Outsourcing the Management of Reusable Medical Devices in a Chain-Wide Care Setting:Mixed Methods Feasibility Study

BACKGROUND: Managing reusable medical devices incurs substantial health care costs and complexity, particularly in integrated care settings. This complexity hampers care quality, safety, and costs. Studying logistical innovations within integrated care can provide insights to medical devices use among staff effectively.OBJECTIVE: This study aimed to establish the feasibility of a logistical intervention through outsourcing and a web portal. The goal was to provide insights into users' acceptability of the intervention, on whether the intervention was successfully implemented, and on the intervention's preliminary efficacy, thus benefiting practitioners and researchers.METHODS: This paper presents a mixed methods feasibility study at a large chain-wide health care provider in the Netherlands. The intervention entailed outsourcing noncritical reusable medical devices and introducing a web portal for device management. A questionnaire gauged perceived ordering and delivery times, satisfaction with the ordering and delivery process, compliance with safety and hygiene certification, and effects on the care delivery process. Qualitative data in the form of observations, documentation, and interviews were used to identify implementing challenges. Using on-site stocktaking and data from information systems, we analyzed the utilization, costs, and rental time of medical devices before and after the intervention for wheelchairs and anti-pressure ulcer mattresses.RESULTS: Looking at the acceptability of the intervention, a high user satisfaction with the ordering and delivery process was reported (rated on a 5-point Likert scale). With respect to preliminary efficacy, we noted a reduction in the utilization of wheelchairs (on average, 1106, SD 106 fewer utilization d/mo), and a halted increase in the utilization of anti-pressure ulcer mattresses. In addition, nurses who used the web portal reported shorter ordering times for wheelchairs (-2.7 min) and anti-pressure ulcer mattresses (-3.1 min), as well as shorter delivery times for wheelchairs (-0.5 d). Moreover, an increase in device certification was reported (average score of 1.9, SD 1.0), indicating higher levels of safety and hygiene standards. In theory, these improvements should translate into better outcomes in terms of costs and the quality of care. However, we were unable to establish a reduction in total care costs or a reduced rental time per device. Furthermore, respondents did not identify improvements in safety or the quality of care. Although implementation challenges related to the diverse supply base and complexities with different care financers were observed, the overall implementation of the intervention was considered successful.CONCLUSIONS: This study confirms the feasibility of our intervention, in terms of acceptability, implementation success, and preliminary efficacy. The integrated management of medical devices should enable a reduction in costs, required devices, and material waste, as well as higher quality care. However, several challenges remain related to the implementation of such interventions.</p

Orchestration versus bookkeeping:How stakeholder pressures drive a healthcare purchaser’s institutional logics

BACKGROUND: Healthcare purchasers such as health insurers and governmental bodies are expected to strategically manage chronic care chains. In doing so, purchasers can contribute to the goal of improving task division and collaboration between chronic care providers as has been recommended by numerous studies. However, healthcare purchasing research indicates that, in most countries, purchasers still struggle to fulfil a proactive, strategic approach. Consequently, a typical pattern occurs in which care improvement initiatives are instigated, but not transformed into regular care. By acknowledging that healthcare purchasers are embedded in a care chain of stakeholders who have different, sometimes conflicting, interests and, by taking an institutional logics lens, we seek to explain why achieving strategic purchasing and sustainable improvement is so elusive. METHOD AND FINDINGS: We present a longitudinal case study in which we follow a health insurer and care providers aiming to improve the care of patients with Chronic Obstructive Pulmonary Disease (COPD) in a region of the Netherlands. Taking a theoretical lens of institutional logics, our aim was to answer ‘how stakeholder pressures influence a purchaser’s use of institutional logics when pursuing the right care at the right place’. The insurer by default predominantly expressed a bookkeeper’s logic, reflecting a focus on controlling short-term care costs by managing individual providers. Over time, a contrasting orchestrator’s logic emerged in an attempt to achieve chain-wide improvement, striving for better health outcomes and lower long-term costs. We established five types of stakeholder pressure to explain the shift in logic adoption: relationship pressures, cost pressures, medical demands, public health demands and uncertainty. Linking the changes in logic over time with stakeholder pressures showed that, firstly, the different pressures interact in influencing the purchaser. Secondly, we saw that the lack of intra-organisational alignment affects how the purchaser deals with the different stakeholder pressures. CONCLUSIONS: By highlighting the purchaser’s difficult position in the care chain and the consequences of their own internal responses, we now better understand why the intended orchestrator’s logic and thereby a strategic approach to purchasing chronic care proves unsustainable within the Dutch healthcare system of managed competition

Intensive out-of-hospital coaching for frequently hospitalized COPD patients::a before-after feasibility study

Background. This study assesses whether out-of-hospital coaching of re-hospitalized, severe COPD patients by specialized respiratory nurses is feasible in terms of cost-effectiveness, implementation, and recipient acceptability. The coaching was aimed at improving patients’ health management abilities, motivation for healthy behavior, strengthening the professional and informal care network, stimulating physiotherapy treatment and exercise training, improving knowledge on symptom recognition and medication use, and providing safety and support. Methods. Cost-effectiveness of 6 months of out-of-hospital coaching was assessed based on a before-after intervention design, with real-life data and one-year follow-up. A total of 170 patients were included. Primary (questionnaires, meeting reports) and secondary data (insurance reimbursement data) were collected in one province in the Netherlands. The implementing and recipient acceptability was assessed based on the number of successfully delivered coaching sessions, questionnaire response rate, Patient Reported Experience Measure, and interviews with coaches. Results. Post-intervention, the COPD-related hospitalization rate was reduced by 24%, and patients improved in terms of health status, anxiety, and nutritional status. Patients with a high mental burden and a poor score for health impairment and wellbeing at the start of the intervention showed the greatest reduction in hospitalizations. The coaching service was successfully implemented and considered acceptable by recipients, based on patient and coach satisfaction and clinical use of patient-reported measures.Conclusion. The study demonstrates the value of coaching patients out-of-hospital, with a strong link to primary care, but with support of hospital expertise, thereby adding to previous studies on disease- or self-management support in either primary or secondary care settings. Patients benefit from personal attention, practical advice, exercise training, and motivational meetings, thereby improving health status and reducing the likelihood of re-hospitalization and its associated costs

DNA bending by photolyase in specific and non-specific complexes studied by atomic force microscopy

Specific and non-specific complexes of DNA and photolyase are visualised by atomic force microscopy. As a substrate for photolyase a 1150 bp DNA restriction fragment was UV-irradiated to produce damaged sites at random positions. Comparison with a 735 bp undamaged DNA fragment made it possible to separate populations of specific and non-specific photolyase complexes on the 1150 bp fragment, relieving the need for highly defined substrates. Thus it was possible to compare DNA bending for specific and non-specific interactions. Non-specific complexes show no significant bending but increased rigidity compared to naked DNA, whereas specific complexes show DNA bending of on average 36°and higher flexibility. A model obtained by docking shows that photolyase can accommodate a 36°bent DNA in the vicinity of the active site

COMODO: an adaptive coclustering strategy to identify conserved coexpression modules between organisms

Increasingly large-scale expression compendia for different species are becoming available. By exploiting the modularity of the coexpression network, these compendia can be used to identify biological processes for which the expression behavior is conserved over different species. However, comparing module networks across species is not trivial. The definition of a biologically meaningful module is not a fixed one and changing the distance threshold that defines the degree of coexpression gives rise to different modules. As a result when comparing modules across species, many different partially overlapping conserved module pairs across species exist and deciding which pair is most relevant is hard. Therefore, we developed a method referred to as conserved modules across organisms (COMODO) that uses an objective selection criterium to identify conserved expression modules between two species. The method uses as input microarray data and a gene homology map and provides as output pairs of conserved modules and searches for the pair of modules for which the number of sharing homologs is statistically most significant relative to the size of the linked modules. To demonstrate its principle, we applied COMODO to study coexpression conservation between the two well-studied bacteria Escherichia coli and Bacillus subtilis. COMODO is available at: http://homes.esat.kuleuven.be/∼kmarchal/Supplementary_Information_Zarrineh_2010/comodo/index.html

Malunion after midshaft clavicle fractures in adults: The current view on clavicular malunion in the literature

This is an overview of the current literature on malunion after midshaft clavicle fracture. Anatomy, trauma mechanism, classification, incidence, symptoms, prevention, and treatment options are all discussed. The conclusion is that clavicle malunion is a distinct clinical entity that can be treated successfully

Directions for next generation microscopic traffic simulation modeling tool under the IntelliDrive environment

Microscopic traffic simulation models have been widely accepted in the evaluations of new treatments in the surface transportation system. These include new highway, lane usage (e.g., high occupancy vehicle lane or high occupancy toll lane), speed limits (e.g., variable speed limit, and uniform or differential speed limits), etc. Additional needs such as considering lateral movements within the lane made researchers develop plug-in modules on the basis of application programming interface (API). With a recent initiation of IntelliDrive or cooperative vehicle infrastructure system, a traffic simulation research community has faced to consider directions for the future microscopic traffic simulation modeling tools.\ud This paper conducted comprehensive assessments on the existing practices in the microscopic simulation modeling and future modeling needs, and recommended that the development of traffic simulation model independent plug-in modules. Additional recommendations including short-term and long-term approaches were\ud discussed