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Objective To determine the health facility cost of cesarean section at a rural district hospital in Rwanda. Methods Using time-driven activity-based costing, this study calculated capacity cost rates (cost per minute) for personnel, infrastructure and hospital indirect costs, and estimated the costs of medical consumables and medicines based on purchase prices, all for the pre-, intra- and post-operative periods. We estimated copay (10% of total cost) for women with community-based health insurance and conducted sensitivity analysis to estimate total cost range. Results The total cost of a cesarean delivery was US$339 including US$118 (35%) for intra-operative costs and US$221 (65%) for pre- and post-operative costs. Costs per category included US$46 (14%) for personnel, US$37 (11%) for infrastructure, US$109 (32%) for medicines, US$122 (36%) for medical consumables, and US$25 (7%) for hospital indirect costs. The estimated copay for women with community-based health insurance was US$34 and the total cost ranged from US$320 to US$380. Duration of hospital stay was the main marginal cost variable increasing overall cost by US$27 (8%). Conclusions for Practice The cost of cesarean delivery and the cost drivers (medicines and medical consumables) in our setting were similar to previous estimates in sub-Saharan Africa but higher than earlier average estimate in Rwanda. The estimated copay is potentially catastrophic for poor rural women. Investigation on the impact of true out of pocket costs on women's health outcomes, and strategies for reducing duration of hospital stay while maintaining high quality care are recommended., Author(s): Jackline Odhiambo [sup.1] , John Ruhumuriza [sup.2] , Theoneste Nkurunziza [sup.2] , Robert Riviello [sup.3] [sup.4] [sup.5] , Mark Shrime [sup.4] [sup.6] , Yihan Lin [sup.4] , Christian Rusangwa [...]

Background: Several international studies have reported negative associations between hospital and/or provider volume and risk of postoperative death following total hip arthroplasty (THA). The only Canadian studies to report on this have been based in Ontario and have found no such association. We describe associations between postoperative deaths following THA and provider caseload volume, also adjusted for hospital volume, in a population-based cohort in New Brunswick. Methods: Our analyses are based on hospital discharge abstract data linked to vital statistics and to patient registry data. We considered all first known admissions for THA in New Brunswick between Jan. 1, 2007, and Dec. 31, 2013. Provider volume was defined as total THAs performed over the preceding 2 years. We fit logistic regression models to identify odds of dying within 30 and 90 days according to provider caseload volume adjusted for selected personal and contextual characteristics. Results: About 7095 patients were admitted for THA in New Brunswick over the 7-year study period and 170 died within 30 days. We found no associations with provider volume and postoperative mortality in any of our models. Adjustment for contextual characteristics or hospital volume had no effects on this association. Conclusion: Our results suggest that patients admitted for hip replacements in New Brunswick can expect to have similar risk of death regardless of whether they are admitted to see a provider with high or low THA volumes and of whether they are admitted to the province's larger or smaller hospitals. Contexte : Plusieurs etudes internationales rapportent un lien negatif entre le volume d'activite de l'hopital ou du fournisseur de soins de sante et le risque de deces postoperatoire lie a une arthroplastie totale de la hanche. Les seules etudes canadiennes qui se sont interessees a cette question ont ete realisees en Ontario et n'ont pas rapporte ce lien. Dans notre etude, nous tentons de decrire des liens entre le deces postoperatoire lie a une arthroplastie totale de la hanche et le volume de la charge de travail du fournisseur de soins de sante, egalement ajustes pour tenir compte du volume d'activite de l'hopital, au sein d'une cohorte basee sur la population au Nouveau-Brunswick Methodes : Nos analyses reposent sur les donnees portant sur les conges des hopitaux, associees aux statistiques de l'etat civil et aux donnees des registres des patients. Nous avons examine toutes les premieres hospitalisations connues en vue d'une arthroplastie totale de la hanche au Nouveau-Brunswick entre le 1 (er) janvier 2007 et le 31 decembre 2013. Le volume d'activite du fournisseur de soins de sante a ete defini comme etant la totalite des arthroplasties totales de la hanche pratiquees au cours des 2 annees precedentes. Nous avons ajuste les modeles de regression logistique de maniere a identifier le risque de deces dans les 30 et 90 jours en fonction du volume de la charge de travail du fournisseur de soins de sante, pour tenir compte de caracteristiques personnelles et contextuelles choisies. Resultats : Environ 7095 patients ont ete admis pour une arthroplastie totale de la hanche au Nouveau-Brunswick au cours de la periode de 7 ans a l'etude, et 170 patients sont decedes dans les 30 jours. Nous n'avons pas observe de liens entre le volume d'activite du fournisseur de soins de sante et la mortalite postoperatoire dans nos modeles. L'ajustement pour tenir compte des caracteristiques contextuelles ou du volume d'activite de l'hopital n'a eu aucune incidence sur ce lien. Conclusion : Nos resultats suggerent que les patients hospitalises afin de subir une arthroplastie de la hanche au Nouveau-Brunswick peuvent s'attendre a un risque similaire de deces, peu importe que leur fournisseur de soins de sante pratique un volume faible ou eleve d'arthroplasties totales de la hanche ou que le patient soit admis dans un petit ou un grand hopital de la province., Extensive research has established that for some surgeries, higher provider caseload volume and/or higher hospital volumes are associated with lower risk of postoperative death. (1-3) This association is based on [...]

IN THIS PAPER, PROFESSOR Regis will argue that the future of conflict resolution in the adoption of new technologies lies in our capacity to minimize conflict, that is, to develop [...]

The NHS is in a state of constant change; therefore, it is necessary to have good leadership in diabetes nursing. This article focuses on how effective leadership can improve the [...]

Despite the increased availability of evidence-based prevention programs targeting serious mental health problems, an ongoing challenge within the field of prevention science is transporting prevention programs into real-world settings where their health impact can be fully realized. As part of a going-to-scale study, we examined how context, namely the characteristics of the practitioners and organizations, promotes or impedes fidelity of implementation of prevention efforts. Practitioners delivered Early Risers, an intensive, multicomponent, indicated prevention program across 27 geographically dispersed elementary schools and recorded 3 indexes of fidelity--exposure, adherence, and quality of implementation. As predicted, practitioner characteristics, including personality traits (low neuroticism, high extraversion, openness, and conscientiousness), beliefs (pre-implementation beliefs about program success), and use of flexible coping strategies (reappraisal coping) were related to various fidelity indexes. Contrary to predictions, teachers' negative perceptions of the organizational structure were positively related to fidelity. Follow-up regression analyses suggested that practitioner characteristics differentially predict fidelity for child and family programming. Keywords: targeted or tertiary prevention, going-to-scale, fidelity, practitioner characteristics, organizational culture and climate DOI: 10.1037/a0014623

Much of prior work in the area of service operations management has assumed service rates to be exogenous to the level of load on the system. Using operational data from patient transport services and cardiothoracic surgery--two vastly different health-care delivery services--we show that the processing speed of service workers is influenced by the system load. We find that workers accelerate the service rate as load increases. In particular, a 10% increase in load reduces length of stay by two days for cardiothoracic surgery patients, whereas a 20% increase in the load for patient transporters reduces the transport time by 30 seconds. Moreover, we show that such acceleration may not be sustainable. Long periods of increased load (overwork) have the effect of decreasing the service rate. In cardiothoracic surgery, an increase in overwork by 1% increases length of stay by six hours. Consistent with prior studies in the medical literature, we also find that overwork is associated with a reduction in quality of care in cardiothoracic surgery--an increase in overwork by 10% is associated with an increase in likelihood of mortality by 2%. We also find that load is associated with an early discharge of patients, which is in turn correlated with a small increase in mortality rate. Key words: health-care operations; productivity; service operations; optimal control of queues; quality History: Received April 24, 2007; accepted April 3, 2009, by Linda V. Green, public sector applications. Published online in Articles in Advance July 6, 2009., 1. Introduction Over the last decade, most hospitals have witnessed a substantial increase in fixed costs, largely reflecting growing expenses for new technologies and liability insurance. Over the same period, [...]

Drawing on a longitudinal study from the early years of implementation of health-care networks in Quebec, this article describes how public-sector managers deal with complex challenges when both organizational structures and organizational strategies are radically transformed simultaneously. The new organizations studied had to completely re-shuffle roles and responsibilities of their management teams while making sense of their new mandate of developing a population-focused approach to health problems--all the time maintaining day-to-day operations. The four health-care networks studied proceeded somewhat differently to meet these reciprocal challenges. The study reveals the importance of balancing organizing initiatives (focused on structures) with "sense-making" initiatives (focused on strategies), of developing capacities for sense-making through the creation of key "sense-maker/sense-giver" positions whose occupants are able to ensure that conceptual activities engage people working at different levels, even as organizational structures are in flux, and of mobilizing external constraints and influences as opportunities and resources in sense-making and organizing. Se fondant sur une etude longitudinale des premieres annees de la mise en oeuvre des reseaux de soins de sante au Quebec, cet article decrit la maniere dont les gestionnaires du secteur public font face a des defis complexes, alors que les structures et les strategies organisationnelles sont radicalement transformees simultanement. Les nouveaux organismes etudies ont du completement remanier les roles et les responsabilites de leurs equipes de gestion et comprendre leur nouveau mandat d'elaborer une approche axee sur la population pour ce qui est des problemes de sante, tout en maintenant leurs activites au jour le jour. Les quatre reseaux de soins de sante etudies ont travaille a relever ces defis reciproques d'une maniere assez differente. L'etude revele l'importance de trouver un equilibre entre les initiatives consistant a organiser (axees sur les structures) et les initiatives consistant a interpreter les faits (axees sur les strategies); de perfectionner les capacites a interpreter les faits grace a la creation de postes cles d' << interpreteurs de faits >>, dont les titulaires veilleraient a ce que des activites conceptuelles fassent intervenir les gens travaillant a differents niveaux meme lorsque les structures organisationnelles fluctuent continuellement; et enfin de tirer parti des contraintes et influences externes comme autant d'occasions et de ressources pour interpreter et organiser les faits., This article examines a key issue in contemporary public administration: the challenge of implementing large-scale reform in public delivery systems (Peters and Savoie 1998; Rocher 2008; Exworthy and Powell 2004; [...]

This ethnographic study of 'goal displacement' in an adult day care center explains how and why certain goals come to surpass others in the organizational practices of elder day care settings. Adult day care is often oriented towards providing family caregivers with respite rather than attempting to directly improve the lives of the elders themselves. Although the adult day care center studied (CADC) was ostensibly founded to care for and improve the lives of elders with dementia, the center instead focused on providing respite for family caregivers who depended on the center for relief from care-giving. I show how the goals that CADC could realistically pursue, and the population it ultimately came to serve, were limited by the larger structural setting in which the organization operated. CADC's dependence on a limited pool of external resources of questionable quality converged with the organizational demands of a difficult population in such a way that simply providing a safe and orderly environment strained the organization to the limit. Providing care that aimed to directly improve elders' lives was seen as unreasonable, because this would have required unavailable resources, personnel, and training. In contrast, helping family caregivers by adopting a 'respite focus' was seen as reasonable and worthwhile. Thus, family caregivers came to supplant elders as the de facto clients of CADC. The goal of improving elders' lives remained, but only in brochures and ideology, not organizational practice. Still, this goal remained an important part of the organizational discourse of CADC, since widely shared cultural understandings of the type of care elders deserve, constrained the way the organization could present itself.

The presence of a long-term care ombudsman in a long-term care or nursing facility helps prevent abusive or neglectful situations before they start. Almost all Missouri long-term care facility administrators responding to the survey reported that they were aware of the ombudsman program; however, only half currently house an ombudsman in their facility. Respondents aware of the program were significantly more likely to currently accommodate an ombudsman in their facility, and those managing larger facilities were significantly more likely to currently have an ombudsman present. Given the numerous changes in the long-term care system, the need for more ombudsman advocates in this setting is crucial. KEYWORDS long-term care, advocates, nursing homes

Since devolution, the four countries of the United Kingdom have pursued strikingly different National Health Service (NHS) reforms. While England created a supply-side market more radical than the previous internal market system, Wales moved to a softer version of the purchaser/provider split emphasizing localism. This article deploys institutional theory to analyze the forces shaping change, and describes the hybrid forms of economic organization emerging, including the economic regulation model implemented in England. The schism that has resulted in separate NHS subsystems warrants a different analysis from the more familiar phenomenon of infield divergence. We argue that schism was triggered by political-regulatory influences rather than economic or other social institutional forces, and predict that other decentralized public healthcare systems may follow a similar path. While political-regulatory, normative, and cognitive institutional influences push in the same direction in Wales, the misalignment of political-regulatory and normative elements in England looks set to result in a period of organizational turbulence.

Several studies have documented low rates of agreement between clinician- and researcher-generated diagnoses. However, little is known about whether this lack of agreement has implications for the processes and outcomes of subsequent treatment. To study this possibility, the authors used diagnostic agreement to predict therapy engagement and outcomes for 197 youths treated in 5 community mental health clinics. Diagnostic agreement predicted better therapy engagement, with the agree group having fewer therapy no-shows and cancellations and a decreased likelihood of therapy dropout. Additionally, support for a link between agreement and treatment outcomes was found, as the agree group obtained larger reductions in parent-reported internalizing problems during treatment. These findings suggest that diagnostic accuracy may be an important precursor to successful treatment and highlight the importance of future research to find ways to incorporate standardized diagnostic procedures into clinical care settings. Keywords: diagnostic agreement, youth mental health services, treatment outcomes, therapy engagement

We examined the differential outcomes in residential treatment for youths with conduct disorder (CD)--with special attention paid to interactions with age and gender--in a sample of children and adolescents in 50 residential treatment centers and group homes across Illinois. Multi-disciplinary teams rated youths ages 6-20 (N = 457) on measures of mental health and other factors within 30 days of admission, about 7 months after admission, and at discharge. While both groups initially responded similarly to treatment, the CD group performed better relative to the non-CD group over the full course of treatment, showing healthier relative change on five outcomes variables and more significant improvement. Age range moderated the relationship between CD group membership and change in work/ school performance. There were significant between groups differences within the youngest age group (6-11 years) in which the CD group worsened relative to the non-CD group. Keywords Conduct disorder * Residential treatment * Outcomes * Children * Adolescents

Leading public health agencies have developed guidelines for essential services and core competencies. The study described here was conducted to determine the level of practice of the 10 essential services and abilities in the 14 core competencies among environmental public health practitioners in Alabama. Questionnaires about the practice of the essential services, abilities in the core competencies, and demographics were collected from 255 (88%) practitioners and analyzed by statistical methods. According to the results of this study, these practitioners spent most of their time diagnosing, investigating, enforcing, educating, and linking people to public health services. They had increasing levels of practice as they were promoted to higher-level jobs, and the level of practice was greater in rural counties than in urban. They rated their skill in all of the core competencies to be at least pretty good. Practitioners with high school degrees had lower abilities than those with college degrees. Overall, these professionals were better educated, younger, and had better skills than expected., Introduction Environmental concerns are considered among the most important health issues and global threats (Centers for Disease Control and Prevention [CDC], 2003). In the past, regulation of water supply, sewage [...]

This study examined predictors of readmission for a sample of 522 adolescents enrolled in Medicaid and admitted to three inpatient psychiatric hospitals in Maryland. Comprehensive data on clinical, treatment, and health care system characteristics were collected from archival sources (medical records, Medicaid claims, and the Area Resource File). Predictors of readmission were examined with bivariate (Kaplan Meier) and multivariate (Cox Regression) survival techniques. One-year readmission rates were 38% with the majority occurring within 3 months after discharge. Adolescent demographic (age and gender), clinical (severity of symptoms, comorbidity, suicidality) and family characteristics (level of family risk) were associated with readmission. However, treatment factors including type of aftercare, postdischarge living environment, medication noncompliance, and hospital provider were among the strongest predictors of readmission. Study findings underscore the importance of careful discharge planning and linkage to appropriate aftercare. The differing rates of readmission across hospitals also suggest that organizational level factors may play a vital role in determining treatment outcomes. Keywords: inpatient psychiatric hospitalization, adolescents, readmission

We describe cases from the clinical records in the Intensive Mental Health Program to illustrate the diverse presenting problems, intervention strategies, therapeutic process, and outcomes for children receiving services in this schoolbased, community-oriented treatment model. Cases reflect varying degrees of treatment response and potential factors that influence the fluctuating levels of emotional disturbance and impaired functioning in the home, school, and community. Keywords Serious emotional disturbance * School-based programs * Intensive mental health program * Case descriptions

We provide information about consumer and provider perceptions using a mixed-model pilot study within the Intensive Mental Health Project (IMHP), a school-based treatment service for children with SED and their families. Caregiver, youth, and provider questionnaires developed for this project elicited quantitative and qualitative information on treatment satisfaction, therapeutic alliance, and active involvement in treatment. Caregivers and children overall had positive perceptions of the services they received through IMHP. Providers reported very good working relationships with most children and families. Consumers also provided constructive comments about how to improve services. Our results add support to the importance of therapeutic alliance and collaboration, which are guiding principles of the IMHP. Keywords Consumer satisfaction * Serious emotional disturbance * Therapist perceptions

We examined behavioral markers of caregiver involvement and the ways in which family participation was related to treatment outcomes in 47 elementary school children with SED enrolled in a school-based intensive mental health program. Measures of caregiver involvement included therapeutic home visits, attendance at therapeutic meetings, completion of ratings on the daily point sheet, and extra communications with the therapeutic team on the point sheet. Greater initial impairment was associated with greater caregiver involvement. Greater caregiver involvement was linked to improvement in child thought processes, increased ability to provide emotional and social supports for the child, and greater overall child functioning at discharge. Our findings also reflected increased therapists' attempts to provide additional in-home services in cases where caregivers demonstrated a decline in their ability to provide for their children's physical and material needs, or in which therapists discovered that the family functioning was more impaired than what was initially assessed. We provide a case study that exemplifies many of these findings. Keywords Caregivers * Serious emotional disturbance * Clinical outcomes * Program evaluation

We investigated the use of a popular measure, the Children and Adolescent Functional Assessment Scale (CAFAS), in treatment outcome research. The sample included 70 children who had been discharged from an elementary therapeutic classroom (Intensive Mental Health Program). Significant relationships were found between decreases in CAFAS scores and optimal educational placement, contributing to evidence of the scale's discriminant validity. Clinically significant change in CAFAS scores was also investigated, with a 30 point change in score most accurately discriminating between placements after discharge. Further investigations of real world outcomes versus changes in score on this measure are warranted. Keywords CAFAS * Discriminant validity * Clinical significance * Outcomes * School-based intervention

We describe changes in adaptive functioning for children enrolled in the Intensive Mental Health Program (IMHP), an innovative model for serving children with the most severe forms of SED. Most children show marked improvements in multiple indicators of role performance and symptomatology. Although a high risk, high need group, most children attended school regularly and lived with a stable caregiver at discharge. Keywords Serious emotional disturbance * Treatment outcome * Program evaluation * School-based interventions

Introduction: The main objective of our study was to determine the rates of negative appendectomies and perforated appendices at the Labrador Health Centre, and make a comparison with the rates [...]

Objective: Multiple studies conducted over many years have demonstrated that pain is poorly managed in the emergency department (ED). This phenomenon has been referred to in the medical literature as [...]

Background. Multidimensional preventive home visit programs aim at maintaining health and autonomy of older adults and preventing disability and subsequent nursing home admission, but results of randomized controlled trials (RCTs) have been inconsistent. Our objective was to systematically review RCTs examining the effect of home visit programs on mortality, nursing home admissions, and functional status decline. Methods. Data sources were MEDLINE, EMBASE, Cochrane CENTRAL database, and references. Studies were reviewed to identify RCTs that compared outcome data of older participants in preventive home visit programs with control group outcome data. Publications reporting 21 trials were included. Data on study population, intervention characteristics, outcomes, and trial quality were double-extracted. We conducted random effects meta-analyses. Results. Pooled effects estimates revealed statistically nonsignificant favorable, and heterogeneous effects on mortality (odds ratio [OR] 0.92, 95% confidence interval [CI], 0.80-1.05), functional status decline (OR 0.89, 95% CI, 0.77- 1.03), and nursing home admission (OR 0.86, 95% CI, 0.68-1.10). A beneficial effect on mortality was seen in younger study populations (OR (I.74, 95% CI, 0.58-0.94) but not in older populations (OR 1.14, 95% CI, 0.90-1.43). Functional decline was reduced in programs including a clinical examination in the initial assessment (OR 0.64, 95% CI, 0.48-0.87) but not in other trials (OR 1.00, 95% CI, 0.88-1.14). There was no single factor explaining the heterogenous effects of trials on nursing home admissions. Conclusion. Multidimensional preventive home visits have the potential to reduce disability burden among older adults when based on multidimensional assessment with clinical examination. Effects on nursing home admissions are heterogeneous and likely depend on multiple factors including population factors, program characteristics, and health care setting. Key Words: Aged--Geriatric assessment--Home visit--In-home--Multidimensional geriatric assessment--Older adults--Preventive home visit.

Background. The quality of health care for older Americans with multiple chronic conditions is suboptimal. We designed 'Guided Care' (GC) to enhance quality of care by integrating a registered nurse, intensively trained in chronic care, into primary care practices to work with physicians in providing comprehensive chronic care to 50-60 multimorbid older patients. Methods. We hypothesized that GC would improve the quality of health care for this population. In 2006, we began a cluster-randomized controlled trial of GC at eight practices (n = 49 physicians). Older patients of these practices were eligible to participate if they were at risk for using health services heavily during the coming year. Teams of two to five physicians and their at-risk older patients were randomized to either GC or usual care (UC). Six months after baseline, participants rated the quality of their health care by answering validated closed-ended questions from telephone interviewers who were masked to group assignment. Results. Of the 13,534 older patients screened, 2391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 6 months, 93.8% and 93.2% of the GC and UC participants who remained alive and eligible completed telephone interviews. GC participants were more likely than UC participants to rate their care highly (adjusted odds ratio = 2.0, 95% confidence interval, 1.2-3.4, p = .006), and primary care physicians were more likely to be satisfied with their interactions with chronically ill older patients and their families (p < .05). Conclusions. GC improves important aspects of the quality of health care for multimorbid older persons. Additional data will become available as this trial continues. Key Words: Multimorbid--Care management--Randomized trial--Self-management--Quality of care.

The systematic adoption of 'second-generation' comprehensive geriatric assessment instruments, initiated with the Minimum Data Set (MDS) implementation in U.S. nursing homes, and continued with the uptake of related MDS instruments internationally, has contributed to the creation of large patient-level data sets. In the present special article, we illustrate the potential of analyses using the MDS data to: (a) identify novel prognostic factors; (b) explore outcomes of interventions in relatively unselected clinical populations; (c) monitor quality of care; and (d) conduct comparisons of case mix, outcomes, and quality of care. To illustrate these applications, we use a sample of elderly patients admitted to home care in 11 European Home Health Agencies that participated in the AgeD in Home Care (AD-HOC) project, sponsored by the European Union. The participants were assessed by trained staff using the MDS for Home Care, 2.0 version. We argue that the harmonization by InterRAI of the MDS forms for different health settings, referred to as 'the third generation of assessment,' has produced the first scientific, standardized methodology in the approach to effective geriatric care. Key Words: Comprehensive geriatric assessment--Minimum data set--Scales--Older adults--Nursing homes--Resident assessment instrument--Home care.

Background. The effectiveness of community-based geriatric intervention models for vulnerable older adults is controversial. We evaluated a problem-based multidisciplinary intervention targeting vulnerable older adults at home that promised efficacy through better timing and increased commitment of patients and primary care physicians. This study compared the effects of this new model to usual care. Methods. Primary care physicians referred older people for problems with cognition, nutrition, behavior, mood, or mobility. One hundred fifty-one participants (mean age 82.2 years, 74.8% women) were included in a pseudocluster randomized trial with 6-month follow-up for the primary outcomes. Eighty-five participants received the new intervention, and 66 usual care. In the intervention arm, geriatric nurses visited patients at home for geriatric assessment and management in cooperation with primary care physicians and geriatricians. Modified intention-to-treat analyses focused on differences between treatment arms in functional abilities (Groningen Activity Restriction Scale-3) and mental well- being (subscale mental health Medical Outcomes Study [MOS]-20), using a mixed linear model. Results. After 3 months, treatment arms showed significant differences in favor of the new intervention. Functional abilities improved 2.2 points (95% confidence interval [CI], 0.3-4.2) and well-being 5.8 points (95% CI, 0.1-11.4). After 6 months, the favorable effect increased for well-being (9.1; 95% C1, 2.4-15.9), but the effect on functional abilities was no longer significant (1.6; 95% CI, 0.7 to 3.9). Conclusions. This problem-based geriatric intervention improved functional abilities and mental well-being of vulnerable older people. Problem-based interventions can increase the effectiveness of primary care for this population. Key Words: Primary health care--Frailty--Health services research--Multidimensional geriatric assessment--Health services for the aged.

The study compares the effects of structural bases and functional elements of social support on mental health in Taiwan and the United States, using the study conducted in the United States by Lin, Ye, and Ensel (1999) as a reference. Based on a nationally representative sample of Taiwanese adults (n = 2,835), a fundamental similarity in social support structure and function between the two countries was observed. First, the structural bases of social support had a hierarchical order in their effects on depression: Binding (presence of an intimate relationship) was the strongest in reducing depression, whereas belonging (community participation) was the weakest, with bonding (social networks) in between. Regarding the functional elements, perceived social support was a better protector of mental health than actual social support, a finding in line with previous research. On the other hand, several notable differences in the structural bases and functional elements of social support between the two societies were observed, possibly due to the differential cultural and historical characteristics.

A retrospective cohort study was conducted to evaluate the effect of the built environment of an emergency department (ED) on the timeliness of physician assessment of chest pain patients. The main outcome variable was time to initial physician assessment. Potential predictor variables included presence of a solid door, distance of treatment room from work area, staffing team, day of week, and the patient's age, sex, and triage level. After multivariate adjustment, the only predictors of time to initial assessment greater than 10 minutes were being placed in a room with a door (adjusted odds ratio [OR] 1.58; 95% confidence interval [CI] 1.01-2.48) and being placed in a room 25 feet or more from the main physician work area (adjusted OR 1.38; 95% CI 1.13-1.67). These findings suggest that the ED built environment can be a barrier for providing timely care for this group of patients and may have implications for future ED architectural designs. Keywords: emergency medicine; built environment; quality of care

Flexibility in health care design is typically addressed from an architectural perspective without a systematic understanding of its meaning from the end-user's viewpoint. Moreover, the architectural perspectives have been generally focused on expandability and convertibility. This study explored flexibility needs in adult medical-surgical inpatient care with the objective to understand its meaning from an end-user perspective and identify characteristics of the physical environment that promote or impede stakeholder' requirements. Semistructured interviews were conducted using a qualitative design with 48 stakeholders in nursing and nursing-support services at 6 hospitals across the United States. Data were collected during September-November 2006. Findings suggest that adaptability influences more aspects of unit operations than convertibility or expandability. Furthermore, physical design characteristics affect 9 critical operational issues where flexibility is required, spanning nursing, environmental services, materials management, dietary services, pharmacy, and respiratory therapy. Keywords: adaptability; convertibility; efficiency; expandability; flexibility; inpatient unit

Qualitative research methodologies can play an important role in health care design as they can provide contextual data about health care settings--specifically the people, processes, and patterns that make up the daily work of providing health care. Health care is provided in complex environments with intricate webs of relationships, which represent the multiple interactions with people, information, technology, culture, and the physical environment in which the care is provided. One could ask, 'Is good design possible without an understanding of the context in which the work occurs?' Qualitative methods can capture the experiential aspects of design and usability; however, certain qualitative methods are better suited to capture the complexity of health care. These include observations, focus groups, and interviews, which are discussed in depth. Keywords: qualitative methods; hospital design; observations; focus groups; process mapping

The Multisite Opiate Substitution Treatment study evaluated whether adhering to clinical-trial-derived practice guidelines improves treatment outcomes of unselected opiate-dependent patients seen in everyday practice. Clinics that were relatively concordant (n = 4) or nonconcordant (n = 4) with guidelines concerning medication dose levels and psychosocial service provision were identified. Staff interviewed 256 patients at intake and 6-month follow-up regarding past month heroin use, criminal activities, and mental health. To represent real-world practice conditions, clinics provided care in accordance with their usual approach, and no patient exclusion criteria were employed. Patients in each type of clinic were similar at baseline, but by follow-up, heroin use and mental health outcomes were significantly better in guideline-concordant clinics than in guideline-discordant clinics. Notably, 60.6% of patients in concordant clinics had urinalysis-confirmed heroin abstinence versus only 40.0% in nonconcordant clinics. Following research-derived practice guidelines seems to increase opiate substitution treatment effectiveness for opiate-dependent patients in the real world. Keywords: Opioid substitution; Evidence-based medicine; Clinical practice guidelines; Heroin dependence; Effectiveness research

Purpose: This article reports on a study to identify 'building blocks' for quality report cards for geriatric care. Its aim is to present (a) the results of the study and (b) the innovative step-by-step approach that was developed to arrive at these results. Design and Methods: We used Concept Mapping/Structured Conceptualization to define the building blocks. Applied to this study, we carried out Concept Mapping using several data collection methods: (a) a Web search, (b) semistructured interviews, (c) document analysis, (d) questionnaires, and (e)focus groups. Results: The findings showed that, although home care and institutional care for elderly adults share many quality themes, experts need to develop separate quality report cards for the two types of geriatric care. Home care consumers attach more value to the availability, continuity, and reliability of care, whereas consumers of institutional care value privacy, respect, and autonomy most. This study also showed, unlike many other quality report card studies, that consumers want information on structure, process and outcome indicators, and rating outcome indicators such as effectiveness and safety of care both for home care and for institutional care. Concept Mapping proved to be a valuable method for developing quality report cards in health care. Implications: Building blocks were delivered for two quality report cards for geriatric care and will be used when quality report cards are built in The Netherlands. For the U.S. context, this study shows that current national report cards for geriatric care should be supplemented with quality-of-life data. Key Words: Indicators, Quality information, Choice, Performance, Health care consumers, Regulated competition

Health care professionals' and trainees' conceptions of their responsibilities to patients can change over time for a number of reasons: evolving career goals, desires to serve different patient populations, and changing family obligations, for example. Some changes in conceptions of responsibility are healthy, but others express moral damage. Clinicians' changes in their conceptions of what they are responsible for express moral damage when their responses to others express a meager, rather than robust, sense of what they owe others. At least two important expressions of moral damage in the context of health care are these., callousness and divestiture. Callousness describes the poor condition of a clinician's capacity for moral perception; when her capacity to accurately appreciate features of moral relevance that configure others' needs, vulnerabilities, and desert of care diminishes, such that she fails to respond with care to those for whom she has duties to care, she is callous. Callousness has been explored in detail elsewhere, (1) and so the focus of this paper is divestiture. A clinician divests when the value of responding with care to others becomes less centrally and importantly constitutive of his personal and professional identity. Divestiture has important consequences for patients and health professions education, which I will explore here. Keywords: callousness, clinical moral perception, legalism, moral damage, professionlism

Background: Psychiatric Intensive Care Units (PICU) have been part of most inpatient psychiatric services for some time, although information about their functioning and outcome has not previously been collated. Aim: To conduct a systematic literature review to assess the current state of knowledge about such services. Method: A search of electronic databases was undertaken, followed by obtaining additional references from items obtained. Results: Over 50 papers in English containing some empirical data were identified. Most studies were retrospective. Typical PICU patients are male, younger, single, unemployed, suffering from schizophrenia or mania, from a Black Caribbean or African background, legally detained, with a forensic history. The most common reason for admission is for aggression management, and most patients stay a week or less. Evidence of the efficacy of PICU care is very poor. Conclusions: Most research so far has been small scale, and more substantial work using better methodologies is clearly required.

The degree of substance-induced syndrome (SIS) was evaluated in 5,116 acutely hospitalized suicidal psychiatric inpatients. Admission and discharge severity ratings were made by academic attendings using structured forms. Outcome variables analyzed include ratings of psychiatric symptom severity on admission and discharge, length of stay, severity of SIS, and severity of alcohol/drug problems. Suicidal inpatients rated with a high degree of SIS were more likely to be homeless, to be unemployed, to be uncooperative, to have shorter lengths of stay, and to show a more rapid improvement in symptoms. These patients represent a subgroup of the co-occurring disorders population having a high degree of addiction severity with temporary substance-induced suicidal syndromes and are subjected to the most expensive level of care in the mental health system. Implications of these findings include the fact that psychiatric inpatient services need to provide intensive addiction intervention treatment and that outpatient addiction services need improved capability and capacity to care for suicidal patients. Keywords: Suicide; Substance induced; Alcohol; Drug

Context.--Pathology services are poorly developed in Sub-Saharan Africa. Komfo Anokye Teaching Hospital in Kumasi, Ghana, asked for help from the pathology department of the University Hospital of North Norway, Tromso. Objective.--To reestablish surgical pathology and cytology in an African pathology department in which these functions had ceased completely, and to develop the department into a self-supporting unit of good international standard and with the capacity to train new pathologists. Design.--Medical technologists from Kumasi were trained in histotechnology in Norway, they were returned to Kumasi, and they produced histologic slides that were temporarily sent to Norway for diagnosis. Two Ghanaian doctors received pathology training for 4 years in Norway. Mutual visits by pathologists and technologists from the 2 hospitals were arranged for the introduction of immunohistochemistry and cytology. Pathologists from Norway visited Kumasi for 1 month each year during 2007-2010. Microscopes and immunohistochemistry equipment were provided from Norway. Other laboratory equipment and a new building were provided by the Ghanaian hospital. Results.--The Ghanaian hospital had a surgical pathology service from the first project year. At 11 years after the start of the project, the services included autopsy, surgical pathology, cytopathology, frozen sections, and limited use of immunohistochemistry, and the department had 10 residents at different levels of training. Conclusions.--A Ghanaian pathology department that performed autopsies only was developed into a self-supported department with surgical pathology, cytology, immunohistochemistry, and frozen section service, with an active residency program and the capacity for further development that is independent from assistance abroad. (Arch Pathol Lab Med. 2017;141:1533-1539; doi: 10.5858/arpa.2016-0498-0A), Pathology services are poorly developed in Sub-Saharan Africa. Most countries have less than 1 pathologist per 1 million inhabitants. (1-3) This is a particular problem for the treatment of cancer, [...]

Abstract The USA and New Zealand have different health and social care systems, but both share a desire for high-quality, affordable, long-term care for elders. In the USA moves have [...]

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.apergo.2005.07.003 Byline: Ben-Tzion Karsh (a), Kamisha Hamilton Escoto (b), John W. Beasley (c), Richard J. Holden (b) Keywords: Patient safety; Medical error; Reporting systems Abstract: The release of the Institute of Medicine () report 'To Err is Human', brought attention to the problem of medical errors, which led to a concerted effort to study and design medical error reporting systems for the purpose of capturing and analyzing error data so that safety interventions could be designed. However, to make real gains in the efficacy of medical error or event reporting systems, it is necessary to begin developing a theory of reporting systems adoption and use and to understand how existing theories may play a role in explaining adoption and use. This paper presents the results of a 9-month study exploring the barriers and facilitators for the design of a statewide medical error reporting system and discusses how several existing theories of technology acceptance, adoption and implementation fit with many of the results. In addition we present an integrated theoretical model of medical error reporting system design and implementation. Author Affiliation: (a) Department of Industrial Engineering, University of Wisconsin-Madison, 1513 University Avenue, Room 387, Madison, WI 53706, USA (b) Department of Industrial Engineering, University of Wisconsin-Madison, 1513 University Avenue, Room 392, Madison, WI 53706, USA (c) Department of Family Medicine, University of Wisconsin-Madison, 777 South Mills Street, Room 2812, Madison, WI 53715, USA Article History: Received 22 February 2005; Accepted 15 July 2005