Η θεωρία του New Public Management στον τομέα της Υγείας

Ο 20ος αιώνας, σημάδεψε την Ευρώπη και επέφερε την ανάγκη για μία σειρά αλλαγών. Οι δύο παγκόσμιοι πόλεμοι, οι πολιτικές ανακατατάξεις, η εισαγωγή νέων οικονομικών συστημάτων και προτύπων έχουν αναπόφευκτες επιδράσεις εκτός των άλλων και στην διοίκηση. Σταδιακά, τα παραδοσιακά μοντέλα διοίκησης κρίνονται αναποτελεσματικά, το γραφειοκρατικό μοντέλο του Weber παρουσιάζει προβλήματα, και ως αποτέλεσμα κάνει την εμφάνιση του ένα νέο μοντέλο δημόσιας διοίκησης, το επονομαζόμενο New Public Management, ένα μοντέλο αρκετά κοντά στα πρότυπα μίας φιλελεύθερης αγοράς και ιδιωτικής πρωτοβουλίας. Η παγκόσμια οικονομική κρίση στα τέλη του 1970-1980, δημιούργησε έντονα κοινωνικά προβλήματα, ανισότητες και ζητήματα ασφάλειας, υγείας και περίθαλψης. Ήταν λοιπόν αναμενόμενη η διείσδυση του New Public Management και στον τομέα της υγείας, δεδομένου ότι ήταν ένας τομέας που έχρηζε αναδιοργάνωσης, και ο τομέας με την μεγαλύτερη άμεση επίδραση στο κοινό. Η διοίκηση αλλάζει και οι υπηρεσίες αποκεντρώνονται, ώστε σύμφωνα με την αρχή της επικουρικότητας να μπορούν να είναι πιο προσβάσιμες στους πολίτες. Η Ελλάδα, στα πλαίσια της παγκοσμιοποίησης δεν μένει ανεπηρέαστη από τις αλλαγές που συντελούνται στην Ευρώπη και προσπαθεί να ενσωματώσει διαδικασίες και πρακτικές που θα την φέρουν πιο κοντά στον πολυπόθητο εκσυγχρονισμό. Οι πολιτικές που εφαρμόστηκαν προς αυτή την κατεύθυνση, τόσο σε παγκόσμιο όσο και σε εθνικό επίπεδο, το ποιες αδυναμίες οδήγησαν στην αναζήτηση μιας νέας μορφής διοίκησης και το αν αυτή υπήρξε επιτυχής ή όχι, αποτελούν τα υπό μελέτη ερωτήματα της παρακάτω εργασίας.The 20th century marked Europe and brought about the need for a series of changes. The two world wars, the changes in the political level, the introduction of new economic systems and standards have inevitable effects on the administration as well. The 20th century marked Europe and brought about the need for a series of changes. The two world wars, the reorganizations, the introduction of new economic systems and standards have inevitable effects on the administration as well. Gradually, traditional management models are considered ineffective, Weber's bureaucratic model presents problems, and as a result a new model of public administration is introduced, called New Public Management, a model quite close to the standards of a liberal market and private initiative. The global economic crisis of the late 1970s and 1980s caused severe social problems, inequalities and issues of security, health and care. It was therefore expected that New Public Management would be introduced in the health sector, as it was one of the first areas to be reorganized, and the sector with the greatest direct impact on the public. Management is changing, services are being decentralized so that, according to the principle of subsidiarity, they can be more accessible to citizens. Greece, in the context of globalization, is not unaffected by the changes taking place in Europe and is trying to integrate processes and practices that will bring it closer to the coveted modernization. The policies implemented in this direction, what weaknesses led to the search for a new form of administration and whether it was successful or not, are the questions under study in the following work

Validation study of a new chemiluminescent singleplex IgE assay in a set of Italian allergic rhinitis patients

Background: The measurement of specific IgE to allergenic extracts and molecules in patients with allergic rhinitis (AR) is crucial for a precise diagnosis and further immunotherapy. Companies providing in vitro diagnostic methods in allergology continuously strive for the optimization and modernization of such methods. A new generation of automated allergy tests based on chemiluminescence detection and paramagnetic microparticles is now available, with possible advantages in sample volume, cost-effectiveness and avoidance of sample-related interference. Objectives: To test whether sIgE antibody levels obtained with a new singleplex chemiluminescent method have a good agreement with the corresponding results obtained with a "gold standard" test. Methods: We tested sera from 368 AR patients. Specific IgE sera levels (kU/L) to a comprehensive panel of 15 allergen extracts and 6 molecules were tested with ImmunoCAP® (Thermo Fisher Scientific Inc, Phadia AB, Uppsala, Sweden) and NOVEOS™ (HYCOR® Biomedical, Garden Grove, CA, USA). We evaluated the qualitative and quantitative performance of the new NOVEOS system in matching the outcome of ImmunoCAP to each of the examined allergens. Results: In relation to ImmunoCAP, the overall diagnostic sensitivity and specificity of sIgE tests with NOVEOS were 90.8% (95% CI = 88.6-92.7) and 96.2% (95% CI = 93.9-97.8), respectively. These values were higher when only molecules were considered (sensitivity = 98.7% [95% CI = 96.4%-99.7%]; specificity = 94.2% [95% CI = 88.4%-97.6%]) and lower when only extracts were considered (sensitivity = 87.6% [95% CI = 84.7%-90.2%]; specificity = 97% [95% CI = 94.4%-98.6%]). Spearman's correlation between the data set of both methods for a ≥ 0.1 kU/L cut-off was 0.84 (p < .001). Conclusions: The new singleplex NOVEOS system presented good results for qualitative and quantitative comparisons when testing specific serum IgE antibodies against a range of 21 allergens. This novel immunoassay system using only 4 µl of sample per test appears to be robust and reliable and can, therefore, be used as an aid in allergy diagnosis

Lung MRI as a Possible Alternative to CT Scan for Patients With Primary Immune Deficiencies and Increased Radiosensitivity

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Asthma Control Test and Bronchial Challenge with Exercise in Pediatric Asthma

Background: Poor asthma control can lead to exercise-induced bronchoconstriction (EIB), but the relationship between subjective disease control and EIB is unclear. No studies have compared asthma control test (ACT) scores of children with those of their parents regarding EIB. We assessed whether ACT scores predict the occurrence of EIB in two age groups. We also evaluated ACT scores and objective measures as explanatory variables for airway response to exercise. Methods: Patients (71 aged <12 years, 93 aged 6512 years) and their parents completed an ACT questionnaire separately. Current therapy, skin prick testing and spirometry at baseline and after exercise were assessed. EIB was defined as a fall in FEV1 of at least 12% from baseline. Sensitivity and specificity for cut-off values of ACT scores predictive of EIB were plotted, and the Area Under Curve (AUC) was described. Results: Atopy and current therapy were similarly frequent. EIB was observed in 23.9% of children aged <12 years and in 33.3% aged 6512 years. EIB occurrence in subjects previously scored as having full control (25), partial control (20\u201024) and no control (<20) varied according to the age group and responder. Percentages of EIB cases increased as ACT scores decreased in children aged 6512 years alone (child ACT scores, 25: 21.9%, 20-24: 31.1%, <20: 62.5%, p=0.017). Plots for ACT scores as predictors of EIB yielded low non\u2010significant AUC values in children aged <12 years; by contrast, moderate AUC values emerged in children aged 6512 years (child: 0.67, p=0.007; parent: 0.69, p=0.002). Sensitivity of ACT scores below 20 as a predictor of EIB was low in older children (child: 32.3%, parent: 22.6%), whereas specificity was high (child: 90.3%, parent: 93.5%). Multiple regression analysis with percent fall in FEV1 as dependent variable included FEV1/FVC%, ACT child score and gender in the prediction model ( r=0.42, p=0.000). Conclusion: ACT scores are a more effective means of excluding than confirming EIB in asthmatic patients aged 6512 years; their predictive value decreases in younger patients. ACT scores together with lung function may help to predict airway response to exercise. New tools for pediatric asthma assessment may optimize this association

The impact of a Clinical Decision Support System on allergen immunotherapy prescription in children and adults with seasonal allergic rhinitis

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@IT2020: An innovative algorithm for allergen immunotherapy prescription in seasonal allergic rhinitis

Background: Allergen immunotherapy (AIT) is the only disease-modifying treatment in patients with seasonal allergic rhinoconjunctivitis (SAR). Its efficacy depends on the precise identification of the triggering allergen. However, diagnostics based on retrospective clinical history and sensitization to whole extracts (SWE) often leads to equivocal results. Objectives: To assess the usability and impact of a recently established algorithm for a clinical decision support system (@IT2020-CDSS) for SAR and its diagnostic steps [anamnesis, SWE (skin prick test or serum IgE), component resolved diagnosis, CRD, and real-time digital symptom recording, eDiary] on doctor's AIT prescription decisions. Methods: After educational training on the @IT2020-CDSS algorithm, 46 doctors (18 allergy specialists, AS, and 28 general practitioners, GP) expressed their hypothetical AIT prescription for 10 clinical index cases. Decisions were recorded repeatedly based on different steps of the algorithm. The usability and perceived impact of the algorithm were evaluated. Results: The combined use of CRD and an eDiary increased the hypothetical AIT prescriptions, both among AS and GP (p < .01). AIT prescription for pollen and Alternaria allergy based on anamnesis and SWE was heterogeneous but converged towards a consensus by integrating CRD and eDiary information. Doctors considered the algorithm useful and recognized its potential in enhancing traditional diagnostics. Conclusions and clinical implications: The implementation of CRD and eDiary in the @IT2020-CDSS algorithm improved consensus on AIT prescription for SAR among AS and GP. The potential usefulness of a CDSS for aetiological diagnosis of SAR and AIT prescription in real-world clinical practice deserves further investigation

Heterogeneous validity of daily data on symptoms of seasonal allergic rhinitis recorded by patients using the e-diary AllergyMonitor®

Background: Patient-generated symptom and medication scores are essential for diagnostic and therapeutic decisions in seasonal allergic rhinitis (SAR). Previous studies have shown solid consistencies between different scores at population level in real-life data and trials. For clinicians, the evaluation of individual data quality over time is essential to decide whether to rely on these data in clinical decision-making. Objective: To analyze the consistency of different symptom (SS) and symptom medication scores (SMSs) at individual level in two study cohorts with different characteristics and explore individual patient trajectories over time. Methods: Within the pilot phase of the @IT.2020 project on diagnostic synergy of mobile health and molecular IgE assessment in patients with SAR, we analyzed data of 101 children and 93 adults with SAR and instructed them to record their symptoms and medication intake daily via the mobile app AllergyMonitor®. We then assessed the correlation between different SMS and a visual analogue scale (VAS) on the impact of allergy symptoms on daily life at population and individual level. Results: At population level, the Rhinoconjunctivitis total symptom score (RTSS) correlated better with VAS than the combined symptom and medication score (CSMS). At individual level, consistency among RTSS and VAS was highly heterogeneous and unrelated to disease severity or adherence to recording. Similar heterogeneity was observed for CSMS and VAS. Conclusions: The correlation of clinical information provided by different disease severity scores based on data collected via electronic diaries (e-diaries), is sufficient at population level, but broadly heterogeneous for individual patients. Consistency of the recorded data must be examined for each patient before remotely collected information is used for clinical decision making

IgE antibody repertoire in nasal secretions of children and adults with seasonal allergic rhinitis: a molecular analysis

Background: There is growing interest both in testing IgE in nasal secretions (NS) and in molecular diagnosis of seasonal allergic rhinitis (SAR). Yet, the reliability of nasal IgE detection with the newest molecular assays has never been assessed in a large cohort of pollen allergic patients. Objective: To investigate with microarray technology and compare the repertoires of specific IgE (sIgE) antibodies in NS and sera of a large population of children and adults with SAR. Methods: Nasal secretions were collected with an absorbent device (Merocel 2000®, Medtronic) and a minimal dilution procedure from 90 children and 71 adults with SAR. Total IgE (tIgE) (ImmunoCAP, Thermo Fisher&nbsp;Scientific (TFS)) and sIgE antibodies against 112 allergen molecules (ISAC-112, TFS) were measured in NS and serum. Results: Nasal sIgE was detectable in 68.3% of the patients. The detected nasal sIgE antibodies recognized airborne (88%), vegetable (10%), and animal food or other (&lt;1%) allergen molecules. The prevalence and average levels of sIgE in NS and serum were highly interrelated at population level. A positive nasal sIgE antibody to a given molecule predicted the detection of the same antibody in the patient's serum with a specificity of 99.7% and a sensitivity of 40%. Conclusions: The concentration of sIgE is much lower in nasal secretions than in the serum. sIgE assays with very high analytical sensitivity and sampling methods with minimal dilution will be therefore needed to validate nasal secretions as alternative to serum in testing the sIgE repertoire