Pregnancy-related factors and the risk of breast carcinoma in situ and invasive breast cancer among postmenopausal women in the California Teachers Study cohort

Abstract Introduction Although pregnancy-related factors such as nulliparity and late age at first full-term pregnancy are well-established risk factors for invasive breast cancer, the roles of these factors in the natural history of breast cancer development remain unclear. Methods Among 52,464 postmenopausal women participating in the California Teachers Study (CTS), 624 were diagnosed with breast carcinoma in situ (CIS) and 2,828 with invasive breast cancer between 1995 and 2007. Multivariable Cox proportional hazards regression methods were used to estimate relative risks associated with parity, age at first full-term pregnancy, breastfeeding, nausea or vomiting during pregnancy, and preeclampsia. Results Compared with never-pregnant women, an increasing number of full-term pregnancies was associated with greater risk reduction for both breast CIS and invasive breast cancer (both P trend < 0.01). Women having four or more full-term pregnancies had a 31% lower breast CIS risk (RR = 0.69, 95% CI = 0.51 to 0.93) and 18% lower invasive breast cancer risk (RR = 0.82, 95% CI = 0.72 to 0.94). Parous women whose first full-term pregnancy occurred at age 35 years or later had a 118% greater risk for breast CIS (RR = 2.18, 95% CI = 1.36 to 3.49) and 27% greater risk for invasive breast cancer (RR = 1.27, 95% CI = 0.99 to 1.65) than those whose first full-term pregnancy occurred before age 21 years. Furthermore, parity was negatively associated with the risk of estrogen receptor-positive (ER+) or ER+/progesterone receptor-positive (PR+) while age at first full-term pregnancy was positively associated with the risk of ER+ or ER+/PR+ invasive breast cancer. Neither of these factors was statistically significantly associated with the risk of ER-negative (ER-) or ER-/PR- invasive breast cancer, tests for heterogeneity between subtypes did not reach statistical significance. No clear associations were detected for other pregnancy-related factors. Conclusions These results provide some epidemiologic evidence that parity and age at first full-term pregnancy are involved in the development of breast cancer among postmenopausal women. The role of these factors in risk of in situ versus invasive, and hormone receptor-positive versus -negative breast cancer merits further exploration

What is the value and impact of quality and safety teams? A scoping review

<p>Abstract</p> <p>Background</p> <p>The purpose of this study was to conduct a scoping review of the literature about the establishment and impact of quality and safety team initiatives in acute care.</p> <p>Methods</p> <p>Studies were identified through electronic searches of Medline, Embase, CINAHL, PsycINFO, ABI Inform, Cochrane databases. Grey literature and bibliographies were also searched. Qualitative or quantitative studies that occurred in acute care, describing how quality and safety teams were established or implemented, the impact of teams, or the barriers and/or facilitators of teams were included. Two reviewers independently extracted data on study design, sample, interventions, and outcomes. Quality assessment of full text articles was done independently by two reviewers. Studies were categorized according to dimensions of quality.</p> <p>Results</p> <p>Of 6,674 articles identified, 99 were included in the study. The heterogeneity of studies and results reported precluded quantitative data analyses. Findings revealed limited information about attributes of successful and unsuccessful team initiatives, barriers and facilitators to team initiatives, unique or combined contribution of selected interventions, or how to effectively establish these teams.</p> <p>Conclusions</p> <p>Not unlike systematic reviews of quality improvement collaboratives, this broad review revealed that while teams reported a number of positive results, there are many methodological issues. This study is unique in utilizing traditional quality assessment and more novel methods of quality assessment and reporting of results (SQUIRE) to appraise studies. Rigorous design, evaluation, and reporting of quality and safety team initiatives are required.</p

An Evidence-based framework : competencies and skills for managers in Australian health services

This paper is concerned with competencies and skills that enhance the capacity of health service managers to handle changes that medical technology and other factors have brought about. The paper takes a strategic rather than an all encompassing approach to identify the systemic changes that have taken place in the last decade. Statistical analysis and other information available were used in this process. One of the reasons for this approach is to take a real-world perspective of contemporary health management issues as the underpinning of the research. The salient systemic changes identified are classified under three major categories: practice evolution, service capacity and inputs and structural changes in public sector administration. The methodology involves a framework that led from systemic changes to related management issues and thence to competencies and skills of relevance. The latter relied on the inventory of health service management competencies and skills identified by academic research. The framework structure took into account the competence/skill domain and context. It led to groups of predisposing, enabling and transforming competencies and skills related to the management issues arising from the systemic changes identified. The findings will help examine strengths of current post-graduate courses in health service management. They also provide an agenda and opportunities for continuing education by relevant professional organisations.16 page(s

The Language of Health Reform and Health Management: critical issues in the management of health systems

Health reform has been a constant feature of most health systems for a number of decades and has often focused on structural change. The lexicon of health reform and health management has also become intertwined with managers reporting that reform has become a constant and that rather than influencing that change they are in fact influenced by it and by its impact on their role, professional development and career. There is a challenge for health service managers to return to a leadership role in enabling health reform. In doing so will this challenge us to think differently about management? This article addresses the significant body of research into health reform and health management through the lens of language used in reporting the context and the significant impact that it has had on the management role. It describes what directions that role might take, the qualities required in selecting capable managers and questions the current status quo in the education, training and development of this significant sector of the health system workforce. It concludes by proposing a way forward that acknowledges that contemporary health reform is shifting the paradigm of healthcare delivery in a way that requires the dominant view of health management to be challenged. This might be achieved by the use of a critical lens on the language of management, a focus on a grounded approach about what managers need to do and an acceptance of variability in that role in adaptive complex contexts

Health service managers in Australia part 3 : field of study, level of education and income

This article is the third by the authors in a four-part series. They deal with the composition and characteristics of health service managers in Australia of relevance to policy and decision-making for the health service labour force in general and health service managers in particular. The first article provided analyses on the specific characteristics of service, geographical and category distribution of health service managers, while the second imparted factual perspectives on age and sex characteristics. The analyses in this third article involve the fields of study, levels of education and income of health service managers in Australia, at the time of 2006 Census of Population. Findings show that health service managers tended to have a higher degree of concentration in health and management/ commerce fields of study than the average for all industries. This also applied to managers in aged care residential services. The majority of females in the health labour force was reflected in most fields of study, with notable exceptions such as engineering and architecture/building. Health service managers had higher levels of education than the average for all industries. This was especially so in the case of hospital managers but also applied to other health services and to a lesser degree in aged care residential services. A larger proportion of female managers in health services had qualifications at bachelor and postgraduate levels than male managers, particularly in hospitals. The same applied to aged care residential services. Following their higher level of academic qualifications, the average income of managers in health services was higher than the average for all industries. There were substantial gaps between the average income of male and female managers in health services and aged care residential services. Some factors that contributed to this difference could be attributed to the higher proportion of female managers working less than full time but other factors must also have been responsible for this difference. The article raises policy and training questions and suggests a related agenda for research.16 page(s

Health service managers in Australia part 1: service, geographical and category distribution

This article is the first of a four-part series in which the authors provide analyses on the composition and characteristics of health service managers in Australia of relevance to policy and decision-making in dealing with these issues. This first article provides analyses on the specific characteristics of service, geographical and category distribution in both the public and private sectors. It gives an estimated number of managers in health services and aged care residential services in relation to the population they serve, as well as their relationship to people employed. It compares these ratios to those for all industries in Australia. The analyses also document and review managers by category and specialisation and compare their composition to the average for all industries. Substantial differences in composition between hospital, medical and other services, aged care residential services and the average for all industries arise from the analyses. Disparities in ratios to population and composition were also found among the various states and territories. The article also discusses the wide range of ratios of health service managers to population in some countries and their lack of consistency. The discussion of findings includes an agenda for future research.13 page(s

Health service managers in Australia part 2 : age and sex characteristics

This article is the second in a four-part series in which the authors provide analyses on the composition and characteristics of health service managers in Australia of relevance to policy and decision-making in dealing with the future of health service labour force in general and health service management in particular. The first article presented analyses on the specific characteristics of service, geographical and category distribution. This second article provides analyses on age and sex characteristics of health service managers in Australia. Findings confirm that the health services labour force was older than the labour force at large at the time of the 2006 Census of Population and that health service managers were also older than those in all industries. The age distribution of managers in health services showed skewness towards younger ages. As expected, those in senior positions tended to be older. Managers in aged care residential services were even older on average, following the older average age of the labour force in these services. In general, female managers tended to be younger than male managers. There was not much difference in the average age of health service managers among the states and territories. The same was the experience in aged care residential services. In a labour force where females were predominant, the majority of managers in health services and aged care residential services were also females. However, their proportion of managers was lower than their proportion in the labour force of these two services. Further, the gap between the proportion of females in the labour force and the proportion of managers was larger in health services and especially aged care residential services than that in all industries. The gap became larger when the positions of chief executive officer and general manager were considered. The article also discusses a number of related policy issues and suggests an agenda for future research.14 page(s

Health service managers in Australia part 4 : hours worked, marital status, country of birth and indigenous status

This fourth article adds to the findings of the three previous articles in a four-part series. These articles are concerned with the composition and characteristics of health service managers in Australia. The data and analyses present factual bases with a bearing on policy formulation and planning of the health labour force in Australia and the training of managers. The first article provided analyses on the specific characteristics of service, geographical and category distributions of health service managers, the second on age and sex, and the third on fields of study, level of education and income characteristics of health service managers. This fourth article investigates hours worked, marital status, country of birth and Indigenous status of health service managers in Australia. Findings confirm that a large proportion of health service managers worked part time and female managers more so than males. Partly as a result of this difference, male managers worked on average longer hours than females, but even full-time female managers worked on average shorter hours than males. The average hours worked was lower than the average for managers in all industries in Australia. When adjusted for differences in age from the average for all industries, a larger proportion of health service managers than average had never married and were divorced or widowed. Conversely, a lower proportion than average were married. More than the average proportion of managers in hospitals were born in Australia, while the inverse was the situation in medical and other health services. The share of Australian-born was about average in aged care residential services. Indigenous health service managers constituted a larger percentage of managers than the average in all industries. Their participation in hospitals was lower than in medical and health services; and about the average for all industries in aged care residential services. In all cases, their participation in the management of health services was lower than their proportion in the adult population. The article presents challenges in policy formulation regarding working conditions and the participation of varied segments of society in the management of health services. It also points to a related research agenda.12 page(s

Managing Quality

The issues associated with total quality management (TQM) in the Australian health care arena are described and discussed first. The notion of continuous quality improvement (CQI) as is relates to health care in Australia today is covered next. Although the terms total quality management and continuous quality improvement are often used synonymously, there is a distinction. TQM is a management philosophy that encapsulates the whole organisation, whereas CQI is specific to one element of the organisation. This distinction is discussed further later in the chapter. These two paradigms are the foundation of quality programs throughout the health care industry here in Australia and elsewhere around the world. They are the basis on which health professionals aim to assure the consumers of health care that the services that are provided in their organisation(s) are quality products