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Organizational interventions to implement improvements in patient care: a structured review of reviews
Michel Wensing, Hub Wollersheim, Richard Grol
Implementation Science , 2006, DOI: 10.1186/1748-5908-1-2
Abstract: To provide an overview of the research evidence on effects of organizational strategies to implement improvements in patient care.Structured review of published reviews of rigorous evaluations.Published reviews of studies on organizational interventions.Searches were conducted in two data-bases (Pubmed, Cochrane Library) and in selected journals. Reviews were included, if these were based on a systematic search, focused on rigorous evaluations of organizational changes, and were published between 1995 and 2003.Two investigators independently extracted information from the reviews regarding their clinical focus, methodological quality and main quantitative findings.A total of 36 reviews were included, but not all were high-quality reviews. The reviews were too heterogeneous for quantitative synthesis. None of the strategies produced consistent effects. Professional performance was generally improved by revision of professional roles and computer systems for knowledge management. Patient outcomes was generally improved by multidisciplinary teams, integrated care services, and computer systems. Cost savings were reported from integrated care services. The benefits of quality management remained uncertain.There is a growing evidence base of rigorous evaluations of organizational strategies, but the evidence underlying some strategies is limited and for no strategy can the effects be predicted with high certainty.Numerous studies have shown that at least 40% of the patients do not receive high-quality medical care [1]. So far, strategies to implement best evidence to improve clinical practice have been mainly targeted at improving the knowledge, attitudes and behaviors of healthcare workers [2]. Examples of these strategies are audit and feedback, reminder systems, educational meetings and educational outreach visits. These strategies appear to achieve a median of 10% absolute change of professional performance and no strategy is uniquely and consistently effective [3].
Medication reconciliation at hospital admission and discharge: insufficient knowledge, unclear task reallocation and lack of collaboration as major barriers to medication safety
Nelleke van Sluisveld, Marieke Zegers, Stephanie Natsch, Hub Wollersheim
BMC Health Services Research , 2012, DOI: 10.1186/1472-6963-12-170
Abstract: We performed face to face, semi-structured interviews with twenty health care professionals and managers from several departments at a 953 bed university hospital in the Netherlands and also from the surrounding community health services. The interviews were analysed using a combined theoretical framework of Grol and Cabana to classify the drivers and barriers identified.There is lack of awareness and insufficient knowledge of health care professionals about the health care problem and the bundle medication reconciliation. These result in a lack of support for implementing the bundle. In addition clinicians are reluctant to reallocate tasks to nurses or pharmacy technicians. Another major barrier is a lack of communication, understanding and collaboration between hospital and community caregivers. The introduction of more competitive market forces has made matters worse. Major drivers are a good implementation plan, patient awareness, and obligation by the government.We identified a wide range of barriers and drivers which health care professionals believe influence the implementation of medication reconciliation. This reflects the complexity of implementation. Implementation can be improved if these factors are adequately addressed. The feasibility and effectiveness of these strategies should be tested in controlled trails.
A retrospective cohort study on lifestyle habits of cardiovascular patients: how informative are medical records?
Annemarie J Fouwels, Sebastiaan JH Bredie, Hub Wollersheim, Gerard M Schippers
BMC Health Services Research , 2009, DOI: 10.1186/1472-6963-9-59
Abstract: For 209 patients information from medical records on lifestyle habits, physician feedback, and interventions in the past year was compared to data gathered in the last month by a self-report LSQ.Doctors register smoking habits most consistently (90.4%), followed by alcohol use (81.8%), physical activity (50.2%), and eating habits (27.3%). Compared to the LSQ, smoking, unhealthy alcohol use, physical activity, and unhealthy eating habits are underreported in medical records by 31, 83, 54 and 97%, respectively. Feedback, advice or referral was documented in 8% for smoking, 3% for alcohol use, 12% for physical activity, and 26% for eating habits.Lifestyle is insufficiently registered or recognized by doctors providing routine care in a cardiovascular outpatient setting. Of the unhealthy lifestyle habits that are registered, few are accompanied by notes on advice or intervention. A lifestyle questionnaire facilitates screening and interventions in target patients and should therefore be incorporated in the cardiovascular setting as a routine patient intake procedure.Cardiovascular and other non communicable diseases (NCD) account for most of the burden of ill health in Europe [1]. Most of these diseases are associated with common risk factors related to lifestyle habits like smoking, excessive alcohol use, unhealthy eating, and a insufficient physical activity that enhance the risk of developing cardiovascular diseases [2,3]. The WHO regional committee for Europe developed a comprehensive strategy for NCD that includes the active targeting of individuals at high risk and promotes disease prevention programmes[4]. In the Dutch adult general population about, 28% are smokers, 10% consume alcoholic beverages beyond health limits, only one third to one fifth eat fruit and vegetables as recommended, and 46% are overweight. [5]. Several studies in patients with elevated risk or manifest cardiovascular disease indicate favourable effects on cardiovascular risk profiles after a
Systematic care for caregivers of people with dementia in the ambulatory mental health service: designing a multicentre, cluster, randomized, controlled trial
Anouk Spijker, Frans Verhey, Maud Graff, Richard Grol, Eddy Adang, Hub Wollersheim, Myrra Vernooij-Dassen
BMC Geriatrics , 2009, DOI: 10.1186/1471-2318-9-21
Abstract: In our ongoing, cluster, randomized, single-blind, controlled trial, the participants in six mental health services in four regions of the Netherlands have been randomized per service. Professionals of the ambulatory mental health services (psychologists and social psychiatric nurses) have been randomly allocated to either the intervention group or the control group. The study population consists of community-dwelling people with dementia and their informal caregivers (patient-caregiver dyads) coming into the health service. The dyads have been clustered to the professionals. The primary outcome measure is the patient's admission to a nursing home or home for the elderly at 12 months of follow-up. This measure is the most important variable for estimating cost differences between the intervention group and the control group. The secondary outcome measure is the quality of the patient's and caregiver's lives.A novelty in the SCPD is the pro-active and systematic approach. The focus on the caregiver's sense of competence is relevant to economical healthcare, since this sense of competence is an important determinant of delay of institutionalization of people with dementia. The SCPD might be able to facilitate this with a relatively small cost investment for caregivers' support, which could result in a major decrease in costs in the management of dementia. Implementation on a national level will be started if the SCPD proves to be efficient.NCT00147693Estimates state that the rapidly aging western European population will peak at about 2040 [1]. An aging population demands more healthcare and challenges the healthcare budget. Two-thirds of the people with dementia (also referred to as "patients" in this study protocol) are cared for at home [2]. Care at home is often intensive and burdensome. Informal caregivers of these patients carry a greater burden than informal caregivers of other chronically ill people [3], and they are at a greater risk of depression [4-6]. The
Evaluation of physicians' professional performance: An iterative development and validation study of multisource feedback instruments
Karlijn Overeem, Hub C Wollersheim, Onyebuchi A Arah, Juliette K Cruijsberg, Richard PTM Grol, Kiki MJMH Lombarts
BMC Health Services Research , 2012, DOI: 10.1186/1472-6963-12-80
Abstract: This observational validation study of three instruments underlying multisource feedback (MSF) was set in 26 non-academic hospitals in the Netherlands. In total, 146 hospital-based physicians took part in the study. Each physician's professional performance was assessed by peers (physician colleagues), co-workers (including nurses, secretary assistants and other healthcare professionals) and patients. Physicians also completed a self-evaluation. Ratings of 864 peers, 894 co-workers and 1960 patients on MSF were available. We used principal components analysis and methods of classical test theory to evaluate the factor structure, reliability and validity of instruments. We used Pearson's correlation coefficient and linear mixed models to address other objectives.The peer, co-worker and patient instruments respectively had six factors, three factors and one factor with high internal consistencies (Cronbach's alpha 0.95 - 0.96). It appeared that only 2 percent of variance in the mean ratings could be attributed to biasing factors. Self-ratings were not correlated with peer, co-worker or patient ratings. However, ratings of peers, co-workers and patients were correlated. Five peer evaluations, five co-worker evaluations and 11 patient evaluations are required to achieve reliable results (reliability coefficient ≥ 0.70).The study demonstrated that the three MSF instruments produced reliable and valid data for evaluating physicians' professional performance in the Netherlands. Scores from peers, co-workers and patients were not correlated with self-evaluations. Future research should examine improvement of performance when using MSF.In view of demands for high quality care, many health care systems aim to assess physicians' professional performance. As the ability to self-assess has shown to be limited, there is a need for external assessments [1]. Reliable, valid, feasible and effective measures of performance are vital to support these efforts. Since 1993, multisource f
Factors predicting doctors’ reporting of performance change in response to multisource feedback
Karlijn Overeem, Hub C Wollersheim, Onyebuchi A Arah, Juliette K Cruijsberg, Richard PTM Grol, Kiki MJMH Lombarts
BMC Medical Education , 2012, DOI: 10.1186/1472-6920-12-52
Abstract: This observational study was set in 26 non-academic hospitals in the Netherlands. In total, 458 specialists participated in the MSF program. Besides the collation of questionnaires, the Dutch MSF program is composed of a reflective portfolio and a facilitative interview aimed at increasing the acceptance and use of MSF. All specialists who finished a MSF procedure between May 2008 and September 2010 were invited to complete an evaluation form. The dependent variable was self-reported change. Three categories of independent variables (personal characteristics, experiences with the assessments and mean MSF ratings) were included in the analysis. Multivariate regression analysis techniques were used to identify the relation between the independent variables and specialists’ reported change in actual practice.In total, 238 medical specialists (response rate 52 percent) returned an evaluation form and participated in the study. A small majority (55 percent) of specialists reported to have changed their professional performance in one or more aspects in response to MSF. Regression analyses revealed that two variables had the most effect on reported change. Perceived quality of mentoring positively influenced reported change (regression coefficient beta?=?0.527, p?<?0.05) as did negative scores offered by colleagues. (regression coefficient beta?=??0.157, p?<?0.05). The explained variance of these two variables combined was 34 percent.Perceived quality of mentoring and MSF ratings from colleagues seem to be the main motivators for the self-reported change in response to MSF by specialists. These insights could leverage in increasing the use of MSF for practice change by investing in the quality of mentors.
Qu’est-ce que l’actualité politique ? Pour une analyse de la hiérarchisation de l’information. Regards croisés sur les Unes de la presse quotidienne fran aise et allemande
Nicolas Hubé
Trajectoires , 2009,
Abstract: S’intéresser aux Unes permet de comprendre les représentations de ce qui importe dans une société et son énonciation. Les Unes sont à considérer comme des lieux de production d’une hiérarchie d’une importance politique : l’actualité.En tant qu’objet d’analyse, la Une est un objet dual : chargée d’apporter une information hiérarchisée au lecteur et, en même temps, investie d’une fonction commerciale d’attraction. Chaque entreprise de presse, suivant sa structure économique et l...
Biogeography of Tick-Borne Bhanja Virus (Bunyaviridae) in Europe
Zdenek Hubálek
Interdisciplinary Perspectives on Infectious Diseases , 2009, DOI: 10.1155/2009/372691
Abstract: Bhanja virus (BHAV) is pathogenic for young domestic ruminants and also for humans, causing fever and affections of the central nervous system. This generally neglected arbovirus of the family Bunyaviridae is transmitted by metastriate ticks of the genera Haemaphysalis, Dermacentor, Hyalomma, Rhipicephalus, Boophilus, and Amblyomma. Geographic distribution of BHAV covers southern and Central Asia, Africa, and southern (partially also central) Europe. Comparative biogeographic study of eight known natural foci of BHAV infections in Europe (in Italy, Croatia, Bulgaria, Slovakia) has revealed their common features. (1) submediterranean climatic pattern with dry growing season and wet mild winter (or microlimatically similar conditions, e.g., limestone karst areas in central Europe), (2) xerothermic woodland-grassland ecosystem, with plant alliances Quercetalia pubescentis, Festucetalia valesiacae, and Brometalia erecti, involving pastoral areas, (3) presence of at least one of the tick species Haemaphysalis punctata, Dermacentor marginatus, Rhipicephalus bursa, and/or Hyalomma marginatum, and (4) presence of ≥60% of the 180 BHAV bioindicator (157 plant, 4 ixodid tick, and 19 vertebrate spp.). On that basis, Greece, France (southern, including Corsica), Albania, Spain, Hungary, European Turkey, Ukraine (southern), Switzerland (southern), Austria (southeastern), Germany (southern), Moldova, and European Russia (southern) have been predicted as additional European regions where BHAV might occur.
Prediction of Dragon's Blood Tree (Dracaena Cinnabari Balf.) Stand Sample Density on Soqotra Island
Irena Hubálková
Journal of Landscape Ecology , 2011, DOI: 10.2478/v10285-012-0035-y
Abstract: Dracaena cinnabari Balf. On The Soqotra Island is a spectacural relict of the Tethys tropical forest. This unique endemic plant, producing medicinally valuable sap, used to cover larger areas in the past. Natural regeneration of this species is restricted to inaccessible localities with steep slopes. All seedlings are threatened by goats grazing. Age structure of Dracaena populations indicates maturity and overmaturity depending on browsing. The objective of this work is to predict growing dynamics of Dragon's Blood Trees in permanent sample plot at Firmihin, where there is the largest existing stand of Dracaena species. The prediction and visualization of variation in abundance of trees over 100 years is based on direct field measurements supported by mathematical calculations. The study presents options in forest regeneration and identifies threats that might occur during the implementation.
Cryptographically Blinded Games: Leveraging Players' Limitations for Equilibria and Profit
Pavel Hubá?ek,Sunoo Park
Computer Science , 2014,
Abstract: In this work we apply methods from cryptography to enable any number of mutually distrusting players to implement broad classes of mediated equilibria of strategic games without the need for trusted mediation. Our implementation makes use of a (standard) pre-play "cheap talk" phase, in which players engage in free and non-binding communication prior to playing in the original game. In our cheap talk phase, the players execute a secure multi-party computation protocol to sample an action profile from an equilibrium of a "cryptographically blinded" version of the original game, in which actions are encrypted. The essence of our approach is to exploit the power of encryption to selectively restrict the information available to players about sampled action profiles, such that these desirable equilibria can be stably achieved. In contrast to previous applications of cryptography to game theory, this work is the first to employ the paradigm of using encryption to allow players to benefit from hiding information \emph{from themselves}, rather than from others; and we stress that rational players would \emph{choose} to hide the information from themselves.
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