U-Form vs. M-Form: How to Understand Decision Autonomy Under Healthcare Decentralization? Comment on "Decentralisation of Health Services in Fiji: A Decision Space Analysis"

For more than three decades healthcare decentralization has been promoted in developing countries as a way of improving the financing and delivery of public healthcare. Decision autonomy under healthcare decentralization would determine the role and scope of responsibility of local authorities. Jalal Mohammed, Nicola North, and Toni Ashton analyze decision autonomy within decentralized services in Fiji. They conclude that the narrow decision space allowed to local entities might have limited the benefits of decentralization on users and providers. To discuss the costs and benefits of healthcare decentralization this paper uses the U-form and M-form typology to further illustrate the role of decision autonomy under healthcare decentralization. This paper argues that when evaluating healthcare decentralization, it is important to determine whether the benefits from decentralization are greater than its costs. The U-form and M-form framework is proposed as a useful typology to evaluate different types of institutional arrangements under healthcare decentralization. Under this model, the more decentralized organizational form (M-form) is superior if the benefits from flexibility exceed the costs of duplication and the more centralized organizational form (U-form) is superior if the savings from economies of scale outweigh the costly decision-making process from the center to the regions. Budgetary and financial autonomy and effective mechanisms to maintain local governments accountable for their spending behavior are key decision autonomy variables that could sway the cost-benefit analysis of healthcare decentralization

Radiocarbon Date List X: Baffin Bay, Baffin Island, Iceland, Labrador Sea, and the Northern North Atlantic

Date List X contains an annotated listing of 213 radiocarbon dates determined on samples from marine and terrestrial environments. The marine samples were collected from the East Greenland, Iceland, Spitzbergen, and Norwegian margins, Baffin Bay, and Labrador Sea. The terrestrial samples were collected from Vestfirdir, Iceland and Baffin Island. The samples were submitted by INSTAAR and researchers affiliated with INSTAAR\u27s Micropaleontology Laboratory under the direction of Dr.’s John T. Andrews and Anne E. Jennings. All of the dates from marine sediment cores were determined from either shells or foraminifera (both benthic and planktic). All dates were obtained by the Accelerator Mass Spectrometry (AMS) method. Regions of concentrated marine research include: Baffin Bay, Baffin Island, Labrador Sea, East Greenland fjords, shelf and slope, Denmark Strait, the southwestern and northwestern Iceland shelves, and Vestfirdir, Iceland. The non-marine radiocarbon dates are from peat, wood, plant microfossils, and mollusc. The radiocarbon dates have been used to address a variety of research objectives such as: 1. determining the timing of northern hemisphere high latitude environmental changes including glacier advance and retreat, and 2. assessing the accuracy of a fluctuating reservoir correction. Thus, most of the dates constrain the timing, rate, and interaction of late Quaternary paleoenvironmental fluctuations in sea level, glacier extent, sediment input, and changes in ocean circulation patterns. Where significant, stratigraphic and sample contexts are presented for each core to document the basis for interpretations

Shared decision making in patients with low risk chest pain: prospective randomized pragmatic trial.

OBJECTIVE: To compare the effectiveness of shared decision making with usual care in choice of admission for observation and further cardiac testing or for referral for outpatient evaluation in patients with possible acute coronary syndrome. DESIGN: Multicenter pragmatic parallel randomized controlled trial. SETTING: Six emergency departments in the United States. PARTICIPANTS: 898 adults (aged \u3e17 years) with a primary complaint of chest pain who were being considered for admission to an observation unit for cardiac testing (451 were allocated to the decision aid and 447 to usual care), and 361 emergency clinicians (emergency physicians, nurse practitioners, and physician assistants) caring for patients with chest pain. INTERVENTIONS: Patients were randomly assigned (1:1) by an electronic, web based system to shared decision making facilitated by a decision aid or to usual care. The primary outcome, selected by patient and caregiver advisers, was patient knowledge of their risk for acute coronary syndrome and options for care; secondary outcomes were involvement in the decision to be admitted, proportion of patients admitted for cardiac testing, and the 30 day rate of major adverse cardiac events. RESULTS: Compared with the usual care arm, patients in the decision aid arm had greater knowledge of their risk for acute coronary syndrome and options for care (questions correct: decision aid, 4.2 v usual care, 3.6; mean difference 0.66, 95% confidence interval 0.46 to 0.86), were more involved in the decision (observing patient involvement scores: decision aid, 18.3 v usual care, 7.9; 10.3, 9.1 to 11.5), and less frequently decided with their clinician to be admitted for cardiac testing (decision aid, 37% v usual care, 52%; absolute difference 15%; P CONCLUSIONS: Use of a decision aid in patients at low risk for acute coronary syndrome increased patient knowledge about their risk, increased engagement, and safely decreased the rate of admission to an observation unit for cardiac testing.Trial registration ClinicalTrials.gov NCT01969240

Effect of Combined PD-1 and STAT3 Pathway Blockade Treatment on K-ras Mutant Lung Cancer

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