Integration of decision support systems to improve decision support performance

Decision support system (DSS) is a well-established research and development area. Traditional isolated, stand-alone DSS has been recently facing new challenges. In order to improve the performance of DSS to meet the challenges, research has been actively carried out to develop integrated decision support systems (IDSS). This paper reviews the current research efforts with regard to the development of IDSS. The focus of the paper is on the integration aspect for IDSS through multiple perspectives, and the technologies that support this integration. More than 100 papers and software systems are discussed. Current research efforts and the development status of IDSS are explained, compared and classified. In addition, future trends and challenges in integration are outlined. The paper concludes that by addressing integration, better support will be provided to decision makers, with the expectation of both better decisions and improved decision making processes

History of Dialysis in the UK: c.1950-1980

Annotated and edited transcript of a Witness Seminar held on 26 February 2008. Introduction by Professor John Pickstone.First published by the Wellcome Trust Centre for the History of Medicine at UCL, 2009.©The Trustee of the Wellcome Trust, London, 2009.All volumes are freely available online at:www.history.qmul.ac.uk/research/modbiomed/wellcome_witnesses/Annotated and edited transcript of a Witness Seminar held on 26 February 2008. Introduction by Professor John Pickstone.Annotated and edited transcript of a Witness Seminar held on 26 February 2008. Introduction by Professor John Pickstone.Annotated and edited transcript of a Witness Seminar held on 26 February 2008. Introduction by Professor John Pickstone.Annotated and edited transcript of a Witness Seminar held on 26 February 2008. Introduction by Professor John Pickstone.Dialysis, the first technological substitution for organ function, is significant not only for the numbers of patients who have benefited. It contributed to the emergence of the field of medical ethics and the development of the nurse specialist, and transformed the relationship between physicians and patients by allowing patients to control their treatment. This seminar drew on participants’ recollections of dialysis from the early, practically experimental days after the Second World War, when resources for research were scant, until the 1980s when it had become an established treatment. Pioneers from the first UK dialysis units recalled the creation of the specialty of nephrology amid discouragement from renal physicians and the MRC, which felt that the artificial kidney was a gadget that would not last. International and interdisciplinary collaborations, and interactions between with industry and clinics in developing and utilising the specialist technology were emphasized. Patients, carers, nurses, technicians and doctors reminisced about their experiences of home dialysis, its complications and impact on family life, as well as the physical effects of surviving on long-term dialysis before transplantation became routine. The meeting was suggested and chaired by Dr John Turney and witnesses include Dr Rosemarie Baillod, Professor Christopher Blagg, Professor Stewart Cameron, Mr Eric Collins, Professor Robin Eady, Mrs Diana Garratt, Professor David Kerr, Professor Sir Netar Mallick, Dr Frank Marsh, Dr Jean Northover, Dr Chisholm Ogg, Dr Margaret Platts, Dr Stanley Rosen and Professor Stanley Shaldon. Two appendices contain reminiscences from Professor Kenneth Lowe and Sir Graham Bull. Crowther S M, Reynolds L A, Tansey E M. (eds) (2009) History of dialysis in the UK: c. 1950–2000, Wellcome Witnesses to Twentieth Century Medicine, vol. 37. London: The Wellcome Trust Centre for the History of Medicine at UCL. ISBN 978 085484 1226The Wellcome Trust Centre for the History of Medicine at UCL is funded by the Wellcome Trust, which is a registered charity, no. 210183

Addressing Profound Disadvantages to Improve Indigenous Health and Reduce Hospitalisation: A Collaborative Community Program in Remote Northern Territory

BACKGROUND: Aboriginal people in rural and remote areas of the Northern Territory of Australia have suffered longstanding issues of homelessness and profound health and social inequities. The town and region of Katherine are particularly impacted by such inequities and have the highest rates of homelessness in Australia, composed almost entirely of Aboriginal people who represent 51% of the total population of 24,000 people. The region is serviced by a 60-bed hospital, and a small cohort of frequent attenders (FAs) represent 11% of the Emergency Department (ED) case load. The vast majority of FAs are Aboriginal and have very high burdens of social inequity and homelessness. FAs are a challenge to efficient and effective use of resources for most hospitals around the world, and investment in programs to address underlying social and chronic health issues contributing to frequent attendance have been demonstrated to be effective. METHODS: These are the interim findings of a prospective cohort study using five sources of linked health and related data to evaluate a community-based case management pilot in a culturally competent framework to support frequent attenders to the Katherine Hospital ED. FAs were defined as people with six or more presentations in 12 preceding months. The intervention composed of a community-based case management program with a multi-agency service delivery addressing underlying vulnerabilities contributing to ED presentations. RESULTS: Among this predominantly Aboriginal cohort (91%), there were high rates of homelessness (64%), food insecurity (60%) and alcohol misuse (64%), limited access to transport, and complex comorbidities (average of 2.8 chronic conditions per client). Following intervention, there was a statistically significant reduction in ED presentations (IRR 0.77, 95% CI 0.69-0.85), increased engagement with primary health care (IRR 1.90, 95% CI 1.78-2.03), and ambulance utilisation (IRR 1.21, 95% CI 1.07-1.38). Reductions in hospital admissions (IRR 0.93, 95% CI 0.77-1.10) and aeromedical retrievals (IRR 0.67, 95% CI 0.35-1.20) were not statistically significant. CONCLUSIONS: This study demonstrates the short-term impacts of community-led case management extending beyond the hospital setting, to address causes of recurrent ED presentations among people with complex social and medical backgrounds. Improving engagement with primary care is a particularly important outcome given the national impetus to reduce preventable hospital admissions

Abstracts of the 12th Congress of the African Association of Nephrology (Accra, Ghana, 20-23 February, 2013)

Accra, Ghana, 20-23 February, 201

A study of the complications associated with haemodialysis vascular access in patients with renal failure

Successful haemodialysis depends on the availability of safe, efficient, and durable access to the vascular tree. This can be provided by creation of an arteriovenous fistula, insertion of a synthetic vascular graft or insertion of a central venous catheter. Established haemodialysis vascular access is associated with a number of important complications which can impact significantly on both the quality of life and survival of haemodialysis patients. The primary aim of this thesis was to perform a detailed evaluation of the risks to health conferred by haemodialysis vascular access and its maintenance in patients with advanced renal failure. The work described in this thesis describes the relative strength and independence of association between haemodialysis vascular access type and risk of mortality, bacteraemia and catheter thrombosis. Greater clarity is demonstrated on the relative effect of heparin-based haemodialysis catheter lock solutions on markers of systemic coagulation in vivo, whilst the in-vitro variability of antimicrobial activity against planktonic and biofilm-embedded staphylococci achieved with catheter lock solutions containing heparin and vancomycin, alone and in combination, is clearly shown. New insights are gained into the benefits of contrast magnetic resonance venography as a tool for demonstrating thrombosis and stenosis of the central veins in the assessment of vascular access in haemodialysis patients. Similarly, the emergence of a new disease, nephrogenic systemic fibrosis was found and its association with gadolinium-enhanced magnetic resonance imaging was explored in detail

Co-designing patient-centred technology for chronic kidney disease : supporting the patient journey

Chronic kidney disease (CKD) patients endure their chronic condition, in addition to complicated treatment pathways and trajectories, high treatment burden and great volumes of information which is not always applicable to their individual situations. There are calls for more patient-centred care, with greater patient involvement in treatment decisions and routine collection of patient outcomes. Digital health innovations have the potential to address these points, but poorly designed or implemented interventions can increase treatment burden, and many fail to reach implementation, described as “pilotitis” in the literature. This thesis explores the use of a Participatory Action Research approach to designing CKD interventions, involving multidisciplinary stakeholders and patients in the design process. First a scoping review on implemented technology-based and patient-centred interventions for high treatment burden populations was conducted, with results providing factors for promoting patient-centredness in technological interventions. A multidisciplinary group of domain experts from academia and medicine was then formed, to identify issues within the community, provide initial design requirements and guide development of a prototype intervention. This prototype would be implemented and evaluated after 6 weeks use by CKD patients in routine care, as part of a vascular access-specific quality-of-life measure (VASQoL) validation study. This resulted in a System Usability Scale (SUS) evaluation and qualitative feedback from 26 CKD patients as well the feedback and observations of a clinical researcher. This evaluation identifies further design requirements as well as the idiosyncratic needs of dialysing CKD patients, such as situational impairment and perceived value of technology. The focus then shifted to patient education, with iterative design and feedback on prototype designs with the MDG, clinical stakeholders and CKD patients in online and in-person workshops, and an interactive symposium. Through multidisciplinary co-design and iterative development, the research produced extensive design requirements and prototype systems for CKD patient education and decision-making aids.Chronic kidney disease (CKD) patients endure their chronic condition, in addition to complicated treatment pathways and trajectories, high treatment burden and great volumes of information which is not always applicable to their individual situations. There are calls for more patient-centred care, with greater patient involvement in treatment decisions and routine collection of patient outcomes. Digital health innovations have the potential to address these points, but poorly designed or implemented interventions can increase treatment burden, and many fail to reach implementation, described as “pilotitis” in the literature. This thesis explores the use of a Participatory Action Research approach to designing CKD interventions, involving multidisciplinary stakeholders and patients in the design process. First a scoping review on implemented technology-based and patient-centred interventions for high treatment burden populations was conducted, with results providing factors for promoting patient-centredness in technological interventions. A multidisciplinary group of domain experts from academia and medicine was then formed, to identify issues within the community, provide initial design requirements and guide development of a prototype intervention. This prototype would be implemented and evaluated after 6 weeks use by CKD patients in routine care, as part of a vascular access-specific quality-of-life measure (VASQoL) validation study. This resulted in a System Usability Scale (SUS) evaluation and qualitative feedback from 26 CKD patients as well the feedback and observations of a clinical researcher. This evaluation identifies further design requirements as well as the idiosyncratic needs of dialysing CKD patients, such as situational impairment and perceived value of technology. The focus then shifted to patient education, with iterative design and feedback on prototype designs with the MDG, clinical stakeholders and CKD patients in online and in-person workshops, and an interactive symposium. Through multidisciplinary co-design and iterative development, the research produced extensive design requirements and prototype systems for CKD patient education and decision-making aids

A study to scope structures, processes and related outcomes of clinical pharmacy practice as part of the multidisciplinary care of patients with chronic kidney disease.

Chronic kidney disease (CKD) is a complex health-related comorbidity with an enormous economic burden on any healthcare system globally. Clinical pharmacy services have potential to contribute significantly to the multidisciplinary team providing safe, effective and economic care for patients. However, published literature shows there is a lack of robust evidence for the role of clinical pharmacists in providing care to patients with CKD. The overall aim of this doctoral research was to investigate the structures, processes and related outcomes of clinical pharmacy practice in the care of patients with CKD. This doctoral research was undertaken under two stages. Stage 1 was a systematic review to appraise, synthesize and present the available evidence on the structures, processes and related outcomes of clinical pharmacy practice in the care of patients with CKD. While there is some evidence of positive impact on clinical, humanistic and economic outcomes, this evidence is generally of low quality and insufficient volume. While the existing evidence is in favour of pharmacists' involvement in the multidisciplinary team providing care to patients with CKD, more high-quality research is warranted. A sequential explanatory design underpinned by the Consolidated Framework of Implementation Research (CFIR) was employed in Stage 2 of this doctoral research. It was executed in two phases of data generation. The findings from the first phase informed the subsequent phase. In Phase 1, an online theoretically based cross-sectional survey was conducted on the behaviours and experiences of clinical pharmacists caring for patients with CKD. Seventy-one respondents completed the survey with a response rate of 50%. The majority of respondents provided general pharmaceutical care to dialysis and transplant patients, were confident in their abilities and tried new ways of working including independent prescribing. There was high level of agreement among the respondents in relation to CFIR items for clinical practice. Most respondents strongly agreed / agreed with CFIR items for prescribing practice, yet 39.6% disagreed that they had sufficient cover for their prescribing duties when they are away. Many expressed that lack of resources was the main barrier to providing more advanced care. Further work is needed to explore these matters in more depth. Phase 2 of Stage 2 involved a semi-structured qualitative interview with clinical pharmacist prescribers' members of the UK Renal Pharmacy Group involved in the care of patients with CKD. Data saturation was confirmed after completing and analysing 14 interviews. The key findings of the interviews demonstrated positive views of prescribing practice for patients with CKD among the pharmacists. Underpinning the research with CFIR helped identify the key facilitators and barriers to the implementation of prescribing practice and facilitated identifying key areas for further developing the service. Overall, this doctoral research produced original contribution to knowledge in the area of clinical pharmacy services in the care for patients with CKD in the UK and with emphasis of prescribing practice. The rigorous and robust findings from Stage 2 of the research can help further develop pharmacy practice and prescribing practice in the care for patients with CKD. More research is needed to explore the potential to implement such practices in a wider context

History of Dialysis in the UK: c. 1950–1980

Dialysis, the first technological substitution for organ function, is significant not only for the numbers of patients who have benefited. It contributed to the emergence of the field of medical ethics and the development of the nurse specialist, and transformed the relationship between physicians and patients by allowing patients to control their treatment. This seminar drew on participants’ recollections of dialysis from the early, practically experimental days after the Second World War, when resources for research were scant, until the 1980s when it had become an established treatment. Pioneers from the first UK dialysis units recalled the creation of the specialty of nephrology amid discouragement from renal physicians and the MRC, which felt that the artificial kidney was a gadget that would not last. International and interdisciplinary collaborations, and interactions between with industry and clinics in developing and utilising the specialist technology were emphasized. Patients, carers, nurses, technicians and doctors reminisced about their experiences of home dialysis, its complications and impact on family life, as well as the physical effects of surviving on long-term dialysis before transplantation became routine. The meeting was suggested and chaired by Dr John Turney and witnesses include Dr Rosemarie Baillod, Professor Christopher Blagg, Professor Stewart Cameron, Mr Eric Collins, Professor Robin Eady, Mrs Diana Garratt, Professor David Kerr, Professor Sir Netar Mallick, Dr Frank Marsh, Dr Jean Northover, Dr Chisholm Ogg, Dr Margaret Platts, Dr Stanley Rosen and Professor Stanley Shaldon. Two appendices contain reminiscences from Professor Kenneth Lowe and Sir Graham Bull