Effect of waiting time on health outcomes and service utilization : A prospective randomized study on patients admitted to hospital for hip or knee replacement

Although the principle of equal access to medically justified treatment has been promoted by official health policies in many Western health care systems, practices do not completely meet policy targets. Waiting times for elective surgery vary between patient groups and regions, and growing problems in the availability of services threaten equal access to treatment. Waiting times have come to the attention of decision-makers, and several policy initiatives have been introduced to ensure the availability of care within a reasonable time. In Finland, for example, the treatment guarantee came into force in 2005. However, no consensus exists on optimal waiting time for different patient groups. The purpose of this multi-centre randomized controlled trial was to analyse health-related quality of life, pain and physical function in total hip or knee replacement patients during the waiting time and to evaluate whether the waiting time is associated with patients health outcomes at admission. This study also assessed whether the length of waiting time is associated with social and health services utilization in patients awaiting total hip or knee replacement. In addition, patients health-related quality of life was compared with that of the general population. Consecutive patients with a need for a primary total hip or knee replacement due to osteoarthritis were placed on the waiting list between August 2002 and November 2003. Patients were randomly assigned to a short waiting time (maximum 3 months) or a non-fixed waiting time (waiting time not fixed in advance, instead the patient followed the hospitals routine practice). Patients health-related quality of life was measured upon being placed on the waiting list and again at hospital admission using the generic 15D instrument. Pain and physical function were evaluated using the self-report Harris Hip Score for hip patients and a scale modified from the Knee Society Clinical Rating System for knee patients. Utilization measures were the use of home health care, rehabilitation and social services, physician visits and inpatient care. Health and social services use was low in both waiting time groups. The most common services used while waiting were rehabilitation services and informal care, including unpaid care provided by relatives, neighbours and volunteers. Although patients suffered from clear restrictions in usual activities and physical functioning, they seemed primarily to lean on informal care and personal networks instead of professional care. While longer waiting time did not result in poorer health-related quality of life at admission and use of services during the waiting time was similar to that at the time of placement on the list, there is likely to be higher costs of waiting by people who wait longer simply because they are using services for a longer period. In economic terms, this would represent a negative impact of waiting. Only a few reports have been published of the health-related quality of life of patients awaiting total hip or knee replacement. These findings demonstrate that, in addition to physical dimensions of health, patients suffered from restrictions in psychological well-being such as depression, distress and reduced vitality. This raises the question of how to support patients who suffer from psychological distress during the waiting time and how to develop strategies to improve patients initiatives to reduce symptoms and the burden of waiting. Key words: waiting time, total hip replacement, total knee replacement, health-related quality of life, randomized controlled trial, outcome assessment, social service, utilization of health services

Service-based Requirements for Future Mobile Networks

The mobile phone has, as a device, taken the world by storm in the past decade; from only 136 million phones globally in 1996, it is now estimated that by the end of 2008 roughly half of the worlds population will own a mobile phone. Over the years, the capabilities of the phones as well as the networks have increased tremendously, reaching the point where the devices are better called miniature computers rather than simply mobile phones. The mobile industry is currently undertaking several initiatives of developing new generations of mobile network technologies; technologies that to a large extent focus at offering ever-increasing data rates. This thesis seeks to answer the question of whether the future mobile networks in development and the future mobile services are in sync; taking a forward-looking timeframe of five to eight years into the future, will there be services that will need the high-performance new networks being planned? The question is seen to be especially pertinent in light of slower-than-expected takeoff of 3G data services. Current and future mobile services are analyzed from two viewpoints; first, looking at the gradual, evolutionary development of the services and second, through seeking to identify potential revolutionary new mobile services. With information on both current and future mobile networks as well as services, a network capability - service requirements mapping is performed to identify which services will work in which networks. Based on the analysis, it is far from certain whether the new mobile networks, especially those planned for deployment after HSPA, will be needed as soon as they are being currently roadmapped. The true service-based demand for the "beyond HSPA" technologies may be many years into the future - or, indeed, may never materialize thanks to the increasing deployment of local area wireless broadband technologies.

A Floor Control Server in a Distributed Conference Service

The conferencing systems in IP Multimedia (IM) networks are going through restructuring, accomplished in the near future. One of the changes introduced is the concept of floors and floor control in its current form with matching entity roles. The Binary Floor Control Protocol (BFCP) is a novelty to be exploited in distributed tightly coupled conferencing services. The protocol defines the floor control server (FCS), which implements floor control giving access to shared resources. As the newest tendency is to distribute the conferencing services, the locations of different functionality units play an important role in developing the standards. The floor control server location is not yet single-mindedly fixed in different standardization bodies, and the debate goes on where to place it within the media server, providing the conferencing service. The thesis main objective is to evaluate two distinctive alternatives in respect the Mp interface protocol between the respective nodes, as the interface in relation to floor control is under standardization work at the moment. The thesis gives a straightforward preamble in IMS network, nodes of interest including floor control server and conferencing. Knowledge on several protocols – BFCP, SDP, SIP and H.248 provides an important background for understanding the functionality changes introduced in the Mp interface and therefore introductions on those protocols and how they are connected to the full picture is given. The actual analysis on the impact of the floor control server into the Mp reference point is concluded in relation to the locations, giving basic flows, requirements analysis including a limited implementation proposal on supporting protocol parameters. The overall conclusion of the thesis is that even if both choices are seemingly useful, not one of the locations is clearly the most suitable in the light of this work. The thesis suggests a solution having both possibilities available to be chosen from in separate circumstances, realized with consistent standardization. It is evident, that if the preliminary assumption for the analysis is kept regarding to only one right place for the floor control server, more work is to be done in connected areas to discover the one most appropriate location.

Service Composition on a Mobile Phone

With the recent increase in interest in service-oriented architectures (SOA) and Web services, developing applications with the Web services paradigm has become feasible. Web services are self-describing, platform-independent computational elements. New applications can be assembled from a set of previously created Web services, which are composed together to make a service that uses its components to perform a certain task. This is the idea of service composition. To bring service composition to a mobile phone, I have created Interactive Service Composer for mobile phones. With Interactive Service Composer, the user is able to build service compositions on his mobile phone, consisting of Web services or services that are available from the mobile phone itself. The service compositions are reusable and can be saved in the phone's memory. Previously saved compositions can also be used in new compositions. While developing applications for mobile phones has been possible for some time, the usability of the solutions is not the same as when developing for desktop computers. When developing for mobile phones, the developer has to more carefully consider the decisions he is going to make with the program he is developing. With the lack of processing power and memory, the applications cannot function as well as on desktop PCs. On the other hand, this does not remove the appeal of developing applications for mobile devices.

Clustering Users of Online Content Service

Online content services can greatly benefit from personalisation features that enable delivery of content that is suited to each user's specific interests. This thesis presents a system that applies text analysis and user modeling techniques in an online news service for the purpose of personalisation and user interest analysis. The system creates a detailed thematic profile for each content item and observes user's actions towards content items to learn user's preferences. A handcrafted taxonomy of concepts, or ontology, is used in profile formation to extract relevant concepts from the text. User preference learning is automatic and there is no need for explicit preference settings or ratings from the user. Learned user profiles are segmented into interest groups using clustering techniques with the objective of providing a source of information for the service provider. Some theoretical background for chosen techniques is presented while the main focus is in finding practical solutions to some of the current information needs, which are not optimally served with traditional techniques.

An XML Messaging Service for Mobile Devices

In recent years, XML has been accepted as the format of messages for several applications. Prominent examples include SOAP for Web services, XMPP for instant messaging, and RSS and Atom for content syndication. This XML usage is understandable, as the format itself is a well-accepted standard for structured data, and it has excellent support for many popular programming languages, so inventing an application-specific format no longer seems worth the effort. Simultaneously with this XML's rise to prominence there has been an upsurge in the number and capabilities of various mobile devices. These devices are connected through various wireless technologies to larger networks, and a goal of current research is to integrate them seamlessly into these networks. These two developments seem to be at odds with each other. XML as a fully text-based format takes up more processing power and network bandwidth than binary formats would, whereas the battery-powered nature of mobile devices dictates that energy, both in processing and transmitting, be utilized efficiently. This thesis presents the work we have performed to reconcile these two worlds. We present a message transfer service that we have developed to address what we have identified as the three key issues: XML processing at the application level, a more efficient XML serialization format, and the protocol used to transfer messages. Our presentation includes both a high-level architectural view of the whole message transfer service, as well as detailed descriptions of the three new components. These components consist of an API, and an associated data model, for XML processing designed for messaging applications, a binary serialization format for the data model of the API, and a message transfer protocol providing two-way messaging capability with support for client mobility. We also present relevant performance measurements for the service and its components. As a result of this work, we do not consider XML to be inherently incompatible with mobile devices. As the fixed networking world moves toward XML for interoperable data representation, so should the wireless world also do to provide a better-integrated networking infrastructure. However, the problems that XML adoption has touch all of the higher layers of application programming, so instead of concentrating simply on the serialization format we conclude that improvements need to be made in an integrated fashion in all of these layers.

Viimeinen matka : Toimintatutkimus kirkollisen hautauskentän professiostruktuurista

This study is a qualitative examination of the professional structure of the ecclesias-tical funeral field. The research material is based on 13 funeral cases in the archdio-cese. The researcher participated in all the funerals and memorial events, interviewed the closest survivors, the officials of the funeral agency and the ecclesiastical actors. The material was collected by means of observation and recording of the interviews, and was later transcribed and analyzed. The actors in this study are the survivors, the funeral agencies and the church. The survivors act as the buyers and users of the products (funeral services) who require both the funeral agencies and the church to assist them with the problems that the death has caused. The numbers of actions related to the death and to the funerals - the rituals of death - are placed on the action field, which in this study is called the funeral field. In this field, the researchquestion focused space and power, and the actions on the funeral field are highly ritualized. The theoretical model comes from Pierre Bourdieu. The study showed an action structure on the funeral field in which the survivors first contacted a funeral agency, which then contacted the other actors of the field, re-served the date and place for the funeral, and organised the funeral arrangements. The funeral agencies arranged an opportunity for the survivors to have a last look at the deceased when he or she was placed in the coffin, and they held a moment of the prayer (if desired) before removing the deceased from the hospital's chapel. The sur-vivors contacted the pastor of the funeral much later. The pastor also participated in the memorial event. The survivors contacted the church musician through via pastor. In some cases, the survivors had neither met nor even seen the musician prior to the actual funeral service. Still, the music was of great importance to the survivors. In the research interviews, tensions emerged to some extent between the funeral agencies and the ecclesiastical actors; these actors attempted to resolve these tensions through organising negotiations. In the beginning of the 20th century, the family took an active part in the preparations of the deceased and in the arrangements of the funerals, whereas this study showed that these days, survivors often transfer the preparations to the funeral agencies. The professional side of the funeral field has grown. The funeral agencies can be seen as providers of full services that act on the survivors' behalf, aspiring to high individu-ality and aiming to fulfil the survivors' wishes. In practise, the role of the church in carrying out the last journey was reduced in the research cases to the actual funeral. In several cases, the pastor or the cantor of the funeral had never before seen the per-son in the coffin at any stage of life or death. The proportion of cremations in funeral cases has increased rapidly, however, special issues related to these cremations (such as the possibility of holding a funeral service for the already cremated deceased) have seen little consideration in the church. In the church's liturgies on funeral rites, cremation is frequently overlooked. The pastors or the cantors did not participate in either the burial of the funeral urn or in the scattering of the deceased's ashes. The verger took care of it. The parishes had no adopted standard practices for cremations, yet in each case for the survivors that moment was crucial.

Dental Service Utilization, Dental Health Production and Equity in Dental Care: the Finnish Experience

This thesis is grounded on four articles. Article I generally examines the factors affecting dental service utilization. Article II studies the factors associated with sector-specific utilization among young adults entitled to age-based subsidized dental care. Article III explores the determinants of dental ill-health as measured by the occurrence of caries and the relationship between dental ill-health and dental care use. Article IV measures and explains income-related inequality in utilization. Data employed were from the 1996 Finnish Health Care Survey (I, II, IV) and the 1997 follow-up study included in the longitudinal study of the Northern Finland 1966 Birth Cohort (III). Utilization is considered as a multi-stage decision-making process and measured as the number of visits to the dentist. Modified count data models and concentration and horizontal equity indices were applied. Dentist s recall appeared very efficient at stimulating individuals to seek care. Dental pain, recall, and the low number of missing teeth positively affected utilization. Public subvention for dental care did not seem to statistically increase utilization. Among young adults, a perception of insufficient public service availability and recall were positively associated with the choice of a private dentist, whereas income and dentist density were positively associated with the number of visits to private dentists. Among cohort females, factors increasing caries were body mass index and intake of alcohol, sugar, and soft drinks and those reducing caries were birth weight and adolescent school achievement. Among cohort males, caries was positively related to the metropolitan residence and negatively related to healthy diet and education. Smoking increased caries, whereas regular teeth brushing, regular dental attendance and dental care use decreased caries. We found equity in young adults utilization but pro-rich inequity in the total number of visits to all dentists and in the probability of visiting a dentist for the whole sample. We observed inequity in the total number of visits to the dentist and in the probability of visiting a dentist, being pro-poor for public care but pro-rich for private care. The findings suggest that to enhance equal access to and use of dental care across population and income groups, attention should focus on supply factors and incentives to encourage people to contact dentists more often. Lowering co-payments and service fees and improving public availability would likely increase service use in both sectors. To attain favorable oral health, appropriate policies aimed at improving dental health education and reducing the detrimental effects of common risk factors on dental health should be strengthened. Providing equal access with respect to need for all people ought to take account of the segmentation of the service system, with its two parallel delivery systems and different supplier incentives to patients and dentists.

Större frihet - bättre lokalt anpassad service? : Förvaltningsreformer och kommunernas service för utvecklingsstörda 1994-2000

In the beginning of the 1990s the legislation regarding the municipalities and the system of central government transfers were reformed in Finland. This resulted in a move from detailed governmental control to increased municipal autonomy. The purpose of this decentralization was to enable the municipalities to better adapt their administration and service supply to local needs. The aim of this study was to explore the effects of the increased municipal autonomy on the organization of services for people with intellectual disabilities. Did the increased autonomy cause the municipalities to alter their service supply and production and did the services become more adapted to local needs? The data consists of statistical information on service use and production, and also of background data such as demographics, economics and political elections on 452 municipalities in Finland from the years 1994 and 2000. The methods used are cluster analysis, discriminant analysis and factor analysis. The municipalities could be grouped in two categories: those which offered mainly one kind of residential services and others which had more varied mixes of services. The use of institutional care had decreased and municipalities which used institutional care as their primary form of service were mostly very small municipalities in 2000. The situation had changed from 1994, when institutional care was the primary service for municipalities of all sizes. Also the service production had become more differentiated and the municipalities had started using more varied ways of production. More municipalities had started producing their own services and private production had increased as well. Furthermore, the increase in local autonomy had opened up possibilities for local politics to influence both the service selection and methods of production. The most significant motive for changes in the service structure was high unemployment and an increasing share of elderly people in the population, particularly in sparsely populated areas. Municipalities with a low level of resources had made more changes in their service organization while those with more resources had been able to carry on as before. Key words: service structure, service for people with intellectual disabilities, municipalities, contingency theory, New Public Management

Sinusta kiinni : Tutkimus puolisohoivan arjen toimijuuksista

Depending on you – A study of spousal care, everyday life and agency The present aim of the aging policy is to promote old peoples´ possibilities to live at their own home. It is also many elderly couples´ own wish. At home a persons spouse is the most natural care giver, if she or he is able to give care. Spousal care means living together, giving and receiving care and interdependency between the spouses. The aim of the policy is to support spousal care by paying financial support to a carer and arrang-ing formal home care services. The purpose of this research is to study the agency of care giving and receiving spouses as care givers and receivers and also as home care service users. The data of the study consist of the interviews of 21 elderly couples. Both spouses were interviewed seper-ately, with the exception of five couples who were interviewed together. In these inter-views a care receiver had difficulties in communicating by speaking and a spouse was her or his interpreter. The study is based on a social constructionistic and a discourse analytical view of con-struction of meanings in human communication. Talking is a social action: people achieve identities, realities, social order and social relationship through talking. In inter-pretating the spouses agency I have used of Harvey Sack´s method of Membership Categorization Device (MCD). The spouses construct social categories which made the meaning of their agency visible. Care changes the routines and actions of everyday life. The couples have to negotiate their duties and rights between each other. Care giving and receiving are both physical and emotional actions. In the end it becomes a part of the couples´ normal life. The pur-pose of couples´ action is to live together as long as possible. They want to strengthen both their own agency and their spouses´ agency. The living together depends on both of them. The spouses decided together what home care services they would like to use and on which conditions they have to use services. Spouses have different kind of agencies as service users which describe their relationship and confidency on formal home care support and services. Services must support the elderly couples´ shared life at home. They cannot be against the conditions on the spousal care. When you want to arrange services to elderly care giving and receiving couples, you have to consider their own wishes and the meanings of their own relationship and shared life.