Funding intensive care - approaches in systems using diagnosis-related groups.

This report reviews approaches to funding intensive care in health systems that use activitybased payment mechanisms based on diagnosis-related groups (DRGs) to reimburse hospital care. The report aims to inform the current debate about options for funding intensive care services for adults, children and newborns in England. Funding mechanisms reviewed here include those in Australia (Victoria), Denmark, France, Germany, Italy, Spain, Sweden and the United States (Medicare). Approaches to organising, providing and funding hospital care vary widely among these countries/states, largely reflecting structural differences in the organisation of healthcare systems. Mechanisms of funding intensive care services tend to fall into three broad categories: • those that fund intensive care through DRGs as part of one episode of hospital care only (US Medicare, Germany, selected regions in Sweden and Italy) • those that use DRGs in combination with co-payments (Victoria, France) • those that exclude intensive care from DRG funding and use an alternative form of payment, for example global budgets (Spain) or per diems (South Australia). Approaches to funding paediatric and neonatal intensive care largely reflect the overall funding mechanism for intensive care. Evidence reviewed here indicates a general concern of potential underfunding of intensive care. These problems may be particularly pertinent for those settings that provide neonatal and paediatric care because of the very high costs and the relatively smaller number of cases in these settings compared with adult intensive care. Similar issues apply to highly specialised services in adult intensive care, such as treatment of severe burns. Given the variety of approaches to funding intensive care services, this review suggests that there is no obvious example of “best practice” or dominant approach used by a majority of systems. Each approach has advantages and disadvantages, particularly in relation to the financial risk involved in providing intensive care. While the risk of underfunding intensive care may be highest in systems that apply DRGs to the entire episode of hospital care, including intensive care, concerns about potential underfunding were voiced in all systems reviewed here. Arrangements for additional funding in the form of co-payments or surcharges may reduce the risk of underfunding. However, these approaches also face the difficulty of determining the appropriate level of (additional) payment and balancing the incentive effect arising from higher payment

What we have learned about policy-research linkage from providing a rapid response facility for international healthcare comparisons to the Department of Health in England

In this paper we reflect on our experience of providing a rapid response facility for international healthcare policy comparisons to the English Department of Health. We examine the challenges of developing sustained relationships with policy officials while providing an 'on-demand' service in an environment with high turnover of policies and staff. It may be easier for policy makers to draw on researchers in such a setting than for researchers to foster 'linkage and exchange' relationships with policy makers. Under the facility, knowledge transfer has mostly been from researchers to policy officials, affording us little insight into the policy process or the impact of our work

Approaches to the measurement of outcomes of chronic disease self-management interventions using a self-report inventory

Background Health education programs that are aimed at improving individuals' skills to self-manage are increasingly recognised as a critical component of chronic disease management. Despite the apparent need for such interventions, current studies show inconsistent results regarding program effectiveness, with meta-analyses indicating only marginal effects for some disease groups. A closer examination of these studies however suggests that the magnitude and inconsistency of the findings may be related to the types of outcomes that were assessed rather than specific disease groups. Where self-report measures were used, results tended to be smaller and inconsistent. It is therefore possible that current studies do not adequately reflect program effects because self-report outcomes have a high risk to be confounded by a range of potential biases. Objective The aim of this thesis was to identify and quantify the potential influence of biases in the measurement of change in chronic disease self-management interventions using self-report. Methods The research design targeted the processes that individuals undergo when filling out questionnaires and whether this has an influence on their self-report outcomes. This was achieved by developing a three-group research design. The Health Education Impact Questionnaire (heiQ) was used to collect outcomes data. While pretest questionnaires were identical across groups, three questionnaire versions were randomly distributed at posttest. One of the groups filled out traditional posttest questions (n=331), whereas the other two groups were asked to provide data in addition to posttest questions, with one group providing transition questions (n=304) and one providing retrospective pretest data (n=314). Resulting datasets were further examined for possible confounding effects through response shift and social desirability bias. Through the random allocation of the heiQs it was ensured that data were not influenced by potential intra-group effects. Results The thesis revealed that the design of the posttest questionnaire significantly influenced people's ratings of their posttest levels. In particular, when participants were asked to provide ratings of their retrospective pretest levels in addition to their posttest levels, the latter scores were significantly higher than those of participants who did not perform this additional task. Subsequent analyses however suggested that these differences could neither be explained by response shift nor by social desirability bias. Conclusions This research has provided important insight into the measurement of outcomes of chronic disease self-management interventions. While the threat to the validity of traditional pretest-posttest data due to confounding effects through response shift and social desirability biases could not be supported, the thesis has highlighted that the cognitive task that subjects are asked to perform when providing data at posttest significantly influenced their self-reported outcomes. Given that previous research has predominantly focused on other aspects of validity - such as applying control group designs to circumvent common threats to internal and external validity - this study suggests that more attention must be paid to the design of questionnaires. The thesis concludes that further research, in particular into the influence of cognitive tasks on obtained scores, is important to improve the interpretation of self-report outcomes data derived from participants of self-management interventions

Measurement of the proton light response of various LAB based scintillators and its implication for supernova neutrino detection via neutrino-proton scattering

The proton light output function in electron-equivalent energy of various scintillators based on linear alkylbenzene (LAB) has been measured in the energy range from 1 MeV to 17.15 MeV for the first time. The measurement was performed at the Physikalisch-Technische Bundesanstalt (PTB) using a neutron beam with continuous energy distribution. The proton light output data is extracted from proton recoil spectra originating from neutron-proton scattering in the scintillator. The functional behavior of the proton light output is described succesfully by Birks' law with a Birks constant kB between (0.0094 +/- 0.0002) cm/MeV and (0.0098 +/- 0.0003) cm/MeV for the different LAB solutions. The constant C, parameterizing the quadratic term in the generalized Birks law, is consistent with zero for all investigated scintillators with an upper limit (95% CL) of about 10^{-7} cm^2/MeV^2. The resulting quenching factors are especially important for future planned supernova neutrino detection based on the elastic scattering of neutrinos on protons. The impact of proton quenching on the supernova event yield from neutrino-proton scattering is discussed.Comment: 12 pages, 17 figures, 4 tables, updated version for publication in Eur.Phys.J.

3D shape reconstruction of the femur from planar X-ray images using statistical shape and appearance models

Major trauma is a condition that can result in severe bone damage. Customised orthopaedic reconstruction allows for limb salvage surgery and helps to restore joint alignment. For the best possible outcome three dimensional (3D) medical imaging is necessary, but its availability and access, especially in developing countries, can be challenging. In this study, 3D bone shapes of the femur reconstructed from planar radiographs representing bone defects were evaluated for use in orthopaedic surgery. Statistical shape and appearance models generated from 40 cadaveric X-ray computed tomography (CT) images were used to reconstruct 3D bone shapes. The reconstruction simulated bone defects of between 0% and 50% of the whole bone, and the prediction accuracy using anterior–posterior (AP) and anterior–posterior/medial–lateral (AP/ML) X-rays were compared. As error metrics for the comparison, measures evaluating the distance between contour lines of the projections as well as a measure comparing similarities in image intensities were used. The results were evaluated using the root-mean-square distance for surface error as well as differences in commonly used anatomical measures, including bow, femoral neck, diaphyseal–condylar and version angles between reconstructed surfaces from the shape model and the intact shape reconstructed from the CT image. The reconstructions had average surface errors between 1.59 and 3.59 mm with reconstructions using the contour error metric from the AP/ML directions being the most accurate. Predictions of bow and femoral neck angles were well below the clinical threshold accuracy of 3°, diaphyseal–condylar angles were around the threshold of 3° and only version angle predictions of between 5.3° and 9.3° were above the clinical threshold, but below the range reported in clinical practice using computer navigation (i.e., 17° internal to 15° external rotation). This study shows that the reconstructions from partly available planar images using statistical shape and appearance models had an accuracy which would support their potential use in orthopaedic reconstruction