Continuity of care and readmission in two service systems: a comparative Victorian and Groningen case-register study

Objective: We compared service consumption, continuity of care and risk of readmission in a record linkage follow-up study of cohorts of patients with schizophrenia and related disorders in Victoria (Australia) and in Groningen (The Netherlands). These areas are interesting to compare because mental health care is in a different stage of deiustitutionalization. More beds are available in Groningen and more community resources are available in Victoria. Method: The cohorts were followed for 4 years, since discharge from inpatient services using record linkage data available in the psychiatric case-registers in both areas. Survival analysis was used to study continuity of care and risk of readmission. Results: Available indicators showed a higher level of continuity of care in Victoria. While the relative risk of readmission was the same in both areas and not affected by aftercare contact after discharge, the number of days spent in hospital was much higher in the Groningen register area. Conclusion: These findings provide further support for earlier reports that the risk of readmission is predominantly affected by attributes of mental illness. However, the duration of admissions, is strongly affected by service system variables, including the provision of continuity of care.

Substance misuse in patients with schizophrenia: epidemiology and management

Substance misuse in individuals with schizophrenia is very common, especially in young men, in communities where use is frequent and in people receiving inpatient treatment. Problematic use occurs at very low intake levels, so that most affected people are not physically dependent (with the exception of nicotine). People with schizophrenia and substance misuse have poorer symptomatic and functional outcomes than those with schizophrenia alone. Unless there is routine screening, substance misuse is often missed in assessments. Service systems tend to be separated, with poor inter-communication, and affected patients are often excluded from services because of their comorbidity. However, effective management of these disorders requires a fully integrated approach because of the close inter-relationship of the disorders. Use of atypical antipsychotics may be especially important in this population because of growing evidence (especially on clozapine and risperidone) that nicotine smoking, alcohol misuse and possibly some other substance misuse is reduced. Several pharmacotherapies for substance misuse can be used safely in people with schizophrenia, but the evidence base is small and guidelines for their use are necessarily derived from experience in the general population.

Public and private psychiatry: Can they work together and is it worth the effort?

Objective: Partnerships in mental health care, particularly between public and private psychiatric services, are being increasingly recognized as important for optimizing patient management and the efficient organization of services. However, public sector mental health services and private psychiatrists do not always work well together and there seem to be a number of barriers to effective collaboration. This study set out to investigate the extent of collaborative 'shared care' arrangements between a public mental health service and private psychiatrists practising nearby. It also examined possible barriers to collaboration and some possible solutions to the identified problems. Method: A questionnaire examining the above factors was sent to all public sector mental health clinicians and all private psychiatrists in the area. Results: One hundred and five of the 154 (68.2%) public sector clinicians and 103 of the 194 (53.1%) private psychiatrists returned surveys. The main barriers to successful collaboration identified by members of both sectors were: 'Difficulty communicating' endorsed by 71.4% of public clinicians and 72% of private psychiatrists, 'Confusion of roles and responsibilities' endorsed by 62.9% and 66%, respectively, and 'Different treatment approach' by 47.6% and 45.6%, respectively. Over 60% of private psychiatrists identified problems with access to the public system as a barrier to successful shared care arrangements. It also emerged, as hypothesized, that the public and private systems tend to manage different patient populations and that public clinicians in particular are not fully aware of the private psychiatrists' range of expertise. This would result in fewer referrals for shared care across the sectors. Conclusions: A number of barriers to public sector clinicians and private psychiatrists collaborating in shared care arrangements were identified. The two groups surveyed identified similar barriers. Some of these can potentially be addressed by changes to service systems. Others require cultural shifts in both sectors. Improved communications including more opportunities for formal and informal meetings between people working in the two sectors would be likely to improve the understanding of the complementary sector's perspective and practice. Further changes would be expected to require careful work between the sectors on training, employment and practice protocols and initiatives, to allow better use of the existing services and resources.

The promotion and disruption of community service delivery systems

In this paper, we report data drawn from a larger project on the functioning of the Queensland community service delivery system, particularly that providing services to people with disabilities. Our reasoning for focusing at this level is that, from the service user's perspective, support is derived from the service delivery system, not just individual service providers. Defining the service delivery system as formal services and informal support networks, we undertook interviews and focus groups with service providers in six areas in Queensland: inner urban, outer urban, rural and remote. The period on which we report is one in which considerable reform activity had been undertaken by funding bodies of the Commonwealth and State governments. We report on those factors we identified which promote the integrated functioning of the service delivery system, as well as those factors that disrupt it. We conclude with a brief evaluative analysis of the current status of the system.

A probabilistic analysis of Clostridium perfringens growth during food service operations

The purpose of this study was threefold: first, the study was designed to illustrate the use of data and information collected in food safety surveys in a quantitative risk assessment. In this case, the focus was on the food service industry; however, similar data from other parts of the food chain could be similarly incorporated. The second objective was to quantitatively describe and better understand the role that the food service industry plays in the safety of food. The third objective was to illustrate the additional decision-making information that is available when uncertainty and variability are incorporated into the modelling of systems. (C) 2002 Elsevier Science B.V. All rights reserved.

Ubiquitous travel service delivery

Free independent travelers require flexible, reactive service delivery due to their regularly changing location and activities and the lack of a wired Internet connection. A ubiquitous travel service delivery system that is able to dynamically deliver services in response to relevant events, such as changing location, availability of new last-minute specials, work opportunities, and safety issues can provide added value while retaining the flexibility that is so important to independent travelers. This article describes such a system. An engineering design research approach has been adopted to design the system. Issues addressed include traveler and service states and events, contexts, situations, and situation-action rules. An architecture is proposed that is based on distributed, cooperating software agents and mobile data technologies. The role of these agents is to continuously monitor situations that are occurring in the physical and virtual service spaces and to take the required action for any situations that are relevant to the traveler.

Improving supportive care for women with breast cancer in Australia: The challenge of modifying health systems

Although the benefits of many psychosocial support strategies in improving well being in women with breast cancer have been demonstrated, few women receive these programs as part of routine care. This paper provides some recommendations, based on experience in Australia, about how access to evidence-based supportive care strategies might be improved through modification of health systems. It demonstrates the paucity of research about the costs and health service implications of psychosocial support strategies, which is vital to health planning and service delivery change. It outlines the systematic approach taken in Australia to improving psychosocial support nationally by: the development of research reviews; preparation of guidelines about supportive care, implementation of programs to foster the adoption of guidelines through modification of policy, health service delivery and clinician training; and monitoring programs. Coalitions of government, health care professionals and consumers are key to effective lobbying for change. If all women with breast cancer are to receive better supportive care, there is a need for approaches which: refocus the research effort in psycho-oncology; develop more strategic approaches to generating change in health systems and health policy and foster partnerships to advocate for improved resources. Copyright (C) 2003 John Wiley Sons, Ltd.

Third sector in transition - A question of sustainability for community service organizations and the sector?

Third sector organizations are transitioning towards entrepreneurial and managerial models as a result of quasi-market strategies. This paper reports on the research findings of a survey of nonprofit disability organizations in Queensland and Victoria impacted upon by quasi-market reform. Enterprising organizations were found to have made substantial change to organizational structures and systems, whilst more traditional organizations made few changes. All organizations demonstrated commitment to a social justice ethos. However across the organizational archetypes there were reports of an organizational 'fragility'. It is argued that the problems of sustainability of community service organizations that existed prior to quasi-market reforms remain. This implies community service organizations will experience ongoing difficulties in the post-market era without further rationalization and change. A conceptual framework for sustainability of the community service sector is presented at the policy and organizational level.

Assessing the effectiveness of a mammography screening service

Background: Trials have shown that mammography screening reduces mortality and probably decreases morbidity related to breast cancer. Methods: We assessed whether the major mammography service in Western Australia (BreastScreen WA) is likely to reduce mortality by comparing prognostic variables between screen-detected and other cases of breast cancer diagnosed in 1999. We assessed likely reductions in morbidity by comparing treatments received by these two groups. To confirm mortality and morbidity reduction, we also compared prognostic variables and treatments with targets. Information on demographic variables, tumour characteristics at presentation and treatments were collected from medical records for all incident cases of breast cancer in Western Australia in 1999. We matched cases with the Western Australian Cancer Registry records to determine which cases had been detected by BreastScreen WA. Results: BreastScreen WA achieved the targets for mortality reduction. Tumours detected by BreastScreen WA were smaller in size, less likely to have vascular invasion, of lower histological grade and were more likely to be ductal carcinoma in situ alone without invasive carcinoma. Oestrogen receptor status was more likely to be positive, the difference in progesterone status was not significant, and lymph node involvement tended to be lower. BreastScreen WA patients were treated more often with local therapy and less often with systemic therapy, and the proportion of patients treated with breast-conserving surgery was close to the target for minimizing morbidity in breast cancer. Conclusion: Mammographic detection of breast cancer by BreastScreen WA is associated with reduced breast cancer morbidity and a more favourable prognosis.

Fixing the system? The experience of service users of the quasi-market in disability services in Australia

A qualitative study involving semi-structured interviews with 31 people with disabilities and 32 carers in the state of Queensland, Australia, found that their experience of supportive service delivery had not improved despite reforms of the service delivery system driven by a version of the quasi-market model. Instead of delivering increased consumer choice and improved efficiency in service delivery, service users experienced inadequate service supply, service cutbacks, and an increased emphasis on cost subsidisation and assessment processes. Additionally, few consumers felt that individualised funding arrangements had personally delivered the benefits which the quasi-market model and associated policy paradigm had indicated that they should receive. For many consumers, the notion of consumer 'choice' around service provision was fictitious and they felt that any efficiency gains were at the agency level, largely at the consumers' cost. It is concluded that there appears to be no particular benefit to service users of quasi-market reforms, particularly in policy contexts where service delivery systems are historically under-funded.

Advanced Asia's health systems in comparison

There is growing interest in comparing patterns of social and health service development in advanced Asian economies. Most publications concentrate broadly on a range of core social services such as education, housing, social security and health care. In terms of those solely focused on health, most discuss arrangements in specific countries and territories. Some take a comparative approach, but are focused on presentation and discussion of expenditure, resourcing and service utilization data. This article extends the comparative analysis of advanced Asian health systems, considering the cases of Japan, South Korea, Taiwan, Hong Kong and Singapore. The article provides basic background information, and delves into common concerns among the world's health systems today including primary care organization, rationing and cost containment, service quality, and system integration. Conclusions include that problems exist in 'classifying' the five diverse systems; that the systems face common pressures; and that there are considerable opportunities to enhance primary care, service quality and system integration. (c) 2006 Elsevier Ireland Ltd. All rights reserved.

Quality of service in flexible workflows through process constraints

Workflow technology has delivered effectively for a large class of business processes, providing the requisite control and monitoring functions. At the same time, this technology has been the target of much criticism due to its limited ability to cope with dynamically changing business conditions which require business processes to be adapted frequently, and/or its limited ability to model business processes which cannot be entirely predefined. Requirements indicate the need for generic solutions where a balance between process control and flexibility may be achieved. In this paper we present a framework that allows the workflow to execute on the basis of a partially specified model where the full specification of the model is made at runtime, and may be unique to each instance. This framework is based on the notion of process constraints. Where as process constraints may be specified for any aspect of the workflow, such as structural, temporal, etc. our focus in this paper is on a constraint which allows dynamic selection of activities for inclusion in a given instance. We call these cardinality constraints, and this paper will discuss their specification and validation requirements.