Development and Validation of eRADAR: A Tool Using EHR Data to Detect Unrecognized Dementia.

ObjectivesEarly recognition of dementia would allow patients and their families to receive care earlier in the disease process, potentially improving care management and patient outcomes, yet nearly half of patients with dementia are undiagnosed. Our aim was to develop and validate an electronic health record (EHR)-based tool to help detect patients with unrecognized dementia (EHR Risk of Alzheimer's and Dementia Assessment Rule [eRADAR]).DesignRetrospective cohort study.SettingKaiser Permanente Washington (KPWA), an integrated healthcare delivery system.ParticipantsA total of 16 665 visits among 4330 participants in the Adult Changes in Thought (ACT) study, who undergo a comprehensive process to detect and diagnose dementia every 2 years and have linked KPWA EHR data, divided into development (70%) and validation (30%) samples.MeasurementsEHR predictors included demographics, medical diagnoses, vital signs, healthcare utilization, and medications within the previous 2 years. Unrecognized dementia was defined as detection in ACT before documentation in the KPWA EHR (ie, lack of dementia or memory loss diagnosis codes or dementia medication fills).ResultsOverall, 1015 ACT visits resulted in a diagnosis of incident dementia, of which 498 (49%) were unrecognized in the KPWA EHR. The final 31-predictor model included markers of dementia-related symptoms (eg, psychosis diagnoses, antidepressant fills), healthcare utilization pattern (eg, emergency department visits), and dementia risk factors (eg, cerebrovascular disease, diabetes). Discrimination was good in the development (C statistic = .78; 95% confidence interval [CI] = .76-.81) and validation (C statistic = .81; 95% CI = .78-.84) samples, and calibration was good based on plots of predicted vs observed risk. If patients with scores in the top 5% were flagged for additional evaluation, we estimate that 1 in 6 would have dementia.ConclusionThe eRADAR tool uses existing EHR data to detect patients with good accuracy who may have unrecognized dementia. J Am Geriatr Soc 68:103-111, 2019

An Assessment of an Experimental Surgery Scheme in General Practice

A study of aspects of the work and of the opinions of patients and staff was made at times over a period of two years before and one year after the opening of an experimental surgery tmit specially designed for a particular way of organising the doctor/nurse team in general practice. The investigation took place in a busy group practice of three doctors caring between them for over 9000 patients living in a London borough

No. 17: International Migration and Good Governance in the Southern African Region

Southern Africa has a long history of intra-regional migration, dating back to the mid-nineteenth century. Migration was probably the single most important factor tying together all of the various colonies and countries of the sub-continent into a single regional labour market during the twentieth century. However, entrenched patterns of migration have undergone major restructuring in the last two decades. Southern Africa is now a region on the move (McDonald 2000). Several broader changes underly this shift towards greater and greater intra-regional mobility. First, the end of apartheid, a system designed to control movement and exclude outsiders, produced new opportunities for internal and cross-border mobility and new incentives for moving. The ensuing integration of South Africa with the SADC region brought a major increase in legal and undocumented cross-border flows and new forms of mobility. Second, the region’s reconnection with the global economy has opened it up to forms of migration commonly associated with globalization (Crush and McDonald 2002). Third, growing rural and urban poverty and unemployment have pushed more people out of households in search of a livelihood. One aspect of this has been a significant gender reconfiguration of migration streams (Dodson 1998). Fourth, HIV/AIDS has also impacted considerably on migration. Not only is the rapid diffusion of the epidemic inexplicable without reference to human mobility but new forms of migration are emerging in response (Williams et al. 2003; IOM 2003a). Finally, the countries of the SADC are still dealing with the legacy of mass displacement and forced migration. The impact of the Mozambican and Angolan civil wars continue to reverberate. Recurrent civil strife in the rest of Africa has generated mass refugee movements and new kinds of asylum seeker to and within the region. The cessation of hostilities and threat has confronted countries of asylum with issues of repatriation and integration. Policy responses as the local, national, regional and continental scale must take into account the extraordinary dynamism and instability of migration forms and patterns in the region. Governments wedded to legal frameworks of control and exclusion are finding it increasingly difficult to cope. The fundamental policy challenge is to move the states of Southern Africa to a regionally-harmonized and consistent set of policies that emphasize good governance, sound management and client-centred service delivery (Klaaren and Rutinwa 2004). In addition, because migration is a cross-cutting phenomenon, it needs to be integrated into all facets of state policymaking and planning, including programs and strategies to alleviate poverty and reduce inequality. For this to happen, migration’s key role needs to be documented by researchers and recognized by policy-makers

A Primer on Quality Assurance and Performance Improvement for Interprofessional Chronic Kidney Disease Care: A Path to Joint Commission Certification.

Interprofessional care for chronic kidney disease facilitates the delivery of high quality, comprehensive care to a complex, at-risk population. Interprofessional care is resource intensive and requires a value proposition. Joint Commission certification is a voluntary process that improves patient outcomes, provides external validity to hospital administration and enhances visibility to patients and referring providers. This is a single-center, retrospective study describing quality assurance and performance improvement in chronic kidney disease, Joint Commission certification and quality outcomes. A total of 440 patients were included in the analysis. Thirteen quality indicators consisting of clinical and process of care indicators were developed and measured for a period of two years from 2009-2017. Significant improvements or at least persistently high performance were noted for key quality indicators such as blood pressure control (85%), estimation of cardiovascular risk (100%), measurement of hemoglobin A1c (98%), vaccination (93%), referrals for vascular access and transplantation (100%), placement of permanent dialysis access (61%), discussion of advanced directives (94%), online patient education (71%) and completion of office visit documentation (100%). High patient satisfaction scores (94-96%) are consistent with excellent quality of care provided

Dynamic modeling of web purchase behavior and e-mailing impact by Petri net

In this article, the authors introduce Petri nets to model the dynamics of web site visits and purchase behaviors in the case of wish list systems. They describe web site activities and their transition with probability distributions and model the sequential impact of influential factors through links that better explain web purchase behavior dynamics. The basic model, which analyzes site connections and purchases to explain visit and purchase behavior, performs better than a classical negative binomial regression model. To demonstrate its flexibility, the authors extend the wish list Petri net model to measure the impact of e-mailing intervals on visit frequency and purchase.internet; wish list; e-mail; Petri net; dynamic model

Integrated out-of-hours care arrangements in England: observational study of progress towards single call access via NHS Direct and impact on the wider health system

Objectives: To assess the extent of service integration achieved within general practice cooperatives and NHS Direct sites participating in the Department of Health’s national “Exemplar Programme” for single call access to out-of-hours care via NHS Direct. To assess the impact of integrated out-of-hours care arrangements upon general practice cooperatives and the wider health system (use of emergency departments, 999 ambulance services, and minor injuries units). Design: Observational before and after study of demand, activity, and trends in the use of other health services. Setting: Thirty four English general practice cooperatives with NHS Direct partners (“exemplars”) of which four acted as “case exemplars”. Also 10 control cooperatives for comparison. Main Outcome Measures: Extent of integration achieved (defined as the proportion of hours and the proportion of general practice patients covered by integrated arrangements), patterns of general practice cooperative demand and activity and trends in use of the wider health system in the first year. Results: Of 31 distinct exemplars 21 (68%) integrated all out-of-hours call management by March 2004. Nine (29%) established single call access for all patients. In the only case exemplar where direct comparison was possible, cooperative nurse telephone triage before integration completed a higher proportion of calls with telephone advice than did NHS Direct afterwards (39% v 30%; p<0.0001). The proportion of calls completed by NHS Direct telephone advice at other sites was lower. There is evidence for transfer of demand from case exemplars to 999 ambulance services. A downturn in overall demand for care seen in two case exemplars was also seen in control sites. Conclusion: The new model of out-of-hours care was implemented in a variety of settings across England by new partnerships between general practice cooperatives and NHS Direct. Single call access was not widely implemented and most patients needed to make at least two telephone calls to contact the service. In the first year, integration may have produced some reduction in total demand, but this may have been accompanied by shifts from one part of the local health system to another. NHS Direct demonstrated capability in handling calls but may not currently have sufficient capacity to support national implementation

Unit-Level Voluntary Turnover Rates and Customer Service Quality: Implications of Group Cohesiveness, Newcomer Concentration, and Size

Despite substantial growth in the service industry and emerging work on turnover consequences, little research examines how unit-level turnover rates affect essential customer-related outcomes. The authors propose an operational disruption framework to explain why voluntary turnover impairs customers’ service quality perceptions. Based on a sample of 75 work units and data from 5,631 employee surveys, 59,602 customer surveys, and organizational records, results indicate that unit-level voluntary turnover rates are negatively related to service quality perceptions. The authors also examine potential boundary conditions related to the disruption framework. Of three moderators studied (group cohesiveness, group size, and newcomer concentration), results show that turnover’s negative effects on service quality are more pronounced in larger units and in those with a greater concentration of newcomers