Performance and Output Measurement: A Joint Meeting of Euro Public Sector and Health Working Groups -- 14-16 January, 1980

Most governmental and public service bodies have developed methods for measuring and controlling the inputs to major programs, in terms of finance, manpower, and other resources. There has, however, been relatively little success in measuring the output of such programs -- except in rather special cases -- and such measurement as takes place is usually on secondary rather than primary measures of output; it is easy to measure the number of patients handled in a clinic, but much more difficult to determine how far their health is improved. The issue of performance and output measurement is thus of major concern to operational research workers and applied systems analysts, much of whose work is directed towards public service programs, and because it cuts across many fields of application. It therefore seemed particularly appropriate that two working groups of the European Association of Operational Research Societies should meet at the International Institute for Applied Systems Analysis in January 1980 to discuss this topic. As the discussion may be of wider interest than to those actually present it all seems appropriate to make these notes more widely available in the form of an IIASA Collaborative Paper. The meeting was the prime responsibility of Peter Turner and Duncan Boldy, chairmen respectively of the Public Sector and Health Working Groups of EURO. At IIASA the coordination was undertaken by Philip Aspden of the Health Care Systems Modeling Task. These three are the joint editors of this report. It was felt that the proceedings were worth recording but that, as they were really part of an ongoing debate, they should be made available as quickly as possible. To avoid further delay some of the papers are therefore presented in note form, and the discussion has been condensed to bring out the main topics of interest. It is too seldom that those engaged in the analytical study of policy issues get together specifically to discuss their problems, rather than to parade their solutions. We hope that this collaborative paper may help to stimulate further such meetings

Modelling home care organisations from an operations management perspective

Home Care (HC) service consists of providing care to patients in their homes. During the last decade, the HC service industry experienced significant growth in many European countries. This growth stems from several factors, such as governmental pressure to reduce healthcare costs, demographic changes related to population ageing, social changes, an increase in the number of patients that suffer from chronic illnesses, and the development of new home-based services and technologies. This study proposes a framework that will enable HC service providers to better understand HC operations and their management. The study identifies the main processes and decisions that relate to the field of HC operations management. Hence, an IDEF0 (Integrated Definition for Function Modelling) activity-based model describes the most relevant clinical, logistical and organisational processes associated with HC operations. A hierarchical framework for operations management decisions is also proposed. This analysis is derived from data that was collected by nine HC service providers, which are located in France and Italy, and focuses on the manner in which operations are run, as well as associated constraints, inputs and outputs. The most challenging research areas in the field of HC operations management are also discussed

Australian health care providers' views on opt-out HIV testing

Background: Opt-out HIV testing is a novel concept in Australia. In the opt-out approach, health care providers (HCPs) routinely test patients for HIV unless they explicitly decline or defer. Opt-out HIV testing is only performed with the patients' consent, but pre-test counselling is abbreviated. Australian national testing guidelines do not currently recommend opt-out HIV testing for the general population. Non-traditional approaches to HIV testing (such as opt-out) could identify HIV infections and facilitate earlier treatment, which is particularly important now that HIV is a chronic, manageable disease. Our aim was to explore HCPs' attitudes toward opt-out HIV testing in an Australian context, to further understanding of its acceptability and feasibility. Methods: In this qualitative study, we used purposeful sampling to recruit HCPs who were likely to have experience with HIV testing in Western Australia. We interviewed them using a semi-structured guide and used content analysis as per Graneheim to code the data. Codes were then merged into subcategories and finally themes that unified the underlying concepts. We refined these themes through discussion among the research team. Results: Twenty four HCPs participated. Eleven participants had a questioning attitude toward opt-out HIV testing, while eleven favoured the approach. The remaining two participants had more nuanced perspectives that incorporated some characteristics of the questioning and favouring attitudes. Participants' views about opt-out HIV testing largely fell into two contrasting themes: normalisation and routinisation versus exceptionalism; and a need for proof versus openness to new approaches. Conclusion: Most HCPs in this study had dichotomous attitudes toward opt-out HIV testing, reflecting contrasting analytical styles. While some HCPs viewed it favourably, with the perceived benefits outweighing the perceived costs, others preferred to have evidence of efficacy and cost-effectiveness

Gastrointestinal decontamination in the acutely poisoned patient

ObjectiveTo define the role of gastrointestinal (GI) decontamination of the poisoned patient.Data sourcesA computer-based PubMed/MEDLINE search of the literature on GI decontamination in the poisoned patient with cross referencing of sources.Study selection and data extractionClinical, animal and in vitro studies were reviewed for clinical relevance to GI decontamination of the poisoned patient.Data synthesisThe literature suggests that previously, widely used, aggressive approaches including the use of ipecac syrup, gastric lavage, and cathartics are now rarely recommended. Whole bowel irrigation is still often recommended for slow-release drugs, metals, and patients who "pack" or "stuff" foreign bodies filled with drugs of abuse, but with little quality data to support it. Activated charcoal (AC), single or multiple doses, was also a previous mainstay of GI decontamination, but the utility of AC is now recognized to be limited and more time dependent than previously practiced. These recommendations have resulted in several treatment guidelines that are mostly based on retrospective analysis, animal studies or small case series, and rarely based on randomized clinical trials.ConclusionsThe current literature supports limited use of GI decontamination of the poisoned patient

Prehospital transdermal glyceryl trinitrate in patients with ultra-acute presumed stroke (RIGHT-2): an ambulance-based, randomised, sham-controlled, blinded, phase 3 trial

Background High blood pressure is common in acute stroke and is a predictor of poor outcome; however, large trials of lowering blood pressure have given variable results, and the management of high blood pressure in ultra-acute stroke remains unclear. We investigated whether transdermal glyceryl trinitrate (GTN; also known as nitroglycerin), a nitric oxide donor, might improve outcome when administered very early after stroke onset. Methods We did a multicentre, paramedic-delivered, ambulance-based, prospective, randomised, sham-controlled, blinded-endpoint, phase 3 trial in adults with presumed stroke within 4 h of onset, face-arm-speech-time score of 2 or 3, and systolic blood pressure 120 mm Hg or higher. Participants were randomly assigned (1:1) to receive transdermal GTN (5 mg once daily for 4 days; the GTN group) or a similar sham dressing (the sham group) in UK based ambulances by paramedics, with treatment continued in hospital. Paramedics were unmasked to treatment, whereas participants were masked. The primary outcome was the 7-level modified Rankin Scale (mRS; a measure of functional outcome) at 90 days, assessed by central telephone follow-up with masking to treatment. Analysis was hierarchical, first in participants with a confirmed stroke or transient ischaemic attack (cohort 1), and then in all participants who were randomly assigned (intention to treat, cohort 2) according to the statistical analysis plan. This trial is registered with ISRCTN, number ISRCTN26986053. Findings Between Oct 22, 2015, and May 23, 2018, 516 paramedics from eight UK ambulance services recruited 1149 participants (n=568 in the GTN group, n=581 in the sham group). The median time to randomisation was 71 min (IQR 45–116). 597 (52%) patients had ischaemic stroke, 145 (13%) had intracerebral haemorrhage, 109 (9%) had transient ischaemic attack, and 297 (26%) had a non-stroke mimic at the final diagnosis of the index event. In the GTN group, participants’ systolic blood pressure was lowered by 5·8 mm Hg compared with the sham group (p<0·0001), and diastolic blood pressure was lowered by 2·6 mm Hg (p=0·0026) at hospital admission. We found no difference in mRS between the groups in participants with a final diagnosis of stroke or transient ischaemic stroke (cohort 1): 3 (IQR 2–5; n=420) in the GTN group versus 3 (2–5; n=408) in the sham group, adjusted common odds ratio for poor outcome 1·25 (95% CI 0·97–1·60; p=0·083); we also found no difference in mRS between all patients (cohort 2: 3 [2–5]; n=544, in the GTN group vs 3 [2–5]; n=558, in the sham group; 1·04 [0·84–1·29]; p=0·69). We found no difference in secondary outcomes, death (treatment-related deaths: 36 in the GTN group vs 23 in the sham group [p=0·091]), or serious adverse events (188 in the GTN group vs 170 in the sham group [p=0·16]) between treatment groups. Interpretation Prehospital treatment with transdermal GTN does not seem to improve functional outcome in patients with presumed stroke. It is feasible for UK paramedics to obtain consent and treat patients with stroke in the ultraacute prehospital setting. Funding British Heart Foundation

Exploring new operational research opportunities within the Home Care context: the chemotherapy at home

Health service, Home care, Operations planning, Anti-cancer drug supply chain, Scheduling,