A multidisciplinary reference framework to support innovative design, implementation and assessment of chronic care models

Hoy en día, por primera vez en la historia, la mayor parte de la población podrá vivir hasta los sesenta años y más (United Nations, 2015). Sin embargo, todavía existe poca evidencia que demuestre que las personas mayores, estén viviendo con mejor salud que sus padres, a la misma edad, ya que la mayoría de los problemas de salud en edades avanzadas están asociados a las enfermedades crónicas (WHO, 2015). Los sistemas sanitarios de los países desarrollados funcionan adecuadamente cuando se trata del cuidado de enfermedades agudas, pero no son lo suficientemente eficaces en la gestión de las enfermedades crónicas. Durante la última década, se han realizado esfuerzos para mejorar esta gestión, por medio de la utilización de estrategias de prevención y de reenfoque de la provisión de los servicios de atención para la salud (Kane et al. 2005). Según una revisión sistemática de modelos de cuidado de salud, comisionada por el sistema nacional de salud Británico, pocos modelos han conceptualizado cuáles son los componentes que hay que utilizar para proporcionar un cuidado crónico efectivo, y estos componentes no han sido suficientemente estructurados y articulados. Por lo tanto, no hay suficiente evidencia sobre el impacto real de cualquier modelo existente en la actualidad (Ham, 2006). Las innovaciones podrían ayudar a conseguir mejores diagnósticos, tratamientos y gestión de pacientes crónicos, así como a dar soporte a los profesionales y a los pacientes en el cuidado. Sin embargo, la forma en las que estas innovaciones se proporcionan no es lo suficientemente eficiente, efectiva y amigable para el usuario. Para mejorar esto, hace falta crear equipos de trabajo y estrategias multidisciplinares. En conclusión, hacen falta actividades que permitan conseguir que las innovaciones sean utilizadas en los sistemas de salud que quieren mejorar la gestión del cuidado crónico, para que sea posible: 1) traducir la “atención sanitaria basada en la evidencia” en “conocimiento factible”; 2) hacer frente a la complejidad de la atención sanitaria a través de una investigación multidisciplinaria; 3) identificar una aproximación sistemática para que se establezcan intervenciones innovadoras en el cuidado de salud. El marco de referencia desarrollado en este trabajo de investigación es un intento de aportar estas mejoras. Las siguientes hipótesis han sido propuestas: Hipótesis 1: es posible definir un proceso de traducción que convierta un modelo de cuidado crónico en una descripción estructurada de objetivos, requisitos e indicadores clave de rendimiento. Hipótesis 2: el proceso de traducción, si se ejecuta a través de elementos basados en la evidencia, multidisciplinares y de orientación económica, puede convertir un modelo de cuidado crónico en un marco descriptivo, que define el ciclo de vida de soluciones innovadoras para el cuidado de enfermedades crónicas. Hipótesis 3: es posible definir un método para evaluar procesos, resultados y capacidad de desarrollar habilidades, y asistir equipos multidisciplinares en la creación de soluciones innovadoras para el cuidado crónico. Hipótesis 4: es posible dar soporte al desarrollo de soluciones innovadoras para el cuidado crónico a través de un marco de referencia y conseguir efectos positivos, medidos en indicadores clave de rendimiento. Para verificar las hipótesis, se ha definido una aproximación metodológica compuesta de cuatro Fases, cada una asociada a una hipótesis. Antes de esto, se ha llevado a cabo una “Fase 0”, donde se han analizado los antecedentes sobre el problema (i.e. adopción sistemática de la innovación en el cuidado crónico) desde una perspectiva multi-dominio y multi-disciplinar. Durante la fase 1, se ha desarrollado un Proceso de Traducción del Conocimiento, elaborado a partir del JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare (Pearson, 2005), y sobre el cual se han definido cuatro Bloques de Innovación. Estos bloques consisten en una descripción de elementos innovadores, definidos en la fase 0, que han sido añadidos a los cuatros elementos que componen el modelo JBI. El trabajo llevado a cabo en esta fase ha servido también para definir los materiales que el proceso de traducción tiene que ejecutar. La traducción que se ha llevado a cabo en la fase 2, y que traduce la mejor evidencia disponible de cuidado crónico en acción: resultado de este proceso de traducción es la parte descriptiva del marco de referencia, que consiste en una descripción de un modelo de cuidado crónico (se ha elegido el Chronic Care Model, Wagner, 1996) en términos de objetivos, especificaciones e indicadores clave de rendimiento y organizada en tres ciclos de innovación (diseño, implementación y evaluación). Este resultado ha permitido verificar la segunda hipótesis. Durante la fase 3, para demostrar la tercera hipótesis, se ha desarrollado un método-mixto de evaluación de equipos multidisciplinares que trabajan en innovaciones para el cuidado crónico. Este método se ha creado a partir del método mixto usado para la evaluación de equipo multidisciplinares translacionales (Wooden, 2013). El método creado añade una dimensión procedural al marco. El resultado de esta fase consiste, por lo tanto, en una primera versión del marco de referencia, lista para ser experimentada. En la fase 4, se ha validado el marco a través de un caso de estudio multinivel y con técnicas de observación-participante como método de recolección de datos. Como caso de estudio se han elegido las actividades de investigación que el grupo de investigación LifeStech ha desarrollado desde el 2008 para mejorar la gestión de la diabetes, actividades realizadas en un contexto internacional. Los resultados demuestran que el marco ha permitido mejorar las actividades de trabajo en distintos niveles: 1) la calidad y cantidad de las publicaciones; 2) se han conseguido dos contratos de investigación sobre diabetes: el primero es un proyecto de investigación aplicada, el segundo es un proyecto financiado para acelerar las innovaciones en el mercado; 3) a través de los indicadores claves de rendimiento propuestos en el marco, una prueba de concepto de un prototipo desarrollado en un proyecto de investigación ha sido transformada en una evaluación temprana de una intervención eHealth para el manejo de la diabetes, que ha sido recientemente incluida en Repositorio de prácticas innovadoras del Partenariado de Innovación Europeo en Envejecimiento saludable y activo. La verificación de las 4 hipótesis ha permitido demonstrar la hipótesis principal de este trabajo de investigación: es posible contribuir a crear un puente entre la atención sanitaria y la innovación y, por lo tanto, mejorar la manera en que el cuidado crónico sea procurado en los sistemas sanitarios. ABSTRACT Nowadays, for the first time in history, most people can expect to live into their sixties and beyond (United Nations, 2015). However, little evidence suggests that older people are experiencing better health than their parents, and most of the health problems of older age are linked to Chronic Diseases (WHO, 2015). The established health care systems in developed countries are well suited to the treatment of acute diseases but are mostly inadequate for dealing with CDs. Healthcare systems are challenging the burden of chronic diseases by putting more emphasis on the prevention of disease and by looking for new ways to reorient the provision of care (Kane et al., 2005). According to an evidence-based review commissioned by the British NHS Institute, few models have conceptualized effective components of care for CDs and these components have been not structured and articulated. “Consequently, there is limited evidence about the real impact of any of the existing models” (Ham, 2006). Innovations could support to achieve better diagnosis, treatment and management for patients across the continuum of care, by supporting health professionals and empowering patients to take responsibility. However, the way they are delivered is not sufficiently efficient, effective and consumer friendly. The improvement of innovation delivery, involves the creation of multidisciplinary research teams and taskforces, rather than just working teams. There are several actions to improve the adoption of innovations from healthcare systems that are tackling the epidemics of CDs: 1) Translate Evidence-Based Healthcare (EBH) into actionable knowledge; 2) Face the complexity of healthcare through multidisciplinary research; 3) Identify a systematic approach to support effective implementation of healthcare interventions through innovation. The framework proposed in this research work is an attempt to provide these improvements. The following hypotheses have been drafted: Hypothesis 1: it is possible to define a translation process to convert a model of chronic care into a structured description of goals, requirements and key performance indicators. Hypothesis 2: a translation process, if executed through evidence-based, multidisciplinary, holistic and business-oriented elements, can convert a model of chronic care in a descriptive framework, which defines the whole development cycle of innovative solutions for chronic disease management. Hypothesis 3: it is possible to design a method to evaluate processes, outcomes and skill acquisition capacities, and assist multidisciplinary research teams in the creation of innovative solutions for chronic disease management. Hypothesis 4: it is possible to assist the development of innovative solutions for chronic disease management through a reference framework and produce positive effects, measured through key performance indicators. In order to verify the hypotheses, a methodological approach, composed of four Phases that correspond to each one of the stated hypothesis, was defined. Prior to this, a “Phase 0”, consisting in a multi-domain and multi-disciplinary background analysis of the problem (i.e.: systematic adoption of innovation to chronic care), was carried out. During phase 1, in order to verify the first hypothesis, a Knowledge Translation Process (KTP) was developed, starting from the JBI Joanna Briggs Institute (JBI) model of evidence-based healthcare was used (Pearson, 2005) and adding Four Innovation Blocks. These blocks represent an enriched description, added to the JBI model, to accelerate the transformation of evidence-healthcare through innovation; the innovation blocks are built on top of the conclusions drawn after Phase 0. The background analysis gave also indication on the materials and methods to be used for the execution of the KTP, carried out during phase 2, that translates the actual best available evidence for chronic care into action: this resulted in a descriptive Framework, which is a description of a model of chronic care (the Chronic Care Model was chosen, Wagner, 1996) in terms of goals, specified requirements and Key Performance Indicators, and articulated in the three development cycles of innovation (i.e. design, implementation and evaluation). Thanks to this result the second hypothesis was verified. During phase 3, in order to verify the third hypothesis, a mixed-method to evaluate multidisciplinary teams working on innovations for chronic care, was created, based on a mixed-method used for the evaluation of Multidisciplinary Translational Teams (Wooden, 2013). This method adds a procedural dimension to the descriptive component of the Framework, The result of this phase consisted in a draft version of the framework, ready to be tested in a real scenario. During phase 4, a single and multilevel case study, with participant-observation data collection, was carried out, in order to have a complete but at the same time multi-sectorial evaluation of the framework. The activities that the LifeStech research group carried out since 2008 to improve the management of diabetes have been selected as case study. The results achieved showed that the framework allowed to improve the research activities in different directions: the quality and quantity of the research publications that LifeStech has issued, have increased substantially; 2 project grants to improve the management of diabetes, have been assigned: the first is a grant funding applied research while the second is about accelerating innovations into the market; by using the assessment KPIs of the framework, the proof of concept validation of a prototype developed in a research project was transformed into an early stage assessment of innovative eHealth intervention for Diabetes Management, which has been recently included in the repository of innovative practice of the European Innovation Partnership on Active and Health Ageing initiative. The verification of the 4 hypotheses lead to verify the main hypothesis of this research work: it is possible to contribute to bridge the gap between healthcare and innovation and, in turn, improve the way chronic care is delivered by healthcare systems.

Nagele: un nuevo asentamiento en un paisaje artificial

Nagele es un asentamiento urbano situado en el Noordoostpolder, territorio neerlandés ganado al mar. Fue diseñado por arquitectos de los grupos De 8 en Opbouw entre los que destacaron Rietveld, Van Eesteren, Van Eyck, Bakema, Stam y Ruys. El proyecto se desarrolló entre 1947 y 1956, un periodo de tiempo con formas de proyectar muy ricas en interpretaciones. Los arquitectos pusieron en crisis los planteamientos historicistas de las nuevas poblaciones de los pólderes. Propusieron un nuevo prototipo, una morfología compacta y concéntrica que transmitiría igualdad a una comunidad agrícola, entendida como una sociedad urbana del siglo XX. La administración apoyó la propuesta que convertiría el proyecto en un arriesgado reto por su falta de antecedentes. La vigencia de las formulaciones permanece hoy en día en la ciudad construida, aunque con alteraciones. En los dibujos del proceso se encuentran los principales enunciados teóricos que este trabajo pretende descubrir. El trabajo aborda aspectos no suficientemente explorados, como su relación con el pólder, la evolución de las estrategias proyectivas, la ordenación paisajista y los elementos urbanos. El Noordoostpolder es la culminación de una serie de experiencias multidisciplinares en el reclamo de tierras a gran escala. Se estudia su estructura urbana policéntrica, la parcelación agrícola que origina el proyecto urbano y la vinculación de la vegetación con la infraestructura, proporcionando orientación, protección climática y escala humana, conceptos que impregnan las estrategias del proyecto urbano. La primera fase de la ordenación configuró áreas monofuncionales que respondían a cada una de las cuatro necesidades básicas del método científico de la ciudad higienista. El acontecimiento que marcó el final de la primera fase fue su presentación en el séptimo CIAM de 1949, cuyo título fue Aplicación de la Carta de Atenas. El programa residencial se dividió en clusters organizados en torno a una pradera vecinal central, vinculándose el orden vecinal, urbano y territorial. La segunda fase fue un catalizador de nuevos planteamientos. El proyecto se transformó en un In-between Realm, un escenario teórico donde coexisten fenómenos tradicionalmente antagónicos que Van Eyck denominó Twin Phenomena, convirtiéndose la ciudad en una réplica formal de la ambivalencia de la mente humana. La indefinición espacial no programada en la propuesta anterior se transformó en un conjunto de espacios urbanos, con límites y dimensiones adaptados a la escala humana. El proyecto es anterior a la obra escrita de Van Eyck por lo que estimuló sus enunciados teóricos. Unas ideas también reconocidas en los tres CIAM posteriores en los que también se expuso el proyecto. El diseño paisajista se integra en el proyecto urbano desde sus orígenes. El límite se compone de una barrera boscosa que protege climáticamente, proporciona escala humana y control visual frente a las llanuras infinitas del pólder. Van Eyck sintetizó el proyecto como una habitación verde sin techo, afirmación que dilucida su equivalencia con el de un interior doméstico. Exteriormente la ciudad se convierte en una unidad autónoma del territorio. Interiormente, un sistema jerarquizado de vegetación vinculado a la arquitectura y la infraestructura constituye espacios urbanos de diferentes escalas. La propuesta fue transformada por Boer y Ruys en un nuevo espacio urbano único, no asimilando los conceptos anteriores. El proyecto y construcción de los primeros elementos urbanos consistió en un reparto de tareas a De 8 en Opbouw, hecho que estimula estudiar su relación con el proyecto urbano. La estructura policéntrica organiza las aulas de las escuelas de Van Eyck, las diferentes áreas confesionales del cementerio de Ruys y las unidades residenciales, diseñadas por Stam, Rietveld y Stam-Besse. Los Twin Phenomena alcanzan un acuerdo en el corredor comercial, diseñado por Bakema y Van der Broek. La generación de espacios dentro de otros aparece también en el cementerio, a través de una nueva barrera boscosa y en el sistema de pliegues del muro que configura la iglesia de Bakema y Van der Broek. El proyecto se vincula a un planteamiento holístico, mediante el que el diseño de cada uno de sus elementos tiene en cuenta las estrategias proyectivas del todo del cual forma parte, convirtiéndose, al igual que las obras de De Stijl, en parte de una composición infinita que acerca arte y diseño en la vida cotidiana de la sociedad. La diversidad generacional e ideológica de estos arquitectos convirtió el proyecto en un tablero de juego sobre el que se aplicaron diferentes formas de proyectar la ciudad, ubicando a Nagele en un punto de inflexión del Movimiento Moderno. ABSTRACT The research focuses on the Nagele project, a Dutch urban settlement located in the Noordoostpolder, a territory which was entirely reclaimed from the IJsselmeer lake. It was designed by a group of architects from the De 8 and Opbouw teams, the leading protagonists being Rietveld, Van Eesteren, Van Eyck, Bakema, Stam y Ruys. It was designed from 1947 to 1956, a fruitful period in urban planning. These architects questioned the traditionalist urban design applied to the new populations in the IJsselmeer polders. Facing their principles, the work group proposed a new prototype; a compact and concentric urban pattern to foster equality in a new community of farm labourers, which was recognized by the architects as a twentieth century urban society. The government supported their new proposals. The lack of implementation of the innovatory conceptual statements subjected the project into a high-risk challenge. However, in spite of these difficulties, the basic concepts remain though partially transformed, in the actual city. The project drawings reflect the principle concepts that this work aims to discover. Some approaches that have not been sufficiently studied are tackled in this thesis. Firstly, the project´s relationship with the polder. Secondly, the evolution of projective strategies during the period of urban planning, the landscape design and the design of urban elements. The Noordoostpolder is the culmination of a series of multi-disciplinary experiences in large scale land reclamation, whose polycentric urban structure and agricultural subdivision provide the framework of Nagele. Linking the vegetation to infrastructure fostered orientation, climate protection and human scale; strategies which were repeated, though on a smaller scale, in the actual city. The first phase of the project was composed of mono-functional urban areas which responded to each of the four basic human needs indicated by the scientific method of the functional city. The presentation of the project at the seventh CIAM in 1949 was the event which marked the end of the first phase of the planning. This congress was entitled Implementation of the Athens Charter. The residential program was divided into housing clusters surrounding a central prairie, a pattern which was related to its urban and territorial whole. The second phase of the plan was subjected to a new theoretical approach. The urban planning became an In-between Realm, a theoretical scenario where traditionally antagonistic concepts coexist. Van Eyck named these concepts Twin Phenomena. The city thus conceived of as a counterform of the ambivalence of the human mind where spatial indefinition in the previous proposals was transformed into a Bunch of Places with defined boundaries and dimensions, all of which reflecting human scale. The landscape design was integrated into the urban project from its inception. The limits consist of a green wind-barrier which not only provides climate protection but also provides human scale and visual control towards the unlimited plains of the polder. Van Eyck summarised the project as a green room without a roof. This statement elucidates its equivalence to a domestic interior. Outwardly, the city becomes an autonomous unit on the territory. Inwardly a hierarchical vegetation system is linked to architecture and infrastructure. Together, they configure different scales of urban spaces. The proposal was transformed by Boer and Ruys into a unique urban space without assimilating Van Eyck´s concepts. The study of the Nagele landscape project of Nagele and the writings of Van Eyck verify the fact that many of his theoretical foundations (In-between Realm, Twin Phenomena, Bunch of Places, Right Scale) can be applied not only to architecture and city but also to landscape design. The application of these principles led the Nagele project to become a counterform of Van Eyck´s thinking. The design and construction of the first urban elements involved a distribution of tasks to De 8 en Opbouw, which stimulated their relationship with the urban project. The polycentric structure organised the school classrooms outlined by Van Eyck, the different areas of the cemetery planned by Ruys and the housing clusters designed by Stam, Rietveld and Stam-Besse. The Twin Phenomena concept can be applied in Van der Broek´s shopping corridor. The concept space within another space is also implemented in the cemetery surrounded by a new green barrier, and in the church built by Van der Broek and Bakema, whose spaces are configured by a folding wall. The project takes a holistic approach, which considers the design of each element within the strategies of the whole, where they become parts of an infinite composition, as in the art works of De Stijl fostering art and design to ordinary people´s daily lives. The generational and ideological diversity of these architects turned the project into a game board on which different ways of planning the city were played, obtaining Nagele the distinction of being a turning point of Modernism.

Sea lions, sacrifice, and ritual : The symbolism of Moche Island imagery

The Mochica, or Moche (c. 100-800 AD) culture, flourished along the northern Peruvian coast. The Moche did not have a formal written language; as such, contemporary scholars base their analysis on Moche iconography and archaeological burial remains. Especially renown for their ceramic artistry, Moche vessels exhibit a wide range of subject matter, including animal and enigmatic figural representations that evoke terrestrial, marine and possibly, spiritual realms. While research has focused on political organization and the interrelationship between sacrifice and warfare, many marine themes have not been fully explored in the discourse. An exploration of sea lion imagery and sacrifice themes suggests that the marine mammals were ritually hunted. A careful iconographic analysis of island scenes demonstrates ritual and gender affiliations held by the Moche about sea lions. In a multi-disciplinary approach, scientific, archaeological and ethnographic resources substantiate this claim.

A detector based on silica fibers for ion beam monitoring in a wide current range

A detector based on doped silica and optical fibers was developed to monitor the profile of particle accelerator beams of intensity ranging from 1 pA to tens of µA. Scintillation light produced in a fiber moving across the beam is measured, giving information on its position, shape and intensity. The detector was tested with a continuous proton beam at the 18 MeV Bern medical cyclotron used for radioisotope production and multi-disciplinary research. For currents from 1 pA to 20 µA, Ce3+ and Sb3+ doped silica fibers were used as sensors. Read out systems based on photodiodes, photomultipliers and solid state photomultipliers were employed. Profiles down to the pA range were measured with this method for the first time. For currents ranging from 1 pA to 3 µA, the integral of the profile was found to be linear with respect to the beam current, which can be measured by this detector with an accuracy of ∼1%. The profile was determined with a spatial resolution of 0.25 mm. For currents ranging from 5 µA to 20 µA, thermal effects affect light yield and transmission, causing distortions of the profile and limitations in monitoring capabilities. For currents higher than ∼1 µA, non doped optical fibers for both producing and transporting scintillation light were also successfully employed.

Accelerator and detector physics at the Bern medical cyclotron and its beam transport line.

The cyclotron laboratory for radioisotope production and multi-disciplinary research at the Bern University Hospital (Inselspital) is based on an 18-MeV proton accelerator, equipped with a specifically conceived 6-m long external beam line, ending in a separate bunker. This facility allows performing daily positron emission tomography (PET) radioisotope production and research activities running in parallel. Some of the latest developments on accelerator and detector physics are reported. They encompass novel detectors for beam monitoring and studies of low current beams.

Zooplankton abundance and vertical fluxes of sedimentary matter and chemical elements in the White Sea from 15 to 24 June, 2000

A multidisciplinary oceanographic survey of the White Sea was carried out in the Gorlo Straight, Basin, and Kandalaksha Bay regions including estuaries of Niva, Kolvitza and Knyazhaya rivers. Hydrophysical study in the northern part of the Basin revealed long-lived step-like structures and inversions in vertical profiles of temperature and salinity, which formed due to tidal mixing of saline and cold Barents Sea waters and warmer White Sea waters in the Gorlo Straight. Biological studies revealed the main features of spatial distribution, as well as qualitative and quantitative composition of phyto- and zooplankton in all studied areas; tolerance of main zooplankton species to fresh water influence in estuaries was shown. Study of suspended matter in estuaries clearly demonstrated physicochemical transformations of material supplied by the rivers. Data on vertical particle flux in the deep part of the Kandalaksha Bay showed difference between the upper and near-bottom layers, which could result from sinking of spring phytoplankton bloom products and supply of terrigenic suspended matter from the nepheloid layer formed by tidal currents.

Annual progress report /

In November 2006, a multi-disciplinary statewide Illinois State Diabetes Commission was established by legislation to be house[d] within the Department of Human Services (DHS) as a means of addressing issues presented by the growing number of children and adults being diagnosed with Diabetes Mellitus.

Empathy and Its Potential in Museum Practice

Thesis (Master's)--University of Washington, 2016-06

Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units

Objective. To determine the population incidence and outcome of severe sepsis occurring in adult patients treated in Australian and New Zealand intensive care units (ICUs), and compare with recent retrospective estimates from the USA and UK. Design. Inception cohort study. Setting. Twenty-three closed multi-disciplinary ICUs of 21 hospitals (16 tertiary and 5 university affiliated) in Australia and New Zealand. Patients. A total of 5878 consecutive ICU admission episodes. Measurements and results. Main outcome measures were population-based incidence of severe sepsis, mortality at ICU discharge, mortality at 28 days after onset of severe sepsis, and mortality at hospital discharge. A total of 691 patients, 11.8 (95% confidence intervals 10.9-12.6) per 100 ICU admissions, were diagnosed with 752 episodes of severe sepsis. Site of infection was pulmonary in 50.3% of episodes and abdominal in 19.3% of episodes. The calculated incidence of severe sepsis in adults treated in Australian and New Zealand ICUs is 0.77 (0.76-0.79) per 1000 of population. 26.5% of patients with severe sepsis died in ICU, 32.4% died within 28 days of the diagnosis of severe sepsis and 37.5% died in hospital. Conclusion. In this prospective study, 11.8 patients per 100 ICU admissions were diagnosed with severe sepsis and the calculated annual incidence of severe sepsis in adult patients treated in Australian and New Zealand ICUs is 0.77 per 1000 of population. This figure for the population incidence falls in the lower range of recent estimates from retrospective studies in the U.S. and the U.K.

Referral to rehabilitation following traumatic brain injury: practitioners and the process of decision-making

The study aimed to examine the factors influencing referral to rehabilitation following traumatic brain injury (TBI) by using social problems theory as a conceptual model to focus on practitioners and the process of decision-making in two Australian hospitals. The research design involved semi-structured interviews with 18 practitioners and observations of 10 team meetings, and was part of a larger study on factors influencing referral to rehabilitation in the same settings. Analysis revealed that referral decisions were influenced primarily by practitioners' selection and their interpretation of clinical and non-clinical patient factors. Further, practitioners generally considered patient factors concurrently during an ongoing process of decision-making, with the combinations and interactions of these factors forming the basis for interpretations of problems and referral justifications. Key patient factors considered in referral decisions included functional and tracheostomy status, time since injury, age, family, place of residence and Indigenous status. However, rate and extent of progress, recovery potential, safety and burden of care, potential for independence and capacity to cope were five interpretative themes, which emerged as the justifications for referral decisions. The subsequent negotiation of referral based on patient factors was in turn shaped by the involvement of practitioners. While multi-disciplinary processes of decision-making were the norm, allied health professionals occupied a central role in referral to rehabilitation, and involvement of medical, nursing and allied health practitioners varied. Finally, the organizational pressures and resource constraints, combined with practitioners' assimilation of the broader efficiency agenda were central factors shaping referral. (C) 2004 Elsevier Ltd. All rights reserved.

Heart failure management programmes in Europe

Background The ESC guidelines recommend that an organised system of specialist heart failure (HF) care should be established to improve outcomes of HF patients. The aim of this study was therefore to identify the number and the content of HF management programmes in Europe. Method A two-phase descriptive study was conducted: an initial screening to identify the existence of HF management programmes; and a survey to describe the content in countries where at least 30% of the hospitals had a programme. Results Of the 43 European countries approached, 26 (60%) estimated the percentage of HF management programmes. Seven countries reported that they had such programmes in more than 30% of their hospitals. Of the 673 hospitals responding to the questionnaire, 426 (63%) had a HF management programme. Half of the programmes (n = 205) were located in an outpatient clinic. In the UK a combination of hospital and home-based programmes was common (75%). The most programmes included physical examination, telephone consultation, patient education, drug titration and diagnostic testing. Most (89%) programmes involved nurses and physicians. Multi-disciplinary teams were active in 56% of the HF programmes. The most prominent differences between the 7 countries were the degree of collaboration with home care and GP's, the role in palliative care and the funding. Conclusion Only a few European countries have a large number of organised programmes for HF care and follow up. To improve outcomes of HF patients throughout Europe more effort should be taken to increase the number of these programmes in all countries.

Editorial

This special issue of the Journal of the Operational Research Society is dedicated to papers on the related subjects of knowledge management and intellectual capital. These subjects continue to generate considerable interest amongst both practitioners and academics. This issue demonstrates that operational researchers have many contributions to offer to the area, especially by bringing multi-disciplinary, integrated and holistic perspectives. The papers included are both theoretical as well as practical, and include a number of case studies showing how knowledge management has been implemented in practice that may assist other organisations in their search for a better means of managing what is now recognised as a core organisational activity. It has been accepted by a growing number of organisations that the precise handling of information and knowledge is a significant factor in facilitating their success but that there is a challenge in how to implement a strategy and processes for this handling. It is here, in the particular area of knowledge process handling that we can see the contributions of operational researchers most clearly as is illustrated in the papers included in this journal edition. The issue comprises nine papers, contributed by authors based in eight different countries on five continents. Lind and Seigerroth describe an approach that they call team-based reconstruction, intended to help articulate knowledge in a particular organisational. context. They illustrate the use of this approach with three case studies, two in manufacturing and one in public sector health care. Different ways of carrying out reconstruction are analysed, and the benefits of team-based reconstruction are established. Edwards and Kidd, and Connell, Powell and Klein both concentrate on knowledge transfer. Edwards and Kidd discuss the issues involved in transferring knowledge across frontières (borders) of various kinds, from those borders within organisations to those between countries. They present two examples, one in distribution and the other in manufacturing. They conclude that trust and culture both play an important part in facilitating such transfers, that IT should be kept in a supporting role in knowledge management projects, and that a staged approach to this IT support may be the most effective. Connell, Powell and Klein consider the oft-quoted distinction between explicit and tacit knowledge, and argue that such a distinction is sometimes unhelpful. They suggest that knowledge should rather be regarded as a holistic systemic property. The consequences of this for knowledge transfer are examined, with a particular emphasis on what this might mean for the practice of OR Their view of OR in the context of knowledge management very much echoes Lind and Seigerroth's focus on knowledge for human action. This is an interesting convergence of views given that, broadly speaking, one set of authors comes from within the OR community, and the other from outside it. Hafeez and Abdelmeguid present the nearest to a 'hard' OR contribution of the papers in this special issue. In their paper they construct and use system dynamics models to investigate alternative ways in which an organisation might close a knowledge gap or skills gap. The methods they use have the potential to be generalised to any other quantifiable aspects of intellectual capital. The contribution by Revilla, Sarkis and Modrego is also at the 'hard' end of the spectrum. They evaluate the performance of public–private research collaborations in Spain, using an approach based on data envelopment analysis. They found that larger organisations tended to perform relatively better than smaller ones, even though the approach used takes into account scale effects. Perhaps more interesting was that many factors that might have been thought relevant, such as the organisation's existing knowledge base or how widely applicable the results of the project would be, had no significant effect on the performance. It may be that how well the partnership between the collaborators works (not a factor it was possible to take into account in this study) is more important than most other factors. Mak and Ramaprasad introduce the concept of a knowledge supply network. This builds on existing ideas of supply chain management, but also integrates the design chain and the marketing chain, to address all the intellectual property connected with the network as a whole. The authors regard the knowledge supply network as the natural focus for considering knowledge management issues. They propose seven criteria for evaluating knowledge supply network architecture, and illustrate their argument with an example from the electronics industry—integrated circuit design and fabrication. In the paper by Hasan and Crawford, their interest lies in the holistic approach to knowledge management. They demonstrate their argument—that there is no simple IT solution for organisational knowledge management efforts—through two case study investigations. These case studies, in Australian universities, are investigated through cultural historical activity theory, which focuses the study on the activities that are carried out by people in support of their interpretations of their role, the opportunities available and the organisation's purpose. Human activities, it is argued, are mediated by the available tools, including IT and IS and in this particular context, KMS. It is this argument that places the available technology into the knowledge activity process and permits the future design of KMS to be improved through the lessons learnt by studying these knowledge activity systems in practice. Wijnhoven concentrates on knowledge management at the operational level of the organisation. He is concerned with studying the transformation of certain inputs to outputs—the operations function—and the consequent realisation of organisational goals via the management of these operations. He argues that the inputs and outputs of this process in the context of knowledge management are different types of knowledge and names the operation method the knowledge logistics. The method of transformation he calls learning. This theoretical paper discusses the operational management of four types of knowledge objects—explicit understanding; information; skills; and norms and values; and shows how through the proposed framework learning can transfer these objects to clients in a logistical process without a major transformation in content. Millie Kwan continues this theme with a paper about process-oriented knowledge management. In her case study she discusses an implementation of knowledge management where the knowledge is centred around an organisational process and the mission, rationale and objectives of the process define the scope of the project. In her case they are concerned with the effective use of real estate (property and buildings) within a Fortune 100 company. In order to manage the knowledge about this property and the process by which the best 'deal' for internal customers and the overall company was reached, a KMS was devised. She argues that process knowledge is a source of core competence and thus needs to be strategically managed. Finally, you may also wish to read a related paper originally submitted for this Special Issue, 'Customer knowledge management' by Garcia-Murillo and Annabi, which was published in the August 2002 issue of the Journal of the Operational Research Society, 53(8), 875–884.

Utilising online shopping environment attributes holistically to create competitive advantage

As more consumers shop online, it becomes crucial for marketers to know how online shopping environments (OSEs) can be used to gain competitive advantage. This dissertation aims to explain theoretically how OSE attributes work together holistically to produce desirable consumer responses, applying and extending a theory from the environmental psychology literature to the online context. Firstly, the study conceptualises OSEs as virtual environments which may be perceived and experienced both cognitively and affectively through a technology-mediated interaction with a computer screen. A multi-disciplinary approach identifies key characteristics of OSEs: they involve consumers; they are more complex than their offline counterparts; they are likely first apprehended holistically; and they can elicit high levels of emotions and cognition. Secondly, the research uses a gestalt approach and extends Kaplan and Kalan’s (1982) Preference Framework, taking account of the specific characteristics of OSEs, which one visits specifically to obtain product information. The results support the proposition that OSEs are perceived in terms of their Sense-making and Exploratory attributes. Thirdly, the research explains how OSE attributes work together to produce desirable consumer responses. As hypothesised, Exploratory potential produces both Hedonic and Utilitarian value, and both kinds of value contribute to Site commitment. An unexpected result is that Sense-making potential does not produce Utilitarian value directly, but only through the mediation of Exploratory potential. The research contributes to marketing theory by: (1) identifying ways the internet has changed the nature of the shopping experience; (2) extending Kaplan and Kaplan’s Preference Framework to explain how consumers perceive OSEs holistically; (3) identifying the distinction between page-level and site-level perceptions, and (4) distinguishing between different sources of information (marketer vs. non-marketer). Managerially, the research provides a model for marketers to conceive and design retail websites whose attributes work together to create competitive advantage.

High-performance liquid chromatography and pharmacokinetics of some antibiotics

The principles of High Performance Liquid Chromatography (HPLC) and pharmacokinetics were applied to the use of several clinically-important drugs at the East Birmingham Hospital. Amongst these was gentamicin, which was investigated over a two-year period by a multi-disciplinary team. It was found that there was considerable intra- and inter-patient variation that had not previously been reported and the causes and consequences of such variation were considered. A detailed evaluation of available pharmacokinetic techniques was undertaken and 1- and 2-compartment models were optimised with regard to sampling procedures, analytical error and model-error. The implications for control of therapy are discussed and an improved sampling regime is proposed for routine usage. Similar techniques were applied to trimethoprim, assayed by HPLC, in patients with normal renal function and investigations were also commenced into the penetration of drug into peritoneal dialysate. Novel assay techniques were also developed for a range of drugs including 4-aminopyridine, chloramphenicol, metronidazole and a series of penicillins and cephalosporins. Stability studies on cysteamine, reaction-rate studies on creatinine-picrate and structure-activity relationships in HPLC of aminopyridines are also reported.