Development of a patient-reported palliative care-specific health classification system: the POS-E

BackgroundGeneric preference-based measures are commonly used to estimate quality-adjusted life-years (QALYs) to inform resource-allocation decisions. However, concerns have been raised that generic measures may be inappropriate in palliative care.ObjectiveOur objective was to derive a health-state classification system that is amenable to valuation from the ten-item Palliative Care Outcome Scale (POS), a widely used patient-reported outcome measure in palliative care.MethodsThe dimensional structure of the original POS was assessed using factor analysis. Item performance was assessed, using Rasch analysis and psychometric criteria, to enable the selection of items that represent the dimensions covered by the POS. Data from six studies of patients receiving palliative care were combined (N = 1011) and randomly split into two halves for development and validation. Analysis was undertaken on the development data, and results were validated by repeating the analysis with the validation dataset.ResultsFollowing Rasch and factor analyses, a classification system of seven items was derived. Each item had two to three levels. Rasch threshold map helped identify a set of 14 plausible health states that can be used for the valuation of the instrument to derive a preference-based index.ConclusionCombining factor analysis and Rasch analysis with psychometric criteria provides a valid method of constructing a classification system for a palliative care-specific preference-based measure. The next stage is to obtain preference weights so the measure can be used in economic evaluations in palliative care

Patient and health care professional decision-making to commence and withdraw from renal dialysis: A systematic review of qualitative research

Background and objectives. To ensure decisions to start and stop dialysis in end stage kidney disease are shared, the factors that affect patients and healthcare professionals in making such decisions need to be understood. This systematic review aims to explore how and why different factors mediate the choices about dialysis treatment. Design, setting, participants, and measurements. Medline, Embase, CINAHL and PsychINFO were searched for qualitative studies of factors that affect patients’ and/or healthcare professionals’ decisions to commence or withdraw from dialysis. A thematic synthesis was conducted. Results. Of 494 articles screened, 12 studies (conducted: 1985-2014) were included. These involved 206 predominantly haemodialysis patients and 64 healthcare professionals (age range: patients 26-93; professionals 26-61 years). (i) Commencing dialysis: patients based their choice on ‘gut-instinct’ as well as deliberating the impact of treatment on quality-of-life and survival. How individuals coped with decision-making was influential, some tried to take control of the problem of progressive renal failure, whilst others focussed on controlling their emotions. Healthcare professionals weighed-up biomedical factors and were led by an instinct to prolong life. Both patients and healthcare professionals described feeling powerless. (ii) Dialysis withdrawal: Only after prolonged periods of time on dialysis, were the realities of life on dialysis fully appreciated and past choice questioned. By this stage however patients were physically treatment dependent. Similar to commencing dialysis, individuals coped with treatment withdrawal in a problem or emotion-controlling way. Families struggled to differentiate choosing versus allowing death. Healthcare teams avoided and queried discussions regarding dialysis withdrawal. Patients however missed the dialogue they experienced during pre-dialysis education. Conclusions. Decision-making in end stage kidney disease is complex, dynamic, and evolves over time and towards death. The factors at work are multi-faceted and operate differently for patients and health professionals. More training and research on open-communication and shared decision-making is needed

Paradigms of family medicine: bridging traditions with new concepts; meeting the challenge of being the good doctor from 2011

This is the paper for the Wes Fabb Oration for the WONCA Asia Pacific Regional Conference 2011. This paper will review the case for the important role of the family physician/general practitioner in worldwide health care as determined by the WHO. The importance of continuing care is highlighted. The features of a good doctor will be defined and the process of meeting this challenge for excellence of care is presented

Mumford dendrograms and discrete p-adic symmetries

In this article, we present an effective encoding of dendrograms by embedding them into the Bruhat-Tits trees associated to $p$-adic number fields. As an application, we show how strings over a finite alphabet can be encoded in cyclotomic extensions of $\mathbb{Q}_p$ and discuss $p$-adic DNA encoding. The application leads to fast $p$-adic agglomerative hierarchic algorithms similar to the ones recently used e.g. by A. Khrennikov and others. From the viewpoint of $p$-adic geometry, to encode a dendrogram $X$ in a $p$-adic field $K$ means to fix a set $S$ of $K$-rational punctures on the $p$-adic projective line $\mathbb{P}^1$. To $\mathbb{P}^1\setminus S$ is associated in a natural way a subtree inside the Bruhat-Tits tree which recovers $X$, a method first used by F. Kato in 1999 in the classification of discrete subgroups of $\textrm{PGL}_2(K)$. Next, we show how the $p$-adic moduli space $\mathfrak{M}_{0,n}$ of $\mathbb{P}^1$ with $n$ punctures can be applied to the study of time series of dendrograms and those symmetries arising from hyperbolic actions on $\mathbb{P}^1$. In this way, we can associate to certain classes of dynamical systems a Mumford curve, i.e. a $p$-adic algebraic curve with totally degenerate reduction modulo $p$. Finally, we indicate some of our results in the study of general discrete actions on $\mathbb{P}^1$, and their relation to $p$-adic Hurwitz spaces.Comment: 14 pages, 6 figure

Funding models in palliative care: lessons from international experience

Background:Funding models influence provision and development of palliative care services. As palliative care integrates into mainstream health care provision, opportunities to develop funding mechanisms arise. However, little has been reported on what funding models exist or how we can learn from them.Aim:To assess national models and methods for financing and reimbursing palliative care.Design:Initial literature scoping yielded limited evidence on the subject as national policy documents are difficult to identify, access and interpret. We undertook expert consultations to appraise national models of palliative care financing in England, Germany, Hungary, Republic of Ireland, New Zealand, The Netherlands, Norway, Poland, Spain, Sweden, Switzerland, the United States and Wales. These represent different levels of service development and a variety of funding mechanisms.Results:Funding mechanisms reflect country-specific context and local variations in care provision. Patterns emerging include the following:Provider payment is rarely linked to population need and often perpetuates existing inequitable patterns in service provision.Funding is frequently characterised as a mixed system of charitable, public and private payers.The basis on which providers are paid for services rarely reflects individual care input or patient needs.Conclusion:Funding mechanisms need to be well understood and used with caution to ensure best practice and minimise perverse incentives. Before we can conduct cross-national comparisons of costs and impact of palliative care, we need to understand the funding and policy context for palliative care in each country of interest

Primary palliative care in Japan: needs estimation and projections – national database study with international comparisons

Objectives We aimed to estimate the potential population that requires palliative care, clarify the relationship between this population and the rate of ageing in Japan, and compare these trends with those of other countries.Design We used the national death registration data and population projections for Japan to estimate the population in need of palliative care using the minimal estimate method developed by Murtagh et al. Linear regression was used to create a model of mortality using sex, age at intervals of 5 years, and each major disease classification. We calculated the future population in need of palliative care until 2040 and compared the ageing data to those of other countries.Setting/participants All adults in Japan who died from 1980 to 2040 at intervals of 5 years.Results The number of people who might need palliative care from 2020 to 2040 will also increase linearly from 1 059 000 to 1 405 000. The proportion of Alzheimer’s, dementia and senility of the total need for palliative care will increase to 43.4% in 2040. The correlation coefficient between the proportion of the population in need of palliative care and the rate of ageing was 0.24 in developed countries.Conclusion In Japan, the population requiring palliative care in 2040 will be 1.5 times that in 2015. Palliative care needs to be provided urgently for people with Alzheimer’s disease, dementia and senility. The proportion of patients in need of palliative care may not change, although the number of patients requiring such gradually increases in developed countries

Florida Energy Assurance Plan

This spring, Florida held the nations first statewide emergency preparedness training and exercises geared specifically to the aftermath of severe geomagnetic events. Funded by the State of Florida Division of Emergency Management (FDEM) via a Department of Energy grant and held in collaboration with Watch House International, Inquesta Corporation, and the Florida Institute of Technology, the 17-19 April 2012 workshop had 99 on-site attendees in an oceanfront hotel in Melbourne, Florida, as well as 16 over live Web streaming. The workshop was the capstone to a three-month season of 21 regional space weather training sessions and workshops serving 386 attendees in total