Predicting the effectiveness of early senior decision-making in urgent internal medical care : application of a hybrid agent-based and discrete event systems simulation model to evaluate UK healthcare policy recommendations

Hospital systems face year-upon-year rises in demand for in-patient services. Moments when urgent care departments are overwhelmed with more patients than they are resourced to provide care for (overcrowding) frequently emerge due to poor availability of hospital beds. Policymakers and healthcare leaders in the UK recommend an early senior decision-making (ESDM) strategy to divert suitable patients away from in-patient services at the time of referral into urgent care. Policies also advise expert clinicians – the highest grade of clinical staff - should perform this task. This research specifically explored the effectiveness of the ESDM strategy when applied to urgent internal medical populations – the largest consumers of in-patient services – with the intention of informing a cost-effectiveness analysis of ESDM. A systems simulation model (SSM) combining agent-based and discrete event systems simulation model was created to reproduce ESDM in a representative acute medical unit in the UK. Data to inform model conceptualisation, programming, and parameter inputs was gathered via observational ethnography, analytic autoethnography of expert early decision-making in urgent care, and prospective data collection of patient-reported outcomes. Outputs aligned with the goals of patients, staff, and provider goals were defined. Upon validation, the model was used to predict how outputs could change with different configurations of expert and non-expert staffing in the decision-maker role. Staffing strategies were analysed at increasing levels of tolerated overcrowding in the department to mimic high hospital occupancies that limited transfer from the unit. Modelled outputs were analysed for meaningful differences and trends. Early senior decision-making realised meaningfully fewer moments of overcrowding and delays, but only when departmental overcrowding was enforced. This occurred via of intuitive decision-making by clinical experts - a phenomenon not previously reported in literature available at the time of writing. System-wide inefficiencies begin to emerge when experts perform decision-making for all patients referred. Impact upon patient health is unclear. The ESDM strategy has the potential to realise safer in-patient care and generate local efficiencies in hospitals that face frequent moments of overcrowding, but not in systems that maintain urgent care bed occupancy levels below 100%. Improving currently available decision-support tools to harness the decision-making of experts may deliver efficiency gains at lesser cost. Further research into the health impact of admission avoidance and overcrowding in urgent care areas outside of the ED is warranted before cost-effectiveness may be explored.Hospital systems face year-upon-year rises in demand for in-patient services. Moments when urgent care departments are overwhelmed with more patients than they are resourced to provide care for (overcrowding) frequently emerge due to poor availability of hospital beds. Policymakers and healthcare leaders in the UK recommend an early senior decision-making (ESDM) strategy to divert suitable patients away from in-patient services at the time of referral into urgent care. Policies also advise expert clinicians – the highest grade of clinical staff - should perform this task. This research specifically explored the effectiveness of the ESDM strategy when applied to urgent internal medical populations – the largest consumers of in-patient services – with the intention of informing a cost-effectiveness analysis of ESDM. A systems simulation model (SSM) combining agent-based and discrete event systems simulation model was created to reproduce ESDM in a representative acute medical unit in the UK. Data to inform model conceptualisation, programming, and parameter inputs was gathered via observational ethnography, analytic autoethnography of expert early decision-making in urgent care, and prospective data collection of patient-reported outcomes. Outputs aligned with the goals of patients, staff, and provider goals were defined. Upon validation, the model was used to predict how outputs could change with different configurations of expert and non-expert staffing in the decision-maker role. Staffing strategies were analysed at increasing levels of tolerated overcrowding in the department to mimic high hospital occupancies that limited transfer from the unit. Modelled outputs were analysed for meaningful differences and trends. Early senior decision-making realised meaningfully fewer moments of overcrowding and delays, but only when departmental overcrowding was enforced. This occurred via of intuitive decision-making by clinical experts - a phenomenon not previously reported in literature available at the time of writing. System-wide inefficiencies begin to emerge when experts perform decision-making for all patients referred. Impact upon patient health is unclear. The ESDM strategy has the potential to realise safer in-patient care and generate local efficiencies in hospitals that face frequent moments of overcrowding, but not in systems that maintain urgent care bed occupancy levels below 100%. Improving currently available decision-support tools to harness the decision-making of experts may deliver efficiency gains at lesser cost. Further research into the health impact of admission avoidance and overcrowding in urgent care areas outside of the ED is warranted before cost-effectiveness may be explored

Psychosocial Determinants of Health Behaviour Change in an E-Counseling Intervention for Hypertension

We evaluated the influence of psychological stress and depression on motivation to adhere to recommended guidelines for exercise and diet. This study was conducted within a larger e-counseling trial. Subjects diagnosed with hypertension (n = 387, age = 44–74 years, 59% female) completed assessments at baseline and within 2 weeks after a 4-month intervention period. Outcomes included mean level of readiness to change diet and exercise and symptoms of depression and stress. Per protocol analysis defined e-counseling support as follows: ≥8 e-mails = therapeutic dose, 1–7 e-mails = subtherapeutic dose, and 0 e-mails = Controls. Baseline adjusted symptoms of depression and stress were inversely correlated with improvement in exercise (partial R = −.14, P = .01, and partial R = −.17, P = .01, resp.) but not diet or e-counseling. Subjects who received a therapeutic dose of e-counseling demonstrated greater readiness for diet adherence versus Controls (P = .02). Similarly, subjects receiving a therapeutic level of e-counseling demonstrated significantly greater readiness for exercise adherence versus Controls (P = .04). In sum, e-counseling is associated with improved motivation to adhere to exercise and diet among patients with hypertension, independent of symptoms of psychological stress and depression

Managing mental health problems in the workplace : are small businesses different?

Purpose This study addresses a gap in evidence on small employer experiences of managing mental health problems in the workplace. The authors gathered first-hand experiences of small business managers to empirically investigate how the small business context affects the management and support of mental health problems in the workplace, and the practice implications that arise. Design/methodology/approach Qualitative interviews, combining semi-structured and narrative approaches, with 21 small business managers with experience of managing employees with mental health difficulties. The 21 managers recounted a total of 45 employee cases, which were analysed thematically, using a case-based matrix. Study participants were drawn from small businesses within England and Scotland (UK). Interviews were conducted between November 2019 and February 2020. Findings Support aligned with current understanding of effective practice, yet was often informal, instinctive and flexible. Accommodating employees with mental health problems impacted the workload of managers and co-workers, and business operation and growth. Challenges and tensions reflected the difficult balancing act faced by managers in organisations of all sizes. However, the intensity and immediacy of cross-pressures was enhanced for small businesses, due to their smaller workforce and lack of dedicated Human Resource Management and occupational health expertise. Practical implications Guidance should address the navigation of day-to-day management and support for employees with mental health difficulties, including approaches to balancing the needs of the wider workforce and business operation. Access to HR and occupational health expertise is valuable. Financial subsidies may be of lesser concern to small businesses. Originality/value This study offers originality in focusing exclusively on small business managers with first-hand experience of supporting employees with mental health problems. Findings challenge the perception that small firms have unique experiences, whilst highlighting contextual features that exacerbate intensity and immediacy of impacts

An interchangeable role for kainate and metabotropic glutamate receptors in the induction of rat hippocampal mossy fiber long-term potentiation in vivo

The roles of both kainate receptors (KARs) and metabotropic glutamate receptors (mGluRs) in mossy fiber long-term potentiation (MF-LTP) have been extensively studied in hippocampal brain slices, but the findings are controversial. In this study, we have addressed the roles of both mGluRs and KARs in MF-LTP in anesthetized rats. We found that MF-LTP could be induced in the presence of either GluK1-selective KAR antagonists or group I mGluR antagonists. However, LTP was inhibited when the group I mGluRs and the GluK1-KARs were simultaneously inhibited. Either mGlu1 or mGlu5 receptor activation is sufficient to induce this form of LTP as selective inhibition of either subtype alone, together with the inhibition of KARs, did not inhibit MF-LTP. These data suggest that mGlu1 receptors, mGlu5 receptors, and GluK1-KARs are all engaged during high-frequency stimulation, and that the activation of any one of these receptors alone is sufficient for the induction of MF-LTP in vivo. © 2015 The Authors Hippocampus Published by Wiley Periodicals, Inc

Investigating linkage rates among probabilistically linked birth and hospitalization records

BACKGROUND: With the increasing use of probabilistically linked administrative data in health research, it is important to understand whether systematic differences occur between the populations with linked and unlinked records. While probabilistic linkage involves combining records for individuals, population perinatal health research requires a combination of information from both the mother and her infant(s). The aims of this study were to (i) describe probabilistic linkage for perinatal records in New South Wales (NSW) Australia, (ii) determine linkage proportions for these perinatal records, and (iii) assess records with linked mother and infant hospital-birth record, and unlinked records for systematic differences. METHODS: This is a population-based study of probabilistically linked statutory birth and hospital records from New South Wales, Australia, 2001-2008. Linkage groups were created where the birth record had complete linkage with hospital admission records for both the mother and infant(s), partial linkage (the mother only or the infant(s) only) or neither. Unlinked hospital records for mothers and infants were also examined. Rates of linkage as a percentage of birth records and descriptive statistics for maternal and infant characteristics by linkage groups were determined. RESULTS: Complete linkage (mother hospital record – birth record – infant hospital record) was available for 95.9% of birth records, partial linkage for 3.6%, and 0.5% with no linked hospital records (unlinked). Among live born singletons (complete linkage = 96.5%) the mothers without linked infant records (1.6%) had slightly higher proportions of young, non-Australian born, socially disadvantaged women with adverse pregnancy outcomes. The unlinked birth records (0.4%) had slightly higher proportions of nulliparous, older, Australian born women giving birth in private hospitals by caesarean section. Stillbirths had the highest rate of unlinked records (3-4%). CONCLUSIONS: This study shows that probabilistic linkage of perinatal records can achieve high, representative levels of complete linkage. Records for mother’s that did not link to infant records and unlinked records had slightly different characteristics to fully linked records. However, these groups were small and unlikely to bias results and conclusions in a substantive way. Stillbirths present additional challenges to the linkage process due to lower rates of linkage for lower gestational ages, where most stillbirths occur

The mental health status of ethnocultural minorities in Ontario and their mental health care.

Background: Mental disorders are a leading cause of disability and early mortality. The objective of this study was to describe and compare psychosocial indicators and mental health service use among ethnoculturally diverse Ontarians. Methods: This is a cross-sectional analysis of the Ontario Health Study pilot investigation. Residents were mailed an invitation to one of 3 assessment centres (urban, rural and northern sites) from March 2009 to July 2010. Participants had an interview with a nurse and completed a questionnaire on a touchscreen kiosk. The questionnaire included sociodemographic items, and scales assessing symptoms of depressive symptoms (CES-D) and anxiety (GAD-7), social support (Lubben Social Network Scale), stressful life events, and mental health service use. Results: Eight thousand two hundred thirty-five residents participated, among whom 6652 (82.4 %) self-reported their ethnocultural background as White, 225 (2.8 %) as South Asian, 222 (2.8 %) East Asian, 214 (2.7 %) Southeast Asian, 197 (2.4 %) Black, and 28 (0.3 %) as Aboriginal. Based on their sociodemographic characteristics, participants from these ethnocultural minority groups were matched to White participants. Black participants reported significantly greater stressful life events than White participants (p = .04), particularly death (p < .05), divorce (p = .002) and financial difficulties (p < .001). East Asian participants reported significantly less social support than their White counterparts (p < .001), and this was not confounded by measurement variance. Mental health service use was significantly lower in all ethnocultural minorities except Aboriginals, when compared to White participants (p = .001). Conclusions: There is a high burden of psychosocial distress in several preponderant ethnocultural minorities in Ontario; many of whom are not accessing available mental health services

Uncovering phantom shocks in cardiac patients with an implantable cardioverter defibrillator

Background: Implantable cardioverter defibrillator recipients sometimes report “phantom shocks” (PSs), defined as a reported shock lacking objective evidence. The aim of this study was to describe the subjective experience of PSs and their psychosocial correlates using a mixed methods approach. Methods: PS participants were matched on sex and age with individuals who received objective shocks only (OSO). Participants were interviewed and completed measures of posttraumatic stress disorder (PTSD Checklist—Civilian Version), depression and anxiety (Hospital Anxiety and Depression Scale), disease-specific distress (Cardiac Anxiety Questionnaire—CAQ), and social desirability (Socially Desirable Response Set—SDRS). Interviews were analyzed using interpretative phenomenological analysis (IPA). Results: Seventeen male patients participated (PS: n = 9; OSO: n = 8). Three themes emerged from IPA: (1) PS as a somatic experience, (2) the emotional impact of PSs, and (3) searching for meaning. Quantitative analyses showed that both groups exhibited elevated trauma and anxiety levels. Effect size differences (ESD) suggested a medium ESD on depression (P = 0.176, ηp 2 = 0.118) and PTSD (avoidance: P = 0.383, ηp 2 = 0.055, numbing: P = 0.311, ηp 2 = 0.068), and a large ESD on SDRS (P = 0.081, ηp 2 = 0.189), where PS participants, comparatively, exhibited elevated levels. A medium ESD was detected on CAQ-fear (P = 0.237, ηp 2 = 0.092) where OSO participants exhibited greater heart-focused worry. Conclusion: The qualitative and quantitative findings of this mixed method study show convergence in terms of the emotional factors associated with the experience of PSs. PSs are often reported to be indistinguishable from objective shocks, evoking alarm, frustration, and confusion, forcing the individual to face the uncertainties of what to them is a novel and confusing experience. (PACE 2013; 36:673–683)This study has not been funded by any source. AB was supported by an Ontario Graduate Scholarship. Dr. Kovacs has received speaking engagement honoraria from Medtronic Inc. Dr. Katz is supported by the Canadian Institutes of Health Research Canada Research Chair in Health Psychology. This paper is derived, in part, from the first author’s Master’s thesis

The Silver Lining of Heart Disease: What Type of Patients Will Be More Likely to Experience It?

After successfully coping with a life threatening event, people tend to look at the brighter side of life.York's Knowledge Mobilization Unit provides services and funding for faculty, graduate students, and community organizations seeking to maximize the impact of academic research and expertise on public policy, social programming, and professional practice. It is supported by SSHRC and CIHR grants, and by the Office of the Vice-President Research & Innovation. [email protected] www.researchimpact.c

Juggling on a tightrope: Experiences of small and micro business managers responding to employees with mental health difficulties

This article presents findings from an in-depth qualitative study focused exclusively on the first-hand experiences of small and micro businesses managers who have responded to employees with mental health difficulties. Despite growing policy focus on workplace mental health, empirical research evidence on management experiences of responding to mental health issues in a small or micro business context is rare. Drawing on in-depth interviews with 21 UK-based small and micro business managers who described 45 individual employee cases, we examine how managers traverse a support-performance continuum, and use a tension-based lens to analyse the tensions that managers experienced. We examine three key tensions for small and micro business managers that surfaced when responding to employees with mental health problems: (1) Individual vs Collective; (2) Confidence vs Caution; (3) Informal vs Formal. Our analysis exposes how managers handle tensions when managing at the nexus of support and performance and contributes a deeper understanding of the dynamics and challenges of managing mental health problems in small and micro businesses