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Examining cost variation across hospital departments--a two-stage multi-level approach using patient-level data

Studies of hospital efficiency seldom lead to changes in practice, partly because recommendations are unspecific or results are not seen as robust. We describe a method to compare hospital costs that utilises patient-level data. We perform a two-stage analysis in which we first consider factors that explain costs among patients and then across hospital departments. We illustrate our approach by examining the costs and characteristics of almost one million patients admitted to 136 English NHS hospital obstetrics departments in 2005/2006. We identify those departments with significantly higher costs that need to take action

New knowledge networks of small-scale farmers in Europe’s periphery

Funding for this research was provided by the European Union’s Seventh Framework Programme for research, technological development and demonstration under grant agreement no 311994, and the Scottish Government’s Strategic Research Programme (2011–2016).In this paper we assess the types of knowledge networks utilised by small-scale farmers in four case studies (located in Bulgaria, Poland, Portugal, and the United Kingdom). We focus on knowledge acquired to inform three new activities being undertaken by study participants: agricultural production, subsidy access and regulatory compliance, and farm diversification (specifically agritourism). Findings demonstrate that the new knowledge networks are dominated by different forms of expertise: formal ‘agricultural advisors’ identified in the case studies primarily offer codified managerial knowledge through centralised networks, suggesting that state-funded services for small-scale farmers are largely embedded in traditional, linear models of knowledge transfer. Production and diversification knowledge is exchanged through ‘distributed’ and ‘decentralised’ networks, where a range of actors are involved across varying geographical distances. Findings highlight issues associated with the quality and independence of both ‘free’ and paid advice, as well as the importance of combining tacit and codified knowledge for credibility. In all four cases, we found that small-scale farmers utilise formal advisory services primarily for accessing subsidies (e.g. completing application forms), rather than acquiring production knowledge. The authors argue that by utilising the state funding allocated to advisory services for small-scale farmers primarily to enable these farmers to access subsidies, important opportunities for innovation by both advisors or farmers can be lost.Publisher PDFPeer reviewe

Molecular mechanisms of cell death: recommendations of the Nomenclature Committee on Cell Death 2018.

Over the past decade, the Nomenclature Committee on Cell Death (NCCD) has formulated guidelines for the definition and interpretation of cell death from morphological, biochemical, and functional perspectives. Since the field continues to expand and novel mechanisms that orchestrate multiple cell death pathways are unveiled, we propose an updated classification of cell death subroutines focusing on mechanistic and essential (as opposed to correlative and dispensable) aspects of the process. As we provide molecularly oriented definitions of terms including intrinsic apoptosis, extrinsic apoptosis, mitochondrial permeability transition (MPT)-driven necrosis, necroptosis, ferroptosis, pyroptosis, parthanatos, entotic cell death, NETotic cell death, lysosome-dependent cell death, autophagy-dependent cell death, immunogenic cell death, cellular senescence, and mitotic catastrophe, we discuss the utility of neologisms that refer to highly specialized instances of these processes. The mission of the NCCD is to provide a widely accepted nomenclature on cell death in support of the continued development of the field

Effects of fluoxetine on functional outcomes after acute stroke (FOCUS): a pragmatic, double-blind, randomised, controlled trial

Background Results of small trials indicate that fluoxetine might improve functional outcomes after stroke. The FOCUS trial aimed to provide a precise estimate of these effects. Methods FOCUS was a pragmatic, multicentre, parallel group, double-blind, randomised, placebo-controlled trial done at 103 hospitals in the UK. Patients were eligible if they were aged 18 years or older, had a clinical stroke diagnosis, were enrolled and randomly assigned between 2 days and 15 days after onset, and had focal neurological deficits. Patients were randomly allocated fluoxetine 20 mg or matching placebo orally once daily for 6 months via a web-based system by use of a minimisation algorithm. The primary outcome was functional status, measured with the modified Rankin Scale (mRS), at 6 months. Patients, carers, health-care staff, and the trial team were masked to treatment allocation. Functional status was assessed at 6 months and 12 months after randomisation. Patients were analysed according to their treatment allocation. This trial is registered with the ISRCTN registry, number ISRCTN83290762. Findings Between Sept 10, 2012, and March 31, 2017, 3127 patients were recruited. 1564 patients were allocated fluoxetine and 1563 allocated placebo. mRS data at 6 months were available for 1553 (99·3%) patients in each treatment group. The distribution across mRS categories at 6 months was similar in the fluoxetine and placebo groups (common odds ratio adjusted for minimisation variables 0·951 [95% CI 0·839–1·079]; p=0·439). Patients allocated fluoxetine were less likely than those allocated placebo to develop new depression by 6 months (210 [13·43%] patients vs 269 [17·21%]; difference 3·78% [95% CI 1·26–6·30]; p=0·0033), but they had more bone fractures (45 [2·88%] vs 23 [1·47%]; difference 1·41% [95% CI 0·38–2·43]; p=0·0070). There were no significant differences in any other event at 6 or 12 months. Interpretation Fluoxetine 20 mg given daily for 6 months after acute stroke does not seem to improve functional outcomes. Although the treatment reduced the occurrence of depression, it increased the frequency of bone fractures. These results do not support the routine use of fluoxetine either for the prevention of post-stroke depression or to promote recovery of function. Funding UK Stroke Association and NIHR Health Technology Assessment Programme

Citizenship: locating people with learning disabilities

This article first identifies citizenship as an ambiguous con-cept with changing and contested meanings. Next it discusses the methodological commitment of a study conducted in 2001 exploring the conceptions of citizenship permeating learning disability services. The third section identifies four themes linked to the citizenship of disabled people: work, participa-tion, community and consumption. Lastly, the article looks to locate the citizenship of people with learning disability within the framework of governmentality. The analysis of interview material from the 2001 study suggested that there was no coherent idea of citizenship operating through the services. However, the analysis of governmentality provides a richer picture. The different discourses of citizenship, while produc-ing contradictory positions for individuals with learning disability, do nevertheless provide positions to be had when less than half a century ago no such positions existed. In this sense these discourses are productive