Exploration of alternative models to calculate wheather effects on nitrate concentration : Comparison of the models ONZAT, HYDRUS-1D and SWAP

Het Landelijk Meetnet effecten Mestbeleid (LMM) meet sinds 1992 de nitraatconcentraties in het bovenste grondwater om de effecten van overheidsbeleid op de concentraties in beeld te brengen. De hoogte van de gemeten nitraatconcentraties is afhankelijk van het weer, vooral van de hoeveelheid neerslag in de voorafgaande jaren. Na een aantal regenrijke jaren is de nitraatconcentratie door verdunning bijvoorbeeld meestal lager dan normaal. Het RIVM verwerkt deze weerseffecten in de meetresultaten, zodat de effecten van het beleid nauwkeuriger zichtbaar zijn. Dit wordt gedaan met een rekenmodel. SWAP-model geschikter voor indexcontratie Tot op heden gebruikt het RIVM voor de berekening van de indexconcentraties het zelf ontwikkelde model ONZAT, een model dat berekent in welke mate stoffen door de bodem naar en in het bovenste grondwater worden getransporteerd. ONZAT wordt echter niet meer verder ontwikkeld of onderhouden. Hierdoor ontstond de behoefte bij het RIVM om over te stappen op een algemener gebruikt model. Na vergelijking van enkele modellen komt het zogeheten SWAP-model (Soil, Water, Atmosphere and Plant) als het meest geschikt naar voren als vervanging voor ONZAT. De migratie van het ONZAT-model naar SWAP blijkt geen significant effect te hebben op de weerscorrectie van de nitraatmetingen, ondanks de verschillen tussen de modellen.The Minerals Policy Monitoring Programme (LMM) has measured the nitrate concentrations in the upper groundwater since 1992 in order to show the effects of the national minerals policies on concentrations. However, these nitrate concentrations are also subject to weather influences, especially the precipitation excess in previous years. After a couple of years with high precipitation excess the measured nitrate concentration usually is lower than normal due to dilution. RIVM accounts for these weather influences on measurement so that policy effects on trends in water quality become more distinct. This is done by using a hydrological process model. SWAP model more suitable for index concentration RIVM still uses the ONZAT model, developed by RIVM, for the calculations of the index concentration. However, ONZAT, a model to calculate transport of substances through the soil towards and through groundwater, is no longer updated or maintained. Therefore, RIVM considered it desirable to select and use another, more generally applied process model for the computation of index concentrations. The model comparisons showed that SWAP (Soil, Water, Atmosphere and Plant) was the most suitable successor for ONZAT to calculate index concentrations. The migration of the ONZAT model to SWAP does not have a significant effect on the weather corrections of the nitrate measurements, notwithstanding the differences between these models.Ministerie van I&

Effectiveness of Serious Gaming During the Multidisciplinary Rehabilitation of Patients With Complex Chronic Pain or Fatigue: Natural Quasi-Experiment

Background: Current evidence for the effectiveness of specialist multidisciplinary programs for burdensome chronic pain and functional somatic syndromes drives the effort to improve approaches, strategies, and delivery modes. It remains unknown to what extent and in what respect serious gaming during the regular outpatient rehabilitation can contribute to health outcomes.Objective: The objectives of our study were to determine the effect of additional serious gaming on (1) physical and emotional functioning in general; (2) particular outcome domains; and (3) patient global impressions of change, general health, and functioning and to determine (4) the dependency of serious gaming effects on adherence.Methods: We conducted a naturalistic quasi-experiment using embedded qualitative methods. The intervention group patients received an additional guided (mindfulness-based) serious gaming intervention during weeks 9-12 of a 16-week rehabilitation program at 2 sites of a Dutch rehabilitation clinic. Simultaneously, 119 control group patients followed the same program without serious gaming at 2 similar sites of the same clinic. Data consisted of 10 semistructured patient interviews and routinely collected patient self-reported outcomes. First, multivariate linear mixed modeling was used to simultaneously estimate a group effect on the outcome change between weeks 8 and 16 in 4 primary outcomes: current pain intensity, fatigue, pain catastrophizing, and psychological distress. Second, similar univariate linear mixed models were used to estimate effects on particular (unstandardized) outcomes. Third, secondary outcomes (ie, global impression of change, general health, functioning, and treatment satisfaction) were compared between the groups using independent t tests. Finally, subgroups were established according to the levels of adherence using log data. Influences of observed confounding factors were considered throughout analyses.Results: Of 329 eligible patients, 156 intervention group and 119 control group patients (N= 275) with mostly chronic back pain and concomitant psychosocial problems participated in this study. Of all, 119 patients played >= 75% of the game. First, the standardized means across the 4 primary outcomes showed a significantly more favorable degree of change during the second part of the treatment for the intervention group than for the control group (beta=-0.119, SE= 0.046, P=. 009). Second, the intervention group showed a greater outcome change in depressive mood (b=-2.748, SE= 1.072, P=. 011) but not in "insufficiency" or concentration problems. Third, no significant group effects on secondary outcomes were found. Fourth, adherence was generally high and invariant.Conclusions: The findings of this study suggest a very small favorable average effect on relevant health outcomes of additional serious gaming during multidisciplinary rehabilitation. The indication that serious gaming could be a relatively time-efficient component warrants further research into if, when, how, and for which patients serious gaming could be cost-effective in treatment and why

Process competences to incorporate in higher education curricula

This study reports on a survey on project managers' priorities. The survey used ISO 21500 as a scaffold to ask various respondents, like junior, experienced, and senior project managers, project sponsors, and students, to share their perceptions on the priorities for junior project managers. The respondent groups shared similar perceptions. Furthermore, project type and sector had little effect on junior project managers' priorities. Experienced and senior project managers shared their own priorities as well. The perceptions of priorities for junior, experienced, and senior project managers were mostly alike. However, experienced and senior project managers' priorities seemed slightly more affected by project type and sector. A session with experts in project management and teaching project management highlighted that the results for junior project managers could provide accents for introducing project management to students in higher education, provided the entire playing field of project management is also introduced.</p

Identifying potentially cost effective chronic care programs for people with COPD

Objective: To review published evidence regarding the cost effectiveness of multi-component COPD programs and to illustrate how potentially cost effective programs can be identified. Methods: Systematic search of Medline and Cochrane databases for evaluations of multicomponent disease management or chronic care programs for adults with COPD, describing process, intermediate, and end results of care. Data were independently extracted by two reviewers and descriptively summarized. Results: Twenty articles describing 17 unique COPD programs were included. There is little evidence for significant improvements in process and intermediate outcomes, except for increased provision of patient self-management education and improved disease-specific knowledge. Overall, the COPD programs generate end results equivalent to usual care, but programs containing ≥3 components show lower relative risks for hospitalization. There is limited scope for programs to break-even or save money. Conclusion: Identifying cost effective multi-component COPD programs remains a challenge due to scarce methodologically sound studies that demonstrate significant improvements on process, intermediate and end results of care. Estimations of potential cost effectiveness of specific programs illustrated in this paper can, in the absence of 'perfect data', support timely decision-making regarding these programs. Nevertheless, well-designed health economic studies are needed to decrease the current decision uncertainty

Care coordination in a business-to-business and a business-to-consumer model for telemonitoring patients with chronic diseases

__Introduction:__ For telemonitoring to support care coordination, a sound business model is conditional. The aim of this study is to explore the systemic and economic differences in care coordination via business-to-business and business-to-consumer models for telemonitoring patients with chronic diseases. __Methods:__ We performed a literature search in order to design the business-to-business and business-to-consumer telemonitoring models, and to assess the design elements and themes by applying the activity system theory, and describe the transaction costs in each model. The design elements are content, structure, and governance, while the design themes are novelty, lock-in, complementarities, and efficiency. In the transaction cost analysis, we looked into all the elements of a transaction in both models. __Results:__ Care coordination in the business-to-business model is designed to be organized between the places of activity, rather than the participants in the activity. The design of the business-to-business model creates a firm lock-in but for a limited time. In the business-to-consumer model, the interdependencies are to be found between the persons in the care process and not between the places of care. The differences between the models were found in both the design elements and the design themes. __Discussion:__ Care coordination in the business-to-business and business-to-consumer models for telemonitoring chronic diseases differs in principle in terms of design elements and design themes. Based on the theoretical models, the transaction costs could potentially be lower in the business-to-consumer model than in the business-to-business, which could be a promoting economic principle for the implementation of telemonitoring

Advancing current approaches to disease management evaluation:Capitalizing on heterogeneity to understand what works and for whom

BACKGROUND: Evaluating large-scale disease management interventions implemented in actual health care settings is a complex undertaking for which universally accepted methods do not exist. Fundamental issues, such as a lack of control patients and limited generalizability, hamper the use of the ‘gold-standard’ randomized controlled trial, while methodological shortcomings restrict the value of observational designs. Advancing methods for disease management evaluation in practice is pivotal to learn more about the impact of population-wide approaches. Methods must account for the presence of heterogeneity in effects, which necessitates a more granular assessment of outcomes. METHODS: This paper introduces multilevel regression methods as valuable techniques to evaluate ‘real-world’ disease management approaches in a manner that produces meaningful findings for everyday practice. In a worked example, these methods are applied to retrospectively gathered routine health care data covering a cohort of 105,056 diabetes patients who receive disease management for type 2 diabetes mellitus in the Netherlands. Multivariable, multilevel regression models are fitted to identify trends in clinical outcomes and correct for differences in characteristics of patients (age, disease duration, health status, diabetes complications, smoking status) and the intervention (measurement frequency and range, length of follow-up). RESULTS: After a median one year follow-up, the Dutch disease management approach was associated with small average improvements in systolic blood pressure and low-density lipoprotein, while a slight deterioration occurred in glycated hemoglobin. Differential findings suggest that patients with poorly controlled diabetes tend to benefit most from disease management in terms of improved clinical measures. Additionally, a greater measurement frequency was associated with better outcomes, while longer length of follow-up was accompanied by less positive results. CONCLUSIONS: Despite concerted efforts to adjust for potential sources of confounding and bias, there ultimately are limits to the validity and reliability of findings from uncontrolled research based on routine intervention data. While our findings are supported by previous randomized research in other settings, the trends in outcome measures presented here may have alternative explanations. Further practice-based research, perhaps using historical data to retrospectively construct a control group, is necessary to confirm results and learn more about the impact of population-wide disease management

A Fourth Party Energy Provider for the Construction Value Chain: Identifying Needs and Establishing Requirements

Today’s building and energy management market is heterogeneous and complex. Most of the players in the construction market are not in possession of the managerial capability to fully control the dynamics that affect their energy costs in terms of energy sourcing and energy management. Moreover, construction industry needs to rely on a stronger technical and commercial expertise. On one hand, there is a need of an in-depth and extensive level of technical know-how that most of facility managers, property developers and building owners at private and public level scarcely hold. On the other hand, this industry is characterized by a fragmentation within the single tiers of the value chain. In this context, the paper aims at proposing a new vision of the building value chain towards a collaborative network led by a new player, namely the Fourth Party Energy Provider, acting as the “one-stop contracting and managing” operator, integrating resources, capabilities, best available technologies and practices for providing energy-efficient building solutions

Towards an international taxonomy of integrated primary care: a Delphi consensus approach

Background Developing integrated service models in a primary care setting is considered an essential strategy for establishing a sustainable and affordable health care system. The Rainbow Model of Integrated Care (RMIC) describes the theoretical foundations of integrated primary care. The aim of this study is to refine the RMIC by developing a consensus-based taxonomy of key features. Methods First, the appropriateness of previously identified key features was retested by conducting an international Delphi study that was built on the results of a previous national Delphi study. Second, categorisation of the features among the RMIC integrated care domains was assessed in a second international Delphi study. Finally, a taxonomy was constructed by the researchers based on the results of the three Delphi studies. Results The final taxonomy consists of 21 key features distributed over eight integration domains which are organised into three main categories: scope (person-focused vs. population-based), type (clinical, professional, organisational and system) and enablers (functional vs. normative) of an integrated primary care service model. Conclusions The taxonomy provides a crucial differentiation that clarifies and supports implementation, policy formulation and research regarding the organisation of integrated primary care. Further research is needed to develop instruments based on the taxonomy that can reveal the realm of integrated primary care in practice

Serious gaming during multidisciplinary rehabilitation for patients with complex chronic pain or fatigue complaints: study protocol for a controlled trial and process evaluation

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