The effectiveness of computerized clinical guidelines in the process of care: a systematic review

<p>Abstract</p> <p>Background</p> <p>Clinical practice guidelines have been developed aiming to improve the quality of care. The implementation of the computerized clinical guidelines (CCG) has been supported by the development of computerized clinical decision support systems.</p> <p>This systematic review assesses the impact of CCG on the process of care compared with non-computerized clinical guidelines.</p> <p>Methods</p> <p>Specific features of CCG were studied through an extensive search of scientific literature, querying electronic databases: Pubmed/Medline, Embase and Cochrane Controlled Trials Register. A multivariable logistic regression was carried out to evaluate the association of CCG's features with positive effect on the process of care.</p> <p>Results</p> <p>Forty-five articles were selected. The logistic model showed that Automatic provision of recommendation in electronic version as part of clinician workflow (Odds Ratio [OR]= 17.5; 95% confidence interval [CI]: 1.6-193.7) and Publication Year (OR = 6.7; 95%CI: 1.3-34.3) were statistically significant predictors.</p> <p>Conclusions</p> <p>From the research that has been carried out, we can conclude that after implementation of CCG significant improvements in process of care are shown. Our findings also suggest clinicians, managers and other health care decision makers which features of CCG might improve the structure of computerized system.</p

Models and enabling IoT technologies for cooperative energy brokerage in smart-grid

Ph.D. in Science and Engineering of Environment, Construction and Energy Ciclo XXXIThe strong decentralization of energy production, especially from nonprogrammable renewable sources (nPRS), obtained with the rising and interconnection of small plants, has placed the end user at the centre of the whole energy system management. Nowadays, the end user has taken the role of a “prosumer”, being at the same time producer and consumer of thermal and electrical energy. While this new bivalent role has clear advantages (onsite production, lower transport losses, reduced dependence on fossil fuels, etc.), the distributed generation from nPRS causes additional injections of energy into the grid, which can bring to stability and safety problems for the operations of the grid itself. As consequence, the end-user needs to be involved in the management of the grid adopting appropriate strategies in order to maintain the balance between generation and consumption of energy, and avoid spikes of energy demand or excessive injections of energy produced but not consumed. The best strategy is to join in energy communities able to coordinate local energy flows and favouring a better use of energy. Moreover, end-users have to adopt new IoT technologies and the grid have to become a smart-grid. This Ph.D. thesis develops some cooperative energy brokerage models based on decentralized scheme proposed in the LAboratory of Electrical Systems for Energies and Renewable sources (LASEER), headed by Prof. D. Menniti, of the Department of Mechanical, Energy and Management (DIMEG) of the University of Calabria. In the proposed models, the end-user takes a fundamental role: he can autonomously make decisions based on thermal and electrical energy requirements and collaborate in energy balancing operations of the energy community and of the national electrical grid. In according to this decentralized approach, a new price based-time of use Demand Response program has been designed. The Demand Response program is determined by solving, in a day ahead strategy, a mixed integer linear optimization problem, called “prosumer problem”. In this context, end-user dwellings need to be purposely equipped with home automation systems and micro-grid devices, appropriately designed to act the planned energy management strategy The effectiveness and the feasibility of the proposed work have been assessed through a testbed performed in an academic experimental demonstrator sited in the University of Calabria, where the proposed model have been implemented. Moreover, different prototype versions of home automation and micro-grids devices have been realized during the development and the work carried out in the MIUR project “Sistemi Domotici per il servizio di brokeraggio energetico cooperativo”. Specific contributions of this thesis are in the following areas: implementing an unified management model of both thermal and electrical energy needs in a price based Demand Response program; providing an option for end-users to participate in the National Electricity Market through demand side bidding and to manage their electricity usage; designing home automation systems and micro-grid devices able to monitor, control and collect data on exchanges of electrical energy flows; customizing cooperative energy brokerage model for supporting the management of Energy Districts; experimenting the energy management strategy in the academic experimental demonstrator; designing smart meter for end-user able to measure energy flows exchange as well as to give a view of real-time energy consumption; collecting representative data about end-user habits to perform statistical analysis and define load forecasting services; evaluating cost and quantifying the global energy demand to sensitize to more conscious consumption of energy. The experience in developing demand response models has been shared inside Marie Skłodowska-Curie project “Research and Innovation Staff Exchange”, with the project partner Exergy Ltd company.Università della Calabri

An Energy Box in a Cloud-Based Architecture for Autonomous Demand Response of Prosumers and Prosumages

The interest in the implementation of demand response programs for domestic customers within the framework of smart grids is increasing, both from the point of view of scientific research and from the point of view of real applications through pilot projects. A fundamental element of any demand response program is the introduction at customer level of a device, generally named energy box, able to allow interaction between customers and the aggregator. This paper proposes two laboratory prototypes of a low-cost energy box, suitable for cloud-based architectures for autonomous demand response of prosumers and prosumages. Details on how these two prototypes have been designed and built are provided in the paper. Both prototypes are tested in the laboratory along with a demonstration panel of a residential unit, equipped with a real home automation system. Laboratory tests demonstrate the feasibility of the proposed prototypes and their capability in executing the customers’ loads scheduling returned by the solution of the demand-response problem. A personal computer and Matlab software implement the operation of the aggregator, i.e., the intermediary of the energy-integrated community constituted by the customers themselves, who participate in the demand response program

Evaluation of the breast cancer care network within the Lazio Region (Central Italy).

Background and objectivesA summary indicator for evaluating the breast cancer network has never been measured at the regional level. The aim is to design treemaps providing a summary description of hospitals (including breast units) and Local Health Units (LHUs) in terms of their levels of performance within the breast cancer network of the Lazio region (central Italy). The treemap structure has an intuitive design and displays information from both general and specific analyses.MethodsPatients admitted to the regional hospitals for malignant breast cancer (MBC) surgery in 2010-2017 were selected in a population-based cohort study. These quality indicators were calculated based on the international guidelines (EUSOMA, ESMO) to assess the performance in terms of volume of activity, surgery procedure, post-surgery assistance and timeliness of medical therapy or radiotherapy beginning. The quality indicators were calculated using administrative health data systematically collected at the regional level and were included in the treemap to represent the surgery or the post-surgery areas of the breast cancer clinical pathway. In order to allow aggregation of scores for different indicators belonging to the same clinical area, up to five evaluation classes were defined using the "Jenks Natural Breaks" algorithm. A score and a colour were assigned to each clinical area based on the ranking of the indicators involved. The analyses were performed on an annual basis, by the LHU of residence and by the hospital which performed the surgical intervention.ResultsIn 2017, 6218 surgical interventions for MBC were performed in the hospitals of Lazio. The results showed a continuous increase of the level of performance over the years. Hospitals showed higher variability in the levels of performance than the LHUs. 36% of the evaluated hospitals reached a high level of performance. An audit of the S. Filippo Neri breast unit revealed incorrect coding of the input data. For this reason, the score for the indicator for the volume of wards was re-calculated and re-evaluated, with a subsequent improvement of the level of performance. Most LHUs achieved at least an average overall level of performance, with 20% of the LHUs reaching a high level of performance.ConclusionsThis is the first attempt to apply the treemap logic to a single clinical network, in order to obtain a summary indicator for the evaluation of the breast cancer care network. Our results supply decision makers with a transparent instrument of governance for heterogeneous users, directing efforts improving and promoting equity of care. The treemaps could be reproduced and adapted for other local contexts, in order to limit inappropriateness and ensure uniform levels of breast cancer care within local areas. The next step is the evaluation of audit and feedback interventions to improve the quality of care and to guarantee homogeneous levels of care throughout the region

L'ospedalizzazione a domicilio: valutazione della dimissione precoce in termini di mortalità e soddisfazione dei pazienti

New organizational models are essentials for European Hospitals because of restraining budget and ageing of population. Hospital at home is an alternative to inpatient care, effective both in clinical and economic ground. The aim of our study was to evaluate the impact of Hospital at Home in terms of decreased mortality and patient satisfaction. We carried out a meta-analysis of the literature about hospital at home interventions. We searched Medline (to December 2002), the Cochrane Controlled Trials Register (to October 2002) and other bibliographical databases, with a supplementary handsearching of literature. We used the following keywords: hospital at home, home hospitalization, mortality, patient satisfaction, cost, acute hospital care, conventional hospitalization. We included studies respecting the following criteria: analytical or experimental studies aimed at compare early discharge to hospital at home and continued care in an acute hospital. Review Manager 4.2 software was used to collect data and perform statistical analysis. We found 2420 articles searching for the chosen keywords. Twelve studies (2048 patients) were included for death outcome and six studies (1382 patients) were included for satisfaction outcome. The selected studies indicated a greater effect size of patient satisfaction in home patients than hospitalized ones (Odds Ratio: 1.58 95% CI: 1.25, 2.00) and showed no difference in terms of mortality (Risk Difference: -0.01 95% CI: -0.03, 0.02). Our results underline the effectiveness of this organizational model, as an alternative to continued care in an acute hospital. Further useful considerations could be drawn by economic evaluation studies carried out on field

A review on the impact of systematic safety processes for the control of error in medicine

Among risk management initiatives, systematic safety processes (SSPs), implemented within health care organizations, could be useful in managing patient safety. The purpose of this article is to conduct a systematic literature review assessing the impact of SSPs on different error categories. Articles that investigated the relation between SSPs, clinical and organizational outcomes were selected from scientific literature. The proportion and impact of proactive and reactive SSPs were calculated among five error categories. Proactive interventions impacted more positively than reactive ones in reducing medication errors, technical errors and errors due to personnel. PSSPs and RSSPs had similar effects in reducing errors related to a wrong procedure. A single reactive study influenced non-positively communication errors. A relevant prevalence of the impact of proactive processes on reactive ones is reported. This article can help decision makers in identifying which SSP can be the most appropriate against specific error categories

Audit and Feedback in the Hospitals of the Emergency Networks in the Lazio Region, Italy: A Cross-Sectional Evaluation of the State of Implementation

Audit and Feedback (A&F) is an effective multidimensional strategy for improving the quality of care. The optimal methods for its implementation remain unclear. This study aimed to map the state of art of A&F strategies in the hospitals involved in a time-dependent emergency network. For these purposes, a structured questionnaire was defined and discussed within the research group. This consists of 29 questions in three sections: (1) characteristics of the structure, (2) internal feedback systems, and (3) external feedback systems. All structures involved in the network were invited to participate in the e-survey by indicating a Health Management representative and a clinical representative for the Cardiovascular (CaV) and/or for the Cerebrovascular area (CeV). Of 20 structures invited, a total of 13 (65%) responded to the survey, 11 for the CaV area and 8 for the CeV area. A total of 10 of 11 (91%) facilities for the CaV area and 8/11 (75%) for the CeV area reported that they perform A&F activities. All facilities perform at least one of the activities defined as “assimilating A&F procedures.” The most frequent is the presentation and discussion of clinical cases (82% CaV and 88% CeV) and the least is the identification of responsible for improvement actions (45% CaV and 38% CeV). In 4/10 (40%) facilities for the CaV area and 4/8 (50%) for the CEV area, corrective actions are suggested or planned when the feedback is returned. These results confirm the need to define, in a synergistic way with the relevant stakeholders, an effective and agreed A&F intervention to improve the level of implementation of A&F strategies