Morphine use in the last six days of life of patients with HIV/AIDS at the inpatient unit of a South African hospice implementing the ICHC model

Background Seventy-five per cent of the world's HIV/AIDS population resides in Sub-Saharan Africa. South Africa, along with the rest of Sub-Saharan Africa, is experiencing an increasing disease and palliative care burden as a result of the HIV/AIDS pandemic. At present there is no cure for AIDS and access to antiretroviral treatment is limited.HIV/AIDS is the largest single cause of death in South Africa, accounting for 30% of deaths in 2000. An estimated 20 000 of the approximately 5 350 000 infected South Africans receive antiretroviral treatment.To cope with the rising need for AIDS-related health services, a comprehensive, integrated approach to health care is advocated, with a shift in focus from hospital care to home-based care. The Department of Health supports a community home-based care (ICHC) model as one of five models of care. It is based on similar principles to palliative care and was piloted at seven hospices in South Africa. This study was conducted in the inpatient unit (IPU) of a hospice participating in the ICHC pilot project. This model requires that the hospice provide the overall management of the home-based care programme, as well as various forms of support. Care provision is shared between professional nurses and non-professional community-based caregivers, who are trained by Hospice. For challenging symptoms, respite or terminal care, the hospice has a six-bed IPU to which patients can be admitted for short periods. The AIDS patients admitted to the IPU of the study hospice were all cared for under the ICHC model.MethodThis study was a retrospective case-control study conducted in a hospice in South Africa. Cases were consecutive deaths related to AIDS. Controls were cancer patients matched for socioeconomic status.ResultsFive days before their death, morphine for pain control was given to three of the 29 (10%) AIDS patients and to 20 of 29 (69%) cancer patients (p < 0.001). On the day of their death, morphine for pain control was given to 17 (59%) of the AIDS patients and 25 (86%) of the cancer patients (p < 0.05). Eleven (65%) of the 17 AIDS patients who were given morphine died within 48 hours of commencing with the treatment. The morphine starting dosages were within the lower therapeutic range.ConclusionsThe palliative care of dying cancer patients met internationally recognised standards. The results suggest that the pain of AIDS patients admitted to the IPU was under treated in terms of both dosage and duration. It is unlikely that the use of opiates or sedatives hastened death in dying AIDS (or cancer) patients. All the AIDS patients admitted to the IPU were cared for under the integrated community home-based care (ICHC) model. This raises the following questions: Is the ICHC model as implemented by this hospice achieving the symptom relief intended? And, is this typical of palliative care for AIDS patients in South Africa?For full text, click here:SA Fam Pract 2006;48(4):14-14

The provision of fire services in rural areas

Fire services have been neglected in discussions of public service provision in rural areas. The way in which they are provided has a broader significance in terms of current debates about risk management. Fire service policy was transferred away from the Home Office, but the Bain Report provided the major stimulus to change. Early central government attempts to stimulate fire service provision in rural area were hampered by a lack of cooperation between local authorities. Rates of death from fire are influenced by attendance times and are particularly high in remote rural areas. The development of national standards of fire cover was focused on protecting property rather than saving lives with disproportionate funding being provided for urban areas. Social changes in rural areas have made it more difficult to secure sufficient numbers of retained fire fighters. It has proved particularly difficult to provide an adequate service in remote rural areas such as the Highlands and Islands of Scotland, despite recent policy initiatives there. Problems of providing fire cover are particularly acute on isolated islands. The development of integrated risk management plans should offer a more fine grained approach to providing fire cover. However, they may be too sophisticated for the task in rural areas and more traditional democratic mechanisms for expressing perceived community needs may have a greater relevance

Optimal Investment in the Development of Oil and Gas Field

Let an oil and gas field consists of clusters in each of which an investor can launch at most one project. During the implementation of a particular project, all characteristics are known, including annual production volumes, necessary investment volumes, and profit. The total amount of investments that the investor spends on developing the field during the entire planning period we know. It is required to determine which projects to implement in each cluster so that, within the total amount of investments, the profit for the entire planning period is maximum. The problem under consideration is NP-hard. However, it is solved by dynamic programming with pseudopolynomial time complexity. Nevertheless, in practice, there are additional constraints that do not allow solving the problem with acceptable accuracy at a reasonable time. Such restrictions, in particular, are annual production volumes. In this paper, we considered only the upper constraints that are dictated by the pipeline capacity. For the investment optimization problem with such additional restrictions, we obtain qualitative results, propose an approximate algorithm, and investigate its properties. Based on the results of a numerical experiment, we conclude that the developed algorithm builds a solution close (in terms of the objective function) to the optimal one

Tackling concentrated worklessness: integrating governance and policy across and within spatial scales

Spatial concentrations of worklessness remained a key characteristic of labour markets in advanced industrial economies, even during the period of decline in aggregate levels of unemployment and economic inactivity evident from the late 1990s to the economic downturn in 2008. The failure of certain localities to benefit from wider improvements in regional and national labour markets points to a lack of effectiveness in adopted policy approaches, not least in relation to the governance arrangements and policy delivery mechanisms that seek to integrate residents of deprived areas into wider local labour markets. Through analysis of practice in the British context, we explore the difficulties of integrating economic and social policy agendas within and across spatial scales to tackle problems of concentrated worklessness. We present analysis of a number of selected case studies aimed at reducing localised worklessness and identify the possibilities and constraints for effective action given existing governance arrangements and policy priorities to promote economic competitiveness and inclusion

Good practice in social care: the views of people with severe and complex needs and those who support them

This paper reports findings drawn from a study of good practice in English social care for adults with disability and older people with severe and complex needs. People with severe and complex needs are a relatively small proportion of adult social care service users, but they are growing in numbers and have resource-intensive needs. The study involved qualitative research with adults with disability and older people with severe and complex needs, family carers and members of specialist organisations (n = 67), focusing on the features of social care services they considered to be good practice. Data were collected between August 2010 and June 2011. The approach to data collection was flexible, to accommodate participants' communication needs and preferences, including face-to-face and telephone interviews, Talking Mats(c) sessions and a focus group. Data were managed using Framework and analysed thematically. Features of good practice were considered at three levels: (i) everyday support, (ii) service organisation, and (iii) commissioning. Findings relating to the first two of these are presented here. Participants emphasised the importance of person-centred ways of working at all levels. Personalisation, as currently implemented in English social care, aims to shift power from professionals to service users through the allocation of personal budgets. This approach focuses very much on the role of the individual in directing his/her own support arrangements. However, participants in this study also stressed the importance of ongoing professional support, for example, from a specialist key worker or case manager to co-ordinate diverse services and ensure good practice at an organisational level. The paper argues that, despite the recent move to shift power from professionals to service users, people with the most complex needs still value support from professionals and appropriate organisational support. Without these, they risk being excluded from the benefits that personalisation, properly supported, could yield. Keywords : continuity of care; dementia; people with disability; qualitative research; service delivery and organisation

e-Social Science and Evidence-Based Policy Assessment : Challenges and Solutions

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Multiple Risk Behavior Interventions: Meta-analyses of RCTs

CONTEXT: Multiple risk behaviors are common and associated with developing chronic conditions such as heart disease, cancer, or Type 2 diabetes. A systematic review, meta-analysis, and meta-regression of the effectiveness of multiple risk behavior interventions was conducted. EVIDENCE ACQUISITION: Six electronic databases including MEDLINE, EMBASE, and PsycINFO were searched to August 2016. RCTs of non-pharmacologic interventions in general adult populations were selected. Studies targeting specific at-risk groups (such as people screened for cardiovascular risk factors or obesity) were excluded. Studies were screened independently. Study characteristics and outcomes were extracted and risk of bias assessed by one researcher and checked by another. The Behaviour Change Wheel and Oxford Implementation Index were used to code intervention content and context. EVIDENCE SYNTHESIS: Random-effects meta-analyses were conducted. Sixty-nine trials involving 73,873 individuals were included. Interventions mainly comprised education and skills training and were associated with modest improvements in most risk behaviors: increased fruit and vegetable intake (0.31 portions, 95% CI=0.17, 0.45) and physical activity (standardized mean difference, 0.25; 95% CI=0.13, 0.38), and reduced fat intake (standardized mean difference, -0.24; 95% CI= -0.36, -0.12). Although reductions in smoking were found (OR=0.78, 95% CI=0.68, 0.90), they appeared to be negatively associated with improvement in other behaviors (such as diet and physical activity). Preliminary evidence suggests that sequentially changing smoking alongside other risk behaviors was more effective than simultaneous change. But most studies assessed simultaneous rather than sequential change in risk behaviors; therefore, comparisons are sparse. Follow-up period and intervention characteristics impacted effectiveness for some outcomes. CONCLUSIONS: Interventions comprising education (e.g., providing information about behaviors associated with health risks) and skills training (e.g., teaching skills that equip participants to engage in less risky behavior) and targeting multiple risk behaviors concurrently are associated with small changes in diet and physical activity. Although on average smoking was reduced, it appeared changes in smoking were negatively associated with changes in other behaviors, suggesting it may not be optimal to target smoking simultaneously with other risk behaviors.This study was funded by the Department of Health Policy Research Programme as part of the Public Health Research Consortium. The funder had no role in the design, management, data collection, analyses, or interpretation of the data or in the writing of the manuscript or the decision to submit for publication

A systems approach to policy evaluation

There is growing interest in evaluating policy implementation in ways that grapple with the complexity of the process. This article offers an example of using systems methodology to explore how the child protection policy in child contact centres has functioned in practice. Rather than just asking the traditional evaluation question “is it working?” this study sought to understand how the policy was working and how it was interpreted as it interacted with other systems, producing conflicts, local variation and emergent effects. It illustrates how the systems concepts of ‘emergence’, ‘local rationality’, ‘socio-technical systems’ and ‘feedback for learning’ can contribute new knowledge and understanding to a complex policy evaluation problem

Regulatory inspection and the changing legitimacy of health and safety

The regulation of conduct via law is a key mechanism through which broader social meanings are negotiated and expressed. The use of regulatory tools to bring about desired outcomes reflects existing social and political understandings about¬ institutional legitimacy, the meanings attached to regulation, and the values it seeks to advance. But these contextual understandings are not static, and their evolution poses challenges for regulators, particularly when they reflect political framing processes. This paper shows how inspection has been reshaped as a tool within the United Kingdom’s health and safety system by changes in the meanings attached to the concept of ‘risk-based regulation’. While rates of inspection have fallen dramatically in recent years, the nature and quality of inspection have also been fundamentally reshaped via an increasingly procedural and economically-rational ‘risk-based’ policy context. This has had consequences for the transformative and symbolic value of inspection as a tool of regulatory practice