The involvement of medical doctors in hospital governance and implications for quality management: a quick scan in 19 and an in depth study in 7 OECD countries.

BACKGROUND: Hospital governance is broadening its orientation from cost and production controls towards 'improving performance on clinical outcomes'. Given this new focus one might assume that doctors are drawn into hospital management across OECD countries. Hospital performance in terms of patient health, quality of care and efficiency outcomes is supposed to benefit from their involvement. However, international comparative evidence supporting this idea is limited. Just a few studies indicate that there may be a positive relationship between medical doctors being part of hospital boards, and overall hospital performance. More importantly, the assumed relationship between these so-called doctor managers and hospital performance has remained a 'black-box' thus far. However, there is an increasing literature on the implementation of quality management systems in hospitals and their relation with improved performance. It seems therefore fair to assume that the relation between the involvement of doctors in hospital management and improved hospital performance is partly mediated via quality management systems. The threefold aim of this paper is to 1) perform a quick scan of the current situation with regard to doctor managers in hospital management in 19 OECD countries, 2) explore the phenomenon of doctor managers in depth in 7 OECD countries, and 3) investigate whether doctor involvement in hospital management is associated with more advanced implementation of quality management systems. METHODS: This study draws both on a quick scan amongst country coordinators in OECD's Health Care Quality Indicator program, and on the DUQuE project which focused on the implementation of quality management systems in European hospitals. RESULTS: This paper reports two main findings. First, medical doctors fulfil a broad scope of managerial roles at departmental and hospital level but only partly accompanied by formal decision making responsibilities. Second, doctor managers having more formal decision making responsibilities in strategic hospital management areas is positively associated with the level of implementation of quality management systems. CONCLUSIONS: Our findings suggest that doctors are increasingly involved in hospital management in OECD countries, and that this may lead to better implemented quality management systems, when doctors take up managerial roles and are involved in strategic management decision making

Point-of-care detection and differentiation of anticoagulant therapy - development of thromboelastometry-guided decision-making support algorithms

BACKGROUND DOAC detection is challenging in emergency situations. Here, we demonstrated recently, that modified thromboelastometric tests can reliably detect and differentiate dabigatran and rivaroxaban. However, whether all DOACs can be detected and differentiated to other coagulopathies is unclear. Therefore, we now tested the hypothesis that a decision tree-based thromboelastometry algorithm enables detection and differentiation of all direct Xa-inhibitors (DXaIs), the direct thrombin inhibitor (DTI) dabigatran, as well as vitamin K antagonists (VKA) and dilutional coagulopathy (DIL) with high accuracy. METHODS Following ethics committee approval (No 17-525-4), and registration by the German clinical trials database we conducted a prospective observational trial including 50 anticoagulated patients (n = 10 of either DOAC/VKA) and 20 healthy volunteers. Blood was drawn independent of last intake of coagulation inhibitor. Healthy volunteers served as controls and their blood was diluted to simulate a 50% dilution in vitro. Standard (extrinsic coagulation assay, fibrinogen assay, etc.) and modified thromboelastometric tests (ecarin assay and extrinsic coagulation assay with low tissue factor) were performed. Statistical analyzes included a decision tree analyzes, with depiction of accuracy, sensitivity and specificity, as well as receiver-operating-characteristics (ROC) curve analysis including optimal cut-off values (Youden-Index). RESULTS First, standard thromboelastometric tests allow a good differentiation between DOACs and VKA, DIL and controls, however they fail to differentiate DXaIs, DTIs and VKAs reliably resulting in an overall accuracy of 78%. Second, adding modified thromboelastometric tests, 9/10 DTI and 28/30 DXaI patients were detected, resulting in an overall accuracy of 94%. Complex decision trees even increased overall accuracy to 98%. ROC curve analyses confirm the decision-tree-based results showing high sensitivity and specificity for detection and differentiation of DTI, DXaIs, VKA, DIL, and controls. CONCLUSIONS Decision tree-based machine-learning algorithms using standard and modified thromboelastometric tests allow reliable detection of DTI and DXaIs, and differentiation to VKA, DIL and controls. TRIAL REGISTRATION Clinical trial number: German clinical trials database ID: DRKS00015704

An evaluation of a model for the systematic documentation of hospital based health promotion activities: results from a multicentre study

BACKGROUND: The first step of handling health promotion (HP) in Diagnosis Related Groups (DRGs) is a systematic documentation and registration of the activities in the medical records. So far the possibility and tradition for systematic registration of clinical HP activities in the medical records and in patient administrative systems have been sparse. Therefore, the activities are mostly invisible in the registers of hospital services as well as in budgets and balances.A simple model has been described to structure the registration of the HP procedures performed by the clinical staff. The model consists of two parts; first part includes motivational counselling (7 codes) and the second part comprehends intervention, rehabilitation and after treatment (8 codes).The objective was to evaluate in an international study the usefulness, applicability and sufficiency of a simple model for the systematic registration of clinical HP procedures in day life. METHODS: The multi centre project was carried out in 19 departments/hospitals in 6 countries in a clinical setup. The study consisted of three parts in accordance with the objectives.A: Individual test. 20 consecutive medical records from each participating department/hospital were coded by the (coding) specialists at local department/hospital, exclusively (n = 5,529 of 5,700 possible tests in total).B: Common test. 14 standardized medical records were coded by all the specialists from 17 departments/hospitals, who returned 3,046 of 3,570 tests.C: Specialist evaluation. The specialists from the 19 departments/hospitals evaluated if the codes were useful, applicable and sufficient for the registration in their own department/hospital (239 of 285). RESULTS: A: In 97 to 100% of the local patient pathways the specialists were able to evaluate if there was documentation of HP activities in the medical record to be coded.B: Inter rater reliability on the use of the codes were 93% (57 to 100%) and 71% (31 to 100%), respectively.C: The majority of the study participants found the codes to be useful (71%), applicable (92%) and sufficient (92%). CONCLUSION: Systematic registration of HP activities is relevant in clinical day life and the suggested codes proved to be applicable for international use. HP is an essential part of the clinical pathway or the value chain. This model promises to improve the documentation and thereby facilitate analysis of records for evidence based medicine as well as cost and policy analyses

Duurzaamheid teelt van suikerbieten voor covergisting; resultaten 2008-2010 van vijf telers in het project Energieboerderij

In deze IRS-publicatie staan de resultaten uit het project Energieboerderij met betrekking tot vijf telers, waar de suikerbietenteelt drie jaar lang is gevolgd. Alle teelthandelingen en inputs zijn meegenomen in de berekening van het energierendement en de broeikasgasemissiereductie. Aan de hand van deze twee duurzaamheidparameters is de keten suikerbieten en loof voor vergisting doorgerekend. Suikerbieten telen voor (co)vergisting tot groene stroom uit biogas voldoet aan de gestelde eisen voor duurzaamheid met een broeikasgasemissiereductie van gemiddeld 78%. De telers verschilden onderling niet op de twee duurzaamheidscriteria. De methaanopbrengst is sterk gecorreleerd aan de suikeropbrengst. Naast een efficiënte teelt is ook een efficiënte logistiek nodig. Afvoer van loof voor vergisting heeft een positieve bijdrage voor de duurzaamheid. Wel worden er dan aanzienlijke hoeveelheden nutriënten extra afgevoerd

Survey of whistler mode chorus intensity at Jupiter

Whistler mode chorus emission is important in the acceleration of electrons and filling of the radiation belts at Jupiter. In this work chorus magnetic intensity levels (frequency-integrated spectral density, PB) at Jupiter are comprehensively binned and parameterized. The frequency range of chorus under study extends from the lower hybrid frequency, flh, to fceq/2 and fceq/2 < f < 0.8 fceq, where fceq is the cyclotron frequency mapped to the magnetic equator. The goal is to obtain a quantized distribution of magnetic intensity for use in stochastic modeling efforts. Parametric fits of magnetic plasma wave intensity are obtained, including PB versus frequency, latitude, and L shell. The results indicate that Jupiter chorus occurrence probability and intensity are higher than those at Saturn, reaching values observed at Earth. Jovian chorus is observed over most local times, confined primarily to the range 8 < L < 15, outside the high densities of the Io torus. The largest intensity levels are seen on the dayside; however, the sampling of chorus on the nightside is much less than on the dayside. Peak intensities occur near the equator with a weak dependence on magnetic latitude, λ. We conclude that Jovian chorus average intensity levels are approximately an order of magnitude lower than those at Earth. In more isolated regions the intensities are comparable to those observed at Earth. The spatial range of the chorus emissions extends beyond that assumed in previous Jovian global diffusive models of wave-particle electron acceleration

Involvement of patients or their representatives in quality management functions in EU hospitals:implementation and impact on patient-centred care strategies

OBJECTIVE: The objective of this study was to describe the involvement of patients or their representatives in quality management (QM) functions and to assess associations between levels of involvement and the implementation of patient-centred care strategies. DESIGN: A cross-sectional, multilevel STUDY DESIGN: that surveyed quality managers and department heads and data from an organizational audit. SETTING: Randomly selected hospitals (n = 74) from seven European countries (The Czech Republic, France, Germany, Poland, Portugal, Spain and Turkey). PARTICIPANTS: Hospital quality managers (n = 74) and heads of clinical departments (n = 262) in charge of four patient pathways (acute myocardial infarction, stroke, hip fracture and deliveries) participated in the data collection between May 2011 and February 2012. MAIN OUTCOME MEASURES: Four items reflecting essential patient-centred care strategies based on an on-site hospital visit: (1) formal survey seeking views of patients and carers, (2) written policies on patients' rights, (3) patient information literature including guidelines and (4) fact sheets for post-discharge care. The main predictors were patient involvement in QM at the (i) hospital level and (ii) pathway level. RESULTS: Current levels of involving patients and their representatives in QM functions in European hospitals are low at hospital level (mean score 1.6 on a scale of 0 to 5, SD 0.7), but even lower at departmental level (mean 0.6, SD 0.7). We did not detect associations between levels of involving patients and their representatives in QM functions and the implementation of patient-centred care strategies; however, the smallest hospitals were more likely to have implemented patient-centred care strategies. CONCLUSIONS: There is insufficient evidence that involving patients and their representatives in QM leads to establishing or implementing strategies and procedures that facilitate patient-centred care; however, lack of evidence should not be interpreted as evidence of no effect

Managing COVID-19 within and across health systems:why we need performance intelligence to coordinate a global response

Background The COVID-19 pandemic is a complex global public health crisis presenting clinical, organisational and system-wide challenges. Different research perspectives on health are needed in order to manage and monitor this crisis. Performance intelligence is an approach that emphasises the need for different research perspectives in supporting health systems’ decision-makers to determine policies based on well-informed choices. In this paper, we present the viewpoint of the Innovative Training Network for Healthcare Performance Intelligence Professionals (HealthPros) on how performance intelligence can be used during and after the COVID-19 pandemic. Discussion A lack of standardised information, paired with limited discussion and alignment between countries contribute to uncertainty in decision-making in all countries. Consequently, a plethora of different non-data-driven and uncoordinated approaches to address the outbreak are noted worldwide. Comparative health system research is needed to help countries shape their response models in social care, public health, primary care, hospital care and long-term care through the different phases of the pandemic. There is a need in each phase to compare context-specific bundles of measures where the impact on health outcomes can be modelled using targeted data and advanced statistical methods. Performance intelligence can be pursued to compare data, construct indicators and identify optimal strategies. Embracing a system perspective will allow countries to take coordinated strategic decisions while mitigating the risk of system collapse.A framework for the development and implementation of performance intelligence has been outlined by the HealthPros Network and is of pertinence. Health systems need better and more timely data to govern through a pandemic-induced transition period where tensions between care needs, demand and capacity are exceptionally high worldwide. Health systems are challenged to ensure essential levels of healthcare towards all patients, including those who need routine assistance. Conclusion Performance intelligence plays an essential role as part of a broader public health strategy in guiding the decisions of health system actors on the implementation of contextualised measures to tackle COVID-19 or any future epidemic as well as their effect on the health system at large. This should be based on commonly agreed-upon standardised data and fit-for-purpose indicators, making optimal use of existing health information infrastructures. The HealthPros Network can make a meaningful contribution

Electron Density Distributions in Saturn's Ionosphere

This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License.Between 26 April and 15 September 2017, Cassini executed 23 highly inclined Grand Finale orbits through a new frontier for space exploration, the narrow region between Saturn and the D Ring, providing the first opportunity for obtaining in situ ionospheric measurements. During the Grand Finale orbits, the Radio and Plasma Wave Science instrument observed broadband whistler mode emissions and narrowband upper hybrid frequency emissions. Using known wave propagation characteristics of these two plasma wave modes, the electron density is derived over a broad range of ionospheric latitudes and altitudes. A two‐part exponential scale height model is fitted to the electron density measurements. The model yields a double‐layered ionosphere with plasma scale heights of 545/575 km for the northern/southern hemispheres below 4,500 km and plasma scale heights of 4,780/2,360 km for the northern/southern hemispheres above 4,500 km. The interpretation of these layers involves the interaction between the rings and the ionosphere

A robust and standardized method to isolate and expand mesenchymal stromal cells from human umbilical cord

Background aimsHuman umbilical cord–derived mesenchymal stromal cells (hUC-MSCs) are increasingly used in research and therapy. To obtain hUC-MSCs, a diversity of isolation and expansion methods are applied. Here, we report on a robust and standardized method for hUC-MSC isolation and expansion.MethodsUsing 90 hUC donors, we compared and optimized critical variables during each phase of the multi-step procedure involving UC collection, processing, MSC isolation, expansion and characterization. Furthermore, we assessed the effect of donor-to-donor variability regarding UC morphology and donor attributes on hUC-MSC characteristics.ResultsWe demonstrated robustness of our method across 90 UC donors at each step of the procedure. With our method, UCs can be collected up to 6 h after birth, and UC-processing can be initiated up to 48 h after collection without impacting on hUC-MSC characteristics. The removal of blood vessels before explant cultures improved hUC-MSC purity. Expansion in Minimum essential medium α supplemented with human platelet lysate increased reproducibility of the expansion rate and MSC characteristics as compared with Dulbecco's Modified Eagle's Medium supplemented with fetal bovine serum. The isolated hUC-MSCs showed a purity of ∼98.9%, a viability of >97% and a high proliferative capacity. Trilineage differentiation capacity of hUC-MSCs was reduced as compared with bone marrow-derived MSCs. Functional assays indicated that the hUC-MSCs were able to inhibit T-cell proliferation demonstrating their immune-modulatory capacity.ConclusionsWe present a robust and standardized method to isolate and expand hUC-MSCs, minimizing technical variability and thereby lay a foundation to advance reliability and comparability of results obtained from different donors and different studies.Molecular Epidemiolog