better defined approaches to enable research funders to determine the relative weight to assign to disease specific research versus HPSR and other forms of cross-cutting health research. While country-level research priority setting is key, there is likely to be a continued need for the identification of global research priorities for HPSR. The paper argues that such global priorities can and should be driven by country level priorities.
Global fiscal constraints mean that the UK healthcare system of the 21st century can no longer provide all possible services and treatment for all the people it serves. Currently, more than ever, there is a need to set priorities in terms of resources. The allocation of scarce healthcare resources will result in some care programmes being supported while others are not. Decision makers are increasingly engaging the public in policy making and priority-setting processes. Advocates of increased public engagement argue that public services are paid for by the people and, therefore, should be shaped more extensively by them, preferably by a fully representative sample. Central to the concept of public engagement is a desire for open dialogue and debate between groups that might not ordinarily have the channels to understand or speak to one another. Public engagement activities aim to link the healthcare community with the general public, community groups, civil society organisations and any other groups or communities in the outside world where healthcare decision-making gains its relevance. This article, therefore, aims to discuss the importance of promoting public engagement.
Arreskov, Anne Beiter; Graungaard, Anette Hauskov; Søndergaard, Jens;
to non-cancer patients. This could possibly be explained by changes in the patient’s priority setting perhaps resulting in comorbidities falling down the agenda. The purpose of this study is to explore priority settings of comorbid chronic diseases in patients who have completed primary cancer treatment...... priority setting of chronic diseases, most patients describe an unchanged focus and preoccupation compared to the time before cancer, and the chronic care follow-up visits are experienced as important regardless of the previous cancer diagnosis. Conclusion This study contributes with knowledge about health...
In 1989, the Space Studies Board created the Task Group on Priorities in Space Research to determine whether scientists should take a role in recommending priorities for long-term space research initiatives and, if so, to analyze the priority-setting problem in this context and develop a method by which such priorities could be established. After answering the first question in the affirmative in a previous report, the task group set out to accomplish the second task. The basic assumption in developing a priority-setting process is that a reasoned and structured approach for ordering competing initiatives will yield better results than other ways of proceeding. The task group proceeded from the principle that the central criterion for evaluating a research initiative must be its scientific merit -- the value of the initiative to the proposing discipline and to science generally. The group developed a two-stage methodology for priority setting and constructed a procedure and format to support the methodology. The first of two instruments developed was a standard format for structuring proposals for space research initiatives. The second instrument was a formal, semiquantitative appraisal procedure for evaluating competing proposals. This report makes available complete templates for the methodology, including the advocacy statement and evaluation forms, as well as an 11-step schema for a priority-setting process. From the beginning of its work, the task group was mindful that the issue of priority setting increasingly pervades all of federally supported science and that its work would have implications extending beyond space research. Thus, although the present report makes no recommendations for action by NASA or other government agencies, it provides the results of the task group's work for the use of others who may study priority-setting procedures or take up the challenge of implementing them in the future.
Majidi, A.; Ghiasvand, R.; Hadji, M.
, ICC has low incidence in Iran and many other Muslim countries. There is no organized cervical screening in these countries. Therefore, ICC is usually diagnosed in advanced stages with poor prognosis in these countries. We performed a priority setting exercise and suggested priorities for prevention...... of ICC in this setting. Methods: We invited experts and researchers to a workshop and asked them to list important suggestions for ICC prevention in Iran. After merging similar items and removing the duplicates, we asked the experts to rank the list of suggested items. We used a strategy grid and Go......-zone analysis to determine final list of priorities for ICC prevention in Iran. Results: From 26 final items suggested as priorities for prevention of ICC, the most important priorities were developing national guidelines for cervical screening and quality control protocol for patient follow-up and management...
Ottersen, Trygve; Førde, Reidun; Kakad, Meetali; Kjellevold, Alice; Melberg, Hans Olav; Moen, Atle; Ringard, Ånen; Norheim, Ole Frithjof
Health systems worldwide struggle to meet increasing demands for health care, and Norway is no exception. This paper discusses the new, comprehensive framework for priority setting recently laid out by the third Norwegian Committee on Priority Setting in the Health Sector. The framework posits that priority setting should pursue the goal of "the greatest number of healthy life years for all, fairly distributed" and centres on three criteria: 1) The health-benefit criterion: The priority of an intervention increases with the expected health benefit (and other relevant welfare benefits) from the intervention; 2) The resource criterion: The priority of an intervention increases, the less resources it requires; and 3) The health-loss criterion: The priority of an intervention increases with the expected lifetime health loss of the beneficiary in the absence of such an intervention. Cost-effectiveness plays a central role in this framework, but only alongside the health-loss criterion which incorporates a special concern for the worse off and promotes fairness. In line with this, cost-effectiveness thresholds are differentiated according to health loss. Concrete implementation tools and open processes with user participation complement the three criteria. Informed by the proposal, the Ministry of Health and Care Services is preparing a report to the Parliament, with the aim of reaching political consensus on a new priority-setting framework for Norway.
Full Text Available Abstract Background In recent years, decision makers in Canada and elsewhere have expressed a desire for more explicit, evidence-based approaches to priority setting. To achieve this aim within health care organizations, knowledge of both the organizational context and stakeholder attitudes towards priority setting are required. The current work adds to a limited yet growing body of international literature describing priority setting practices in health organizations. Methods A qualitative study was conducted using in-depth, face-to-face interviews with 25 key decision makers of the Provincial Health Services Authority (PHSA of British Columbia. Major themes and sub-themes were identified through content analysis. Results Priorities were described by decision makers as being set in an ad hoc manner, with resources generally allocated along historical lines. Participants identified the Strategic Plan and a strong research base as strengths of the organization. The main areas for improvement were a desire to have a more transparent process for priority setting, a need to develop a culture which supports explicit priority setting, and a focus on fairness in decision making. Barriers to an explicit allocation process included the challenge of providing specialized services for disparate patient groups, and a lack of formal training in priority setting amongst decision makers. Conclusion This study identified factors important to understanding organizational context and informed next steps for explicit priority setting for a provincial health authority. While the PHSA is unique in its organizational structure in Canada, lessons about priority setting should be transferable to other contexts.
Douw, Karla; Vondeling, Hindrik; Oortwijn, Wija
In the context of the establishment of a Danish Horizon Scanning System (HSS) the views of health care stakeholders and health economists were solicitated by means of postal survey on the need for adaptation of a priority setting instrument for health technology assessment (HTA). The aim was to i......In the context of the establishment of a Danish Horizon Scanning System (HSS) the views of health care stakeholders and health economists were solicitated by means of postal survey on the need for adaptation of a priority setting instrument for health technology assessment (HTA). The aim...
Full Text Available Abstract Background Priority setting in every health system is complex and difficult. In less wealthy countries the dominant approach to priority setting has been Burden of Disease (BOD and cost-effectiveness analysis (CEA, which is helpful, but insufficient because it focuses on a narrow range of values – need and efficiency – and not the full range of relevant values, including legitimacy and fairness. 'Accountability for reasonableness' is a conceptual framework for legitimate and fair priority setting and is empirically based and ethically justified. It connects priority setting to broader, more fundamental, democratic deliberative processes that have an impact on social justice and equity. Can 'accountability for reasonableness' be helpful for improving priority setting in less wealthy countries? Methods In 2005, Tanzanian scholars from the Primary Health Care Institute (PHCI conducted 6 capacity building workshops with senior health staff, district planners and managers, and representatives of the Tanzanian Ministry of Health to discussion improving priority setting in Tanzania using 'accountability for reasonableness'. The purpose of this paper is to describe this initiative and the participants' views about the approach. Results The approach to improving priority setting using 'accountability for reasonableness' was viewed by district decision makers with enthusiastic favour because it was the first framework that directly addressed their priority setting concerns. High level Ministry of Health participants were also very supportive of the approach. Conclusion Both Tanzanian district and governmental health planners viewed the 'accountability for reasonableness' approach with enthusiastic favour because it was the first framework that directly addressed their concerns.
Arreskov, Anne Beiter; Graungaard, Anette Hauskov; Søndergaard, Jens
Priority setting in patients with cancer and comorbidities Background and aim As both the cancer incidence and the number of patients diagnosed with chronic diseases are increasing, a growing population of cancer survivors will also deal with comorbid chronic diseases. The period after completed...... to comorbidities. Some studies show that participation in regular follow-up consultations concerning comorbid chronic diseases and lifestyle are lower among cancer survivors than non-cancer patients. This could be explained by changes in the patient’s priority setting or in the doctor’s priority and attempt...... datasets: 1) video recordings of consultations in general practice, 2) semi-structured interviews with patients who have a chronic disease and who have recently finished primary treatment for a non-metastatic cancer, 3) semi-structured interviews with general practitioners. Video recordings...
Full Text Available Background Cervical cancer is the fourth most common cancer among women worldwide. Organized cervical screening and vaccination against human papilloma virus (HPV have been successful interventions for prevention of invasive cervical cancer (ICC. Because of cultural and religious considerations, ICC has low incidence in Iran and many other Muslim countries. There is no organized cervical screening in these countries. Therefore, ICC is usually diagnosed in advanced stages with poor prognosis in these countries. We performed a priority setting exercise and suggested priorities for prevention of ICC in this setting. Methods We invited experts and researchers to a workshop and asked them to list important suggestions for ICC prevention in Iran. After merging similar items and removing the duplicates, we asked the experts to rank the list of suggested items. We used a strategy grid and Go-zone analysis to determine final list of priorities for ICC prevention in Iran. Results From 26 final items suggested as priorities for prevention of ICC, the most important priorities were developing national guidelines for cervical screening and quality control protocol for patient follow-up and management of precancerous lesions. In addition, we emphasized considering insurance coverage for cervical screening, public awareness, and research priorities, and establishment of a cervical screening registry. Conclusion A comprehensive approach and implementation of organized cervical screening program is necessary for prevention of ICC in Iran and other low incidence Muslim countries. Because of high cost for vaccination and low incidence of cervical cancer, we do not recommend HPV vaccination for the time being in Iran.
Fábio Alexandre Melo do Rego Sousa
Full Text Available ABSTRACT OBJECTIVE To describe the methodology used in the process of setting health priorities for community intervention in a community of older adults. METHODS Based on the results of a health diagnosis related to active aging, a prioritization process was conceived to select the priority intervention problem. The process comprised four successive phases of problem analysis and classification: (1 grouping by level of similarity, (2 classification according to epidemiological criteria, (3 ordering by experts, and (4 application of the Hanlon method. These stages combined, in an integrated manner, the views of health team professionals, community nursing and gerontology experts, and the actual community. RESULTS The first stage grouped the identified problems by level of similarity, comprising a body of 19 issues for analysis. In the second stage these problems were classified by the health team members by epidemiological criteria (size, vulnerability, and transcendence. The nine most relevant problems resulting from the second stage of the process were submitted to expert analysis and the five most pertinent problems were selected. The last step identified the priority issue for intervention in this specific community with the participation of formal and informal community leaders: Low Social Interaction in Community Participation. CONCLUSIONS The prioritization process is a key step in health planning, enabling the identification of priority problems to intervene in a given community at a given time. There are no default formulas for selecting priority issues. It is up to each community intervention team to define its own process with different methods/techniques that allow the identification of and intervention in needs classified as priority by the community.
Sousa, Fábio Alexandre Melo do Rego; Goulart, Maria José Garcia; Braga, Antonieta Manuela dos Santos; Medeiros, Clara Maria Oliveira; Rego, Débora Cristina Martins; Vieira, Flávio Garcia; Pereira, Helder José Alves da Rocha; Tavares, Helena Margarida Correia Vicente; Loura, Marta Maria Puim
ABSTRACT OBJECTIVE To describe the methodology used in the process of setting health priorities for community intervention in a community of older adults. METHODS Based on the results of a health diagnosis related to active aging, a prioritization process was conceived to select the priority intervention problem. The process comprised four successive phases of problem analysis and classification: (1) grouping by level of similarity, (2) classification according to epidemiological criteria, (3) ordering by experts, and (4) application of the Hanlon method. These stages combined, in an integrated manner, the views of health team professionals, community nursing and gerontology experts, and the actual community. RESULTS The first stage grouped the identified problems by level of similarity, comprising a body of 19 issues for analysis. In the second stage these problems were classified by the health team members by epidemiological criteria (size, vulnerability, and transcendence). The nine most relevant problems resulting from the second stage of the process were submitted to expert analysis and the five most pertinent problems were selected. The last step identified the priority issue for intervention in this specific community with the participation of formal and informal community leaders: Low Social Interaction in Community Participation. CONCLUSIONS The prioritization process is a key step in health planning, enabling the identification of priority problems to intervene in a given community at a given time. There are no default formulas for selecting priority issues. It is up to each community intervention team to define its own process with different methods/techniques that allow the identification of and intervention in needs classified as priority by the community. PMID:28273229
Upshur Ross EG
Full Text Available Abstract Background Priority setting is one of the most difficult issues facing hospitals because of funding restrictions and changing patient need. A deadly communicable disease outbreak, such as the Severe Acute Respiratory Syndrome (SARS in Toronto in 2003, amplifies the difficulties of hospital priority setting. The purpose of this study is to describe and evaluate priority setting in a hospital in response to SARS using the ethical framework 'accountability for reasonableness'. Methods This study was conducted at a large tertiary hospital in Toronto, Canada. There were two data sources: 1 over 200 key documents (e.g. emails, bulletins, and 2 35 interviews with key informants. Analysis used a modified thematic technique in three phases: open coding, axial coding, and evaluation. Results Participants described the types of priority setting decisions, the decision making process and the reasoning used. Although the hospital leadership made an effort to meet the conditions of 'accountability for reasonableness', they acknowledged that the decision making was not ideal. We described good practices and opportunities for improvement. Conclusions 'Accountability for reasonableness' is a framework that can be used to guide fair priority setting in health care organizations, such as hospitals. In the midst of a crisis such as SARS where guidance is incomplete, consequences uncertain, and information constantly changing, where hour-by-hour decisions involve life and death, fairness is more important rather than less.
Goldberg, Daniel S
Application of fundamental cause theory to Powers and Faden's model of social justice highlights the ethical superiority of upstream public health interventions. In this article, I assess the ramifications of fundamental cause theory specifically in context of public health priority setting. Ethically optimal public health policy simultaneously maximizes overall population health and compresses health inequalities. The fundamental cause theory is an important framework in helping to identify which categories of public health interventions are most likely to advance these twin goals.
Colenbrander, Sarah; Birungi, Charles; Mbonye, Anthony K
Health priority setting is a critical and contentious issue in low-income countries because of the high burden of disease relative to the limited resource envelope. Many sophisticated quantitative tools and policy frameworks have been developed to promote transparent priority setting processes and allocative efficiency. However, low-income countries frequently lack effective governance systems or implementation capacity, so high-level priorities are not determined through evidence-based decision-making processes. This study uses qualitative research methods to explore how key actors' priorities differ in low-income countries, using Uganda as a case study. Human resources for health, disease prevention and family planning emerge as the common priorities among actors in the health sector (although the last of these is particularly emphasized by international agencies) because of their contribution to the long-term sustainability of health-care provision. Financing health-care services is the most disputed issue. Participants from the Ugandan Ministry of Health preferentially sought to increase net health expenditure and government ownership of the health sector, while non-state actors prioritized improving the efficiency of resource use. Ultimately it is apparent that the power to influence national health outcomes lies with only a handful of decision-makers within key institutions in the health sector, such as the Ministries of Health, the largest bilateral donors and the multilateral development agencies. These power relations reinforce the need for ongoing research into the paradigms and strategic interests of these actors.
Full Text Available Abstract Background Decisions regarding the allocation of available resources are a source of growing dissatisfaction for healthcare decision-makers. This dissatisfaction has led to increased interest in research on evidence-based resource allocation processes. An emerging area of interest has been the empirical analysis of the characteristics of existing and desired priority setting processes from the perspective of decision-makers. Methods We conducted in-depth, face-to-face interviews with 18 senior managers and medical directors with the Vancouver Island Health Authority, an integrated health care provider in British Columbia responsible for a population of approximately 730,000. Interviews were transcribed and content-analyzed, and major themes and sub-themes were identified and reported. Results Respondents identified nine key features of a desirable priority setting process: inclusion of baseline assessment, use of best evidence, clarity, consistency, clear and measurable criteria, dissemination of information, fair representation, alignment with the strategic direction and evaluation of results. Existing priority setting processes were found to be lacking on most of these desired features. In addition, respondents identified and explicated several factors that influence resource allocation, including political considerations and organizational culture and capacity. Conclusion This study makes a contribution to a growing body of knowledge which provides the type of contextual evidence that is required if priority setting processes are to be used successfully by health care decision-makers.
Jansen, Maarten P.; Helderman, Jan-Kees; Boer, Bert; Baltussen, Rob
Embedding health technology assessment (HTA) in a fair process has great potential to capture societal values relevant to public reimbursement decisions on health technologies. However, the development of such processes for priority setting has largely been theoretical. In this paper, we provide further practical lead ways on how these processes can be implemented. We first present the misconception about the relation between facts and values that is since long misleading the conduct of HTA and underlies the current assessment-appraisal split. We then argue that HTA should instead be explicitly organized as an ongoing evidence-informed deliberative process, that facilitates learning among stakeholders. This has important consequences for whose values to consider, how to deal with vested interests, how to consider all values in the decision-making process, and how to communicate decisions. This is in stark contrast to how HTA processes are implemented now. It is time to set the stage for HTA as learning. PMID:28005541
Full Text Available Abstract Background It is estimated that more than $130 billion is invested globally into health research each year. Increasingly, there is a need to set priorities in health research investments in a fair and legitimate way, using a sound and transparent methodology. In this paper we review selected priority setting processes at national level in low and middle income countries. We outline a set of criteria to assess the process of research priority setting and use these to describe and evaluate priority setting exercises that have taken place at country level. Based on these insights, recommendations are made regarding the constituents of a good priority setting process. Methods Data were gathered from presentations at a meeting held at the World Health Organization (WHO in 2008 and a web-based search. Based on this literature review a number of criteria were developed to evaluate the priority setting processes. Results Across the countries surveyed there was a relative lack of genuine stakeholder engagement; countries varied markedly in the extent to which the priority setting processes were documented; none of the countries surveyed had a systematic or operational appeals process for outlined priorities; and in all countries (except South Africa the priorities that were outlined described broad disease categories rather than specific research questions. Conclusions Country level priority setting processes differed significantly in terms of the methods used. We argue that priority setting processes must have in-built mechanisms for publicizing results, effective procedures to enforce decisions as well as processes to ensure that the revision of priorities happens in practice.
Husting, P M; Alderman, M
Nurses' increasing age coupled with health care's rapidly changing environment moves succession planning, originally only a business sector tool, to a top administrative priority. Through active support of your facility's executive leadership and a clear linkage to long range organization objectives, you can implement this progressive procedure.
Chappel, D; Bailey, J; Stacy, R; Rodgers, H; Thomson, R
We aimed to develop and evaluate a prioritisation process to combine the evidence base with stakeholder involvement within a stroke programme for a Health Improvement Programme (HImP). Implementation involved: formation of a district stroke group (DSG); review of the evidence; survey of DSG members; survey of other key professionals; consensus within the DSG; consultation with local users of the service. Evaluation was through semi-structured interviews and documentary analysis. The process was accepted as appropriate and valuable by the majority of participants, and a district HImP implementation group allocated pound sterling 100 000 for stroke development as a result of this process. However, some felt that stroke itself had been an imposed, rather than an agreed, local priority. The priority setting process was not clear to all participants and change of personnel, particularly in the NHS trusts, led to some perceived lack of ownership. Professionals from secondary care participated, but later criticised the process when they felt that the priorities in the HImP could limit their ability to access money for other service developments. The user consultation days occurred too late to influence the 1999/2002 HImP. We have shown that it is possible to develop an approach that is broadly accepted by stakeholders and balance the evidence base with local ownership. The participation of stakeholders, clarity of procedures, local ownership and awareness of local politics are important in effective priority setting. The model developed will be of value in other settings.
Zulu, Joseph M.; Michelo, Charles; Msoni, Carol
to enhance legitimate and fair PS was introduced by researchers and decision makers within the health sector in the EU funded research project entitled 'Response to Accountable priority setting for Trust in health systems' (REACT). The project aimed to strengthen fairness and accountability in the PS...... by the present project with its emphasis on fairness and enhanced participation. A responsive leadership that was increasingly accountable to its operational staff and communities emerged as one of the key elements in driving the processes forward....... processes of health systems at district level in Zambia, Tanzania and Kenya. This paper focuses on local perceptions and practices of fair PS (baseline study) as well as at the evolution of such perceptions and practices in PS following an AFR based intervention (evaluation study), carried out at district...
Kang, Minah; Reich, Michael R
Priority-setting involves diverse parties with intense and often conflicting interests and values. Still, the political aspects of priority-setting are largely unexplored in the literature on health policy. In this paper, we examine how policy makers in Korea changed their strategies as the policy context for priority setting changed from only expanding benefits to a double burden of benefit expansion plus cost containment. This analysis shows that priority-setting is a profoundly political process. The policy context shapes how policy makers choose their political strategies. In particular, we find that policy makers sway between "credit claiming" and "blame avoidance" strategies. Korean policy makers resorted to three types of political strategies when confronted with a double burden of benefit expansion and cost containment: delegating responsibility to other institutions (agency strategies), replacing judgment-based decisions with automatic rules (policy strategies), and focusing on the presentation of how decisions are made (presentational strategies). The paper suggests implications for future studies on priority-setting in the Korean health care system and in other countries that face similar challenges, and concludes that Korean policy makers need to put more effort into developing transparent and systematic priority-setting processes, especially in times of double burden of benefit expansion and cost containment.
De Coster, Carolyn; Fitzgerald, Avril; Cepoiu, Monica
As part of a larger body of work to develop a rheumatology priority referral score, a literature review was conducted. The objective of the literature review was to identify preexisting priority-setting, triage, and referral tools/scales developed to guide referrals from primary care to specialist care/consultation usually provided by a rheumatologist. Using a combination of database, citation, Internet, and hand-searching, 20 papers were identified that related to referral prioritization in three areas: rheumatoid arthritis (RA; 5), musculoskeletal (MSK) diseases other than RA (3), and MSK diseases in general (12). No single set of priority-setting criteria was identified for rheumatologic disorders across the spectrum of patients who may be referred from primary care providers (PCPs) to rheumatologists. There appears to be more congruence on conditions at either end of the urgency spectrum with conditions such as suspected cranial arteritis or systemic vasculitis deemed to be emergency referrals and fibromyalgia and other soft-tissue syndromes deemed to be more routine referrals. Between these two extremes, there is a divergence of opinion about urgency and few papers on the issue. The exception to this is referral for early RA for which several criteria have been established. Despite the inherent complexities in developing a tool to prioritize patients referred by PCPs to rheumatologists, there are compelling reasons to proceed. With the aging of the population, the number of patients being referred to rheumatologists is expected to increase. With pharmaceutical advances, there are demonstrable benefits in early referral for some conditions. These trends have led to increased pressure on scarce rheumatological human resources. A tool to prioritize referrals is a critical component of improving access and the referral process.
Byskov, Jens; Marchal, Bruno; Maluka, Stephen;
BACKGROUND: Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions...... of the potential of AFR in supporting priority-setting and other decision-making processes in health systems to achieve better agreed and more sustainable health improvements linked to a mutual democratic learning with potential wider implications....
Edwine W. Barasa
Full Text Available Background Priority setting in healthcare is a key determinant of health system performance. However, there is no widely accepted priority setting evaluation framework. We reviewed literature with the aim of developing and proposing a framework for the evaluation of macro and meso level healthcare priority setting practices. Methods We systematically searched Econlit, PubMed, CINAHL, and EBSCOhost databases and supplemented this with searches in Google Scholar, relevant websites and reference lists of relevant papers. A total of 31 papers on evaluation of priority setting were identified. These were supplemented by broader theoretical literature related to evaluation of priority setting. A conceptual review of selected papers was undertaken. Results Based on a synthesis of the selected literature, we propose an evaluative framework that requires that priority setting practices at the macro and meso levels of the health system meet the following conditions: (1 Priority setting decisions should incorporate both efficiency and equity considerations as well as the following outcomes; (a Stakeholder satisfaction, (b Stakeholder understanding, (c Shifted priorities (reallocation of resources, and (d Implementation of decisions. (2 Priority setting processes should also meet the procedural conditions of (a Stakeholder engagement, (b Stakeholder empowerment, (c Transparency, (d Use of evidence, (e Revisions, (f Enforcement, and (g Being grounded on community values. Conclusion Available frameworks for the evaluation of priority setting are mostly grounded on procedural requirements, while few have included outcome requirements. There is, however, increasing recognition of the need to incorporate both consequential and procedural considerations in priority setting practices. In this review, we adapt an integrative approach to develop and propose a framework for the evaluation of priority setting practices at the macro and meso levels that draws from
Zuber, P L; Dignam, T A; Caldwell, M B; Wiesner, P J
National data sets are often insufficient for priority setting by local public health systems and the communities they serve. We used marketing data to conduct an ecological analysis of hospital discharge rates in DeKalb County, Georgia, during 1996. Persons living in poorer areas had significantly higher discharge rates for the following conditions: hypertensive disease, blood-related conditions, pneumonia/influenza, diabetes, and chronic obstructive pulmonary diseases. Local marketing data helped identify conditions associated with higher hospital utilization in poorer areas of this urban county. This identification of priority issues informs plans for behavior modification, access to primary care and a healthy environment.
Priority in ICU care of multiple trauma should be given to shock, respiratory failure, intracranial hypertension, and the identification of occult injuries. Diagnosis and treatment must occur simultaneously. If metabolic acidosis and hyperlactatemia persist despite normalization of vital signs, prolonged hypoperfusion may exist. Threshold of treatment for intracranial hypertension is 15 to 25 mmHg in accompanied traumatic brain injury. Stabilization of ABCDE should be prioritized in first 24 hours, followed by controlling double I (infection and ischemia). Early enteral nutrition has been estimated to reduce the incidence of infectious complication.
Silva Diego S
Full Text Available Abstract Background Pandemic influenza may exacerbate existing scarcity of life-saving medical resources. As a result, decision-makers may be faced with making tough choices about who will receive care and who will have to wait or go without. Although previous studies have explored ethical issues in priority setting from the perspective of clinicians and policymakers, there has been little investigation into how the public views priority setting during a pandemic influenza, in particular related to intensive care resources. Methods To bridge this gap, we conducted three public town hall meetings across Canada to explore Canadian's perspectives on this ethical challenge. Town hall discussions group discussions were digitally recorded, transcribed, and analyzed using thematic analysis. Results Six interrelated themes emerged from the town hall discussions related to: ethical and empirical starting points for deliberation; criteria for setting priorities; pre-crisis planning; in-crisis decision-making; the need for public deliberation and input; and participants' deliberative struggle with the ethical issues. Conclusions Our findings underscore the importance of public consultation in pandemic planning for sustaining public trust in a public health emergency. Participants appreciated the empirical and ethical uncertainty of decision-making in an influenza pandemic and demonstrated nuanced ethical reasoning about priority setting of intensive care resources in an influenza pandemic. Policymakers may benefit from a better understanding the public's empirical and ethical 'starting points' in developing effective pandemic plans.
Members of the public can adopt any one of at least three roles when providing input to public decision-making: taxpayer, collective community decision-maker, or patient. Each of these potential roles can be mapped onto three areas of public policy decision-making in health care: funding levels and organization for the system, the services we choose to offer under public funding, and the characteristics of those who should receive the offered services. The increasing desire to involve the public across the spectrum of health care decision-making has yet to result in a clear delineation of either which of the areas are most appropriate for public input or which of the roles we wish individual participants to adopt. The average citizen (as opposed to the self-interested patient, the provider or the manager) has so far shown little interest in contributing and rarely has the requisite skills for most of the tasks asked of him or her. The widespread motivation of governments and others for seeking public input appears to be to get the public to take or share ownership in the tough rationing choices consequent on fiscal retrenchment in health care. Evaluation of existing literature leads to the conclusion that there are only limited areas where we might wish to obtain significant public input if we adopt this widespread policy motivation. Specifically, the general public should be asked to give input to, but not determine, priorities across the broad service categories that could potentially be publicly funded. Members of the public have neither the interest nor the skills to do this at the level of specific services. The role expected of such members of the public should be made explicit and should focus on collective views of the community good rather than self-interested views of individual benefit. Groups of patients, however, should be the source of input when socio-demographic characteristics are being used to decide who should receive offered services. The role
Maluka, Stephen; Kamuzora, Peter; Sebastián, Miguel San
In 2006, researchers and decision-makers launched a five-year project - Response to Accountable Priority Setting for Trust in Health Systems (REACT) - to improve planning and priority-setting through implementing the Accountability for Reasonableness framework in Mbarali District, Tanzania...
Byskov, Jens; Marchal, Bruno; Maluka, Stephen
BACKGROUND: Priority-setting decisions are based on an important, but not sufficient set of values and thus lead to disagreement on priorities. Accountability for Reasonableness (AFR) is an ethics-based approach to a legitimate and fair priority-setting process that builds upon four conditions......: relevance, publicity, appeals, and enforcement, which facilitate agreement on priority-setting decisions and gain support for their implementation. This paper focuses on the assessment of AFR within the project REsponse to ACcountable priority setting for Trust in health systems (REACT). METHODS......-aligned with general values expressed by both service providers and community representatives. There was some variation in the interpretations and actual use of the AFR in the decision-making processes in the three districts, and its effect ranged from an increase in awareness of the importance of fairness...
Full Text Available Abstract Background The World Health Organization (WHO, like many other organisations around the world, has recognised the need to use more rigorous processes to ensure that health care recommendations are informed by the best available research evidence. This is the second of a series of 16 reviews that have been prepared as background for advice from the WHO Advisory Committee on Health Research to WHO on how to achieve this. Objectives We reviewed the literature on priority setting for health care guidelines, recommendations and technology assessments. Methods We searched PubMed and three databases of methodological studies for existing systematic reviews and relevant methodological research. We did not conduct systematic reviews ourselves. Our conclusions are based on the available evidence, consideration of what WHO and other organisations are doing and logical arguments. Key questions and answers There is little empirical evidence to guide the choice of criteria and processes for establishing priorities, but there are broad similarities in the criteria that are used by various organisations and practical arguments for setting priorities explicitly rather than implicitly, What criteria should be used to establish priorities? • WHO has limited resources and capacity to develop recommendations. It should use these resources where it has the greatest chance of improving health, equity, and efficient use of healthcare resources. • We suggest the following criteria for establishing priorities for developing recommendations based on WHO's aims and strategic advantages: • Problems associated with a high burden of illness in low and middle-income countries, or new and emerging diseases. • No existing recommendations of good quality. • The feasibility of developing recommendations that will improve health outcomes, reduce inequities or reduce unnecessary costs if they are implemented. • Implementation is feasible, will not exhaustively
Dutton, John A.; Abelson, Philip H.; Beckwith, Steven V. W.; Bishop, William P.; Byerly, Radford, Jr.; Crowe, Lawson; Dews, Peter; Garriott, Owen K.; Lunine, Jonathan; Macauley, Molly K.
This report represents the first phase of a study by a task group convened by the Space Studies Board to ascertain whether it should attempt to develop a methodology for recommending priorities among the various initiatives in space research (that is, scientific activities concerned with phenomena in space or utilizing observations from space). The report argues that such priority statements by the space research community are both necessary and desirable and would contribute to the formulation and implementation of public policy. The report advocates the establishment of priorities to enhance effective management of the nation's scientific research program in space. It argues that scientific objectives and purposes should determine how and under what circumstances scientific research should be done. The report does not take a position on the controversy between advocates of manned space exploration and those who favor the exclusive use of unmanned space vehicles. Nor does the report address questions about the value or appropriateness of Space Station Freedom or proposals to establish a permanent manned Moon base or to undertake a manned mission to Mars. These issues lie beyond the charge to the task group.
Terry Robert F
Full Text Available Abstract Health research priority setting processes assist researchers and policymakers in effectively targeting research that has the greatest potential public health benefit. Many different approaches to health research prioritization exist, but there is no agreement on what might constitute best practice. Moreover, because of the many different contexts for which priorities can be set, attempting to produce one best practice is in fact not appropriate, as the optimal approach varies per exercise. Therefore, following a literature review and an analysis of health research priority setting exercises that were organized or coordinated by the World Health Organization since 2005, we propose a checklist for health research priority setting that allows for informed choices on different approaches and outlines nine common themes of good practice. It is intended to provide generic assistance for planning health research prioritization processes. The checklist explains what needs to be clarified in order to establish the context for which priorities are set; it reviews available approaches to health research priority setting; it offers discussions on stakeholder participation and information gathering; it sets out options for use of criteria and different methods for deciding upon priorities; and it emphasizes the importance of well-planned implementation, evaluation and transparency.
Full Text Available Background: Community participation in priority setting in health systems has gained importance all over the world, particularly in resource-poor settings where governments have often failed to provide adequate public-sector services for their citizens. Incorporation of public views into priority setting is perceived as a means to restore trust, improve accountability, and secure cost-effective priorities within healthcare. However, few studies have reported empirical experiences of involving communities in priority setting in developing countries. The aim of this article is to provide the experience of implementing community participation and the challenges of promoting it in the context of resource-poor settings, weak organizations, and fragile democratic institutions. Design: Key informant interviews were conducted with the Council Health Management Team (CHMT, community representatives, namely women, youth, elderly, disabled, and people living with HIV/AIDS, and other stakeholders who participated in the preparation of the district annual budget and health plans. Additionally, minutes from the Action Research Team and planning and priority-setting meeting reports were analyzed. Results: A number of benefits were reported: better identification of community needs and priorities, increased knowledge of the community representatives about priority setting, increased transparency and accountability, promoted trust among health systems and communities, and perceived improved quality and accessibility of health services. However, lack of funds to support the work of the selected community representatives, limited time for deliberations, short notice for the meetings, and lack of feedback on the approved priorities constrained the performance of the community representatives. Furthermore, the findings show the importance of external facilitation and support in enabling health professionals and community representatives to arrive at effective
Maluka, Stephen; Kamuzora, Peter; Sebastián, Miguel San;
In 2006, researchers and decision-makers launched a five-year project - Response to Accountable Priority Setting for Trust in Health Systems (REACT) - to improve planning and priority-setting through implementing the Accountability for Reasonableness framework in Mbarali District, Tanzania....... The objective of this paper is to explore the acceptability of Accountability for Reasonableness from the perspectives of the Council Health Management Team, local government officials, health workforce and members of user boards and committees....
Doherty, W J; Colangelo, N; Hovander, D
We update a theoretical framework for understanding priority setting for the management of family change, with special emphasis on developmental change. We propose that three core dimensions of family interaction--inclusion, control, and intimacy--constitute an optimal priority sequence for managing major family change stemming from life-cycle transitions and other stressful experiences. In the next section of the article, we compare the Family FIRO Model and other models of family change. Finally, we suggest that therapists can benefit from an explicit, clinical decision-making model for setting priorities in treatment: issues of inclusion take precedence over issues of control, which in turn take precedence over issues of intimacy.
Kelly, R Patrick; Stoll, Shelley C; Bryant-Stephens, Tyra; Janevic, Mary R; Lara, Marielena; Ohadike, Yvonne U; Persky, Victoria; Ramos-Valencia, Gilberto; Uyeda, Kimberly; Malveaux, Floyd J
Asthma affects 7.1 million children in the United States, disproportionately burdening African American and Latino children. Barriers to asthma control include insufficient patient education and fragmented care. Care coordination represents a compelling approach to improve quality of care and address disparities in asthma. The sites of The Merck Childhood Asthma Network Care Coordination Programs implemented different models of care coordination to suit specific settings-school district, clinic or health care system, and community-and organizational structures. A variety of qualitative data sources were analyzed to determine the role setting played in the manifestation of care coordination at each site. There were inherent strengths and challenges of implementing care coordination in each of the settings, and each site used unique strategies to deliver their programs. The relationship between the lead implementing unit and entities that provided (1) access to the priority population and (2) clinical services to program participants played a critical role in the structure of the programs. The level of support and infrastructure provided by these entities to the lead implementing unit influenced how participants were identified and how asthma care coordinators were integrated into the clinical care team.
Norheim, Ole F
Priority setting is inevitable on the path towards universal health coverage. All countries experience a gap between their population's health needs and what is economically feasible for governments to provide. Can priority setting ever be fair and ethically acceptable? Fairness requires that unmet health needs be addressed, but in a fair order. Three criteria for priority setting are widely accepted among ethicists: cost-effectiveness, priority to the worse-off, and financial risk protection. Thus, a fair health system will expand coverage for cost-effective services and give extra priority to those benefiting the worse-off, whilst at the same time providing high financial risk protection. It is considered unacceptable to treat people differently according to their gender, race, ethnicity, religion, sexual orientation, social status, or place of residence. Inequalities in health outcomes associated with such personal characteristics are therefore unfair and should be minimized. This commentary also discusses a third group of contested criteria, including rare diseases, small health benefits, age, and personal responsibility for health, subsequently rejecting them. In conclusion, countries need to agree on criteria and establish transparent and fair priority setting processes.
Rudan, Igor; Gibson, Jennifer; Kapiriri, Lydia; Lansang, Mary Ann; Hyder, Adnan A; Lawn, Joy; Darmstadt, Gary L; Cousens, Simon; Bhutta, Zulfiqar A; Brown, Kenneth H; Hess, Sonja Y; Black, Maureen; Gardner, Julie Meeks; Webster, Jayne; Carneiro, Ilona; Chandramohan, Daniel; Kosek, Margaret; Lanata, Claudio F; Tomlinson, Mark; Chopra, Mickey; Ameratunga, Shanthi; Campbell, Harry; El Arifeen, Shams; Black, Robert E
This article reviews theoretical and practical approaches for setting priorities in global child health research investments. It also provides an overview of previous attempts to develop appropriate tools and methodologies to define priorities in health research investments. A brief review of the most important theoretical concepts that should govern priority setting processes is undertaken, showing how different perspectives, such as medical, economical, legal, ethical, social, political, rational, philosophical, stakeholder driven, and others will necessarily conflict each other in determining priorities. We specially address present research agenda in global child health today and how it relates to United Nation's (UN) Millennium Development Goal 4, which is to reduce child mortality by two-thirds between 1990 and 2015. The outcomes of these former approaches are evaluated and their benefits and shortcomings presented. The case for a new methodology for setting priorities in health research investments is presented, as proposed by Child Health and Nutrition Research Initiative, and a need for its implementation in global child health is outlined. A transdisciplinary approach is needed to address all the perspectives from which investments into health research can be seen as priorities. This prioritization requires a process that is transparent, systematic, and that would take into account many perspectives and build on advantages of previous approaches.
Full Text Available Setting health research priorities is a complex and value–driven process. The introduction of the Child Health and Nutrition Research Initiative (CHNRI method has made the process of setting research priorities more transparent and inclusive, but much of the process remains in the hands of funders and researchers, as described in the previous two papers in this series. However, the value systems of numerous other important stakeholders, particularly those on the receiving end of health research products, are very rarely addressed in any process of priority setting. Inclusion of a larger and more diverse group of stakeholders in the process would result in a better reflection of the system of values of the broader community, resulting in recommendations that are more legitimate and acceptable.
Full Text Available In the last 20 years, priority setting in mine actions, i.e. in humanitarian demining, has become an increasingly important topic. Given that mine action projects require management and decision-making based on a multi -criteria approach, multi-criteria decision-making methods like PROMETHEE and AHP have been used worldwide for priority setting. However, from the aspect of mine action, where stakeholders in the decision-making process for priority setting are project managers, local politicians, leaders of different humanitarian organizations, or similar, applying these methods can be difficult. Therefore, a specialized web-based decision support system (Web DSS for priority setting, developed as part of the FP7 project TIRAMISU, has been extended using a module for developing custom priority setting scenarios in line with an exceptionally easy, user-friendly approach. The idea behind this research is to simplify the multi-criteria analysis based on the PROMETHEE method. Therefore, a simplified PROMETHEE method based on statistical analysis for automated suggestions of parameters such as preference function thresholds, interactive selection of criteria weights, and easy input of criteria evaluations is presented in this paper. The result is web-based DSS that can be applied worldwide for priority setting in mine action. Additionally, the management of mine action projects is supported using modules for providing spatial data based on the geographic information system (GIS. In this paper, the benefits and limitations of a simplified PROMETHEE method are presented using a case study involving mine action projects, and subsequently, certain proposals are given for the further research.
Ocampo-Peñuela, Natalia; Pimm, Stuart L
We aspired to set conservation priorities in ways that lead to direct conservation actions. Very large-scale strategic mapping leads to familiar conservation priorities exemplified by biodiversity hotspots. In contrast, tactical conservation actions unfold on much smaller geographical extents and they need to reflect the habitat loss and fragmentation that have sharply restricted where species now live. Our aspirations for direct, practical actions were demanding. First, we identified the global, strategic conservation priorities and then downscaled to practical local actions within the selected priorities. In doing this, we recognized the limitations of incomplete information. We started such a process in Colombia and used the results presented here to implement reforestation of degraded land to prevent the isolation of a large area of cloud forest. We used existing range maps of 171 bird species to identify priority conservation areas that would conserve the greatest number of species at risk in Colombia. By at risk species, we mean those that are endemic and have small ranges. The Western Andes had the highest concentrations of such species-100 in total-but the lowest densities of national parks. We then adjusted the priorities for this region by refining these species ranges by selecting only areas of suitable elevation and remaining habitat. The estimated ranges of these species shrank by 18-100% after accounting for habitat and suitable elevation. Setting conservation priorities on the basis of currently available range maps excluded priority areas in the Western Andes and, by extension, likely elsewhere and for other taxa. By incorporating detailed maps of remaining natural habitats, we made practical recommendations for conservation actions. One recommendation was to restore forest connections to a patch of cloud forest about to become isolated from the main Andes.
Full Text Available In 2013, an estimated 2.8 million newborns died and 2.7 million were stillborn. A much greater number suffer from long term impairment associated with preterm birth, intrauterine growth restriction, congenital anomalies, and perinatal or infectious causes. With the approaching deadline for the achievement of the Millennium Development Goals (MDGs in 2015, there was a need to set the new research priorities on newborns and stillbirth with a focus not only on survival but also on health, growth and development. We therefore carried out a systematic exercise to set newborn health research priorities for 2013–2025.
Rajiv Bahl Department of Child and Adolescent Health and Development, World Health Organization, Geneva, Switzerland
Full Text Available This paper aims to identify health research priorities that could improve the rate of progress in reducing global neonatal mortality from preterm birth and low birth weight (PB/LBW, as set out in the UN's Millennium Development Goal 4.
Baltussen, R.M.P.M.; Stolk, E.; Chisholm, D.; Aikins, M.
BACKGROUND: Many criteria have been proposed to guide priority setting in health, but their relative importance has not yet been determined in a way that allows a rank ordering of interventions. METHODS: In an explorative study, a discrete choice experiment was carried out to determine the relative
U.S. Department of Health & Human Services — The Long-Term Care Minimum Data Set (MDS) is a standardized, primary screening and assessment tool of health status that forms the foundation of the comprehensive...
Jordans, Mark J D; Tol, Wietse A
Mental health in low- and middle income countries has received increasing attention. This attention has shifted focus, roughly moving from demonstrating the burden of mental health problems, to establishing an evidence base for interventions, to thinking about care delivery frameworks. This paper reviews these trends specifically for humanitarian settings and discusses lessons learned. Notably, that mental health assessments need to go beyond measuring the impact of traumatic events on circumscribed psychiatric disorders; that evidence for effectiveness of interventions is still too weak and its focus too limited; and that development of service delivery in the context of instable community and health systems should be an area of key priority.
Full Text Available In 2007 and 2008, the World Health Organization's Department for Child and Adolescent Health and Development commissioned five large research priority setting exercises using the CHNRI (Child Health and Nutrition Research Initiative method. The aim was to define research priorities related to the five major causes of child deaths for the period up to the year 2015. The selected causes were childhood pneumonia, diarrhoea, birth asphyxia, neonatal infections and preterm birth/low birth weight. The criteria used for prioritization in all five exercises were the “standard” CHNRI criteria: answerability, effectiveness, deliverability, potential for mortality burden reduction and the effect on equity. Having completed the exercises, the WHO officers were left with another question: how “fundable” were the identified priorities, i.e. how attractive were they to research funders?
Cady, Rhonda G; Looman, Wendy S; Lindeke, Linda L; LaPlante, Bonnie; Lundeen, Barbara; Seeley, Amanda; Kautto, Mary E
A fundamental component of the medical home model is care coordination. In Minnesota, this model informed design and implementation of the state's health care home (HCH) model, a key element of statewide healthcare reform legislation. Children with medical complexity (CMC) often require care from multiple specialists and community resources. Coordinating this multi-faceted care within the HCH is challenging. This article describes the need for specialized models of care coordination for CMC. Two models of care coordination for CMC were developed to address this challenge. The TeleFamilies Model of Pediatric Care Coordination uses an advanced practice registered nurse care (APRN) coordinator embedded within an established HCH. The PRoSPer Model of Pediatric Care Coordination uses a registered nurse/social worker care coordinator team embedded within a specialty care system. We describe key findings from implementation of these models, and conclude with lessons learned. Replication of the models is encouraged to increase the evidence base for care coordination for the growing population of children with medical complexities.
Van der Voordt, D.J.M.
Purpose Due to the transition of the Dutch health care sector from a governmentally steered domain towards regulated market forces, health care organisations have become fully responsible for their real estate. This paper explores if/how Dutch health care organisations adopt the concept of adding v
Kapiriri, Lydia; Norheim, Ole F; Martin, Douglas K
Accountability for reasonableness is an ethical framework for fair priority setting process. This framework has been used to evaluate fairness in several contexts, and a few studies have evaluated its acceptability to decision makers. However, no studies have compared the acceptability of the four conditions of the framework to decision makers across health systems and levels of priority setting. This paper reports the elements of fairness described by 184 decision makers involved in priority setting at the macro-, meso- and micro-levels of priority setting in the Canadian (Ontario), Norwegian and Ugandan health care systems and compares them against the four conditions of 'Accountability for Reasonableness' and across levels of decision making, and health care systems. Our respondents identified 23 elements of fair priority setting. Most of these (17) were well aligned with the four conditions of Accountability for Reasonableness; six were not. Comparisons across health care system and levels of decision making revealed that four elements (transparency, participatory and among the criteria-need based and objective) were common to all and the rest were common to only the health care systems (but not at all levels), or only the levels of decision making (but not to all health are systems). Perceptions varied remarkably across levels of decision making. The overlap between the elements of fairness found in this study and the conditions of Accountability for Reasonableness demonstrates that the four conditions are recognizable and applicable across health care systems and levels of decision making. However, the framework should be used with flexibility to allow for identification of elements and relevant explicit criteria (such as those identified in this study) - that may not directly fit under any of the four conditions.
O'Hagan, Joshua; Persaud, David
Improving customer-service in health care organizations has been linked to better patient care, satisfied staff, a reduction in preventable medical errors, fewer malpractice lawsuits and improved revenue. However, it has been observed that there is sometimes a gap between the level of customer-service provided by health care organizations and their clients' expectations. This paper integrates, synthesizes and extends theory and practice from existing literature to provide health care organizations with strategies for closing this gap. Methods are also outlined for creating, implementing and evaluating an organizational plan for improving customer-service.
Pilgrim, Randy; Hilton, Joshua A; Carrier, Emily; Pines, Jesse M; Hufstetler, Greg; Thorby, Suzette; Milling, T J; Cesta, Beth; Hsia, Renee Y
In 2006, the Institute of Medicine (IOM) advanced the concept of "coordinated, regionalized, and accountable emergency care systems" to address significant problems with the delivery of emergency medical care in the United States. Achieving this vision requires the thoughtful implementation of well-aligned, system-level structures and processes that enhance access to emergency care and improve patient outcomes at a sustainable cost. Currently, the delivery of emergency medical care is supported by numerous administrative systems, including economic; reimbursement; legal and regulatory structures; licensure, credentialing, and accreditation processes; medicolegal systems; and quality reporting mechanisms. In addition, many regionalized systems may not optimize patient outcomes because of current administrative barriers that make it difficult for providers to deliver the best care. However, certain administrative barriers may also threaten the sustainability of integration efforts or prevent them altogether. This article identifies significant administrative challenges to integrating networks of emergency care in four specific areas: reimbursement, medical-legal, quality reporting mechanisms, and regulatory aspects. The authors propose a research agenda for indentifying optimal approaches that support consistent access to quality emergency care with improved outcomes for patients, at a sustainable cost. Researching administrative challenges will involve careful examination of the numerous natural experiments in the recent past and will be crucial to understand the impact as we embark on a new era of health reform.
Tinetti, Mary E; Esterson, Jessica; Ferris, Rosie; Posner, Philip; Blaum, Caroline S
Older adults with multiple conditions receive care that is often fragmented, burdensome, and of unclear benefit. An advisory group of patients, caregivers, clinicians, health system engineers, health care system leaders, payers, and others identified three modifiable contributors to this fragmented, burdensome care: decision making and care focused on diseases, not patients; inadequate delineation of roles and responsibilities and accountability among clinicians; and lack of attention to what matters to patients and caregivers (ie, their health outcome goals and care preferences). The advisory group identified patient priority-directed care as a feasible, sustainable approach to addressing these modifiable factors.
Jurgita Januleviciute Gangstøe
Full Text Available Background: Different strategies for addressing the challenge of prioritizing elective patients efficiently and fairly have been introduced in Norway. In the time period studied, there were three possible outcomes for elective patients that had been through the process of priority setting: (i high priority with assigned individual maximum waiting time; (ii low priority without a maximum waiting time; and (iii refusal (not in need for specialized services. We study variation in priority status and waiting time of the first two groups across different medical disciplines. Methods: Data was extracted from the Norwegian Patient Register (NPR and contains information on elective referrals to 41 hospitals in the Western Norway Regional Health Authority in 2010. The hospital practice across different specialties was measured by patient priority status and waiting times. The distributions of assigned maximum waiting times and the actual ones were analyzed using standard Kernel density estimation. The perspective of the planning process was studied by measuring the time interval between the actual start of healthcare and the maximum waiting time. Results: Considerable variation was found across medical specialties concerning proportion of priority patients and their maximum waiting times. The degree of differentiation in terms of maximum waiting times also varied by medical discipline. We found that the actual waiting time was very close to the assigned maximum waiting time. Furthermore, there was no clear correspondence between the actual waiting time for patients and their priority status. Conclusion: Variations across medical disciplines are often interpreted as differences in clinical judgment and capacity. Alternatively they primarily reflect differences in patient characteristics, patient case-mix, as well as capacity. One hypothesis for further research is that the introduction of maximum waiting times may have contributed to push the actual
Brown, Jeremy; Grudzen, Corita; Kyriacou, Demetrios N; Obermeyer, Ziad; Quest, Tammie; Rivera, Donna; Stone, Susan; Wright, Jason; Shelburne, Nonniekaye
To identify research priorities and appropriate resources and to establish the infrastructure required to address the emergency care of patients with cancer, the National Institutes of Health's National Cancer Institute and the Office of Emergency Care Research sponsored a one-day workshop, "Cancer and Emergency Medicine: Setting the Research Agenda," in March 2015 in Bethesda, MD. Participants included leading researchers and clinicians in the fields of oncology, emergency medicine, and palliative care, and representatives from the National Institutes of Health. Attendees were charged with identifying research opportunities and priorities to advance the understanding of the emergency care of cancer patients. Recommendations were made in 4 areas: the collection of epidemiologic data, care of the patient with febrile neutropenia, acute events such as dyspnea, and palliative care in the emergency department setting.
Feijtel, T C
Abstract Impending changes in EEC legislation have accelerated the need to define the principles and practical considerations of the use of QSARs in priority setting and risk assessment. It is important to delineate the limitations of this approach and to review whether and how this information should be used in the risk assessment. The value and limitations of QSARs for use in priority setting and risk assessment will not be discussed in detail since the European Chemical Industry Ecology and Toxicology Centre (ECETOC) has only recently established a Task Force to tackle this issue. The terms of reference of the Task Force are: (1) compare the predictions obtained with QSARs to measured data using ECETOC databases and other sources of data and comment on the validity and applicability of such QSARs; (2) identify and review software packages which are available for accessing and using appropriate QSARs; (3) identify those aspects of environmental distribution, fate and effects where the further development of QSARs is desirable and feasible; and (4) provide a scientific basis for ECETOC's contribution to the activities of the European Chemicals Bureau (ECB) in this area. In this short paper, only an initial and personal evaluation is made of when and where to use QSARs in the priority setting and risk assessment process within the regulatory framework. Some critical remarks and suggestions are provided to guide future developments and integration of QSARs in the risk assessment process.
Mitton, Craig; Levy, Adrian; Gorsky, Diane; MacNeil, Christina; Dionne, Francois; Marrie, Tom
Facing a projected $1.4M deficit on a $35M operating budget for fiscal year 2011/2012, members of the Dalhousie University Faculty of Medicine developed and implemented an explicit, transparent, criteria-based priority setting process for resource reallocation. A task group that included representatives from across the Faculty of Medicine used a program budgeting and marginal analysis (PBMA) framework, which provided an alternative to the typical public-sector approaches to addressing a budget deficit of across-the-board spending cuts and political negotiation. Key steps to the PBMA process included training staff members and department heads on priority setting and resource reallocation, establishing process guidelines to meet immediate and longer-term fiscal needs, developing a reporting structure and forming key working groups, creating assessment criteria to guide resource reallocation decisions, assessing disinvestment proposals from all departments, and providing proposal implementation recommendations to the dean. All departments were required to submit proposals for consideration. The task group approved 27 service reduction proposals and 28 efficiency gains proposals, totaling approximately $2.7M in savings across two years. During this process, the task group faced a number of challenges, including a tight timeline for development and implementation (January to April 2011), a culture that historically supported decentralized planning, at times competing interests (e.g., research versus teaching objectives), and reductions in overall health care and postsecondary education government funding. Overall, faculty and staff preferred the PBMA approach to previous practices. Other institutions should use this example to set priorities in times of fiscal constraints.
Shi, H.; Singh, A.; Kant, S.; Zhu, Z.; Waller, E.
Priority setting is an essential component of biodiversity conservation. Existing methods to identify priority areas for conservation have focused almost entirely on biological factors. We suggest a new relative ranking method for identifying priority conservation areas that integrates both biological and social aspects. It is based on the following criteria: the habitat's status, human population pressure, human efforts to protect habitat, and number of endemic plant and vertebrate species. We used this method to rank 25 hotspots, 17 megadiverse countries, and the hotspots within each megadiverse country. We used consistent, comprehensive, georeferenced, and multiband data sets and analytical remote sensing and geographic information system tools to quantify habitat status, human population pressure, and protection status. The ranking suggests that the Philippines, Atlantic Forest, Mediterranean Basin, Caribbean Islands, Caucasus, and Indo-Burma are the hottest hotspots and that China, the Philippines, and India are the hottest megadiverse countries. The great variation in terms of habitat, protected areas, and population pressure among the hotspots, the megadiverse countries, and the hotspots within the same country suggests the need for hotspot- and country-specific conservation policies. ??2005 Society for Conservation Biology.
Schäfer, W.; Groenewegen, P.P.; Hansen, J.; Black, N.
Background: All European health systems face several common challenges related to increases in lifestyle and chronic diseases, a decreasing future workforce, inequalities in health and the consequences of societal changes. Primary care, which has the potential to help meet these challenges, would be
Lorant, Vincent; Grard, Adeline; Nicaise, Pablo
Belgium has recently reformed its mental health care delivery system with the goals to strengthen the community-based supply of care, care integration, and the social rehabilitation of users and to reduce the resort to hospitals. We assessed whether these different reform goals were endorsed by stakeholders. One-hundred and twenty-two stakeholders ranked, online, eighteen goals of the reform according to their priorities. Stakeholders supported the goals of social rehabilitation of users and community care but were reluctant to reduce the resort to hospitals. Stakeholders were averse to changes in treatment processes, particularly in relation to the reduction of the resort to hospitals and mechanisms for more care integration. Goals heterogeneity and discrepancies between stakeholders' perspectives and policy priorities are likely to produce an uneven implementation of the reform process and, hence, reduce its capacity to achieve the social rehabilitation of users.
Full Text Available The main intention of this paper is focus on mechanism for reducing congestion in the network by free resources to set accurate rates and priority data needs. If two nodes send their packets in the shortest path to the parent node in a crowded place, a source node must prioritize the data and uses data that have lower priorities of a suitable detour nodes consisting of low or non- active consciously. The proposed algorithm is applied to the nodes near the base station (which convey more traffic after the congestion detection mechanism detected the congestion. Obtained results from simulation test done by NS-2 simulator demonstrate the innovation and validity of proposed method with better performance in comparison with CCF, PCCP and DCCP protocols.
Bus, Sicco A; van Netten, Jaap J
Diabetic foot ulceration poses a heavy burden on the patient and the healthcare system, but prevention thereof receives little attention. For every euro spent on ulcer prevention, ten are spent on ulcer healing, and for every randomized controlled trial conducted on prevention, ten are conducted on healing. In this article, we argue that a shift in priorities is needed. For the prevention of a first foot ulcer, we need more insight into the effect of interventions and practices already applied globally in many settings. This requires systematic recording of interventions and outcomes, and well-designed randomized controlled trials that include analysis of cost-effectiveness. After healing of a foot ulcer, the risk of recurrence is high. For the prevention of a recurrent foot ulcer, home monitoring of foot temperature, pressure-relieving therapeutic footwear, and certain surgical interventions prove to be effective. The median effect size found in a total of 23 studies on these interventions is large, over 60%, and further increases when patients are adherent to treatment. These interventions should be investigated for efficacy as a state-of-the-art integrated foot care approach, where attempts are made to assure treatment adherence. Effect sizes of 75-80% may be expected. If such state-of-the-art integrated foot care is implemented, the majority of problems with foot ulcer recurrence in diabetes can be resolved. It is therefore time to act and to set a new target in diabetic foot care. This target is to reduce foot ulcer incidence with at least 75%.
Grube, Mark E; Kaufman, Kenneth; Clarin, Dan; O'Riordan, Jason
Consumers who are accustomed to on-demand, virtual services are looking for more convenient ways to access health care. Giving patients the opportunity to connect with physicians remotely can promote higher patient satisfaction and engagement. Telehealth options may have a high start-up cost, but that cost is likely well-justified by the potential to enhance quality, outcomes, and customer attraction and satisfaction/retention over the long-term.
Priority Setting Meets Multiple Streams: A Match to Be Further Examined?; Comment on “Introducing New Priority Setting and Resource Allocation Processes in a Canadian Healthcare Organization: A Case Study Analysis Informed by Multiple Streams Theory”
Jacqueline Margaret Cumming
Full Text Available With demand for health services continuing to grow as populations age and new technologies emerge to meet health needs, healthcare policy-makers are under constant pressure to set priorities, ie, to make choices about the health services that can and cannot be funded within available resources. In a recent paper, Smith et al apply an influential policy studies framework – Kingdon’s multiple streams approach (MSA – to explore the factors that explain why one health service delivery organization adopted a formal priority setting framework (in the form of programme budgeting and marginal analysis [PBMA] to assist it in making priority setting decisions. MSA is a theory of agenda-setting, ie, how it is that different issues do or do not reach a decision-making point. In this paper, I reflect on the use of the MSA framework to explore priority setting processes and how the framework might be applied to similar cases in future.
Kjaer, Monica Linda; Mainz, Jan; Sorensen, Lars Tue
of >5 years. Seventy-three patients (91%) were satisfied with the overall quality of care. A linear relationship was observed between average assessment score and the relative importance of the quality aspects studied. The quality of medical technical care and empathy aspects of interpersonal care......-sectional study to assess the quality of and assign priority to 28 aspects of medical technical, interpersonal, and organizational care. The response rate to the mailed questionnaire and follow-up telephone survey was 80%. Almost half (46%) of patients (median age 76 years, range 30 to 92) had an ulcer history...
Gesell, Sabina B; Gregory, Nancy
In parallel to developing new cancer therapies, the healthcare community has the responsibility of creating positive treatment experiences for patients. Data from 5907 cancer outpatients treated at 23 hospitals across the United States were analyzed to identify the top priorities for service improvement in outpatient cancer treatment facilities. They included meeting patients' emotional needs, providing information to patients and family members, reducing waiting times, and providing convenience and coordinated care among physicians and other care providers.
Pressure ulcer prevention in the care home setting can be challenging and is often compromised by a lack of access to education and resources. There are measures that have been shown to consistently improve outcomes in pressure ulcer prevention including assessment of the patient and their individual risks, delivery of a consistent plan of care that meets patients' needs, and regular evaluation to identify shortfalls. In addition, there should be a robust approach to investigating events that lead to a person developing a pressure ulcer and that information should be used to improve future practice. Pressure ulcer prevention in care homes is achievable and nurses should all be aware of the necessary measures detailed in this article.
Mortimer, Duncan; Peacock, Stuart
The creation of the Patient-Centered Outcomes Research Institute (PCORI) under the Affordable Care Act has set comparative effectiveness research (CER) at centre stage of US health care reform. Comparative cost analysis has remained marginalised and it now appears unlikely that the PCORI will require comparative cost data to be collected as an essential component of CER. In this paper, we review the literature to identify ethical and distributional objectives that might motivate calls to set priorities without regard to comparative cost. We then present argument and evidence to consider whether there is any plausible set of objectives and constraints against which priorities can be set without reference to comparative cost. We conclude that - to set aside comparative cost even after accounting for ethical and distributional constraints - would be truly to act as if money is no object.
Koch, Christiane; Jeschke, Jonathan M.; Overbeck, Gerhard E.; Kollmann, Johannes
Land managers face the challenge to set priorities in monitoring and managing non-native plant species, as resources are limited and not all non-natives become invasive. Existing frameworks that have been proposed to rank non-native species require extensive information on their distribution, abundance, and impact. This information is difficult to obtain and often not available for many species and regions. National watch or priority lists are helpful, but it is questionable whether they provide sufficient information for environmental management on a regional scale. We therefore propose a decision tree that ranks species based on more simple albeit robust information, but still provides reliable management recommendations. To test the decision tree, we collected and evaluated distribution data from non-native plants in highland grasslands of Southern Brazil. We compared the results with a national list from the Brazilian Invasive Species Database for the state to discuss advantages and disadvantages of the different approaches on a regional scale. Out of 38 non-native species found, only four were also present on the national list. If management would solely rely on this list, many species that were identified as spreading based on the decision tree would go unnoticed. With the suggested scheme, it is possible to assign species to active management, to monitoring, or further evaluation. While national lists are certainly important, management on a regional scale should employ additional tools that adequately consider the actual risk of non-natives to become invasive.
Jo, Heui-Sug; Kim, Dong Ik; Oh, Moo-Kyung
By November 2013, a total of 125 clinical practice guidelines (CPGs) have been developed in Korea. However, despite the high burden of diseases and the clinical importance of CPGs, most chronic diseases do not have available CPGs. Merely 83 CPGs are related to chronic diseases, and only 40 guidelines had been developed in the last 5 yr. Considering the rate of the production of new evidence in medicine and the worsening burden from chronic diseases, the need for developing CPGs for more chronic diseases is becoming increasingly pressing. Since 2011, the Korean Academy of Medical Sciences and the Korea Centers for Disease Control and Prevention have been jointly developing CPGs for chronic diseases. However, priorities have to be set and resources need to be allocated within the constraint of a limited funding. This study identifies the chronic diseases that should be prioritized for the development of CPGs in Korea. Through an objective assessment by using the analytic hierarchy process and a subjective assessment with a survey of expert opinion, high priorities were placed on ischemic heart disease, cerebrovascular diseases, Alzheimer's disease and other dementias, osteoarthritis, neck pain, chronic kidney disease, and cirrhosis of the liver.
Sigurdardottir, Katrin Ruth; Haugen, Dagny Faksvåg; van der Rijt, Carin C D;
The PRISMA project is aiming to co-ordinate research priorities, measurement and practice in end-of-life (EOL) care in Europe. As part of PRISMA we undertook a questionnaire survey and a subsequent workshop to (1) identify clinical priorities for EOL care research in Europe and propose a future r...... research agenda and (2) identify barriers to EOL care research, and possibilities and solutions to improve the research....
Sigurdardottir, Katrin Ruth; Haugen, Dagny Faksvåg; van der Rijt, Carin C D;
The PRISMA project is aiming to co-ordinate research priorities, measurement and practice in end-of-life (EOL) care in Europe. As part of PRISMA we undertook a questionnaire survey and a subsequent workshop to (1) identify clinical priorities for EOL care research in Europe and propose a future...... research agenda and (2) identify barriers to EOL care research, and possibilities and solutions to improve the research....
Whether institutions or extended families are better suited to care for orphans depends on the specific circumstances. Reported rates of traumatic experiences among orphans and vulnerable children are high in both institutions and extended families; improving the quality of care for such children should be the paramount priority in all settings.
Gimon de Graaf
Full Text Available Translational research is conducted to achieve a predefined set of economic or societal goals. As a result, investment decisions on where available resources have the highest potential in achieving these goals have to be made. In this paper, we first describe how multicriteria decision analysis can assist in defining the decision context and in ensuring that all relevant aspects of the decision problem are incorporated in the decision making process. We then present the results of a case study to support priority setting in a translational research consortium aimed at reducing the burden of disease of type 2 diabetes. During problem structuring, we identified four research alternatives (primary, secondary, tertiary microvascular, and tertiary macrovascular prevention and a set of six decision criteria. Scoring of these alternatives against the criteria was done using a combination of expert judgement and previously published data. Lastly, decision analysis was performed using stochastic multicriteria acceptability analysis, which allows for the combined use of numerical and ordinal data. We found that the development of novel techniques applied in secondary prevention would be a poor investment of research funds. The ranking of the remaining alternatives was however strongly dependent on the decision maker’s preferences for certain criteria.
Full Text Available As a new service model, home health care can provide effective health care by adopting door-to-door service. The reasonable arrangements for nurses and their routes not only can reduce medical expenses, but also can enhance patient satisfaction. This research focuses on the home health care scheduling optimization problem with known demands and service capabilities. Aimed at minimizing the total cost, an integer programming model was built in this study, which took both the priorities of patients and constraints of time windows into consideration. The genetic algorithm with local search was used to solve the proposed model. Finally, a case study of Shanghai, China, was conducted for the empirical analysis. The comparison results verify the effectiveness of the proposed model and methodology, which can provide the decision support for medical administrators of home health care.
Full Text Available Background: South Africa is currently undergoing major health system restructuring in an attempt to improve health outcomes and reduce inequities in access. Such inequities exist between private and public health care and within the public health system itself. Experience shows that rural health care can be disadvantaged in policy formulation despite good intentions. The objective of this study was to identify the major challenges and priority interventions for rural health care provision in South Africa thereby contributing to pro-rural health policy dialogue. Methods: The Delphi technique was used to develop consensus on a list of statements that was generated through interviews and literature review. A panel of rural health practitioners and other stakeholders was asked to indicate their level of agreement with these statements and to rank the top challenges in and interventions required for rural health care. Results: Response rates ranged from 83% in the first round (n=44 to 64% in the final round (n=34. The top five priorities were aligned to three of the WHO health system building blocks: human resources for health (HRH, governance, and finance. Specifically, the panel identified a need to focus on recruitment and support of rural health professionals, the employment of managers with sufficient and appropriate skills, a rural-friendly national HRH plan, and equitable funding formulae. Conclusion: Specific policies and strategies are required to address the greatest rural health care challenges and to ensure improved access to quality health care in rural South Africa. In addition, a change in organisational climate and a concerted effort to make a career in rural health appealing to health care workers and adequate funding for rural health care provision are essential.
Full Text Available Abstract Background Health systems have experienced unprecedented stress in recent years, and as yet no consensus has emerged as to how to deal with the multiple burden of disease in the context of HIV and AIDS and other competing health priorities. Priority setting is essential, yet this is a complex, multifaceted process. Drawing on a study conducted in five African countries, this paper explores different stakeholders′ perceptions of health priorities, how priorities are defined in practice, the process of resource allocation for HIV and Health and how different stakeholders perceive this. Methods A sub-analysis was conducted of selected data from a wider qualitative study that explored the interactions between health systems and HIV and AIDS responses in five sub-Saharan countries (Burkina Faso, the Democratic Republic of Congo, Ghana, Madagascar and Malawi. Key background documents were analysed and semi-structured interviews (n = 258 and focus group discussions (n = 45 were held with representatives of communities, health personnel, decision makers, civil society representatives and development partners at both national and district level. Results Health priorities were expressed either in terms of specific health problems and diseases or gaps in service delivery requiring a strengthening of the overall health system. In all five countries study respondents (with the exception of community members in Ghana identified malaria and HIV as the two top health priorities. Community representatives were more likely to report concerns about accessibility of services and quality of care. National level respondents often referred to wider systemic challenges in relation to achieving the Millennium Development Goals (MDGs. Indeed, actual priority setting was heavily influenced by international agendas (e.g. MDGs and by the ways in which development partners were supporting national strategic planning processes. At the same time, multi
Johnstone, Megan-Jane; Kanitsaki, Olga
Since the early 1990s, research studies conducted respectively in the USA, UK and Australia have found that between 4 and 16.6 per cent of patients suffer from some kind of harm (including permanent disability and death) as a result of human errors and adverse events while in hospital. It has been further estimated that approximately 50 per cent of these human errors/adverse events resulting in harm could have been prevented. In response to the significant financial, social, and political implications of these figures, a range of processes have been put in place in an attempt to improve patient safety and quality care in Australia. Nonetheless, it is evident that more can be done to improve the status quo. One process that warrants consideration is that of peak health professional groups and organisations providing active leadership in the promotion of patient safety, such as by making a visible and recognisable commitment to patient safety as a strategic research priority area. In this paper it is contended that, given the moral importance of patient safety and quality care in nursing and related health care domains, the inseparable link between nursing practice and patient safety, and the central role that research has to play in driving safety improvements in these domains, it is morally imperative that the nursing profession gives sustained and focussed public attention to patient safety and quality care as a national research priority.
Kathrin M Cresswell
Full Text Available Using a modified Delphi exercise, Aziz Sheikh and colleagues identify research priorities for patient safety research in primary care contexts. Please see later in the article for the Editors' Summary.
This report summarizes work done by Applied Decision Analysis (ADA) for Los Alamos National Laboratory (LANL) under Subcontract Number 9-XQ2-Y3837-1 with the University of California. The purpose of this work was to develop a method of setting priorities for environmental, safety, and health (ES&H) deficiencies at Los Alamos. The deficiencies were identified by a DOE Tiger Team that visited LANL in the fall of 1991, and by self assessments done by the Laboratory. ADA did the work described here between October 1991 and the end of September 1992. The ADA staff working on this project became part of a Risk Management Team in the Laboratory`s Integration and Coordination Office (ICO). During the project, the Risk Management Team produced a variety of documents describing aspects of the action-plan prioritization system. Some of those documents are attached to this report. Rather than attempt to duplicate their contents, this report provides a guide to those documents, and references them whenever appropriate.
Mort, Elizabeth A; Demehin, Akinluwa A; Marple, Keith B; McCullough, Kathryn Y; Meyer, Gregg S
Hospitals are continually challenged to provide safer and higher-quality patient care despite resource constraints. With an ever-increasing range of quality and safety targets at the national, state, and local levels, prioritization is crucial in effective institutional quality goal setting and resource allocation.Organizational goal-setting theory is a performance improvement methodology with strong results across many industries. The authors describe a structured goal-setting process they have established at Massachusetts General Hospital for setting annual institutional quality and safety goals. Begun in 2008, this process has been conducted on an annual basis. Quality and safety data are gathered from many sources, both internal and external to the hospital. These data are collated and classified, and multiple approaches are used to identify the most pressing quality issues facing the institution. The conclusions are subject to stringent internal review, and then the top quality goals of the institution are chosen. Specific tactical initiatives and executive owners are assigned to each goal, and metrics are selected to track performance. A reporting tool based on these tactics and metrics is used to deliver progress updates to senior hospital leadership.The hospital has experienced excellent results and strong organizational buy-in using this effective, low-cost, and replicable goal-setting process. It has led to improvements in structural, process, and outcomes aspects of quality.
Jansen, M.P. (Maarten P.); J.-K. Helderman (Jan-Kees); Boer, B. (Bert); R. Baltussen (R.)
textabstractEmbedding health technology assessment (HTA) in a fair process has great potential to capture societal values relevant to public reimbursement decisions on health technologies. However, the development of such processes for priority setting has largely been theoretical. In this paper, we
Tyler, R D
One of the most utilitarian developments in the field of quality assurance in health care has been the introduction of industrial concepts of quality management. These concepts, coupled with buyer demand for accountability, are bringing new perspectives to health care quality assurance. These perspectives provide a new view of quality assurance as a major responsibility and strategic opportunity for management; a competitive and marketable commodity; and a method of improving safety, effectiveness, and satisfaction with medical care.
Incorporating Cost-Effectiveness Data in a Fair Process for Priority Setting Efforts; Comment on “Use of Cost-Effectiveness Data in Priority Setting Decisions: Experiences from the National Guidelines for Heart Diseases in Sweden”
Full Text Available Cost-effectiveness data is useful for use in priority setting decisions in order to improve the efficiency of resources used. This paper thereby responds to Eckard et al. which addressed the use of cost-effectiveness data in the actual prioritization decisions in the Swedish national clinical guidelines for heart diseases. Based on a set of experiences on the use of economic evaluation in priority setting processes, this paper emphasizes the potential approach to incorporating cost-effectiveness data in the prioritization process to enhance transparency of the decisions, and highlights the importance of designing a fair decision-making process that can enforce the sustained implementation of cost-effectiveness data.
the ability to interpret and utilise pharmacoeconomic evidence. Relevant health authorities in Tanzania should also consider how to apply pharmacoeconomic analyses more consistently in the future priority-setting decisions for selection of essential medicines.
Kimberly, John; Cronk, Imran
The world of health care is changing dramatically, as reflected in the number, magnitude, and scope of innovative new approaches-to how illness is treated and how better health is promoted-that are being implemented around the globe. The changes triggered by these initiatives affect both how care is organized, managed, and paid for and the kinds of approaches that are being developed to keep people healthy. Underlying these changes is a more fundamental paradigm shift, a shift in the priority given to "value" in the formulation of policy and management practice. This brief essay highlights five trends that are central in this shift: increasing emphasis on health promotion, movement toward value-based payment, advances in digital/mobile technology, exploitation of big data, and changes in support for biomedical research. Each of these has its own value controversies, and the individual impact of each is impossible to predict. Collectively, however, their impact is likely to be significant.
Full Text Available BACKGROUND: The main aim of this study is to review the agenda for research priorities of mental health in Brazil. METHODOLOGY: The first step was to gather 28 experts (22 researchers, five policy makers, and the coordinator representing all mental health fields from different geographical areas of the country. Participants were asked to list what they considered to be the most relevant mental health research questions for the country to address in the next 10 years. Seventeen participants answered this question; after redundancies were excluded, a total of 110 responses were collected. As the second step, participants were asked to rank which questions were the 35 most significant. The final step was to score 15 items for each of the 35 selected questions to determine whether it would be a answerable, b effective, c deliverable, d equitable, and e effective at reducing the burden of mental health. The ten highest ranked questions were then selected. RESULTS: There were four questions addressing primary care with respect to a the effectiveness of interventions, b "matrix support", c comparisons of different models of stepped care, and d interventions to enhance identification and treatment of common mental disorders at the Family Health Program. The other questions were related to the evaluation of mental health services for adults and children/adolescents to clarify barriers to treatment in primary care, drug addiction, and severe mental disorders; to investigate the cost-benefit relationship of anti-psychotics; to design interventions to decrease alcohol consumption; and to apply new technologies (telemedicine for education and supervision of non-specialists. CONCLUSION: This priority-setting research exercise highlighted a need for implementing investments at the primary-care level, particularly in the family health program; the urgent need to evaluate services; and policies to improve equity by increasing accessibility to services and
Morgan, Debra G.; Kosteniuk, Julie G.; O'Connell, Megan E.; Dal Bello-Haas, Vanina; Stewart, Norma J.; Karunanayake, Chandima
An understanding of the specific dementia learning needs of home care staff is needed to plan relevant continuing education (CE) programs and supports. The study's objective was to examine frequency and perceived competence in performing 20 dementia-related work activities, and identify CE priorities among home care staff. A cross-sectional survey…
Rosenstein, Alan H
Disruptive behaviors can have a significant negative impact on staff relationships, communication flow, task responsibility, and team collaboration, all of which can adversely impact patient outcomes of care. Addressing disruptive behaviors in a positive manner by emphasizing the benefits of mutual understanding, shared goals and priorities, and adherence to accepted standards of care will enhance communication flow and improve the process and outcomes of care. This is particularly relevant in the obstetrics setting, where care is delivered over a continuum of time, with multiple different members of the health care team playing a vital role as the patient progresses from labor to delivery. Critical strategies for success include having strong organizational commitment and leadership support, raising provider insight and awareness, implementing appropriate policies and procedures, providing appropriate educational and training programs, and facilitating action-oriented interventional support.
Davey, Antoinette; Carter, Mary; Campbell, John L
This literature review focuses on what matters to young adults when they access primary care services in the United Kingdom. Patients' access to and experience of primary care services differs across age groups. Existing research has largely focused on the needs and experiences of children, adolescents, and adults. There is some evidence to suggest the views of young adults (aged 18-25 years) that may differ from the views of other age groups, and research has not previously reported specifically on the views of this group of the population. The literature was reviewed to identify the views and priorities of young UK adults regarding primary healthcare provision, and furthermore, to identify those related topics that would benefit from further research. Relevant academic publications and grey literature published from 2000 onwards was reviewed and synthesised. We identified and reported emerging themes that were of importance to young adults in respect of the UK primary care provision. A total of 19 papers met our inclusion criteria. Young adults access primary care services less frequently than other age groups; this may be because of their experience of primary care throughout childhood and adolescence. Five aspects of primary care provision emerged as being of importance to young adults--the accessibility and availability of services, the confidentiality of health-related information, issues relating to communication with healthcare professionals, continuity of care, and behaviours and attitudes expressed towards young adults by healthcare professionals. There is a lack of focus of current research on the expectations, needs, and primary healthcare experiences of young adults. Young adults may hold views that are distinct from other age groups. Further research is needed to better understand the needs of a young adult population as their needs may impact the future use of services.
van der Merwe Aletia
Full Text Available Abstract Background Joint rehabilitation goals are an important component for effective teamwork in the rehabilitation field. The activities and participation domain of the ICF provides a common language for professionals when setting these goals. Involving clients in the formulation of rehabilitation goals is gaining momentum as part of a person-centred approach to rehabilitation. However, this is particularly difficult when clients have an acquired communication disability. The expressive communication difficulties negatively affect the consensus building process. As a result, obtaining information regarding rehabilitation goals from professionals and their clients warrants further investigation for this particular population. Methods This comparative study investigated clients and their assigned rehabilitation professionals' perception of the importance of ICF activities and participation domains for inclusion in their rehabilitation program. Twelve clients in an acute rehabilitation centre and twenty of their corresponding rehabilitation professionals participated in an activity using the Talking Mats™ visual framework for goal setting. Each participant rated the importance of the nine activities and participation domains of the ICF for inclusion in their current rehabilitation program. Results The ICF domains which consistently appear as very important across these groups are mobility, self-care and communication. Domains which consistently appear in the lower third of the rankings include spare time, learning and thinking and domestic life. Results indicate however that no statistical significant differences exist in terms of the individual domains across each of the participant groups. Within group differences however indicated that amongst the speech-language therapists and physiotherapists there was a statistical significant difference between spare time activities and communication and mobility. Conclusions Findings indicate that
T.M. Benning (Tim)
textabstractThe rise of consumerism and the increasing availability of information through the Internet have increased patients’ demand for care that is more in line with their preferences. Because of this trend the expectation that hospitals act according to each individual patient’s preferences is
Honig, Alice S.
This speech presents observations, made on a trip in June 1976, of the aesthetic environments of children in China, Japan, and Hong Kong. Home, school and day care environments are compared in terms of living and play space, room decor, the presence of art and toys, dramatic play and performance, music, nature and outdoor appreciation, food and…
Eriksson, E; Donner, E; Ledin, A
In recent years, concerns about climate change and the inefficient use and ongoing pollution of water resources have increased the political motivation to encourage water recycling. This has led to the widespread introduction of water saving measures and to advances in the decentralised treatment and reuse of wastewater. In particular, the treatment and reuse of greywater has received attention, although important information such as greywater substance loadings is still only rarely available. With the implementation of the European Water Framework Directive the focus on controlling and phasing-out Priority/Priority Hazardous Substances (PS/PHS) is growing, and it is vital to know their sources and flows in order to generate sustainable emission control strategies. The main objective of this study was to quantify the concentrations and loads of PS/PHS and personal care substances in bathroom greywater, and to thereby assess the contribution of household activities to municipal wastewater loads for these substances. Nickel and mercury may be sourced substantially from household activities as it shown in the paper that bathroom greywater contributed a significant proportion of the overall load of these substances at the municipal wastewater treatment plant. Organic matter in the influent greywater was found to be principally associated with large particles (>8 µm), however it was the dissolved and small sized particles that were predominantly removed in the treatment.
During the past decade, health care delivery has undergone enormous changes. The nationwide growth in managed care organizations and the changing methods of provider reimbursement are restructuring the entire health care system. Diversification and integration strategies have blurred historical separations between the activities of hospitals, nursing homes, physicians, and other providers. Services are being offered in and shifting to less costly settings, such as ambulatory clinics, work sites, and homes. Many factors have contributed to the increasing trend of health care delivery outside hospitals. This presentation will provide insight to the management and surveillance of infection prevention in these health care settings.
Higginson, I.J.; Gomes, B.; Calanzani, N.; Gao, W.; Bausewein, C.; Daveson, B.A.; Deliens, L.; Ferreira, P.L.; Toscani, F.; Gysels, M.; Ceulemans, L.; Simon, S.T.; Cohen, J.; Harding, R.
BACKGROUND: Health-care costs are growing, with little population-based data about people's priorities for end-of-life care, to guide service development and aid discussions. AIM: We examined variations in people's priorities for treatment, care and information across seven European countries. DESIG
R. Baltussen (R.); Jansen, M.P. (Maarten P.); T.S. Mikkelsen; N. Tromp; J.A.C. Hontelez (Jan A.C.); Bijlmakers, L. (Leon); G.-J. van der Wilt (Gert-Jan)
textabstractPriority setting of health interventions is generally considered as a valuable approach to support low- and middle-income countries (LMICs) in their strive for universal health coverage (UHC). However, present initiatives on priority setting are mainly geared towards the development of m
Garpenby, Peter; Nedlund, Ann-Charlotte
This paper contributes to the knowledge on the governing of healthcare in a democratic context in times of austerity. Resource allocation in healthcare is a highly political issue but the political nature of healthcare is not always made clear and the role of politicians is often obscure. The absence of politicians in rationing/disinvestment arrangements is usually explained with blame-shifting arguments; they prefer to delegate "the burden of responsibility" to administrative agencies or professionals. Drawing on a case where Swedish regional politicians involved themselves in setting priorities at a more detailed level than previously, the findings suggest that the subject of "blame avoidance" is more complicated than usually assumed. A qualitative case study was designed, involving semi-structured interviews with 14 regionally elected politicians in one Swedish health authority, conducted in June 2011. The interviews were analysed through a thematic analysis in accordance with the "framework approach" by Ritchie and Lewis. Findings show that an overarching strategy among the politicians was to appear united and to suppress conflict, which served to underpin the vital strategy of bringing the medical profession into the process. A key finding is the importance that politicians, when appearing "backstage", attach to the prevention of blame from the medical profession. This case illustrates that one has to take into account that priority settings requires various types of skills and knowledges - not only technical but also political and social. Another important lesson points toward the need to broaden the political leadership repertoire, as leadership in the case of priority setting is not about politicians being all in or all out. The results suggest that in a priority-setting process it is of importance to have politics on-board at an early stage to secure loyalty to the process, although not necessarily being involved in all details.
Walt, Gill; Gilson, Lucy
This article systematically reviews a set of health policy papers on agenda setting and tests them against a specific priority-setting framework. The article applies the Shiffman and Smith framework in extracting and synthesizing data from an existing set of papers, purposively identified for their relevance and systematically reviewed. Its primary aim is to assess how far the component parts of the framework help to identify the factors that influence the agenda setting stage of the policy process at global and national levels. It seeks to advance the field and inform the development of theory in health policy by examining the extent to which the framework offers a useful approach for organizing and analysing data. Applying the framework retrospectively to the selected set of papers, it aims to explore influences on priority setting and to assess how far the framework might gain from further refinement or adaptation, if used prospectively. In pursuing its primary aim, the article also demonstrates how the approach of framework synthesis can be used in health policy analysis research.
Full Text Available Climate and other global change phenomena affecting biodiversity require monitoring to track ecosystem changes and guide policy and management actions. Designing a biodiversity monitoring program is a difficult task that requires making decisions that often lack consensus due to budgetary constrains. As monitoring programs require long-term investment, they also require strong and continuing support from all interested parties. As such, stakeholder consultation is key to identify priorities and make sound design decisions that have as much support as possible. Here, we present the results of a consultation conducted to serve as an aid for designing a large-scale biodiversity monitoring program for the province of Québec (Canada. The consultation took the form of a survey with 13 discrete choices involving tradeoffs in respect to design priorities and 10 demographic questions (e.g., age, profession. The survey was sent to thousands of individuals having expected interests and knowledge about biodiversity and was completed by 621 participants. Overall, consensuses were few and it appeared difficult to create a design fulfilling the priorities of the majority. Most participants wanted 1 a monitoring design covering the entire territory and focusing on natural habitats; 2 a focus on species related to ecosystem services, on threatened and on invasive species. The only demographic characteristic that was related to the type of prioritization was the declared level of knowledge in biodiversity (null to high, but even then the influence was quite small.
Alexander, Carla S; Memiah, Peter; Henley, Yvonne B; Kaiza-Kangalawe, Angela; Shumbusho, Anna Joyce; Obiefune, Michael; Enejoh, Victor; Stanis-Ezeobi, Winifred; Eze, Charity; Odion, Ehekhaye; Akpenna, Donald; Effiong, Amana; Miriti, Kenneth; Aduda, Samson; Oko, John; Melaku, Gebremedhin D; Baribwira, Cyprien; Umutesi, Hassina; Shimabale, Mope; Mugisa, Emmanuel; Amoroso, Anthony
To combat morbidity and mortality from the worldwide epidemic of the human immunodeficiency virus (HIV), the United States Congress implemented a President's Emergency Plan for AIDS Relief (PEPFAR) in 30 resource-limited countries to integrate combination antiretroviral therapy (ART) for both prevention and cure. Over 35% of eligible persons have been successfully treated. Initial legislation cited palliative care as an essential aspect of this plan but overall health strengthening became critical to sustainability of programming and funding priorities shifted to assure staffing for care delivery sites; laboratory and pharmaceutical infrastructure; data collection and reporting; and financial management as individual countries are being encouraged to assume control of in-country funding. Given infrastructure requisites, individual care delivery beyond ART management alone has received minimal funding yet care remains necessary for durable viral suppression and overall quality of life for individuals. Technical assistance staff of one implementing partner representing seven African countries met to clarify domains of palliative care compared with the substituted term "care and support" to understand potential gaps in on-going HIV care. They prioritized care needs as: 1) mental health (depression and other mood disorders); 2) communication skills (age-appropriate disclosure of HIV status); 3) support of care-providers (stress management for sustainability of a skilled HIV workforce); 4) Tied Priorities: symptom management in opportunistic infections; end-of-life care; spiritual history-taking; and 5) Tied Priorities: attention to grief-related needs of patients, their families and staff; and management of HIV co-morbidities. This process can inform health policy as funding transitions to new priorities.
Maluka, Stephen; Kamuzora, Peter; Ndawi, Benedict; Hurtig, Anna-Karin
The past two decades have seen a growing call for researchers, policy-makers and health care providers to collaborate in efforts to bridge the gaps between research, policy and practice. However, there has been a little attention focused on documenting the challenges of dealing with decision-makers in the course of implementing a research project. This paper highlights a collaborative research project aiming to implement the accountability for reasonableness (AFR) approach to priority setting in accordance with the Response to Accountable Priority Setting for Trust in Health Systems (REACT) project in Tanzania. Specifically, the paper examines the challenges of dealing with decision-makers during the project-implementation process and shows how the researchers dealt with the decision-makers to facilitate the implementation of the REACT project. Key informant interviews were conducted with the Council Health Management Team (CHMT), local government officials and other stakeholders, using a semi-structured interview guide. Minutes of the Action Research Team and CHMT were analysed. Additionally, project-implementation reports were analysed and group priority-setting processes in the district were observed. The findings show that the characteristics of the REACT research project, the novelty of some aspects of the AFR approach, such as publicity and appeals, the Action Research methodology used to implement the project and the traditional cultural contexts within which the project was implemented, created challenges for both researchers and decision-makers, which consequently slowed down the implementation of the REACT project. While collaboration between researchers and decision-makers is important in bridging gaps between research and practice, it is imperative to understand the challenges of dealing with decision-makers in the course of implementing a collaborative research project. Such analyses are crucial in designing proper strategies for improved communication
Malcolm, C; Forbat, L; Knighting, K; Kearney, N
The main objective of this study is to generate a list of priority topics for children's hospice care research in Scotland from the perspective of its key stakeholders. The method consists of qualitative semi-structured interviews with families using hospice services (n = 5), four focus groups with hospice staff and volunteers (n = 44) and telephone interviews with professionals associated with the hospice (n = 18). Fourteen broad themes emerged following thematic content and interpretive analysis of the interview data. Some of the research themes were specific to certain stakeholder groups, whereas other themes were identified unanimously across all the stakeholder groups as being priority areas for future research. Increasing awareness of and improving access to children's hospice care, hospice and respite care needs of young people, community/home care and issues related to supporting the wider family arose, independently, in all three stakeholder groups as being priority topics for future research. In conclusion, a greater evidence base is required in the field of children's palliative care and the topics researched should be identified and led by those most closely involved in the hospices. Engaging families and care providers in the process of identifying research priorities resulted in the development of an extensive research agenda, which will contribute to quality hospice care for children and families.
Mønsted, Troels; Johansen, Andreas Kaas; Lauridsen, Frederik Vahr Bjarnø
a heterogeneous ensemble of care providers. In this paper, we present findings from a field study of coordinative work in distributed elder care in Denmark. The purpose of this study is to further our understanding of the coordinative challenges of distributed elder care, and to inform design of new care......, that are needed by the healthcare system, but also the work involved in balancing priorities....
Full Text Available Abstract Introduction Several studies carried out to establish the relative preference of cost-effectiveness of interventions and severity of disease as criteria for priority setting in health have shown a strong preference for severity of disease. These preferences may differ in contexts of resource scarcity, as in developing countries, yet information is limited on such preferences in this context. Objective This study was carried out to identify the key players in priority setting in health and explore their relative preference regarding cost-effectiveness of interventions and severity of disease as criteria for setting priorities in Uganda. Design 610 self-administered questionnaires were sent to respondents at national, district, health sub-district and facility levels. Respondents included mainly health workers. We used three different simulations, assuming same patient characteristics and same treatment outcome but with varying either severity of disease or cost-effectiveness of treatment, to explore respondents' preferences regarding cost-effectiveness and severity. Results Actual main actors were identified to be health workers, development partners or donors and politicians. This was different from what respondents perceived as ideal. Above 90% of the respondents recognised the importance of both severity of disease and cost-effectiveness of intervention. In the three scenarios where they were made to choose between the two, a majority of the survey respondents assigned highest weight to treating the most severely ill patient with a less cost-effective intervention compared to the one with a more cost-effective intervention for a less severely ill patient. However, international development partners in in-depth interviews preferred the consideration of cost-effectiveness of intervention. Conclusions In a survey among health workers and other actors in priority setting in Uganda, we found that donors are considered to have more say than
Miller, Carla K; Bauman, Jennifer
Goal setting is a widely used behavior change tool in diabetes education and training. Prior research found specific relatively difficult but attainable goals set within a specific timeframe improved performance in sports and at the workplace. However, the impact of goal setting in diabetes self-care has not received extensive attention. This review examined the mechanisms underlying behavioral change according to goal setting theory and evaluated the impact of goal setting in diabetes intervention studies. Eight studies were identified, which incorporated goal setting as the primary strategy to promote behavioral change in individual, group-based, and primary care settings among patients with type 2 diabetes. Improvements in diabetes-related self-efficacy, dietary intake, physical activity, and A1c were observed in some but not all studies. More systematic research is needed to determine the conditions and behaviors for which goal setting is most effective. Initial recommendations for using goal setting in diabetes patient encounters are offered.
Smith, Stephanie L; Shiffman, Jeremy
This study investigates a puzzle concerning global health priorities-why do comparable issues receive differential levels of attention and resources? It considers maternal and neonatal mortality, two high-burden issues that pertain to groups at risk at birth and whose lives could be saved with effective intrapartum care. Why did maternal survival gain status as a global health priority earlier and to a greater degree than newborn survival? Higher mortality and morbidity burdens among newborns and the cost-effectiveness of interventions would seem to predict that issue's earlier and higher prioritization. Yet maternal survival emerged as a priority two decades earlier and had attracted considerably more attention and resources by the close of the Millennium Development Goals era. This study uses replicative process-tracing case studies to examine the emergence and growth of political priority for these two issues, probing reasons for unexpected variance. The study finds that maternal survival's grounding as a social justice issue spurred growth of a strong and diverse advocacy network and aligned the issue with powerful international norms (e.g. expectations to advance women's rights and the Millennium Development Goals), drawing attention and resources to the issue over three decades. Newborn survival's disadvantage stems from its long status as an issue falling under the umbrellas of maternal and child survival but not fully adopted by these networks, and with limited appeal as a public health issue advanced by a small and technically focused network; network expansion and alignment with child survival norms have improved the issue's status in the past few years.
Goodrich, David E; Kilbourne, Amy M; Nord, Kristina M; Bauer, Mark S
Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems, as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims underhealth care reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components.
Powers, James S
Health care professionals encounter elder abuse in the community and in medical offices, emergency rooms, hospitals, and long-term care facilities. Keen awareness of risk factors for elder abuse and the variety of presentations in different health settings helps promote detection, treatment, and prevention of elder abuse.
Mobinizadeh, Mohammadreza; Raeissi, Pouran; Nasiripour, Amir Ashkan; Olyaeemanesh, Alireza; Tabibi, Seyed Jamaleddin
Background: In the recent years, using health technologies to diagnose and treat diseases has had a considerable and accelerated growth. The proper use of these technologies may considerably help in the diagnosis and treatment of different diseases. On the other hand, unlimited and unrestricted entry of these technologies may result in induced demand by service providers. The aim of this study was to determine the appropriate criteria used in health technologies priority-setting models in the world. Methods: Using MESH and free text, we sought and retrieved the relevant articles from the most appropriate medical databases (the Cochrane Library, PubMed and Scopus) through three separate search strategies up to March 2015. The inclusion criteria were as follows: 1) Studies with specific criteria; 2) Articles written in English; 3) Those articles conducted in compliance with priority setting of health technologies. Data were analyzed qualitatively using a thematic synthesis technique. Results: After screening the retrieved papers via PRISMA framework, from the 7,012 papers, 40 studies were included in the final phase. Criteria for selecting health technologies (in pre assessment and in the assessment phase) were categorized into six main themes: 1) Health outcomes; 2) Disease and target population; 3) Technology alternatives; 4) Economic aspects; 5) Evidence; 6) and other factors. "Health effects/benefits" had the maximum frequency in health outcomes (8 studies); "disease severity" had the maximum frequency in disease and target population (12 studies); "the number of alternatives" had the maximum frequency in alternatives (2 studies); "cost-effectiveness" had the maximum frequency in economic aspects (15 studies); "quality of evidence" had the maximum frequency in evidence (4 studies); and "issues concerning the health system" had the maximum frequency in other factors (10 studies). Conclusion: The results revealed an increase in the number of studies on health
Youngkong, S.; Teerawattananon, Y.; Tantivess, S.; Baltussen, R.M.
BACKGROUND: A wide range of preventive, treatment, and care programs for HIV/AIDS are currently available and some of them have been implemented in Thailand. Policy makers are now facing challenges on how the scarce resources for HIV/AIDS control can be spent more wisely. Although effectiveness and
Byskov, Jens; Bloch, Paul; Blystad, Astrid
decisions; iv) the provision of leadership to ensure that the first three conditions are met.REACT - "REsponse to ACcountable priority setting for Trust in health systems" is an EU-funded five-year intervention study started in 2006, which is testing the application and effects of the AFR approach in one...... from burden of disease statistics, cost effectiveness analysis, and published clinical trials. However, priority setting involves value-laden choices and these technical approaches do not equip decision-makers to address a broader range of relevant values - such as trust, equity, accountability...... and fairness - that are of concern to other partners and, not least, the populations concerned. A new focus for priority setting is needed.Accountability for Reasonableness (AFR) is an explicit ethical framework for legitimate and fair priority setting that provides guidance for decision-makers who must...
Barasa, Edwine W; Molyneux, Sassy; English, Mike; Cleary, Susan
There is a dearth of literature on priority setting and resource allocation (PSRA) practices in hospitals, particularly in low and middle income countries (LMICs). Using a case study approach, we examined PSRA practices in 2 public hospitals in coastal Kenya. We collected data through a combination of in-depth interviews of national level policy makers, hospital managers, and frontline practitioners in the case study hospitals (n = 72), review of documents such as hospital plans and budgets, minutes of meetings and accounting records, and non-participant observations of PSRA practices in case study hospitals over a period of 7 months. In this paper, we apply complex adaptive system (CAS) theory to examine the factors that influence PSRA practices. We found that PSRA practices in the case hospitals were influenced by, 1) inadequate financing level and poorly designed financing arrangements, 2) limited hospital autonomy and decision space, and 3) inadequate management and leadership capacity in the hospital. The case study hospitals exhibited properties of complex adaptive systems (CASs) that exist in a dynamic state with multiple interacting agents. Weaknesses in system 'hardware' (resource scarcity) and 'software' (including PSRA guidelines that reduced hospitals decision space, and poor leadership skills) led to the emergence of undesired properties. The capacity of hospitals to set priorities should be improved across these interacting aspects of the hospital organizational system. Interventions should however recognize that hospitals are CAS. Rather than rectifying isolated aspects of the system, they should endeavor to create conditions for productive emergence.
Zvinavashe, E.; Murk, A.J.; Vervoort, J.J.M.; Soffers, A.E.M.F.; Freidig, A.; Rietjens, I.M.C.M.
Fifteen experimental literature data sets on the acute toxicity of substituted nitrobenzenes to algae (Scenedesmus obliquus, Chlorella pyrenoidosa, C. vulgaris), daphnids (Daphnia magna, D. carinata), fish (Cyprinus carpio, Poecilia reticulata), protozoa (Tetrahymena pyriformis), bacteria (Phosphoba
Ohashi, Haruka; Yoshikawa, Masato; Oono, Keiichi; Tanaka, Norihisa; Hatase, Yoriko; Murakami, Yuhide
Irreversible shifts in ecosystems caused by large herbivores are becoming widespread around the world. We analyzed data derived from the 2009-2010 Sika Deer Impact Survey, which assessed the geographical distribution of deer impacts on vegetation through a questionnaire, on a scale of 5-km grid-cells. Our aim was to identify areas facing irreversible ecosystem shifts caused by deer overpopulation and in need of management prioritization. Our results demonstrated that the areas with heavy impacts on vegetation were widely distributed across Japan from north to south and from the coastal to the alpine areas. Grid-cells with heavy impacts are especially expanding in the southwestern part of the Pacific side of Japan. The intensity of deer impacts was explained by four factors: (1) the number of 5-km grid-cells with sika deer in neighboring 5 km-grid-cells in 1978 and 2003, (2) the year sika deer were first recorded in a grid-cell, (3) the number of months in which maximum snow depth exceeded 50 cm, and (4) the proportion of urban areas in a particular grid-cell. Based on our model, areas with long-persistent deer populations, short snow periods, and fewer urban areas were predicted to be the most vulnerable to deer impact. Although many areas matching these criteria already have heavy deer impact, there are some areas that remain only slightly impacted. These areas may need to be designated as having high management priority because of the possibility of a rapid intensification of deer impact.
Maarten P. Jansen
Full Text Available Embedding health technology assessment (HTA in a fair process has great potential to capture societal values relevant to public reimbursement decisions on health technologies. However, the development of such processes for priority setting has largely been theoretical. In this paper, we provide further practical lead ways on how these processes can be implemented. We first present the misconception about the relation between facts and values that is since long misleading the conduct of HTA and underlies the current assessmentappraisal split. We then argue that HTA should instead be explicitly organized as an ongoing evidenceinformed deliberative process, that facilitates learning among stakeholders. This has important consequences for whose values to consider, how to deal with vested interests, how to consider all values in the decisionmaking process, and how to communicate decisions. This is in stark contrast to how HTA processes are implemented now. It is time to set the stage for HTA as learning.
Hageman, Jeffrey C; Hazim, Carmen; Wilson, Katie; Malpiedi, Paul; Gupta, Neil; Bennett, Sarah; Kolwaite, Amy; Tumpey, Abbigail; Brinsley-Rainisch, Kristin; Christensen, Bryan; Gould, Carolyn; Fisher, Angela; Jhung, Michael; Hamilton, Douglas; Moran, Kerri; Delaney, Lisa; Dowell, Chad; Bell, Michael; Srinivasan, Arjun; Schaefer, Melissa; Fagan, Ryan; Adrien, Nedghie; Chea, Nora; Park, Benjamin J
The 2014-2016 Ebola virus disease (Ebola) epidemic in West Africa underscores the need for health care infection prevention and control (IPC) practices to be implemented properly and consistently to interrupt transmission of pathogens in health care settings to patients and health care workers. Training and assessing IPC practices in general health care facilities not designated as Ebola treatment units or centers became a priority for CDC as the number of Ebola virus transmissions among health care workers in West Africa began to affect the West African health care system and increasingly more persons became infected. CDC and partners developed policies, procedures, and training materials tailored to the affected countries. Safety training courses were also provided to U.S. health care workers intending to work with Ebola patients in West Africa. As the Ebola epidemic continued in West Africa, the possibility that patients with Ebola could be identified and treated in the United States became more realistic. In response, CDC, other federal components (e.g., Office of the Assistant Secretary for Preparedness and Response) and public health partners focused on health care worker training and preparedness for U.S. health care facilities. CDC used the input from these partners to develop guidelines on IPC for hospitalized patients with known or suspected Ebola, which was updated based on feedback from partners who provided care for Ebola patients in the United States. Strengthening and sustaining IPC helps health care systems be better prepared to prevent and respond to current and future infectious disease threats.The activities summarized in this report would not have been possible without collaboration with many U.S. and international partners (http://www.cdc.gov/vhf/ebola/outbreaks/2014-west-africa/partners.html).
Swanson, J C; Lee, Y; Thompson, P B; Bawden, R; Mench, J A
Setting directions and goals for animal production systems requires the integration of information achieved through internal and external processes. The importance of stakeholder input in setting goals for sustainable animal production systems should not be overlooked by the agricultural animal industries. Stakeholders play an integral role in setting the course for many aspects of animal production, from influencing consumer preferences to setting public policy. The Socially Sustainable Egg Production Project (SSEP) involved the development of white papers on various aspects of egg production, followed by a stakeholder workshop to help frame the issues for the future of sustainable egg production. Representatives from the environmental, food safety, food retail, consumer, animal welfare, and the general farm and egg production sectors participated with members of the SSEP coordination team in a 1.5-d workshop to explore socially sustainable egg production. This paper reviews the published literature on values integration methodologies and the lessons learned from animal welfare assessment models. The integration method used for the SSEP stakeholder workshop and its outcome are then summarized. The method used for the SSEP stakeholder workshop can be used to obtain stakeholder input on sustainable production in other farm animal industries.
Full Text Available Priority setting of health interventions is generally considered as a valuable approach to support low- and middle-income countries (LMICs in their strive for universal health coverage (UHC. However, present initiatives on priority setting are mainly geared towards the development of more cost-effectiveness information, and this evidence does not sufficiently support countries to make optimal choices. The reason is that priority setting is in reality a value-laden political process in which multiple criteria beyond cost-effectiveness are important, and stakeholders often justifiably disagree about the relative importance of these criteria. Here, we propose the use of ‘evidence-informed deliberative processes’ as an approach that does explicitly recognise priority setting as a political process and an intrinsically complex task. In these processes, deliberation between stakeholders is crucial to identify, reflect and learn about the meaning and importance of values, informed by evidence on these values. Such processes then result in the use of a broader range of explicit criteria that can be seen as the product of both international learning (‘core’ criteria, which include eg, cost-effectiveness, priority to the worse off, and financial protection and learning among local stakeholders (‘contextual’ criteria. We believe that, with these evidence-informed deliberative processes in place, priority setting can provide a more meaningful contribution to achieving UHC.
Yount, Brian; McNamara, Timothy
Effective standardization of clinical processes, which is a growing priority for healthcare provider organizations and networks, requires effective teamwork among clinicians and staff from multidisciplinary backgrounds--often from geographically dispersed facilities--to reach consensus on care practices. Yet, most healthcare provider organizations have no precedence or tools for managing large-scale, sustained, collaborative activities. This presentation explores the human and social implications of technology. It specifically addresses healthcare collaboration and describes how innovative collaboration management technologies can be used in the healthcare industry to accelerate care standardization, order set standardization and other initiatives necessary for successful computerized provider order entry and electronic health record deployments. These topics are explored through presentation of a survey of healthcare executives and a case study of an advanced collaboration application that was adapted and deployed in a partnership between a large healthcare provider organization and a commercial developer of document management and collaboration management technologies.
...: Cardiovascular Disease Priorities Table 3: Respiratory Disease Priorities Table 4: Intensive Care Priorities..., which can be a group of conditions, a subgroup of the population, or a setting of care. The first... pediatric therapeutics. The Obstetric and Pediatric Pharmacology Branch of the NICHD has developed...
Kent, Erin E; Rowland, Julia H; Northouse, Laurel; Litzelman, Kristin; Chou, Wen-Ying Sylvia; Shelburne, Nonniekaye; Timura, Catherine; O'Mara, Ann; Huss, Karen
Informal/family caregivers are a fundamental source of care for cancer patients in the United States, yet the population of caregivers and their tasks, psychosocial needs, and health outcomes are not well understood. Changes in the nature of cancer care and its delivery, along with the growing population of survivors and their caregivers, warrant increased attention to the roles and demands of caregiving. This article reviews current evidence presented at a 2-day meeting examining the state of the science of informal cancer caregiving that was convened by the National Cancer Institute and the National Institute of Nursing Research. The meeting sought to define who is an informal cancer caregiver, summarize the state of the science in informal cancer caregiving, and describe both the kinds of interventions developed to address caregiving challenges and the various outcomes used to evaluate their impact. This article offers recommendations for moving science forward in 4 areas: 1) improving the estimation of the prevalence and burden of informal cancer caregiving; 2) advancing the development of interventions designed to improve outcomes for cancer patients, caregivers, and patient-caregiver dyads; 3) generating and testing strategies for integrating caregivers into formal health care settings; and 4) promoting the use of technology to support informal cancer caregivers. Cancer 2016;122:1987-95. © 2016 American Cancer Society.
Cohen, Ted; Nuermberger, Eric; Dooley, Kelly E.; Gonzalez-Angulo, Lice; Churchyard, Gavin J.; Nahid, Payam; Rich, Michael L.; Bansbach, Cathy; Forissier, Thomas; Dowdy, David W.
Background Novel drug regimens are needed for tuberculosis (TB) treatment. New regimens aim to improve on characteristics such as duration, efficacy, and safety profile, but no single regimen is likely to be ideal in all respects. By linking these regimen characteristics to a novel regimen’s ability to reduce TB incidence and mortality, we sought to prioritize regimen characteristics from a population-level perspective. Methods and Findings We developed a dynamic transmission model of multi-strain TB epidemics in hypothetical populations reflective of the epidemiological situations in India (primary analysis), South Africa, the Philippines, and Brazil. We modeled the introduction of various novel rifampicin-susceptible (RS) or rifampicin-resistant (RR) TB regimens that differed on six characteristics, identified in consultation with a team of global experts: (1) efficacy, (2) duration, (3) ease of adherence, (4) medical contraindications, (5) barrier to resistance, and (6) baseline prevalence of resistance to the novel regimen. We compared scale-up of these regimens to a baseline reflective of continued standard of care. For our primary analysis situated in India, our model generated baseline TB incidence and mortality of 157 (95% uncertainty range [UR]: 113–187) and 16 (95% UR: 9–23) per 100,000 per year at the time of novel regimen introduction and RR TB incidence and mortality of 6 (95% UR: 4–10) and 0.6 (95% UR: 0.3–1.1) per 100,000 per year. An optimal RS TB regimen was projected to reduce 10-y TB incidence and mortality in the India-like scenario by 12% (95% UR: 6%–20%) and 11% (95% UR: 6%–20%), respectively, compared to current-care projections. An optimal RR TB regimen reduced RR TB incidence by an estimated 32% (95% UR: 18%–46%) and RR TB mortality by 30% (95% UR: 18%–44%). Efficacy was the greatest determinant of impact; compared to a novel regimen meeting all minimal targets only, increasing RS TB treatment efficacy from 94% to 99
Zweig, Richard A.; Siegel, Lawrence; Hahn, Steven; Kuslansky, Gail; Byrne, Kathy; Fyffe, Denise; Passman, Vicki; Stewart, Douglas; Hinrichsen, Gregory
Most older adults diagnosed with a mental disorder receive treatment in primary care settings that lack personnel skilled in geropsychological diagnosis and treatment. The Ferkauf Older Adult Program of Yeshiva University endeavors to bridge this gap by providing training in geriatric psychology, through coursework and diverse clinical practica,…
de Guzman, Allan B.; Satuito, James Cyril B.; Satumba, Miko Anne E.; Segui, Diego Rey A.; Serquina, Faith Evelyn C.; Serrano, Lawrence Jan P.; Sevilla, Madelyn D.
The use of traditional art in recreational therapies is unexplored. This paper, thus, attempts to surface the unique power of traditional Filipino arts (TFA) as synergizing lens in capturing the individual and the collective experiences of a select group of Filipino elderly in an institutionalized care setting relative to their feelings of…
Bond, Penny; Goudie, Karen
Delirium is an acute medical emergency affecting about one in eight acute hospital inpatients. It is associated with poor outcomes, is more prevalent in older people and it is estimated that half of all patients receiving intensive care or surgery for a hip fracture will be affected. Despite its prevalence and impact, delirium is not reliably identified or well managed. Improving the identification and management of patients with delirium has been a focus for the national improving older people's acute care work programme in NHS Scotland. A delirium toolkit has been developed, which includes the 4AT rapid assessment test, information for patients and carers and a care bundle for managing delirium based on existing guidance. This toolkit has been tested and implemented by teams from a range of acute care settings to support improvements in the identification and immediate management of delirium.
Austin, Wendy; Goble, Erika; Strang, Vicki; Mitchell, Agnes; Thompson, Elizabeth; Lantz, Helen; Balt, Linda; Lemermeyer, Gillian; Vass, Kelly
In this Canadian study, a participatory action research approach was used to examine the relationships between families of residents of traditional continuing care facilities and the health care team. The objectives were to (a) explore the formation and maintenance of family-staff relationships, with attention paid to the relational elements of engagement and mutual respect; (b) explore family and staff perspectives of environmental supports and constraints; and (c) identify practical ways to support and enhance these relationships. Results indicate that the resource-constrained context of continuing care has directly impacted family and staff relationships. The nature of these relationships are discussed using the themes of "Everybody Knows Your Name," "Loss and Laundry," "It's the Little Things That Count," and "The Chasm of Us Versus Them." Families' and staff's ideas of behaviors that support or undermine relationships are identified, as are concrete suggestions for improving family- staff relationships in traditional continuing care settings in Canada.
Leung, Maria; Lambert, James H; Mosenthal, Alexander
This article presents an approach to the problem of terrorism risk assessment and management by adapting the framework of the risk filtering, ranking, and management method. The assessment is conducted at two levels: (1) the system level, and (2) the asset-specific level. The system-level risk assessment attempts to identify and prioritize critical infrastructures from an inventory of system assets. The definition of critical infrastructures offered by Presidential Decision Directive 63 was used to determine the set of attributes to identify critical assets--categorized according to national, regional, and local impact. An example application is demonstrated using information from the Federal Highway Administration National Bridge Inventory for the State of Virginia. Conversely, the asset-specific risk assessment performs an in-depth analysis of the threats and vulnerabilities of a specific critical infrastructure. An illustration is presented to offer some insights in risk scenario identification and prioritization, multiobjective evaluation of management options, and extreme-event analysis for critical infrastructure protection.
Spigolon, Dandara Novakowski; Moro, Claudia Maria Cabral
This study aimed to develop an Essential Data Set for Nursing Care of Patients with Endometriosis (CDEEPE), represented by archetypes. An exploratory applied research with specialists' participation that was carried out at Heath Informatics Laboratory of PUCPR, between February and November of 2010. It was divided in two stages: CDEEPE construction and evaluation including Nursing Process phases and Basic Human Needs, and archetypes development based on this data set. CDEEPE was evaluated by doctors and nurses with 95.9% of consensus and containing 51 data items. The archetype "Perception of Organs and Senses" was created to represents this data set. This study allowed identifying important information for nursing practices contributing to computerization and application of nursing process during care. The CDEEPE was the basis for archetype creation, that will make possible structured, organized, efficient, interoperable, and semantics records.
Radwin, Laurel E; Castonguay, Denise; Keenan, Carolyn B; Hermann, Cherice
For many patients, high-quality, patient-centered, and cost-effective health care requires coordination among multiple clinicians and settings. Ensuring optimal care coordination requires a clear understanding of how clinician activities and continuity during transitions affect patient-centeredness and quality outcomes. This article describes an expanded theoretical framework to better understand care coordination. The framework provides clear articulation of concepts. Examples are provided of ways to measure the concepts.
Xiaofeng, Luan; Yi, Qu; Diqiang, Li; Shirong, Liu; Xiulei, Wang; Bo, Wu; Chunquan, Zhu
The Amur Tiger (Panthera tigris altaica) is one of the world's most endangered species. Recently, habitat fragmentation, food scarcity and human hunting have drastically reduced the population size and distribution areas of Amur tigers in the wild, leaving them on the verge of extinction. Presently, they are only found in the north-eastern part of China. In this study, we developed a reference framework using methods and technologies of analytic hierarchy process (AHP), remote sensing (RS), geographic information system (GIS), GAP analysis and Natural Break (Jenks) classification to evaluate the habitat and to set the conservation priorities for Amur tigers in eastern areas of Heilongjiang and Jilin Provinces of northeast China. We proposed a Habitat Suitability Index (HSI) incorporating 7 factors covering natural conditions and human disturbance. Based on the HSI values, the suitability was classified into five levels from the most to not suitable. Finally, according to results of GAP analysis, we identified six conservation priorities and designed a conservation landscape incorporating four new nature reserves, enlarging two existing ones, and creating four linkages for Amur tigers in northeast China. The case study showed that the core habitats (the most suitable and highly suitable habitats) identified for Amur tigers covered 35,547 km(2), accounting for approximately 26.71% of the total study area (1,33,093 km(2)). However, existing nature reserves protected only (7124 km(2) or) 20.04% of the identified core habitats. Thus, enlargement of current reserves is necessary and urgent for the tiger's conservation and restoration. Moreover, the establishment of wildlife corridors linking core habitats will provide an efficient reserve network for tiger conservation to maintain the evolutionary potential of Amur tigers facing environmental changes.
ALwaer, H. [The University of Dundee, School of Architecture, Matthew Building, 13 Perth Road, Dundee DD1 4HT (United Kingdom); Clements-Croome, D.J. [School of Construction Management and Engineering, The University of Reading, Whiteknights, PO Box 219, Reading RG6 6AW (United Kingdom)
The main objectives of this paper are to: firstly, identify key issues related to sustainable intelligent buildings (environmental, social, economic and technological factors); develop a conceptual model for the selection of the appropriate KPIs; secondly, test critically stakeholder's perceptions and values of selected KPIs intelligent buildings; and thirdly develop a new model for measuring the level of sustainability for sustainable intelligent buildings. This paper uses a consensus-based model (Sustainable Built Environment Tool- SuBETool), which is analysed using the analytical hierarchical process (AHP) for multi-criteria decision-making. The use of the multi-attribute model for priority setting in the sustainability assessment of intelligent buildings is introduced. The paper commences by reviewing the literature on sustainable intelligent buildings research and presents a pilot-study investigating the problems of complexity and subjectivity. This study is based upon a survey perceptions held by selected stakeholders and the value they attribute to selected KPIs. It is argued that the benefit of the new proposed model (SuBETool) is a 'tool' for 'comparative' rather than an absolute measurement. It has the potential to provide useful lessons from current sustainability assessment methods for strategic future of sustainable intelligent buildings in order to improve a building's performance and to deliver objective outcomes. Findings of this survey enrich the field of intelligent buildings in two ways. Firstly, it gives a detailed insight into the selection of sustainable building indicators, as well as their degree of importance. Secondly, it tesst critically stakeholder's perceptions and values of selected KPIs intelligent buildings. It is concluded that the priority levels for selected criteria is largely dependent on the integrated design team, which includes the client, architects, engineers and facilities managers
Plas, A.G. van der; Deliens, L.; Watering, M. van de; Jansen, W.J.; Vissers, K.C.P.; Onwuteaka-Philipsen, B.D.
BACKGROUND: In case management an individual or small team is responsible for navigating the patient through complex care. Characteristics of case management within and throughout different target groups and settings vary widely. Case management is relatively new in palliative care. Insight into the
Wiseman, Virginia; Mitton, Craig; Doyle-Waters, Mary M; Drake, Tom; Conteh, Lesong; Newall, Anthony T; Onwujekwe, Obinna; Jan, Stephen
Policy makers in low-income and lower-middle-income countries (LMICs) are increasingly looking to develop 'evidence-based' frameworks for identifying priority health interventions. This paper synthesises and appraises the literature on methodological frameworks--which incorporate economic evaluation evidence--for the purpose of setting healthcare priorities in LMICs. A systematic search of Embase, MEDLINE, Econlit and PubMed identified 3968 articles with a further 21 articles identified through manual searching. A total of 36 papers were eligible for inclusion. These covered a wide range of health interventions with only two studies including health systems strengthening interventions related to financing, governance and human resources. A little under half of the studies (39%) included multiple criteria for priority setting, most commonly equity, feasibility and disease severity. Most studies (91%) specified a measure of 'efficiency' defined as cost per disability-adjusted life year averted. Ranking of health interventions using multi-criteria decision analysis and generalised cost-effectiveness were the most common frameworks for identifying priority health interventions. Approximately a third of studies discussed the affordability of priority interventions. Only one study identified priority areas for the release or redeployment of resources. The paper concludes by highlighting the need for local capacity to conduct evaluations (including economic analysis) and empowerment of local decision-makers to act on this evidence.
Olsen Øystein E
Full Text Available Abstract Despite multiple efforts to strengthen health systems in low and middle income countries, intended sustainable improvements in health outcomes have not been shown. To date most priority setting initiatives in health systems have mainly focused on technical approaches involving information derived from burden of disease statistics, cost effectiveness analysis, and published clinical trials. However, priority setting involves value-laden choices and these technical approaches do not equip decision-makers to address a broader range of relevant values - such as trust, equity, accountability and fairness - that are of concern to other partners and, not least, the populations concerned. A new focus for priority setting is needed. Accountability for Reasonableness (AFR is an explicit ethical framework for legitimate and fair priority setting that provides guidance for decision-makers who must identify and consider the full range of relevant values. AFR consists of four conditions: i relevance to the local setting, decided by agreed criteria; ii publicizing priority-setting decisions and the reasons behind them; iii the establishment of revisions/appeal mechanisms for challenging and revising decisions; iv the provision of leadership to ensure that the first three conditions are met. REACT - "REsponse to ACcountable priority setting for Trust in health systems" is an EU-funded five-year intervention study started in 2006, which is testing the application and effects of the AFR approach in one district each in Kenya, Tanzania and Zambia. The objectives of REACT are to describe and evaluate district-level priority setting, to develop and implement improvement strategies guided by AFR and to measure their effect on quality, equity and trust indicators. Effects are monitored within selected disease and programme interventions and services and within human resources and health systems management. Qualitative and quantitative methods are being
Full Text Available Abstract Background In Norway, admission teams at Community Mental Health Centres (CMHCs assess referrals from General Practitioners (GPs, and classify the referrals into priority groups according to treatment needs, as defined in the Act of Patient Rights. In this study, we analyzed classification of similar referrals to determine the reliability of classification into priority groups (i.e., horizontal equity. Methods Twenty anonymous case vignettes based on representative referrals were classified by 42 admission team members at 16 CMHCs in the South-East Health Region of Norway. All clinicians were experienced, and were responsible for priority setting at their centres. The classifications were first performed independently by the 42 clinicians (i.e., individual rating, and then evaluated utilizing team consensus within each CMHC (i.e., team rating. Interrater reliability was estimated using intraclass correlation coefficients (ICCs while the reliability of rating across raters and units (generalizability were estimated using generalizability analysis. Results The ICCs (2.1 single measure, absolute agreement varied between 0.40 and 0.51 using individual ratings and between 0.39 and 0.58 using team ratings. Our findings suggest a fair (low degree of interrater reliability, and no improvement of team ratings was observed when compared to individual ratings. The generalizability analysis, for one rater within each unit, yields a generalizability coefficient of 0.50 and a dependability coefficient of 0.53 (D study. These findings confirm that the reliability of ratings across raters and across units is low. Finally, the degree of inconsistency, for an average measurement, appears to be higher within units than between units (G study. Conclusion The low interrater reliability and generalizability found in our study suggests that horizontal equity to mental health services is not ensured with respect to priority. Priority -setting in teams provides
Ibrahim, Ahmed; Aro, Arja R.; Rasch, Vibeke;
OBJECTIVE: To determine the feasibility of visual inspection with the use of acetic acid (VIA) as a screening method for cervical cancer, an alternative to the Pap smear used in primary health care setting in Sudan, and to compare sensitivity, specificity, positive and negative predictive values....../119 (73.9%) were positive for cervical intraepithelial neoplasia. VIA had higher sensitivity than Pap smear (74.2% versus 72.9%; P = 0.05) respectively. Out of 88 confirmed positive cases, 22 (25.0%) cases were invasive cervical cancer in stage 1, of which 19 versus three were detected by VIA and Pap...... of this study showed that VIA has higher sensitivity and lower specificity compared to Pap smear, but a combination of both tests has greater sensitivity and specificity than each test independently. It indicates that VIA is useful for screening of cervical cancer in the primary health care setting in Sudan...
Payne, Sarah; Cole, Elaine
Many patients with minor burns present at emergency departments and urgent care centres, where their management is often undertaken by experienced nurses rather than experts in treating burns. This article describes a small study of the clinical decision making that underpins nurses' management of minor burns in these non-specialist settings. The results suggest that, due to a lack of relevant research, nurses base their decisions on previous experience or expert colleagues' opinions and advice rather than on the evidence.
Larsen, Frank Wugt; Rahbek, Carsten
The higher-taxon approach may provide a pragmatic surrogate for the rapid identification of priority areas for conservation. To date, no continent-wide study has examined the use of higher-taxon data to identify complementarity-based networks of priority areas, nor has the influence of spatial gr...
Lyles, Courtney R; Aulakh, Veenu; Jameson, Wendy; Schillinger, Dean; Yee, Hal; Sarkar, Urmimala
Health reform requires safety net settings to transform care delivery, but how they will innovate in order to achieve this transformation is unknown. Two series of key informant interviews (N = 28) were conducted in 2012 with leadership from both California's public hospital systems and community health centers. Interviews focused on how innovation was conceptualized and solicited examples of successful innovations. In contrast to disruptive innovation, interviewees often defined innovation as improving implementation, making incremental changes, and promoting integration. Many leaders gave examples of existing innovative practices to meeting their diverse patient needs, such as patient-centered approaches. Participants expressed challenges to adapting quickly, but a desire to partner together. Safety net systems have already begun implementing innovative practices supporting their key priority areas. However, more support is needed, specifically to accelerate the change needed to succeed under health reform.
Greene, Laurence; Moreo, Kathleen
Studies on inflammatory bowel disease (IBD) have reported suboptimal approaches to patient care. In the United States, the findings have motivated leading gastroenterology organizations to call for initiatives that support clinicians in aligning their practices with quality measures for IBD and priorities of the National Quality Strategy (NQS). We designed and implemented a quality improvement (QI) education program on ulcerative colitis in which patient charts were audited for 30 gastroenterologists before (n = 300 charts) and after (n = 290 charts) they participated in QI-focused educational activities. Charts were audited for nine measures, selected for their alignment with four NQS priorities: making care safer, ensuring patient engagement, promoting communication, and promoting effective treatment practices. Four of the measures, including guideline-directed vaccinations and assessments of disease type and activity, were part of the CMS Physician Quality Reporting System (PQRS). The other five measures involved counseling patients on various topics in ulcerative colitis management, documentation of side effects, assessment of adherence status, and simplification of dosing. The gastroenterologists also completed baseline and post-education surveys designed to assess qualitative outcomes. One of the educational interventions was a private audit feedback session conducted for each gastroenterologist. The sessions were designed to support participants in identifying measures reflecting suboptimal care quality and developing action plans for improvement. In continuous improvement cycles, follow-up interventions included QI tools and educational monographs. Across the nine chart variables, post-education improvements ranged from 0% to 48%, with a mean improvement of 15.9%. Survey findings revealed improvements in self-reported understanding of quality measures and intentions to apply them to practice, and lower rates of perceived significant barriers to high
Full Text Available We review the utility of centrifugal microfluidic technologies applied to point-of-care diagnosis in extremely under-resourced environments. The various challenges faced in these settings are showcased, using areas in India and Africa as examples. Measures for the ability of integrated devices to effectively address point-of-care challenges are highlighted, and centrifugal, often termed CD-based microfluidic technologies, technologies are presented as a promising platform to address these challenges. We describe the advantages of centrifugal liquid handling, as well as the ability of a standard CD player to perform a number of common laboratory tests, fulfilling the role of an integrated lab-on-a-CD. Innovative centrifugal approaches for point-of-care in extremely resource-poor settings are highlighted, including sensing and detection strategies, smart power sources and biomimetic inspiration for environmental control. The evolution of centrifugal microfluidics, along with examples of commercial and advanced prototype centrifugal microfluidic systems, is presented, illustrating the success of deployment at the point-of-care. A close fit of emerging centrifugal systems to address a critical panel of tests for under-resourced clinic settings, formulated by medical experts, is demonstrated. This emphasizes the potential of centrifugal microfluidic technologies to be applied effectively to extremely challenging point-of-care scenarios and in playing a role in improving primary care in resource-limited settings across the developing world.
Luyirika, Emmanuel Bk; Namisango, Eve; Garanganga, Eunice; Monjane, Lidia; Ginindza, Ntombi; Madonsela, Gugulethu; Kiyange, Fatia
Given the high unmet need for palliative care in Africa and other resource limited settings, it is important that countries embrace the public health approach to increasing access through its integration within existing healthcare systems. To give this approach a strong foundation that would ensure sustainability, the World Health Organisation urges member states to ensure that policy environments are suitable for this intervention. The development, strengthening, and implementation of national palliative care policies is a priority. Given the lack of a critical mass of palliative care professionals in the region and deficiency in documenting and sharing best practices as part of information critical for regional development, policy development becomes a complex process. This article shares experiences with regard to best practices when advocating the national palliative care policies. It also tells about policy development process, the important considerations, and cites examples of policy content outlines in Africa.
Keenan, Gail; Stocker, Julia; Barkauskas, Violet; Treder, Marcy; Heath, Crystal
The purpose of our research is to identify a realistic subset of North American Nursing Diagnosis Association (NANDA), Nursing Outcome Classification (NOC), and Nursing Interventions Classification (NIC) terms specific to the home care (HC) setting. A subset of 89 NOC outcomes were identified for study in HC through a baseline survey. Three research assistants then observed the care of 258 patients to whom the 89 NOC outcomes applied and recorded the associated NANDA and NIC terms. Follow-up surveys and focus groups were conducted with the nurses and research assistants. There were 81 different NANDA and 226 NIC labels used to describe study patients' care. Only 36 of the 89 NOC labels studied were deemed clinically useful for HC. We found that expert opinion about terminology usage before actual experience under practice conditions is unreliable.
Palmer, Greta M
Pain management in the paediatric acute care setting is underutilised and can be improved. An awareness of the analgesic options available and their limitations is an important starting point. This article describes the evolving understanding of relevant pharmacogenomics and safety data of the various analgesic agents with a focus on agents available in Australia and New Zealand. It highlights the concerns with the use of codeine in children and discusses alternative oral opioids. Key features of oral, parenteral, inhaled and intranasal analgesic agents are discussed, as well as evidence supported use of sweet tasting solutions and non-pharmacological interventions. One of the biggest changes in acute care pain management has been the advent of intranasal fentanyl providing reliable potent analgesia without the need for intravenous access. The article will also address the issue of multimodal analgesia where a single agent is insufficient.
Weber, Deanne; Wolff, Lisa S; Orleans, Tracy; Mockenhaupt, Robin E; Massett, Holly A; Vose, Kathryn Kahler
This study describes a new segmentation strategy exploring smokers' interest levels in counseling in the medical care setting in order to understand how public health communications can be designed to increase consumer demand for cessation services within this population. A subsample of 431 smokers from a large, nationally representative mail survey was analyzed and categorized into three cessation-demand groups: Low demand (LD), medium demand (MD), and high demand (HD). HD smokers were most likely to be heavy smokers, to make quitting a high priority, and to have self-efficacy in quitting. MD and LD smokers were less likely than HD smokers to have been told to quit smoking by a health care provider in the past or to believe that counseling is effective. The first step in the regression analysis revealed that age, cigarettes smoked per month, whether smokers were currently trying to quit, and whether they were ever told to quit smoking by their health care provider accounted for 21% of the variance in smokers' interest in smoking cessation counseling, F(4, 234) = 16.49, pconsumer demand for cessation counseling.
McInnis, Ian; Murray, Sarah J; Serio-Melvin, Maria; Aden, James K; Mann-Salinas, Elizabeth; Chung, Kevin K; Huzar, Todd; Wolf, Steven; Nemeth, Christopher; Pamplin, Jeremy C
Multidisciplinary rounds (MDRs) in the burn intensive care unit serve as an efficient means for clinicians to assess patient status and establish patient care priorities. Both tasks require significant cognitive work, the magnitude of which is relevant because increased cognitive work of task completion has been associated with increased error rates. We sought to quantify this workload during MDR using the National Aeronautics and Space Administration Task Load Index (NASA-TLX). Research staff at three academic regional referral burn centers administered the NASA-TLX to clinicians during MDR. Clinicians assessed their workload associated with 1) "Identify(ing) if the patient is better, same, or worse than yesterday" and 2) "Identify(ing) the most important objectives of care for the patient today." Data were collected on clinician type, years of experience, and hours of direct patient care. Surveys were administered to 116 total clinicians, 41 physicians, 25 nurses, 13 medical students, and 37 clinicians in other roles. Clinicians with less experience reported more cognitive work when completing both tasks (P Clinicians in the "others" group (respiratory therapists, dieticians, pharmacists, etc.) reported less cognitive work than all other groups for both tasks (P clinician type and experience level when completing two key tasks. Less experience was associated with increased perceived work, potentially increasing mental error rates, and increasing risk to patients. Creating tools or work processes to reduce cognitive work may improve clinician performance.
Full Text Available Abstract Background Hepatitis C virus (HCV recently emerged as a major public health hazard in Egypt. However, dramatic healthcare budget constraints limit access to the costly treatment. We assessed risk perception and priority setting for intervention among HCV, unsafe water, and outdoor air pollution in Cairo city. Methods A survey was conducted in the homes of a representative sample of household heads in Cairo city. Risk perception was assessed using the "psychometric paradigm" where health hazards are evaluated according to several attributes and then summarized by principal component analysis. Priority setting was assessed by individual ranking of interventions reducing health hazards by 50% over five years. The Condorcet method was used to aggregate individual rankings of the three interventions (main study or two of three interventions (validation study. Explanatory factors of priority setting were explored in multivariate generalized logistic models. Results HCV was perceived as having the most severe consequences in terms of illness and out-of-pocket costs, while outdoor air pollution was perceived as the most uncontrollable risk. In the main study (n = 2,603, improved water supply received higher priority than both improved outdoor air quality (60.1%, P P Conclusions The Cairo community prefers to further improving water supply as compared to improved outdoor air quality and screening and treatment of chronic hepatitis C.
Pharmaceuticals and personal care products (PPCPs) are widely discharged into the environment via diverse pathways. The effects of PPCPs in the environment have potentially important human and ecosystem health implications, so credible, salient, and legitimate scientific evidence...
Blaise, P; Dujardin, B; de Béthune, X; Vandenbergh, D
Health sector reform is a key priority of many governments throughout the world. Drug supply systems are a major element of public health policy design in Africa, where 90% of drugs are imported. The WHO Essential Drugs Program and the UNICEF sponsored Bamako Initiative have, since the late 1980s, promoted the rational use of essential drugs and attempted to ensure a sustainable drug supply through the implementation of cost recovery schemes and quality assurance mechanisms in public health services. A new market for drugs is emerging within this framework and there is growing competition for its control. Government medical stores are all too often bankrupt and the private sector is expensive, catering mainly for the middle to upper classes of urban areas. An intermediate alternative. Essential Drugs Purchasing Offices (EDPOs), has been proposed to balance social objectives and economic constraints. Some of the experimental strategies have given promising results. However, their implementation raises a number of questions: What is the role of the EDPO? Should it promote public health issues in general or focus purely on drug availability? What is the most appropriate legal status? Public or private? For profit or not? How should the investment capital be structured? In drugs or in funds? With ample provision or a tight budget? How should drug purchases be managed? Where should drugs be purchased? How much? How often? According to which procedures? How should the distribution of drugs be organized? Supplying everyone? Pushing supplies or pulling purchasers in? The answers to these questions, analysis of the reasons for success and failure and the dissemination of the information gathered should identify priorities for action and future research and define a framework for expansion. These are the objectives of the "Concerted Action for the Development of EDPO in Sub-Saharan African Countries" which is supported by the European Union (DG XII).
Elizabeth A Blain
Full Text Available Elizabeth A Blain, Timothy J CraigPenn State Hershey Medical Center, Hershey, PA, USAObjective: To determine the use of spirometry in family practice, internal medicine, and pediatric outpatient settings.Methods: Data were collected from 45 outpatient offices in the central Pennsylvania area via phone survey that asked a set of four questions: 1 Do you have spirometry in your office? 2 Do you use spirometry for asthma patients? 3 In what situation do you use spirometry for? 4 Do you use spirometry more for chronic obstructive pulmonary disease (COPD or asthma? Results: It was found that pediatricians used spirometry 66% of the time, family practitioners 47% of the time, and internal medicine practitioners 60% of the time. Of those who did not use spirometry, 94% stated that they refer to a hospital if they required spirometry and 6% referred to subspecialists if the patient required spirometry. 10% of pediatricians performed the test on each asthma visit, otherwise the others used it only for exacerbations or as a baseline. No internists used spirometry regularly for asthma patients, and 22% used it more for COPD. In family practice only 14% used spirometry routinely at each visit for asthma patients.Conclusions: Pediatricians used spirometry more often in the outpatient setting than other specialists, followed closely by internal medicine physicians. Family practice physicians were the least likely to use spirometry. Multiple barriers seemed to prevent routine use of spirometry, but no one barrier accounted for the majority.Keywords: spirometry, asthma, primary care
Jang, Sung-In; Nam, Jung-Mo; Choi, Jongwon; Park, Eun-Cheol
Limited healthcare resources make it necessary to maximize efficiency in disease management at the country level by priority-setting according to disease burden. To make the best priority settings, it is necessary to measure health status and have standards for its judgment, as well as consider disease management trends among nations. We used 17 International Classification of Diseases (ICD) categories of potential years of life lost (YPLL) from Organization for Economic Co-operation and Development (OECD) health data for 2012, 37 disease diagnoses YPLL from OECD health data for 2009 across 22 countries and disability-adjusted life years (DALY) from the World Health Organization (WHO). We set a range of 1-1 for each YPLL per disease in a nation (position value for relative comparison, PARC). Changes over 5 years were also accounted for in this disease management index (disease management index, DMI). In terms of ICD categories, the DMI indicated specific areas for priority setting for different countries with regard to managing disease treatment and diagnosis. Our study suggests that DMI is a realistic index that reflects trend changes over the past 5 years to the present state, and PARC is an easy index for identifying relative status. Moreover, unlike existing indices, DMI and PARC make it easy to conduct multiple comparisons among countries and diseases. DMI and PARC are therefore useful tools for policy implications and for future studies incorporating them and other existing indexes.
Smith, Neale; Mitton, Craig; Hall, William; Bryan, Stirling; Donaldson, Cam; Peacock, Stuart; Gibson, Jennifer L; Urquhart, Bonnie
Priority setting and resource allocation, or PSRA, are key functions of executive teams in healthcare organizations. Yet decision-makers often base their choices on historical patterns of resource distribution or political pressures. Our aim was to provide leaders with guidance on how to improve PSRA practice, by creating organizational contexts which enable high performance. We carried out in-depth case studies of six Canadian healthcare organizations to obtain from healthcare leaders their understanding of the concept of high performance in PSRA and the factors which contribute to its achievement. Individual and group interviews were carried out (n = 62) with senior managers, middle managers and Board members. Site observations and document review were used to assist researchers in interpreting the interview data. Qualitative data were analyzed iteratively with the literature on empirical examples of PSRA practice, in order to develop a framework of high performance in PSRA. The framework consists of four domains - structures, processes, attitudes and behaviours, and outcomes - within which are 19 specific elements. The emergent themes derive from case studies in different kinds of health organizations (urban/rural, small/large) across Canada. The elements can serve as a checklist for 'high performance' in PSRA. This framework provides a means by which decision-makers in healthcare might assess their practice and identify key areas for improvement. The findings are likely generalizable, certainly within Canada but also across countries. This work constitutes, to our knowledge, the first attempt to present a full package of elements comprising high performance in health care PSRA.
Abarshi, E.; Echteld, M.; Block, L. van den; Donker, G.; Deliens, L.; Onwuteaka-Philipsen, B.
Background: Transitions between care settings at the end of life could hinder continuity of care for the terminally ill, suggesting a low quality of end-of-life care. Objective: To examine the nature and prevalence of care setting transitions in the last 3 months of life in the Netherlands, and to i
Abarshi, E.; Echteld, M.; Block, L. van den; Donker, G.; Deliens, L.; Onwuteaka-Philipsen, B.
Issue/problem: Transitions between care settings at the end of life could hinder continuity of care for the terminally ill, suggesting a low quality of end-of-life care. Aim: To examine the nature and prevalence of care setting transitions in the last 3 months of life in the Netherlands, and to iden
School nurses are in a unique position to provide care for students with special health care needs in the school setting. The incidence of chronic conditions and improved technology necessitate care of complex health care needs that had formerly been managed in inpatient settings. Delegation is a tool that may be used by registered nurses to allow…
Full Text Available Jocelyn Steward,1 Cheryl L Holt,2 David E Pollio,3 Erika L Austin,4,5 Nancy Johnson,4 Adam J Gordon,6,7 Stefan G Kertesz4,81Department of Health Care Management, Clayton State University, Morrow, GA, 2Department of Psychology, University of Maryland, College Park, MD, 3Department of Social Work, University of Alabama at Birmingham, 4Birmingham VA Medical Center, 5Department of Biostatistics, University of Alabama at Birmingham School of Public Health, Birmingham, AL, 6VA Pittsburgh Health Care System, 7University of Pittsburgh School of Medicine, Pittsburgh, PA, 8Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USAPurpose: Homeless individuals face unique challenges in health care. Several US initiatives seeking to advance patient-centered primary care for homeless persons are more likely to succeed if they incorporate the priorities of the patients they are to serve. However, there has been no prior research to elicit their priorities in primary care. This study sought to identify aspects of primary care important to persons familiar with homelessness based on personal experience or professional commitment, and to highlight where the priorities of patients and professionals dedicated to their care converge or diverge.Methods: This qualitative exercise asked 26 homeless patients and ten provider/experts to rank 16 aspects of primary care using a card sort. Patient-level respondents (n=26 were recruited from homeless service organizations across all regions of the USA and from an established board of homeless service users. Provider/expert-level respondents (n=10 were recruited from veteran and non-veteran-focused homeless health care programs with similar geographic diversity.Results: Both groups gave high priority to accessibility, evidence-based care, coordination, and cooperation. Provider/experts endorsed patient control more strongly than patients. Patients ranked information about their care
Doering, G T
The focus of the study was to prioritize six emergency medical service treatment factors in terms of their impact upon patient satisfaction in the prehospital setting. The six treatment areas analyzed were: EMS response time; medical care provided on scene; explanation of care by the provider; the provider's ability to reduce patient anxiety; the provider's ability to meet the patient's non-medical needs; and the level of courtesy/politeness shown by the EMS provider toward the patient. Telephone interviews were conducted with both patients and bystanders to obtain their perception of how well the system met their needs. The study analyzed how the six issues were rated and then evaluated the impact an individual's low score in a category had on that person's overall rating of the service provided. The overall satisfaction rating is not a calculated score, but an overall score specified by the respondent. The effect each issue had on the respondent's overall rating was determined by averaging the overall ratings for a category's low scorers, averaging the overall ratings for high scorers and then measuring the difference. Results of the study indicate that the factor with the greatest negative impact on patient satisfaction came from a perceived lack of crew courtesy and politeness. Respondents who indicated a fair to poor score in this category decreased their overall score by 60.2%. Ratings in other categories yielded the following results: When respondents rated the response time as fair to poor, their average overall rating showed an 18.4% decrease. When respondents rated the quality of medical care as fair to poor, their average overall rating showed a decrease of 22.6%. When the crew's ability to explain what was happening to the patient was rated as fair to poor, the average overall score dropped 33.6%. When the EMT's and medic's ability to reduce the patient's anxiety was rated fair to poor, average overall score declined by 32.6%. Finally, when the crew
Full Text Available Background: Infectious disease and malnutrition are common in children. Primary health care came into being to decrease the morbidity. Quality assessment is neither clinical research nor technology assessment. It is primarily an administrative device used to monitor performance to determine whether it continues to remain within acceptable bounds. Aims and Objectives: To assess the quality of service in the delivery of child health care in a primary health care setting. To evaluate client satisfaction. To assess utilization of facilities by the community. Materials and Methods: Study Type: Cross-sectional community-based study. Quality assessment was done by taking 30-50%, of the service provider. Client satisfaction was determined with 1 Immunization and child examination-90 clients each. Utilization of services was assessed among 478 households. Statistical Analysis: Proportions, Likert′s scale to grade the services and Chi-square. Results: Immunization service: Identification of needed vaccine, preparation and care was average. Vaccination technique, documentation, EPI education, maintenance of cold chain and supplies were excellent. Client satisfaction was good. Growth monitoring: It was excellent except for mother′s education andoutreach educational session . Acute respiratory tract infection care: History, physical examination, ARI education were poor. Classification, treatment and referral were excellent. Client satisfaction was good. Diarrheal disease care: History taking was excellent. But examination, classification, treatment, ORT education were poor. Conclusion: Mothers education was not stressed by service providers. Service providers′ knowledge do not go with the quality of service rendered. Physical examination of the child was not good. Except for immunization other services were average.
Roark, G A; Tucker, S L
Military health care leaders must recognize the importance of satisfied consumers. As part of this recognition, the focus of military medicine must change from a coercive-power to a reward-power system. This change highlights the need for business practices such as marketing. Encouraging military health care administrators to learn and understand the applications of the marketing variables will enhance demand management and health care delivery for beneficiaries. This paper describes some applications of marketing variables, informs the military health care administrator about the process of marketing, and describes the utility of marketing in the current paradigm shift in military health care delivery.
Ahnert, L; Rickert, H; Lamb, M E
The experiences of 84 German toddlers (12-24 months old) who were either enrolled or not enrolled in child care were described with observational checklists from the time they woke up until they went to bed. The total amount of care experienced over the course of a weekday by 35 pairs of toddlers (1 member of each pair in child care, 1 member not) did not differ according to whether the toddlers spent time in child care. Although the child-care toddlers received lower levels of care from care providers in the centers, their mothers engaged them in more social interactions during nonworking hours than did the mothers of home-only toddlers, which suggests that families using child care provided different patterns of care than families not using child care. Child-care toddlers experienced high levels of emotional support at home, although they experienced less prompt responses to their distress signals. Mothers' ages were unrelated to the amounts of time toddlers spent with them, but older mothers initiated more proximity.
Full Text Available Abstract Background Physician-manned emergency medical teams supplement other emergency medical services in some countries. These teams are often selectively deployed to patients who are considered likely to require critical care treatment in the pre-hospital phase. The evidence base for guidelines for pre-hospital triage and immediate medical care is often poor. We used a recognised consensus methodology to define key priority areas for research within the subfield of physician-provided pre-hospital critical care. Methods A European expert panel participated in a consensus process based upon a four-stage modified nominal group technique that included a consensus meeting. Results The expert panel concluded that the five most important areas for further research in the field of physician-based pre-hospital critical care were the following: Appropriate staffing and training in pre-hospital critical care and the effect on outcomes, advanced airway management in pre-hospital care, definition of time windows for key critical interventions which are indicated in the pre-hospital phase of care, the role of pre-hospital ultrasound and dispatch criteria for pre-hospital critical care services. Conclusion A modified nominal group technique was successfully used by a European expert group to reach consensus on the most important research priorities in physician-provided pre-hospital critical care.
Sosinsky, Laura Stout; Kim, Se-Kang
Building on prior variable-oriented research which demonstrates the independence of the associations of child care quality, quantity, and type of setting with family factors and child outcomes, the current study identifies four profiles of child care dimensions from the NICHD Study of Early Child Care and Youth Development. Profiles accounted for…
The purpose of this article is to explore the way preschool teachers teach reflective care in Japan. The article builds on a two-month ethnographic study conducted in Japanese kindergartens and nurseries among children aged 3-6 years. The data were analysed using concepts of age and gender. The results show that care in Japan, in contrast to…
Nugent, Rachel A
Over the past decade, universal health coverage (UHC) has emerged as a major policy goal for many low- and middle-income country governments. Yet, despite the high burden of cardiovascular diseases (CVD), relatively little is known about how to address CVD through UHC. This review covers three major topics. First, we define UHC and provide some context for its importance, and then we illustrate its relevance to CVD prevention and treatment. Second, we discuss how countries might select high-priority CVD interventions for a UHC health benefits package drawing on economic evaluation methods. Third, we explore some implementation challenges and identify research gaps that, if addressed, could improve the inclusion of CVD into UHC. PMID:28321266
Resnick, Daniel K.; Tosteson, Anna N. A.; Groman, Rachel F.; Ghogawala, Zoher
Study Design Topic review Objective Describe value measurement in spine care and discuss the motivation for, methods for, and limitations of such measurement. Summary of Background Data Spinal disorders are common and are an important cause of pain and disability. Numerous complimentary and competing treatment strategies are used to treat spinal disorders and the costs of these treatments is substantial and continues to rise despite clear evidence of improved health status as a result of these expenditures. Methods The authors present the economic and legislative imperatives forcing the assessment of value in spine care. The definition of value in health care and methods to measure value specifically in spine care are presented. Limitations to the utility of value judgements and caveats to their use are presented. Results Examples of value calculations in spine care are presented and critiqued. Methods to improve and broaden the measurement of value across spine care are suggested and the role of prospective registries in measuring value is discussed. Conclusions Value can be measured in spine care through the use of appropriate economic measures and patient reported outcomes measures. Value must be interpreted in light of the perspective of the assessor, the duration of the assessment period, the degree of appropriate risk stratification, and the relative value of treatment alternatives. PMID:25299258
Full Text Available Inverse kinematics algorithms are commonly used in robotic systems to transform tasks to joint references, and several methods exist to ensure the achievement of several tasks simultaneously. The multiple task-priority inverse kinematicsframework allows tasks to be considered in a prioritized order by projecting task velocities through the nullspaces of higherpriority tasks. This paper extends this framework to handle setbased tasks, i.e. tasks with a range of valid values, in addition to equality tasks, which have a specific desired value. Examples of set-based tasks are joint limit and obstacle avoidance. The proposed method is proven to ensure asymptotic convergence of the equality task errors and the satisfaction of all high-priority set-based tasks. The practical implementation of the proposed algorithm is discussed, and experimental results are presented where a number of both set-based and equality tasks have been implemented on a 6 degree of freedom UR5 which is an industrial robotic arm from Universal Robots. The experiments validate thetheoretical results and confirm the effectiveness of the proposed approach.
Duke, Trevor; Cheema, Baljit
Acute care of seriously ill children is a global public health issue, and there is much scope for improving quality of care in hospitals at all levels in many developing countries. We describe the current state of paediatric emergency and acute care in the least developed regions of low and middle income countries and identify gaps and requirements for improving quality. Approaches are needed which span the continuum of care: from triage and emergency treatment, the diagnostic process, identification of co-morbidities, treatment, monitoring and supportive care, discharge planning and follow-up. Improvements require support and training for health workers and quality processes. Effective training is that which is ongoing, combining good technical training in under-graduate courses and continuing professional development. Quality processes combine evidence-based guidelines, essential medicines, appropriate technology, appropriate financing of services, standards and assessment tools and training resources. While initial emergency treatment is based on common clinical syndromes, early differentiation is required for specific treatment, and this can usually be carried out clinically without expensive tests. While global strategies are important, it is what happens locally that makes a difference and is too often neglected. In rural areas in the poorest countries in the world, public doctors and nurses who provide emergency and acute care for children are revered by their communities and demonstrate daily that much can be carried out with little.
M. Chersich (Matthew); S. Luchters (Stanley); I. Ntaganira (Innocent); A. Gerbase (Antonio); Y-R. Lo (Ying-Ru); F. Scorgie (Fiona); R. Steen (Richard)
textabstractIntroduction: Virtually no African country provides HIV prevention services in sex work settings with an adequate scale and intensity. Uncertainty remains about the optimal set of interventions and mode of delivery. Methods: We systematically reviewed studies reporting interventions for
The objectives of this study were to assess site-specific carcinogenic risk of incinerator-emitted dioxins in a manner reflecting pollutant transfer across multimedia and multi-pathways. The study used site-specific environmental and exposure information and combined the Monte Carlo method with multimedia modeling to produce probability distributions of risk estimates. The risk estimates were further categorized by contaminated environmental media and exposure pathways that are experienced by human receptors in order to pinpoint significant sources of risk. Rank correlation coefficients were also calculated along with the Monte Carlo sampling to identify key factors that influenced estimation of risk. The results showed that ingestion accounted for more than 90% of the total risk and that risk control on ingestion of eggs, aboveground vegetables, and poultry should receive priority. It was also found that variation of parameters with variability accounted for around 35% of the total risk variance, while uncertainty contributed to the remaining 65%. Intake rates of aboveground vegetables, eggs, and poultry were the key parameters with the largest contribution to variance. In addition, sufficient sampling and analysis of dioxin contents in eggs, aboveground vegetables, poultry, soil, and fruit should be performed to improve risk estimation because the variation in concentrations in these media accounted for the largest overall risk variance. Finally, focus should be placed on reduction of uncertainty associated with the risk estimation through ingestion of aboveground vegetables, eggs, poultry, fruit, and soil because the risk estimates associated with these exposure pathways had the largest variance.
Saravanakumar, K; Davies, L; Lewis, M; Cooper, G M
Our objective was to establish the utilisation and pattern of high dependency care in a tertiary referral obstetric unit. Data of pregnant or recently pregnant women admitted to the obstetric high dependency unit from 1984 to 2007 were included to evaluate the admission rate. Four years' information of an ongoing prospective audit was collated to identify the indications for admission, maternal monitoring, transfers to intensive care unit, and location of the baby. The overall high dependency unit admission rate is 2.67%, but increased to 5.01% in the most recent 4 years. Massive obstetric haemorrhage is now the most common reason for admission. Invasive monitoring was undertaken in 30% of women. Two-thirds of neonates (66.3%) stayed with their critically ill mothers in the high dependency unit. Transfer to the intensive care unit was needed in 1.4 per 1000 deliveries conducted. We conclude that obstetric high dependency care provides holistic care from midwives, obstetricians and anaesthetists while retaining the opportunity of early bonding with babies for critically ill mothers.
Full Text Available Background In this article, we analyze one case instance of how proposals for change to the priority setting and resource allocation (PSRA processes at a Canadian healthcare institution reached the decision agenda of the organization’s senior leadership. We adopt key concepts from an established policy studies framework – Kingdon’s multiple streams theory – to inform our analysis. Methods Twenty-six individual interviews were conducted at the IWK Health Centre in Halifax, NS, Canada. Participants were asked to reflect upon the reasons leading up to the implementation of a formal priority setting process – Program Budgeting and Marginal Analysis (PBMA – in the 2012/2013 fiscal year. Responses were analyzed qualitatively using Kingdon’s model as a template. Results The introduction of PBMA can be understood as the opening of a policy window. A problem stream – defined as lack of broad engagement and information sharing across service lines in past practice – converged with a known policy solution, PBMA, which addressed the identified problems and was perceived as easy to use and with an evidence-base from past applications across Canada and elsewhere. Conditions in the political realm allowed for this intervention to proceed, but also constrained its potential outcomes. Conclusion Understanding in a theoretically-informed way how change occurs in healthcare management practices can provide useful lessons to researchers and decision-makers whose aim is to help health systems achieve the most effective use of available financial resources.
Full Text Available At a recent conference, a definition was drawn up that is most appropriate to the South African situation: “ Primary health care is essential health care made universally accessible to individuals and families in the community by means acceptable to them, through their full participation, and at a cost that the community and country can afford. It forms an integral part both of the country’s health system of which it is the nucleus, and of the overall social and economic development of the community.”
Khazei, Afshin; Jarvis-Selinger, Sandra; Ho, Kendall; Lee, Anna
We surveyed eight Canadian physicians who had each provided medical care for six months on the remote and under-served island of Tanna in Vanuatu. The most frequently encountered medical problems on Tanna were infectious diseases (tuberculosis, hepatitis, abscesses, malaria, pneumonia, typhoid fever, meningitis and skin infections). When physicians were asked about the top three health-care priorities, they ranked tuberculosis control, clean water and improved health-care delivery/communication between hospital and outposts as most important. The key issues were: (1) basic public health needs and infrastructure development are higher in priority than telehealth; (2) telehealth consultants must have knowledge pertinent to local conditions and resources available to the population; (3) electronic equipment suited to tropical environments is needed; (4) projects must be developed locally rather than internationally. Understanding how telehealth can provide support to health professionals under challenging conditions may assist with the health priorities in developing countries and potentially provide access to resources both locally and internationally.
Mitchell, Pamela R.
Background: Communication skills are important to the pursuit of increased self-determination in individuals with disabilities. The aim of this investigation was to gather information about communication supports in state-run residential care facilities in Ohio, and to compare findings with a previous investigation on this topic examining such…
Explored how primary care clinician-teachers actually attempt to convey empathy to medical students and residents. Found that they stress the centrality of role modeling in teaching, and most used debriefing strategies as well as both learner- and patient-centered approaches in instructing learners about empathy. (EV)
Larsen, John A.
Argues that Kohlberg's theory of moral development and his methods of moral education have special relevance to residential treatment because they (1) provide a framework for understanding the moral decision-making process at various levels of development, and (2) encourage child care professionals of any theoretical or clinical persuasion to…
Maslach, Christina; Pines, Ayala
Results of a study of personal job-stress factors among day care center personnel focus on impact of staff-child ratio, working hours, time out, staff meetings and program structure. Recommended institutional changes for prevention of staff "burn-out" involve reduction in amount of direct staff-child contact, development of social-professional…
Full Text Available Anthony T Gerlach, Claire V Murphy The Ohio State University Medical Center, Ohio State University, Columbus, OH, USA Abstract: Dexmedetomidine is an α-2 agonist that produces sedation and analgesia without compromising the respiratory drive. Use of dexmedetomidine as a sedative in the critically ill is associated with fewer opioid requirements compared with propofol and a similar time at goal sedation compared with benzodiazepines. Dexmedetomidine may produce negative hemodynamic effects including lower mean heart rates and potentially more bradycardia than other sedatives used in the critically ill. Recent studies have demonstrated that dexmedetomidine is safe at higher dosages, but more studies are needed to determine whether the efficacy of dexmedetomidine is dose dependent. In addition, further research is required to define dexmedetomidine's role in the care of delirious critically ill patients, as many, but not all, studies have indicated favorable outcomes. Keywords: dexmedetomidine, sedation, critical care
We report the results of a pilot study designed to describe nurses’ information needs and searching behavior in acute care settings. Several studies have indicated that nurses have unmet information needs while delivering care to patients. AIM: Identify the information needs of nurses in acute care settings. METHODS: Nurses at three hospitals were asked to use an information retrieval tool (CPG Viewer). A detailed log of their interactions with the tool was generated. RESULT...
Full Text Available Objective: To introduce pharmacists to the process, challenges, and opportunities of creating transitions of care (TOC models in the inpatient, ambulatory, and community practice settings. Methods: TOC literature and resources were obtained through searching PubMed, Ovid, and GoogleScholar. The pharmacist clinicians, who are the authors in this manuscript are reporting their experiences in the development, implementation of, and practice within the TOC models. Results: Pharmacists are an essential part of the multidisciplinary team and play a key role in providing care to patients as they move between health care settings or from a health care setting to home. Pharmacists can participate in many aspects of the inpatient, ambulatory care, and community pharmacy practice settings to implement and ensure optimal TOC processes. This article describes establishing the pharmacist’s TOC role and practicing within multiple health care settings. In these models, pharmacists focus on medication reconciliation, discharge counseling, and optimization of medications. Additionally, a checklist has been created to assist other pharmacists in developing the pharmacist’s TOC roles in a practice environment or incorporating more TOC elements in their practice setting. Conclusion: Optimizing the TOC process, reducing medication errors, and preventing adverse events are important focus areas in the current health care system, as emphasized by The Joint Commission and other health care organizations. Pharmacists have the unique opportunity and skillset to develop and participate in TOC processes that will enhance medication safety and improve patient care.
Full Text Available Abstract Background Patients’ experiences have become central to assessing the performance of healthcare systems worldwide and are increasingly being used to inform quality improvement processes. This paper explores the relative value of surveys and detailed patient narratives in identifying priorities for improving breast cancer services as part of a quality improvement process. Methods One dataset was collected using a narrative interview approach, (n = 13 and the other using a postal survey (n = 82. Datasets were analyzed separately and then compared to determine whether similar priorities for improving patient experiences were identified. Results There were both similarities and differences in the improvement priorities arising from each approach. Day surgery was specifically identified as a priority in the narrative dataset but included in the survey recommendations only as part of a broader priority around improving inpatient experience. Both datasets identified appointment systems, patients spending enough time with staff, information about treatment and side effects and more information at the end of treatment as priorities. The specific priorities identified by the narrative interviews commonly related to ‘relational’ aspects of patient experience. Those identified by the survey typically related to more ‘functional’ aspects and were not always sufficiently detailed to identify specific improvement actions. Conclusions Our analysis suggests that whilst local survey data may act as a screening tool to identify potential problems within the breast cancer service, they do not always provide sufficient detail of what to do to improve that service. These findings may have wider applicability in other services. We recommend using an initial preliminary survey, with better use of survey open comments, followed by an in-depth qualitative analysis to help deliver improvements to relational and functional aspects of patient
Mensberg Karen-Lise D
Full Text Available Abstract Background Adaptive radiation within fishes of the Coregonus lavaretus complex has created numerous morphs, posing significant challenges for taxonomy and conservation priorities. The highly endangered North Sea houting (C. oxyrhynchus; abbreviated NSH has been considered a separate species from European lake whitefish (C. lavaretus; abbreviated ELW due to morphological divergence and adaptation to oceanic salinities. However, its evolutionary and taxonomic status is controversial. We analysed microsatellite DNA polymorphism in nine populations from the Jutland Peninsula and the Baltic Sea, representing NSH (three populations, two of which are reintroduced and ELW (six populations. The objectives were to: 1 analyse postglacial recolonization of whitefish in the region; 2 assess the evolutionary distinctiveness of NSH, and 3 apply several approaches for defining conservation units towards setting conservation priorities for NSH. Results Bayesian cluster analyses of genetic differentiation identified four major groups, corresponding to NSH and three groups of ELW (Western Jutland, Central Jutland, Baltic Sea. Estimates of historical migration rates indicated recolonization in a north-eastern direction, suggesting that all except the Baltic Sea population predominantly represent postglacial recolonization via the ancient Elbe River. Contemporary gene flow has not occurred between NSH and ELW, with a divergence time within the last 4,000 years suggested from coalescence methods. NSH showed interbreeding with ELW when brought into contact by stocking. Thus, reproductive isolation of NSH was not absolute, although possible interbreeding beyond the F1 level could not be resolved. Conclusion Fishes of the C. lavaretus complex in the Jutland Peninsula originate from the same recolonization event. NSH has evolved recently and its species status may be questioned due to incomplete reproductive isolation from ELW, but it was shown to merit
Elizabeth A Blain; Craig, Timothy J.
Elizabeth A Blain, Timothy J CraigPenn State Hershey Medical Center, Hershey, PA, USAObjective: To determine the use of spirometry in family practice, internal medicine, and pediatric outpatient settings.Methods: Data were collected from 45 outpatient offices in the central Pennsylvania area via phone survey that asked a set of four questions: 1) Do you have spirometry in your office? 2) Do you use spirometry for asthma patients? 3) In what situation do you use spirometry for? 4) Do you use s...
Full Text Available Psychiatric and psychosocial disorders among cancer patients have been reported as a major consequence of the disease and treatment. The problems in applying a pure psychiatric approach have determined the need for structuring more defined methods, including screening for distress and emotional symptoms and a more specific psychosocial assessment, to warrant proper care to cancer patients with psychosocial problems. This review examines some of the most significant issues related to these two steps, screening and assessment of psychosocial morbidity in cancer and palliative care. With regard to this , the many different variables, such as the factors affecting individual vulnerability (e.g. life events, chronic stress and allostatic load, well-being, and health attitudes and the psychosocial correlates of medical disease (e.g. psychiatric disturbances, psychological symptoms, illness behavior, and quality of life which are possibly implicated not only in classical psychiatric disorders but more broadly in psychosocial suffering. Multidimensional tools (e.g. and specific psychosocially oriented interview (e.g. the Diagnostic Criteria for Psychosomatic Research - DCPR represent a way to screen for and assess emotional distress, anxiety and depression, maladaptive coping, dysfunctional attachment, as well as other significant psychosocial dimensions secondary to cancer, such as demoralization and health anxiety. Cross-cultural issues, such as language, ethnicity, race, and religion, are also discussed as possible factors influencing the patients and families perception of illness, coping mechanisms, psychological response to a cancer diagnosis.
Stephens, Samuel A.
Child care centers, Head Start programs, and family child care providers serving young children--as well as after school programs and homeless shelters that reach older children, adults, and families--are supported in providing healthy meals and snacks by reimbursements through the Child and Adult Care Food Program (CACFP). Administered by the…
Nace, David A; Archbald-Pannone, Laurie R; Ashraf, Muhammad S; Drinka, Paul J; Frentzel, Elizabeth; Gaur, Swati; Mahajan, Dheeraj; Mehr, David R; Mercer, William C; Sloane, Philip D; Jump, Robin L P
Efforts at preventing pneumococcal disease are a national health priority, particularly in older adults and especially in post-acute and long-term care settings The Advisory Committee on Immunization Practices recommends that all adults ≥65 years of age, as well as adults 18-64 years of age with specific risk factors, receive both the recently introduced polysaccharide-protein conjugate vaccine against 13 pneumococcal serotypes as well as the polysaccharide vaccine against 23 pneumococcal serotypes. Nursing facility licensure regulations require facilities to assess the pneumococcal vaccination status of each resident, provide education regarding pneumococcal vaccination, and administer the appropriate pneumococcal vaccine when indicated. Sorting out the indications and timing for 13 pneumococcal serotypes and 23 pneumococcal serotypes administration is complex and presents a significant challenge to healthcare providers. Here, we discuss the importance of pneumococcal vaccination for older adults, detail AMDA-The Society for Post-Acute and Long-Term Care Medicine (The Society)'s recommendations for pneumococcal vaccination practice and procedures, and offer guidance to postacute and long-term care providers supporting the development and effective implementation of pneumococcal vaccine policies.
Full Text Available Blood stream infections and pneumonia caused by Pseudomonas aeruginosa is associated with high mortality, especially in an immunocompromised host. A large section of the palliative care patient population has varied forms of compromised immunity due to advanced cancer or cancer treatment, organ failures, chronic autoimmune disorders, degenerative conditions, and acquired immunodeficiency syndrome. The lung is one of the most frequently involved organs in a variety of complications in an immunocompromised host and infection is the most common complication. P. aeruginosa is one of the most common pathogens associated with bronchopulmonary infections in an immunocompromised host. Routine radiological tests like chest X-ray may often be unyielding and an early and a prompt initiation of treatment reduces mortality and morbidity risk.
Full Text Available BACKGROUND: Trust in health care has been intensely researched in resource rich settings. Some studies in resource poor settings suggest that the dimensions and determinants of trust are likely to be different. OBJECTIVES: This study was done as a qualitative exploration of the dimensions and determinants of trust in health care in Tamil Nadu, a state in south India to assess the differences from dimensions and determinants in resource rich settings. METHODOLOGY: The participants included people belonging to marginalized communities with poor access to health care services and living in conditions of resource deprivation. A total of thirty five in depth interviews were conducted. The interviews were summarized and transcribed and data were analyzed following thematic analysis and grounded theory approach. RESULTS: The key dimensions of trust in health care identified during the interviews were perceived competence, assurance of treatment irrespective of ability to pay or at any time of the day, patients' willingness to accept drawbacks in health care, loyalty to the physician and respect for the physician. Comfort with the physician and health facility, personal involvement of the doctor with the patient, behavior and approach of doctor, economic factors, and health awareness were identified as factors determining the levels of trust in health care. CONCLUSIONS: The dimensions and determinants of trust in health care in resource poor settings are different from that in resource rich settings. There is a need to develop scales to measure trust in health care in resource poor settings using these specific dimensions and determinants.
Montano, C Brendan; Rasgon, Natalie L; Herman, Barry K
Binge eating disorder (BED), now recognized as a distinct eating disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, is the most prevalent eating disorder. Although nearly half of individuals with BED are obese, BED also occurs in nonobese individuals. Despite the relatively high percentage of weight loss treatment-seeking individuals meeting BED criteria, primary care physicians may not be familiar with or have ever diagnosed BED. Many providers may also have difficulty distinguishing BED as a contributory factor in obesity. This review differentiates BED from other causes of obesity by describing how obese individuals with BED differ from obese individuals without BED and from nonobese individuals with BED in areas including psychopathology, behavior, genetics, physiology, quality of life and productivity. The ways in which health-care providers can identify individuals who may have BED are also highlighted so the proper course of treatment is pursued. Overall, obese individuals with BED demonstrate a number of key characteristics that differentiate them from obese individuals without eating disorders, including increased impulsivity in response to food stimuli with loss of control over eating, resulting in the consumption of more calories. They also experience significant guilt and other negative emotions following a meal. In addition, individuals with BED patients have more psychiatric comorbidity, display more psychopathology, exhibit longer binge durations, consume more meals as snacks during the day and have less dietary restraint compared with individuals with BED who are not obese. However, the differences between individuals with BED who are obese versus not obese are not as prominent. Taken together, the evidence appears to support the conclusion that BED is a unique and treatable neurobehavioral disorder associated with distinct behavioral and psychological profiles and distinct medical and functional outcomes, and that
In the previous issue of the Journal of Pediatric Nursing, one type of evidence-based practice (EBP) format was provided for potential nurse scholars who utilize the EBP process [MacPhee, M. (2002). Journal of Pediatric Nursing, 17(4);313-20]. There are, however, many potential formats to present evidence-based clinical practice innovations. I am eager to work with nurses who have been involved in promoting evidence-based nursing practice. The Journal of Pediatric Nursing will use this column as a forum for sharing evidence-based clinical practice innovations, such as case studies, clinical teaching exemplars, and interdisciplinary programs highlighting collaborative practice among nurses and other health care professionals. Please contact me at firstname.lastname@example.org for editorial advice and assistance. The following article is a clinical contribution from a nurse on the Neurosurgery-Rehabilitation Unit of The Children's Hospital, Denver. This evidence-based clinical project evolved from a nurse's recognition of the importance of spiritual care for families of children with serious brain injuries. It is an example of how an EBP formula can facilitate change and innovation. Start with a clinical problem; get help; look to the literature for best research evidence; look to other clinical sources for best practice ideas; evaluate what you have; and make a decision to maintain the status quo, gather more data, or change practice. This clinical project is an example of the collaborative, interdisciplinary nature of EBP, and it is also an example of the collaborative work among differently skilled nurses. In this instance, a clinically based nurse identified a practice problem and recruited a nurse researcher to help design, analyze, and evaluate the findings from an interview study. The results are being implemented via nursing leadership to change practice.
Full Text Available Abstract Background Knowledge about the quality and organisation of care to terminally ill cancer patients with a relatives' view in a primary health care setting is limited. The aim of the study is to analyse experiences and preferences of bereaved relatives to terminally ill cancer patients in a primary care setting to explore barriers and facilitators for delivery of good palliative home care. Methods Three focus group interviews with fourteen bereaved relatives in Aarhus County, Denmark. Results Three main categories of experience were identified: 1 The health professionals' management, where a need to optimize was found. 2 Shared care, which was lacking. 3 The relatives' role, which needs an extra focus. Conclusion Relatives experience insufficient palliative care mainly due to organizational and cultural problems among professionals. Palliative care in primary care in general needs improvement and attention should be drawn to the "professionalization" of the relatives and the need to strike a balance between their needs, wishes and resources in end-of-life care and bereavement.
Neergaard, Mette Asbjørn; Olesen, Frede; Jensen, Anders Bonde;
Background: Knowledge about the quality and organisation of care to terminally ill cancer patients with a relatives' view in a primary health care setting is limited. The aim of the study is to analyse experiences and preferences of bereaved relatives to terminally ill cancer patients in a primar...... improvement and attention should be drawn to the "professionalization" of the relatives and the need to strike a balance between their needs, wishes and resources in end-of-life care and bereavement.......Background: Knowledge about the quality and organisation of care to terminally ill cancer patients with a relatives' view in a primary health care setting is limited. The aim of the study is to analyse experiences and preferences of bereaved relatives to terminally ill cancer patients in a primary...... care setting to explore barriers and facilitators for delivery of good palliative home care. Methods: Three focus group interviews with fourteen bereaved relatives in Aarhus County, Denmark. Results: Three main categories of experience were identified: 1) The health professionals' management, where...
Olusanya Bolajoko O
Full Text Available Abstract Background An understanding of the perception of paediatricians as key stakeholders in child healthcare delivery and the degree of congruence with current investment priorities is crucial in accelerating progress towards the attainment of global targets for child survival and overall health in developing countries. This study therefore elicited the views of paediatricians on current global priorities for newborn health in Nigeria as possible guide for policy makers. Methods Paediatric consultants and residents in the country were surveyed nationally between February and March 2011 using a questionnaire requiring the ranking of nine prominent and other neonatal conditions based separately on hospital admissions, mortality, morbidity and disability as well as based on all health indices in order of importance or disease burden. Responses were analysed with Friedman test and differences between subgroups of respondents with Mann-Whitney U test. Results Valid responses were received from 152 (65.8% of 231 eligible physicians. Preterm birth/low birthweight ranked highest by all measures except for birth asphyxia which ranked highest for disability. Neonatal jaundice ranked next to sepsis by all measures except for disability and above tetanus except mortality. Preterm birth/low birthweight, birth asphyxia, sepsis, jaundice and meningitis ranked highest by composite measures while jaundice had comparable rating with sepsis. Birth trauma was most frequently cited under other unspecified conditions. There were no significant differences in ranking between consultants and residents except for birth asphyxia in relation to hospital admissions and morbidity as well as sepsis and tetanus in relation to mortality. Conclusions Current global priorities for neonatal survival in Nigeria largely accord with paediatricians’ views except for neonatal jaundice which is commonly subsumed under “other“ or "miscellaneous" neonatal conditions. While the
Benzer, Justin K; Beehler, Sarah; Miller, Christopher; Burgess, James F; Sullivan, Jennifer L; Mohr, David C; Meterko, Mark; Cramer, Irene E
Objective. There is limited theory regarding the real-world implementation of mental health care in the primary care setting: a type of organizational coordination intervention. The purpose of this study was to develop a theory to conceptualize the potential causes of barriers and facilitators to how local sites responded to this mandated intervention to achieve coordinated mental health care. Methods. Data from 65 primary care and mental health staff interviews across 16 sites were analyzed to identify how coordination was perceived one year after an organizational mandate to provide integrated mental health care in the primary care setting. Results. Standardized referral procedures and communication practices between primary care and mental health were influenced by the organizational factors of resources, training, and work design, as well as provider-experienced organizational boundaries between primary care and mental health, time pressures, and staff participation. Organizational factors and provider experiences were in turn influenced by leadership. Conclusions. Our emergent theory describes how leadership, organizational factors, and provider experiences affect the implementation of a mandated mental health coordination intervention. This framework provides a nuanced understanding of the potential barriers and facilitators to implementing interventions designed to improve coordination between professional groups.
Justin K. Benzer
Full Text Available Objective. There is limited theory regarding the real-world implementation of mental health care in the primary care setting: a type of organizational coordination intervention. The purpose of this study was to develop a theory to conceptualize the potential causes of barriers and facilitators to how local sites responded to this mandated intervention to achieve coordinated mental health care. Methods. Data from 65 primary care and mental health staff interviews across 16 sites were analyzed to identify how coordination was perceived one year after an organizational mandate to provide integrated mental health care in the primary care setting. Results. Standardized referral procedures and communication practices between primary care and mental health were influenced by the organizational factors of resources, training, and work design, as well as provider-experienced organizational boundaries between primary care and mental health, time pressures, and staff participation. Organizational factors and provider experiences were in turn influenced by leadership. Conclusions. Our emergent theory describes how leadership, organizational factors, and provider experiences affect the implementation of a mandated mental health coordination intervention. This framework provides a nuanced understanding of the potential barriers and facilitators to implementing interventions designed to improve coordination between professional groups.
Full Text Available Preetinder S Gill,1 Ashwini Kamath,2 Tejkaran S Gill31College of Technology, Eastern Michigan University, Ypsilanti, MI, USA; 2School of Information, University of Texas, Austin, TX, USA; 3College of Engineering, University of Michigan, Ann Arbor, MI, USAAbstract: Smartphone use in health care work settings presents both opportunities and challenges. The benefits could be severely undermined if abuse and overuse are not kept in check. This practice-focused research paper examines the current panorama of health software applications. Findings from existing research are consolidated to elucidate the level and effects of distraction in health care work settings due to smartphone use. A conceptual framework for crafting guidelines to regulate the use of smartphones in health care work settings is then presented. Finally, specific guidelines are delineated to assist in creating policies for the use of smartphones in a health care workplace.Keywords: smartphone, health care, distraction, workplace, mobile apps, health informatics
Quesenberry, Amanda C.; Hemmeter, Mary Louise; Ostrosky, Michaelene M.; Hamann, Kira
In this study, 9 teachers from 5 child care centers were interviewed to examine their perceptions on including children with challenging behavior in their classrooms. The findings provide a firsthand view into how child care teachers support children's social and emotional development and address challenging behavior. Results confirm previous…
The overall aim of this thesis was to describe quality of care from different perspectives in the psychiatric setting, to develop an instrument for measuring quality of care from the in-patient perspective and to use this instrument empirically. A qualitative descriptive design involving a phenomenographic analysis was used in Studies I, III and IV, and a descriptive and comparative design with statistical analysis in Study II. In Study I, 20 patients were interviewed. The results showed that...
Massey, Philip M.; Prelip, Michael; Calimlim, Brian M.; Quiter, Elaine S.; Glik, Deborah C.
The current emphasis on preventive health care and wellness services suggests that measures of skills and competencies needed to effectively navigate the health care system need to be better defined. We take an expanded perspective of health literacy and define it as a set of skills used to organize and apply health knowledge, attitudes and…
N Ann Scott
Full Text Available OBJECTIVE: To ascertain knowledge gaps in the diagnosis and treatment of acute and chronic low back pain (LBP in the primary care setting to prepare a scoping survey for identifying knowledge gaps in LBP management among Alberta’s primary care practitioners, and to identify potential barriers to implementing a multidisciplinary LBP guideline.
Adams, Carolyn D.; Hinojosa, Sara; Armstrong, Kathleen; Takagishi, Jennifer; Dabrow, Sharon
This article discusses an innovative example of integrated care in which doctoral level school psychology interns and residents worked alongside pediatric residents and pediatricians in the primary care settings to jointly provide services to patients. School psychologists specializing in pediatric health are uniquely trained to recognize and…
L. V. Laktionova
Full Text Available The paper discusses the issues of setting up a quality management system in a multidisciplinary specialized clinical research center. It describes the experience with information technologies used in a prophylactic facility to set up effective out- and inpatient health care control. Measures to optimize work under present-day conditions to upgrade the quality of health care are given using the federal health facility as an example.
Tees, Bob; Budd, Jennifer
The article describes how music has been integrated into spiritual and supportive care for palliative care patients at Brantford General Hospital (Ontario). Numerous case examples illustrate how a song or piece of music can play a vital role in the spiritual dimension of end of life care. The article expands the concept of the "living human document" by positing that a life story has an accompanying soundtrack: a musical memory and sensorial attunement that can be energized when music is offered at the bedside. The writers suggest that music provides an alternate spiritual language for patients whether or not they have a religious affiliation.
Franck, Kristina T; Fonager, Jannik; Ersbøll, Annette K;
. In community and health care settings, we found an association between infection with GII.4 and increasing age. Norovirus GII.4 predominated in patients ≥60 years of age and in health care settings. A larger proportion of children than adults were infected with NoV GII.3 or GII.P21. Susceptibility to No......Norovirus (NoV) is a major cause of gastroenteritis. NoV genotype II.4 (GII.4) is the predominant genotype in health care settings but the reason for this finding is unknown. Stool samples containing isolates with a known NoV genotype from 2,109 patients in Denmark (patients consulting a general...... practitioner or outpatient clinic, inpatients, and patients from foodborne outbreaks) were used to determine genotype distribution in relation to age and setting. NoV GII.4 was more prevalent among inpatients than among patients in community settings or those who became infected during foodborne outbreaks...
Berry, Leonard L; Rock, Beth L; Smith Houskamp, Beth; Brueggeman, Joan; Tucker, Lois
Patients with the most complex health profiles consume a disproportionate percentage of health care expenditures, yet often receive fragmented, suboptimal care. Since 2003, Wisconsin-based Gundersen Health has improved the quality of life and reduced the cost burden of patients with complex health profiles with an integrated care coordination program. Those results are consistent with data from the most successful care coordination demonstration projects funded by the Centers for Medicare and Medicaid Services. Specifically, Gundersen's program has been associated with reduced hospital stays, lower costs for inpatients, less use of inpatient services, and increased patient satisfaction. Gundersen's success is rooted in its team-based approach to coordinated care. Teams, led by a subspecialty-trained nurse, have regular, face-to-face contact with patients and their physicians in both inpatient and outpatient settings; involve patients deeply in care-related decisions; access a system-wide electronic medical record database that tracks patients' care; and take a macrolevel view of care-related factors and costs. Gundersen's model offers specific take-home lessons for institutions interested in coordinated care as they design programs aimed at improving quality and lowering costs. This institutional case study provides a window into well-executed care coordination at a large health care system in an era when major changes in health care provision and reimbursement mechanisms are on the horizon.
Full Text Available Given a set of interacting components with non-deterministic variable update and given safety requirements, the goal of priority synthesis is to restrict, by means of priorities, the set of possible interactions in such a way as to guarantee the given safety conditions for all possible runs. In distributed priority synthesis we are interested in obtaining local sets of priorities, which are deployed in terms of local component controllers sharing intended next moves between components in local neighborhoods only. These possible communication paths between local controllers are specified by means of a communication architecture. We formally define the problem of distributed priority synthesis in terms of a multi-player safety game between players for (angelically selecting the next transition of the components and an environment for (demonically updating uncontrollable variables. We analyze the complexity of the problem, and propose several optimizations including a solution-space exploration based on a diagnosis method using a nested extension of the usual attractor computation in games together with a reduction to corresponding SAT problems. When diagnosis fails, the method proposes potential candidates to guide the exploration. These optimized algorithms for solving distributed priority synthesis problems have been integrated into the VissBIP framework. An experimental validation of this implementation is performed using a range of case studies including scheduling in multicore processors and modular robotics.
Mariet Caroline, MPT,
Full Text Available Child care workers are those who take care of children in the absence of their parents. Child care workers are exposed to various kinds of occupational injuries which include infections, sprains and strains, trauma like bites from children, trip falls and noise exposure. The risks of injury among these workers are due to their nature of the job. One of the common occupational risks found in these workers is musculoskeletal injury, it occurs as a result of working in awkward postures such as bending, twisting, lifting and carrying in incorrect positions, which may result in various injuries like strain, sprain and soft tissue ruptures. Workers with poor physical conditioning may tend to undergo these changes very rapidly. The purpose of this study was to find out the prevalence of various musculoskeletal disorders in child care workers who are taking care of the babies. The study was conducted around various day care centres, among 160 women from who were chosen for the study and were given musculoskeletal analysis questionnaires (Nordic musculoskeletal questionnaire , The Questionnaires were evaluated using descriptive statistics, analysed using SPSS and the results were computed in percentage. Following the analysis, it was concluded that low back injury was predominant among 44% of workers followed by 18% with neck pain, 11% of shoulder pain, 9% of knee pain, 7% of elbow, 6% of wrist, 4% of others and surprisingly 1 % had no musculoskeletal complaints.
Specchia, Maria Lucia; Veneziano, Maria Assunta; Cadeddu, Chiara; Ferriero, Anna Maria; Capizzi, Silvio; Ricciardi, Walter
In the last few years, the need of public reporting of health outcomes has acquired a great importance. The public release of performance results could be a tool for improving health care quality and many attempts have been made in order to introduce public reporting programs within the health care context at different levels. It would be necessary to promote the introduction of a standardized set of outcome and performance measures in order to improve quality of health care services and to make health care providers aware of the importance of transparency and accountability.
Poghosyan, Lusine; Nannini, Angela; Stone, Patricia W; Smaldone, Arlene
The expansion of the nurse practitioner (NP) workforce in primary care is key to meeting the increased demand for care. Organizational climates in primary care settings affect NP professional practice and the quality of care. This study investigated organizational climate and its domains affecting NP professional practice in primary care settings. A qualitative descriptive design, with purposive sampling, was used to recruit 16 NPs practicing in primary care settings in Massachusetts. An interview guide was developed and pretested with two NPs and in 1 group interview with 7 NPs. Data collection took place in spring of 2011. Individual interviews lasted from 30-70 minutes, were audio recorded, and transcribed. Data were analyzed using Atlas.ti 6.0 software by 3 researchers. Content analysis was applied. Three previously identified themes, NP-physician relations, independent practice and autonomy, and professional visibility, as well as two new themes, organizational support and resources and NP-administration relations emerged from the analyses. NPs reported collegial relations with physicians, challenges in establishing independent practice, suboptimal relationships with administration, and lack of support. NP contributions to patient care were invisible. Favorable organizational climates should be promoted to support the expanding of NP workforce in primary care and to optimize recruitment and retention efforts.
Topazian, Rachel J; Hook, C Christopher; Mueller, Paul S
Staff and students working in health care settings are sometimes reluctant to speak up when they perceive patients to be at risk for harm. In this article, we describe four incidents that occurred at our institution (Mayo Clinic). In two of them, health care professionals failed to speak up, which resulted in harm; in the other two, they did speak up, which prevented harm and improved patient care. We analyzed each scenario using the Physician's Charter on Medical Professionalism and prima facie ethics principles to determine whether principles were violated or upheld. We conclude that anyone who works in a health care setting has a duty to speak up when a patient faces harm. We also provide guidance for health care institutions on promoting a culture in which speaking up is encouraged and integrated into routine practice.
China-Russia relations Our relationship with Russia is one of the priorities of China’s diplomacy. The two countries have enjoyed mutual support on issues that concern each other’s core interests. We have
Apker, Julie; Propp, Kathleen M; Zabava Ford, Wendy S; Hofmeister, Nancee
This study explored how nurses communicate professionalism in interactions with members of their health care teams. Extant research show that effective team communication is a vital aspect of a positive nursing practice environment, a setting that has been linked to enhanced patient outcomes. Although communication principles are emphasized in nursing education as an important component of professional nursing practice, actual nurse interaction skills in team-based health care delivery remain understudied. Qualitative analysis of interview transcripts with 50 participants at a large tertiary hospital revealed four communicative skill sets exemplified by nursing professionals: collaboration, credibility, compassion, and coordination. Study findings highlight specific communicative behaviors associated with each skill set that exemplify nurse professionalism to members of health care teams. Theoretical and pragmatic conclusions are drawn regarding the communicative responsibilities of professional nurses in health care teams. Specific interaction techniques that nurses could use in nurse-team communication are then offered for use in baccalaureate curriculum and organizational in-service education.
Full Text Available Abstract Background Population ageing, the emergence of chronic illness, and the shift away from institutional care challenge conventional approaches to assessment systems which traditionally are problem and setting specific. Methods From 2002, the interRAI research collaborative undertook development of a suite of assessment tools to support assessment and care planning of persons with chronic illness, frailty, disability, or mental health problems across care settings. The suite constitutes an early example of a "third generation" assessment system. Results The rationale and development strategy for the suite is described, together with a description of potential applications. To date, ten instruments comprise the suite, each comprising "core" items shared among the majority of instruments and "optional" items that are specific to particular care settings or situations. Conclusion This comprehensive suite offers the opportunity for integrated multi-domain assessment, enabling electronic clinical records, data transfer, ease of interpretation and streamlined training.
Abarshi, E.; Echteld, M.; Block, L. van den; Donker, G.; Deliens, L.; Onwuteaka-Philipsen, B.
Multiple transitions between care settings in the last phase of life could jeopardize continuity of care and overall end-of-life patient care. Using a mortality follow-back study, we examined the nature and prevalence of transitions between Dutch care settings in the last 3 months of life, and ident
Full Text Available Abstract Background Preeclampsia is a complex disease in which several providers should interact continuously and in a coordinated manner to provide proper health care. However, standardizing criteria to treat patients with preeclampsia is problematical and severe flaws have been observed in the management of the disease. This paper describes a set of critical pathways (CPs designed to provide uniform criteria for clinical decision-making at different levels of care of pregnant patients with preeclampsia or severe preeclampsia. Methods Clinicians and researchers from different countries participated in the construction of the CPs. The CPs were developed using the following steps: a Definition of the conceptual framework; b Identification of potential users: primary care physicians and maternal and child health nurses in ambulatory settings; ob/gyn and intensive care physicians in secondary and tertiary care levels. c Structural development. Results The CPs address the following care processes: 1. Screening for preeclampsia, risk assessment and classification according to the level of risk. 2. Management of preeclampsia at primary care clinics. 3. Evaluation and management of preeclampsia at secondary and tertiary care hospitals: 4. Criteria for clinical decision-making between conservative management and expedited delivery of patients with severe preeclampsia. Conclusion Since preeclampsia continues to be one of the primary causes of maternal deaths and morbidity worldwide, the expected impact of these CPs is the contribution to improving health care quality in both developed and developing countries. The CPs are designed to be applied in a complex health care system, where different physicians and health providers at different levels of care should interact continuously and in a coordinated manner to provide care to all preeclamptic women. Although the CPs were developed using evidence-based criteria, they could require careful evaluation and
Izzo, Charles V; Smith, Elliott G; Holden, Martha J; Norton, Catherine I; Nunno, Michael A; Sellers, Deborah E
The current study examined the impact of a setting-level intervention on the prevention of aggressive or dangerous behavioral incidents involving youth living in group care environments. Eleven group care agencies implemented Children and Residential Experiences (CARE), a principle-based program that helps agencies use a set of evidence-informed principles to guide programming and enrich the relational dynamics throughout the agency. All agencies served mostly youth referred from child welfare. The 3-year implementation of CARE involved intensive agency-wide training and on-site consultation to agency leaders and managers around supporting and facilitating day-to-day application of the principles in both childcare and staff management arenas. Agencies provided data over 48 months on the monthly frequency of behavioral incidents most related to program objectives. Using multiple baseline interrupted time series analysis to assess program effects, we tested whether trends during the program implementation period declined significantly compared to the 12 months before implementation. Results showed significant program effects on incidents involving youth aggression toward adult staff, property destruction, and running away. Effects on aggression toward peers and self-harm were also found but were less consistent. Staff ratings of positive organizational social context (OSC) predicted fewer incidents, but there was no clear relationship between OSC and observed program effects. Findings support the potential efficacy of the CARE model and illustrate that intervening "upstream" at the setting level may help to prevent coercive caregiving patterns and increase opportunities for healthy social interactions.
Semeraro, V; Zantedeschi, E; Pasquarella, A; Guerrera, C; Guasticchi, G
Waiting lists are one of the main Public Health issues within developed countries. To promote appropriateness about General Practitioners' (GPs) prescriptions, during 2009 the project "Priority setting in outpatient prescriptions" in Latium Region has been approved. Regional referees, Latium Public Health Agency managers and advisors, managers and advisors of three Local Public Health Units (LPHUs) within the Latium region and some voluntarily recruited General Practitioners (each one with more than 800 patients enrolled) were included in a team work with the duty to develop the project. During two selected months of 2010, 46 GPs have forwarded overall 2.229 medical prescriptions. The six most numerous prescriptions were picked out and analyzed by the team work. 42% of these prescriptions were identified as belonging to category D of the priority level--"standard", while 42% and 41% of prescriptions bore the expressions of "control" and "diagnostic purpose" respectively. Among these ones, 75% were represented by bilateral mammography, prescribed to women aged between 50 and 69 years: but for those people bilateral mammography is already provided free of charge within the regional program of breast cancer screening, making the routine prescription by their physician a useless duplication, unacceptable in a healthcare system of good quality. Therefore at the conclusion of the project, the team work suggests proper standards be applied by healthcare professionals and GPs to achieve a significant objective: mammography appropriateness prescriptions.
Anger, Jennifer T.; Alas, Alexandriah; Litwin, Mark S.; Chu, Stephanie D.; Bresee, Catherine; Roth, Carol P.; Rashid, Rezoana; Shekelle, Paul; Wenger, Neil S.
Purpose Our aim was to test the feasibility of a set of quality-of-care indicators for urinary incontinence (UI) and, at the same time, measure the care provided to women with UI in two different clinical settings. Materials and Methods This was a pilot test of a set of quality-of-care indicators (QIs). This was a pilot test of a set of quality-of-care indicators (QIs). Twenty QIs were previously developed using the RAND Appropriateness method. These QIs were used to measure care received for 137 women with a urinary incontinence (UI) diagnosis in a 120-physician hospital-based multi-specialty medical group (MSG). We also performed an abstraction of 146 patient records from primary care offices in Southern California. These charts were previously used as part of the Assessing Care of Vulnerable Elders Project (ACOVE). As a post-hoc secondary analysis, the two populations were compared with respect to quality, as measured by compliance with the QIs. Results In the ACOVE population, 37.7% of patients with UI underwent a pelvic examination, versus 97.8% in the MSG. Only 15.6% of cases in the MSG and 14.2% in ACOVE (p=0.86) had documentation that pelvic floor exercises were offered. Relatively few women with a body mass index (BMI) of >25 were counseled about weight loss in either population (20.9% MSG vs. 26.1% ACOVE, p=0.76). For women undergoing sling surgery, documentation of counseling about risks was lacking, and only 9.3% of eligible cases (MSG only) had documentation of the risks of mesh. Conclusions QIs are a feasible means to measure the care provided to women with UI. Care varied by population studied, yet deficiencies in care were prevalent in both patient populations studied. PMID:27164512
Steffen, Robert; Baños, Ana; deBernardis, Chiara
priorities need to be set correctly.
Haas, Sheila A; Vlasses, Frances; Havey, Julia
There are multiple demands and challenges inherent in establishing staffing models in ambulatory heath care settings today. If health care administrators establish a supportive physical and interpersonal health care environment, and develop high-performing interprofessional teams and staffing models and electronic documentation systems that track performance, patients will have more opportunities to receive safe, high-quality evidence-based care that encourages patient participation in decision making, as well as provision of their care. The health care organization must be aligned and responsive to the community within which it resides, fully invested in population health management, and continuously scanning the environment for competitive, regulatory, and external environmental risks. All of these challenges require highly competent providers willing to change attitudes and culture such as movement toward collaborative practice among the interprofessional team including the patient.
Conclusions: Nurse practitioners in acute care hospital and long-term care settings have valued attributes that can promote interprofessional care. Effective strategies to promote interprofessional care emerge from these role attributes. However, the interprofessional relationship type perceived could enhance or impede the contribution of the strategies to interprofessional care promotion.
Hirdes John P
Full Text Available Abstract Background There has been increasing interest in enhancing accountability in health care. As such, several methods have been developed to compare the quality of home care services. These comparisons can be problematic if client populations vary across providers and no adjustment is made to account for these differences. The current paper explores the effects of risk adjustment for a set of home care quality indicators (HCQIs based on the Minimum Data Set for Home Care (MDS-HC. Methods A total of 22 home care providers in Ontario and the Winnipeg Regional Health Authority (WRHA in Manitoba, Canada, gathered data on their clients using the MDS-HC. These assessment data were used to generate HCQIs for each agency and for the two regions. Three types of risk adjustment methods were contrasted: a client covariates only; b client covariates plus an "Agency Intake Profile" (AIP to adjust for ascertainment and selection bias by the agency; and c client covariates plus the intake Case Mix Index (CMI. Results The mean age and gender distribution in the two populations was very similar. Across the 19 risk-adjusted HCQIs, Ontario CCACs had a significantly higher AIP adjustment value for eight HCQIs, indicating a greater propensity to trigger on these quality issues on admission. On average, Ontario had unadjusted rates that were 0.3% higher than the WRHA. Following risk adjustment with the AIP covariate, Ontario rates were, on average, 1.5% lower than the WRHA. In the WRHA, individual agencies were likely to experience a decline in their standing, whereby they were more likely to be ranked among the worst performers following risk adjustment. The opposite was true for sites in Ontario. Conclusions Risk adjustment is essential when comparing quality of care across providers when home care agencies provide services to populations with different characteristics. While such adjustment had a relatively small effect for the two regions, it did
Full Text Available Oral care is a crucial routine for patients with dysphagia that, when completed routinely, can prevent the development of aspiration pneumonia. There is no standardised protocol for oral care within government hospitals in South Africa. This study aimed to investigate the outcome of an oral care protocol. Participants were patients with oropharyngeal dysphagia, with either stroke or traumatic brain injury as the underlying medical pathology, and nurses. All participants were recruited from one tertiary level government hospital in Gauteng, South Africa. 139 nurses participated in the study and received training on the oral care protocol. There were two groups of participants with oropharyngeal dysphagia. Group one (study group, n = 23 was recruited by consecutive sampling, received regular oral care and were not restricted from drinking water; however, all other liquids were restricted. Group two (comparison group, n = 23 was recruited via a retrospective record review, received inconsistent oral care and were placed on thickened liquids or liquid restricted diets. Results showed that a regimen of regular oral care and free water provision when combined with dysphagia intervention did prevent aspiration pneumonia in patients with oropharyngeal dysphagia. The article highlights two key findings: that regular and routine oral care is manageable within an acute government hospital context and a strict routine of oral care can reduce aspiration pneumonia in patients with oropharyngeal dysphagia. An implication from these findings is confirmation that teamwork in acute care settings in developing contexts must be prioritised to improve dysphagia management and patient prognosis.
Dorairajan, Natarajan; Andappan, Anandi; Arun, B; Siddharth, Dorairajan; Meena, M
Day care surgery has generated a lot of interest, among both surgeons and the common people. This study aims to explore the management and advantages, including the cost benefits and cost effectiveness, of day care surgery in a government hospital setting. A prospective, single-center, single-unit study was carried out over 1 year from August 2006 to January 2008. The total number of patients studied was 327. Surgeries for hernia, hydrocele, fibroadenoma, fissure in ano, and phimosis were included. Patients were admitted on the day of surgery and were discharged the same day or evening. Patients were analyzed with respect to failure to discharge, wound infection, duration of stay in the ward, cost benefits, cost effectiveness, and postoperative pain. A total of 157 patients were treated for hernia, 61 for hydrocele, 52 for fibroadenoma, 34 for fissure in ano, and 23 for phimosis. Day care surgery is a fast growing and well accepted way of providing care to patients. Most of the patients studied had a favorable impression of the day care surgical procedure compared with inpatient care. In a country like India, in spite of problems of financial constraints and insufficient grants for health care, we are able to enjoy all the advantages of day care surgery, even in a government hospital setting.
Moss, Jacqueline; Saba, Virginia
The purpose of this study was to combine an established methodology for coding nursing interventions and action types using the Clinical Care Classification System with a reliable formula (relative value units) to cost nursing services. Using a flat per-diem rate to cost nursing care greatly understates the actual costs and fails to address the high levels of variability within and across units. We observed nurses performing commonly executed nursing interventions and recorded these into an electronic database with corresponding Clinical Care Classification System codes. The duration of these observations was used to calculate intervention costs using relative value unit calculation formulas. The costs of the five most commonly executed interventions were nursing care coordination/manage-refer ($2.43), nursing status report/assess-monitor ($4.22), medication treatment/perform-direct ($6.33), physical examination/assess-monitor ($3.20), and universal precautions/perform-direct ($1.96). Future studies across a variety of nursing specialties and units are needed to validate the relative value unit for Clinical Care Classification System action types developed for use with the Clinical Care Classification System nursing interventions as a method to cost nursing care.
Holtzer-Goor Kim M
Full Text Available Abstract Background Healthcare systems are challenged by a demand that exceeds available resources. One policy to meet this challenge is task substitution-transferring tasks to other professions and settings. Our study aimed to explore stakeholders’ perceived feasibility of transferring hospital-based monitoring of stable glaucoma patients to primary care optometrists. Methods A case study was undertaken in the Rotterdam Eye Hospital (REH using semi-structured interviews and document reviews. They were inductively analysed using three implementation related theoretical perspectives: sociological theories on professionalism, management theories, and applied political analysis. Results Currently it is not feasible to use primary care optometrists as substitutes for optometrists and ophthalmic technicians working in a hospital-based glaucoma follow-up unit (GFU. Respondents’ narratives revealed that: the glaucoma specialists’ sense of urgency for task substitution outside the hospital diminished after establishing a GFU that satisfied their professionalization needs; the return on investments were unclear; and reluctant key stakeholders with strong power positions blocked implementation. The window of opportunity that existed for task substitution in person and setting in 1999 closed with the institutionalization of the GFU. Conclusions Transferring the monitoring of stable glaucoma patients to primary care optometrists in Rotterdam did not seem feasible. The main reasons were the lack of agreement on professional boundaries and work domains, the institutionalization of the GFU in the REH, and the absence of an appropriate reimbursement system. Policy makers considering substituting tasks to other professionals should carefully think about the implementation process, especially in a two-step implementation process (substitution in person and in setting such as this case. Involving the substituting professionals early on to ensure all
Abdou, Cleopatra M; Fingerhut, Adam W
The first of its kind, the present experiment applied stereotype threat-the threat of being judged by or confirming negative group-based stereotypes-to the health sciences. Black and White women (N = 162) engaged in a virtual health care situation. In the experimental condition, one's ethnic identity and negative stereotypes of Black women specifically were made salient. As predicted, Black women in the stereotype threat condition who were strongly identified as Black (in terms of having explored what their ethnic identity means to them and the role it plays in their lives) reported significantly greater anxiety while waiting to see the doctor in the virtual health care setting than all other women. It is hypothesized that stereotype threat experienced in health care settings is one overlooked social barrier contributing to disparities in health care utilization and broader health disparities among Black women.
Nurse practitioners are expanding their scope of practice and moving into acute care settings. Striving to be part of the nursing organizational structure in the acute care setting will keep NP's practice firmly rooted in nursing theory. Remaining within the nursing realm will enable them to receive support and guidance from their nursing colleagues while advancing the profession through their knowledge and expertise. Within the nursing organizational structure, NPs can become leaders as clinicians and role models. Without the formal support of the nursing organizational structure, the unique skills and contributions nurse practitioners furnish to the profession will be lost, as others will then dictate the NP role and scope of practice within the acute care setting.
Krist, Alex H; Glasgow, Russell E; Heurtin-Roberts, Suzanne; Sabo, Roy T; Roby, Dylan H; Gorin, Sherri N Sheinfeld; Balasubramanian, Bijal A; Estabrooks, Paul A; Ory, Marcia G; Glenn, Beth A; Phillips, Siobhan M; Kessler, Rodger; Johnson, Sallie Beth; Rohweder, Catherine L; Fernandez, Maria E
Patient-centered health risk assessments (HRAs) that screen for unhealthy behaviors, prioritize concerns, and provide feedback may improve counseling, goal setting, and health. To evaluate the effectiveness of routinely administering a patient-centered HRA, My Own Health Report, for diet, exercise, smoking, alcohol, drug use, stress, depression, anxiety, and sleep, 18 primary care practices were randomized to ask patients to complete My Own Health Report (MOHR) before an office visit (intervention) or continue usual care (control). Intervention practice patients were more likely than control practice patients to be asked about each of eight risks (range of differences 5.3-15.8 %, p set goals for six risks (range of differences 3.8-16.6 %, p controls, intervention patients felt clinicians cared more for them and showed more interest in their concerns. Patient-centered health risk assessments improve screening and goal setting.Trial RegistrationClinicaltrials.gov identifier: NCT01825746.
Full Text Available Joshua R Burke, Rachael Morley, Mustafa Khanbhai Academic Surgery Unit, Education and Research Centre, University Hospital of South Manchester, Manchester, UK Abstract: Negative pressure wound therapy (NPWT is the continuous or intermittent application of subatmospheric pressure to the surface of a wound that improves the wound environment, accelerates healing, and reduces wound closure time. Since its first documented use, this technology has lent itself to a number of adaptations, most notably, the development of portable devices facilitating treatment in the home care setting. With advancing surgical standards, wound healing is an important rate-limiting factor in early patient discharge and often a major cost of inpatient treatment. The efficacy of NPWT in the home care setting has been investigated through rate of wound closure, time in care, and patient experience. Rate of wound closure is the most appropriate primary end point. Much can be gleaned from patient experience, but the future success of portable NPWT will be measured on time in care and therefore cost effectiveness. However, there is a lack of level 1a evidence demonstrating increased efficacy of portable over inpatient NPWT. The development of portable NPWT is an encouraging innovation in wound care technology, and extending the benefits to the home care setting is both possible and potentially more beneficial. Keywords: portable, negative pressure wound therapy, vacuum-assisted closure, topical negative pressure therapy
Kornhaber, Rachel; Walsh, Kenneth; Duff, Jed; Walker, Kim
Therapeutic interpersonal relationships are the primary component of all health care interactions that facilitate the development of positive clinician–patient experiences. Therapeutic interpersonal relationships have the capacity to transform and enrich the patients’ experiences. Consequently, with an increasing necessity to focus on patient-centered care, it is imperative for health care professionals to therapeutically engage with patients to improve health-related outcomes. Studies were identified through an electronic search, using the PubMed, Cumulative Index to Nursing and Allied Health Literature, and PsycINFO databases of peer-reviewed research, limited to the English language with search terms developed to reflect therapeutic interpersonal relationships between health care professionals and patients in the acute care setting. This study found that therapeutic listening, responding to patient emotions and unmet needs, and patient centeredness were key characteristics of strategies for improving therapeutic interpersonal relationships. PMID:27789958
Full Text Available Abstract Background By measuring the quality of the organisation of palliative care with process and structure quality indicators (QIs, patients, caregivers and policy makers are able to monitor to what extent recommendations are met, like those of the council of the WHO on palliative care and guidelines. This will support the implementation of public programmes, and will enable comparisons between organisations or countries. Methods As no European set of indicators for the organisation of palliative care existed, such a set of QIs was developed. An update of a previous systematic review was made and extended with more databases and grey literature. In two project meetings with practitioners and experts in palliative care the development process of a QI set was finalised and the QIs were categorized in a framework, covering the recommendations of the Council of Europe. Results The searches resulted in 151 structure and process indicators, which were discussed in steering group meetings. Of those QIs, 110 were eligible for the final framework. Conclusions We developed the first set of QIs for the organisation of palliative care. This article is the first step in a multi step project to identify, validate and pilot QIs.
McKenna, Brian; Furness, Trentham; Dhital, Deepa; Ennis, Garry; Houghton, James; Lupson, Christine; Toomey, Nigel
Australian mental health nurses will need to care with consumers of mental health services, within the domains of recovery. However, in acute inpatient mental health settings, nurses are without a clear description of how to be recovery-oriented. The intent of this qualitative study was to ask nurses to reflect on and describe current practice within acute inpatient services that are not overtly recovery-oriented. Results show that nurses can identify recovery and articulate with pragmatic clarity how to care within a recovery-oriented paradigm. Pragmatic modes of care described by nurses support using "champions" to assist with eventual system transformation in the delivery of mental health services.
Lightfoot, Marguerita; Rotheram-Borus, Mary Jane; Comulada, W Scott; Reddy, Vanessa S; Duan, Naihua
Prevention of HIV transmission from patients living with HIV (PLH) is a high national priority and strategies that are easy to implement and sustain to eliminate sexual transmission acts among PLH are needed. We evaluated a brief intervention that focused primarily on the enhancing motivations and encouraging PLH to act in accordance with their values without providing the intensity of the existing evidence-based programs for PLH. Using a quasiexperimental design, six medical clinics in Los Angeles County, CA, were evaluated across three intervention conditions: 1) computerized delivery; 2) provider delivery; or 3) standard care. We examined longitudinal changes in patients' reports of the number of HIV-negative (HIV-) or serostatus-unknown sexual partners and the number of unprotected vaginal and anal sex acts. Among 566 PLH, PLH in the computerized delivery condition reported a significant decrease in the number of HIV-/unknown sexual partners compared with the provider delivery and standard care conditions and a significant decrease in the number of unprotected sex acts in comparison to the standard care condition. Computerized motivational interventions delivered in waiting rooms at medical clinics may be an efficient strategy to reduce unprotected sex acts among PLH.
Full Text Available BACKGROUND: Care of the elderly is recognized as an increasingly important segment of health care. The Assessing Care Of Vulnerable Elderly (ACOVE quality indicators (QIs were developed to assess and improve the care of elderly patients. OBJECTIVES: The purpose of this review is to summarize studies that assess the quality of care using QIs from or based on ACOVE, in order to evaluate the state of quality of care for the reported conditions. METHODS: We systematically searched MEDLINE, EMBASE and CINAHL for English-language studies indexed by February 2010. Articles were included if they used any ACOVE QIs, or adaptations thereof, for assessing the quality of care. Included studies were analyzed and relevant information was extracted. We summarized the results of these studies, and when possible generated an overall conclusion about the quality of care as measured by ACOVE for each condition, in various settings, and for each QI. RESULTS: Seventeen studies were included with 278 QIs (original, adapted or newly developed. The quality scores showed large variation between and within conditions. Only a few conditions showed a stable pass rate range over multiple studies. Overall, pass rates for dementia (interquartile range (IQR: 11%-35%, depression (IQR: 27%-41%, osteoporosis (IQR: 34%-43% and osteoarthritis (IQR: 29-41% were notably low. Medication management and use (range: 81%-90%, hearing loss (77%-79% and continuity of care (76%-80% scored higher than other conditions. Out of the 278 QIs, 141 (50% had mean pass rates below 50% and 121 QIs (44% had pass rates above 50%. Twenty-three percent of the QIs scored above 75%, and 16% scored below 25%. CONCLUSIONS: Quality of care per condition varies markedly across studies. Although there has been much effort in improving the care for elderly patients in the last years, the reported quality of care according to the ACOVE indicators is still relatively low.
Bähler, Caroline; Signorell, Andri; Reich, Oliver
Background Many efforts are undertaken in Switzerland to enable older and/or chronically ill patients to stay home longer at the end-of-life. One of the consequences might be an increased need for hospitalisations at the end-of-life, which goes along with burdensome transitions for patients and higher health care costs for the society. Aim We aimed to examine the health care utilisation in the last six months of life, including transitions between health care settings, in a Swiss adult population. Methods The study population consisted of 11'310 decedents of 2014 who were insured at the Helsana Group, the leading health insurance in Switzerland. Descriptive statistics were used to analyse the health care utilisation by age group, taking into account individual and regional factors. Zero-inflated Poisson regression model was used to predict the number of transitions. Results Mean age was 78.1 in men and 83.8 in women. In the last six months of life, 94.7% of the decedents had at least one consultation; 61.6% were hospitalised at least once, with a mean length of stay of 28.3 days; and nursing home stays were seen in 47.4% of the decedents. Over the same time period, 64.5% were transferred at least once, and 12.9% experienced at least one burdensome transition. Main predictors for transitions were age, sex and chronic conditions. A high density of home care nurses was associated with a decrease, whereas a high density of ambulatory care physicians was associated with an increase in the number of transitions. Conclusions Health care utilisation was high in the last six months of life and a considerable number of decedents were being transferred. Advance care planning might prevent patients from numerous and particularly from burdensome transitions. PMID:27598939
Schmeidel, Amy N; Daly, Jeanette M; Rosenbaum, Marcy E; Schmuch, Gretchen A; Jogerst, Gerald J
The purpose of this study was to explore health care professionals' perspectives on elder abuse to achieve a better understanding of the problems of reporting and to generate ideas for improving the detection and reporting process. Through a mailed survey, nurses, physicians, and social workers were invited to participate in an interview. Nine nurses, 8 physicians, and 6 social workers were interviewed, and thematic analysis was used to identify the following core themes: preconceptions, assessment, interpretation, systems, and knowledge and education. Participants suggested a reorganization of the external reporting system. More frequent and pragmatic education is necessary to strengthen practical knowledge about elder abuse.
Molloy, C Johnston
A pre-school offering a full-day-care service provides for children aged 0-5 years for more than 4 h\\/d. Researchers have called for studies that will provide an understanding of nutrition and physical activity practices in this setting. Obesity prevention in pre-schools, through the development of healthy associations with food and health-related practices, has been advocated. While guidelines for the promotion of best nutrition and health-related practice in the early years\\' setting exist in a number of jurisdictions, associated regulations have been noted to be poor, with the environment of the child-care facility mainly evaluated for safety. Much cross-sectional research outlines poor nutrition and physical activity practice in this setting. However, there are few published environmental and policy-level interventions targeting the child-care provider with, to our knowledge, no evidence of such interventions in Ireland. The aim of the present paper is to review international guidelines and recommendations relating to health promotion best practice in the pre-school setting: service and resource provision; food service and food availability; and the role and involvement of parents in pre-schools. Intervention programmes and assessment tools available to measure such practice are outlined; and insight is provided into an intervention scheme, formulated from available best practice, that was introduced into the Irish full-day-care pre-school setting.
Full Text Available Abstract Background In Switzerland the extent to which patients with chronic illnesses receive care congruent with the Chronic Care Model (CCM is unknown. Methods According to guidelines we translated the Assessment of Chronic Illness Care (ACIC into German (G-ACIC. We tested the instrument in different primary care settings and compared subscales with the original testing. Results Difficulties encountered during the translation process consisted in the difference of health care settings in Switzerland and USA. However initial testing showed the G-ACIC to be a suitable instrument. The average ACIC subscale scores in Swiss managed care (MC-, group (GP- and single handed practices (SP were higher for MC practices than for group- and single handed practices: Organization of the healthcare delivery system: MC mean (m = 6.80 (SD 1.55, GP m = 5.42 (SD 0.99, SP m = 4.60 (SD 2.07; community linkages: MC m = 4.19 (SD 1.47, GP m = 4.83 (SD 1.81, SP m = 3.10 (SD 2.12; self-management support: MC m = 4.96 (SD 1.13, GP m = 4.73 (SD 1.40, SP m = 4.43 (SD 1.34; decision support: MC m = 4.75 (SD 1.06; GP m = 4.20 (SD 0.87, SP m = 3.25 (SD 1.59; delivery system design: MC m = 5.98 (SD 1.61, GP m = 5.05 (SD 2.05, SP m = 3.86 (SD 1.51 and clinical information systems: MC m = 4.34 (SD = 2.49, GP m = 2.06 (SD 1.35, SP m = 3.20 (SD 1.57. Conclusions The G-ACIC is applicable and useful for comparing different health care settings in German speaking countries. Managed care organizations seem to implement the different components of the CCM in a greater extend than group and single handed practices. However, much room exists for further improvement.
Hack, Nawaz; Akbar, Umer; Monari, Erin H; Eilers, Amanda; Thompson-Avila, Amanda; Hwynn, Nelson H; Sriram, Ashok; Haq, Ihtsham; Hardwick, Angela; Malaty, Irene A; Okun, Michael S
Objective. (1) To evaluate the feasibility of implementing and evaluating a home visit program for persons with Parkinson's disease (PD) in a rural setting. (2) To have movement disorders fellows coordinate and manage health care delivery. Background. The University of Florida, Center for Movement Disorders and Neurorestoration established Operation House Call to serve patients with PD who could not otherwise afford to travel to an expert center or to pay for medical care. PD is known to lead to significant disability, frequent hospitalization, early nursing home placement, and morbidity. Methods. This was designed as a quality improvement project. Movement disorders fellows travelled to the home(s) of underserved PD patients and coordinated their clinical care. The diagnosis of Parkinson's disease was confirmed using standardized criteria, and the Unified Parkinson's Disease Rating Scale was performed and best treatment practices were delivered. Results. All seven patients have been followed up longitudinally every 3 to 6 months in the home setting, and they remain functional and independent. None of the patients have been hospitalized for PD related complications. Each patient has a new updatable electronic medical record. All Operation House Call cases are presented during video rounds for the interdisciplinary PD team to make recommendations for care (neurology, neurosurgery, neuropsychology, psychiatry, physical therapy, occupational therapy, speech therapy, and social work). One Operation House Call patient has successfully received deep brain stimulation (DBS). Conclusion. This program is a pilot program that has demonstrated that it is possible to provide person-centered care in the home setting for PD patients. This program could provide a proof of concept for the construction of a larger visiting physician or nurse program.
@@ China-Russia relations Our relationship with Russia is one of the priorities of China's diplomacy.The two countries have enjoyed mutual support on issues that concern each other's core interests.We have the same or similar views on many major international and regional issues.And we coordinate and communicate closely.
Lavin, Mary Ann; Harper, Ellen; Barr, Nancy
The electronic health record (EHR) is a documentation tool that yields data useful in enhancing patient safety, evaluating care quality, maximizing efficiency, and measuring staffing needs. Although nurses applaud the EHR, they also indicate dissatisfaction with its design and cumbersome electronic processes. This article describes the views of nurses shared by members of the Nursing Practice Committee of the Missouri Nurses Association; it encourages nurses to share their EHR concerns with Information Technology (IT) staff and vendors and to take their place at the table when nursing-related IT decisions are made. In this article, we describe the experiential-reflective reasoning and action model used to understand staff nurses' perspectives, share committee reflections and recommendations for improving both documentation and documentation technology, and conclude by encouraging nurses to develop their documentation and informatics skills. Nursing issues include medication safety, documentation and standards of practice, and EHR efficiency. IT concerns include interoperability, vendors, innovation, nursing voice, education, and collaboration.
Full Text Available Lyne Lalonde,1–4 Manon Choinière,3,5 Elisabeth Martin,3 Lise Lévesque,3 Éveline Hudon,2,3,6 Danielle Bélanger,2 Sylvie Perreault,1,7 Anaïs Lacasse,8 Marie-Claude Laliberté1,9 1Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada; 2Équipe de recherche en soins de première ligne, Centre de santé et de services sociaux de Laval, Laval, QC, Canada; 3Centre de recherche, Centre hospitalier de l'Université de Montréal (CRCHUM, Montreal, QC, Canada; 4Sanofi Aventis Endowment Chair in Ambulatory Pharmaceutical Care, Faculty of Pharmacy, Université de Montréal and Centre de santé et de services sociaux de Laval, QC, Canada; 5Department of Anesthesiology, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada; 6Department of Family Medicine and Emergency, Faculty of Medicine, Université de Montréal, Montreal, QC, Canada; 7Sanofi Aventis Endowment Chair in Drug Utilization, Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada; 8Département des sciences de la santé, Université du Québec en Abitibi-Témiscamingue, Rouyn-Noranda, QC, Canada; 9AbbVie Corporation, St-Laurent, QC, Canada Purpose: There is evidence that the management of chronic non-cancer pain (CNCP in primary care is far from being optimal. A 1-day workshop was held to explore the perceptions of key actors regarding the challenges and priority interventions to improve CNCP management in primary care. Methods: Using the Chronic Care Model as a conceptual framework, physicians (n=6, pharmacists (n=6, nurses (n=6, physiotherapists (n=6, psychologists (n=6, pain specialists (n=6, patients (n=3, family members (n=3, decision makers and managers (n=4, and pain researchers (n=7 took part in seven focus groups and five nominal groups. Results: Challenges identified in focus group discussions were related to five dimensions: knowledge gap, “work in silos”, lack of awareness that CNCP represents an important clinical problem
Gear, Sabra; Bobzien, Jonna; Judge, Sharon; Raver, Sharon A.
Adults with intellectual disabilities face difficulty seeking employment in the community workforce. Using a single-subject design, this study examined the utility of role playing and self-management strategies to enhance work performance by promoting the social skills of a young woman with Down syndrome working in a community child care setting.…
Kampfe, Charlene M.
This paper describes the types of attitudes and behaviors that might be destructive to an individual's sense of self-worth, and suggests that counselors in long-term care settings face the challenge of changing these. One strategy for counteracting potential dehumanization, offering in-service training to all levels of staff and administrators, is…
Oelke, Nelly; Wilhelm, Amanda; Jackson, Karen
The role of nurses in primary care is poorly understood and many are not working to their full scope of practice. Building on previous research, this knowledge translation (KT) project's aim was to facilitate nurses' capacity to optimise their practice in these settings. A Summit engaging Alberta stakeholders in a deliberative discussion was the…
Schryer, Catherine; McDougall, Allan; Tait, Glendon R.; Lingard, Lorelei
This article investigates an emerging practice in palliative care: dignity therapy. Dignity therapy is a psychotherapeutic intervention that its proponents assert has clinically significant positive impacts on dying patients. Dignity therapy consists of a physician asking a patient a set of questions about his or her life and returning to the…
Sorensen, Bjarke Lund; Nielsen, Birgitte Bruun; Rasch, Vibeke
The aim of this field study was to analyze the main dynamics and conflicts in attending and providing good quality delivery care in a local Tanzanian rural setting. The women and their relatives did not see the problems of pregnancy and birth in isolation but in relation to multiple other problem...... "actantial model is suggested for that purpose....
Bullen, Tracey; Maher, Kate; Rosenberg, John P; Smith, Bradley
There are many challenges in developing research projects in research-naïve clinical settings, especially palliative care where resistance to participate in research has been identified. These challenges to the implementation of research are common in nursing practice and are associated with attitudes towards research participation, and some lack of understanding of research as a process to improve clinical practice. This is despite the professional nursing requirement to conduct research into issues that influence palliative care practice. The purpose of this paper is to describe the process of implementing a clinical research project in collaboration with the clinicians of a palliative care community team and to reflect on the strategies implemented to overcome the challenges involved. The challenges presented here demonstrate the importance of proactively implementing engagement strategies from the inception of a research project in a clinical setting.
Lim, Ching Jou; Kong, David C M; Stuart, Rhonda L
Residential aged care facilities are increasingly identified as having a high burden of infection, resulting in subsequent antibiotic use, compounded by the complexity of patient demographics and medical care. Of particular concern is the recent emergence of multidrug-resistant organisms among this vulnerable population. Accordingly, antimicrobial stewardship (AMS) programs have started to be introduced into the residential aged care facilities setting to promote judicious antimicrobial use. However, to successfully implement AMS programs, there are unique challenges pertaining to this resource-limited setting that need to be addressed. In this review, we summarize the epidemiology of infections in this population and review studies that explore antibiotic use and prescribing patterns. Specific attention is paid to issues relating to inappropriate or suboptimal antibiotic prescribing to guide future AMS interventions.
DuGoff, Eva H; Dy, Sydney; Giovannetti, Erin R; Leff, Bruce; Boyd, Cynthia M
The primary study objective is to assess how three major health reform care coordination initiatives (Accountable Care Organizations, Independence at Home, and Community-Based Care Transitions) measure concepts critical to care coordination for people with multiple chronic conditions. We find that there are major differences in quality measurement across these three large and politically important programs. Quality measures currently used or proposed for these new health reform-related programs addressing care coordination primarily capture continuity of care. Other key areas of care coordination, such as care transitions, patient-centeredness, and cross-cutting care across multiple conditions are infrequently addressed. The lack of a comprehensive and consistent measure set for care coordination will pose challenges for healthcare providers and policy makers who seek, respectively, to provide and reward well-coordinated care. In addition, this heterogeneity in measuring care coordination quality will generate new information, but will inhibit comparisons between these care coordination programs.
Full Text Available Homeless health is government and NGO’s responsibilities for creating optimal citizen health status. Homeless is one of community health nursing clients. The Self Care Theory is used in nursing science for giving conceptual framework as a practical guidance and building self care knowledge through research. Orem described self care as a continuing intervention. It was needed and done by adult to be survived, healthy, and wellness. This theory is also used in homeless setting by many experts. This article aims to describe Orem’s Self Care Theory, describe homeless’ self care, and apply Orem’s Self Care Theory in homeless setting.
Blackstone, Sarah W; Pressman, Harvey
Delivering quality health care requires effective communication between health care providers and their patients. In this article, we call on augmentative and alternative communication (AAC) practitioners to offer their knowledge and skills in support of a broader range of patients who confront communication challenges in health care settings. We also provide ideas and examples about ways to prepare people with complex communication needs for the inevitable medical encounters that they will face. We argue that AAC practitioners, educators, and researchers have a unique role to play, important expertise to share, and an extraordinary opportunity to advance the profession, while positively affecting patient outcomes across the health care continuum for a large number of people.
Snell, Anita J; Briscoe, Don; Dickson, Graham
Health care delivery must be transformed to manage spiraling costs and preserve quality care. Transforming complex health systems will require the engagement of physicians as leaders in their health care settings, in both formal and informal roles. In this article we explore the experience of physician leader engagement and identify factors operating at the individual, team, and organizational levels related to increased or decreased physician leader engagement. Using an inductive approach, our analysis of the transcribed interviews yielded a rich understanding of what motivates physicians to be engaged as leaders, how they experience engagement, the role of the physician leader, how physicians understand other physicians' engagement, what encourages and discourages their engagement efforts, and the role that education and training has in physician engagement. We conclude by offering strategies that physicians, health care organizations, and educational institutions can implement to increase the engagement of physician leaders.
Younies, Hassan; Barhem, Belal; Younis, Mustafa Z
A reward and recognition (RR) system is a tool widely applied by organizations to motivate their employees. Outstanding employees expect their effort to be acknowledged by the organization. However, the variety of rewards and recognitions systems used by organizations may be perceived differently by different employees. The diverse workforce structure in the United Arab Emirates (UAE) poses various challenges for organization managers. Managers need to implement the shrewd RR system which best fits their diverse workforce. This research studied how medical sector employees in the private and public health sector view the RR systems in the UAE. Two lists, comprising 26 major approaches to RR, were prepared and its items prioritized by taking inputs from 250 employees working in more than 30 varied public and private health care organizations in the UAE. The findings of the research are expected to provide guidelines for developing appropriate RR systems for organizations in general, and UAE health care organizations in particular.
Lee, Sook Y; Chaudhury, Habib; Hung, Lillian
This study explored staff perceptions of the role of physical environment in dementia care facilities in affecting resident's behaviors and staff care practice. We conducted focus groups with staff (n = 15) in two purposely selected care facilities in Vancouver, Canada. Focus group participants included nurses, care aides, recreation staff, administrative staff, and family. Data analysis revealed two themes: (a) a supportive physical environment contributes positively to both quality of staff care interaction and residents' quality of life and (b) an unsupportive physical environment contributes negatively to residents' quality of life and thereby makes the work of staff more challenging. The staff participants collectively viewed that comfort, familiarity, and an organized space were important therapeutic resources for supporting the well-being of residents. Certain behaviors of residents were influenced by poor environmental factors, including stimulation overload, safety risks, wayfinding challenge, and rushed care This study demonstrates the complex interrelationships among the dementia care setting's physical environment, staff experiences, and residents' quality of life.
Hodgkinson, Stacy; Godoy, Leandra; Beers, Lee Savio; Lewin, Amy
Poverty is a common experience for many children and families in the United States. Children low-income household has been linked to poor health and increased risk for mental health problems in both children and adults that can persist across the life span. Despite their high need for mental health services, children and families living in poverty are least likely to be connected with high-quality mental health care. Pediatric primary care providers are in a unique position to take a leading role in addressing disparities in access to mental health care, because many low-income families come to them first to address mental health concerns. In this report, we discuss the impact of poverty on mental health, barriers to care, and integrated behavioral health care models that show promise in improving access and outcomes for children and families residing in the contexts of poverty. We also offer practice recommendations, relevant to providers in the primary care setting, that can help improve access to mental health care in this population.
Franck, Kristina T; Fonager, Jannik; Ersbøll, Annette K; Böttiger, Blenda
Norovirus (NoV) is a major cause of gastroenteritis. NoV genotype II.4 (GII.4) is the predominant genotype in health care settings but the reason for this finding is unknown. Stool samples containing isolates with a known NoV genotype from 2,109 patients in Denmark (patients consulting a general practitioner or outpatient clinic, inpatients, and patients from foodborne outbreaks) were used to determine genotype distribution in relation to age and setting. NoV GII.4 was more prevalent among inpatients than among patients in community settings or those who became infected during foodborne outbreaks. In community and health care settings, we found an association between infection with GII.4 and increasing age. Norovirus GII.4 predominated in patients ≥ 60 years of age and in health care settings. A larger proportion of children than adults were infected with NoV GII.3 or GII.P21. Susceptibility to NoV infection might depend on patient age and infecting NoV genotype. Cohort studies are warranted to test this hypothesis.
Luděk Cienciala; Lucie Ciencialová
In this paper the one-way P automata with priorities are introduced. Such automata are P systemshere the membranes are only allowed to consume objects from parent membranes, under the given conditions. The result of computation of these systems is the set of multiset sequences consumed by skin membrane intc the system. The rules associated in some order with each membrane cannot modify any objects, they can only move them through membrane. We show that P automata with priorities and two membranes can accept every recursively enumerated language.
Rogers, Peter A W; Adamson, G David; Al-Jefout, Moamar;
The 3rd International Consensus Workshop on Research Priorities in Endometriosis was held in São Paulo on May 4, 2014, following the 12th World Congress on Endometriosis. The workshop was attended by 60 participants from 19 countries and was divided into 5 main sessions covering pathogenesis...... stratification, and research in emerging nations, in addition to an increased focus on translational research. A revised and updated set of research priorities that builds on this document will be developed at the 13th World Congress on Endometriosis to be held on May 17-20, 2017, in Vancouver, British Columbia...
Talib, Faisal; Rahman, Zillur; Azam, Mohammed
Due to the growing prominence of total quality management (TQM) in health care, the present study was conducted to identify the set of TQM practices for its successful implementation in healthcare institutions through a systematic review of literature. A research strategy was performed on the selected papers published between 1995 and 2009. An appropriate database was chosen and 15 peer-reviewed research papers were identified through a screening process and were finally reviewed for this study. Eight supporting TQM practices, such as top-management commitment, teamwork and participation, process management, customer focus and satisfaction, resource management, organization behavior and culture, continuous improvement, and training and education were identified as best practices for TQM implementation in any health care setting. The article concludes with a set of recommendations for the future researchers to discuss, develop, and work upon in order to achieve better precision and generalizations.
Last week the European Strategy Group met in Erice (Italy) to distil reams of input and months of discussion into a concise document outlining an updated Strategy for European Particle Physics. The result is a document that will be presented to the Council for feedback next month, before final approval by the Council at a special meeting in Brussels on 29 May. The Strategy process was important when it began in 2005, and is even more so today with important discoveries behind us and a changing global landscape for particle physics ahead. The draft update, it’s fair to say, contains few surprises, but there are nevertheless some weighty issues for the Council to deliberate. The top priority is, of course, the full exploitation of the LHC, but the Strategy goes further, stating unambiguously that Europe’s top priority should be the high-luminosity upgrade of the machine. Other high-priority items are accelerator R&D to ensure the long-term global future of the field. O...
Trauma-informed care is an emerging value that is seen as fundamental to effective and contemporary mental health nursing practice. Trauma-informed care, like recovery, leaves mental health nurses struggling to translate these values into day-to-day nursing practice. Many are confused about what individual actions they can take to support these values. To date, the most clearly articulated policy to emerge from the trauma-informed care movement in Australia has been the agreement to reduce, and wherever possible, eliminate the use of seclusion and restraint. Confronted with the constant churn of admissions and readmissions of clients with challenging behaviours, and seemingly intractable mental illness, the elimination of seclusion and restraint is seen to be utopian by many mental health nurses in inpatient settings. Is trauma-informed care solely about eliminating seclusion and restraint, or are there other tangible practices nurses could utilize to effect better health outcomes for mental health clients, especially those with significant abuse histories? This article summarizes the findings from the literature from 2000-2011 in identifying those practices and clinical activities that have been implemented to effect trauma-informed care in inpatient mental health settings.
Full Text Available Ching Jou Lim,1 David CM Kong,1 Rhonda L Stuart2,31Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia; 2Monash Infectious Diseases, Monash Health, Clayton, VIC, Australia; 3Department of Medicine, Monash University, Clayton, VIC, AustraliaAbstract: Residential aged care facilities are increasingly identified as having a high burden of infection, resulting in subsequent antibiotic use, compounded by the complexity of patient demographics and medical care. Of particular concern is the recent emergence of multidrug-resistant organisms among this vulnerable population. Accordingly, antimicrobial stewardship (AMS programs have started to be introduced into the residential aged care facilities setting to promote judicious antimicrobial use. However, to successfully implement AMS programs, there are unique challenges pertaining to this resource-limited setting that need to be addressed. In this review, we summarize the epidemiology of infections in this population and review studies that explore antibiotic use and prescribing patterns. Specific attention is paid to issues relating to inappropriate or suboptimal antibiotic prescribing to guide future AMS interventions.Keywords: residential aged care, health care-associated infection, surveillance, multidrug-resistant, antibiotic prescribing, antimicrobial stewardship
Konstantinov, Konstantin N; Tzamaloukas, Antonios; Rubin, Robert L
Autoimmune rheumatic diseases are common and confront society with serious medical, social, and financial burdens imposed by their debilitating nature. Many autoimmune diseases are associated with a particular set of autoantibodies, which have emerged as highly useful to define and classify disease, predict flares, or monitor efficacy of therapy. However, current practice for monitoring autoantibodies is protracted, labor-intensive, and expensive. This review provides an overview on the value of point-of-care (POC) biosensor technology in the diagnosis and management of patients with autoimmune rheumatic diseases. Real-time measurement of autoantibodies will clearly benefit the rheumatology practice in emergency and urgent care settings, where definitive diagnosis is essential for initiation of correct critical care therapy. Immediate serological information in clinic will provide considerable value for long-term patient care and an opportunity for an instant, result-deduced therapeutic action, avoiding delays and improving compliance, especially in field-based and remote areas. We describe the particular autoantibodies that are useful disease and activity markers and would, therefore, be attractive to POC applications. Already existing biosensors and platforms that show promise for autoantibody testing are summarized and comparatively evaluated. As POC assessment is gaining momentum in several areas of patient care, we propose that rheumatology is poised to benefit from this innovative and affordable technology.
Holst, Lone; Lundgren, Maren; Olsen, Lutte; Ishøy, Torben
Working in a hospice and being able to focus on individualized, specialized end-of-life care is a privilege for the hospice staff member. However, it also presents the hospice staff with unique challenges. This descriptive study is based upon two cases from an end-of-life care setting in Denmark, where dysfunctional family dynamics presented added challenges to the staff members in their efforts to provide optimal palliative care. The hospice triad--the patient, the staff member and the family member--forms the basis for communication and intervention in a hospice. Higher expectations and demands of younger, more well-informed patients and family members challenge hospice staff in terms of information and communication when planning for care. The inherent risk factors of working with patients in the terminal phase of life become a focal point in the prevention of the development of compassion fatigue among staff members. A series of coping strategies to more optimally manage dysfunctional families in a setting where time is of the essence are then presented in an effort to empower the hospice team, to prevent splitting among staff members, and to improve quality of care.
David C. Currow
Full Text Available AbstractIn Australia, many people ageing in their own homes are becoming increasingly frail and unwell, approaching the end of life. A palliative approach, which adheres to palliative care principles, is often appropriate. These principles provide a framework for proactive and holistic care in which quality of life and of dying is prioritised, as is support for families. A palliative approach can be delivered by the general practitioner working with the community aged care team, in collaboration with family carers. Support from specialist palliative care services is available if necessary. The Guidelines for a Palliative Approach for Aged Care in the Community Setting were published by the Australian Government Department of Health and Ageing to inform practice in this area. There are three resource documents. The main document provides practical evidence based guidelines, good practice points, tools, and links to resources. This document is written for general practitioners, nurses, social workers, therapists, pastoral care workers, and other health professionals and responded to needs identified during national consultation. Evidence based guidelines were underpinned by systematic reviews of the research literature. Good practice points were developed from literature reviews and expert opinion. Two ‘plain English’ booklets were developed in a process involving consumer consultation; one is for older people and their families, the other for care workers. The resources are intended to facilitate home care that acknowledges and plans for the client’s deteriorating functional trajectory and inevitable death. At a time when hospitals and residential aged care facilities are under enormous pressure as the population ages, such a planned approach makes sense for the health system as a whole. The approach also makes sense for older people who wish to die in their own homes. Family needs are recognised and addressed. Unnecessary hospitalisations
Full Text Available Abstract Background Delirium is a common and serious condition, which affects many of our older hospitalised patients. It is an indicator of severe underlying illness and requires early diagnosis and prompt treatment, associated with poor survival, functional outcomes with increased risk of institutionalisation following the delirium episode in the acute care setting. We describe a new model of delirium care in the acute care setting, titled Geriatric Monitoring Unit (GMU where the important concepts of delirium prevention and management are integrated. We hypothesize that patients with delirium admitted to the GMU would have better clinical outcomes with less need for physical and psychotropic restraints compared to usual care. Methods/Design GMU models after the Delirium Room with adoption of core interventions from Hospital Elder Life Program and use of evening bright light therapy to consolidate circadian rhythm and improve sleep in the elderly patients. The novelty of this approach lies in the amalgamation of these interventions in a multi-faceted approach in acute delirium management. GMU development thus consists of key considerations for room design and resource planning, program specific interventions and daily core interventions. Assessments undertaken include baseline demographics, comorbidity scoring, duration and severity of delirium, cognitive, functional measures at baseline, 6 months and 12 months later. Additionally we also analysed the pre and post-GMU implementation knowledge and attitude on delirium care among staff members in the geriatric wards (nurses, doctors and undertook satisfaction surveys for caregivers of patients treated in GMU. Discussion This study protocol describes the conceptualization and implementation of a specialized unit for delirium management. We hypothesize that such a model of care will not only result in better clinical outcomes for the elderly patient with delirium compared to usual geriatric care
McCracken, George H
The prevalence of otitis media is increasing, which affects health care resource utilization across all segments, including the urgent care setting. One of the greatest challenges in the management of acute otitis media (AOM) is the effective treatment of cases caused by pathogens that are resistant to commonly used antibiotics. Whereas the production of beta-lactamases among strains of Haemophilus influenzae and Moraxella catarrhalis is an important consideration for antimicrobial therapy, the high prevalence of resistance to penicillin and other classes of antibiotics among strains of Streptococcus pneumoniae represents a greater clinical concern. The Centers for Disease Control and Prevention (CDC) recently convened the Drug Resistant S. pneumoniae Therapeutic Working Group to develop evidence-based recommendations for the treatment of AOM in an era of prevalent resistance. The recommendations from this group included amoxicillin as the preferred first-line drug because of the demonstrated activity against penicillin-intermediate and -resistant strains of S. pneumoniae, using higher dosages of up to 90 mg/kg per day in certain settings. For patients in whom initial treatment is unsuccessful after 3 days, the recommended agents included high-dose amoxicillin-clavulanate (for activity against beta-lactamase-producing pathogens), clindamycin, cefuroxime axetil, or 1 to 3 doses of intramuscular ceftriaxone. The principles set forth in these guidelines can assist the therapeutic decisionmaking process for practitioners in the urgent care setting.
Teichert, Martina; Schoenmakers, Tim; Kylstra, Nico; Mosk, Berend; Bouvy, Marcel L; van de Vaart, Frans; De Smet, Peter A G M; Wensing, Michel
Background The quality of pharmaceutical care in community pharmacies in the Netherlands has been assessed annually since 2008. The initial set has been further developed with pharmacists and patient organizations, the healthcare inspectorate, the government and health insurance companies. The set over 2012 was the first set of quality indicators for community pharmacies which was validated and supported by all major stakeholders. The aims of this study were to describe the validated set of quality indicators for community pharmacies and to report their scores over 2012. In subanalyses the score development over 5 years was described for those indicators, that have been surveyed before and remained unchanged. Methods Community pharmacists in the Netherlands were invited in 2013 to provide information for the set of 2012. Quality indicators were mapped by categories relevant for pharmaceutical care and defined for structures, processes and dispensing outcomes. Scores for categorically-measured quality indicators were presented as the percentage of pharmacies reporting the presence of a quality aspect. For numerical quality indicators, the mean of all reported scores was expressed. In subanalyses for those indicators that had been questioned previously, scores were collected from earlier measurements for pharmacies providing their scores in 2012. Multilevel analysis was used to assess the consistency of scores within one pharmacy over time by the intra-class correlation coefficient (ICC). Results For the set in 2012, 1739 Dutch community pharmacies (88 % of the total) provided information for 66 quality indicators in 10 categories. Indicator scores on the presence of quality structures showed relatively high quality levels. Scores for processes and dispensing outcomes were lower. Subanalyses showed that overall indicators scores improved within pharmacies, but this development differed between pharmacies. Conclusions A set of validated quality indicators provided
Gable, Robert K.; And Others
The article presents the Special Education Needs Assessment Priorities model which establishes training priorities for both regular and special educators. The model consists of four stages: identification of competencies, development of discrepancies, setting training priorities, and resource allocation. (SB)
Karen E. Hamilton
Full Text Available Purpose: To investigate the set up and operation of a Managed Clinical Network for cardiac services and assess its impact on patient care. Methods: This single case study used process evaluation with observational before and after comparison of indicators of quality of care and costs. The study was conducted in Dumfries and Galloway, Scotland and used a three-level framework. Process evaluation of the network set-up and operation through a documentary review of minutes; guidelines and protocols; transcripts of fourteen semi-structured interviews with health service personnel including senior managers, general practitioners, nurses, cardiologists and members of the public. Outcome evaluation of the impact of the network through interrupted time series analysis of clinical data of 202 patients aged less than 76 years admitted to hospital with a confirmed myocardial infarction one-year pre and one-year post, the establishment of the network. The main outcome measures were differences between indicators of quality of care targeted by network protocols. Economic evaluation of the transaction costs of the set-up and operation of the network and the resource costs of the clinical care of the 202 myocardial infarction patients from the time of hospital admission to 6 months post discharge through interrupted time series analysis. The outcome measure was different in National Health Service resource use. Results: Despite early difficulties, the network was successful in bringing together clinicians, patients and managers to redesign services, exhibiting most features of good network management. The role of the energetic lead clinician was crucial, but the network took time to develop and ‘bed down’. Its primary “modus operand” was the development of a myocardial infarction pathway and associated protocols. Of sixteen clinical care indicators, two improved significantly following the launch of the network and nine showed improvements, which were
Televisitation is the virtual transportation of a patient's family to the bedside, regardless of the patient's location within an acute care setting. This innovation in the Telemedicine Program at Thunder Bay Regional Health Sciences Centre (TBRHSC) in Ontario, Canada, embraces the concept of patient- and family-centered care and has been identified as a leading practice by Accreditation Canada. The need to find creative ways to link patients to their family and friend supports hundreds of miles away was identified more than ten years ago. The important relationship between health outcomes and the psychosocial needs of patients and families has been recognized more recently. TBRHSC's patient- and family-centered model of care focuses on connecting patients with their families. First Nations renal patients with family in remote communities were some of the earliest users of videoconferencing technology for this purpose.
Segaric, Cheryl Ann; Hall, Wendy A
In this grounded theory study, informed by symbolic interactionism, we explain how nurses, patients, and family members construct relationships in acute care settings, including managing effects of work environments. We recruited participants from 10 acute care units across four community hospitals in a Western Canadian city. From 33 hr of participant observation and 40 interviews with 13 nurses, 17 patients, and 10 family members, we constructed the basic social-psychological process of progressively engaging. Nurses, patients, and family members approached constructing relationships through levels of engagement, ranging from perspectives about "just doing the job" to "doing the job with heart." Progressively engaging involved three stages: focusing on tasks, getting acquainted, and building rapport. Workplace conditions and personal factors contributed or detracted from participants' movement through the stages of the process; with higher levels of engagement, participants experienced greater satisfaction and cooperation. Progressively engaging provides direction for how all participants in care can invest in relationships.
Cioffi, R N Jane
Communication with culturally and linguistically diverse (CLD) patients has been shown to be difficult. This study describes nurses' experiences of communicating with CLD patients in an acute care setting. A purposive sample of registered nurses and certified midwives (n=23) were interviewed. Main findings were: interpreters, bilingual health workers and combinations of different strategies were used to communicate with CLD patients; some nurses showed empathy, respect and a willingness to make an effort in the communication process with others showing an ethnocentric orientation. Main recommendations were: prioritising access to appropriate linguistic services, providing nurses with support from health care workers, e.g., bilingual health care workers who are able to provide more in-depth information, increasing nurses' understanding of legal issues within patient encounters, supporting nurses to translate their awareness of cultural diversity into acceptance of, appreciation for and commitment to CLD patients and their families.
Neergaard, Mette Asbjørn; Olesen, Frede; Vedsted, Peter;
Background: In most western countries, the majority of palliative cancer patients wish to die at home, where GPs are often deeply involved. However, most research focuses on specialised palliative care, which results in a lack of reliable predictors of home death in primary care. Aim: To analyse...... predictors of home death among deceased palliative cancer patients in a primary care setting. Methods: Using Danish registers, we identified 787 deceased cancer patients and sent a questionnaire to their GPs. The questions concerned the GPs' involvement and the duration of the palliative period at home. We......-of-hours, and whether the GP had had contact with the relatives. Results: 350 questionnaires were filled out. In the preliminary analysis we found that even though many patients died in hospital, this group spent nearly as much of their last time at home as the patients who actually died at home. The analysis...
Full Text Available Abstract Background Screening for psychiatric disorders in primary care can improve the detection rate and helps in preventing grave consequences of unrecognised and untreated psychiatric morbidity. This is relevant to the Malaysian setting where mental health care is now also being provided at primary care level. The aim of this paper is to report the prevalence of psychiatric illness in a semi-urban primary care setting in Malaysia using the screening tool Patient Health Questionnaire (PHQ. Methods This is a cross-sectional study carried out in a semi-urban primary healthcare centre located south of Kuala Lumpur. Systematic random sampling was carried out and a total of 267 subjects completed the PHQ during the study period. Results The proportion of respondents who had at least one PHQ positive diagnosis was 24.7% and some respondents had more than one diagnosis. Diagnoses included depressive illness (n = 38, 14.4%, somatoform disorder (n = 32, 12.2%, panic and anxiety disorders (n = 17, 6.5%, binge eating disorder (n = 9, 3.4% and alcohol abuse (n = 6, 2.3%. Younger age (18 to 29 years and having a history of stressors in the previous four weeks were found to be significantly associated (p = 0.036 and p = 0.044 respectively with PHQ positive scores. Conclusion These findings are broadly similar to the findings of studies done in other countries and are a useful guide to the probable prevalence of psychiatric morbidity in primary care in other similar settings in Malaysia.
Kummer, Ann W; Turner, Jan
ETHICS refers to a moral philosophy or a set of moral principles that determine appropriate behavior in a society. Medical ethics includes a set of specific values that are considered in determining appropriate conduct in the practice of medicine or health care. Because the practice of medicine and medical speech-language pathology affects the health, well-being, and quality of life of individuals served, adherence to a code of ethical conduct is critically important in the health care environment. When ethical dilemmas arise, consultation with a bioethics committee can be helpful in determining the best course of action. This article will help to define medical ethics and to discuss the six basic values that are commonly considered in discussions of medical ethics. Common ethical mistakes in the practice of speech-language pathology will be described. Finally, the value of a bioethics consultation for help in resolving complex ethical issues will be discussed.
Painter, J; Akroyd, D; Wilson, S; Figuers, C
Using a perceived reward model of overall job satisfaction, this study utilized a correlational research design with multiple regression analysis to determine the predictive power of extrinsic rewards and intrinsic rewards, collectively and individually, as determinants of overall job satisfaction among registered occupational therapists (OTR) working full-time in ambulatory care settings. The intrinsic rewards (task involvement and task autonomy), collectively and individually, were perceived to be significant overall job satisfaction determinants. General working conditions was the only significant extrinsic reward. Given the demand for OTRs in ambulatory care settings, a better understanding of factors that influence overall job satisfaction among OTRs could prove beneficial in developing appropriate recruitment and retention job design strategies.
Barnes, Sarah; Wasielewska, Anna; Raiswell, Christine; Drummond, Barbara
Improving the mealtime experience in residential care can be a major facilitator in improving care, well-being and QoL. Evidence suggests that, despite guidance on the subject of food, nutrition and hydration, there are still concerns. Although there is a range of methods to research and assess the quality of food provision, there is a challenge in capturing the experiences of those residents who are unable or unwilling to describe their feelings and experiences because of frailty, impaired communication or other vulnerability. The aim of this exploratory study was to capture and describe individual residents' mealtime experience. In spring 2011, a small-scale, observational study was carried out in seven dining settings in four residential care homes in Manchester. An adapted dementia care mapping tool was used alongside field notes. Observations showed two major differences in the way the mealtimes were organised: 'pre-plated' and 'family-style' (where either bowls of food are placed in the centre of the table or food is served directly from a hotplate by a chef). These two styles of service are discussed in relation to the emerging themes of 'task versus resident-centred mealtimes', 'fostering resident independence' and 'levels of interaction'. Although improving mealtimes alone is not enough to improve quality of life in care homes, findings showed that relatively small changes to mealtime delivery can potentially have an impact on resident well-being in these homes. Observation is a useful method of engaging residents in care settings for older people who may not otherwise be able to take part in research.
Lauriks, Steve; de Wit, Matty A S; Buster, Marcel C A; Arah, Onyebuchi A; Klazinga, Niek S
Public mental health care (PMHC) systems are responsible for the wellbeing of vulnerable groups that cope with complex psychosocial problems. This article describes the development of a set of performance indicators that are feasible, meaningful, and useful to assess the quality of the PMHC system in Amsterdam, the Netherlands. Performance indicators were selected from an international inventory and presented to stakeholders of the PMHC system in a modified Delphi procedure. Characteristics of indicators were judged individually, before consensus on a core set was reached during a plenary discussion. Involving stakeholders at early stages of development increases support for quality assessment.
Balas, Michele; Buckingham, Rose; Braley, Tami; Saldi, Sarah; Vasilevskis, Eduard E
A recently proposed interprofessional, evidence-based, multicomponent approach to mitigating the effects of intensive care unit (ICU)-acquired delirium and weakness has the potential to radically transform the way care is delivered to older adults requiring sedation, mechanical ventilation, or both. The Awakening and Breathing Coordination, Delirium Monitoring and Management, and Early Mobility (ABCDE) bundle empowers members of the interdisciplinary ICU team to implement the best available evidence regarding mechanical ventilation, sedation, weakness, and delirium in a safe, effective, and patient-centered manner. Considering that critically ill older adults are cared for in a number of different settings during the course of hospitalization and recovery, the purpose of this article is to explore the rationale and possible benefits of extending the ABCDE bundle into the post-ICU setting. We provide a case study that illustrates how ABCDE bundle adoption could be the key to improving the quality of care provided to seriously ill older adults in the ICU and beyond.
M A Muckaden
Full Text Available Background: Volunteers are an integral part of the palliative care services in the Tata Memorial Hospital, Mumbai, Maharashtra, India. These volunteers are an important resource for the department. Thus, it is necessary for the department to determine what motivates these volunteers to continue to work in the setting, acknowledge them and direct efforts toward retaining them and giving them opportunities to serve to the best of their desire and abilities. Aims: The current study aimed at understanding the motivation of volunteers to work in palliative care, to identify the challenges they face and also the effect of their work on their self and relationships. Methodology: In-depth interviews were conducted using semistructured interview guide to study above mentioned aspects. Themes were identified and coding was used to analyze the data. Results: The results suggested that the basic motivation for all the volunteers to work in a palliative care setting is an inherent urge, a feeling of need to give back to the society by serving the sick and the suffering. Other motivating factors identified were team spirit, comfort shared, warm and respectful treatment by the team, satisfying nature of work, experience of cancer in the family, and aligned values and beliefs. Some intrinsic rewards mentioned by volunteers were joy of giving, personal growth, enriching experiences, and meaningful nature of work. Conclusion: The study attempted to improve opportunities of working for these volunteers. Although limited in scope, it offers insight for future research in the area of volunteerism in palliative care setup.
Anindo Majumdar; Jayaprakash Sahoo; Gautam Roy; Sadishkumar Kamalanathan
In the recent years, outbreaks of blood-borne infections have been reported from assisted living facilities, which were traced back to improper blood glucose monitoring practices. Needle-stick injuries have been implicated in many such cases. This directly raises concerns over sharp disposal practices of diabetic patients self-managing their condition in home care settings. With India being home to a huge diabetic population, this issue, if neglected, can cause substantial damage to the healt...
This research study was designed to evaluate whether or not Gestalt therapy approaches could be used effectively when intervening with aggressive acts in a day care setting. Five focus children were observed at timed intervals as to whether or not they were aggressive, how the caretaker intervened, and how the children responded to the caretaker intervention. After a baseline of aggressive acts was established, caretakers were trained to use Gestalt therapy interventio...
Thomas A Barnes
Full Text Available Thomas A Barnes1, Len Fromer21Department of Cardiopulmonary Sciences, Northeastern University, Boston, MA, USA; 2David Geffen School of Medicine at UCLA, Los Angeles, CA, USAObjective: To describe a practical method for family practitioners to stage chronic obstructive pulmonary disease (COPD by the use of office spirometry.Methods: This is a review of the lessons learned from evaluations of the use of office spirometry in the primary care setting to identify best practices using the most recent published evaluations of office spirometry and the analysis of preliminary data from a recent spirometry mass screening project. A mass screening study by the American Association for Respiratory Care and the COPD Foundation was used to identify the most effective way for general practitioners to implement office spirometry in order to stage COPD.Results: A simple three-step method is described to identify people with a high pre-test probability in an attempt to detect moderate to severe COPD: COPD questionnaire, measurement of peak expiratory flow, and office spirometry. Clinical practice guidelines exist for office spirometry basics for safety, use of electronic peak flow devices, and portable spirometers.Conclusion: Spirometry can be undertaken in primary care offices with acceptable levels of technical expertise. Using office spirometry, primary care physicians can diagnose the presence and severity of COPD. Spirometry can guide therapies for COPD and predict outcomes when used in general practice.Keywords: chronic obstructive pulmonary disease, spirometry, family practice, primary care physician
Full Text Available Abstract Background The roles of pharmacists have evolved from product oriented, dispensing of medications to more patient-focused services such as the provision of pharmaceutical care. Such pharmacy service is also becoming more widely practised in Malaysia but is not well documented. Therefore, this study is warranted to fill this information gap by identifying the types of pharmaceutical care issues (PCIs encountered by primary care patients with diabetes mellitus, hypertension or hyperlipidaemia in Malaysia. Methods This study was part of a large controlled trial that evaluated the outcomes of multiprofessional collaboration which involved medical general practitioners, pharmacists, dietitians and nurses in managing diabetes mellitus, hypertension and hyperlipidaemia in primary care settings. A total of 477 patients were recruited by 44 general practitioners in the Klang Valley. These patients were counselled by the various healthcare professionals and followed-up for 6 months. Results Of the 477 participants, 53.7% had at least one PCI, with a total of 706 PCIs. These included drug-use problems (33.3%, insufficient awareness and knowledge about disease condition and medication (20.4%, adverse drug reactions (15.6%, therapeutic failure (13.9%, drug-choice problems (9.5% and dosing problems (3.4%. Non-adherence to medications topped the list of drug-use problems, followed by incorrect administration of medications. More than half of the PCIs (52% were classified as probably clinically insignificant, 38.9% with minimal clinical significance, 8.9% as definitely clinically significant and could cause patient harm while one issue (0.2% was classified as life threatening. The main causes of PCIs were deterioration of disease state which led to failure of therapy, and also presentation of new symptoms or indications. Of the 338 PCIs where changes were recommended by the pharmacist, 87.3% were carried out as recommended. Conclusions This study
Lehrer, Joanne S.; Lemay, Lise; Bigras, Nathalie
The current study examined how parental perceptions of child care quality were related to external quality ratings and considered how parental perceptions of quality varied according to child care context (home-based or centre-based settings). Parents of 179 4-year-old children who attended child care centres (n = 141) and home-based settings…
Larson, Nicole; Ward, Dianne; Neelon, Sara Benjamin; Story, Mary
Child-care settings provide numerous opportunities to promote healthy eating and physical activity behaviors among preschool children. The majority of U.S. children are placed in some form of non-parental care during their preschool years. While approximately 15 percent of preschool children are primarily cared for by their relatives, most…
Full Text Available Elena L Bamm,1 Peter Rosenbaum,1,2 Seanne Wilkins,1 Paul Stratford11School of Rehabilitation Science, 2CanChild Centre for Childhood Disability Research, McMaster University, Hamilton, ON, CanadaIntroduction: In recent years, client-centered care has been embraced as a new philosophy of care by many organizations around the world. Clinicians and researchers have identified the need for valid and reliable outcome measures that are easy to use to evaluate success of implementation of new concepts.Objective: The current study was developed to complete adaptation and field testing of the companion patient-reported measures of processes of care for adults (MPOC-A and the service provider self-reflection measure of processes of care for service providers working with adult clients (MPOC-SP(A.Design: A validation studySettings: In-patient rehabilitation facilities.Main outcome measures: MPOC-A and measure of processes of care for service providers working with adult clients (MPOC-SP(A.Results: Three hundred and eighty-four health care providers, 61 patients, and 16 family members completed the questionnaires. Good to excellent internal consistency (0.71–0.88 for health care professionals, 0.82–0.90 for patients, and 0.87–0.94 for family members, as well as moderate to good correlations between domains (0.40–0.78 for health care professionals and 0.52–0.84 for clients supported internal reliability of the tools. Exploratory factor analysis of the MPOC-SP(A responses supported the multidimensionality of the questionnaire.Conclusion: MPOC-A and MPOC-SP(A are valid and reliable tools to assess patient and service-provider accounts, respectively, of the extent to which they experience, or are able to provide, client-centered service. Research should now be undertaken to explore in more detail the relationships between client experience and provider reports of their own behavior.Keywords: client-centered care, service evaluation, MPOC, models of
Biegler, Kelly; Mollica, Richard; Sim, Susan Elliott; Nicholas, Elisa; Chandler, Maria; Ngo-Metzger, Quyen; Paigne, Kittya; Paigne, Sompia; Nguyen, Danh V; Sorkin, Dara H
The prevalence rate of depression in primary care is high. Primary care providers serve as the initial point of contact for the majority of patients with depression, yet, approximately 50% of cases remain unrecognized. The under-diagnosis of depression may be further exacerbated in limited English-language proficient (LEP) populations. Language barriers may result in less discussion of patients' mental health needs and fewer referrals to mental health services, particularly given competing priorities of other medical conditions and providers' time pressures. Recent advances in Health Information Technology (HIT) may facilitate novel ways to screen for depression and other mental health disorders in LEP populations. The purpose of this paper is to describe the rationale and protocol of a clustered randomized controlled trial that will test the effectiveness of an HIT intervention that provides a multi-component approach to delivering culturally competent, mental health care in the primary care setting. The HIT intervention has four components: 1) web-based provider training, 2) multimedia electronic screening of depression and PTSD in the patients' primary language, 3) Computer generated risk assessment scores delivered directly to the provider, and 4) clinical decision support. The outcomes of the study include assessing the potential of the HIT intervention to improve screening rates, clinical detection, provider initiation of treatment, and patient outcomes for depression and post-traumatic stress disorder (PTSD) among LEP Cambodian refugees who experienced war atrocities and trauma during the Khmer Rouge. This technology has the potential to be adapted to any LEP population in order to facilitate mental health screening and treatment in the primary care setting.
Full Text Available Abstract Background General Practitioners (GPs in Thailand play an important role in treating psychiatric disorders since there is a shortage of psychiatrists in the country. Our aim was to examine GP's perception of psychiatric problems, drug treatment and service problems encountered in primary care settings. Methods We distributed 1,193 postal questionnaires inquiring about psychiatric practices and service problems to doctors in primary care settings throughout Thailand. Results Four hundred and thirty-four questionnaires (36.4% were returned. Sixty-seven of the respondents (15.4% who had taken further special training in various fields were excluded from the analysis, giving a total of 367 GPs in this study. Fifty-six per cent of respondents were males and they had worked for 4.6 years on average (median = 3 years. 65.6% (SD = 19.3 of the total patients examined had physical problems, 10.7% (SD = 7.9 had psychiatric problems and 23.9% (SD = 16.0 had both problems. The most common psychiatric diagnoses were anxiety disorders (37.5%, alcohol and drugs abuse (28.1%, and depressive disorders (29.2%. Commonly prescribed psychotropic drugs were anxiolytics and antidepressants. The psychotropic drugs most frequently prescribed were diazepam among anti-anxiety drugs, amitriptyline among antidepressant drugs, and haloperidol among antipsychotic drugs. Conclusion Most drugs available through primary care were the same as what existed 3 decades ago. There should be adequate supply of new and appropriate psychotropic drugs in primary care. Case-finding instruments for common mental disorders might be helpful for GPs whose quality of practice was limited by large numbers of patients. However, the service delivery system should be modified in order to maintain successful care for a large number of psychiatric patients.
…THE POLITICAL LEADERS of the local government of Chongqing, China, vigorously promote a low-carbon economy and sustainable development to mitigate environmental pollution. Accordingly, research grants focused on this issue were supported by the government, and our group obtained a grant for a pr......…THE POLITICAL LEADERS of the local government of Chongqing, China, vigorously promote a low-carbon economy and sustainable development to mitigate environmental pollution. Accordingly, research grants focused on this issue were supported by the government, and our group obtained a grant...... for a project about industrial park planning and design.…In my view, political priorities based on correct decision-making and market requirements are beneficial for researchers....
Full Text Available Abstract Background Early diagnosis of anaemia represents an important task within primary care settings. This study reports on the frequency of new cases of anaemia among patients attending rural primary care settings in Crete (Greece and to offer an estimate of iron deficiency anaemia (IDA frequency in this study group. Methods All patients attending the rural primary health care units of twelve general practitioners (GPs on the island of Crete for ten consecutive working days were eligible to participate in this study. Hemoglobin (Hb levels were measured by portable analyzers. Laboratory tests to confirm new cases of anaemia were performed at the University General Hospital of Heraklion. Results One hundred and thirteen out of 541 recruited patients had a low value of Hb according to the initial measurement obtained by the use of the portable analyzer. Forty five (45.5% of the 99 subjects who underwent laboratory testing had confirmed anaemia. The mean value of the Hb levels in the group with confirmed anaemia, as detected by the portable analyzer was 11.1 g/dl (95% Confidence Interval (CI from 10.9 to 11.4 and the respective mean value of the Hb levels obtained from the full blood count was 11.4 g/dl (95% CI from 11.2 to 11.7 (P = 0.01. Sixteen out of those 45 patients with anaemia (35.6% had IDA, with ferritin levels lower than 30 ng/ml. Conclusion Keeping in mind that this paper does not deal with specificity or sensitivity figures, it is suggested that in rural and remote settings anaemia is still invisible and point of care testing may have a place to identify it.
Wendsche, Johannes; Hacker, Winfried; Wegge, Jürgen; Rudolf, Matthias
We investigated how two types of care setting (home care and nursing home) and type of ownership (for-profit vs. public/non-profit) of geriatric care services interacted in influencing registered nurses' intention to give up their profession. In prior research, employment in for-profit-organizations, high job demands, and low job control were important antecedents of nurses' intent to leave. However, the impact of care setting on these associations was inconclusive. Therefore, we tested a mediated moderation model predicting that adverse work characteristics would drive professional leaving intentions, particularly in for-profit services and in nursing homes. A representative German sample of 304 registered nurses working in 78 different teams participated in our cross-sectional study. As predicted, lower job control and higher job demands were associated with higher professional leaving intentions, and nurses reported higher job demands in public/non-profit care than in for-profit care, and in nursing homes compared to home care. Overall, RNs in nursing homes and home care reported similar intent to leave, but in for-profit settings only, nurses working in nursing homes reported higher professional leaving intentions than did nurses in home care, which was linked to lower job control in the for-profit nursing home setting, supporting mediated moderation. Taken together, our results indicate that the interplay of care setting and type of ownership is important when explaining nurses' intentions to give up their profession. © 2016 Wiley Periodicals, Inc.
Montes de Oca, Maria; Aguirre, Carlos; Lopez Varela, Maria Victorina; Laucho-Contreras, Maria E; Casas, Alejandro; Surmont, Filip
Background COPD, asthma, and asthma–COPD overlap increase health care resource consumption, predominantly because of hospitalization for exacerbations and also increased visits to general practitioners (GPs) or specialists. Little information is available regarding this in the primary care setting. Objectives To describe the prevalence and number of GP and specialist visits for any cause or due to exacerbations in patients with COPD, asthma, and asthma–COPD overlap. Methods COPD was defined as post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC) ratio <0.70; asthma was defined as prior medical diagnosis, wheezing in the last 12 months, or wheezing plus reversibility (post-bronchodilator FEV1 or FVC increase ≥200 mL and ≥12%); asthma–COPD overlap was defined as post-bronchodilator FEV1/FVC <0.70 plus prior asthma diagnosis. Health care utilization was evaluated as GP and/or specialist visits in the previous year. Results Among the 1,743 individuals who completed the questionnaire, 1,540 performed acceptable spirometry. COPD patients had a higher prevalence of any medical visits to any physician versus those without COPD (37.2% vs 21.8%, respectively) and exacerbations doubled the number of visits. The prevalence of any medical visits to any physician was also higher in asthma patients versus those without asthma (wheezing: 47.2% vs 22.7%; medical diagnosis: 54.6% vs 21.6%; wheezing plus reversibility: 46.2% vs 23.8%, respectively). Asthma patients with exacerbations had twice the number of visits versus those without an exacerbation. The number of visits was higher (2.8 times) in asthma–COPD overlap, asthma (1.9 times), or COPD (1.4 times) patients versus those without these respiratory diseases; the number of visits due to exacerbation was also higher (4.9 times) in asthma–COPD overlap, asthma (3.5 times), and COPD (3.8 times) patients. Conclusion COPD, asthma, and asthma–COPD overlap increase the prevalence of
Full Text Available Levofloxacin is a commonly prescribed antibiotic for managing chest and urinary tract infections in a palliative care setting. Incidence of Levofloxacin-associated anaphylaxis is rare and delirium secondary to Levofloxacin is a seldom occurrence with only few published case reports. It is an extremely rare occurrence to see this phenomenon in combination. Early identification and prompt intervention reduces both mortality and morbidity. A 17-year-old male with synovial sarcoma of right thigh with chest wall and lung metastasis and with no prior psychiatric morbidity presented to palliative medicine outpatient department with community-acquired pneumonia. He was initiated on intravenous (IV Ceftriaxone and IV Levofloxacin. Post IV Levofloxacin patient developed anaphylaxis and acute delirium necessitating IV Hydrocortisone, IV Chlorpheneramine, Oxygen and IV Haloperidol. Early detection and prompt intervention helped in complete recovery. Patient was discharged to hospice for respite after 2 days of hospitalization and then discharged home. Acute palliative care approach facilitated management of two life-threatening medical complications in a palliative care setting improving both quality and length of life.
Aim. To incorporate an international and multidisciplinary consensus in the determination of the research and education priorities for wound healing and tissue repair. Background. A compelling reason for the study is the lack of an agreed list of priorities for wound care research and education. Furthermore, there is a growth in the prevalence of chronic wounds, a growth in wound care products and marketing, and an increase in clinician attendance at conferences and education programmes. Design. The study used a survey method. Methods. A four-round eDelphi technique was used to collect responses from an international population of health professionals across 24 countries. Results. Responses were obtained from 360 professionals representing many health care settings. The top education priorities related to the standardisation of all foundation education programmes in wound care, the inclusion of wound care in all professional undergraduate and postgraduate education programmes, selecting dressings and the prevention of pressure ulcers. The top research priorities related to the dressing selection, pressure ulcer prevention and wound infection. Conclusion. Professionals from different backgrounds and countries who are engaged in wound management share a common set of priorities for research and education. Most notably, the priorities identified relate to long-established clinical challenges in wound care and underpin the principles of good patient care practices. The priorities are closely allied to an ageing population and identify many challenges ahead for practitioners engaged in wound management services. Relevance to clinical practice. The provision of wound care is a major investment of health service resources and remains a clinical challenge today. Research is essential to building evidence-based practice and fundamental to development of quality in standards of practice; education is central to achieving competence to deliver effective care. The
Full Text Available Objectives: To determine the effectiveness of nutritional screening programmes in improving quality of care and patient outcomes compared with usual care. Methods: Searches were performed on MEDLINE, EMBASE, CINHAL, the Cochrane database, and Current Controlled Trials. Due to the assumed scarcity of high quality evidence, interventional studies in hospital or primary care settings with adequate reporting and comparisons were considered as eligible. Team members met after reviewing the papers. Decisions on inclusion or exclusion of papers were made when all agreed. Two reviewers independently extracted data from included studies. Results: 705 abstracts were considered and thirty full-text papers were ordered and reviewed. Following further review of the extracted data two papers met the inclusion criteria. One was a clustered randomized study of 26 general practices to evaluate the effectiveness of screening for elderly ailments including malnutrition. It concluded nutritional screening did not improve referral to dieticians, detection of nutritional problems, or patients’ quality of life. This study was underpowered for evaluating the effectiveness of nutritional screening. A non-randomized controlled before-after study of four hospital wards concluded that intervention improved weight recording, but not referral to dieticians or care at the mealtime of at risk patients. Discussion: Very few studies assess the effectiveness of nutritional screening with relevant outcomes and acceptable quality. The available evidence does not support systematic application of screening tools to hospital, or general practice patients. Given the current level of interest and political support for nutritional screening, further studies are urgently required.
Torres-Ricarte, Marc; Crusat-Abelló, Ernest; Peñuelas-Rodríguez, Silvia; Zabaleta-del-Olmo, Edurne
At present, the severe economic crisis along with the increasing prevalence of chronic diseases is leading to different countries to consider updating their Primary Health Care (PHC) services in order to make them more efficient and reduce health inequalities. To that end, various initiatives are being carried out, such as the provision of Nurse-led services and interventions. The purpose of this article is to present the available knowledge, controversies and opportunities for Nurse-led initiatives in the setting of PHC. Nurse- led interventions or health services in PHC have proven to be equal or more effective than usual care in disease prevention, the routine follow-up of patients with chronic conditions, and first contact care for people with minor illness. However, as there are only a few health economic evaluation studies published their efficiency is still potential. In conclusion, the Nurse-led care could be an innovative organizational initiative with the potential to provide an adequate response to the contemporary health needs of the population, as well as an opportunity for the nursing profession and for PHC and health systems in general.
Full Text Available Abstract Background Injection drug users (IDUs represent a significant proportion of patients with chronic hepatitis C (CHC. The low treatment uptake among these patients results in a low treatment effectiveness and a limited public health impact. We hypothesised that a general practitioner (GP providing an opioid maintenance treatment (OMT for addicted patients can achieve CHC treatment and sustained virological response rates (SVR comparable to patients without drug dependency. Methods Retrospective patient record analysis of 85 CHC patients who received OMT for more than 3 months in a single-handed general practice in Zurich from January 1, 2002 through May 31, 2008. CHC treatment was based on a combination with pegylated interferon and ribavirin. Treatment uptake and SVR (undetectable HCV RNA 6 months after end of treatment were assessed. The association between treatment uptake and patient characteristics was investigated by multiple logistic regression. Results In 35 out of 85 CHC patients (52 males with a median (IQR age of 38.8 (35.0-44.4 years, antiviral therapy was started (41.2%. Median duration (IQR of OMT in the treatment group was 55.0 (35.0-110.1 months compared to the group without therapy 24.0 (9.8-46.3 months (p Conclusion In addicted patients a high CHC treatment and viral eradication rate in a primary care setting in Switzerland is feasible. Opioid substitution seems a beneficial framework for CHC care in this “difficult to treat” population.
Ottiger, Cornelia; Gygli, Nicole; Huber, Andreas R; Fernandez-Tresguerres, Beatriz; Pardo, Scott; Petruschke, Thorsten
This study assesses and demonstrates that CONTOUR® XT-BGMS (CXT-BGMS) complies with the requirements of the German (RiliBÄK) and Swiss (QUALAB) quality control guidelines for point-of-care testing (POCT) and fulfills the ISO15197:2013 accuracy limits criteria under the routine conditions of a hospital point-of care setting. This single-center study was conducted in Switzerland using 105 venous blood samples from hospitalized patients. Each sample was tested in comparison to the hexokinase reference method. Compliance with POCT guidelines was assessed by daily BGMS measurements using control solutions. Accuracy of CXT-BGMS according to ISO limits was 98.41%. All control measurements were within the limits defined by RiliBÄK (within ± 11% of target values and root mean square error [RMSE] within RMSE limits), and QUALAB (within ± 10% of target values).
Ottiger, Cornelia; Gygli, Nicole; Huber, Andreas R.; Fernandez-Tresguerres, Beatriz; Pardo, Scott; Petruschke, Thorsten
This study assesses and demonstrates that CONTOUR® XT-BGMS (CXT-BGMS) complies with the requirements of the German (RiliBÄK) and Swiss (QUALAB) quality control guidelines for point-of-care testing (POCT) and fulfills the ISO15197:2013 accuracy limits criteria under the routine conditions of a hospital point-of care setting. This single-center study was conducted in Switzerland using 105 venous blood samples from hospitalized patients. Each sample was tested in comparison to the hexokinase reference method. Compliance with POCT guidelines was assessed by daily BGMS measurements using control solutions. Accuracy of CXT-BGMS according to ISO limits was 98.41%. All control measurements were within the limits defined by RiliBÄK (within ± 11% of target values and root mean square error [RMSE] within RMSE limits), and QUALAB (within ± 10% of target values). PMID:26989068
Sathish, Thirunavukkarasu; Kannan, Srinivasan; Sarma, P Sankara; Razum, Oliver; Thrift, Amanda Gay; Thankappan, Kavumpurathu Raman
We used the data of 297 participants (15-64 years old) from a cohort study (2003-2010) who were free from hypertension at baseline, to develop a risk score to predict hypertension by primary health care workers in rural India. Age ≥35 years, current smoking, prehypertension, and central obesity were significantly associated with incident hypertension. The optimal cutoff value of ≥3 had a sensitivity of 78.6%, specificity of 65.2%, positive predictive value of 41.1%, and negative predictive value of 90.8%. The area under the receiver operating characteristic curve of the risk score was 0.802 (95% confidence interval = 0.748-0.856). This simple and easy to administer risk score could be used to predict hypertension in primary care settings in rural India.
Rhee, Susan M; Valle, M Frances; Wilson, Lisa M; Lazarus, Gerald; Zenilman, Jonathan M; Robinson, Karen A
The use of negative pressure wound therapy (NPWT) is increasing in both the inpatient and outpatient settings. We conducted a systematic review on the efficacy and safety of NPWT for the treatment of chronic wounds in the home setting. We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and the Cumulative Index to Nursing and Allied Health Literature, up to June 2014. Two independent reviewers screened search results. Seven studies met our criteria for inclusion. Six of the studies compared NPWT devices to other wound care methods and one study compared two different NPWT technologies. Data were limited by variability in the types of comparator groups, methodological limitations, and poor reporting of outcomes. We were unable to draw conclusions about the efficacy or safety of NPWT for the treatment of chronic wounds in the home setting due to the insufficient evidence. Consensus is needed on the methods of conducting and reporting wound care research so that future studies are able inform decisions about the use of NPWT in the home environment for chronic wounds.
Montes de Oca M
Full Text Available Maria Montes de Oca,1 Carlos Aguirre,2 Maria Victorina Lopez Varela,3 Maria E Laucho-Contreras,1 Alejandro Casas,2 Filip Surmont4 1Service of Pneumology, Hospital Universitario de Caracas, Facultad de Medicina, Universidad Central de Venezuela, Caracas, Venezuela; 2Colombian Pneumological Foundation, Bogotá, Colombia; 3Universidad de la República, Facultad de Medicina, Hospital Maciel, Montevideo, Uruguay; 4Medical Affairs, AstraZeneca Latin America, Coral Gables, FL, USA Background: COPD, asthma, and asthma–COPD overlap increase health care resource consumption, predominantly because of hospitalization for exacerbations and also increased visits to general practitioners (GPs or specialists. Little information is available regarding this in the primary care setting. Objectives: To describe the prevalence and number of GP and specialist visits for any cause or due to exacerbations in patients with COPD, asthma, and asthma–COPD overlap. Methods: COPD was defined as post-bronchodilator forced expiratory volume in 1 second/forced vital capacity (FEV1/FVC ratio <0.70; asthma was defined as prior medical diagnosis, wheezing in the last 12 months, or wheezing plus reversibility (post-bronchodilator FEV1 or FVC increase ≥200 mL and ≥12%; asthma–COPD overlap was defined as post-bronchodilator FEV1/FVC <0.70 plus prior asthma diagnosis. Health care utilization was evaluated as GP and/or specialist visits in the previous year. Results: Among the 1,743 individuals who completed the questionnaire, 1,540 performed acceptable spirometry. COPD patients had a higher prevalence of any medical visits to any physician versus those without COPD (37.2% vs 21.8%, respectively and exacerbations doubled the number of visits. The prevalence of any medical visits to any physician was also higher in asthma patients versus those without asthma (wheezing: 47.2% vs 22.7%; medical diagnosis: 54.6% vs 21.6%; wheezing plus reversibility: 46.2% vs 23.8%, respectively
Wyder, Marianne; Ehrlich, Carolyn; Crompton, David; McArthur, Leianne; Delaforce, Caroline; Dziopa, Fiona; Ramon, Shulamit; Powell, Elizabeth
Inpatient psychiatric care requires a balance between working with consumers' priorities and goals, managing expectations of the community, legal, professional and service responsibilities. In order to improve service delivery within acute mental health units, it is important to understand the constraints and facilitating factors for good care. We conducted a systematic narrative synthesis, where findings of qualitative studies are synthesised to generate new insights. 21 articles were identified. Our results show that personal qualities, professional skills as well as environmental factors all influence the ability to provide recovery focused care. Three overarching themes which either facilitated or hindered were identified. These included: (i) Complexity of the nursing role (clinical care; practical and emotional support: advocacy and education; enforcing aspects of the Mental Health Act. and, maintaining ward safety); (ii) Constraining factors (operational barriers; change in patient characteristic; and competing understandings of care); and (iii) Facilitating factors (ward factors; nursing tools; nurse characteristics; approach to people; approach to work and ability to self-care). We suggest that the therapeutic use of self is central to the provision of recovery oriented care. However person-centred practice can be fragile and fluid and a compassionate system of support is needed to enable an understanding of context and self. It is critical to have a work environment which fosters hope and optimism and is supportive of autonomy, ensures workload balance, and is safe.
Daugaard, Morten; Nielsen, Lars Hedemann
In Denmark, early rehabilitation of acquired head injuries is centralised in two centres, each covering half the country as uptake area. The Regional Hospital Hammel Neurocenter (HN), which covers the western half of Denmark, traditionally receives patients for rehabilitation after discharge from the intensive care unit (ICU). In collaboration with the Regional Hospital in Silkeborg HN now offers early rehabilitation in Silkeborg's ICU setting to patients with acquired brain injury. This preliminary study discusses whether the collaboration facilitates rehabilitation at an earlier state than previously.
The term "invasive candidiasis" encompasses a group of infections of increasing relevance in the intensive care setting. Prophylaxis is an attractive strategy when dealing with diseases of high prevalence, morbidity, and mortality. The success of prophylaxis is determined by the selection of a population at high risk and the use of the safest and most effective drug. Although risk factors for this disease are known, risk assessment strategies need to be developed to predict a high likelihood of disease so that targeted prophylaxis can be offered. Recent advances in antifungal therapy, such as development of the azoles and echinocandins, have resulted in excellent prophylactic and therapeutic choices for the management of this problem.
Fransina J. de Jong
Full Text Available Background: In the Depression Initiative, a promising collaborative care model for depression that was developed in the US was adapted for implementation in the Netherlands. Aim: Description of a collaborative care model for major depressive disorder (MDD and of the factors influencing its implementation in the primary care setting in the Netherlands. Data sources: Data collected during the preparation phase of the CC:DIP trial of the Depression Initiative, literature, policy documents, information sheets from professional associations. Results: Factors facilitating the implementation of the collaborative care model are continuous supervision of the care managers by the consultant psychiatrist and the trainers, a supportive web-based tracking system and the new reimbursement system that allows for introduction of a mental health care-practice nurse (MHC-PN in the general practices and coverage of the treatment costs. Impeding factors might be the relatively high percentage of solo-primary care practices, the small percentage of professionals that are located in the same building, unfamiliarity with the concept of collaboration as required for collaborative care, the reimbursement system that demands regular negotiations between each health care provider and the insurance companies and the reluctance general practitioners might feel to expand their responsibility for their depressed patients. Conclusion: Implementation of the collaborative care model in the Netherlands requires extensive training and supervision on micro level, facilitation of reimbursement on meso- and macro level and structural effort to change the treatment culture for chronic mental disorders in the primary care setting.
Homeless health is government and NGO’s responsibilities for creating optimal citizen health status. Homeless is one of community health nursing clients. The Self Care Theory is used in nursing science for giving conceptual framework as a practical guidance and building self care knowledge through research. Orem described self care as a continuing intervention. It was needed and done by adult to be survived, healthy, and wellness. This theory is also used in homeless setting by many exp...
Leemans, K.; Deliens, L.; Block, L. van den; Stichele, R. Vander; Francke, A.L.; Cohen, J.
Background: A feasibility evaluation of a comprehensive quality indicator set for palliative care identified the need for a minimal selection of these indicators to monitor quality of palliative care services with short questionnaires for the patients, caregivers, and family carers. Objectives: To d
Full Text Available Hemichorea hemiballismus (HCHB is a rare and debilitating presentation of hyperglycemia and subcortical stroke. Early identification, proper assessment and management of HCHB can lead to complete symptom relief. We describe a case of HCHB presenting to a palliative care setting. A 63-year-old diabetic and hypertensive lady, with history of ovarian cancer presented to Palliative Medicine outpatient clinic with two days history of right HCHB. Blood investigations and brain imaging showed high blood sugar levels and lacunar subcortical stroke. Blood sugar levels were controlled with human insulin and Aspirin. Clopidogrel and Atorvastatin were prescribed for the management of lacunar stroke. HCHB reduced markedly post-treatment, leading to significant reduction in morbidity and improvement in quality of life. The symptoms completely resolved within one week of starting the treatment and the patient was kept on regular home and outpatient follow up for further monitoring. Acute palliative care (APC approach deals with the management of comorbidities and their complications along with supportive care. Prompt assessment and management of such complications lead to better patient outcomes.
Full Text Available Introduction: The Ramsay Hunt syndrome is characterized by combination of herpes infection and lower motor neuron type of facial nerve palsy. The disease is caused by a reactivation of Varicella Zoster virus and can be unrepresentative since the herpetic lesions may not be always be present (zoster sine herpete and might mimic other severe neurological illnesses. Case Report: A 63-year-old man known case of carcinoma of gall bladder with liver metastases, post surgery and chemotherapy with no scope for further disease modifying treatment, was referred to palliative care unit for best supportive care. He was on regular analgesics and other supportive treatment. He presented to Palliative Medicine outpatient with 3 days history of ipsilateral facial pain of neuropathic character, otalgia, diffuse vesciculo-papular rash over ophthalmic and maxillary divisions of left trigeminal nerve distribution of face and ear, and was associated with secondary bacterial infection and unilateral facial edema. He was clinically diagnosed to have Herpes Zoster with superadded bacterial infection. He was treated with tablet Valacyclovir 500 mg four times a day, Acyclovir cream for local application, Acyclovir eye ointment for prophylactic treatment of Herpetic Keratitis, low dose of Prednisolone, oral Amoxicillin and Clindamycin for 7 days, and Pregabalin 150 mg per day. After 7 days of treatment, the rash and vesicles had completely resolved and good improvement of pain and other symptoms were noted. Conclusion: Management of acute infections and its associated complications in an acute palliative care setting improves both quality and length of life.
Damani, Anuja; Ghoshal, Arunangshu; Salins, Naveen; Deodhar, Jayita; Muckaden, Mary Ann
Hemichorea hemiballismus (HCHB) is a rare and debilitating presentation of hyperglycemia and subcortical stroke. Early identification, proper assessment and management of HCHB can lead to complete symptom relief. We describe a case of HCHB presenting to a palliative care setting. A 63-year-old diabetic and hypertensive lady, with history of ovarian cancer presented to Palliative Medicine outpatient clinic with two days history of right HCHB. Blood investigations and brain imaging showed high blood sugar levels and lacunar subcortical stroke. Blood sugar levels were controlled with human insulin and Aspirin. Clopidogrel and Atorvastatin were prescribed for the management of lacunar stroke. HCHB reduced markedly post-treatment, leading to significant reduction in morbidity and improvement in quality of life. The symptoms completely resolved within one week of starting the treatment and the patient was kept on regular home and outpatient follow up for further monitoring. Acute palliative care (APC) approach deals with the management of comorbidities and their complications along with supportive care. Prompt assessment and management of such complications lead to better patient outcomes.
Cowin, Leanne S
Poor collegial relations can cause communication breakdown, staff attrition and difficulties attracting new nursing staff. Underestimating the potential power of nursing team relationships means that opportunities to create better working environments and increase the quality of nursing care can be missed. Previous research on improving collegiality indicates that professionalism and work satisfaction increases and that staff attrition decreases. This study explores challenges, strengths and strategies used in nursing team communication in order to build collegial relationships. A qualitative approach was employed to gather nurses experiences and discussion of communication within their nursing teams and a constant comparison method was utilised for data analysis. A convenience sampling technique was employed to access both Registered Nurses and Enrolled Nurses to partake in six focus groups. Thirty mostly female nurses (ratio of 5:1) participated in the study. Inclusion criteria consisted of being a nurse currently working in acute care settings and the exclusion criteria included nursing staff currently working in closed specialty units (i.e. intensive care units). Results revealed three main themes: (1) externalisation and internalisation of nursing team communication breakdown, (2) the importance of collegiality for retention of nurses and (3) loss of respect, and civility across the healthcare workplace. A clear division between hierarchies of nurses was apparent in how nursing team communication was delivered and managed. Open, respectful and collegial communication is essential in today's dynamic and complex health environments. The nurses in this study highlighted how important nursing communication can be to work motivation and how leadership fosters teamwork.
Kostanecka, Anna; Power, Thomas; Clarke, Angela; Watkins, Marley; Hausman, Cheryl L; Blum, Nathan J
The Pediatric Symptom Checklist-17 (PSC-17) is a brief form of the Pediatric Symptom Checklist that is designed to screen for behavioral health problems in primary care settings. It has been proposed to have three subscales: externalizing, internalizing, and attention problems. In the context of developing a behavioral health screening program in an inner-city primary care practice, we evaluated the construct validity of the PSC-17. A total of 331 families with children between 4 and 12 years of age who were seen for well-child care during the study were invited to complete the PSC-17 and 320 families (96.5%) did so. A confirmatory factor analysis was performed and the Comparative Fit Index and root mean square error of approximation fit statistics were calculated to determine whether the data fit the proposed three-factor model. We found that although the PSC-17 contained three subscales, several items did not load predominantly on the subscale that they were proposed to measure. Specifically, although the five items on the internalizing subscale loaded only on this subscale, only four of the seven externalizing items loaded exclusively on the externalizing subscale, and only two of the five attention items loaded exclusively on the attention problems subscale. Clinicians using the PSC-17 in urban low-income communities should recognize that the externalizing and attention problems subscales of the PSC-17 may not be valid measures of these dimensions of child behavior in this population.
Stevens, Wendy; Gous, Natasha; Ford, Nathan; Scott, Lesley E
Improved access to anti-retroviral therapy increases the need for affordable monitoring using assays such as CD4 and/or viral load in resource-limited settings. Barriers to accessing treatment, high rates of loss to initiation and poor retention in care are prompting the need to find alternatives to conventional centralized laboratory testing in certain countries. Strong advocacy has led to a rapidly expanding repertoire of point-of-care tests for HIV. point-of-care testing is not without its challenges: poor regulatory control, lack of guidelines, absence of quality monitoring and lack of industry standards for connectivity, to name a few. The management of HIV increasingly requires a multidisciplinary testing approach involving hematology, chemistry, and tests associated with the management of non-communicable diseases, thus added expertise is needed. This is further complicated by additional human resource requirements and the need for continuous training, a sustainable supply chain, and reimbursement strategies. It is clear that to ensure appropriate national implementation either in a tiered laboratory model or a total decentralized model, clear country-specific assessments need to be conducted.
Krause, S K; Meyers, J L; Friedlander, E
This paper describes an emergency obstetric care (EmOC) project implemented by the Reproductive Health Response in Conflict (RHRC) Consortium in 12 conflict-affected settings in nine countries from 2000-2005 with funding and technical support from Columbia University's Mailman School of Public Health Averting Maternal Death and Disability (AMDD) programme. The overall goal of the project was to reduce maternal morbidity and mortality in select conflict-affected settings by improving the availability of EmOC. Another aim of the project was to institutionalize EmOC within RHRC Consortium agencies by modelling how to improve the availability of basic and comprehensive EmOC at clinics and hospitals. The specific project purpose was to increase the availability of EmOC in select conflict-affected settings. The project demonstrated that a great deal more can and should be done by humanitarian workers to improve the availability of basic and comprehensive emergency obstetric services in conflict-affected settings.
Jangam, Sujit R; Agarwal, Abhishek K; Sur, Kunal; Kelso, David M
A low-cost, fully integrated sample-to-answer, quantitative PCR (qPCR) system that can be used for detection of HIV-1 proviral DNA in infants at the point-of-care in resource-limited settings has been developed and tested. The system is based on a novel DNA extraction method, which uses a glass fiber membrane, a disposable assay card that includes on-board reagent storage, provisions for thermal cycling and fluorescence detection, and a battery-operated portable analyzer. The system is capable of automated PCR mix assembly using a novel reagent delivery system and performing qPCR. HIV-1 and internal control targets are detected using two spectrally separated fluorophores, FAM and Quasar 670. In this report, a proof-of-concept of the platform is demonstrated. Initial results with whole blood demonstrate that the test is capable of detecting HIV-1 in blood samples containing greater than 5000 copies of HIV-1. In resource-limited settings, a point-of-care HIV-1 qPCR test would greatly increase the number of test results that reach the infants caregivers, allowing them to pursue anti-retroviral therapy.
Andrew M. Harrison
Full Text Available Background Electronic Health Record (EHR-based sepsis alert systems have failed to demonstrate improvements in clinically meaningful endpoints. However, the effect of implementation barriers on the success of new sepsis alert systems is rarely explored. Objective To test the hypothesis time to severe sepsis alert acknowledgement by critical care clinicians in the ICU setting would be reduced using an EHR-based alert acknowledgement system compared to a text paging-based system. Study Design In one arm of this simulation study, real alerts for patients in the medical ICU were delivered to critical care clinicians through the EHR. In the other arm, simulated alerts were delivered through text paging. The primary outcome was time to alert acknowledgement. The secondary outcomes were a structured, mixed quantitative/qualitative survey and informal group interview. Results The alert acknowledgement rate from the severe sepsis alert system was 3% (N = 148 and 51% (N = 156 from simulated severe sepsis alerts through traditional text paging. Time to alert acknowledgement from the severe sepsis alert system was median 274 min (N = 5 and median 2 min (N = 80 from text paging. The response rate from the EHR-based alert system was insufficient to compare primary measures. However, secondary measures revealed important barriers. Conclusion Alert fatigue, interruption, human error, and information overload are barriers to alert and simulation studies in the ICU setting.
Wallington, Sherrie Flynt; Blake, Kelly; Taylor-Clark, Kalahn; Viswanath, K
The influence of news media on audience cognitions, attitudes, and behaviors in the realm of politics, race relations, science, and health has been extensively documented.Agenda setting and framing studies show that news media influence how people develop schema and place priorities on issues, with media stories serving as a major source of issue frames. Although news media are an important intermediary in the translation of scientific knowledge to different publics, little has been documented about the production of health news and factors that may predict media agenda setting and framing in health journalism. We used data from a 2005 national survey of U.S. health reporters and editors to examine predictors of source, resource, story angle, and frame usage among reporters and editors by variables such as organizational structure, individual characteristics of respondents (such as education and years working as a journalist),and perceptions of occupational autonomy. Multivariable logistic regression models revealed several differences among U.S. health reports and editors in the likelihood of using a variety of news sources, resources, priorities, and angles in reporting. Media agenda setting and framing theories suggest that practitioners familiar with media processes can work with journalists to frame messages, thereby increasing the probability of accurate and effective reporting. Results from this study may help to inform interactions between public health and medical practitioners and the press [corrected].
Margaretha Norell Pejner
Full Text Available Emotional support is considered to be important to older patients because it is a contributing factor to experiencing good health and it has been shown that it can prevent depression after a hip fracture. Opinions differ on whether emotional support falls within the field of nursing, and studies also show that nurses in an elderly home care setting fail when it comes to giving emotional support. The aim of this study was to explore reasons for registered nurses to give emotional support to older patients in a municipal home care setting. The study was conducted using Grounded Theory. Data collection was carried out through interviews with 16 registered nurses. The inclusion criteria were emotional support given to patients aged 80 years and above living in ordinary or sheltered housing and who were in need of help from both the home help service and registered nurses. The results show that the main concern of emotional support was “Trying to relieve the patient from their emotions so they are able to cope with everyday life.” This core category illustrates how registered nurses tried to support the patients’ own strength, so that they were able to move forward. Registered nurses consider that they could support the patients because they give them access to, or could create access to, their emotions, but there were also times when they felt helplessness and as a result, consciously opted out. The results also indicate that registered nurses were keen to give emotional support. To develop patient-centered elderly care, more knowledge of emotional support and the elderly's need for this support is required.
Cheong, Chin Yee; Tan, Jane An Qi; Foong, Yi-Lin; Koh, Hui Mien; Chen, Denise Zhen Yue; Tan, Jessie Joon Chen; Ng, Chong Jin; Yap, Philip
Background/Aims The acute hospital ward can be unfamiliar and stressful for older patients with impaired cognition, rendering them prone to agitation and resistive to care. Extant literature shows that music therapy can enhance engagement and mood, thereby ameliorating agitated behaviours. This pilot study evaluates the impact of a creative music therapy (CMT) programme on mood and engagement in older patients with delirium and/or dementia (PtDD) in an acute care setting. We hypothesize that CMT improves engagement and pleasure in these patients. Methods Twenty-five PtDD (age 86.5 ± 5.7 years, MMSE 6/30 ± 5.4) were observed for 90 min (30 min before, 30 min during, and 30 min after music therapy) on 3 consecutive days: day 1 (control condition without music) and days 2 and 3 (with CMT). Music interventions included music improvisation such as spontaneous music making and playing familiar songs of patient's choice. The main outcome measures were mood and engagement assessed with the Menorah Park Engagement Scale (MPES) and Observed Emotion Rating Scale (OERS). Results Wilcoxon signed-rank test showed a statistically significant positive change in constructive and passive engagement (Z = 3.383, p = 0.01) in MPES and pleasure and general alertness (Z = 3.188,p = 0.01) in OERS during CMT. The average pleasure ratings of days 2 and 3 were higher than those of day 1 (Z = 2.466, p = 0.014). Negative engagement (Z = 2.582, p = 0.01) and affect (Z = 2.004, p = 0.045) were both lower during CMT compared to no music. Conclusion These results suggest that CMT holds much promise to improve mood and engagement of PtDD in an acute hospital setting. CMT can also be scheduled into the patients' daily routines or incorporated into other areas of care to increase patient compliance and cooperation. PMID:27489560
Chin Yee Cheong
Full Text Available Background/Aims: The acute hospital ward can be unfamiliar and stressful for older patients with impaired cognition, rendering them prone to agitation and resistive to care. Extant literature shows that music therapy can enhance engagement and mood, thereby ameliorating agitated behaviours. This pilot study evaluates the impact of a creative music therapy (CMT programme on mood and engagement in older patients with delirium and/or dementia (PtDD in an acute care setting. We hypothesize that CMT improves engagement and pleasure in these patients. Methods: Twenty-five PtDD (age 86.5 ± 5.7 years, MMSE 6/30 ± 5.4 were observed for 90 min (30 min before, 30 min during, and 30 min after music therapy on 3 consecutive days: day 1 (control condition without music and days 2 and 3 (with CMT. Music interventions included music improvisation such as spontaneous music making and playing familiar songs of patient's choice. The main outcome measures were mood and engagement assessed with the Menorah Park Engagement Scale (MPES and Observed Emotion Rating Scale (OERS. Results: Wilcoxon signed-rank test showed a statistically significant positive change in constructive and passive engagement (Z = 3.383, p = 0.01 in MPES and pleasure and general alertness (Z = 3.188,p = 0.01 in OERS during CMT. The average pleasure ratings of days 2 and 3 were higher than those of day 1 (Z = 2.466, p = 0.014. Negative engagement (Z = 2.582, p = 0.01 and affect (Z = 2.004, p = 0.045 were both lower during CMT compared to no music. Conclusion: These results suggest that CMT holds much promise to improve mood and engagement of PtDD in an acute hospital setting. CMT can also be scheduled into the patients' daily routines or incorporated into other areas of care to increase patient compliance and cooperation.
Full Text Available Integrating reproductive health (RH with HIV care is a policy priority in high HIV prevalence settings, despite doubts surrounding its feasibility and varying evidence of effects on health outcomes. The process and outcomes of integrated RH-HIV care were investigated in Swaziland, through a comparative case study of four service models, ranging from fully integrated to fully stand-alone HIV services, selected purposively within one town. A client exit survey (n=602 measured integrated care received and unmet family planning (FP needs. Descriptive statistics were used to assess the degree of integration per clinic and client demand for services. Logistic regression modelling was used to test the hypothesis that clients at more integrated sites had lower unmet FP needs than clients in a stand-alone site. Qualitative methods included in-depth interviews with clients and providers to explore contextual factors influencing the feasibility of integrated RH-HIV care delivery; data were analysed thematically, combining deductive and inductive approaches. Results demonstrated that clinic models were not as integrated in practice as had been claimed. Fragmentation of HIV care was common. Services accessed per provider were no higher at the more integrated clinics compared to stand-alone models (p>0.05, despite reported demand. While women at more integrated sites received more FP and pregnancy counselling than stand-alone models, they received condoms (a method of choice less often, and there was no statistical evidence of difference in unmet FP needs by model of care. Multiple contextual factors influenced integration practices, including provider de-skilling within sub-specialist roles; norms of task-oriented routinised HIV care; perceptions of heavy client loads; imbalanced client-provider interactions hindering articulation of RH needs; and provider motivation challenges. Thus, despite institutional support, factors related to the social context of
Weigl, Bernhard H; Neogi, Tina; McGuire, Helen
The emergence of point-of-care (POC) diagnostics specifically designed for low-resource settings coupled with the rapid increase in need for routine care of patients with chronic diseases should prompt reconsideration of how health care can be delivered most beneficially and cost-effectively in developing countries. Bolstering support for primary care to provide rapid and appropriate integrated acute and chronic care treatment may be a possible solution. POC diagnostics can empower local and primary care providers and enable them to make better clinical decisions. This article explores the opportunity for POC diagnostics to strengthen primary care and chronic disease diagnosis and management in a low-resource setting (LRS) to deliver appropriate, consistent, and integrated care. We analyze the requirements of resource-appropriate chronic disease care, the characteristics of POC diagnostics in LRS versus the developed world, the many roles of diagnostics in the care continuum in LRS, and the process and economics of developing LRS-compatible POC diagnostics.
Houweling, Sebastiaan T.; Kleefstra, Nanne; van Hateren, Kornelis J. J.; Groenier, Klaas H.; Meyboom-de Jong, Betty; Bilo, Henk J. G.
Aims and objectives. To determine whether the management of type 2 diabetes mellitus in a primary care setting can be safely transferred to practice nurses. Background. Because of the increasing prevalence of type 2 diabetes mellitus and the burden of caring for individual patients, the demand type
China ratified the UNESCO Convention Concerning the Protection of World Cultural and Natural Heritage in 1985. This set the tone for a course of action aimed at protecting the common heritage of mankind in tandem with the international community. Recently, Chao Huashan, a renowned expert on world heritage studies in China, spoke to Beijing Review reporter Zan Jifang, sharing his understanding about the value of the World Heritage Convention and his suggestions for China’s future work on preserving its heritage. Excerpts follow:
Glaze, L. S.; Beauchamp, P. M.; Chin, G.; Crisp, D.; Grimm, R. E.; Herrick, R. R.; Johnston, S.; Limaye, S. S.; Smrekar, S. E.; Ocampo, A.; Thompson, T. W.
Venus remains one of the most enigmatic bodies in our Solar System. Important questions remain regarding the origin and evolution of the atmosphere, the history of the surface and interior, and how the surface and atmosphere interact. In a broader context, understanding Venus has implications for understanding the evolution of terrestrial planets in our Solar System as well as for interpreting the growing set of observations of extra-solar planets. The Venus Exploration Analysis Group (VEXAG), established in 2005, is chartered by NASA's Planetary Science Division and reports its findings to the NASA Advisory Council. Open to all interested scientists, VEXAG regularly evaluates Venus exploration goals, scientific objectives, investigations and critical measurement requirements, including especially recommendations in the NRC Decadal Survey and the Solar System Exploration Strategic Roadmap. At the last general meeting in November 2012, VEXAG resolved to update the scientific priorities and strategies for Venus exploration. To achieve this goal, three major tasks were defined for 2013, (1) update the document prioritizing Goals, Objectives and Investigations for Venus Exploration, (2) develop a Roadmap for Venus exploration that is consistent with VEXAG priorities as well as Planetary Decadal Survey priorities, and (3) develop a white paper on technologies for Venus missions. Proposed versions of all three documents were presented at the VEXAG general meeting in November 2013. Here, we present the findings and final versions of all three documents for community comment and feedback. A follow-on Workshop on Venus Exploration Targets is also being planned for the early summer of 2014. The workshop will provide a forum for the Venus science community to discuss approaches for addressing high priority investigations. Participants will be encouraged to present their ideas for specific targets on Venus (interior, surface and atmosphere) as well as to present specific data
research on child care environmental health issues, identify key state and regional healthy child care organizations for partnerships, and see how other states are addressing child care environmental health issues.
Ubesie, Ac; Ibeziakor, Ns
There is still a high burden of protein-energy malnutrition in Nigeria. The severe forms of the disease are usually associated with high level of mortality even in the tertiary health facilities. To review the cost-effective health promotional strategies at community levels that could aid prevention, early detection, and prompt treatment of protein-energy malnutrition. The strategy used for locating articles used for this review was to search databases like Google, Google scholar, relevant electronic journals from the universities' libraries, including PubMed and Scirus, Medline, Cochrane library and WHO's Hinari. We believe that strategies beyond the health care setting have potential of significantly reducing the morbidity and mortality associated with protein-energy malnutrition in Nigeria.
Andersen, Christen Bertel L; Lindegaard, Hanne Merete; Vestergaard, Hanne;
lymphoproliferative malignancies or solid cancers. These risk estimates did not change when eosinophilia, CRP, and comorbidities were included in the models. CONCLUSIONS: In this large cohort of patients with RA of short or long duration recruited from a primary care resource, RA was not associated with an increased...... risk of lymphoproliferative or solid cancers during 4 years of follow-up, when the models were adjusted for confounders. Blood eosinophilia could not be identified as a mediator of cancer development in the present setting.......BACKGROUND: Several studies have demonstrated an association between rheumatoid arthritis (RA) and lymphoproliferative malignancies, but pathogenic mechanisms remain unclear. We investigated 1) the risk of lymphoproliferative malignancies and solid tumors in adults with RA identified in primary...
Full Text Available This article reviews some of the prevailing health needs of elderly people living permanently in a residential old age home. A qualitative, exploratory and descriptive design was employed. Twenty-one black elderly people were purposively selected to participate in a focus group interview session for the purpose of describing their perception of their health care needs. From descriptive content analysis, three main data sets emerged, namely physical health needs, unmet psychological needs and the need for a healthy social relationship. Recommendations to deal with these health needs were made based on the empirical data supported by literature. Measures of trustworthiness were ensured as described by Lincoln and Guba (1985:316-327.
Albina, Julie K
Incidents of verbal and physical patient abuse in health care settings continue to occur, with some making headline news. Nurses have a professional and ethical responsibility to advocate for their patients when incidents of abuse occur. Tolerating or ignoring inappropriate behaviors occurs for multiple reasons, including ignorance, fear of retaliation, the need for peer acceptance, and concerns for personal advancement. Nurses need to reflect on their biases before they can truly respect patients' autonomy. Through the examination of reported cases of patient abuse, the need for a change in hospital culture becomes evident. The primary steps in eliminating patient abuse are opening communication, providing education, establishing competency, eliminating tolerance of unacceptable behavior, and creating a code of mutual respect. A change in culture to one of mutual respect and dignity for staff members and patients will lead to the best outcomes for all involved.
Roberts, G W; Paden, L
The recent enhanced status of many minority languages across the European Community has led to increasing demands for their use within the public sector. This is particularly evident in health care, where, in circumstances of stress and vulnerability, denying opportunities for clients to communicate in their preferred language may place them at a personal disadvantage and compromise their health chances. In view of the exclusion of many minority languages from the public domain over the years, their re-introduction demands adaptations to health care education programmes in order to promote language sensitivity in practice. Before embarking on developments which establish such languages within the professional sphere, valuable insight may be gained by examining their current use in practice education. Furthermore, comparing their use across language communities enables the sharing of common experiences and furthers opportunities for developing networks across Europe. This paper describes an ethnographic study of the use, within midwifery education, of the Welsh language in north Wales, the Catalan language in Barcelona and the Irish language in Western Ireland. Semi-structured interviews were conducted with key lecturers, clinical mentors and students across the three communities in order to determine patterns of language use within a range of learning environments. Focus groups were also held in order to confirm the findings. The data reveal many commonalities in terms of language use across the three settings and important factors are identified which support the use of minority languages in practice education. The findings are invaluable for guiding future bilingual initiatives across health care education programmes.
Full Text Available Aachal Kotecha,1,2 Alex Baldwin,1 John Brookes,1 Paul J Foster1,2 1Glaucoma Service, Moorfields Eye Hospital National Health Service Foundation Trust, 2NIHR BRC, Moorfields Eye Hospital, NHS Foundation Trust and UCL Institute of Ophthalmology, University College London, London, UK Background: This article describes the development of a virtual glaucoma clinic, whereby technicians collect information for remote review by a consultant specialist.Design and Methods: This was a hospital-based service evaluation study. Patients suitable for the stable monitoring service (SMS were low-risk patients with “suspect”, “early”-to-“moderate” glaucoma who were deemed stable by their consultant care team. Three technicians and one health care assistant ran the service. Patients underwent tests in a streamlined manner in a dedicated clinical facility, with virtual review of data by a consultant specialist through an electronic patient record.Main outcome measure: Feasibility of developing a novel service within a UK National Health Service setting and improvement of patient journey time within the service were studied.Results: Challenges to implementation of virtual clinic include staffing issues and use of information technology. Patient journey time within the SMS averaged 51 minutes, compared with 92 minutes in the glaucoma outpatient department. Patient satisfaction with the new service was high.Conclusion: Implementing innovation into existing services of the National Health Service is challenging. However, the virtual clinic showed an improved patient journey time compared with that experienced within the general glaucoma outpatient department. There exists a discrepancy between patient management decisions of reviewers, suggesting that some may be more risk averse than others when managing patients seen within this model. Future work will assess the ability to detect progression of disease in this model compared with the general
Staci M. Williams, PharmD
Full Text Available Objective: To assess the feasibility of a workflow process in which pharmacists in an independent community pharmacy group conduct medication reconciliation for patients undergoing transitions in care.Methods: Three workflow changes were made to improve the medication reconciliation process in a group of three independent community pharmacies. Analysis of the process included workflow steps performed by pharmacy staff, pharmacist barriers encountered during the medication reconciliation process, number of medication discrepancies identified, and pharmacist comfort level while performing each medication reconciliation service.Key Findings: Sixty patient medication reconciliation services met the inclusion criteria for the study. Pharmacists were involved in all steps associated with the medication reconciliation workflow, and were the sole performer in four of the steps: verifying discharge medications with the pharmacy medication profile, resolving discrepancies, contacting the prescriber, and providing patient counseling. Pharmacists were least involved in entering medications into the pharmacy management system, performing that workflow step 13% of the time. The most common barriers were the absence of a discharge medication list (24% and patient not present during consultation (11%. A total of 231 medication discrepancies were identified, with an average of 3.85 medication discrepancies per discharge. Pharmacists’ comfort level performing medication reconciliation improved through the 13 weeks of the study.Conclusions: These findings suggest that medication reconciliation for patients discharged from hospitals and long term care facilities can be successfully performed in an independent community pharmacy setting. Because many medication discrepancies were identified during this transition of care, it is highly valuable for community pharmacists to perform medication reconciliation services.
Rabia, K; Khoo, E M
The aims of the study were to determine the prevalence of peripheral arterial disease (PAD) in diabetic patients and in different ethnic groups at a primary care setting, and to evaluate risk factors associated with PAD in these diabetic patients. A cross sectional study of 200 diabetic patients over 18 years old who attended a primary care clinic at a teaching hospital in Kuala Lumpur, Malaysia was carried out. Face-to-face interviews were conducted using structured questionnaires for demographic characteristics and risk factors evaluation. Blood pressure measurements, assessment of peripheral neuropathy and ankle brachial pressures were performed. PAD was diagnosed by an ankle brachial pressure index (ABPI) of <0.9 on either leg. The overall prevalence of PAD was 16% in this diabetic population. The prevalence of PAD was 5.8% in Malays, 19.4% in Chinese and 19.8% in Indians. The prevalence of peripheral neuropathy was 41%, foot ulcer 9.5%, and gangrene 3.0%. The presence of foot ulcer was weakly associated with PAD (P=0.052). No significant relationships were found between age, gender, smoking status, duration of diabetes mellitus, hypertension, dyslipidaemia, and PAD. PAD is common in the diabetic population of this study.
Yeung, Albert; Slipp, Lauren E; Jacquart, Jolene; Fava, Maurizio; Denninger, John W; Benson, Herbert; Fricchione, Gregory L
Background. This pilot study examined the feasibility and efficacy of providing Qigong treatment in a health center to Chinese Americans with major depressive disorder (MDD). Methods. Fourteen Chinese Americans with MDD were enrolled, and they received a 12-week Qigong intervention. The key outcome measurement was the 17-item Hamilton Rating Scale for Depression (HAM-D17); the Clinical Global Impressions-Severity (CGI-S) and -Improvement (CGI-I), the Quality of Life Enjoyment and Satisfaction Questionnaire, Short Form (Q-LES-Q-SF), and the Multidimensional Scale of Perceived Social Support (MSPSS) were also administered. Positive response was defined as a decrease of 50% or more on the HAM-D17, and remission was defined as HAM-D17 ≤ 7. Patients' outcome measurements were compared before and after the Qigong intervention. Results. Participants (N = 14) were 64% female, with a mean age of 53 (±14). A 71% of participants completed the intervention. The Qigong intervention resulted in a positive treatment-response rate of 60% and a remission rate of 40% and statistically significant improvement, as measured by the HAM-D17, CGI-S, CGI-I, Q-LES-Q-SF, and the family support subscale of the MSPSS. Conclusions. The Qigong intervention provided at a health care setting for the treatment of primary care patients with MDD is feasible. Further studies with larger sample sizes are warranted.
Full Text Available Background. This pilot study examined the feasibility and efficacy of providing Qigong treatment in a health center to Chinese Americans with major depressive disorder (MDD. Methods. Fourteen Chinese Americans with MDD were enrolled, and they received a 12-week Qigong intervention. The key outcome measurement was the 17-item Hamilton Rating Scale for Depression (HAM-D17; the Clinical Global Impressions-Severity (CGI-S and -Improvement (CGI-I, the Quality of Life Enjoyment and Satisfaction Questionnaire, Short Form (Q-LES-Q-SF, and the Multidimensional Scale of Perceived Social Support (MSPSS were also administered. Positive response was defined as a decrease of 50% or more on the HAM-D17, and remission was defined as HAM-D17 ≤ 7. Patients' outcome measurements were compared before and after the Qigong intervention. Results. Participants (N=14 were 64% female, with a mean age of 53 (±14. A 71% of participants completed the intervention. The Qigong intervention resulted in a positive treatment-response rate of 60% and a remission rate of 40% and statistically significant improvement, as measured by the HAM-D17, CGI-S, CGI-I, Q-LES-Q-SF, and the family support subscale of the MSPSS. Conclusions. The Qigong intervention provided at a health care setting for the treatment of primary care patients with MDD is feasible. Further studies with larger sample sizes are warranted.
Full Text Available Purpose. To evaluate the acceptance and effectiveness of acupuncture in a hospital setting. Methods. This 18-month pragmatic randomized controlled trial used a two-tiered consent process for all patients admitted to the acute care unit by study physician groups. The primary study comparison was between those randomized (using biased-coin randomization after initial consent to be offered acupuncture or not. The primary outcome was length of stay (LOS. Other measures include costs, self-reported anxiety, depression, health status, and patient satisfaction. Results. Of the 383 patients consented to the study, 253 were randomized to be offered acupuncture, and 130 were not offered acupuncture. Of those offered acupuncture, 173 (69% accepted and received daily acupuncture. On average, patients offered acupuncture had longer LOSs (4.9 versus 4.1 days than those not offered acupuncture (=.047. Adjustment for diagnosis and severity mix reduced this difference and its significance (=.108. No other significant differences in outcomes were found. Patients who were more anxious (=.000 or depressed (=.017 at admission tended to more often accept acupuncture when offered. Conclusion. Acupuncture is accepted by a majority of hospitalized acute care patients. However, it did not reduce LOS in this already short-stay population.
Full Text Available In the recent years, outbreaks of blood-borne infections have been reported from assisted living facilities, which were traced back to improper blood glucose monitoring practices. Needle-stick injuries have been implicated in many such cases. This directly raises concerns over sharp disposal practices of diabetic patients self-managing their condition in home care settings. With India being home to a huge diabetic population, this issue, if neglected, can cause substantial damage to the health of the population and a marked economic loss. This article discusses the sharp disposal practices prevalent among diabetes patients, the importance of proper sharp disposal, barriers to safe disposal of sharps, and the options available for doing the same. For adopting an environmentally safe wholesome approach, disposal of plastics generated as a result of diabetes self-care at home is important as well. The article also looks at the possible long-term solutions to these issues that are sustainable in an Indian context.
Peterson, K Jean
Shared decision making (SDM) is a process integral to social work practice, one where the provider/professional and the consumer/patient discuss treatment alternatives based on patient values and life circumstances and make a shared decision about whether and how to proceed with treatment. Evidence-based medicine suggests that for many health conditions, having the choice of several effective treatment options is not uncommon. In these cases treatment should be based on what is best for the individual, since many factors influence an individual's treatment preference, including the psychological, social, cultural, and spiritual history she/he brings to the medical encounter; a history that has long been ignored in somatic health care. This article develops the argument that medical social workers possess the professional knowledge and skill base to provide decisional coaching, and implementing SDM in primary care settings. Of particular importance are the values that guide professional social work practice, including client self-determination, which is the basis of SDM, and the ability to maintain neutrality.
Maha Mohamed Ghobashi
Full Text Available Background Patient safety is critical component of health care quality. We aimed to assess the awareness of primary healthcare staff members about patient safety culture and explore the areas of deficiency and opportunities for improvement concerning this issue.Methods: This descriptive cross sectional study surveyed 369 staff members in four primary healthcare centers in Kuwait using self-administered “Hospital Survey on Patient Safety Culture” adopted questionnaire. The total number of respondents was 276 participants (response rate = 74.79%.Results: Five safety dimensions with lowest positivity (less than 50% were identified and these are; the non – punitive response to errors, frequency of event reporting, staffing, communication openness, center handoffs and transitions with the following percentages of positivity 24%, 32%, 41%, 45% and 47% respectively. The dimensions of highest positivity were teamwork within the center’s units (82% and organizational learning (75%.Conclusion: Patient safety culture in primary healthcare settings in Kuwait is not as strong as improvements for the provision of safe health care. Well-designed patient safety initiatives are needed to be integrated with organizational policies, particularly the pressing need to address the bioethical component of medical errors and their disclosure, communication openness and emotional issues related to them and investing the bright areas of skillful organizational learning and strong team working attitudes.
Full Text Available Within the past decade, there has been a surge of interest in investigating the effects of clown intervention in a large variety of clinical settings. Many studies have focused on the effects of clown intervention on children. However, few studies have investigated clowning effects on adults. This paper presents an overview of the concept of medical clowning followed by a literature review conducted on the empirical studies drawn from three data bases (PubMed, PsycINFO, and Google Scholar, with the aim of mapping and discussing the evidence of clowning effects on non-children, namely adults. The following areas were investigated: Adult and elderly patients (mainly those with dementia, observers of clowning, namely non-hospitalized adults who are at the hospital as relatives of patients or health-care staff, and finally clowns themselves. The main results are that 1 clown intervention induces positive emotions, thereby enhancing the patient’s well-being, reduces psychological symptoms and emotional reactivity, and prompts a decrease in negative emotions, such as anxiety and stress; 2 clown doctors are also well-perceived by relatives and healthcare staff and their presence appears to be useful in creating a lighter atmosphere in the health setting; 3 few pilot studies have been conducted on clown doctors and this lacuna represents a subject for future research.
Dionigi, Alberto; Canestrari, Carla
Within the past decade, there has been a surge of interest in investigating the effects of clown intervention in a large variety of clinical settings. Many studies have focused on the effects of clown intervention on children. However, few studies have investigated clowning effects on adults. This paper presents an overview of the concept of medical clowning followed by a literature review conducted on the empirical studies drawn from three data bases (PubMed, PsycINFO, and Google Scholar), with the aim of mapping and discussing the evidence of clowning effects on non-children, namely adults. The following areas were investigated: Adult and elderly patients (mainly those with dementia), observers of clowning, namely non-hospitalized adults who are at the hospital as relatives of patients or health-care staff, and finally clowns themselves. The main results are that 1) clown intervention induces positive emotions, thereby enhancing the patient's well-being, reduces psychological symptoms and emotional reactivity, and prompts a decrease in negative emotions, such as anxiety and stress; 2) clown doctors are also well-perceived by relatives and healthcare staff and their presence appears to be useful in creating a lighter atmosphere in the health setting; 3) few pilot studies have been conducted on clown doctors and this lacuna represents a subject for future research.
Dionigi, Alberto; Canestrari, Carla
Within the past decade, there has been a surge of interest in investigating the effects of clown intervention in a large variety of clinical settings. Many studies have focused on the effects of clown intervention on children. However, few studies have investigated clowning effects on adults. This paper presents an overview of the concept of medical clowning followed by a literature review conducted on the empirical studies drawn from three data bases (PubMed, PsycINFO, and Google Scholar), with the aim of mapping and discussing the evidence of clowning effects on non-children, namely adults. The following areas were investigated: Adult and elderly patients (mainly those with dementia), observers of clowning, namely non-hospitalized adults who are at the hospital as relatives of patients or health-care staff, and finally clowns themselves. The main results are that 1) clown intervention induces positive emotions, thereby enhancing the patient’s well-being, reduces psychological symptoms and emotional reactivity, and prompts a decrease in negative emotions, such as anxiety and stress; 2) clown doctors are also well-perceived by relatives and healthcare staff and their presence appears to be useful in creating a lighter atmosphere in the health setting; 3) few pilot studies have been conducted on clown doctors and this lacuna represents a subject for future research. PMID:27547261
Selim, Heba Sayed
Full Text Available Aim: This study aimed at investigating the microbial contamination of mobile phones in a hospital setting. Methods: Swab samples were collected from 40 mobile phones of patients and health care workers at the Alexandria University Students’ Hospital. They were tested for their bacterial contamination at the microbiology laboratory of the High Institute of Public Health. Quantification of bacteria was performed using both surface spread and pour plate methods. Isolated bacterial agents were identified using standard microbiological methods. Methicillin-resistant was identified by disk diffusion method described by Bauer and Kirby. Isolated Gram-negative bacilli were tested for being extended spectrum beta lactamase producers using the double disk diffusion method according to the Clinical and Laboratory Standards Institute recommendations.Results: All of the tested mobile phones (100% were contaminated with either single or mixed bacterial agents. The most prevalent bacterial contaminants were methicillin-resistant and coagulase-negative staphylococci representing 53% and 50%, respectively. The mean bacterial count was 357 CFU/ml, while the median was 13 CFU/ml using the pour plate method. The corresponding figures were 2,192 and 1,720 organisms/phone using the surface spread method. Conclusions: Mobile phones usage in hospital settings poses a risk of transmission of a variety of bacterial agents including multidrug-resistant pathogens as methicillin-resistant . The surface spread method is an easy and useful tool for detection and estimation of bacterial contamination of mobile phones.
Full Text Available Billy M Tsima,1 Vincent Setlhare,1 Oathokwa Nkomazana2 1Department of Family Medicine and Public Health, 2Department of Surgery, Faculty of Medicine, University of Botswana, Gaborone, Botswana Background: Botswana’s health care system is based on a primary care model. Various national guidelines exist for specific diseases. However, most of the guidelines address management at a tertiary level and often appear nonapplicable for the limited resources in primary care facilities. An integrated symptom-based guideline was developed so as to translate the Botswana national guidelines to those applicable in primary care. The Botswana Primary Care Guideline (BPCG integrates the care of communicable diseases, including HIV/AIDS and noncommunicable diseases, by frontline primary health care workers.Methods: The Department of Family Medicine, Faculty of Medicine, University of Botswana, together with guideline developers from the Knowledge Translation Unit (University of Cape Town collaborated with the Ministry of Health to develop the guideline. Stakeholder groups were set up to review specific content of the guideline to ensure compliance with Botswana government policy and the essential drug list.Results: Participants included clinicians, academics, patient advocacy groups, and policymakers from different disciplines, both private and public. Drug-related issues were identified as necessary for implementing recommendations of the guideline. There was consensus by working groups for updating the essential drug list for primary care and expansion of prescribing rights of trained nurse prescribers in primary care within their scope of practice. An integrated guideline incorporating common symptoms of diseases seen in the Botswana primary care setting was developed.Conclusion: The development of the BPCG took a broad consultative approach with buy in from relevant stakeholders. It is anticipated that implementation of the BPCG will translate into better
This article tells the story of the 4-year consensus-building process to design quality standards for the field of family child care. Working with the National Association for Family Child Care, the Family Child Care Project at Wheelock College was funded to create an accreditation system for home-based child care programs using innovative methods…
Askari, M.; Wierenga, P.C.; Eslami, S.; Medlock, S.; de Rooij, S.E.; Abu-Hanna, A.
Background: Care of the elderly is recognized as an increasingly important segment of health care. The Assessing Care Of Vulnerable Elderly (ACOVE) quality indicators (QIs) were developed to assess and improve the care of elderly patients. Objectives: The purpose of this review is to summarize studi
Flint, S R
This workshop addressed two important issues: first, the global evidence of HIV transmission from health care provider to patient and from patient to health care provider in the general health care environment and the dental practice setting; second, in the era of highly active antiretroviral therapy, whether oral health care professionals living with HIV pose a risk of transmission to their patients and whether standard infection control is adequate to protect both the patient and the oral health care professional in dental practice. The workshop culminated in a general discussion and the formulation of a consensus statement from the participating delegates, representing more than 30 countries, on the criteria under which an HIV-infected oral health care professional might practice dentistry without putting patients at risk. This consensus statement, the Beijing Declaration, was agreed nem con.
Deal, Belinda; Grassley, Jane S
The purpose of this study was to explore the lived experiences of nephrology nurses giving spiritual care in acute and chronic hemodialysis settings. Ten nurses were interviewed. Five themes were identified: a) drawing close, b) drawing from the well of my spiritual resources, c), sensing the pain of spiritual distress, d) lacking resources to give spiritual care, and e) giving spiritual care is like diving down deep. The study findings suggest that patients and nurses draw close during the giving of spiritual care, that nurses have spiritual resources they use to prepare for and give spiritual care, and that giving spiritual care can have an emotional cost. These findings have implications for nursing practice, nursing education, and nursing research.
Definición de prioridades para las intervenciones de salud en el Sistema de Protección Social en Salud de México Priority setting for health interventions in Mexico's System of Social Protection in Health
Full Text Available La definición explícita de prioridades en intervenciones de salud representa una oportunidad para México de equilibrar la presión y la complejidad de una transición epidemiológica avanzada, con políticas basadas en evidencias generadas por la inquietud de cómo optimizar el uso de los recursos escasos para mejorar la salud de la población. La experiencia mexicana en la definición de prioridades describe cómo los enfoques analíticos estandarizados en la toma de decisiones, principalmente los de análisis de la carga de la enfermedad y de costo-efectividad, se combinan con otros criterios -tales como dar respuesta a las expectativas legítimas no médicas de los pacientes y asegurar un financiamiento justo para los hogares-, para diseñar e implementar un grupo de tres paquetes diferenciados de intervenciones de salud. Éste es un proceso clave dentro de un conjunto más amplio de elementos de reforma dirigidos a extender el aseguramiento en salud, especialmente a los pobres. Las implicaciones más relevantes en el ámbito de políticas públicas incluyen lecciones sobre el uso de las herramientas analíticas disponibles y probadas para definir prioridades nacionales de salud; la utilidad de resultados que definan prioridades para guiar el desarrollo de capacidades a largo plazo; la importancia de favorecer un enfoque para institucionalizar el análisis ex-ante de costo-efectividad; y la necesidad del fortalecimiento de la capacidad técnica local como un elemento esencial para equilibrar los argumentos sobre maximización de la salud con criterios no relacionados con la salud en el marco de un ejercicio sistemático y transparente.Explicit priority setting presents Mexico with the opportunity to match the pressure and complexity of an advancing epidemiological transition with evidence-based policies driven by a fundamental concern for how to make the best use of scarce resources to improve population health. The Mexican priority-setting
Mohd Suki, Norazah; Chwee Lian, Jennifer Chiam; Suki, Norbayah Mohd
In today's highly competitive health care environment, many private health care settings are now looking into customer service indicators to learn customers' perceptions and determine whether they are meeting customers' expectations in order to ensure that their customers are satisfied with the services. This research paper aims to investigate whether the human elements were more important than the nonhuman elements in private health care settings. We used the internationally renowned SERVQUAL five-dimension model plus three additional dimensions-courtesy, communication, and understanding of customers of the human element-when evaluating health care services. A total of 191 respondents from three private health care settings in the Klang Valley region of Malaysia were investigated. Descriptive statistics were calculated by the Statistical Package for Social Sciences (SPSS) computer program, version 15. Interestingly, the results suggested that customers nowadays have very high expectations especially when it comes to the treatment they are receiving. Overall, the research indicated that the human elements were more important than the nonhuman element in private health care settings. Hospital management should look further to improve on areas that have been highlighted. Implications for management practice and directions for future research are discussed.
Rabold, S; Görgen, T
Although some anecdotal evidence for the phenomenon of abuse and neglect of community-dwelling older care recipients by in-home care services exists, there is an almost complete lack of data on this topic. In order to determine extent and risk factors of abuse and neglect of older care recipients by nurses, we conducted a self-report study among in-home care workers in the German city of Hanover. A total of 503 nurses took part in the study; the response rate was 43.3%. Nearly 40% of all respondents reported having abused or neglected at least one patient within the last 12 months. Psychological abuse/verbal aggression and neglect were most common. Serious problem behavior could be predicted by patients' aggressive behavior, the number of clients suffering from dementia, subjects' use of alcohol as a means of alleviating work-related stress, and nurses' general judgments of quality of care delivered by the respective in-home service. The results of this study show that the problem of abuse and neglect of care recipients is not limited to nursing homes and care by family members. Findings point at opportunities for prevention and accentuate the need for further research in this field.
Bultas, Margaret W; McMillin, Stephen Edward; Zand, Debra H
The purpose of this survey-design research study was to evaluate the usefulness of a researcher-developed tool designed to improve office-based health care services and to assess the barriers and resources affecting office-based health care services for children with autism spectrum disorder. Fifty-four health care providers (HCPs) and 59 parents participated in the study. HCPs reported child behaviors, communication, and fears as barriers to providing care, whereas parents reported child behavior, sensory issues, and feelings of a disconnect with the HCP as barriers. HCPs identified the parent as a key resource. Parent-identified resources included provider adaptations to the patient, including slowing down the delivery of care and environmental adaptations to the office. In addition, both HCPs and parents indicated that the researcher-developed tool would be useful in reducing barriers during the HCE. Reducing barriers and improving health care interactions during delivery of care for children with autism spectrum disorder has the potential to improve health outcomes.
Abolfotouh Mostafa A
Full Text Available Abstract Background Medication errors (MEs are among the most common types of medical errors and one of the most common and preventable causes of iatrogenic injuries. The aims of the present study were; (i to determine the incidence and types of medication prescribing errors (MPEs, and (ii to identify some potential risk factors in a pediatric inpatient tertiary care setting in Saudi Arabia. Findings A five-week retrospective cohort study identified medication errors in the general pediatric ward and pediatric intensive care unit (PICU at King Abdulaziz Medical City (KAMC through the physical inspection of physician medication orders and reviews of patients' files. Out of the 2,380 orders examined, the overall error rate was 56 per 100 medication orders (95% CI: 54.2%, 57.8%. Dose errors were the most prevalent (22.1%. These were followed by route errors (12.0%, errors in clarity (11.4% and frequency errors (5.4%. Other types of errors were incompatibility (1.9%, incorrect drug selection (1.7% and duplicate therapy (1%. The majority of orders (81.8% had one or more abbreviations. Error rates were highest in prescriptions for electrolytes (17.17%, antibiotics (13.72% and bronchodilators (12.97%. Medication prescription errors occurred more frequently in males (64.5%, infants (44.5% and for medications with an intravenous route of administration (50.2%. Approximately one third of the errors occurred in the PICU (33.9%. Conclusions The incidence of MPEs was significantly high. Large-scale prospective studies are recommended to determine the extent and outcome of medication errors in pediatric hospitals in Saudi Arabia.
Full Text Available Professional nurses working in rural, primary health-care settings are experiencing burnout due to serious shortages of personnel. This is exacerbated by the brain drain of nurses leaving the country. Rural settings are resource constrained in terms of personnel and equipment. This results in dissatisfaction among nurses due to the unbearable working conditions which result in stress and frustration. A qualitative, explorative, descriptive study was conducted to explore and describe the experiences of nurses working in a rural primary health-care setting in the greater Letaba sub district in Limpopo Province. Purposive sampling was used to identify the participants. Data was collected in the form of in-depth interviews. The study revealed that nurses working in primary health-care settings were experiencing emotional and physical strain as a result of the shortage of human resources. It was recommended that policies that meet the health-care needs of rural communities be developed, and that strategies to retain professional nurses in primary health-care settings be formulated.
Cochran, Maggie F; Berkowitz, Aaron L
The Global Health Delivery (GHD) framework (Farmer, Kim, and Porter, Lancet 2013;382:1060-69) allows for the analysis of health care delivery systems along four axes: a care delivery value chain that incorporates prevention, diagnosis, and treatment of a medical condition; shared delivery infrastructure that integrates care within existing healthcare delivery systems; alignment of care delivery with local context; and generation of economic growth and social development through the health care delivery system. Here, we apply the GHD framework to epilepsy care in rural regions of low- and middle-income countries (LMIC) where there are few or no neurologists.
Patient-centered care and self-management of chronic disease are optimally characterized by distinct adjunct services such as education, and support for the behavioral and psychosocial elements of managing disease. The collaborative care model for the treatment of depression and anxiety in primary care includes the integration of a behavioral health specialist, in collaboration with the primary care provider, and psychiatric consultation to effectively screen and treat common mental health problems. Dissemination and sustainability of the model have encountered numerous barriers across systems of care. This article represents a discussion of the key barriers to collaborative care and offers a discussion of opportunities for dissemination and sustainability of the model.
Prioridades de investigación en servicios sanitarios en el Sistema Nacional de Salud: Una aproximación por consenso de expertos Setting health services research priorities in the public health system: An approach through expert consensus
Technique features. Health Services Research Priorities were identified and scored (7 to 9, high relevance; 4 to 6 mild relevance and 1 to 3, low or no relevance. Results were sorted regarding the median score and its dispersion. Results: 53 research issues were identified. Strategies to improve effectiveness in health care, information to patients, health care quality and safety, equity, access and sustainability were considered of high priority and high consensus; just 4 items had remarkable dispersion (Intercuartile interval (ICI ≥ 2. Organizational improvement, productivity and efficiency enhancement, workforce and equipments were classified of mild priority. Additionally, this group of items reached very low consensus: 59% of them reached ICI ≥ 2. Conclusions: Our approach offers reference about priorities to Spanish health services researchers, and also, orientation to financers and users of this kind of research, though several limitations have been described.
patient satisfaction , nurse -sensitive indicators of quality care as measured by...Project Number: N10-C04 Aim one Evaluate levels of nursing and patient satisfaction in ambulatory care clinics following implementation of a...Clarke, S.P., Sloane, D., Lake, E.T., Cheney, T. (2008). Effects of hospital care environment on patient mortality and nurse outcomes. Journal of Nursing
Fraisse, Alain; Le Bel, Stéphane; Mas, Bertrand; Macrae, Duncan
Over recent decades, specialized paediatric cardiac intensive care has emerged as a central component in the management of critically ill, neonatal, paediatric and adult patients with congenital and acquired heart disease. The majority of high-volume centres (dealing with over 300 surgical cases per year) have dedicated paediatric cardiac intensive care units, with the smallest programmes more likely to care for paediatric cardiac patients in mixed paediatric or adult intensive care units. Specialized nursing staff are also a crucial presence at the patient's bedside for quality of care. A paediatric cardiac intensive care programme should have patients (preoperative and postoperative) grouped together geographically, and should provide proximity to the operating theatre, catheterization laboratory and radiology department, as well as to the regular ward. Age-appropriate medical equipment must be provided. An optimal strategy for running a paediatric cardiac intensive care programme should include: multidisciplinary collaboration and involvement with paediatric cardiology, anaesthesia, cardiac surgery and many other subspecialties; a risk-stratification strategy for quantifying perioperative risk; a personalized patient approach; and anticipatory care. Finally, progressive withdrawal from heavy paediatric cardiac intensive care management should be institutionalized. Although the countries of the European Union do not share any common legislation on the structure and organization of paediatric intensive care or paediatric cardiac intensive care, any paediatric cardiac surgery programme in France that is agreed by the French Health Ministry must perform at least '150 major procedures per year in children' and must provide a 'specialized paediatric intensive care unit'.
Full Text Available We ascertained the prevalence of resistant hypertension (RH among blacks and determined whether RH patients are at greater risk for obstructive sleep apnea (OSA than hypertensives. Method. Data emanated from Metabolic Syndrome Outcome Study (MetSO, a study investigating metabolic syndrome among blacks in the primary-care setting. Sample of 200 patients (mean age = 63 ± 13 years; female = 61% with a diagnosis of hypertension provided subjective and clinical data. RH was defined using the JNC 7and European Society guidelines. We assessed OSA risk using the Apnea Risk Evaluation System ARES, defining high risk as a total ARES score ≥6. Results. Overall, 26% met criteria for RH and 40% were at high OSA risk. Logistic regression analysis, adjusting for effects of age, gender, and medical co morbidities, showed that patients with RH were nearly 2.5 times more likely to be at high OSA risk, relative to those with hypertension (OR = 2.46, 95% CI: 1.03–5.88, P<.05. Conclusion. Our findings show that the prevalence of RH among blacks fell within the range of RH for the general hypertensive population (3–29%. However, patients with RH were at significantly greater risk of OSA compared to patients with hypertension.
Kumar, Mahadeo Santosh; Gurrib, Mahomed Aniff
This article discusses the Priority Education Zones project (ZEP) in Mauritius. The original and innovative dimensions of the project are described, together with the difficulties encountered during the setting-up of the ZEP schools. The article covers five main issues: the status of the ZEP project; the minimal conditions for success; the…
John P Hirdes
Full Text Available BACKGROUND: Persons with certain neurological conditions have higher mortality rates than the population without neurological conditions, but the risk factors for increased mortality within diagnostic groups are less well understood. The interRAI CHESS scale has been shown to be a strong predictor of mortality in the overall population of persons receiving health care in community and institutional settings. This study examines the performance of CHESS as a predictor of mortality among persons with 11 different neurological conditions. METHODS: Survival analyses were done with interRAI assessments linked to mortality data among persons in home care (n = 359,940, complex continuing care hospitals/units (n = 88,721, and nursing homes (n = 185,309 in seven Canadian provinces/territories. RESULTS: CHESS was a significant predictor of mortality in all 3 care settings for the 11 neurological diagnostic groups considered after adjusting for age and sex. The distribution of CHESS scores varied between diagnostic groups and within diagnostic groups in different care settings. CONCLUSIONS: CHESS is a valid predictor of mortality in neurological populations in community and institutional care. It may prove useful for several clinical, administrative, policy-development, evaluation and research purposes. Because it is routinely gathered as part of normal clinical practice in jurisdictions (like Canada that have implemented interRAI assessment instruments, CHESS can be derived without additional need for data collection.
Bernard, Kristin; Peloso, Elizabeth; Laurenceau, Jean-Philippe; Zhang, Zhiyong; Dozier, Mary
The transition to out-of-home child care brings a number of challenges for children, including complex peer interactions and extended separations from parents. Children often show a midmorning to afternoon rise in cortisol on child-care days, compared to the typical diurnal decline seen at home. Changes in cortisol were examined in a wide age range of children (N = 168; 1.2 months to 8 years, M = 3.27 years) during the 10-week transition to a new child-care setting. Structural equation modeling using latent change scores showed that children experienced an increase in the cortisol rise at child care across the 10-week transition. Furthermore, child age moderated the difference between home- and child-care cortisol patterns. Findings are placed in a developmental context, and potential implications and future directions are discussed.
Piper, Llewellyn E
The growing number of medical errors and resulting preventable deaths in hospitals presents an ethical dilemma that must be addressed by health care leaders and managers. These medical errors and deaths raise questions about safety and quality issues resulting in rising public mistrust and patient dissatisfaction. Many of these medical errors and deaths could have been avoided by including the patient and family in the care. The ethical challenge for leadership is creating a culture of patient- and family-centered care as a means to improve quality, safety, patient satisfaction, and public trust. This article addresses ways to improve safety, quality, patient satisfaction, and cost and thereby reduce medical errors and deaths by implementing a patient- and family-centered care culture. The first critical step for improvement is for hospital leaders and managers to answer the ethical call to create a culture centered on patient- and family-centered care in the hospital setting.
Ortiz, Justin R; Jacob, Shevin T; West, T Eoin
The 2009 influenza A (H1N1) pandemic highlighted the importance of quality hospital care of the severely ill, yet there is evidence that the impact of the 2009 pandemic was highest in low- and middle-income countries with fewer resources. Recent data indicate that death and suffering from seasonal influenza and severe illness in general are increased in resource-limited settings. However, there are limited clinical data and guidelines for the management of influenza and other severe illness in these settings. Life-saving supportive care through syndromic case management is used successfully in high-resource intensive care units and in global programs such as the Integrated Management of Childhood Illness (IMCI). While there are a variety of challenges to the management of the severely ill in resource-limited settings, several new international initiatives have begun to develop syndromic management strategies for these environments, including the World Health Organization's Integrated Management of Adult and Adolescent Illness Program. These standardized clinical guidelines emphasize syndromic case management and do not require high-resource intensive care units. These efforts must be enhanced by quality clinical research to provide missing evidence and to refine recommendations, which must be carefully integrated into existing healthcare systems. Realizing a sustainable, global impact on death and suffering due to severe influenza and other severe illness necessitates an ongoing and concerted international effort to iteratively generate, implement, and evaluate best-practice management guidelines for use in resource-limited settings.
Peisah, C; Lawrence, G; Reutens, S
Behavioral and psychological symptoms of dementia (BPSD) are common, distressing and compromise care. Their diverse etiology necessitates targeted, individualized treatment. We present a case of an 82-year-old with severe dementia and BPSD, and with limited response to a range of pharmacological and non-pharmacological treatments. Individualized art therapy was developed in an inpatient setting using felt material cut into shapes and coloring with stencils and pre-drawn line drawings utilizing preserved skills of coloring, while supporting frontal-executive and language deficits. The activity was replicable and carried over to the residential care setting and supported by family and professional carers.
Larzelere, Michele McCarthy
The practice of family medicine includes the care of many patients with mental health or behavior change needs. Patients in mild to moderate distress may benefit from brief interventions performed in the family physician's office. Patients in more extreme distress may be helped by referral to behavioral health clinicians for short-term or open-ended therapies. Electronic therapy programs and bibliotherapy are also useful resources. The transition to the patient-centered medical home model may allow for more widespread integration of behavioral health care clinicians into primary care, in person and through telemental health care. Integrated care holds the promise of improved access, greater effectiveness of behavioral health service provision, and enhanced efficiency of primary care for patients with behavioral health care needs.
Kemeny, M Elizabeth; Mabry, J Beth
Well-intentioned policy governing the training of direct care workers (DCWs) who serve older persons, in practice, may become merely a compliance issue for organizations rather than a meaningful way to improve quality of care. This study investigates the relationships between best practices in DCW training and the structure and culture of long term support service (LTSS) organizations. Using a mixed-methods approach to analyzing data from 328 licensed LTSS organizations in Pennsylvania, the findings suggest that public policy should address methods of training, not just content, and consider organizational variations in size, training evaluation practices, DCW integration, and DCW input into care planning. Effective training also incorporates support for organizations and supervisors as key aspects of DCWs' learning and working environment.
Eisenthal, Sherman; And Others
A survey of 63 general medical residents found most accepted the psychosocial role of the primary care physician, found it most appropriate in ambulatory care settings, felt ambivalent about their ability to perform it, and assigned it secondary priority in patient care. More attention by training programs to ambulatory care and psychosocial…
Mansfield Richard J
Full Text Available Abstract Background Although shoulder pain is a commonly encountered problem in primary care, there are few studies examining its presenting characteristics and clinical management in this setting. Methods We performed secondary data analysis of 692 office visits for shoulder pain collected through the National Ambulatory Medical Care Survey (Survey years 1993–2000. Information on demographic characteristics, history and place of injury, and clinical management (physician order of imaging, physiotherapy, and steroid intraarticular injection were examined. Results Shoulder pain was associated with an injury in one third (33.2% (230/692 of office visits in this population of US primary care physicians. Males, and younger adults (age ≤ 52 more often associated their shoulder pain with previous injury, but there were no racial differences in injury status. Injury-related shoulder pain was related to work in over one-fifth (21.3% (43/202 of visits. An x-ray was performed in 29.0% (164/566 of office visits, a finding that did not differ by gender, race, or by age status. Other imaging (CT scan, MRI, or ultrasound was infrequently performed (6.5%, 37/566. Physiotherapy was ordered in 23.9% (135/566 of visits for shoulder pain. Younger adults and patients with a history of injury more often had physiotherapy ordered, but there was no significant difference in the ordering of physiotherapy by gender or race. Examination of the use of intraarticular injection was not possible with this data set. Conclusion These data from the largest sample of patients with shoulder pain presenting to primary care settings offer insights into the presenting characteristics and clinical management of shoulder pain at the primary care level. The National Ambulatory Medical Care Survey is a useful resource for examining the clinical management of specific symptoms in U.S. primary care offices.
Kululanga Lucy I
Full Text Available Abstract Background Understanding the strategies that health care providers employ in order to invite men to participate in maternal health care is very vital especially in today's dynamic cultural environment. Effective utilization of such strategies is dependent on uncovering the salient issues that facilitate male participation in maternal health care. This paper examines and describes the strategies that were used by different health care facilities to invite husbands to participate in maternal health care in rural and urban settings of southern Malawi. Methods The data was collected through in-depth interviews from sixteen of the twenty health care providers from five different health facilities in rural and urban settings of Malawi. The health facilities comprised two health centres, one district hospital, one mission hospital, one private hospital and one central hospital. A semi-structured interview guide was used to collect data from health care providers with the aim of understanding strategies they used to invite men to participate in maternal health care. Results Four main strategies were used to invite men to participate in maternal health care. The strategies were; health care provider initiative, partner notification, couple initiative and community mobilization. The health care provider initiative and partner notification were at health facility level, while the couple initiative was at family level and community mobilization was at village (community level. The community mobilization had three sub-themes namely; male peer initiative, use of incentives and community sensitization. The sustainability of each strategy to significantly influence behaviour change for male participation in maternal health care is discussed. Conclusion Strategies to invite men to participate in maternal health care were at health facility, family and community levels. The couple strategy was most appropriate but was mostly used by educated and city
Nutting, Paul A; Crabtree, Benjamin F; McDaniel, Reuben R
Transforming small independent practices to patient-centered medical homes is widely believed to be a critical step in reforming the US health care system. Our team has conducted research on improving primary care practices for more than fifteen years. We have found four characteristics of small primary care practices that seriously inhibit their ability to make the transformation to this new care model. We found that small practices were extremely physician-centric, lacked meaningful communication among physicians, were dominated by authoritarian leadership behavior, and were underserved by midlevel clinicians who had been cast into unimaginative roles. Our analysis suggests that in addition to payment reform, a shift in the mind-set of primary care physicians is needed. Unless primary care physicians can adopt new mental models and think in new ways about themselves and their practices, it will be very difficult for them and their practices to create innovative care teams, become learning organizations, and act as good citizens within the health care neighborhood.
Cucalón José M
Full Text Available Abstract Background Ischaemic heart disease is a global priority of health-care policy, because of its social repercussions and its impact on the health-care system. Yet there is little information on coronary morbidity in Spain and on the effect of the principal risk factors on risk of coronary heart disease. The objective of this study is to describe the epidemiology of coronary disease (incidence, mortality and its association with cardiovascular risk factors using the information gathered by primary care practitioners on cardiovascular health of their population. Methods A prospective study was designed. Eight primary-care centres participated, each contributing to the constitution of the cohort with the entire population covered by the centre. A total of 6124 men and women aged over 25 years and free of cardiovascular disease agreed to participate and were thus enrolled and followed-up, with all fatal and non-fatal coronary disease episodes being registered during a 5-year period. Repeated measurements were collected on smoking, blood pressure, weight and height, serum total cholesterol, high-density and low-density lipoproteins and fasting glucose. Rates were calculated for acute myocardial infarction and ischaemic heart disease. Associations between cardiovascular risk factors and coronary disease-free survival were evaluated using Kaplan-Meier and Cox regression analyses. Results Mean age at recruitment was 51.6 ± 15, with 24% of patients being over 65. At baseline, 74% of patients were overweight, serum cholesterol over 240 was present in 35% of patients, arterial hypertension in 37%, and basal glucose over 126 in 11%. Thirty-four percent of men and 13% of women were current smokers. During follow-up, 155 first episodes of coronary disease were detected, which yielded age-adjusted rates of 362 and 191 per 100,000 person-years in men and women respectively. Disease-free survival was associated with all risk factors in univariate
Full Text Available BACKGROUND: This article describes the setting-up process for nurse-led pilot clinics for the management of four chronic diseases: asthma, type 2 diabetes mellitus, epilepsy and hypertension at the primary health care level in urban and rural Cameroon. METHODS: The Biyem-Assi urban and the Bafut rural health districts in Cameroon served as settings for this study. International and local guidelines were identified and adapted to the country's; circumstances. Training and follow-up tools were developed and nurses trained by experienced physicians in the management of the four conditions. Basic diagnostic and follow-up materials were provided and relevant essential drugs made available. RESULTS: Forty six nurses attended six training courses. By the second year of activity, three and four clinics were operational in the urban and the rural areas respectively. By then, 925 patients had been registered in the clinics. This represented a 68.5% increase from the first year. While the rural clinics relied mainly on essential drugs for their prescriptions, a prescription pattern combining generic and proprietary drugs was observed in the urban clinics. CONCLUSION: In the quest for cost-effective health care for NCD in sub-Saharan Africa, rethinking health workforce and service delivery has relevance. Nurse-led clinics, algorithm driven service delivery stands as alternatives to overcome the shortage of trained physicians and other issues relating to access to care.
Full Text Available Palliative cancer treatment is a system of care that seeks to relieve suffering in patients with progressive cancer. Given the intractable symptoms with which certain malignancies manifest, palliative care offers a practical approach towards improving the patient′s quality of life. However, there are an array of ethical issues associated with this treatment strategy such as particular methods of pain relief, a reliable assessment of suffering, autonomy, and multi-specialist care. While these principles are important to increase and improve the network of palliative care, the resource-poor Indian environments present numerous barriers for these principles to be practically applied. As the infrastructure of comprehensive cancer centers develop, paralleled with an increase in training of palliative care professionals, significant improvements need to be made in order to elevate the status of palliative cancer care in India.
Nijs, Jo; Mannerkorpi, Kaisa; Descheemaeker, Filip; Van Houdenhove, Boudewijn
Despite the fact that people with fibromyalgia syndrome (FMS) frequently are seen by primary care physical therapists, guidelines for the management of FMS are based primarily on outcomes from multidisciplinary and tertiary care treatment studies. Few data addressing the treatment of patients with FMS in primary care currently are available. The evidence-based guidelines on the management of FMS are based, in part, on evidence from studies examining physical therapy treatment components alone (eg, aerobic exercise, education). Thus, the recommendations can be applied to primary care physical therapy. Primary care physical therapy for patients with FMS should include education, aerobic exercise, and strengthening exercise. For other treatment components such as passive treatments, activity management, and relaxation, less evidence currently is available to advocate their use in primary care physical therapy. Superior results are to be expected when various treatment components are combined.
Tøttenborg, Sandra S; Lange, Peter; Thomsen, Reimar W
-ever outpatient contact for COPD during 2008-2012 (N = 23,741). Adjusted year-specific relative risks (RR) of fulfilling all relevant process performance measures was compared according to ethnicity, education, income, employment, and cohabitation using Poisson regression. RESULTS: Quality of care improved...... during the study period. CONCLUSION: A systematic quality improvement initiative including regular audits, knowledge sharing, and detailed disease-specific recommendations for care improvement may increase the overall quality of care and considerably modify the substantial socioeconomic inequalities...
Keele E Wurst
Full Text Available RATIONALE: To assess the treatment progression during the 24 months following a formal diagnosis of chronic obstructive pulmonary disease (COPD in the UK primary care setting. METHODS: A retrospective cohort of newly diagnosed COPD patients was identified in the Clinical Practice Research Datalink (CPRD from 1/1/2008 until 31/12/2009. Maintenance therapy prescribed within the first 3 months of diagnosis and in the subsequent 3-month intervals for 24 months were analyzed. Treatment classes included long-acting β2-agonists (LABAs, long-acting muscarinic antagonists (LAMAs, inhaled corticosteroids (ICSs, and respective combinations. At each 3-month interval, discontinuation, switching, addition, and stepping down patterns were analyzed cumulatively for the first 12 months and over the 24-month of follow-up. RESULTS: A total of 3199 patients with at least one prescription of a maintenance therapy at baseline and during 4th-6th month interval were included in the analysis. At diagnosis (0-3 months, the most frequently prescribed maintenance therapy was LABA+ICS (43%, followed by LAMA (24% and LABA+LAMA+ICS (23%. Nearly half the patients (LABA-50%, LAMA-43% starting on a monobronchodilator had additions to their treatment in 24 months. Compared to other medications, patients starting on a LAMA were most likely to escalate to triple therapy in 24 months. Nearly one-fourth of the patients prescribed triple therapy at baseline stepped down to LABA+ICS (25% or LAMA (31% within 24 months. CONCLUSION: Disease progression is evident over the 24 months after COPD diagnosis, as more patients were prescribed additional maintenance therapy in the 24-month period compared to baseline. The changes in therapy suggest that it is difficult to achieve a consistently improved COPD disease state.
Rey-Bellet, Sarah; Dubois, Julie; Vannotti, Marco; Zuercher, Marili; Faouzi, Mohamed; Devaud, Karen; Rodondi, Nicolas; Rodondi, Pierre-Yves
At the beginning of the medical encounter, clinicians should elicit patients' agendas several times using open-ended questions. Little is known, however, about how many times physicians really solicit a patient's agenda during follow-up encounters. The objective was to analyze the number of agenda solicitations by physicians, of agendas initiated by physicians, and of patients' spontaneous agendas during the beginning and the entire encounter. We analyzed 68 videotaped follow-up encounters at a university primary care outpatient clinic. The number of different types of agenda setting was searched for and analyzed using negative binomial regression or logistic regression models. Physicians solicited agendas a mean ± SD of 0.8 ± 0.7 times/patient during the first 5 minutes and 1.7 ± 1.2 times/patient during the entire encounter. Physicians in 32.4% of encounters did not solicit the patient agenda, and there were never more than two physician's solicitations during the first 5 minutes. The mean number of physician's solicitations of the patients' agenda was 42% lower among female physicians during the first 5 minutes and 34% lower during the entire encounter. The number of agendas initiated by physicians was 1.2 ± 1.2/patient during the beginning and 3.2 ± 2.3/patient during the entire encounter. In 58.8% of the encounters, patients communicated their agendas spontaneously. There were twice as many patient spontaneous agendas (IRR = 2.12, p = .002) with female physicians than with males. This study showed that agenda solicitation with open-ended questions in follow-up encounters does not occur as often as recommended. There is thus a risk of missing new agendas or agendas that are important to the patient.
Lars Tomas Hillered
Full Text Available Cerebral microdialysis (MD was introduced as a neurochemical monitoring tool in the early 1990s and is currently well established for the sampling of low molecular weight biomarkers of energy metabolic perturbation and cellular distress in the neurointensive care (NIC setting. There is now a growing interest in MD for intracerebral sampling of protein biomarkers of secondary injury mechanisms in acute traumatic and neurovascular brain injury in the NIC community. The initial enthusiasm over the opportunity to sample protein biomarkers with high molecular weight cut-off (MWCO MD catheters has dampened somewhat with the emerging realization of inherent problems with this methodology including protein adhesion, protein-protein interaction and biofouling, leading to unstable MD catheter performance (i.e. fluid recovery and extraction efficiency. This review will focus on the results of a multidisciplinary collaborative effort, within the Uppsala Berzelii Centre for Neurodiagnostics during the past several years, to study the features of the complex process of high MWCO MD for protein biomarkers. This research has led to new methodology showing robust in vivo performance with optimized fluid recovery and improved extraction efficiency, allowing for more accurate biomarker monitoring. In combination with evolving analytical methodology allowing for multiplex biomarker analysis in ultra-small MD samples a new opportunity opens up for high-resolution temporal mapping of secondary injury cascades, such as neuroinflammation and other cell injury reactions directly in the injured human brain. Such data may provide an important basis for improved characterization of complex injuries, e.g. traumatic and neurovascular brain injury, and help in defining targets and treatment windows for neuroprotective drug development
Hermann, K.; Boelter, R.; Engeser, P.; Szecsenyi, J.; Campbell, S.M.; Peters-Klimm, F.
BACKGROUND: The care of patients with a life-threatening, progressive and far advanced illness in a home-care setting requires appropriate individual care and requires the active support of family caregivers. General practice teams are usually the primary care givers and first contact and are best p
Peterson, Lars E.; Litaker, David G.
Context: Regional poverty is associated with reduced access to health care. Whether this relationship is equally strong in both rural and urban settings or is affected by the contextual and individual-level characteristics that distinguish these areas, is unclear. Purpose: Compare the association between regional poverty with self-reported unmet…
Steeg, N. van de; Sielk, M.; Pentzek, M.; Bakx, C.; Altiner, A.
PURPOSE: To validate two established questionnaires [Morisky and Medication Adherence Report Scale (MARS-5)] for the measurement of medical adherence of patients treated with antihypertensive drugs in primary care in Germany. SETTING: General practitioners (GPs) and their patients in North Rhine-Wes
specific health care-related risks (needlestick, hemorrhagic fever viruses, severe viral respiratory disease, and tuberculosis ), with suggestions...specific Japanese encephalitis virus (parts of South and Southeast Asia) Meningococcal ( meningitis belt of Africa) Yellow fever (parts of Africa...indicated in certain settings, such as direct contact with sources of avian influenza . DRUG-RESISTANT TUBERCULOSIS In general, tuberculosis is a
Background: There are limited studies on the clinical profile of children attending child guidance clinic under Paediatric background. Aims: To study clinical profile of Children & adolescents attending the Behavioural Paediatrics Unit (BPU) OPD under department of Paediatrics in a tertiary care set up. Methods: Monthly average turnover in the…
Mouton, Lauren; Bruce, Jacklyn
The theory of inclusion is the foundation for the study reported here; inclusion is a focus not only of formal education, but also of nonformal educational settings such as 4-H. Ideally, 4-H camps are designed to serve youth of all backgrounds and abilities. By accommodating youth with special health care needs, 4-H camps are effectively meeting…
Hussein, Shereen; Manthorpe, Jill
In the UK context of financial austerity and the promotion of the social responsibility through the concept of the "Big Society," volunteers are becoming a more important part of the labor workforce. This is particularly so in the long-term care (LTC) sector, where both shortages of staff and demands for support are particularly high. This article investigate the levels and profile of contribution of volunteers in the LTC sector using a large national data set, National Minimum Data Set for Social Care, linked to local area levels of rurality and socio-economic status. The analysis shows that volunteer activity in formal care services varies between sectors and service types, with no strong relationship between local area deprivation, unemployment levels, and levels of volunteering. However, some significant association was found with level of rurality. The contribution of volunteers is most evident in provision of counseling, support, advocacy, and advice.
Johansson, Ann-Caroline; Axelsson, Malin; Berndtsson, Ina; Brink, Eva
Illness is constituted by subjective experiences of symptoms and their psychosocial consequences. Illness perceptions concern people's lay beliefs about understandings and interpretation of a disease and expectations as to disease outcome. Our knowledge about illness perceptions and coping in relation to the cancer care context among persons with colorectal cancer (CRC) and their partners is incomplete. The aim of the present study was to explore illness perceptions in relation to contemporary cancer care settings among CRC survivors and partners. The present research focused on illness rather than disease, implying that personal experiences are central to the methodology. The grounded theory method used is that presented by Kathy Charmaz. The present results explore illness perceptions in the early recovery phase after being diagnosed and treated for cancer in a contemporary cancer care setting. The core category outlook on the cancer diagnosis when quickly informed, treated, and discharged illustrates the illness perceptions of survivors and partners as well as the environment in which they were found. The cancer care environment is presented in the conceptual category experiencing contemporary cancer care settings. Receiving treatment quickly and without waiting was a positive experience for both partners and survivors; however partners experienced the information as massive and as causing concern. The period after discharge was being marked by uncertainty and loneliness, and partners tended to experience non-continuity in care as more problematic than the survivor did. The results showed different illness perceptions and a mismatch between illness perceptions among survivors and partners, presented in the conceptual category outlook on the cancer diagnosis. One illness perception, here presented among partners, focused on seeing the cancer diagnosis as a permanent life-changing event. The other illness perception, here presented among survivors, concentrated on
Conclusions: Learning more about medication errors may enhance health care professionals' ability to provide safe care to their patients. Hence, A focus on easy-to-use and inexpensive techniques for medication error reduction should be used to have the greatest impact. [Int J Basic Clin Pharmacol 2015; 4(6.000: 1235-1240
Gustavo Diniz Ferreira Gusso
Full Text Available Objective: The purpose of this study is to present a methodology for assessing patients’ demands and calculating pre-test probabilities using paper forms in Primary Care. Method: Most developing countries do not use Electronic Health Records (EHR in primary care settings. This makes it difficult to access information regarding what occurs within the health center working process. Basically, there are two methodologies to assess patients’ demands and problems or diagnosis stated by doctors. The first is based on single attendance at each appointment, while the second is based on episodes of care; the latter deals with each problem in a longitudinal manner. The methodology developed in this article followed the approach of confronting the ‘reason for the appointment’ and ‘the problem registered’ by doctors. Paper forms were developed taking this concept as central. All appointments were classified by the International Classification of Primary Care (ICPC. Discussion: Even in paper form, confrontation between ‘reason for the appointment’ and ‘problem registered’ is useful for measuring the pre-test probabilities of each problem-based appointment. This approach can be easily reproduced in any health center and enables a better understanding of population profile. Prevalence of many illnesses and diseases are not known in each reality, and studies conducted in other settings, such as secondary and tertiary care, are not adequate for primary health care. Conclusion: This study offers adequate technology for primary health care workers that have potential to transform each health center into a research-led practice, contributing directly to patient care.
Bawo, Luke; Hunter, Jennifer C.; Massaquoi, Moses; Matanock, Almea; Dahn, Bernice; Ayscue, Patrick; Nyenswah, Tolbert; Forrester, Joseph D.; Hensley, Lisa E.; Monroe, Benjamin; Schoepp, Randal J.; Chen, Tai-Ho; Schaecher, Kurt E.; George, Thomas; Rouse, Edward; Schafer, Ilana J.; Pillai, Satish K.; De Cock, Kevin M.
Over the span of a few weeks during July and August 2014, events in West Africa changed perceptions of Ebola virus disease (EVD) from an exotic tropical disease to a priority for global health security. We describe observations during that time of a field team from the Centers for Disease Control and Prevention and personnel of the Liberian Ministry of Health and Social Welfare. We outline the early epidemiology of EVD within Liberia, including the practical limitations on surveillance and the effect on the country’s health care system, such as infections among health care workers. During this time, priorities included strengthening EVD surveillance; establishing safe settings for EVD patient care (and considering alternative isolation and care models when Ebola Treatment Units were overwhelmed); improving infection control practices; establishing an incident management system; and working with Liberian airport authorities to implement EVD screening of departing passengers. PMID:25811176
Arwady, M Allison; Bawo, Luke; Hunter, Jennifer C; Massaquoi, Moses; Matanock, Almea; Dahn, Bernice; Ayscue, Patrick; Nyenswah, Tolbert; Forrester, Joseph D; Hensley, Lisa E; Monroe, Benjamin; Schoepp, Randal J; Chen, Tai-Ho; Schaecher, Kurt E; George, Thomas; Rouse, Edward; Schafer, Ilana J; Pillai, Satish K; De Cock, Kevin M
Over the span of a few weeks during July and August 2014, events in West Africa changed perceptions of Ebola virus disease (EVD) from an exotic tropical disease to a priority for global health security. We describe observations during that time of a field team from the Centers for Disease Control and Prevention and personnel of the Liberian Ministry of Health and Social Welfare. We outline the early epidemiology of EVD within Liberia, including the practical limitations on surveillance and the effect on the country's health care system, such as infections among health care workers. During this time, priorities included strengthening EVD surveillance; establishing safe settings for EVD patient care (and considering alternative isolation and care models when Ebola Treatment Units were overwhelmed); improving infection control practices; establishing an incident management system; and working with Liberian airport authorities to implement EVD screening of departing passengers.
Khursheed, Munawar; Fayyaz, Jabeen; Jamil, Ahsan
The history of triage started from the French battle field for prioritizing patients. Emergency triage was started in early 1950's in USA in order to treat the sickest first. It has now become an integral component of all emergency departments (ED). The basic aim of triage is not only to sort out patients according to the criticality of their illness, but it also serves to streamline the patient flow. This will ultimately enable the ED physician to provide right management at the right time to the right patient in the available resources. In turn has a positive impact in reducing the ED overcrowding. The history of triage at AKUH-ED dated back in 2000. In the beginning physicians and nurse both were assigned to triage desk where they use to sort out the patient according to presenting complaints. At that time the documentation was manual with locally developed triage priorities. With the expansion of ED in 2008, responsibility of triage was shifted to nursing services. Triage policy was established and implemented. Specific triage protocols were developed for guidance and uniformity of care. Manual recording system was replaced by computerized triage data entry software. Enabling the department to monitor patient quality care indicators like total number of patients triaged, triage category, lag time reports and left without being seen by physicians.
А.Yu. Popova; N. V. Zaitseva; I.V. May; P.Z. Shur
Significant volumes of mutual trade between the countries of the Eurasian Economic Union, combined with the urgency of protecting the population against the risks of negative impacts on the health products are aiming to optimize the supervision of the products traded in the market. One of the ways to optimize is the transition to a risk-based model of health service activities and choice of products for top-priority (priority) control. The approaches to the selection of priorities are offered...
Garmire, Derrick L.; Herring, Jay R.; Stunkel, Craig B.
A method is provided for selecting a data source for transmission on one of several logical (virtual) lanes embodied in a single physical connection. Lanes are assigned to either a high priority class or to a low priority class. One of six conditions is employed to determine when re-arbitration of lane priorities is desired. When this occurs a next source for transmission is selected based on a the specification of the maximum number of high priority packets that can be sent after a lower priority transmission has been interrupted. Alternatively, a next source for transmission is selected based on a the specification of the maximum number of high priority packets that can be sent while a lower priority packet is waiting. If initialized correctly, the arbiter keeps all of the packets of a high priority packet contiguous, while allowing lower priority packets to be interrupted by the higher priority packets, but not to the point of starvation of the lower priority packets.
Identification of sources of priority substances set out in Article 16 of the Water Framework Directive and estimation of their discharges into the German aquatic environment; Ermittlung der Quellen fuer die prioritaeren Stoffe nach Artikel 16 der Wasserrahmenrichtlinie und Abschaetzung ihrer Eintragsmengen in die Gewaesser in Deutschland
Boehm, E.; Hillenbrand, T.; Marscheider-Weidemann, F.; Mueller, B.; Wiederhold, J.; Herrchen, M.; Klein, M.
The Water Framework Directive (2000/60/EC) is a new instrument, that inter alia has replaced, harmonized and further developed the control and reduction of point and diffuse discharges of dangerous substances according to Council Directive 76/464/EEC. Article 16 of the Water Framework Directive set out a 'Strategy against pollution of water' which demands specific measures against pollution of water by individual pollutants or groups of pollutants presenting a significant risk to or via the aquatic environment (e.g. by drinking water consumed). For these priority substances community-wide water quality standards and emission controls have to be established. On the basis of Article 16 of Directive 2000/60/EC a list of 33 priority substances has been adopted by the decision of the European Parliament and of the Council of November 2001. This list identifies 11 priority hazardous substances, 14 substances subject to a review for identification as possible priority hazardous substance and 8 priority substances. The Commission will make a proposal for the final classification of the 'substances subject to a review' (priority hazardous or priority substances) not later than 12 months after adoption of this list. The planned measures aim at the cessation or phasing out of discharges, emissions and losses to the aquatic environment within 20 years for the priority hazardous substances and at the progressive reduction for the priority substances. In this project the available data for these 33 substances resp. groups of substances for the Federal Republic of Germany were put forward and described in a standardized pattern. This pattern includes the following items: nomenclature and properties of the substances, monitoring data, production and fields of application of these substances, existing regulations in Germany, releases to environment and possibilities to reduce discharges to the aquatic environment. The basis of the data is the year 2000 as far as
Full Text Available Abstract Background Many studies on diabetes have demonstrated that an intensive control of glycaemia and the main associated risk factors (hypertension, dislipidaemia, obesity and smoking reduce cardiovascular morbi-mortality. Different scientific societies have proposed a multifactorial approach to type 2 diabetes. The objective of this study was to identify the degree of control of glycosylated haemoglobin (HbA1c and of cardiovascular risk factors in type 2 diabetic patients, using the GedapS 2004 guidelines, and to analyse the type and intensity of drug treatment. Methods This cross-sectional, multicentre, epidemiological study was conducted in a primary care setting in Vallès Occidental South, Catalonia. Data were collected of 393 patients aged 18 and above who were diagnosed with diabetes mellitus type 2. Biodemographic and clinical data, cardiovascular risk factors, associated cardiovascular disease, and treatment were assessed. Descriptive and multivariable analysis with logistic regression was realized. Results A total of 392 patients with a mean age of 66.8 years (SD = 10.6 (45.4% male patients were analyzed. The duration of diabetes was 8.4 years (SD = 7.6. The degree of multifactorial control of risk factors was only 2.6%, although in more than 50% individual cardiovascular risk factor was controlled, except for LDL cholesterol (40.6% and systolic blood pressure (29.6%. Furthermore, only 13.0% of subjects had an optimal BMI, 27.5% an optimal waist circumference. Treatment for diabetes was prescribed in 82.7% of patients, for hypertension 70.7%, for dyslipidaemia 47.2% and 40.1% were taking antiplatelets. Conclusion Over 50% of type 2 diabetic patients presented optimal control of the majority of individual cardiovascular risk factors, although the degree of multifactorial control of diabetes was insufficient (2.6% and should be improved. Drug treatment can be intensified using a larger number of combinations, particularly in
Goodman, Jesse H.
As John Dewey noted in his last book, each generation, in its turn, must assume responsibility as caretaker of democracy. He noted that one should never take democracy for granted. Everyone lives in an imperfect democracy, and teacher educators should play their part in protecting, nurturing, and advancing democratic ideals, rituals, values, and…
Metamaterials – Integrated Computational Material Sciences – Nano-Manufacturing • Counter IED Sciences O F F I C E O F...Biologically-inspired Intelligent Metamaterials – Computing with Natural Language – The Micro-physics of a Liquid-Solid-Gas Interaction – Acoustical...Science Examples of cutting-edge Basic Research at ONR (PE 0601153N) • Code 31: Fast Multipole Methods Reversible Hydrogenation of Graphene • Code 32
tried herbal remedies for both of them for a week but without effect. The family permits her to travel with her child quite some distance to a fairly run down health centre ---- (Cont. with her meeting services, but going home unserved) WHAT ARE HEALTH SYSTEMS AND HEALTH SYSTEMS RESEARCH? Health systems...... and constraints. This effectively leaves policy-makers.without scientifically sound ideas of what they can and should actually strengthen within ever limited resources. Within such unmapped and misunderstood systems, interventions – even the very simplest – often fail to achieve their goals and no recommeded...
Kilinc Balci, F. Selcen
Although they play an important role in infection prevention and control, textile materials and personal protective equipment (PPE) used in health care settings are known to be one of the sources of cross-infection. Gowns are recommended to prevent transmission of infectious diseases in certain settings; however, laboratory and field studies have produced mixed results of their efficacy. PPE used in health care is regulated as either class I (low risk) or class II (intermediate risk) devices in the United States. Many organizations have published guidelines for the use of PPE, including isolation gowns, in health care settings. In addition, the Association for the Advancement of Medical Instrumentation published a guidance document on the selection of gowns and a classification standard on liquid barrier performance for both surgical and isolation gowns. However, there is currently no existing standard specific to isolation gowns that considers not only the barrier resistance but also a wide array of end user desired attributes. As a result, infection preventionists and purchasing agents face several difficulties in the selection process, and end users have limited or no information on the levels of protection provided by isolation gowns. Lack of knowledge about the performance of protective clothing used in health care became more apparent during the 2014 Ebola epidemic. This article reviews laboratory studies, regulations, guidelines and standards pertaining to isolation gowns, characterization problems, and other potential barriers of isolation gown selection and use. PMID:26391468
Thomson, Linda J M; Chatterjee, Helen J
The extent to which a museum object-handling intervention enhanced older adult well-being across three health care settings was examined. The program aimed to determine whether therapeutic benefits could be measured objectively using clinical scales. Facilitator-led, 30 to 40 min sessions handling and discussing museum objects were conducted in acute and elderly care (11 one-to-ones), residential (4 one-to-ones and 1 group of five), and psychiatric (4 groups of five) settings. Pre-post measures of psychological well-being (Positive Affect and Negative Affect Schedule) and subjective wellness and happiness (Visual Analogue Scales) were compared. Positive affect and wellness increased significantly in acute and elderly and residential care though not psychiatric care whereas negative affect decreased and happiness increased in all settings. Examination of audio recordings revealed enhanced confidence, social interaction, and learning. The program allowed adults access to a museum activity who by virtue of age and ill health would not otherwise have engaged with museum objects.
Full Text Available Objective. (1 To evaluate the feasibility of implementing and evaluating a home visit program for persons with Parkinson’s disease (PD in a rural setting. (2 To have movement disorders fellows coordinate and manage health care delivery. Background. The University of Florida, Center for Movement Disorders and Neurorestoration established Operation House Call to serve patients with PD who could not otherwise afford to travel to an expert center or to pay for medical care. PD is known to lead to significant disability, frequent hospitalization, early nursing home placement, and morbidity. Methods. This was designed as a quality improvement project. Movement disorders fellows travelled to the home(s of underserved PD patients and coordinated their clinical care. The diagnosis of Parkinson’s disease was confirmed using standardized criteria, and the Unified Parkinson’s Disease Rating Scale was performed and best treatment practices were delivered. Results. All seven patients have been followed up longitudinally every 3 to 6 months in the home setting, and they remain functional and independent. None of the patients have been hospitalized for PD related complications. Each patient has a new updatable electronic medical record. All Operation House Call cases are presented during video rounds for the interdisciplinary PD team to make recommendations for care (neurology, neurosurgery, neuropsychology, psychiatry, physical therapy, occupational therapy, speech therapy, and social work. One Operation House Call patient has successfully received deep brain stimulation (DBS. Conclusion. This program is a pilot program that has demonstrated that it is possible to provide person-centered care in the home setting for PD patients. This program could provide a proof of concept for the construction of a larger visiting physician or nurse program.
大量的科学研究、监管和大众媒体一直关注于内分泌干扰物，它们主要是能够模仿天然激素功能的合成化学物质。法律要求开发一种程序，用以筛选和测试水和食品添加剂中是否含有潜在内分泌干扰物。根据法规，大量的化学品将会接受各种体外和体内的实验用以测试其潜在荷尔蒙的活性，例如雌激素活性。因此，需要对这些化学物质进行分层筛选，以降低测试成本及加快筛选和测试的速度。在已经开发的内分泌干扰物知识数据库(EDKB)项目中，将实验和建模进行了整合，以便于更加高效地进行优先级的设置。%Considerable scientific, regulatory and popular press attention has been devoted to the Endocrine Disrupting Chemicals (EDCs) which are predominantly synthetic chemicals with an ability of mimicking the functions of natural hormones. The legislation requires development of a screening and testing program for potential EDCs in drinking water and food additives. Under the legislation, a large number of chemicals will undergo various in vitro and in vivo assays for their potential hormonal activities such as estrogenicity. There is a crucial need to set priority for these chemicals to reduce the cost and speed the screening and testing process. We have developed an Endocrine Disruptor Knowledge Base (EDKB) project where experimentation and modeling were integrated to assist the priority setting process.
Cline, Daniel D; Rosenberg, Marie-Claire; Kovner, Christine T; Brewer, Carol
The purpose of this study was to explore early-career registered nurses' perceptions of high-quality nursing care in hospitals. The study findings contribute to ongoing work intended to explore and define what quality nursing care is and how it ultimately impacts patients. The final sample analyzed for this article consisted of 171 narrative responses from hospital-based registered nurses. We used Krippendorff's technique for qualitative content analysis to identify themes. Three themes emerged as integral to high quality nursing care: registered nurse presence, developing relationships, and facilitating the flow of knowledge and information. Development of nursing quality indicators should focus on nursing processes in addition to patient outcomes. Such a focus would better capture the complexity of hospital nursing care.
Introduction of the advanced nurse practitioner (ANP) role has enabled nurses to develop their clinical knowledge and skills, providing greater service provision and improved access to healthcare services. It can also help with the challenges of providing care to an ageing population in primary care. This article reports on the evaluation of an ANP-led clinic in two residential care homes that provides annual reviews for chronic disease management (CDM). A mixed method approach was used to evaluate the service using clinical data obtained from the electronic patient record system and software and patient satisfaction questionnaires. The number of patients receiving CDM reviews in the homes increased as a result of the clinic. Completed satisfaction questionnaires further demonstrated patients' satisfaction and willingness to engage with the service. The service highlights the ANP's effectiveness in managing residential care home patients with chronic diseases and improving their access to healthcare services.
A federal court decision overturning federal regulations requiring research institutions to present plans for care and use of laboratory animals has renewed debate over laboratory animal welfare. University scientists fear new, stricter Department of Agriculture regulations will result. (MSE)
While calling for culturally sensitive healthcare services in migrant communities, the internation-al nursing literature on intercultural care predominantly describes nursing staff as lacking cultur-al competences and immigrant customers as lacking cleverness to navigate the labyrinths of na-tional healthcare systems. Congruences in language, culture and religion in the customer-caregiver relationship can decisively improve the quality of care. However, they do not automat-ically guarantee sm...
Pérez-Cuevas, R; Reyes, H; Guiscafré, H; Juárez-Díaz, N; Oviedo, M; Flores, S; Muñoz, O
The Mexican Institute of Social Security (IMSS) is Mexico's Largest state-financed health care system, providing care to 50 million people. This system comprises 1450 family medicine clinics staffed by 14,000 family physicians, as well as 240 secondary care hospitals and 10 tertiary care medical centres. We developed a program of continuing medical education (CME) for IMSS family physicians. The program had 4 stages, which were completed over a 7-month period: development of clinical guidelines, training of clinical instructors, an educational intervention (consisting of interactive workshops, individual tutorials and peer group sessions), and evaluation of both physicians' performance and patients' health status. The pilot study was conducted in an IMSS family medicine clinic providing care to 45,000 people; 20 family physicians and 4 clinical instructors participated. The 2 main reasons for visits to IMSS family medicine clinics are acute respiratory infections and type 2 diabetes mellitus. Therefore, patients being treated at the clinic for either of these illnesses were included in the study. The sources of data were interviews with physicians and patients, clinical records and written prescriptions. A 1-group pretest-posttest design was used to compare physicians' performance in treating the 2 illnesses of interest. We found that the daily activities of the clinic could be reorganized to accommodate the CME program and that usual provision of health care services was maintained. Physicians accepted and participated actively in the program, and their performance improved over the course of the study. We conclude that this CME strategy is feasible, is acceptable to family physicians and may improve the quality of health care provided at IMSS primary care facilities. The effectiveness and sustainability of the strategy should be measured through an evaluative study.
Lim CJ; Kong DCM; Stuart RL
Ching Jou Lim,1 David CM Kong,1 Rhonda L Stuart2,31Centre for Medicine Use and Safety, Monash University, Parkville, VIC, Australia; 2Monash Infectious Diseases, Monash Health, Clayton, VIC, Australia; 3Department of Medicine, Monash University, Clayton, VIC, AustraliaAbstract: Residential aged care facilities are increasingly identified as having a high burden of infection, resulting in subsequent antibiotic use, compounded by the complexity of patient demographics and medical care. Of parti...
McKenna, Brian; Furness, Trentham; Dhital, Deepa; Ireland, Susan
Recovery-oriented care acknowledges the unique journey that consumers lead with the aim of regaining control of their lives in order to live a good life. Recovery has become a dominant policy-directed model of many mental health care organizations, but in older-adult acute mental health inpatient settings, nurses do not have a clear description of how to be recovery-oriented. The aims of this study were to determine the extent to which elements of existing nursing practice resemble the domains of recovery-oriented care and provide a baseline understanding of practice in preparation for transformation to recovery-oriented mental health care provision. An exploratory, qualitative research design was used to meet the research aims. A purposive sample of mental health nurses (N = 12) participated in focus groups in three older-adult inpatient settings in Australia. A general inductive approach was used to analyze the qualitative data. The mental health nurses in this study readily discussed aspects of their current practice within the recovery domains. They described pragmatic ways to promote a culture of hope, collaborative partnerships, meaningful engagement, autonomy and self-determination, and community participation and citizenship. Nurses also discussed challenges and barriers to recovery-oriented care in older-adult acute mental health settings. This study identified a reasonable baseline understanding of practice in preparation for transformation to recovery-oriented older-adult mental healthcare provision. A concerted drive focused on recovery education is required to effectively embed a recovery-orientated paradigm into older-adult mental health settings.
Full Text Available Introduction, definition, rationale and scope: Lasers are now becoming an integral part of dermatological practice in India, with more and more dermatologists starting laser dermatology practice. Lasers, when are used with care, by properly trained operators, in carefully designed environment, can deliver a range of useful aesthetic and dermatologic treatments. Facility: Laser treatment is an office procedure, hence it does not require hospital set-up. The laser room facility requires careful planning keeping in mind safety of both patient and operator, convenience of operating, and optimum handling of costly equipments. The facility should be designed to handle procedures under local anesthesia and sedation. Facilities, staff and equipment to handle any emergencies should be available. Location: A room in existing dermatology clinic can be adequately converted to a laser room. Dimensions of laser room, its door and patient′s table should be such that it should facilitate easy movement of patient, machine trolley, operator and assistant in case of routine procedures and in emergency. Physician Qualification: Any dermatologist with MD or diploma in dermatology can do laser procedures, provided he/ she has acquired necessary skills by virtue of training, observing a competent dermatologist. Such training may be obtained during post graduation or later in specified workshops or courses under a competent dermatologist or at centre which routinely performs such procedures. Electricity and uninterrupted power supply: Laser equipments should be connected to stabilizer or UPS circuits only. Preferably an on line UPS as recommended by the laser company should be installed. Earthing of the equipment is essential to avoid damage to the equipment and electrical shocks to the operator. Sufficient power back up to complete the procedure if power is off midway, is essential. Air-conditioning: Laser machines should be operated in low ambient temperature, with
Ho, Anita; Jameson, Kim; Pavlish, Carol
As healthcare delivery becomes increasingly interprofessional, it is imperative to identify opportunities for effective collaboration and coordination of care. Drawing on a Canadian qualitative study that adopted a constant comparative method based on the grounded theory approach, we report how healthcare providers' (HCPs) personal experiences and professional roles intersect with system factors in hindering or enhancing their ability to support patients and families in planning for end-of-life (EOL) care. We used a criterion-based sampling strategy and sought HCPs who had direct experience engaging patients and families in complex healthcare decisions on: (1) initiating, withholding, or withdrawing treatment; (2) care planning; and/or (3) discharge planning. Interviews sought to understand what HCPs perceived as individual, (inter)professional, and system factors that might hinder, promote, or enhance support for patients/families. We present four major intersecting themes from in-depth interviews with 28 HCPs across acute, long-term, and community care settings that represent three barriers and one facilitator: discomfort with death and dying, confusion about role responsibility, lack of coordinated care, and importance of interprofessional teamwork. Attending to system power hierarchy, we explore interprofessional strategies to support patients' and families' care experiences and promote team-based decision-making. We recommend an interprofessional team approach to facilitate EOL decision-making across care settings and before death becomes imminent. Increasing educational initiatives and developing tools that focus on interprofessional collaboration may help HCPs to understand each other's roles and perspectives, so that they can work together to provide a more coherent and coordinated approach to EOL decision-making.
and skills about advance directives have been cited for low completion rates. Family nurse practitioners ( FNPs ), in both civilian and military settings...receive training on ethical and moral implications of advanced nursing practice. These characteristics make the FNP an ideal candidate for promoting...environment (Hunter et al., 1997). Advanced Nursing Role Family nurse practitioners ( FNPs ) are well suited to initiate conversations concerning end-of-life
O Brien, J A Jordan
OBJECTIVE: To explore the nature and quality of documented care planning for pressure ulcers in a large teaching hospital in the Republic of Ireland. METHOD: A mixed method design was used; this encompassed a descriptive survey that retrospectively evaluated nursing records (n=85) in two wards (orthopaedic and care of the older adult) and a focus group (n=13) that explored nurses\\' perspectives of the factors influencing concordance and the quality of nursing documentation. Only records of at-risk patients (Waterlow score of >10) were included. RESULTS: It was identified that 47% (n=40) were assessed as at high or very high risk of developing a pressure ulcer. Fifty-two patients (61%) had a weekly risk assessment, but 25% (n=21) had only one follow-up assessment. Only 45% (n=38) of charts had some evidence of documented care planning, and of those 53% (n=20) had no evidence of implementation of the care plan and 66% (n=25) had no evidence of outcome evaluation. Only 48% (n=41) of this at-risk population was nutritionally assessed. Of patients admitted with and without a pressure ulcer, there was no record of regular positioning in 70% (n=59) and 60% (n=51) respectively. CONCLUSION: Documentation on pressure ulcer care is not standardised and requires development. Conflict of interest: None.
Munck, Berit; Sandgren, Anna
The increase in the use of medical devices in palliative home care requires that patients and next-of-kin feel secure. Therefore, the aim was to describe medical technology's impact on the sense of security for patients, next-of-kin and district nurses. Deductive content analysis was conducted on data from three previous studies, using the theoretical framework 'palliative home care as a secure base'. The use of medical technology was shown to have an impact on the sense of security for all involved. A sense of control was promoted by trust in staff and their competence in managing the technology, which was linked to continuity. Inner peace and being in comfort implied effective symptom relief facilitated by pain pumps and being relieved of responsibility. Health care professionals need to have practical knowledge about medical technology, but at the same time have an awareness of how to create and maintain a sense of security.
Kotval, Jeroo S.
In a policy climate where incentives to cherry pick are minimized, Managed Care Organizations can implement practices that safeguard medical privacy to the extent that data is protected from falling into the hands of third parties who could misuse it to discriminate. To the extent that these practices have been codified into the regulatory Network of the Health Insurance Portability and Accountability Act (HIPAA) Consumers may be able to rest easy about their genetic data being revealed to third parties who may discriminate. However, there are limitations to the use of policy instruments to prevent the discrimination of an entire genre of clients by market driven managed care organizations. Policy measures, to assure that knowledge of genetic conditions and their future costs would not be used by market driven managed care organizations to implement institutional policies and products that would implicitly discriminate against a genre of clients with genetic conditions, present difficulties.
Michalopoulou, Georgia; Falzarano, Pamela; Butkus, Michael; Zeman, Lori; Vershave, Judy; Arfken, Cynthia
Minorities in the United States have well-documented health disparities. Cultural barriers and biases by health care providers may contribute to lower quality of services which may contribute to these disparities. However, evidence linking cultural competency and health outcomes is lacking. This study, part of an ongoing quality improvement effort, tested the mediation hypothesis that patients' perception of provider cultural competency indirectly influences patients' health outcomes through process of care. Data were from patient satisfaction surveys collected in seven mental health clinics (n=94 minority patients). Consistent with our hypothesis, patients' perception of clinicians' cultural competency was indirectly associated with patients' self-reported improvements in social interactions, improvements in performance at work or school, and improvements in managing life problems through the patients' experience of respect, trust, and communication with the clinician. These findings indicate that process of care characteristics during the clinical encounter influence patients' perceptions of clinicians' cultural competency and affect functional outcomes.
Humphreys, José V A
With increasing burdens placed on Primary Care Physicians in the prevention and management of Sickle Cell Disease (SCD), it is imperative that there is some basic understanding of the same. Needless to say, its management is a multifocal, multidisciplinary approach which includes a collaborative effort between patients, family members and the healthcare team. Primary Care Physicians must be familiar with the pathophysiological processes, diagnostic evaluation, and current standard of care, new treatment options, clinical research advances and medical management of sickle hemoglobinopathies and their complications. The guidelines should include new born screening and assessment, accessible medical records for those diagnosed with SCD, system support and prevention, management of complication and crisis periods and home management (dietary and lifestyle modifications).
Travers Catherine M
Full Text Available Abstract Background Frail older people admitted to acute care hospitals are at risk of a range of adverse outcomes, including geriatric syndromes, although targeted care strategies can improve health outcomes for these patients. It is therefore important to assess inter-hospital variation in performance in order to plan and resource improvement programs. Clinical quality outcome indicators provide a mechanism for identifying variation in performance over time and between hospitals, however to date there has been no routine use of such indicators in acute care settings. A barrier to using quality indicators is lack of access to routinely collected clinical data. The interRAI Acute Care (AC assessment system supports comprehensive geriatric assessment of older people within routine daily practice in hospital and includes process and outcome data pertaining to geriatric syndromes. This paper reports the study protocol for the development of aged care quality indicators for acute care hospitals. Methods/Design The study will be conducted in three phases: 1. Development of a preliminary inclusive set of quality indicators set based on a literature review and expert panel consultation, 2. A prospective field study including recruitment of 480 patients aged 70 years or older across 9 Australian hospitals. Each patient will be assessed on admission and discharge using the interRAI AC, and will undergo daily monitoring to observe outcomes. Medical records will be independently audited, and 3. Analysis and compilation of a definitive quality indicator set, including two anonymous voting rounds for quality indicator inclusion by the expert panel. Discussion The approach to quality indicators proposed in this protocol has four distinct advantages over previous efforts: the quality indicators focus on outcomes; they can be collected as part of a routinely applied clinical information and decision support system; the clinical data will be robust and will
Dykeman, Sarah; Williams, Allison M
The Compassionate Care Benefit was implemented in Canada in 2004 to support employed informal caregivers, the majority of which we know are women given the gendered nature of caregiving. In order to examine how this policy might evolve over time, we examine the evolution of a similar employment insurance program, Canada's Maternity Leave Benefit. National media articles were reviewed (n = 2,698) and, based on explicit criteria, were analyzed using content analysis. Through the application of Kingdon's policy agenda-setting framework, the results define key recommendations for the Compassionate Care Benefit, as informed by the developmental trajectory of the Maternity Leave Benefit. Recommendations for revising the Compassionate Care Benefit are made.
Fleming, M; Manwell, L B
Primary health care providers identify and treat many patients who are at risk for or are already experiencing alcohol-related problems. Brief interventions--counseling delivered by primary care providers in the context of several standard office visits--can be a successful treatment approach for many of these patients. Numerous trials involving a variety of patient populations have indicated that brief interventions can reduce patients' drinking levels, regardless of the patients' ages and gender. In clinical practice, brief interventions can help reduce the drinking levels of nondependent drinkers who drink more than the recommended limits, facilitate therapy and abstinence in patients receiving pharmacotherapy, and enhance the effectiveness of assessment and treatment referral in patients who do not respond to brief interventions alone. Despite the evidence for their usefulness, however, brief interventions for alcohol-related problems have not yet been widely implemented in primary care settings.
Uri Adrian Prync Flato
prevention of secondary acute coronary syndrome. Antithrombotic agents such as Aspirin, clopidogrel, vitamin K antagonists and fondaparinux, an indirect Factor Xa inhibitor, are already incorporated into our clinical practice. New small-molecule, selective Factor Xa and thrombin inhibitors that simultaneously inhibit free plasma and clot-associated factor activities have received considerable attention recently. These new oral anticoagulants are in various phases of clinical development. dabigatran, rivaroxaban and apixaban are in more advanced phases of clinical development and are already available in a number of countries. This review article highlights the studies describing the use of these three anticoagulants in an intensive care setting.
Miller, Edward Alan; Nadash, Pamela; Goldstein, Rachel
This study investigates the role of print media in state policy agendas in four states-Connecticut, Minnesota, Oregon, and Utah-in rebalancing long-term care away from institutions toward home- and community-based (HCBS) services. Ordinary least squares regression is used to model states' policy agendas, as measured by the proportion of Medicaid long-term care spending on HCBS expenditures and number of rebalancing bills proposed, from 1999 to 2008. Results reveal a relationship between states' rebalancing agendas and the extent of media coverage, and state economic, political, and programmatic characteristics. Findings suggest that media coverage reflects broader shifts in state-level attitudes toward rebalancing.
Darrow, Mark D
As the population ages, fear of memory loss and potential diagnosis of dementia increases. Primary care providers, with their medical knowledge, familiarity with patients and their loved ones, and knowledge of the community and its resources, are perfectly placed to diagnose and treat commonly presenting types of dementia. As knowledge of the types of dementia and their categorization, presentation, and course has increased, diagnosis and treatment of this problem have become more understandable and amenable to primary care intervention. Diagnosis and work-up use common techniques and studies to assist providers. Treatment and management have evolved over time to include nonpharmacologic or behavioral interventions.
Sheehan, Diane Dudas; Zeigler, Mary H
People with disability are at high risk for skin breakdown,which requires ongoing prevention and management. An outpatient rehabilitation wound clinic was developed to handle a variety of acute and chronic wounds for this unique population. This article describes how two advanced practice nurses proposed the idea for the wound care clinic and formulated a business plan, which was critical to successfully administering an outpatient wound care service. Essential components of the business plan included the goals, scope of service, professional practice model, benefits, rationale, marketing analysis, predicted volumes, regulatory imperatives, and financial needs.
ENDORSE (Epidemiologic International Day for the Evaluation of Patients at Risk for Venous Thromboembolism in the Acute Hospital Care Setting), is a multinational, cross-sectional survey of venous thromboembolism (VTE) risk prevalence and effective prophylaxis in the acute hospital care setting. Three Irish hospitals enrolled in the study. The American College of Chest Physicians (ACCP) guidelines were employed to evaluate VTE risk and prophylaxis. Of 552 patients, 297 (53.8%) and 255 (46.2%) were categorised as surgical or medical, respectively, with 175 (59%) surgical and 109 (43%) medical patients deemed to be at risk for VTE. Of these, only 112 (64%) and 51 (47%) received recommended VTE prophylaxis, respectively. The results are consistent with those observed in other countries and demonstrate a high prevalence of risk for VTE and a low rate of prophylaxis use, particularly in medical patients. Awareness of VTE guidelines should be an integral component of health policy.
Al-Janabi, Hareth; Currow, David; Hoefman, Renske; Ratcliffe, Julie
Introduction Despite informal caregivers' integral role in supporting people affected by disease or disability, economic evaluations often ignore the costs and benefits experienced by this group, especially in the palliative setting. The purpose of this systematic review is to identify preference-based instruments for measuring care-related outcomes and provide guidance on the selection of instrument in palliative care economic evaluations. Methods and analysis A comprehensive search of the literature will be conducted from database inception (ASSIA; CINAHL; Cochrane library including DARE, NHS EED, HTA; Econlit; Embase; PsychINFO; PubMed). Published peer-reviewed, English-language articles reporting preference-based instruments for measuring care-related outcomes in any clinical area will be included. One researcher will complete the searches and screen the results for potentially eligible studies. A randomly selected subset of 10% citations will be independently screened by two researchers. Any disagreement will be resolved by consensus among the research team. Subsequently, a supplementary search will identify studies detailing the development, valuation, validation and application of the identified instruments. The degree of suitability of the instruments for palliative economic evaluations will be assessed using criteria in the International Society for Quality of Life Research minimum standards for patient-reported outcome measures, the checklist for reporting valuation studies of multiattribute utility-based instruments and information on the development of the instrument in the palliative setting. A narrative summary of the included studies and instruments will be provided; similarities and differences will be described and possible reasons for variations explored. Recommendations for practice on selection of instruments in palliative care economic analyses will be provided. Ethics and dissemination This is a planned systematic review of published
Descriptions of patient mistreatment fill ethnographic accounts of healthcare in resource-poor settings. Often, anthropologists point to structural factors and the ways that the global political economy produces substandard care. This approach makes it difficult to hold parties accountable when there is blatant disregard for human life on the part of individuals providing care. In this article, I draw on the illness narrative of Magaly Chacón, the first HIV positive individual in Bolivia to file charges of medical negligence after failing to receive care to prevent mother-to-child transmission. Magaly's narrative demonstrates how structural conditions are often used to explain away poor patient outcomes, shifting attention away from and normalizing the symbolic violence that also perpetuates substandard care of marginalized patients. I use Magaly's accusations to interrogate how defining acts of mistreatment as medical negligence can be a productive exercise, even when it is difficult to disentangle structural constraints from blatant acts of negligence. Defining who is negligent in resource-poor settings is not easy, as Magaly's case demonstrates. However, Magaly's case also demonstrates that accusations of negligence themselves can demand accountability and force changes within the local structures that contribute to the systematic mistreatment of marginalized patients.
Robinson, Jeffrey D; Heritage, John
In the more than 1 billion primary-care visits each year in the United States, the majority of patients bring more than one distinct concern, yet many leave with "unmet" concerns (i.e., ones not addressed during visits). Unmet concerns have potentially negative consequences for patients' health, and may pose utilization-based financial burdens to health care systems if patients return to deal with such concerns. One solution to the problem of unmet concerns is the communication skill known as up-front agenda setting, where physicians (after soliciting patients' chief concerns) continue to solicit patients' concerns to "exhaustion" with questions such as "Are there some other issues you'd like to address?" Although this skill is trainable and efficacious, it is not yet a panacea. This article uses conversation analysis to demonstrate that patients understand up-front agenda-setting questions in ways that hamper their effectiveness. Specifically, we demonstrate that up-front agenda-setting questions are understood as making relevant "new problems" (i.e., concerns that are either totally new or "new since last visit," and in need of diagnosis), and consequently bias answers away from "non-new problems" (i.e., issues related to previously diagnosed concerns, including much of chronic care). Suggestions are made for why this might be so, and for improving up-front agenda setting. Data are 144 videotapes of community-based, acute, primary-care, outpatient visits collected in the United States between adult patients and 20 family-practice physicians.
Saravanakumar, Padmapriya; Higgins, Isabel Johanna; Van Der Riet, Pamela Jane; Marquez, Jodie; Sibbritt, David
Abstract Falls amongst older people is a global public health concern. Whilst falling is not a typical feature of ageing, older people are more likely to fall. Fall injuries amongst older people are a leading cause of death and disability. Many older people do not do regular exercise so that they lose muscle tone, strength, and flexibility which affect balance and predispose them to falls. The management of falls in residential care settings is a major concern with strategies for prevention and monitoring a focus in this setting. Yoga and tai chi have shown potential to improve balance and prevent falls in older adults. They also have potential to improve pain and quality of life. The aim of this study was to determine the feasibility of conducting a 3-arm RCT with frail older people in a residential care setting to test the hypothesis that a 14 week modified tai chi or yoga program is more effective than usual care activity in improving balance function, quality of life, pain experience and in reducing number of falls. There were no statistically significant differences between the three groups in the occurrence of falls. Yoga demonstrated a slight decrease in fall incidence; quality of life improved for the tai chi group. Only the yoga group experienced a reduction in average pain scores though not statistically significant. The findings of the study suggest it is possible to safely implement modified yoga and tai chi in a residential care setting and evaluate this using RCT design. They show positive changes to balance, pain and quality of life and a high level of interest through attendance amongst the older participants. The results support offering tai chi and yoga to older people who are frail and dependent with physical and cognitive limitations.
de Vroege, Lars; Hoedeman, Rob; Nuyen, Jasper; Sijtsma, Klaas; van der Feltz-Cornelis, Christina M.
Introduction Within the occupational health setting, somatoform disorders are a frequent cause of sick leave. Few validated screening questionnaires for these disorders are available. The aim of this study is to validate the PHQ-15 in this setting. Methods In a cross-sectional study of 236 sickliste
Murray, Ann D.; Fees, Bronwyn S.; Crowe, Linda K.; Murphy, Molly E.; Henriksen, Amanda L.
Children's language development is significantly affected by the quantity and quality of language input, particularly during infancy and toddlerhood. The purpose of this study was to compare the language environment in an accredited child care program with data collected by Hart and Risley (1995). Fourteen toddlers (mean age 24.4 months) were…
Aruda, Mary M.; Kelly, Mary; Newinsky, Karina
Children with Special Health Care Needs (CSHCN) represent a significant component of the pediatric population. They often present to schools with multiple and increasingly complex health issues, including medical technology dependency. Their daily variation in health status requires close monitoring and communication among caregivers. Limited…
Morris, Heather; Skouteris, Helen; Edwards, Susan; Rutherford, Leonie
Partnering early childhood education and care (ECEC) and the home together may be more effective in combating obesogenic risk factors in preschool children. Thus, an evaluation of ECEC obesity prevention interventions with a parental component was conducted, exploring parental engagement and its effect on obesity and healthy lifestyle outcomes. A…
Burgess, K.; McKenzie, W.; Fehr, F.
This pilot study explored the international female (IF) students' (n = 17) lived experiences of health care accessibility while studying in a small town in Canada. Analysis guided by a phenomenological method resulted in three major themes--(1) after arriving to attend university, IF students experienced challenges in staying healthy, such as…
Lordly, Daphne; Taper, Janette
Traditionally, an emphasis has been placed on dietetic interns' attainment of entry-level clinical competence in acute care facilities. The perceived risks and benefits of acquiring entry-level clinical competence within long-term and acute care clinical environments were examined. The study included a purposive sample of recent graduates and dietitians (n=14) involved in an integrated internship program. Study subjects participated in in-depth individual interviews. Data were thematically analyzed with the support of data management software QSR N6. Perceived risks and benefits were associated with receiving clinical training exclusively in either environment; risks in one area surfaced as benefits in the other. Themes that emerged included philosophy of care, approach to practice, working environment, depth and breadth of experience, relationships (both client and professional), practice outcomes, employment opportunities, and attitude. Entry-level clinical competence is achievable in both acute and long-term care environments; however, attention must be paid to identified risks. Interns who consider gaining clinical competence exclusively in one area can reduce risks and better position themselves for employment in either practice area by incorporating an affiliation in the other area into their internship program.
Patel, Priti R; Srinivasan, Arjun; Perz, Joseph F
Our experiences with health departments and health care facilities suggest that questions surrounding instrument reprocessing errors and other infection control breaches are becoming increasingly common. We describe an approach to management of these incidents that focuses on risk of bloodborne pathogen transmission and the role of public health and other stakeholders to inform patient notification and testing decisions.
When the author was adviser to the Australian Minister for Education for writing the national Safe Schools Framework (2003), meetings were held with early-childhood care and education administrators from all state, Catholic and independent sectors. Their unexpected message was that educators were facing new problems, those of child sexual abuse in…
Slot, P.L.; Leseman, P.P.M.; Verhagen, J.; Mulder, H.
The relationship between structural quality and process quality in early childhood education and care (ECEC) has been addressed in several studies. However, the findings are not conclusive. The present study was conducted in the Netherlands, which has a strongly regulated mid-quality ECEC system reg
Dixon, John B
Indications for bariatric surgery have been clear for some time and many would say that they are conservative. Unfortunately few eligible candidates seek or are referred for bariatric surgery, with less than 1% currently treated annually. In recent years, the evidence base supporting surgical therapy has strengthened with demonstrable improvements in both safety and efficacy. We now have evidence of remarkable improvements in health, quality of life, and increased life expectancy. There is continued frustration with the poor efficacy of non-surgical therapies and no indication that this is about to change. A caring physician should, as best care, refer the seriously ill morbidly obese patient for a surgical opinion. It is no different from their obligation to adequately manage type-2 diabetes, depression or unstable angina. Currently, even discussion of a surgical referral is optional. It is time we articulated and defined a group of patients where referral for a surgical opinion is no longer merely an option but a physician's responsibility as best care for the patient. It is time to provide leadership towards the delivery of better care for these patients.
Gillette, Joyce L.; And Others
Five hundred college students who had used Kent State University's School Health Service were surveyed to determine patient satisfaction with health care services. Overall satisfaction with the services was high, and satisfaction was significantly influenced by patients' perceptions of practitioners' technical competence and by the adequacy of the…
This report details a national survey study of parents, age 54 or younger, living with children under age 18. The study examined parents' physical health status, stress levels and negative feelings, health habits, and access to health care. Findings indicated that one in eight parents reported health problems, with health related to education,…
Full Text Available Orientation: The relocation of older people to residential facilities has implications for their relationships.Research purpose: This article reports older residents’ perceptions of effective relationships.Motivation for the study: Effective relationships protect against loneliness and depression and contribute to well-being. The facility was identified by a social worker as a showcase for effective relationships, but it was not clear what these consist of.Research approach, design and method: The World Café, a qualitative, participatory action research method, was applied to an economically deprived, urban facility caring for older people in Gauteng, South Africa. Three positively framed questions elicited perceptions from participants (nine men, ten women, aged 65–89. Visual and textual data were obtained and thematically analysed until saturation had been achieved. Themes were then subjected to deductive direct content analysis in terms of Self-Interactional Group Theory (SIGT.Main findings: Older residents perceive care managers as friendly and trustworthy and co-residents as caring. Care managers were seen as flexible, empathetic and congruent leaders and they confirmed residents. Relationships between residents were parallel-defined with relational qualities such as empathy and unconditional acceptance. Residents’ needs for privacy were honoured and they felt confirmed. Group dynamics were underpinned by caring and a stimulating environment provided opportunities for engagement.Practical/managerial implications: Relationships between managers and consumers are facilitated by flexibility, empathy, congruence and unconditional acceptance. Supportive group dynamics develop when people confirm and accept one another. A stimulating environment that encourages continuous and close interpersonal contact contributes to effective relationships.Contribution/value-add: Effective relationships should be understood on different levels.
Roberts, C M; Ryland, I; Lowe, D; Kelly, Y; Bucknall, C E; Pearson, M G
Despite publication of several management guidelines for COPD, relatively little is known about standards of care in clinical practice. Data were collected on the management of 1400 cases of acute admission with Chronic Obstructive Pulmonary Disease in 38 UK hospitals to compare clinical practice against the recommended British Thoracic Society standards. Variation in the process of care between the different centres was analysed and a comparison of the management by respiratory specialists and nonrespiratory specialists made. There were large variations between centres for many of the variables studied. A forced expiratory volume in one second measurement was found in only 53% of cases. Of the investigations recommended in the acute management arterial blood gases were performed in 79% (interhospital range 40-100%) of admissions and oxygen was formally prescribed in only 64% (range 9-94%). Of those cases with acidosis and hypercapnia 35% had no further blood gas analysis and only 13% received ventilatory support. Long-term management was also deficient with 246 cases known to be severely hypoxic on admission yet two-thirds had no confirmation that oxygen levels had returned to levels above the requirements for long-term oxygen therapy. Only 30% of current smokers had cessation advice documented. To conclude, the median standards of care observed fell below those recommended by the guidelines. The lowest levels of performance were for patients not under the respiratory specialists, but specialists also have room for improvement. The substantial variation in the process of care between hospitals is strong evidence that it is possible for other centres with poorer performance to improve their levels of care.
Khattab, M S; Swidan, A M; Farghaly, M N; Swidan, H M; Ashtar, M S; Darwish, E A; Al Mazrooei, A K; Mohammad, A A
A continuous quality improvement programme for the care of registered diabetes patients was introduced in 16 government-affiliated primary health care centres in Dubai. Quality improvement teams were formed, clinical guidelines and information systems were developed, diabetes nurse practitioners were introduced and a team approach was mobilized. Audits before and after the introduction of the scheme showed significant improvements in rates of recording key clinical indicators and in their outcomes. For example, the proportion of patients with glycosylated haemoglobin levels < 7% increased from 20.6% to 31.7% and with LDL cholesterol < 100 mg/dL increased from 20.8% to 33.6%. Mean systolic blood pressure of registered patients fell from 135.3 mmHg to 133.2 mmHg.
Full Text Available Obesity and being overweight could be real chronic conditions above all if there are other complications such as type 2 diabetes, cardiovascular diseases, hypertension, dyslipidemia, hypercholesterolemia, cancer and various psychosocial and psychopathological disorders,. Due to the multifactorial etiology of obesity, evidence-based interventions to improve weight loss, maintain a healthy weight, and reduce related comorbidities combine different treatment approaches: dietetic, nutritional, physical, behavioral, psychological, and, in some situations, pharmacological and surgical. There are significant limitations in this multidisciplinary chronic care management of obesity, most notably those regarding costs and long-term adherence and efficacy. Programs including eHealth platforms and new technologies could overcome limitations connected to the traditional in-patient chronic care management of obesity, thus providing promising opportunities in enhancing weight reduction and reducing complications in terms of long-term efficacy and effectiveness across clinical, organizational, and economic perspectives.
Maloney, J P; Anderson, F D; Gladd, D L; Brown, D L; Hardy, M A
The purpose of this study was to describe health care providers' perceptions of their work environment at a large U.S. Army medical center, and to compare the findings to other military medical centers. The sample (N = 112) consisted of the professional nursing staff working on the nine inpatient units. The Work Environmental Scale (WES) was used to measure perceptions of the workplace relative to gender, position (head nurses, staff nurses, and agency nurses), specialty nursing (intensive care unit [ICU] versus non-ICU), education (MSN, BSN, and ADN), and patterns of differences between the WES subscales of four military medical centers. Results of the study indicate that there were no significant gender differences. Head nurses, non-ICU nurses, and MSN nurses perceived their environment more positively. There were significant differences in the WES subscales between the military hospitals. Implications for nursing using the WES were recommended.
Macbeth, Fergus R; Abratt, Raymond P; Cho, Kwan H; Stephens, Richard J; Jeremic, Branislav
Lung cancer is a major cause of cancer death worldwide and is becoming an increasing problem in developing countries. It is important that, in countries where health care resources are limited, these resources are used most effectively and cost-effectively. The authors, with the support of the International Atomic Energy Agency, drew on existing evidence-based clinical guidelines, published systematic reviews and meta-analyses, as well as recent research publications, to summarise the current evidence and to make broad recommendations on the non-surgical treatment of patients with lung cancer. Tables were constructed which summarise the different treatment options for specific groups of patients, the increase in resource use for and the likely additional clinical benefit from each option. These tables can be used to assess the cost-effectiveness and appropriateness of different interventions in a particular health care system and to develop local clinical guidelines.
Venkat, Arvind; Drori, Jonathan
Attempted suicide represents a personal tragedy for the patient and their loved ones and can be a challenge for acute care physicians. Medical professionals generally view it as their obligation to aggressively treat patients who are critically ill after a suicide attempt, on the presumption that a suicidal patient lacks decision making capacity from severe psychiatric impairment. However, physicians may be confronted by deliberative patient statements, advanced directives or surrogate decision makers who urge the withholding or withdrawal of life sustaining treatments based on the patient's underlying medical condition or life experience. How acute care providers weigh these expressions of patient wishes versus their own views of beneficence, non-maleficence and professional integrity poses a significant ethical challenge. This article presents a case that exemplifies the medical and ethical tensions that can arise in treating a patient following a suicide attempt and how to approach their resolution.
Albada, A.; Triemstra, M.
Objective: This study established patients' preferences regarding the facilities in an adjacent centre for ambulatory hospital care. It also identified determinants of patients' choice to visit this centre instead of the regional hospital. Methods: A questionnaire survey among 1477 elderly and chron
Lazarus, Jeff; Laukamm-Josten, Ulrich; Atun, Rifat A;
there have been many declarations and strategies addressing HIV/AIDS, today the goal is universal access to HIV/AIDS prevention, treatment, care and support services by 2010. The articles included in this thematic issue of the Central European Journal of Public Health on HIV/AIDS reflect this, while the ten...
Maha Mohamed Ghobashi; Hanan Abdel Ghani El-ragehy; Hanan Mosleh Ibrahim; Fatma Abdullah Al-Doseri
Background Patient safety is critical component of health care quality. We aimed to assess the awareness of primary healthcare staff members about patient safety culture and explore the areas of deficiency and opportunities for improvement concerning this issue.Methods: This descriptive cross sectional study surveyed 369 staff members in four primary healthcare centers in Kuwait using self-administered “Hospital Survey on Patient Safety Culture” adopted questionnaire. The total number of resp...
Aabenhus, Rune; Jensen, Jens Ulrik Stæhr
Clinical signs of infection do not allow for correct identification of bacterial and viral aetiology in acute respiratory infections. A valid tool to assist the clinician in identifying patients who will benefit from antibiotic therapy, as well as patients with a potentially serious infection......, could greatly improve patient care and limit excessive antibiotic prescriptions. Procalcitonin is a new marker of suspected bacterial infection that has shown promise in guiding antibiotic therapy in acute respiratory tract infections in hospitals without compromising patient safety. Procalcitonin...
Drohan, Samantha H
The purpose of this article is to encourage primary care pediatric nurses to begin behavioral-based obesity treatment efforts as early as the preschool years. By examining the critical periods for obesity development and how the formation of food and activity behaviors interacts with those critical periods during the preschool years, the value of initiating early obesity treatment will be highlighted. Furthermore, the theory of behavior modification is presented and core principles are applied to early childhood weight management efforts.
Carter, Caroline A; Ruhe, Mary C; Weyer, Sharon; Litaker, David; Fry, Ronald E; Stange, Kurt C
Amid tremendous changes and widespread dissatisfaction with the current health care system, many approaches to improve practice have emerged; however, their effects on quality of care have been disappointing. This article describes the application of a new approach to promote organizational improvement and transformation that is built upon collective goals and personal motivations, invites participation at all levels of the organization and connected community, and taps into latent creativity and energy. The essential elements of the appreciative inquiry (AI) process include identification of an appreciative topic and acting on this theme through 4 steps: Discovery, Dream, Design, and Destiny. We describe each step in detail and provide a case study example, drawn from a composite of practices, to highlight opportunities and challenges that may be encountered in applying AI. AI is a unique process that offers practice members an opportunity to reflect on the existing strengths within the practice, leads them to discover what is important, and builds a collective vision of the preferred future. New approaches such as AI have the potential to transform practices, improve patient care, and enhance individual and group motivation by changing the way participants think about, approach, and envision the future.
Full Text Available Carl McQueen,1 Charlotte Davies21The Air Ambulance Service, Coventry, Warwickshire, 2Yorkshire Deanery, Yorkshire, UKAbstract: The last 25 years has seen an explosion in the popularity of outdoor music festivals, especially in the UK. Coupled with this has been the development of the trend for major sporting events that were once confined to stadia to be accompanied by mass gatherings of spectators and fans in "fan parks" and public places. The majority of music festivals and sporting events are considered to be mass gatherings, using the popular definition of more than 1000 people in one place.1 Despite the increasing popularity of music festivals and other mass gathering events, there is a lack of scientifically robust data concerning the provision of medical care in these circumstances. Published studies are almost exclusively retrospective reviews or case studies of the care provided at individual events. Prospective studies analyzing the role of medical professionals and the quality of care provided at mass gathering events are extremely rare. This literature review aims to summarize the current literature and provide an opportunity to identify new and exciting avenues for research into this unique field.Keywords: emergency medicine, mass gatherings, festivals, training, governance
Full Text Available Abstract Background Despite endorsement by national organizations, the impact of screening for intimate partner violence (IPV is understudied, particularly as it occurs in different clinical settings. We analyzed interviews of IPV survivors to understand the risks and benefits of disclosing IPV to clinicians across specialties. Methods Participants were English-speaking female IPV survivors recruited through IPV programs in Massachusetts. In-depth interviews describing medical encounters related to abuse were analyzed for common themes using Grounded Theory qualitative research methods. Encounters with health care clinicians were categorized by outcome (IPV disclosure by patient, discovery evidenced by discussion of IPV by clinician without patient disclosure, or non-disclosure, attribute (beneficial, unhelpful, harmful, and specialty (emergency department (ED, primary care (PC, obstetrics/gynecology (OB/GYN. Results Of 27 participants aged 18–56, 5 were white, 10 Latina, and 12 black. Of 59 relevant health care encounters, 23 were in ED, 17 in OB/GYN, and 19 in PC. Seven of 9 ED disclosures were characterized as unhelpful; the majority of disclosures in PC and OB/GYN were characterized as beneficial. There were no harmful disclosures in any setting. Unhelpful disclosures resulted in emotional distress and alienation from health care. Regardless of whether disclosure occurred, beneficial encounters were characterized by familiarity with the clinician, acknowledgement of the abuse, respect and relevant referrals. Conclusion While no harms resulted from IPV disclosure, survivor satisfaction with disclosure is shaped by the setting of the encounter. Clinicians should aim to build a therapeutic relationship with IPV survivors that empowers and educates patients and does not demand disclosure.
Millery, Mari; Kukafka, Rita
Health information technology (health IT) has potential for facilitating quality improvement and reducing quality disparities found in underresourced settings (URSs). With this systematic literature review, complemented by key informant interviews, the authors sought to identify evidence regarding health IT and quality outcomes in URSs. The review included 105 peer-reviewed studies (2004-2009) in all settings. Only 15 studies included URSs, and 8 focused on URSs. Based on literature across settings, most evidence was available for quality impact of order entry, clinical decision support systems, and computerized reminders. Study designs were predominantly quasi-experimental (37%) or descriptive (35%); 90% of the studies focused on the microsystem level of quality improvement, indicating a need for expanding research into patient experience and organizational and environmental levels. Key informants highlighted organizational partnerships and health IT champions and emphasized that for health IT to have an impact on quality, there must be an organizational culture of quality improvement.
Collaborative goal setting in patient-provider communication with chronic patients is the phase in which--after collecting the data regarding the patient's health--it is necessary to make a decision regarding the best therapy and behaviors the patient should adopt until the next encounter. Although it is considered a pivotal phase of shared decision making, there remain a few open questions regarding its components and its efficacy: What are the factors that improve or impede agreement on treatment goals and strategies?; What are the 'success conditions' of collaborative goal setting?; How can physicians effectively help patients make their preferences explicit and then co-construct with them informed preferences to help them reach their therapeutic goals? Using the theoretical framework of dialogue types, an approach developed in the field of Argumentation Theory, it will be possible to formulate hypotheses on the success conditions' and effects on patient commitment of collaborative goal setting.