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Introduction: Multiple reports have cited the looming shortage of physicians over the next decades related to increasing demand, an aging of the population, and a stagnant level in the production of new physicians. General surgery shares in this problem, and the specialty is 'stressed' by a declining workforce related to increasing specialization that leaves gaps in emergency, trauma, and rural surgical care. Summary: The Society of Surgery of the Alimentary Tract (SSAT) Public Policy and Advocacy Committee sponsored panel discussions regarding the general surgery workforce shortage at the Digestive Disease Week 2012 and 2013 meetings. The 2012 panel focused on defining the problem. This is the summation of the series with the solutions to the general surgery workforce shortage as offered by the 2013 panel. [ABSTRACT FROM AUTHOR]

Ensuring a safe and effective transition of young people with chronic illness and disability from paediatric care to adult health services is a key quality issue for the NHS. To achieve this, three elements must be pursued with vigour. Firstly, a cultural shift in NHS staff attitudes and training is required. Secondly, systems must change to ensure that all paediatric chronic illness and disability services have effective transition programmes in place. Thirdly, young patients need to be trained and empowered to allow them to be an effective partner in their own transition. Improvement of this transition is merely one part of a wider need to improve health care for adolescents. [ABSTRACT FROM AUTHOR]

Background: The UK medicines legislation was amended ten years ago (2013) to allow podiatrists and physiotherapists independent prescribing rights, the first of the allied health professions to do so. Non-medical prescribing formed one part of a broader policy agenda promoting role flexibility in response to the challenge of an ageing population and the need to maintain effective health provision in the face of a contracting workforce. Aim: The aim of this study was to outline the experiences of the Department of Health AHP medicines project board team in working towards independent prescribing for podiatry and physiotherapy, with a particular focus on the challenges encountered. Methods: In depth, open-ended interviews were conducted with eight of the core members of the project team, drawn from those individuals who served throughout the duration of the project (2010–2013). Included were the former Department of Health Chief and Deputy Chief Allied Health Professions Officers; the Department of Health Engagement and Communications Officer; representatives of the Health and Care Professions Council; the Medicines and Healthcare products Regulatory Agency; the Council of Deans of Health; the Royal College of Podiatry and the Chartered Society of Physiotherapy (The team also included the representative of the Allied Health Professions Federation. However, as that representative is also a researcher in this study, he has recused himself from any role as a participant.). Data were transcribed and subject to a thematic analysis. Results: A complex picture of the project emerged revealing a range of obstacles and challenges, including inter-professional role boundary tensions and negative prior assumptions about the two professions. Success hinged upon the adoption of a dual strategy involving submission of a robust case of need focused on patient benefit coupled with the careful management of professional expectations. Underpinning theory from the sociology of the professions offers a supportive explanatory framework for understanding the relationships between the various stakeholders involved. Conclusions: Ultimately, success depended upon aligning the project aims with healthcare policy through a clear focus on patient benefit. Balancing competing professional and policy demands through a continual emphasis on improved patient care laid the foundations for future projects by other allied health professions. [ABSTRACT FROM AUTHOR]

The health of any nation, and the Bulgarian one in particular, is extremely important for the economy, security and development of the country. Unlike other European countries, due to defects in the structure and functioning, the Bulgarian health system could not achieve satisfactory final results in a number of important aspects of public health. One part of the essential problems includes high rates of morbidity, mortality, wide spread of health risk factors, and on the other - insufficient satisfaction of medical professionals (doctors, nurses, support staff) and patients. This, combined with the changes in the political administration of Bulgaria, led to a decision for a radical reform in the health care system. Conditionally, the changes can be divided, according to their nature, into 6 large groups: 1) Reforms leading to democratization of the system; 2) Reforms related to liberalization; 3) Reforms in the status of primary care practices; 4) Reforms in the organization, construction and structure of the system; 5) Reforms in financing and payment methods; 6) Reforms in the management of the primary care system and practices. The purpose of this review article is to present the theoretical framework, grounds and goals for the reform of the health care system in Bulgaria carried out in the past, with a focus on primary care and the current state. [ABSTRACT FROM AUTHOR]

The COVID-19 disease pandemic, representing a worldwide problem, has moved the world population into a position it has not experienced since World War II. However, there is one difference: the problem has stricken not only Europe but the whole American continent, Asia and Africa. Solution to the problem can be divided into two levels, namely medical and social. At the social level, the only solution is crisis management, or simply prevention and crisis activities carried out by representatives of the governments, and the willingness of citizens to follow specific regulations. However, a combination of the estimate of risk and efficient regulations in compliance with medical care must pursue the sole aim, namely to stabilise and stop the spread of the coronavirus. One part of crisis management is represented by the proper documentation of particular procedures and the drawing of conclusions for the future. This paper is the result of conducting an institutional project at the University of Security Management in Košice, and characterizes the position of the crisis management and rescue units in solving the pandemic in the Slovak Republic. In addition, the paper compares starting points of crisis management and measures taken by selected countries, and identifies the problem of the crisis management both at state and individual levels in Slovakia. [ABSTRACT FROM AUTHOR]

Care robots are machines, operating partly or completely autonomously, that are intended to assist older people and their caregivers. Care robots are seen as one part of the solution to the aging population, allowing fewer professional caregivers to provide the necessary assistance and care. Despite the potential benefits, the dissemination of care robots, and welfare technology in general, is limited in Swedish elder care. To explore the challenges of introducing welfare technology, particularly care robots, in elder care. Twenty-one individual interviews with key actors at the societal level, analysed by thematic analysis. The challenges, from the societal actors' perspectives, were related to; the beliefs in technology, attitudes, ethics, collaboration, and the need for knowledge and skills regarding care robots (individual and group challenges). Challenges of a national character were: national governance, infrastructure, laws and regulations, economics, and procurement (systemic and societal challenges). In addition, the necessary preconditions for successful introduction were revealed as: the utility of the technology, implementation, evaluation and safety, security, and integrity (preconditional challenges). The introduction of care robots in elder care services seems to be more challenging than that of welfare technology in general, given the context and prevailing attitudes and preconceptions about robotics. Significant challenges need to be managed, at all levels of the society, before care robots can become an integral part of daily care and assist older people and their caregivers in activities and rehabilitation. The challenges described by the societal actors', are partly similar to those of the end users', in terms of attitudes, ethics, knowledge and skills, and collaboration. This consensus should provide a solid foundation for the conceptualization and introduction of care robots in elderly care. The challenges follow the pattern of an ecosystem involving all sections of society, which are intertwined and require consideration before the expected benefits can be realised. A user-centred approach is necessary to support the design, implementation, and usefulness of care robots and their suitability for meeting the real needs of older persons and professional caregivers. [ABSTRACT FROM AUTHOR]

Background: It seems to be a truth universally acknowledged that pathways to care for people with eating disorders are inconsistent and difficult to navigate. This may, in part, be a result of the complex nature of the illness comprising both mental and medical ill-health across a broad range of severity. Care therefore is distributed across all parts of the health system resulting in many doors into the system, distributed care responsibility, without well developed or integrated pathways from one part of the system to another. Efforts in many parts of the world to redesign health service delivery for this illness group are underway, each dependent upon the local system structures, geographies served, funding sources and workforce availability. Methods: In NSW—the largest populational jurisdiction in Australia, and over three times the size of the UK—the government embarked six years ago on a program of whole-of-health system reform to embed identification and treatment of people with eating disorders across the lifespan and across the health system, which is largely publicly funded. Prior to this, eating disorders had not been considered a 'core' part of service delivery within the health system, meaning many patients received no treatment or bounced in and out of 'doorways'. The program received initial funding of $17.6 million ($12.5 million USD) increasing to $29.5 million in phase 2 and the large-scale service and workforce development program has been implemented across 15 geographical districts spanning almost one million square kilometres servicing 7.75 million people. Conclusions: In the first five years of implementation there has been positive effects of the policy change and reform on all three service targets—emergency departments presentations, hospital admissions and community occasions of service as well as client hours. This paper describes the strategic process of policy and practice change, utilising well documented service design and change strategies and principles with relevance for strategic change within health systems in general. Plain English summary: This review outlines a $30 million health system reform to eating disorder treatment implemented by the NSW State Government six years ago which has seen large-scale service and workforce development across 15 geographical districts. This spans almost one million square kilometres and services 7.75 million people in Australia. The reform is very large in scale and is now in its second phase of implementation. Here outlined is the strategic process of policy and practice change of the entire reform and initial findings from an external review of phase one, which demonstrates positive effects on all three service targets—emergency departments presentations, hospital admissions and community occasions of service—including increased rates of treatment provision, improved perception of eating disorders amongst health professionals, improved pathway options and better communication within multidisciplinary teams. This type of whole-of-health system government led reform has relevance and learnings for health systems internationally. [ABSTRACT FROM AUTHOR]

Background: It seems to be a truth universally acknowledged that pathways to care for people with eating disorders are inconsistent and difficult to navigate. This may, in part, be a result of the complex nature of the illness comprising both mental and medical ill-health across a broad range of severity. Care therefore is distributed across all parts of the health system resulting in many doors into the system, distributed care responsibility, without well developed or integrated pathways from one part of the system to another. Efforts in many parts of the world to redesign health service delivery for this illness group are underway, each dependent upon the local system structures, geographies served, funding sources and workforce availability. Methods: In NSW—the largest populational jurisdiction in Australia, and over three times the size of the UK—the government embarked six years ago on a program of whole-of-health system reform to embed identification and treatment of people with eating disorders across the lifespan and across the health system, which is largely publicly funded. Prior to this, eating disorders had not been considered a 'core' part of service delivery within the health system, meaning many patients received no treatment or bounced in and out of 'doorways'. The program received initial funding of $17.6 million ($12.5 million USD) increasing to $29.5 million in phase 2 and the large-scale service and workforce development program has been implemented across 15 geographical districts spanning almost one million square kilometres servicing 7.75 million people. Conclusions: In the first five years of implementation there has been positive effects of the policy change and reform on all three service targets—emergency departments presentations, hospital admissions and community occasions of service as well as client hours. This paper describes the strategic process of policy and practice change, utilising well documented service design and change strategies and principles with relevance for strategic change within health systems in general. Plain English summary: This review outlines a $30 million health system reform to eating disorder treatment implemented by the NSW State Government six years ago which has seen large-scale service and workforce development across 15 geographical districts. This spans almost one million square kilometres and services 7.75 million people in Australia. The reform is very large in scale and is now in its second phase of implementation. Here outlined is the strategic process of policy and practice change of the entire reform and initial findings from an external review of phase one, which demonstrates positive effects on all three service targets—emergency departments presentations, hospital admissions and community occasions of service—including increased rates of treatment provision, improved perception of eating disorders amongst health professionals, improved pathway options and better communication within multidisciplinary teams. This type of whole-of-health system government led reform has relevance and learnings for health systems internationally. [ABSTRACT FROM AUTHOR]

The goal of this study was to examine psychosocial adjustment following transition from the nursing home (NH) to community and understand the ways in which adjustment intersects with social connection. We conducted interviews with community-dwelling older male Veterans after they were discharged from an NH. Interviews focused on Veterans' experience during the transition process. We utilized conventional content analysis to inductively code the interviews. We reviewed evidence in each identified domain for common themes. We interviewed 13 NH residents after recent transitions from the NH back to the community. Four themes were identified: (1) access to and quality of social support network are important for social connection, (2) engagement in meaningful activities with family and friends improves well-being, (3) service providers form link to social connection, and (4) external stressors affect the quality of social connections. Identified themes aligned with respondents' social connectedness and perceived psychosocial and physical well-being. Our results suggest that social connectedness is one part of the larger milieu of healthy aging including the importance of engagement with social opportunities and having a purpose. Social connectedness is critical to assess for older adults transitioning between care settings. Developing screening tools and other interventions focused on social isolation are needed. [ABSTRACT FROM AUTHOR]

Recent changes to US reimbursement policies are increasingly holding providers financially accountable for patients' health. Providing nonmedical services in conjunction with primary care--known as wraparound services--is one strategy to improve patient outcomes and reduce overall health care spending. These services leverage additional providers to address patients' social determinants of health. Eskenazi Health--an Indianapolis, Indiana, safety-net provider--introduced wraparound services at its federally qualified health center sites. Behavioral health, social work, dietetics, patient navigation, and other services that address patients' social and behavioral needs are co-located with primary care services. In an eleven-year panel of primary care patients, receipt of any wraparound service was negatively associated with subsequent hospitalizations and emergency department visits. The estimated cost savings from potentially avoided hospitalizations alone was $1.4 million annually. Under value-based payment, wraparound services may be one part of a portfolio of strategies to address the social, behavioral, and environmental factors that drive poor patient health and increase costs. [ABSTRACT FROM AUTHOR]

Objective: To compare different strategies for analyzing longitudinal expenditure data that have a point mass at $0. We provide guidance on parameter interpretation, research questions, and model selection.Data Sources, Study Design, and Data Collection: One-part models, uncorrelated two-part models, correlated conditional two-part (CTP) models, and correlated marginalized two-part (MTP) models have been proposed for longitudinal expenditures that often exhibit a large proportion of zeros and a distribution of continuous, highly right-skewed positive values. Guidance on implementing and interpreting each of these model is illustrated with an example of longitudinal (2000-2003) specialty care expenditures of veterans with hypertension, drawn from Veterans Administration data.Principal Findings: The four strategies answer different research questions, are appropriate for different structures of data, and provide different results. If there is a point mass at $0, then the MTP model may be most useful if the primary interest is in mean expenditures of the entire population. A CTP model may be most useful if the primary interest is in the level of expenditures conditional on them being incurred.Conclusions: Researchers should consider which modeling strategy for longitudinal expenditure outcomes is both consistent with research aims and appropriate for the data at hand. [ABSTRACT FROM AUTHOR]

Health is only one part of the story - Case and Deaton carefully chart the underlying economic picture, which is no less stark. As well as the death data, Case and Deaton also show deteriorating health in this group, in particular depression, other mental illness and distress, and chronic pain and disability. In dissecting aggregate statistics, Case and Deaton home in on one group where health has deteriorated fastest - middle aged (45-54 years) white Americans. [Extracted from the article]

Abstract: Despite significant changes to mental health services, nurses remain the professional group most likely to be in close contact with people who experience mental health problems. A core part of the contemporary identity of the mental health nurse is one who is able to provide acceptance and support for an individual's recovery through the therapeutic relationship. Yet there have always been some tensions with the mental health nursing role that can appear to challenge this relational focus. An increasing prominence of risk management in mental health care can position mental health nurses as responsible for enacting restrictions and has reignited interest in the role of mental health professionals in social control. This paper reports on one part of a multiple case study, which aimed to explore mental health professionals’ experiences of such tensions in the context of decision‐making. Interviews and observations were undertaken in acute ward and assertive outreach settings. Findings suggested that risk dominated decision‐making to such an extent it defined the way service users were understood and treated. A distant relationship between professionals and service users helped to create and maintain this situation. There needs to be a greater focus on service users’ subjective experiences in the decision‐making process to challenge the definition of people with mental health problems as risky. [ABSTRACT FROM AUTHOR]

Background: The aim of this Western Australian study was to describe the overall labour and birth experience of women who were transferred during the first and second stages of labour from a low risk woman-centred, midwifery-led birth centre to a co-located tertiary maternity referral hospital.Methods: Using a descriptive phenomenological design, fifteen women were interviewed up to 8 weeks post birth (July to October, 2013) to explore their experience of the intrapartum transfer. Giorgi's method of analysis was used.Results: The following themes and subthemes emerged: 1) The midwife's voice with subthemes, a) The calming effect and b) Speaking up on my behalf; 2) In the zone with subthemes, a) Hanging in there and b) Post birth rationalizing; 3) Best of both worlds with subthemes a) The feeling of relief on transfer to tertiary birth suite and b) Returning back to the comfort and familiarity of the birth centre; 4) Lost sense of self; and 5) Lost birth dream with subthemes a) Narrowing of options and b) Feeling of panic. Women found the midwife's voice guided them through the transfer experience and were appreciative of continuity of care. There was a sense of disruption to expectations and disappointment in not achieving the labour and birth they had anticipated. There was however appreciation that the referral facility was nearby and experts were close at hand. The focus of care altered from woman to fetus, making women feel diminished. Women were glad to return to the familiar birth centre after the birth with the opportunity to talk through and fully understand their labour journey which helped them contextualise the transfer as one part of the whole experience.Conclusions: Findings can inform midwives of the value of a continuity of care model within a birth centre, allowing women both familiarity and peace of mind. Maternity care providers should ensure that the woman remains the focus of care after transfer and understand the significance of effective communication to ensure women are included in all care discussions. [ABSTRACT FROM AUTHOR]

Introduction: To combat the AIDS epidemic and increase HIV treatment access, the South African government implemented a nurse-based, doctor-supported model of care that decentralizes administration of antiretroviral treatment (ART) for HIV positive patients through nurse initiated and managed ART. Médecins Sans Frontières (MSF) implemented a mentorship programme to ensure successful task-shifting, subsequently assessing the quality of clinical care provided by nurses. Methods: A before-after cross-sectional study was conducted on nurses completing the mentorship programme in Khayelitsha, South Africa, from February 2011-September 2012. Routine clinical data from 229 patient folders and 21 self-assessment questionnaires was collected to determine the number of patients initiated on ART by nurses; quality of ART management before-after mentorship; patient characteristics for doctor and nurse ART initiations; and nurse self-assessments after mentorship. Results: Twenty one nurses were authorized by one nurse mentor with one part-time medical officer's support, resulting in nurses initiating 77% of ART eligible patients. Improvements in ART management were found for drawing required bloods (91% vs 99%, p = 0.03), assessing adherence (50% vs 78%, p<0.001) and WHO staging (63% vs 91%, p<0.001). Nurse ART initiation indicators were successfully completed at 95–100% for 11 of 16 indicators: clinical presentation; patient weight; baseline blood work (CD4, creatinine, haemoglobin); STI screening; WHO stage, correlating medical history; medications prescribed appropriately; ART start date; and documented return date. Doctors initiated more patients with TB/HIV co-infection and WHO Stage 3 and 4 disease than nurses. Nurse confidence improved for managing HIV-infected children and pregnant women, blood result interpretation and long-term side effects. Conclusions: Implementation of a clinical mentorship programme in Khayelitsha led to nurse initiation of a majority of eligible patients, enabling medical officers to manage complex cases. As mentorship can increase clinical confidence and enhance professional development, it should be considered essential for universal ART access in resource limited settings. [ABSTRACT FROM AUTHOR]

For elderly patients with relevant comorbidities, combined cardiac surgery may be inadequate due to excessive surgical risk. Combining interventional valvular and surgical approaches may decrease surgical burden and operative risk. In the present case, we report a staged strategy of interventional mitral valve repair and secondary surgical aortic valve replacement and replacement of the ascending aorta in a patient at high risk for surgery. This hybrid approach allowed for substitution of one part of surgery by the relatively low-risk MitraClip procedure. For the future, increasing clinical importance of interventional valve therapies either for stand-alone or hybrid procedures can be anticipated. [ABSTRACT FROM AUTHOR]

Over the past decade, researchers have shifted their focus from documenting health care disparities to identifying solutions to close the gap in care. Finding Answers: Disparities Research for Change, a national program of the Robert Wood Johnson Foundation, is charged with identifying promising interventions to reduce disparities. Based on our work conducting systematic reviews of the literature, evaluating promising practices, and providing technical assistance to health care organizations, we present a roadmap for reducing racial and ethnic disparities in care. The roadmap outlines a dynamic process in which individual interventions are just one part. It highlights that organizations and providers need to take responsibility for reducing disparities, establish a general infrastructure and culture to improve quality, and integrate targeted disparities interventions into quality improvement efforts. Additionally, we summarize the major lessons learned through the Finding Answers program. We share best practices for implementing disparities interventions and synthesize cross-cutting themes from 12 systematic reviews of the literature. Our research shows that promising interventions frequently are culturally tailored to meet patients' needs, employ multidisciplinary teams of care providers, and target multiple leverage points along a patient's pathway of care. Health education that uses interactive techniques to deliver skills training appears to be more effective than traditional didactic approaches. Furthermore, patient navigation and engaging family and community members in the health care process may improve outcomes for minority patients. We anticipate that the roadmap and best practices will be useful for organizations, policymakers, and researchers striving to provide high-quality equitable care. [ABSTRACT FROM AUTHOR]

The past two decades have seen an explosion in funding and research for Alzheimer's disease (AD), which has resulted in a wealth of data exploring the potential underlying processes, particularly with regard to amyloid-β (Aβ). However, to date, therapies based on this knowledge have not been forthcoming. In seeking an explanation for our current pharmacological failures, it has become clear that amyloid is only one part of a multi-factorial disease process incorporating a wealth of deleterious factors. Additionally, there is strong evidence that the initial production of Aβ is part of the evolutionarily conserved stress response, triggered by a host of upstream factors highly altered in aging. Taken together, these observations place Aβ in a drastically different context, with toxicity occurring secondarily to upstream deleterious factors and rendering current therapeutic strategies oversimplified. This re-conceptualization necessitates a paradigm shift in our scientific and social response to AD, placing a greater emphasis on upstream interventions and public health awareness of the measures that can be taken by most individuals to reduce the risk of AD. With the increasing prevalence of AD and the realization that disease-modifying drugs may not be available in the near future, it is the responsibility of science to better communicate the worth of preventative healthcare measures to the public. [ABSTRACT FROM AUTHOR]

This article discusses the process, results and implications of a financial feasibility assessment of social health insurance (SHI), as one part of Lesotho's exploration of how to move towards achieving universal health care coverage. Quantitative data from government and other sources, and qualitative data from discussions with stakeholders, were entered into SimIns, a health insurance simulation software, through which SHI revenue and expenditure for 11 years was projected. In principle, the assessment reveals that through a mix of tax financing and SHI contributions, all citizens of Lesotho could be covered with a defined benefit package of health services under the defined policy assumptions. Such a financing scheme would provide financial risk protection and enhance equity in access and health financing. [ABSTRACT FROM AUTHOR]

Development of rehabilitation treatments and services that are effective and supported by rigorous evidence is a long and multi-step process. Although there are similarities between this process and that used in pharmaceutical development, the sequence involved in developing this evidence in rehabilitation is more complex and less linear. The specific steps involved depend on a variety of factors including the location of the target of treatment within the International Classification of Functioning, Disability, and Health (ICF; World Health Organisation, 2006), the degree to which the treatment is guided by an underlying theory, the availability of animal models, and the plausibility of safety concerns. Similarly, the research designs chosen and the setting of the research vary both by treatment target and by maturity of the programme of evidence development. A full picture of the appropriate role and anticipated impact of specific rehabilitation treatments can benefit from a marriage between rehabilitation research (which seeks to understand how to change specific aspects of function), and enablement/disablement research (which seeks to understand how changes in one part of the ICF framework affect functioning elsewhere). Although the specific steps involved in a programmatic approach to rehabilitation treatment research vary, development of evidence about all treatments can benefit from a systematic programmatic approach in which each step seeks to answer specific questions and set the stage for subsequent investigation. [ABSTRACT FROM AUTHOR]

The author comments on the problems facing state health care reform and coverage in the U.S. He says health insurance in the country is generally accessed through employer-provided benefits and 82 percent of Americans without health insurance are in families with at least one part time worker. He discusses the Employee Retirement Income Security Act (ERISA) of 1974, which was enacted to regulate the increasing size and complexity of private pension plans provided by employers to their employees. Alternatives to mandated health insurance are explored.

Abstract: A 24-year-old male underwent awake surgery for a lesion in the left dominant basal temporo-occipital junction. During the intraoperative functional mapping using picture naming, cortical stimulation near the visual word form area led to visual paraphasia. These visual paraphasias were also elicited axonally by subcortical stimulation at the anterior wall of the cavity. We propose to discuss the existence of this “visual object form area”, devoted to the visual recognition of object, and its links with the closely related “visual word form area”. We suggest that its afference, whose stimulation also induced visual paraphasias, may be one part of the U-shaped fibers distributed along the posterior part of the occipito-temporal connection system (inferior longitudinal fasciculus). Preservation of this white matter tract is essential for visual recognition. Thus, it should be mapped intraoperatively more systematically. [Copyright &y& Elsevier]

The article discusses a study which investigated the factors that affect hospital length of stay (LOS) among patients with heart failure (HF). The study included 285 HF patients, along with clinical physicians. It found that various factors influence LOS among HF patients. Study authors noted that LOS reduction can only be achieved by making changes in the hospital, shifting from traditional hospital-centric to patient-centric paradigm. They added that every factors in medical care are interrelated and any change in one part can have an effect on others.

Objective. To characterize the activities of projects funded in Agency for Healthcare Research and Quality (AHRQ)'s patient safety portfolio and assess their aggregate potential to contribute to knowledge development. Data Sources. Information abstracted from proposals for projects funded in AHRQ's patient safety portfolio, information on safety practices from the AHRQ Evidence Report on Patient Safety Practices, and products produced by the projects. Study Design. This represented one part of the process evaluation conducted as part of a longitudinal evaluation based on the Context–Input–Process–Product model. Principal Findings. The 234 projects funded through AHRQ's patient safety portfolio examined a wide variety of patient safety issues and extended their work beyond the hospital setting to less studied parts of the health care system. Many of the projects implemented and tested practices for which the patient safety evidence report identified a need for additional evidence. The funded projects also generated a substantial body of new patient safety knowledge through a growing number of journal articles and other products. Conclusions. The projects funded in AHRQ's patient safety portfolio have the potential to make substantial contributions to the knowledge base on patient safety. The full value of this new knowledge remains to be confirmed through the synthesis of results. [ABSTRACT FROM AUTHOR]

Abstract: Incidents and accidents analysis is one part of risk management in healthcare organisations. It is based on methods such as healthcare process analysis and the Association of Litigation and Risk Management (ALARM) method, to understand not only immediate causes but also root causes. The goal is to implement relevant remedial and preventive actions to secure healthcare processes. The hospital''s risk management unit has to be involved in the methodological analysis of every grade zero transfusion incident. The system is based on a retrospective analysis process in compliance with the French National Authority for Health''s ongoing requirements for risk reactive approach, allowing to identify failures and start relevant actions. Healthcare teams should overcome difficulties in order to be totally involved in the process. Human factors recognition, establishment of clear and effective communication between individuals and critical points of control should provide optimum quality care services that are safe and free of unnecessary risks. [Copyright &y& Elsevier]

Background: Tandem stenosis is the occurrence of concurrent cervical and lumbar stenosis. The prevalence has been estimated to be from 5% to 25%. Symptomatic tandem stenosis can present with a confusing scenario of both neurogenic claudication and myelopathy symptoms. Purpose: The purpose of this study was to determine 1) the prevalence of anatomic tandem stenosis in a cadaveric population, 2) if there was an associative relationship between lumbar and cervical stenosis, and 3) the positive predictive values of stenosis in one area for stenosis in the other. Study Design: We obtained 440 skeletally mature skeletons and examined the cervical and lumbar spines from the Hamann Todd Collection in the Cleveland Museum of Natural History. Methods: For the cervical spine, we measured the mid-sagittal canal diameter using digital calipers for every level from C3 through C7. The minimum full central sagittal diameter was recorded for each level. For the lumbar spine, we measured the minimum full mid-sagittal canal diameter for every level from L1 through L5, using digital calipers. Stenosis was defined as a mid-sagittal canal diameter of less than 12 mm at at least one level. After analysis of this data, a second analysis was performed after correcting the data for contemporary body size and radiographic manifestation. Results: The prevalence of tandem stenosis ranged from 0.9% to 5.4% in this population. The association of cervical and lumbar stenosis was found to be statistically significant (p < .05). Stenosis in one part of the spine positively predicts for stenosis in the other area of the spine 15.3% to 32.4% of the time. Conclusion: Tandem stenosis should be considered when evaluating a patient with mixed claudication and myeloradiculopathy symptoms. [ABSTRACT FROM AUTHOR]

Rationale and aims This study focuses on the development of an instrument for the evaluation of clinical practice guidelines and is one part of a research project about the implementation and use of such guidelines among hospitals in the southern region of Sweden. The aim of the present paper was to investigate the test-retest reliability of a questionnaire. Method A questionnaire was designed to gather data about guidelines that have been implemented as well as information about factors, which, according to the Promoting Action on Research Implementation in Health Services (PARIHS)-model, influence the success of implementation. Thirty-nine health professionals at one of the hospitals included in the survey completed the questionnaire on two occasions within a mean time of 5.5 weeks. The test-retest reliability was analysed by means of Cohen's Kappa and percentage concordance. Results Eight items had good agreement in terms of strength and high percentage concordance. With regard to the Kappa values, 13 items show moderate and two fair agreement. Conclusions The test-retest reliability scores show mainly acceptable results indicating a reasonable stability, thus suggesting the possibility of further developing the instrument. The factors described in the PARIHS-model seem relevant for use in evaluating implementation and use of guidelines. The instrument could benefit from a revision of the language in order to enhance clarity and make it less abstract. [ABSTRACT FROM AUTHOR]

The Department of Veterans Affairs (VA) established community-based outpatient clinics to improve veterans' access to primary care. This article compares VA use and expenditures among primary care users at 76 VA-staffed community clinics (n = 17,060) and 32 non-VA contract community clinics receiving capitation (n = 6,842) using VA administrative databases. It estimates utilization using negative binomial models and expenditures using generalized linear one-part or two-part models. Contract community clinic patients are less likely to use all types of outpatient services than VA-staffed community clinic patients but had similar quality of care. For patients seeking care, contract community clinic patients had similar specialty care expenditures but lower primary care, outpatient, and overall expenditures. Results suggest that capitated contract clinics did not shift costs to specialty care and appeared to be an economically efficient mechanism for improving veterans' access to primary care while meeting VA quality of care standards. [ABSTRACT FROM AUTHOR]

There are three known criteria that underlie drug reimbursement decisions: therapeutic value, cost-effectiveness, and burden of disease. However, evidence from recent reimbursement decisions in several jurisdictions points to residual, unexplained variables, among which is budget impact. Budget impact refers to the total costs that drug reimbursement and use entail with respect to one part of the health care system, pharmaceutical care, or to the entire health care system, taking into account the possible reallocation of resources across budgets or sectors of the health care system. The economic and equity rationale for carrying out budget impact analyses is opportunity cost, or benefits forgone, measured in terms of utility or equitable distribution, by using resources in one way rather than another. In other words, by choosing to draw down the budget in one way, decision makers forgo other opportunities to use the same resources. Under a set of unrealistic assumptions, cost-effectiveness analysis accounts for opportunity cost while conveying to the decision maker the price of maximizing health gains, subject to a budget or resource constraint. However, the underlying assumptions are implausible, particularly in the context of pharmaceutical care. Moreover, budget impact analysis is more useful to the decision maker than cost-effectiveness analysis if the objective is not to maximize health gains subject to a budget or resource constraint, but to reduce variance in health gains. With respect to equitable distribution, budget impact analyses lay bare the individuals or groups who lose out-those who bear the opportunity cost of spending resources in accordance with one decision rule rather than another. [ABSTRACT FROM AUTHOR]

Abstract: Assisted reproductive technology (ART) for couples affected by HIV constitutes an important progress for public health. France has been the first country to offer this possibility on a national level, within the public health care system, with the best security and quality standards. This progress is, for one part, a consequence of the collaboration between community-based organizations representing HIV positive persons and their close relations, and pioneer medical teams in this field. This collaboration and this alliance have led to progressively convince the medical community and public health authorities concerned by the fight against aids of the usefulness of this care. Nevertheless, different obstacles have been encountered on the way between theory (decision of the Minister of Health, May 2001, allowing ART for couples affected by HIV), and practice. Medical teams often lack staff in sufficient number. Some doctors have, for reasons they qualify as ethical, refused to take HIV positive women into care. The opening of medical centers in areas where they are missing, particularly the French territories of America, remains a high priority. Last, the legal limits restricting access to ART in France deserve to be questioned. Community-based organizations and medical teams have been able to work as partners, sharing common goals of public health and quality of care. Nevertheless, among health institutions and national agencies in France, the consideration of the point of view of patients and their organizations is far from being a general rule, despite laws which clearly define patients'' collective rights. We thank the Fédération française d''étude de la reproduction (FFER) and the journal Gynécologie Obstétrique & Fertilité for giving non-governmental organizations an opportunity to reaffirm our commitment to constructive common work. [Copyright &y& Elsevier]

Is the British National Health Service (NHS) equitable? This paper considers one part of the answer to this: the utilization of the NHS by different socioeconomic groups (SEGs). It reviews recent evidence from studies on NHS utilization as a whole based on household surveys (macro-studies) and from studies of the utilization of particular services in particular areas (micro-studies). The principal conclusion from the majority of these studies is that, while the distribution of use of general practitioners (GPs) is broadly equitable, that for specialist treatment is pro-rich. Recent micro-studies of cardiac surgery, elective surgery, cancer care, preventive care and chronic care support the findings of an earlier review that use of services was higher relative to need among higher SEGs. [ABSTRACT FROM AUTHOR]

Objective: To reflect on the surge of interest in ‘outcomes’ in mental health services. Conclusions: Reliable assessments underpin the ability to measure change in clinically relevant health status, and no single measure can represent all relevant variables. The measure of change should be regarded as only one part of a larger and dynamic process. Consumer management and service quality improvement activities may be better enhanced by placing emphasis on assessing those domains, which will inform the development of potential clinical management plans, in a quantitative fashion. Where indicated, repeated assessment will provide information which will inform individual patient care, and by grouping data, service planning and continuous improvement activities. [ABSTRACT FROM AUTHOR]

This focus group study examined immigrant Hispanic women's and providers assumptions about and expectations of healthcare encounters in the context of menopause. Four groups of immigrant women from Central America and one group of healthcare providers were interviewed in Spanish and English, respectively. The women wanted provider-initiated, individualized anticipatory guidance about menopause, acknowledgement of their symptoms, and mainstream medical treatment for disruptive symptoms. Providers believed that menopause was an unimportant health issue for immigrant women and was overshadowed by concerns about high-risk medical problems, such as diabetes, heart disease and HIV prevention. The women expected a healthcare encounter to be patient centered, social, and complete in itself. Providers expected an encounter to be businesslike and one part of multiple visit care. Language and lack of time were barriers cited by all. Dissonance between patient-provider assumptions and expectations around issues of healthcare leads to missed opportunities for care. [ABSTRACT FROM AUTHOR]

The overburdening of colorectal out-patient clinics necessarily leads to delays in time from referral to consultation and subsequent clinic attendance. This study aimed to ascertain the feasibility of ‘paper clinic’ follow-up rather than all patients receiving a routine follow-up appointment following investigation. A more efficient outpatient follow-up process should reduce unnecessary follow-up, thereby facilitating the speedy investigation and diagnosis of patients through changes in clinic profiles. From August 2001 all patients seen in the outpatient clinic of one (part time) Consultant colorectal surgeon, who required investigation, were prospectively recorded on a ‘paper clinic’ form. These patients were given the necessary test request forms but were not given a further outpatient appointment. The results of the investigations were reviewed, together with the patients' medical records at a formal fortnightly ‘paper clinic’ session carried out by the Consultant and Nurse Consultant, and a treatment plan derived. Patients then followed one of 5 follow-up pathways and were notified in writing with a copy to their GP. During a 24-month period a total of 897 patients were reviewed using the ‘paper clinic’ follow-up system. Of these, 285 (31.8%) patients were discharged without further follow-up. In a given 3-month period when the clinic was well established, 152 patients were reviewed, of whom 27% were discharged from follow-up, 17% received SOS appointments, 13% required further investigation (and consequently were returned to ‘paper clinic’ follow-up), and 7% received Nurse led follow-up. In this 3-month period 64% of patients reviewed by ‘paper clinic’ follow-up did not return to Surgical Outpatient's and 12% received a Surgical Outpatient appointment for review. ‘Paper clinic’ follow-up is an effective and feasible follow-up alternative, resulting in a major decrease in outpatient follow-up burden. This has allowed the redesign of the outpatient clinic profile allowing for an increase in new urgent slots, and more rapid clinic follow up review of those patients who need it. Re-design and rationalization of existing services can result in considerable service improvement. Expanding clinics should not be considered the only option when faced with capacity and demand issues. [ABSTRACT FROM AUTHOR]

This article explores the recent ferment surrounding professional self-regulation in medicine and other health professions. It reviews the academic literature and sets out an agenda for research. The first section considers definitions, acknowledging the particularly complex regulatory maze in UK health care at present, in which professional self-regulation is only one part. The second section reviews academic writing, currently dispersed among the disciplines. 'The logic of light touch regulation', a feature of the 19th century establishment of the General Medical Council, can perhaps shed light on present debates. Alongside the intense political spotlight on regulation in the wake of the Bristol case, consumer-led research and consumer pressure to rethink the principles of regulation has emerged. This is examined in the third section. Finally, themes for research are advanced. First, there is a need to explore the changing relationship between the state and professions and implications, not only for the professions but for health care more broadly. Second, calls for a new professionalism need to be given clearer content. Third, the moves towards more lay involvement in regulatory bodies need study. Fourth, questions of human rights and professional registers must be explored. Fundamental questions of what professional self-regulation can hope to achieve and where it fits in relation to government ambitions as a whole, remain unresolved. Alongside the work programme of the new overarching regulator, there may well be scope for a new style of public enquiry covering the whole territory of regulation. [ABSTRACT FROM AUTHOR]

A Nursing Centre in Canada was initiated to demonstrate nursing practice in a primary health care context, unencumbered by conventional health care agency parameters. As one part of a multimethod evaluation, a 5 instrument client questionnaire was designed. The main instrument was developed by the researchers to measure the impact of the Centre and nurses' work from the perspective of clients. No established instrument could be found that was appropriate for the Centre's diverse client population and nature and variation in outcomes. To guide the development of the new instrument, minimally structured client interviews were conducted with 15 clients. To assess the validity and reliablity of other selected instruments for the population, clients were asked to comment on the appropriateness of items. Based on findings, the Nurses' Work and Client Outcomes Questionnaire (NWCOQ) was developed, the Client Satisfaction Questionnaire and demographic questions modified, and a Cantril Self-Anchoring ladder to assess health status was supported for use. An open section was added to invite further description of clients' experiences, in particular, the unexpected, contrary or outstanding. Further pilot work was done and the refined five instrument questionnaire then was used to survey all clients who used the Centre during a seven month period. Findings from the NWCOQ revealed the nature of the nurses' work and the degree change occured for clients on multiple health dimensions: physical, emotional, managing their situation, and group and community involvement. Clients were highly satisfied with the Centre and experienced many positive outcomes. The quantitative instruments and results were examined in relation to results from other data collection approaches and data sources. The NWCOQ has evidence of content validity and internal consistency reliability. The use of qualitative methods to develop and refine quantitative instruments for assessment of health outcomes for... [ABSTRACT FROM AUTHOR]

• This paper describes one part of a first-stage study concerned with the care received by a group of adolescents and young adults with insulin-dependent diabetes mellitus (IDDM) in one district health authority. • The paper reports findings from a self-selected sample of 30 patients aged between 15 and 25. Each of the 30 patients was interviewed during a routine appointment at a diabetes clinic. The patients' doctor at the clinic and one of the diabetes specialist nurses also filled in a short questionnaire for each of the patients interviewed. • The main finding was that although all 30 patients interviewed reported that their diabetes control was at least moderately good, a significant number of patients had blood glucose levels above the recommended norm. • The study lends support to the widely held belief that young adults with diabetes have particular difficulties in maintaining blood glucose levels within a normal range. • It is suggested that processes within the current mode of care may be contributing to this poor level of control. Recommendations for a controlled trial of specialist nurse versus doctor care are made. [ABSTRACT FROM AUTHOR]

Background. Between 26th-31th July 2016 r. the World Youth Days took place in Krakow. The program of the event consisted of a youth meeting with the Holy Father Francis and accompanying events with religious and cultural center. Meetings with the biggest number of people took place at Błonie, Kraków and Campus Misericordiae in Brzegi. The Holy Mass at the conclusion of World Youth Day, held on 31st of July gathered around 1.5 - 2 million pilgrims. According to information provided by the Organizing Committee of World Youth Days celebrations in Krakow accumulated almost 3 million participants and the Sunday Mass was attended by 2.5 million people. Medical support of these events was organized by the Krakow Rescue Team. One part of medical coverage of these celebrations was the Medical Component of the State Fire Service (COMED SFS). It provided medical aid to 388 people from countries around the world. The aim of this study is to present the dominant health risks and characteristics of the patient groups which aid was provided to. At COMED SFS and to gather general information about the COMED SFS. Material and methods. The research material contains of the medical documentation, which includes information on age, gender, nationality, patient's initial diagnosis, the procedure and the information about the request of transportation to the hospital or being discharged. Conclusions. In the vast majority of patients, which were provided aid at the COMED SFS, there were no signs of life-threatening factors and the aid was granted at the scene. [ABSTRACT FROM AUTHOR]

There have been numerous initiatives for a long period of time to enhance integration in healthcare in many countries, but these processes still prove to be challenging. More research is needed to understand the interplay between different factors and different collaboration contexts, and this paper makes a contribution in this respect. We explore how collaboration can be established and sustained across organizational boundaries. Theory and methods: We draw on the concept of sense-making (Weick) as we investigate the complex interplay between structure and agency in facilitating or constraining collaboration across organizational boundaries. The empirical material consists of 35 interviews with health personnel participating in three different collaboration initiatives between primary and secondary care regarding obesity and diabetes in Norway. The health care providers involved are all public. The aim of the collaboration is to enhance knowledge sharing and to improve prevention and treatment across primary and secondary care providers tailored to the needs of the patient. The study is part of The Research Council of Norway's evaluation program of The Coordination Reform, a reform addressing coordination and collaboration in healthcare. Results: We find that structure, competence, equality and commitment are important elements to establish and sustain collaboration across organizational boundaries. Discussion: Organizational, technological and financial structures can both facilitate and constrain collaboration. When participants determine their scope of action, they do so by interpreting the latitude provided by structural frames, but also by how they interpret the interaction with others. When participants in primary and secondary care each interpret each other as competent professionals, this enhances collaboration. Furthermore, when participants in both organizations experience the relationship between them as equal, this also enhances collaboration. Likewise, if one part interprets the other part as regarding them as less competent or superior in the relationship, this represents a barrier for collaboration. Many collaboration initiatives have one or several dedicated persons who are highly committed to the collaboration and who drive the work forward in spite of many challenges. However, if not other participants in the collaboration initiatives, as well as in their local community, interpret the collaboration as meaningful and commit themselves to the work, this represents a barrier for collaboration over time. Conclusions: Collaboration depends on participants finding collaboration meaningful. Development of integrated care in our study is neither a result of structural adaptation alone, nor of strategic action alone, but a result of the interactions between concerned actors and their interpretations of structural frames and the actions of others. Implications for policy makers and practitioners are to pay attention to both agency and structure when planning for integration of healthcare services. Limitations: The majority of the informants come from primary care. This could possibly imply a bias towards perspectives from primary care. On the other hand, informants from secondary care are included, and the collaboration initiatives are originally initiated by secondary care. Suggestions for future research: Possible future research includes focusing on how different groups of patients and their carers experience these and other collaboration initiatives. [ABSTRACT FROM AUTHOR]

Introduction: Lithuanian society is one of the rapidly aging societies in Europe. The rise of aging population challenges to rethink policies and to develop new forms and strategies of long term care for chronically ill and dependent elderly. In Lithuania Social welfare and Health care systems are functioning separately and lack patient centered approach to service provision. Assurance sustainability for shifting society forces for intensive transformation of systems. The questions raise how to shape long term home care services for elderly persons based on patient centered approach and how to develop co-ordinated assistance between social and health care providers. The first step of health and social care systems transformation to integrated long term home care is seen the development of mobile teams of health and social care providers. Recently in twenty municipalities departments of social care started experimental integrated home care projects with mobile teams assembled of social and health care providers. Aims: to evaluate the development of new organizational form "mobile teams" in providing integrated home care and interaction of this new form with existing health and social care structures. Methods/settings/participants: conducted qualitative study based on social constructivist strategy. Five semi structured interviews with 5 administrators of mobile teams and focus groups with 5 mobile teams of care providers from five municipalities. Results: In the departments social care provision one part of day social care providers were restructured into mobile teams: next to social worker were employed nurses. The understanding of integrated care provision distinguished between health and social care providers. The social care and health care providers differed in approach to care provision. In the mobile team social care provider seeked empowerment of client in self care activities, the nurses assisted clients without encouraging them to be active in the care process. The nurses tended to take passive role in care planning and see their role to follow physician's prescription. The health care providers were used to subordinated professional interaction, where the physician is responsible for treatment process. The social worker took responsibility for case management, but nurses ignored or did not react to social worker's requests related to persons health care. The health care providers were reluctant to discuss issues as they are not used to dialog culture. The mobile teams' service providers seeking to overcome challenges of integrated care provision initiated round tables discussions with health care service providers and administrators of other municipalities. Challenges in working together provoked new communication models. models: social care providers used psychosocial and health care providers (nurses) applied biomedical model in integrated care provision. The professional status unequalilies caused tension between care providers in the mobile teams. The new model of mobile teams provoked turn of care towards patient centered approach and integration processes between existing social and health care structures. [ABSTRACT FROM AUTHOR]

Background: The successful mainstreaming of assisted living technologies remains an important policy and commercial concern within the UK. Despite this, local telehealth services have not developed at the pace and scale anticipated. This project, funded by the Technology Strategy Board through the Assisted Living Innovation Platform, aims to understand and seeks ways to overcome the financial, organisational and operational barriers to mainstreaming telehealth. Aim: To highlight and reflect on the methodological and practical issues in conducting participatory research in collaboration with telehealth services. Methods: Within the MALT study, a multi-disciplinary consortium of research organisations are collaborating with telehealth services in four specific sites in the Yorkshire and Humber region. The research is composed of two phases: phase 1 involves producing detailed qualitative case studies to identify barriers and facilitators to successful delivery of telehealth, with a view to developing 'change projects'; the implementation and delivery of which will be explored through action research in phase 2. Results: The role of the research team in participatory action research is one of partnership and collaboration. However, there is a consultative element to projects of this nature, as the researchers work alongside stakeholders using the findings from phase 1 to inform the telehealth change projects to initiate and evaluate in phase 2. While participatory research methods are useful for understanding and evaluating change, this partnership approach blurs the role of researchers, who may be seen as imposing change by encouraging sites to look at ways to expand or improve their existing service at a time when cost effectiveness and patient benefit remain unclear. The pace of development regarding the wider use of assisted living technologies also has implications for this research project, given the growing consensus that telehealth should form only one part of a wider menu of digital options that clinicians use with their patients to promote self-management. This broad approach to technology adoption underpins the Department of Health's 3 Million Lives initiative, which can also be seen as an additional top down pressure at the local level to drive forward adoption and upscaling. This makes for complex, yet interesting, case studies within a context of wider structural and commissioning changes for NHS primary care, and equivocal evidence on the effectiveness of telehealth. Conclusion: The MALT study highlights the complexity of telehealth service re-design and the importance of the shifting policy emphasis and technological advancements. Crucially, as local services respond to these developments, the changes can be reactive and organic, and difficult to capture as the research moves forward. It is therefore crucial for the research team to maintain close and regular contact with participants to ensure the ongoing relevance of data collection, analysis and recommendations, and to manage the sometimes competing expectations for the research among different stakeholders. Maintaining this relationship is an integral aspect of the research, however the blurring of researcher roles requires careful reflection on both the extent of and limits to the role played in service development. [ABSTRACT FROM AUTHOR]

The author examines whether improving quality of care helps in saving money. He cites examples where changing clinical practice or improving the way patients move from one part of a health system to another can enhance quality of care for patients and save money. According to a review for the Health Foundation by John Øvretveit, saving money is not a prime motivating factor for clinicians. The review also suggests that the incentive and financial systems for health care providers should be redesigned so that they can start change.

The article discusses how social exclusion has affected the health service sector in Great Britain. According to the author, it is important that every midwife examines their own thoughts, feelings and prejudices, because it would appear that one part of the problem is that a small minority of health professionals harbour negative attitudes towards some groups, which can only be based on ignorance and tired stereotypes. Midwifery leaders often discuss the challenges of making care individualized but if people and health professionals in particular harbour resentments and prejudices then it will be even harder to offer individualized care to all women.