Do healthcare services behave as complex systems? Analysis of patterns of attendance and implications for service delivery

Background: The science of complex systems has been proposed as a way of understanding health services and the demand for them, but there is little quantitative evidence to support this. We analysed patterns of healthcare use in different urgent care settings to see if they showed two characteristic statistical features of complex systems: heavy-tailed distributions (including the inverse power law) and generative burst patterns. Methods: We conducted three linked studies. In study 1 we analysed the distribution of number of contacts per patient with an urgent care service in two settings: emergency department (ED) and primary care out-of-hours (PCOOH) services. We hypothesised that these distributions should be heavy-tailed (inverse power law or log-normal) in keeping with typical complex systems. In study 2 we analysed the distribution of bursts of contact with urgent care services by individuals: correlated bursts of activity occur in complex systems and represent a mechanism by which overall heavy-tailed distributions arise. In study 3 we replicated the approach of study 1 using data systematically identified from published sources. Results: Study 1 involved data from a PCOOH service in Scotland (725,000) adults, 1.1 million contacts) and an ED in New Zealand (60,000 adults, 98,000 contacts). The total number of contacts per individual in each dataset was statistically indistinguishable from an inverse power law (p &gt; 0.05) above 4 contacts for the PCOOH data and 3 contacts for the ED data. Study 2 found the distribution of contact bursts closely followed a heavy-tailed distribution (p &lt; 0.008), indicating the presence of correlated bursts. Study 3 identified data from 17 studies across 8 countries and found distributions similar to study 1 in all of them. Conclusions: Urgent healthcare use displays characteristic statistical features of large complex systems. These studies provide strong quantitative evidence that healthcare services behave as complex systems and have important implications for urgent care. Interventions to manage demand must address drivers for consultation across the whole system: focusing on only the highest users (in the tail of the distribution) will have limited impact on efficiency. Bursts of attendance - and ways to shorten them - represent promising targets for managing demand.</p

Development of a novel clinical scoring system for on-farm diagnosis of bovine respiratory disease in pre-weaned dairy calves.

Several clinical scoring systems for diagnosis of bovine respiratory disease (BRD) in calves have been proposed. However, such systems were based on subjective judgment, rather than statistical methods, to weight scores. Data from a pair-matched case-control study on a California calf raising facility was used to develop three novel scoring systems to diagnose BRD in preweaned dairy calves. Disease status was assigned using both clinical signs and diagnostic test results for BRD-associated pathogens. Regression coefficients were used to weight score values. The systems presented use nasal and ocular discharge, rectal temperature, ear and head carriage, coughing, and respiratory quality as predictors. The systems developed in this research utilize fewer severity categories of clinical signs, require less calf handling, and had excellent agreement (Kappa &gt; 0.8) when compared to an earlier scoring system. The first scoring system dichotomized all clinical predictors but required inducing a cough. The second scoring system removed induced cough as a clinical abnormality but required distinguishing between three levels of nasal discharge severity. The third system removed induced cough and forced a dichotomized variable for nasal discharge. The first system presented in this study used the following predictors and assigned values: coughing (induced or spontaneous coughing, 2 points), nasal discharge (any discharge, 3 points), ocular discharge (any discharge, 2 points), ear and head carriage (ear droop or head tilt, 5 points), fever (≥39.2°C or 102.5°F, 2 points), and respiratory quality (abnormal respiration, 2 points). Calves were categorized "BRD positive" if their total score was ≥4. This system correctly classified 95.4% cases and 88.6% controls. The second presented system categorized the predictors and assigned weights as follows: coughing (spontaneous only, 2 points), mild nasal discharge (unilateral, serous, or watery discharge, 3 points), moderate to severe nasal discharge (bilateral, cloudy, mucoid, mucopurlent, or copious discharge, 5 points), ocular discharge (any discharge, 1 point), ear and head carriage (ear droop or head tilt, 5 points), fever (≥39.2°C, 2 points), and respiratory quality (abnormal respiration, 2 points). Calves were categorized "BRD positive" if their total score was ≥4. This system correctly classified 89.3% cases and 92.8% controls. The third presented system used the following predictors and scores: coughing (spontaneous only, 2 points), nasal discharge (any, 4 points), ocular discharge (any, 2 points), ear and head carriage (ear droop or head tilt, 5 points), fever (≥39.2°C, 2 points), and respiratory quality (abnormal respiration, 2 points). Calves were categorized "BRD positive" if their total score was ≥5. This system correctly classified 89.4% cases and 90.8% controls. Each of the proposed systems offer few levels of clinical signs and data-based weights for on-farm diagnosis of BRD in dairy calves

Agreement between bovine respiratory disease scoring systems for pre-weaned dairy calves.

Clinical scoring systems have been proposed for respiratory disease diagnosis in calves, including the Wisconsin (WI) system (McGuirk in 2008) which uses five clinical signs, each partitioned into four levels of severity. Recently, we developed the California (CA) bovine respiratory disease (BRD) scoring system requiring less calf handling and consisting of six clinical signs, each classified as normal or abnormal. The objective of this study was to estimate the on-farm agreement between the WI and the CA scoring systems. A total of 100 calves were enrolled on a CA dairy and assessed for BRD case status using the two scoring systems simultaneously. The Kappa coefficient of agreement between these two systems was estimated to be 0.85, which indicated excellent agreement beyond chance. The simpler design and reduced calf handling required by the CA BRD scoring system may make it advantageous for on-farm use

Parent Perspectives on Special Education Services: How Do Schools Implement Team Decisions?

The purpose of this qualitative study was to examine parents’ perspectives and experiences of special education, including the degree to which decisions about their child’s education were implemented as they had agreed upon with the school personnel. Additionally, a secondary purpose of this study was to understand how parents explain why school personnel do or do not implement elements of their child’s Individualized Education Program (IEP). In this study, parents of children with intellectual and developmental disabilities described their experiences attempting to reach agreement with school personnel on decisions involving their child’s educational placement and special education services. Parents expressed a desire to be involved in decisions, and they described a desire to obtain inclusive educational placements for their children. Parents described varied experiences with the implementation of special education services. They also described both successes and concerns related to the special education services their child was receiving at school. Implications for special education policy, practice, and research are discussed from the perspective of supporting family involvement in the special education process

Bearded pig (Sus barbatus) utilisation of a fragmented forest-oil palm landscape in Sabah, Malaysian Borneo

Context: Oil palm plantations have become a dominant landscape in Southeast Asia, yet we still understand relatively little about the ways wildlife are adapting to fragmented mosaics of forest and oil palm. The bearded pig is of great ecological, social, and conservation importance in Borneo and is declining rapidly due to habitat loss and overhunting. Aims: We sought to assess how the bearded pig is adapting to oil palm expansion by investigating habitat utilisation, activity patterns, body condition, and minimum group size in a mosaic composed of forest fragments and surrounding oil palm. Methods: We conducted our study in Sabah, Malaysian Borneo, in and around the Lower Kinabatangan Wildlife Sanctuary, an area consisting of secondary forest fragments (ranging 1200-7400 ha) situated within an extensive oil palm matrix. We modelled bearded pig habitat use in forest fragments and oil palm plantations using survey data from line transects. Camera traps placed throughout the forest fragments were used to assess pig activity patterns, body condition, and minimum group size. Key results: All forest transects and 80% of plantation transects showed pig presence, but mean pig signs per transect were much more prevalent in forest (70.00 ± 13.00 SE) than in plantations (0.91 ± 0.42 SE). Pig tracks had a positive relationship with leaf cover and a negative relationship with grass cover; pig rooting sites had a positive relationship with wet and moderate soils as compared to drier soils. Pigs displayed very good body condition in forests across the study area, aggregated in small groups (mean = 2.7 ± 0.1 SE individuals), and showed diurnal activity patterns that were accentuated for groups with piglets and juveniles. Conclusions: Our findings suggest that bearded pigs in our study area regularly utilise oil palm as habitat, given their signs in most oil palm sites surveyed. However, secondary forest fragments adjacent to oil palm remain the most important habitat for the bearded pig, as well as many other species, and therefore must be conserved. Implications: Consistent bearded pig presence in oil palm is a potential indication of successful adaptation to agricultural expansion in the study area. However, the net effect of oil palm expansion in the region on bearded pig populations remains unknown

Parent identity and family-school partnerships: Animating diverse enactments for (special) education decision-making

Family-school partnerships between family members and school personnel can be successful as well as unproductive for parents who have children and youth with developmental disabilities. This qualitative study sought to capture parents’ identities as they negotiated family-school partnerships when making inclusive education decisions and discussing special education service-delivery options for their children and youth with developmental disabilities. Seventeen participants shared their personal narratives in interviews and focus groups. Data were thematically analyzed after an initial round of open-coding generated broad themes. Findings revealed the experiences parents have in partnering with schools span an identity spectrum, including: (a) victim, (b) advocate, (c) perseverer, (d) educator, (e) broker and negotiator, and (f) surrenderer. Implications for policy, practice, and research focus on parent identity and familyschool partnerships

Parents’ experiences in education decision-making for children and youth with disabilities

Families should be an active part of educational decision-making for their children and can be particularly influential in advocating for inclusion for students with intellectual and developmental disabilities. Yet, significant research has shown that parents do not feel schools effectively collaborate with them. We interviewed 19 parents of children with disabilities to investigate the ways they were included and excluded from educational decision-making, and how they decided on their children’s placement and services. Five themes emerged: parents’ exclusion from decision-making, parents’ independent efforts to shape their children’s educational services, parents’ decisions as a result of school and district factors, parents’ role changes to direct their children’s education, and discrepancies between beliefs and experiences of inclusion. Parents’ responses indicate that specific school structures and institutionalized procedures may regularly exclude parents from decision-making. Results have implications for parent-professional partnership during decision-making for students with disabilities and personnel preparation

Vital lines drawn from books: difficult feelings in Alison Bechdel’s Fun Home and Are You My Mother?

This article examines the representation of a transnational archive of queer books in Alison Bechdel’s graphic memoirs Fun Home and Are You My Mother? for the insights it provides into role of reading in making sense of the often difficult “felt experiences” of lesbian life. In both memoirs, books serve an important narrative function in the portrayal of Alison’s lesbian identification and its complex emotional entanglements with the lives of parents who are trapped – killed even, in the case of the father – in the wastelands of patriarchy and heterosexual expectation. The article argues that in this complex family dynamic in which “sexual identity” itself is a problem and emotions remain largely unspoken, books act as fragile conduits of feelings, shaping familial relationships even as they allow Alison to contextualise her life in relation to historical events and social norms. Reading books allows her to understand the apparently U.S.-specific history of her family in relation to a wider queer history in the West

A critical review of the epidemiological evidence of effects of air pollution on dementia, cognitive function and cognitive decline in adult population

Dementia is arguably the most pressing public health challenge of our age. Since dementia does not have a cure,identifying risk factors that can be controlled has become paramount to reduce the personal, societal and eco-nomic burden of dementia. The relationship between exposure to air pollution and effects on cognitive function,cognitive decline and dementia has stimulated increasing scientific interest in the past few years. This review ofthe literature critically examines the available epidemiological evidence of associations between exposure to am-bient air pollutants, cognitive performance, acceleration of cognitive decline, risk of developing dementia, neuro-imaging and neurological biomarker studies, following Bradford Hill guidelines for causality.The evidence reviewed has been consistent in reporting associations between chronic exposure to air pollutionand reduced global cognition, as well as impairment in specific cognitive domains including visuo-spatial abili-ties. Cognitive decline and dementia incidence have also been consistently associated with exposure to air pollu-tion. The neuro-imaging studies reviewed report associations between exposure to air pollution and whitematter volume reduction. Other reported effects include reduction in gray matter, larger ventricular volume,and smaller corpus callosum. Findings relating to ischemic (white matter hyperintensities/silent cerebralinfarcts) and hemorrhagic (cerebral microbleeds) markers of cerebral small vessel disease have been heteroge-neous, as have observations on hippocampal volume and air pollution. The few studies available on neuro-inflammation tend to report associations with exposure to air pollution. everal effect modifiers have been suggested in the literature, but more replication studies are required. Tradi-tional confounding factors have been controlled or adjusted for in most of the reviewed studies. Additional con-founding factors have also been considered, but the inclusion of these has varied among the different studies.Despite all the efforts to adjust for confounding factors, residual confounding cannot be completely ruled out, es-pecially since the factors affecting cognition and dementia are not yet fully understood.The available evidence meets many of the Bradford Hill guidelines for causality. The reported associations be-tween a range of air pollutants and effects oncognitive function in older people,including the acceleration of cog-nitive decline and the induction of dementia, are likely to be causal in nature.However, the diversity of study designs, air pollutants and endpoints examined precludes the attribution of theseadverse effects to a single class of pollutant and makes meta-analysis inappropriate