Health care performance management : insights from applications of data envelopment analysis

The comprehensive measurement of efficiency and performance in the Health Service in the UK has become one of the most important managerial developments of recent years. The reasons for this development were examined, particularly in relation to the difficulties involved with performance assessment in such a context. The most widely utilised techniques were evaluated from the perspective of the Health Care Manager and a number of serious limitations were identified. In response to these limitations, the technique of Data Envelopment Analysis was evaluated as an alternative. It has been proposed as an appropriate and useful tool for the assessment of efficiency, although the literature on DEA showed limited practical application to public sector services in the UK. The many facets of the technique were investigated and literature on its application to hospital data was reviewed. A two-stage application procedure for the DEA technique was developed in response to this evaluation, to be used in the measurement hospital efficiency. The procedure was based on a deep theoretical understanding of the DEA methodology. The most important elements of the process were related to selection of the initial sample, the identification of the variables to be included in the DEA model and the definition of the weight restrictions to be incorporated. Input from Health Care Managers was used to guide the application and data from a sample of acute hospitals in Scotland was utilised in the analysis. The application procedure showed how the practicalities of the DEA technique could be enhanced, in particular through the inclusion of weight restrictions. This led to the development of efficiency strategies for the inefficient hospitals, which could be related to the policy objectives or managerial structure of the hospitals in the sample. It was concluded that there were many potential benefits of the DEA approach to efficiency assessment and the two-stage application procedure defined here, which could be seen to fulfil many of the requirements of the Health Care Manager. It was determined that combining theoretical and practical issues can enhance the applicability of the DEA methodology

Feeding and mortality in the early months of life : changes in medical opinion and popular feeding practice, 1850-1900

This thesis is concerned with the artificial feeding of very young children during the second half of the nineteenth century, and its implications for infant health and survival. The decline of breastfeeding which occurred in England between the years 1850 and 1900 was regarded by contemporary critics as largely responsible for the high rate of infant mortality which persisted throughout the half century, at a time when premature deaths in other age-groups were declining in number. This thesis examines, in the light both of contemporary judgements and of modern knowledge, the artificial feeding methods which were adopted in place of breastfeeding. Changes in medical attitudes and opinion during this period in relation to artificial feeding are described, and their influence on popular feeding practice in different social contexts discussed. Rival influences, such as shortcomings in the supply of certain foods and the pressure of commercial advertising, are also examined, and the influence of social factors in general on the development of effective methods of artificial feeding assessed. Finally, the state of health of handfed infants as described in contemporary sources is considered in relation to their diet. Contemporary assumptions about the relationship between artificial feeding and high infant mortality and morbidity are largely found to be justified; it is argued that the period 1850 to 1900 was, nevertheless, one of notable advance both in attitudes towards handfeeding and in the technical skill and understanding which was brought to bear on the problems it involved. Although this period itself saw no reduction in the infant mortality rate, it is seen as a time of adjustment to new ideas and practices, forming a necessary prelude to subsequent and more effective attempts at reform

Transnational engagements: cultural and religious practices related to menstruation

This transnational engagement brings together participants from various cultural and religious backgrounds in a dialogue about menstrual practices. They are asked to consider their own experiences with these practices and reflect on how the practices have affected them. The discussion makes clear that participants have varying understandings and views of traditional menstrual practices, and that these views often challenge the common depiction of traditional practices as restrictions that are forced upon women

Therapist variation within meta-analyses of psychotherapy trials

Randomised trials of complex interventions are typically designed, conducted, and analysed as if they are drug trials. Although there are many parallels there are also a number of important distinctions, which are seldom considered when designing individual trials. One of these concerns the involvement of therapists in delivering psychotherapy. Systematic reviews and meta-analyses provide an opportunity for exploring the full range and complexity of issues encountered in realistically complex situations. The first objective of the thesis was therefore to develop a conceptual framework for understanding the role of the therapist in trial designs. It was addressed by a review of the psychotherapy and statistical literatures structured according to the broad concepts of precision, internal and external validity and refined on the basis of a systematic methodological review of Cochrane reviews meta-analysing trials involving psychotherapy. The second objective was then to review, adapt, illustrate and compare methods for meta-analysing psychotherapy trials with nested designs. Methods for meta-analysing ICC estimates, absolute and standardised mean differences were adapted to allow for heteroscedasticity between treatments at the therapist- and patient- levels. These were illustrated using the example of counselling in primary care, with comparisons being made between aggregate and one-step approaches to the meta-analysis of individual-patient-data.It was argued that the therapist has two roles in randomised trials. Firstly, they are one component of a multi-component intervention, and are thus a potential treatment variable. Second, the nesting of patients within therapists creates an additional level in the design, so the therapist is also an experimental unit. The inability to conceal or randomise allocations leads to observational components within the trial design and to heteroscedasticity which deserves more attention. Characterising complex interventions, like psychotherapy, with more than one treatment variable could facilitate greater understanding of their components, how they interact, which are important, to what extent, and for whom. It also brings what is currently referred to as process research into the remit of trials, enabling a more complete evaluation of the causal effects. The broad concept of multiple experimental units makes cluster-randomised, longitudinal, multi-centre, crossover, therapist- and group-based intervention trials special cases of a more general class of multilevel trial. All involve clustering effects; their nature and the appropriate statistical model varying according to the design. Methods were proposed for the meta-analysis of continuous outcome data for two-level nested designs. A general approach was adopted, where possible, to incorporate methods covering cluster-randomised trials and the Behrens-Fisher problem. It was clear that this is a relatively untouched methodological area in need of further exploration. For the same reasons as it became necessary to summarise clinical research, it is recommended that systematic methodological reviews be carried out on a larger scale in future.EThOS - Electronic Theses Online ServiceMedical Research CouncilGBUnited Kingdo

Ultra-small graphitization reactors for ultra-microscale 14C analysis at the National Ocean Sciences Accelerator Mass Spectrometry (NOSAMS) Facility

© The Arizona Board of Regents on behalf of the University of Arizona, 2015. This article is distributed under the terms of the Creative Commons Attribution License. The definitive version was published in Radiocarbon 57, no. 1 (2015): 109–122, doi:10.2458/azu_rc.57.18118.In response to the increasing demand for 14C analysis of samples containing less than 25 µg C, ultra-small graphitization reactors with an internal volume of ~0.8 mL were developed at NOSAMS. For samples containing 6 to 25 µg C, these reactors convert CO2 to graphitic carbon in approximately 30 min. Although we continue to refine reaction conditions to improve yield, the reactors produce graphite targets that are successfully measured by AMS. Graphite targets produced with the ultra-small reactors are measured by using the Cs sputter source on the CFAMS instrument at NOSAMS where beam current was proportional to sample mass. We investigated the contribution of blank carbon from the ultra-small reactors and estimate it to be 0.3 ± 0.1 µg C with an Fm value of 0.43 ± 0.3. We also describe equations for blank correction and propagation of error associated with this correction. With a few exceptions for samples in the range of 6 to 7 µg C, we show that corrected Fm values agree with expected Fm values within uncertainty for samples containing 6–100 µg C.This work was funded by the NSF Cooperative Agreement for the Operation of a National Ocean Sciences Accelerator Mass Spectrometry Facility (OCE-0753487). S R Shah Walter was also partially supported by the WHOI Postdoctoral Scholar Program

Thin film notch filters as platforms for biological image processing

Many image processing operations involve the modification of the spatial frequency content of images. Here we demonstrate object-plane spatial frequency filtering utilizing the angular sensitivity of a commercial spectral bandstop filter. This approach to all-optical image processing is shown to generate real-time pseudo-3D images of transparent biological and other samples, such as human cervical cancer cells. This work demonstrates the potential of non-local, non-interferometric approaches to image processing for uses in label-free biological cell imaging and dynamical monitoring.Comment: manuscript 14 pages, 5 figures, supplementary material 7 pages, 4 supplementary figure

Tissue iron promotes wound repair via M2 macrophage polarisation and the chemokines CCL17 and CCL22

Macrophages are important for effective iron recycling and erythropoiesis, but they also play a crucial role in wound healing, orchestrating tissue repair. Recently, we demonstrated a significant accumulation of iron in healing wounds and a requirement of iron for effective repair. Herein, we sought to determine the influence of iron on macrophage function in the context of wound healing. Interestingly, wound macrophages extensively sequestered iron throughout healing, associated with a prohealing M2 phenotype. In delayed healing diabetic mouse wounds, both macrophage polarization and iron sequestration were impaired. In vitro studies revealed that iron promotes differentiation, while skewing macrophages toward a hypersecretory M2-like polarization state. These macrophages produced high levels of chemokine (C-C motif) ligands 17 and 22, promoting wound reepithelialization and extracellular matrix deposition in a human ex vivo wound healing model. Together, these findings reveal a novel, unappreciated role for iron in modulating macrophage behavior to promote subsequent wound repair. These findings support therapeutic evaluation of iron use to promote wound healing in the clinic

Consumer and Provider Perspectives on Hospital in the Home : A Qualitative Study

The delivery of acute health care has changed with the adoption of new technologies to meet changing community needs. In response to this, hospital systems and governments have invested in alternative models of care, including hospital in the home (HITH), where acute care that would typically require inpatient treatment is provided in the patient’s home. The academic literature presents evidence for comparable or improved patient outcomes associated with HITH interventions. However, it is currently unknown how consumers and providers view the model in the context of a new healthcare facility. This study aimed to elicit consumer and provider views about HITH and how the implementation of a HITH model of care in a new hospital could meet their healthcare needs. We adopted a qualitative approach for this research. Semistructured workshops and interviews were conducted via Zoom, where we presented patient vignettes of different models of care to consumers and providers and recorded their responses using scribes. Qualitative data were independently coded by pairs of researchers to identify themes and subthemes, and demographic data were aggregated. A total of 51 consumers and 35 providers attended the workshops. Consumers and providers frequently described similar themes, particularly accessibility, patient factors, and the health system consequences of HITH. However, the importance and focus of these topics varied across participants. Participants endorsed HITH as a flexible, patient-centred model with potential for wellbeing benefits. However, they noted the potential need for additional resources and increased anxiety among patients with lower health literacy. To address this, participants described the need for clear escalation protocols, communication channels, and expectations around HITH care. In conclusion, HITH is an established model that brings acute care into the homes of patients. The findings of this study support the provision of flexible acute care delivery to meet consumer needs and address the challenges encountered during the COVID-19 pandemic

What do consumer and providers view as important for integrated care? A qualitative study

Background: Integrated care is a model recognised internationally, however, there is limited evidence about its usability in the community. This study aimed to elicit community and provider views about integrated care and how implementation could meet their healthcare needs in a new hospital. Methods: Using a qualitative approach, consumer and provider views on the strengths, barriers and enablers for integrated care were collected via a series of online workshops and supplementary interviews. Results: A total of 22 consumers and 49 providers participated in 11 focus groups; all perceived integrated care to be an accessible and efficient model that offers a high level of care which enhanced staff and patient well-being. Providers expressed concerns about longer waiting times and safety risks associated with communication gaps and insufficient staff. Enablers include supporting consumers in navigating the integrated care process, co-ordinating and integrating primary care into the model as well as centralising patient electronic medical records. Discussion: Primary, tertiary and community linkages are key for integrated care. Successful interoperability of services and networks requires an investment in resources and infrastructure to build the capability for providers to seamlessly access information at all points along the patient pathway. Conclusion: Integrated care is perceived by consumers and providers to be a flexible and patient-focused model of healthcare that offers benefits for a hospital of the future

ATA Practice Guidelines for Live, On-Demand Primary and Urgent Care

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/140286/1/tmj.2015.0008.pd