A CLINICAL & HEALTH ECONOMIC EVALUATION OF THORACIC AORTIC ANEURYSM SURGERY

Thoracic aortic aneurysm is a life-threatening condition which affects different parts of the aorta. A significant proportion of patients present with incidental aneurysmal disease and are physically asymptomatic at the time of their first presentation. However, despite their asymptomatic nature the existence of an acute aortic syndrome represents a life threatening disease which is associated with a high mortality rate. Thus the effective and efficient diagnosis and treatment of such patients is essential in optimizing both their quality and quantity of life. This thesis takes advantage of a range of structural and policy changes that have been undertaken at Liverpool Heart and Chest Hospital (LHCH) to evaluate the impact of such changes on the clinical and cost effectiveness of aortic surgery. Foremost amongst these changes was the reorganization of the aortic service in 2007 to concentrate treatment in the hands of a small number of specialists. This thesis examines subspecialisation and reorganisation of surgical expertise and activity for the treatment of aortic surgery patients at LHCH resulted in significantly improved patient outcomes which is being achieved with cost neutral changes in service delivery. The thesis will assess the impact of this subspecialisation on a range of outcome dimensions including patient outcomes and the efficiency of resource utilization within the aortic service at LHCH. The focus of this study is in tune with increased sub-specialization in a wide range of therapeutic areas in hospitals throughout the UK. It is hoped that the methodology and findings of this study may contain lessons that may be applicable to specialisms outside aortic surgery throughout the NHS and assist in developing an evidence based health policy to inform the ever growing trend towards increased sub specialization. The improvements appeared to simply result from the natural enhancement of expertise that results from concentration of specialist surgery in fewer and hence more experienced hands. In this regard, centralization of thoracic aortic aneurysm service appears to enhance both survival. The generalizability of these findings and potential lessons for the provision of specialist surgery in other therapeutic areas await further investigation

Organizational life cycle: leadership style and employee satisfaction: a case study of hospital in China

There is a lack of empirical research on the leadership styles applicable to hospitals, particularly in the fast changing healthcare environment of China. This study answers the following two questions: What are the different leadership styles that are suitable for different hospital development stages? What are the relationships between leadership styles, strategic positioning, culture and satisfaction? Using a combination of qualitative and quantitative analyses of a large Chinese hospital, referred to as GZR hospital, this study shows that four different leadership styles are suitable for different hospital development periods. Transformational and charismatic leadership are suitable for the start up and the recession/regeneration periods; charismatic and parent leadership are suitable for the growth period; maintained leadership is suitable for the maturity period. The effectiveness o f the different leadership styles is in a descending order: transformational, charismatic, parent, and maintained. The findings suggest that hospitals need different leadership styles in different development stages. Analyses of survey data suggest that leadership style is significantly associated with strategic positioning, sub culture and employee satisfaction. This research contributes to the literature by proposing and empirically examining a theoretical model of the different types of leadership styles and their relationships with strategic positioning, sub culture and staff satisfaction in the unique fast changing environment of Chinese healthcare sector. It also makes practical contribution by highlighting how hospitals should align leadership styles with their development stages and make appropriate management choices to achieve desired organizational outcomes.A falta de pesquisa empírica sobre os estilos de liderança aplicados aos hospitais tornou se numa questão mais importante devido à mudança constante dos serviços de saúde da China. Este estudo responde às duas pergunta s seguintes: Quais são os diferentes estilos de liderança adequados para os diferentes períodos de desenvolvimento dos hospitais? Quais são as correlações entre o estilo de liderança, a posição estratégica, a cultura e o grau de satisfação dos empregados? Aplicando métodos quantitativos e qualitativos na análise de um grande hospital chinês (adiante denominado de GZR), este estudo identificou quatro estilos diferentes de liderança adequados aos diferentes períodos de desenvolvimento do hospital. A liderança transformacional e carismática é adequada para as fases de arranque e recessão / regeneração; a liderança carismática e parental são adequados para o período de crescimento; a liderança de manutenção/prática é adequada para o período de maturidade. A eficácia dos diferentes estilos de liderança ordena se de uma forma decrescente: transformacional, carismática, parental e manutenção. Os resultados sugerem que os hospitais precisam de diferentes estilos de liderança em diferentes períodos do seu desenvolvi mento. A análises dos dados da pesquisa sugere que o estilo de liderança está significativamente associado à posição estratégica, à subcultura e à satisfação do pessoal. Esta pesquisa efetuou um estudo empírico e propôs um modelo teórico dos diferentes tip os de estilos de liderança e as relações com a posição estratégica, a subcultura e a satisfação do pessoal no ambiente único de mudança constante dos serviços de saúde chineses, contribuindo para a literatura da área de saúde. Ao destacar que os hospitais devem alinhar os estilos de liderança e práticas de gestão com os diferentes períodos de desenvolvimento e que se encontram, este estudo está a contribuir para a melhoria das práticas de gestão hospitalar na China

Transbronchial cryobiopsy and Neutrophil Lymphocyte Ratio - new precision medicine tools and markers in Interstitial Lung Disease

The interstitial lung diseases (ILDs) are a group of over 200 disease that may lead to progressive fibrosis and respiratory failure. ILDs are heterogenous, with varying amounts of inflammation and fibrosis, and differ in response to therapy and outcome. The most severe fibrotic (f) ILD, idiopathic pulmonary fibrosis (IPF), has a median survival of just three years. Progressive fILD may respond to antifibrotic treatments which slow down, but do not reverse, fibrosis albeit often with significant side effects. Better treatments or delivery of treatments are needed. Diagnosis of ILD relies on clinical history, imaging and, in some cases lung biopsy, with associated risks. Better diagnostic and prognostic biomarkers in ILD are urgently needed. This thesis examines the approach to diagnosis, prognostication, and treatment in fILDs, and, in particular IPF. It begins with the finding that Neutrophil Lymphocyte Ratio (NLR), derived from a simple, widely available blood test, is a prognostic biomarker in IPF. The role of lung biopsy in the diagnostic pathway is considered and the use of a relatively new minimally invasive technique of transbronchial cryo lung biopsy (TBCB) as an alternative to surgical lung biopsy (SLB) is described. The value of TBCB to obtain lung tissue for research is demonstrated with evaluation of the distribution of inhaled ipratropium in fILD. Using matrix-assisted laser desorption/ionization (MALDI) mass spectrometry (MS) on samples of lung taken using TBCB, it was demonstrated that inhaled medication was able to reach the fibrotic lung, presenting a new approach to drug delivery in fILD. Further discussion focusses on the current role of SLB in the diagnostic pathway in ILD, the presentation of a systematic literature review, and a discussion of future trials to assess the potential benefits of a wider use of TBCB

Can diagnosis-based capital allocation facilitate more appropriate, sustainable and innovative acute care?

Australians value access to public hospitals with technologically-appropriate clinical care. However, the Australian system of capital funding for public hospitals is not appropriate, effective, equitable, clinically-responsive, patient-centred, evidence-based or sustainable. A new model to effectively fund patient access to efficient public hospitals was developed from international evidence, Australian standards, clinical guidelines and expert clinical interviews. Capital was costed by patient diagnosis group to enable comprehensive funding for public hospital clinical care, for the first time

Digital Health Care in Taiwan

This open access book introduces the National Health Insurance (NHI) system of Taiwan with a particular emphasis on its application of digital technology to improve healthcare access and quality. The authors explicate how Taiwan integrates its strong Information and Communications Technology (ICT) industry with 5G to construct an information system that facilitates medical information exchange, collects data for planning and research, refines medical claims review procedures and even assists in fighting COVID-19. Taiwan's NHI, launched in 1995, is a single-payer system funded primarily through payroll-based premiums. It covers all citizens and foreign residents with the same comprehensive benefits without the long waiting times seen in other single-payer systems. Though premium rate adjustment and various reforms were carried out in 2010, the NHI finds itself at a crossroads over its financial stability. With the advancement of technologies and an aging population, it faces challenges of expanding coverage to newly developed treatments and diagnosis methods and applying the latest innovations to deliver telemedicine and more patient-centered services. The NHI, like the national health systems of other countries, also needs to address the privacy concerns of the personal health data it collects and the issues regarding opening this data for research or commercial use. In this book, the 12 chapters cover the history, characteristics, current status, innovations and future reform plans of the NHI in the digital era. Topics explored include: Income Strategy Payment Structure Pursuing Health Equity Infrastructure of the Medical Information System Innovative Applications of the Medical Information Applications of Big Data and Artificial Intelligence Digital Health Care in Taiwan is essential reading for academic researchers and students in healthcare administration, health policy, health systems research, and health services delivery, as well as policymakers and public officials in relevant government departments. It also would appeal to academics, practitioners, and other professionals in public health, health sciences, social welfare, and health and biotechnology law

Timely and reliable evaluation of the effects of interventions: a framework for adaptive meta-analysis (FAME)

Most systematic reviews are retrospective and use aggregate data AD) from publications, meaning they can be unreliable, lag behind therapeutic developments and fail to influence ongoing or new trials. Commonly, the potential influence of unpublished or ongoing trials is overlooked when interpreting results, or determining the value of updating the meta-analysis or need to collect individual participant data (IPD). Therefore, we developed a Framework for Adaptive Metaanalysis (FAME) to determine prospectively the earliest opportunity for reliable AD meta-analysis. We illustrate FAME using two systematic reviews in men with metastatic (M1) and non-metastatic (M0)hormone-sensitive prostate cancer (HSPC)