Nutritional management of individuals with Huntington’s disease: nutritional guidelines

The delivery of good nutritional care is a fundamental element of the management of individuals with Huntington’s disease and all patients with Huntington’s disease will, at some time, need dietary intervention because of the sequela of the disease; yet there are no European nutritional guidelines. The European Huntington’s Disease Network Standards of Care Dietitians Group has brought together expert dietitians from across Europe to produce nutritional guidelines to improve the nutritional management of individuals with Huntington’s disease. The guidelines were developed to promote optimal nutritional screening, assessment and management of individuals throughout all stages of the disease, with the aim of improving the standard of nutritional care delivered. Literature was systematically searched in an attempt to ensure that the recommendations are based on sound evidence and where evidence is lacking, specific guidance is based on consensus expert dietetic opinion. The provision of nutritional care varies widely between countries. Implementation of these nutritional guidelines across Europe should improve the quality of nutritional care delivered to individuals with Huntington’s disease

Interoperability between health information systems in the hospital context

The information systems had a positive effect on the health service by reducing the physical documentation, more available information to monitor the patient and safer data storage. On the other hand, there was a negative impact due to an increase of diverse systems operating which demanded more training and support to hospitals structure aligned with the lack of interoperability standards that promote the patient´s data sharing between them. Therefore, this dissertation focused on analysing the existent interoperability between information systems in the Portuguese health service, determine the key aspects to establish communication among them, and the consequences it has on the healthcare professional´s routines. Interviews were conducted with healthcare professionals and hospital suppliers to collect their experience on interacting with this technology, their opinion about the influence it has on the hospital´s routine, and the potential measures to improve the current situation. This research concluded that the lack of interoperability and an unfriendly interface generates a complex use of the systems with a high number of clicks and slower navigation to execute the tasks that can cause loss of time for healthcare professionals. Besides, the public hospital demonstrated to have a higher number of IS suppliers and lower levels of integration between systems compared with private hospitals. Lastly, it was demonstrated that an organisational culture oriented to the technology change and a strategic plan to adapt to the hospital's approach is necessary to a successful implementation of health information systems.Os sistemas de informação tiveram um efeito positivo no serviço de saúde com redução na documentação em papel, maior disponibilidade de informação sobre o paciente e segurança no armazenamento de dados. Por outro lado, houve um impacto negativo devido ao aumento na diversidade de sistemas a operar, que exigiram mais treino e apoio à estrutura hospitalar, associado à falta de padrões de interoperabilidade que promovam a partilha de dados do paciente. Assim, esta dissertação centra-se na análise da interoperabilidade existente entre os sistemas de informação no serviço de saúde português, em determinar os aspetos fundamentais para estabelecer a comunicação entre os mesmos e as consequências que têm na rotina do profissional de saúde. Foram realizadas entrevistas com profissionais da área e fornecedores hospitalares para recolher informação sobre a experiência na interação com esta tecnologia, a opinião sobre a influência que ela exerce na rotina hospitalar e as possíveis medidas para melhorar a atual situação. Esta investigação concluiu que a falta de interoperabilidade e uma interface pouco apelativo determinam um uso complexo destes sistemas com um elevado número de cliques e uma navegação mais lenta para executar as tarefas, que podem causar perda de tempo aos profissionais de saúde. Além disso, os hospitais públicos demonstram ter um maior número de fornecedores e menores níveis de integração entre os sistemas em comparação com os privados. Por fim, expõem-se que uma cultura organizacional direcionada para a mudança tecnológica e um plano estratégico de adaptação são necessários para o sucesso da implantação destes sistemas

Transforming Health in Prince George's County, Maryland: A Public Health Impact Study

Executive Summary and Technical Reports and Supporting Documents Section II of the Public Health Impact Study of Prince George’s County report includes technical reports that document the methods, findings, limitations and a summary for each of the seven study components. We also include copies of the study instruments, where appropriate. While the findings of these study components formed the basis for the integrated answers to the study’s five framing questions, the technical reports include more detailed data than was possible to include in Section I, and also provide insights for the study as a whole.http://sph.umd.edu/princegeorgeshealth/SPH_ImpactStudy_TechnicalReports.pd

Questioning the Premedical Paradigm

This book raises fundamental questions about the propriety of continuing to use a premedical curriculum developed more than a century ago to select students for training as future physicians for the twenty-first century. In it, Dr. Donald A. Barr examines the historical origins, evolution, and current state of premedical education in the United States. One hundred years ago, Abraham Flexner's report on Medical Education in the United States and Canada helped establish the modern paradigm of premedical and medical education. Barr’s research finds the system of premedical education that evolved to be a poor predictor of subsequent clinical competency and professional excellence, while simultaneously discouraging many students from underrepresented minority groups or economically disadvantaged backgrounds from pursuing a career as a physician. Analyzing more than fifty years of research, Barr shows that many of the best prospects are not being admitted to medical schools, with long-term adverse consequences for the U.S. medical profession. The root of the problem, Barr argues, is the premedical curriculum—which overemphasizes biology, chemistry, and physics by teaching them as separate, discrete subjects. In proposing a fundamental restructuring of premedical education, Barr makes the case for parallel tracks of undergraduate science education: one that would largely retain the current system; and a second that would integrate the life sciences in a problem-based, collaborative learning pedagogy. Barr argues that the new, integrated curriculum will encourage greater educational and social diversity among premedical candidates without weakening the quality of the education. He includes an evaluative research framework to judge the outcome of such a restructured system.This historical and cultural analysis of premedical education in the United States is the crucial first step in questioning the appropriateness of continuing a hundred-year-old, empirically dubious pedagogical model for the twenty-first century

ENGAGING VULNERABLE WOMEN WHO USE ILLICIT DRUGS: EXPERIENCES OF DRUG-USING WOMEN AND FAMILY PHYSICIANS

Aims: This thesis explored the experiences of vulnerable women using illicit drugs and inner-city family physicians in order to better understand the process of engagement. Methods: This qualitative, phenomenological study used in-depth interviews with vulnerable, drug-using women and inner-city family physicians. An iterative and interpretive analysis was conducted. Findings: All participants identified proximal and distal contexts that were barriers to engagement. Women and family physician participants took actions that served to both facilitate and hinder access to primary health care. Lastly, participants identified the central role of the patient-physician relationship in the process of engagement and maintenance. Conclusions: Engagement is a two-step process characterized by engagement and maintenance phases. Strategies which enhance engagement include: 1) housing, 2) harm reduction programs 3) investing in peer programs, 4) concurrent social and medical services; and 5) patient-centered care

Decision support systems for adoption in dental clinics: a survey

While most dental clinicians use some sort of information system, they are involved with administrative functions, despite the advisory potential of some of these systems. This paper outlines some current decision support systems (DSS) and the common barriers facing dentists in adopting them within their workflow. These barriers include lack of perceived usefulness, complicated social and economic factors, and the difficulty for users to interpret the advice given by the system. A survey of current systems found that although there are systems that suggest treatment options, there is no real-time integration with other knowledge bases. Additionally, advice on drug prescription at point-of-care is absent from such systems, which is a significant omission, in consideration of the fact that disease management and drug prescription are common in the workflow of a dentist. This paper also addresses future trends in the research and development of dental clinical DSS, with specific emphasis on big data, standards and privacy issues to fulfil the vision of a robust, user-friendly and scalable personalised DSS for dentists. The findings of this study will offer strategies in design, research and development of a DSS with sufficient perceived usefulness to attract adoption and integration by dentists within their routine clinical workflow, thus resulting in better health outcomes for patients and increased productivity for the clinic

Developing a recovery ethos for psychiatric services in New Zealand

This thesis is about developing a recovery ethos for psychiatric services in New Zealand. The argument of the thesis is that currently a procedural ethos is dominant in psychiatric services in New Zealand, based on eclectic ways of facilitating recovery. Recovery from mental illness, is based on the criteria of symptom reduction and functioning and can be further refined to have a client and professional perspective. Rather than using an eclectic approach to facilitating recovery the thesis argues for a pluralistic approach, where the virtues, the relationship with professionals, client narrative and the psychiatric community become central to decision making, rather than principle based procedures. The thesis is an argued, applied philosophical thesis in terms of methodology. The scope of the thesis is psychiatric services and the focus is broadly ethical decision making. There are three main divisions to the thesis. Part 1 is concerned with clarification of the main terms used in the thesis. This involves exploring the historical background to the concept of recovery, clarifying the concept of recovery itself and providing an argument for giving greater prominence to the term mental illness over the term mental disorder. Part 2 identifies the main problem of the thesis, namely the procedural ethos, and the problems it is causing clients suffering from mental illness in facilitating their recovery. Part 3 shows what is involved in developing a recovery ethos for psychiatric services in New Zealand

Exploring patient safety in rural general practice - a mixed-methods approach

Unsafe medical practices and incidents where safety hazards cause harm to patients occur daily in general practice. The costs to society, health care personnel and individual patients are substantial and deserve attention. “Hazards” can be regarded as local error-producing factors, latent failures, which create conditions for unsafe medical practice to take place. “Harm” occurs when these conditions breach safety barriers and reach the patients. Individual doctors who make mistakes created by these factors are most likely to continue to make mistakes until the underlying conditions are remedied. The responsibility for establishing safety barriers in healthcare systems is assigned to health professionals, health organisations and the government. In Norway, there is a general practitioner (GP) scheme involving more than 4700 doctors at present. It includes a patient list system that enables the care of individuals over time, i.e. continuity of care. Continuity varies between municipalities in Norway. In small municipalities, the GP scheme is affected by the frequent use of locums (substitute GPs). Rural GP clinics also face challenges in care provision in terms of vast transportation distances and possible support of secondary care specialists. Little is known about patient safety threats in these clinics, which is the basis for my research for this doctoral dissertation. In the first study we interviewed rural general practice patients and in the third study GPs and other health care personnel. In these studies we asked about their experiences with hazards, harm, patient safety incidents and low quality of care. The second study was a quantitative analysis of disciplinary actions against doctors in Norway in 2011-2018. The doctoral dissertation is based on a mixed-method approach to analyse these results in combination. In paper I and III the participants described many different safety hazards and harm. In paper I patients coped with these conditions by accepting, confronting or planful problem-solving. In paper III the rural general practice staff described how vulnerability for patient safety incidents were linked to frequent use of locums, work overload and contextual factors like bad weather and distance to hospitals. The personnel used knowledge of local context and an awareness to risk of error to hinder patient safety incidents. Results from paper II showed that primary care doctors got 8 times more disciplinary actions than hospital doctors. Rural GPs got relatively most disciplinary actions, 1.7 times more compared to urban GPs. To perform a scientific analysis of qualitative and quantitative results, I have used pragmatism as a theory of science and a mixed-methods design. In brief, this means transforming the quantitative results in Paper II into narrative descriptions. These descriptions are then jointly analysed with the results from Papers I and III. The analysis shows that safety hazards and harm in rural general practice are diverse and seem to occur nation-wide. The causes of harm are both individual and system safety hazards such as frequent use of locum GPs, lack of continuity of care, long distances and high workload. Patients, health care personnel, and the Norwegian Board of Health Supervision (NBHS) are aware of this. Harming patients in rural areas is likely to continue. However, health care workers and patients both help to reduce risks through an awareness of potential safety hazards, the use of local contextual knowledge and confronting errors, especially those made by locum GPs. The method of risk reduction used by the NBHS is system-based by taking disciplinary action against individual doctors based on individual behaviour. Incentives and initiatives from local and national health care leaders to address the safety issues mentioned here and develop safer health care are needed. Greater insight into patient safety in general practice can be revealed through future qualitative, quantitative and mixed-methods studies.Utrygg medisinsk praksis som skader pasienter, forekommer daglig i allmennpraksis. Helsetjenesten i distrikt er påvirket av store reiseavstander for pasientene til legekontoret, og til spesialisthelsetjenesten på sykehus. Lite er imidlertid kjent om pasientsikkerheten ved slike legekontor i distrikt. Vi intervjuet pasienter, og deretter fastleger og helsepersonell som alle bor og jobber i distrikt. Vi har undersøkt deres erfaringer med uheldige hendelser, utrygg medisinsk praksis, pasientskader og lav kvalitet på helseomsorgen. Vi har også gjort en kvantitativ analyse av administrative reaksjoner gitt norske leger mellom 2011-2018. Doktorgraden baserer seg på en mixed-methods tilnærming til disse resultatene. Uheldige hendelser og utrygg medisinsk praksis ved distriktslegekontor er varierte og forekommer antakelig over hele landet. Hyppig bruk av vikarleger, manglende kontinuitet, lang reiseavstand og høy arbeidsbelastning er alle mulige risikofaktorer. Basert på indikasjoner fra trendanalysene, vil skade av pasienter på legekontor i distrikt sannsynligvis fortsette å skje i fremtiden. Flere insentiver og initiativ fra lokale og nasjonale myndigheter trengs for å bedre pasientsikkerheten. Gjennom kvalitativ, kvantitativ og mixed-methods forskning kan man øke forståelsen og bedre kunnskapen om pasientsikkerhet på legekontor i distrikt

Pay for performance in health care

This book provides a balanced assessment of pay for performance (P4P), addressing both its promise and its shortcomings. P4P programs have become widespread in health care in just the past decade and have generated a great deal of enthusiasm in health policy circles and among legislators, despite limited evidence of their effectiveness. On a positive note, this movement has developed and tested many new types of health care payment systems and has stimulated much new thinking about how to improve quality of care and reduce the costs of health care. The current interest in P4P echoes earlier enthusiasms in health policy—such as those for capitation and managed care in the 1990s—that failed to live up to their early promise. The fate of P4P is not yet certain, but we can learn a number of lessons from experiences with P4P to date, and ways to improve the designs of P4P programs are becoming apparent. We anticipate that a “second generation” of P4P programs can now be developed that can have greater impact and be better integrated with other interventions to improve the quality of care and reduce costs.Publishe

Changing practice in dementia care in the community: developing and testing evidence-based interventions, from timely diagnosis to end of life (EVIDEM)

Background Dementia has an enormous impact on the lives of individuals and families, and on health and social services, and this will increase as the population ages. The needs of people with dementia and their carers for information and support are inadequately addressed at all key points in the illness trajectory. Methods The Unit is working specifically on an evaluation of the impact of the Mental Capacity Act 2005, and will develop practice guidance to enhance concordance with the Act. Phase One of the study has involved baseline interviews with practitioners across a wide range of services to establish knowledge and expectations of the Act, and to consider change processes when new policy and legislation are implemented. Findings Phase 1, involving baseline interviews with 115 practitioners, identified variable knowledge and understanding about the principles of the Act. Phase 2 is exploring everyday decision-making by people with memory problems and their carers