Níveis de controle gerencial em hospitais: a influência da acreditação em outros sistemas de controle gerencial

The objective of this study is to identify the influence of accreditation on management control systems (MCS) before and after implementation. A survey was performed, with a sample of 92 respondents (professionals responsible for implementing accreditation) and a t-test was used to evaluate the difference between the two samples (before and after accreditation). The results show that after accreditation, management control systems (beliefs, boundary, diagnostic, and interactive control systems) had seen significant improvements, leading to better management and quality of the health services provided. In the face of growing demands from the health sector, analyzing the balanced use of management techniques that improve organizational control in companies is expected to contribute to better service delivery and maximization of generally scarce resources.El objetivo del estudio es identificar la influencia de la acreditación en los sistemas de control de gestión (SCG) antes y después de la implementación de la acreditación. Para esto se realizó una encuesta, con una muestra de 92 encuestados (profesionales responsables de implementar la acreditación) y se utilizó la prueba t para evaluar la diferencia entre las dos muestras (antes y después de la implementación de la acreditación). Los resultados muestran que después de la implementación de la acreditación, los sistemas de control de gestión (creencias, frontera, diagnóstico e interactivos) tuvieron mejoras significativas en sus procesos, caracterizando una mejor gestión y calidad de los servicios de salud prestados. Al analizar el uso equilibrado de las herramientas de control de gestión que maximizan el control organizacional de las empresas, se espera contribuir a una mejor prestación de servicios y la maximización de los recursos organizacionales generalmente escasos ante las crecientes demandas del sector de la salud.O objetivo do estudo é identificar a influência da acreditação nos Sistemas de Controle de Gestão (SCG) antes e após a implementação da acreditação. Para isso, foi realizada uma pesquisa, com uma amostra de 92 respondentes (profissionais responsáveis pela implementação da acreditação) e utilizou-se o teste t para avaliar a diferença entre as duas amostras (antes e após a implementação da acreditação). Os resultados mostram que, após a implantação da acreditação, os sistemas de controle gerencial (crenças, fronteiras, diagnóstico e interativo) apresentaram melhorias significativas em seus processos, caracterizando melhor gerenciamento e qualidade para o hospital acreditado. Ao analisar o uso equilibrado das ferramentas de controle gerencial que maximizam o controle organizacional das empresas, espera-se que contribua para uma melhor prestação de serviços e para a maximização de recursos organizacionais geralmente escassos, à luz das crescentes demandas do setor de saúde

Conservadorismo contábil em empresas complexas

O estudo busca averiguar a influência da complexidade de empresas nos níveis de conservadorismo contábil. O tema de análise, conservadorismo contábil em empresas complexas, pode ser considerado relevante porque analisa as práticas de conservadorismo levando em conta o contexto organizacional das empresas, fato ignorado em outros estudos que investigam os incentivos ou determinantes do conservadorismo contábil, pelo menos quanto à complexidade empresarial. A pesquisa apresenta evidências estatísticas de que o conservadorismo contábil varia de forma positiva com a assimetria da informação ocasionada por características específicas de ambientes complexos. Em contrapartida, quando estas apresentam, em conjunto, diversas características complexas, então a tendência é de pouca adoção do conservadorismo. Além disso, a presente pesquisa reúne evidências que visam a contribuir para a ciência contábil pela análise de empresas complexas e conservadorismo, e não práticas oportunistas observadas em estudos prévios. A amostra refere-se a 110 empresas de capital aberto no período de 2010 a 2016. A coleta de dados foi realizada por meio de relatórios das empresas, como formulários de referência, dados cadastrais e notas explicativas, bem como da base de dados Economatica®. A análise dos dados foi realizada por meio de regressão linear múltipla e regressão quantílica. Evidências obtidas na pesquisa indicam que o conservadorismo contábil varia conforme a assimetria de informação ocasionada por ambientes complexos em que pode apresentar uma relação positiva em empresas com poucas características de complexidade ou relação negativa se a empresa tem complexidade em diversas características ao mesmo tempo. Lança luz, então, sobre os diferentes níveis de conservadorismo observados nas empresas que muitas vezes podem ser atribuídos a mecanismos de governança, cultura organizacional, padrões contábeis, entre outros fatores, resultados que podem estar enviesados por não considerar o fator complexidade de empresas.This study seeks to investigate the influence of the complexity of companies on levels of accounting conservatism. The subject of analysis, accounting conservatism in complex companies, can be considered relevant because it analyzes conservative practices taking into account the organizational context of companies; something that is ignored in other studies that investigate the incentives or determinants of accounting conservatism, at least as far as firm complexity is concerned. The research presents statistical evidence that accounting conservatism varies positively with the information asymmetry caused by specific characteristics of complex environments. On the other hand, when companies present several complex characteristics together, then the trend is one of little adoption of conservatism. In addition, this research brings together evidence that aims to contribute to accounting science by analyzing complex companies and conservatism and not the opportunistic practices observed in previous studies. The sample refers to 110 publicly traded companies from 2010 to 2016. The data collection was carried out using company reports, such as reference forms, registration data, and explanatory notes, as well as the Economatica® database. The data analysis was performed using multiple linear regression and quantile regression. The evidence obtained in the research indicates that accounting conservatism varies according to the information asymmetry caused by complex environments, in which it can present a positive relationship in companies with few characteristics of complexity, or a negative relationship if the company has complexity in several characteristics at the same time. It throws light on the different levels of conservatism observed in companies, which can often be attributed to mechanisms of governance, organizational culture, and accounting standards, among other factors, which are results that may be biased if the company complexity factor is not considered

Options for early breast cancer follow-up in primary and secondary care : a systematic review

Background Both incidence of breast cancer and survival have increased in recent years and there is a need to review follow up strategies. This study aims to assess the evidence for benefits of follow-up in different settings for women who have had treatment for early breast cancer. Method A systematic review to identify key criteria for follow up and then address research questions. Key criteria were: 1) Risk of second breast cancer over time - incidence compared to general population. 2) Incidence and method of detection of local recurrence and second ipsi and contra-lateral breast cancer. 3) Level 1–4 evidence of the benefits of hospital or alternative setting follow-up for survival and well-being. Data sources to identify criteria were MEDLINE, EMBASE, AMED, CINAHL, PSYCHINFO, ZETOC, Health Management Information Consortium, Science Direct. For the systematic review to address research questions searches were performed using MEDLINE (2011). Studies included were population studies using cancer registry data for incidence of new cancers, cohort studies with long term follow up for recurrence and detection of new primaries and RCTs not restricted to special populations for trials of alternative follow up and lifestyle interventions. Results Women who have had breast cancer have an increased risk of a second primary breast cancer for at least 20 years compared to the general population. Mammographically detected local recurrences or those detected by women themselves gave better survival than those detected by clinical examination. Follow up in alternative settings to the specialist clinic is acceptable to women but trials are underpowered for survival. Conclusions Long term support, surveillance mammography and fast access to medical treatment at point of need may be better than hospital based surveillance limited to five years but further large, randomised controlled trials are needed

Formative evaluation of the telecare fall prevention project for older veterans

<p>Abstract</p> <p>Background</p> <p>Fall prevention interventions for community-dwelling older adults have been found to reduce falls in some research studies. However, wider implementation of fall prevention activities in routine care has yielded mixed results. We implemented a theory-driven program to improve care for falls at our Veterans Affairs healthcare facility. The first project arising from this program used a nurse advice telephone line to identify patients' risk factors for falls and to triage patients to appropriate services. Here we report the formative evaluation of this project.</p> <p>Methods</p> <p>To evaluate the intervention we: 1) interviewed patient and employee stakeholders, 2) reviewed participating patients' electronic health record data and 3) abstracted information from meeting minutes. We describe the implementation process, including whether the project was implemented according to plan; identify barriers and facilitators to implementation; and assess the incremental benefit to the quality of health care for fall prevention received by patients in the project. We also estimate the cost of developing the pilot project.</p> <p>Results</p> <p>The project underwent multiple changes over its life span, including the addition of an option to mail patients educational materials about falls. During the project's lifespan, 113 patients were considered for inclusion and 35 participated. Patient and employee interviews suggested support for the project, but revealed that transportation to medical care was a major barrier in following up on fall risks identified by nurse telephone triage. Medical record review showed that the project enhanced usual medical care with respect to home safety counseling. We discontinued the program after 18 months due to staffing limitations and competing priorities. We estimated a cost of $9194 for meeting time to develop the project.</p> <p>Conclusions</p> <p>The project appeared feasible at its outset but could not be sustained past the first cycle of evaluation due to insufficient resources and a waning of local leadership support due to competing national priorities. Future projects will need both front-level staff commitment and prolonged high-level leadership involvement to thrive.</p

Sensing Senses: Tactile Feedback for the Prevention of Decubitus Ulcers

Decubitus ulcers, also known as pressure sores, is a major problem in health care, in particular for patients with spinal cord injuries. These patients cannot feel the discomfort that would urge healthy people to change their posture. We describe a system that uses a sensor mat to detect problematic postures and provides tactile feedback to the user. The results of our preliminary study with healthy subjects show that the tactile feedback is a viable option to spoken feedback. We envision the system being used for rehabilitation games, but also for everyday Decubitus ulcers prevention

Design of a continuous quality improvement program to prevent falls among community-dwelling older adults in an integrated healthcare system

<p>Abstract</p> <p>Background</p> <p>Implementing quality improvement programs that require behavior change on the part of health care professionals and patients has proven difficult in routine care. Significant randomized trial evidence supports creating fall prevention programs for community-dwelling older adults, but adoption in routine care has been limited. Nationally-collected data indicated that our local facility could improve its performance on fall prevention in community-dwelling older people. We sought to develop a sustainable local fall prevention program, using theory to guide program development.</p> <p>Methods</p> <p>We planned program development to include important stakeholders within our organization. The theory-derived plan consisted of 1) an initial leadership meeting to agree on whether creating a fall prevention program was a priority for the organization, 2) focus groups with patients and health care professionals to develop ideas for the program, 3) monthly workgroup meetings with representatives from key departments to develop a blueprint for the program, 4) a second leadership meeting to confirm that the blueprint developed by the workgroup was satisfactory, and also to solicit feedback on ideas for program refinement.</p> <p>Results</p> <p>The leadership and workgroup meetings occurred as planned and led to the development of a functional program. The focus groups did not occur as planned, mainly due to the complexity of obtaining research approval for focus groups. The fall prevention program uses an existing telephonic nurse advice line to 1) place outgoing calls to patients at high fall risk, 2) assess these patients' risk factors for falls, and 3) triage these patients to the appropriate services. The workgroup continues to meet monthly to monitor the progress of the program and improve it.</p> <p>Conclusion</p> <p>A theory-driven program development process has resulted in the successful initial implementation of a fall prevention program.</p

How are falls and fear of falling associated with objectively measured physical activity in a cohort of community-dwelling older men?

BACKGROUND: Falls affect approximately one third of community-dwelling older adults each year and have serious health and social consequences. Fear of falling (FOF) (lack of confidence in maintaining balance during normal activities) affects many older adults, irrespective of whether they have actually experienced falls. Both falls and fear of falls may result in restrictions of physical activity, which in turn have health consequences. To date the relation between (i) falls and (ii) fear of falling with physical activity have not been investigated using objectively measured activity data which permits examination of different intensities of activity and sedentary behaviour. METHODS: Cross-sectional study of 1680 men aged 71-92 years recruited from primary care practices who were part of an on-going population-based cohort. Men reported falls history in previous 12 months, FOF, health status and demographic characteristics. Men wore a GT3x accelerometer over the hip for 7 days. RESULTS: Among the 12% of men who had recurrent falls, daily activity levels were lower than among non-fallers; 942 (95% CI 503, 1381) fewer steps/day, 12(95% CI 2, 22) minutes less in light activity, 10(95% CI 5, 15) minutes less in moderate to vigorous PA [MVPA] and 22(95% CI 9, 35) minutes more in sedentary behaviour. 16% (n = 254) of men reported FOF, of whom 52% (n = 133) had fallen in the past year. Physical activity deficits were even greater in the men who reported that they were fearful of falling than in men who had fallen. Men who were fearful of falling took 1766(95% CI 1391, 2142) fewer steps/day than men who were not fearful, and spent 27(95% CI 18, 36) minutes less in light PA, 18(95% CI 13, 22) minutes less in MVPA, and 45(95% CI 34, 56) minutes more in sedentary behaviour. The significant differences in activity levels between (i) fallers and non-fallers and (ii) men who were fearful of falling or not fearful, were mediated by similar variables; lower exercise self-efficacy, fewer excursions from home and more mobility difficulties. CONCLUSIONS: Falls and in particular fear of falling are important barriers to older people gaining health benefits of walking and MVPA. Future studies should assess the longitudinal associations between falls and physical activity

Accuracy of magnetic resonance studies in the detection of chondral and labral lesions in femoroacetabular impingement : systematic review and meta-analysis

Background: Several types of Magnetic resonance imaging (MRI) are commonly used in imaging of femoroacetabular impingement (FAI), however till now there are no clear protocols and recommendations for each type. The aim of this meta-analysis is to detect the accuracy of conventional magnetic resonance imaging (cMRI), direct magnetic resonance arthrography (dMRA) and indirect magnetic resonance arthrography (iMRA) in the diagnosis of chondral and labral lesions in femoroacetabular impingement (FAI). Methods: A literature search was finalized on the 17th of May 2016 to collect all studies identifying the accuracy of cMRI, dMRA and iMRA in diagnosing chondral and labral lesions associated with FAI using surgical results (arthroscopic or open) as a reference test. Pooled sensitivity and specificity with 95% confidence intervals using a random-effects meta-analysis for MRI, dMRA and iMRA were calculated also area under receiver operating characteristic (ROC) curve (AUC) was retrieved whenever possible where AUC is equivocal to diagnostic accuracy. Results: The search yielded 192 publications which were reviewed according inclusion and exclusion criteria then 21 studies fulfilled the eligibility criteria for the qualitative analysis with a total number of 828 cases, lastly 12 studies were included in the quantitative meta-analysis. Meta-analysis showed that as regard labral lesions the pooled sensitivity, specificity and AUC for cMRI were 0.864, 0.833 and 0.88 and for dMRA were 0.91, 0.58 and 0.92. While in chondral lesions the pooled sensitivity, specificity and AUC for cMRI were 0.76, 0.72 and 0.75 and for dMRA were 0.75, 0.79 and 0.83, while for iMRA were sensitivity of 0.722 and specificity of 0.917. Conclusions: The present meta-analysis showed that the diagnostic test accuracy was superior for dMRA when compared with cMRI for detection of labral and chondral lesions. The diagnostic test accuracy was superior for labral lesions when compared with chondral lesions in both cMRI and dMRA. Promising results are obtained concerning iMRA but further studies still needed to fully assess its diagnostic accuracy

Insulin signaling pathways in a patient with insulin resistance of difficult management - a case report

Insulin signalling pathways were investigated in a 33 year-old woman with immunologic insulin resistance. Her past medical history was remarkable for intermittent use of insulin and allergic reactions to several drugs, and measure of plasma anti-insulin antibodies level corroborated the clinical suspicion of immune mediated insulin resistance (8074 nU/ml - RIA - Ref value: <60). Treatment with several immunosuppressive regimens was tried, however the results were disappointing. Possible subcellular mechanisms of insulin resistance were investigated by performing analysis of insulin receptor and post receptor signaling in skeletal muscle biopsy. The expression of insulin receptor (IR), insulin receptor substrate 1 (IRS-1) and glucose transporter 4 (GLUT-4) was evaluated in total extract from muscle tissue by Western blotting. Basal IR, IRS-1 and GLUT-4 expression was detected, however receptor autophosphorylation was not observed. A study of translocation of GLUT-4 to plasma membrane showed that tissue presented low levels of membrane-associated GLUT-4. When in vitro stimulation was undertaken, tissue was capable to be responsive to insulin. Our results suggest that even though IR expression was normally occurring, IR β-subunit tyrosine kinase activity in muscle was down-regulated leading to alterations in insulin post receptor signaling. Consistent with normal insulin receptor and post receptor signaling, our results were compatible with decreased insulin binding to IR probably due to neutralization by anti-insulin antibodies. In conclusion, this patient has immunologic insulin resistance and treatment should be based on immunosuppressive drugs as tolerated

Abdominal aortic calcification quantified by the Morphological Atherosclerotic Calcification Distribution (MACD) index is associated with features of the metabolic syndrome

<p>Abstract</p> <p>Background</p> <p>Abdominal aortic calcifications (AAC) predict cardiovascular mortality. A new scoring model for AAC, the Morphological Atherosclerotic Calcification Distribution (MACD) index may contribute with additional information to the commonly used Aortic Calcification Severity (AC24) score, when predicting death from cardiovascular disease (CVD). In this study we investigated associations of MACD and AC24 with traditional metabolic-syndrome associated risk factors at baseline and after 8.3 years follow-up, to identify biological parameters that may account for the differential performance of these indices.</p> <p>Methods</p> <p>Three hundred and eight healthy women aged 48 to 76 years, were followed for 8.3 ± 0.3 years. AAC was quantified using lumbar radiographs. Baseline data included age, weight, blood pressure, blood lipids, and glucose levels. Pearson correlation coefficients were used to test for relationships.</p> <p>Results</p> <p>At baseline and across all patients, MACD correlated with blood glucose (r²= 0.1, P< 0.001) and to a lesser, but significant extent with traditional risk factors (p < 0.01) of CVD. In the longitudinal analysis of correlations between baseline biological parameters and the follow-up calcification assessment using radiographs we found LDL-cholesterol, HDL/LDL, and the ApoB/ApoA ratio significantly associated with the MACD (P< 0.01). In a subset of patients presenting with calcification at both baseline and at follow-up, all cholesterol levels were significantly associated with the MACD (P< 0.01) index. AC24 index was not correlated with blood parameters.</p> <p>Conclusion</p> <p>Patterns of calcification identified by the MACD, but not the AC24 index, appear to contain useful biological information perhaps explaining part of the improved identification of risk of cardiovascular death of the MACD index. Correlations of MACD but not the AC24 with glucose levels at baseline suggest that hyperglycemia may contribute to unique patterns of calcification indicated by the MACD.</p