Reported barriers to evaluation in chronic care: experiences in six European countries.

INTRODUCTION: The growing movement of innovative approaches to chronic disease management in Europe has not been matched by a corresponding effort to evaluate them. This paper discusses challenges to evaluation of chronic disease management as reported by experts in six European countries. METHODS: We conducted 42 semi-structured interviews with key informants from Austria, Denmark, France, Germany, The Netherlands and Spain involved in decision-making and implementation of chronic disease management approaches. Interviews were complemented by a survey on approaches to chronic disease management in each country. Finally two project teams (France and the Netherlands) conducted in-depth case studies on various aspects of chronic care evaluation. RESULTS: We identified three common challenges to evaluation of chronic disease management approaches: (1) a lack of evaluation culture and related shortage of capacity; (2) reluctance of payers or providers to engage in evaluation and (3) practical challenges around data and the heterogeity of IT infrastructure. The ability to evaluate chronic disease management interventions is influenced by contextual and cultural factors. CONCLUSIONS: This study contributes to our understanding of some of the most common underlying barriers to chronic care evaluation by highlighting the views and experiences of stakeholders and experts in six European countries. Overcoming the cultural, political and structural barriers to evaluation should be driven by payers and providers, for example by building in incentives such as feedback on performance, aligning financial incentives with programme objectives, collectively participating in designing an appropriate framework for evaluation, and making data use and accessibility consistent with data protection policies

A novel machine learning-derived radiotranscriptomic signature of perivascular fat improves cardiac risk prediction using coronary CT angiography

Background: Coronary inflammation induces dynamic changes in the balance between water and lipid content in perivascular adipose tissue (PVAT), as captured by perivascular Fat Attenuation Index (FAI) in standard coronary CT angiography (CCTA). However, inflammation is not the only process involved in atherogenesis and we hypothesized that additional radiomic signatures of adverse fibrotic and microvascular PVAT remodelling, may further improve cardiac risk prediction. Methods and results: We present a new artificial intelligence-powered method to predict cardiac risk by analysing the radiomic profile of coronary PVAT, developed and validated in patient cohorts acquired in three different studies. In Study 1, adipose tissue biopsies were obtained from 167 patients undergoing cardiac surgery, and the expression of genes representing inflammation, fibrosis and vascularity was linked with the radiomic features extracted from tissue CT images. Adipose tissue wavelet-transformed mean attenuation (captured by FAI) was the most sensitive radiomic feature in describing tissue inflammation (TNFA expression), while features of radiomic texture were related to adipose tissue fibrosis (COL1A1 expression) and vascularity (CD31 expression). In Study 2, we analysed 1391 coronary PVAT radiomic features in 101 patients who experienced major adverse cardiac events (MACE) within 5 years of having a CCTA and 101 matched controls, training and validating a machine learning (random forest) algorithm (fat radiomic profile, FRP) to discriminate cases from controls (C-statistic 0.77 [95%CI: 0.62–0.93] in the external validation set). The coronary FRP signature was then tested in 1575 consecutive eligible participants in the SCOT-HEART trial, where it significantly improved MACE prediction beyond traditional risk stratification that included risk factors, coronary calcium score, coronary stenosis, and high-risk plaque features on CCTA (Δ[C-statistic] = 0.126, P  Conclusion: The CCTA-based radiomic profiling of coronary artery PVAT detects perivascular structural remodelling associated with coronary artery disease, beyond inflammation. A new artificial intelligence (AI)-powered imaging biomarker (FRP) leads to a striking improvement of cardiac risk prediction over and above the current state-of-the-art. </p

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Correction to: Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

The original version of this article unfortunately contained a mistake

Prevalence, associated factors and outcomes of pressure injuries in adult intensive care unit patients: the DecubICUs study

Funder: European Society of Intensive Care Medicine; doi: http://dx.doi.org/10.13039/501100013347Funder: Flemish Society for Critical Care NursesAbstract: Purpose: Intensive care unit (ICU) patients are particularly susceptible to developing pressure injuries. Epidemiologic data is however unavailable. We aimed to provide an international picture of the extent of pressure injuries and factors associated with ICU-acquired pressure injuries in adult ICU patients. Methods: International 1-day point-prevalence study; follow-up for outcome assessment until hospital discharge (maximum 12 weeks). Factors associated with ICU-acquired pressure injury and hospital mortality were assessed by generalised linear mixed-effects regression analysis. Results: Data from 13,254 patients in 1117 ICUs (90 countries) revealed 6747 pressure injuries; 3997 (59.2%) were ICU-acquired. Overall prevalence was 26.6% (95% confidence interval [CI] 25.9–27.3). ICU-acquired prevalence was 16.2% (95% CI 15.6–16.8). Sacrum (37%) and heels (19.5%) were most affected. Factors independently associated with ICU-acquired pressure injuries were older age, male sex, being underweight, emergency surgery, higher Simplified Acute Physiology Score II, Braden score 3 days, comorbidities (chronic obstructive pulmonary disease, immunodeficiency), organ support (renal replacement, mechanical ventilation on ICU admission), and being in a low or lower-middle income-economy. Gradually increasing associations with mortality were identified for increasing severity of pressure injury: stage I (odds ratio [OR] 1.5; 95% CI 1.2–1.8), stage II (OR 1.6; 95% CI 1.4–1.9), and stage III or worse (OR 2.8; 95% CI 2.3–3.3). Conclusion: Pressure injuries are common in adult ICU patients. ICU-acquired pressure injuries are associated with mainly intrinsic factors and mortality. Optimal care standards, increased awareness, appropriate resource allocation, and further research into optimal prevention are pivotal to tackle this important patient safety threat

Community, Infant Feeding, and AIDS: Empowerment Evaluation in Rural Eastern Cape

As a part of a three week learnership practicum, empowerment evaluation principles and practices were applied to antenatal and postnatal infant feeding counseling services offered by Iapile Gateway Clinic’s prevention of mother to child transmission (PMTCT) of HIV program. Empowerment evaluation engages stakeholders through the processes of planning, implementation, and evaluation, ultimately building these stakeholders’ capacities to sustain and improve services. Because of powerful sociocultural norms regarding infant feeding, empowerment evaluation was selected as a tool that would allow for sustainable and hermeneutic evaluation of the program, taking into account its dialectic relationship with local knowledge on infant feeding. Data on resources, strengths, achievements, challenges, and recommendations was collected through a series of formal and informal discussions with key personnel while assisting with daily duties. Additionally, baseline data was extrapolated from records routinely kept by the clinic. Generally, the antenatal and postnatal infant feeding counseling programs were highly efficient, testing and monitoring a large number of clients, given resource constraints. The programs were largely challenged by a shortage in highly trained personnel, a lack of social support for PMTCT clients, and incongruent record keeping for postnatal tracking. Recommendations thus included further skills development of staff, creation of a PMTCT-specific support group given the facilities and resources, and increased tracking of postnatal exposed infant health. With the last recommendation enacted, the program will have greater capacity for self-monitoring and will be able to better tailor the program to the needs of the clients. The evaluation was generally successful in its implementation of empowerment evaluation methodology, revealing the promise of improved community health promotion through the utilization of action research methods. Limitations of empowerment evaluation and action research are finally explored and recommendations for further study are offered

Recovering from the constitutional failure. An analysis of the EU reflection period. ZEI Discussion Paper C182 2008

[From the Introduction]. After the rejection of the European Union’s (EU) Constitutional Treaty in Spring 2005 by both France and the Netherlands, the heads of state and government called for a “reflection period” to provide opportunities to resolve constitutional difficulties, and to further engage Member State citizen populations, national parliaments and political parties. The ultimate aim was to provide sufficient time for Member States to further the Constitutional debate and garner enough support to continue the ratification process. Initially, the reflection period had not been intended to last longer than a year, but in June 2006 the European Council outlined a timeline to reach a solution, extending the deadline until the end of 2008. Through a six-part analysis, this paper will examine how the European Union used its self-imposed “reflection period” to overcome the constitutional deadlock. To begin, the paper will provide a historical overview, including origins of the Constitutional Treaty and the initial signs of tribulations during the referenda process. Given the significance of the treaty rejections in France and the Netherlands, the second part of this paper devotes special attention to public opinion polls and attempts to identify the motivations of French and Dutch voters in their decisions to vote “no.” In the third part, this paper takes a closer look at the three main EU institutions, European Commission, European Parliament and European Council, and attempts to illustrate the actions that were taken in response to their call to “reflect.” This section also briefly describes Member States’ activities during this time. These include various strategies to ensure EU institutions remain both accountable and reliable and establish a long-lasting link between the Union and its citizens. An overview of several academic contributions to the reflection period debate is presented in the fourth section. Research activities related to this discussion are presented in summary form from a selection of key European research institutes. In the fifth section of analysis, the EU Council Presidency debates are addressed. This section attempts to highlight the discrepancies that existed between the public debate and the negotiations occurring behind the “closed doors” of Member State governments. As the Lisbon Treaty (i.e. Reform Treaty) was the result of this government bargaining process, the sixth and final section of this paper summarizes the content of the Lisbon Treaty and provides a short comparison of its changes to the modifications envisaged in the Constitutional Treaty

A multi-stakeholder evaluation of the Baltimore City virtual supermarket program

Abstract Background Increasing access to healthy foods and beverages in disadvantaged communities is a public health priority due to alarmingly high rates of obesity. The Virtual Supermarket Program (VSP) is a Baltimore City Health Department program that uses online grocery ordering to deliver food to low-income neighborhoods. This study evaluates stakeholder preferences and barriers of program implementation. Methods This study assessed the feasibility, sustainability and efficacy of the VSP by surveying 93 customers and interviewing 14 programmatic stakeholders who had recently used the VSP or been involved with program design and implementation. Results We identified the following themes: The VSP addressed transportation barriers and food availability. The VSP impacted customers and the city by including improving food purchasing behavior, creating a food justice “brand for the city”, and fostering a sense of community. Customers appreciated using Supplemental Nutrition Assistance Program (SNAP) benefits to pay for groceries, but policy changes are needed allow online processing of SNAP benefits. Conclusions This evaluation summarizes lessons learned and serves as a guide to other public health leaders interested in developing similar programs. Provisions in the U.S. Department of Agriculture (USDA) Farm Bill 2014 allow for select grocers to pilot online transactions with SNAP benefits. If these pilots are efficacious, the VSP model could be easily disseminated