The nurse and the care to the elderly women: a social phenomenological approach

Objective: To understand how nurses see care delivery to elderly women. Methods: In this phenomenological study, ten nurses working at Primary Health Care Units were interviewed between September 2010 and January 2011. Results: In care delivery, nurses consider the elderly women's knowledge background and biographical situation, and also value the family's participation as a care mediator. These professionals have the acuity to capture these women's specific demands, but face difficulties to deliver care to these clients. Nurses expect to deliver qualified care to these women. Conclusion: The theoretical and methodological approach of social phenomenology permitted revealing that the nurse designs qualified care to elderly women, considering the possibilities in the context. This includes the participation of different social actors and health sectors, assuming collective efforts in action strategies and professional training, in line with the particularities and care needs of elderly women nurses identify.

Qualifying instrument for evaluation of food and nutritional care in hospital

Establishing criteria for hospital nutrition care ensures that quality care is delivered to patients. The responsibility of the Hospital Food and Nutrition Service (HFNS) is not always well defined, despite efforts to establish guidelines for patient clinical nutrition practice. This study describes the elaboration of an Instrument for Evaluation of Food and Nutritional Care (IEFNC) aimed at directing the actions of the Hospital Food and Nutrition Service. This instrument was qualified by means of a comparative analysis of the categories related to hospital food and nutritional care, published in the literature. Elaboration of the IEFNC comprised the following stages: (a) a survey of databases and documents for selection of the categories to be used in nutrition care evaluation, (b) a study of the institutional procedures for nutrition practice at two Brazilian hospitals, in order to provide a description of the sequence of actions that should be taken by the HFNS as well as other services participating in nutrition care, (c) design of the IEFNC based on the categories published in the literature, adapted to the sequence of actions observed in the routines of the hospitals under study, (d) application of the questionnaire at two different hospitals that was mentioned in the item (b), in order to assess the time spent on its application, the difficulties in phrasing the questions, and the coverage of the instrument, and (e) finalization of the instrument. The IEFNC consists of 50 open and closed questions on two areas of food and nutritional care in hospital: inpatient nutritional care and food service quality. It deals with the characterization and structure of hospitals and their HFNS, the actions concerning the patients' nutritional evaluation and monitoring, the meal production system, and the hospital diets. "This questionnaire is a tool that can be seen as a portrait of the structure and characteristics of the HFNS and its performance in clinical and meal management dietitian activities." (Nutr Hosp. 2012;27:1170-1177) DOI:10.3305/nh.2012.27.4.5868

Sexual selection in Pomatoschistus – nests, sperm competition, and paternal care

Sexual selection arises through variation in reproductive success. This thesis investigates different aspects important in sexual selection, namely nest building, sperm competition, paternity and paternal care, and their mutual interrelationships. In the studied species, the sand goby (Pomatoschistus minutus) and the common goby (Pomatoschistus microps), sperm competition did arise when small males, so called sneakers, sneaked into other males nests and released sperm. They seemed to use female behaviour as their prime cue for a sneaking opportunity. However, also nest-holders, both with and without eggs, were found to fertilize eggs in the nests of other males. Clearly, nest-holding males tried to prevent other males from spreading their sperm in their nests, since they showed aggression towards such males. A nest building experiment indicated that the small nest-openings found in the sneaker male treatment were sexually selected through protection against sneaking or by female choice. Yet, no behavioural or genetical support for the hypothesis that the nest functions as a physical or visual defence, or that sneaker males prefer to sneak upon nests with wide nest-openings, were found in the other studies. Still, individual nest-holding males showed a higher mucus preparation effort inside the nest in the presence of a sneaker male than when alone. In close relatives, such mucus contains sperm, suggesting an importance in sperm competition. However, the mucus may also have pheromone and anti-bacterial functions and may constitute a mating effort, as found in other gobies. Both a behavioural and a mate choice experiment suggested that the males were not less eager to spawn in the presence of a sneaker male. Sneak intrusion did not affect nest defence, fanning or filial cannibalism, nor had paternity an effect on filial cannibalism. This and various life history aspects, together with the fact that the parasitic male only fertilized a fraction of the clutches, would predict females to ignore sneaker males. This was also the case, as the presence of sneaker males was found not to affect female spawning decision. Still, several females spawned in two nests, which coincided with parasitic spawnings, suggesting a cost of disturbance for the females and thus a substantial cost to the nest-holding males in terms of lost mating success. However, females paid attention to other traits in their choice of mate since spawning was associated with sand volume of the nest, but not with nest-opening width. Also, female (but not male) courtship was correlated with partial clutch filial cannibalism, indicating that females are able to anticipate future male cannibalism. In a partial correlation of nest opening, sand volume, male courtship display, displacement fanning and male size, a large number of traits were correlated both positively and negatively with regard to how we may expect them to be appreciated by females. For instance, males which fan well also build large nests or display intensely (but not both). Together with all the other results of this thesis, this shows the entangled selection pressures working on breeding animals, as well as the different male and female tactics employed to maximize their reproduction.

Essays in Applied Health Economics: Evidence on Health and Health Care in Italy and UK

This thesis is the result of my experience as a PhD student taking part in the Joint Doctoral Programme at the University of York and the University of Bologna. In my thesis I deal with topics that are of particular interest in Italy and in Great Britain. Chapter 2 focuses on the empirical test of the existence of the relationship between technological profiles and market structure claimed by Sutton’s theory (1991, 1998) in the specific economic framework of hospital care services provided by the Italian National Health Service (NHS). In order to test the empirical predictions by Sutton, we identify the relevant markets for hospital care services in Italy in terms of both product and geographic dimensions. In particular, the Elzinga and Hogarty (1978) approach has been applied to data on patients’ flows across Italian Provinces in order to derive the geographic dimension of each market. Our results provide evidence in favour of the empirical predictions of Sutton. Chapter 3 deals with the patient mobility in the Italian NHS. To analyse the determinants of patient mobility across Local Health Authorities, we estimate gravity equations in multiplicative form using a Poisson pseudo maximum likelihood method, as proposed by Santos-Silva and Tenreyro (2006). In particular, we focus on the scale effect played by the size of the pool of enrolees. In most of the cases our results are consistent with the predictions of the gravity model. Chapter 4 considers the effects of contractual and working conditions on selfassessed health and psychological well-being (derived from the General Health Questionnaire) using the British Household Panel Survey (BHPS). We consider two branches of the literature. One suggests that “atypical” contractual conditions have a significant impact on health while the other suggests that health is damaged by adverse working conditions. The main objective of our paper is to combine the two branches of the literature to assess the distinct effects of contractual and working conditions on health. The results suggest that both sets of conditions have some influence on health and psychological well-being of employees.

Systems medicine and integrated care to combat chronic noncommunicable diseases

We propose an innovative, integrated, cost-effective health system to combat major non-communicable diseases (NCDs), including cardiovascular, chronic respiratory, metabolic, rheumatologic and neurologic disorders and cancers, which together are the predominant health problem of the 21st century. This proposed holistic strategy involves comprehensive patient-centered integrated care and multi-scale, multi-modal and multi-level systems approaches to tackle NCDs as a common group of diseases. Rather than studying each disease individually, it will take into account their intertwined gene-environment, socio-economic interactions and co-morbidities that lead to individual-specific complex phenotypes. It will implement a road map for predictive, preventive, personalized and participatory (P4) medicine based on a robust and extensive knowledge management infrastructure that contains individual patient information. It will be supported by strategic partnerships involving all stakeholders, including general practitioners associated with patient-centered care. This systems medicine strategy, which will take a holistic approach to disease, is designed to allow the results to be used globally, taking into account the needs and specificities of local economies and health systems.

Health status and health care utilisation of patients in complementary and conventional primary care in Switzerland--an observational study

BACKGROUND: The study is part of a nationwide evaluation of complementary and alternative medicine (CAM) in primary care in Switzerland. OBJECTIVES: Patient health status with respect to demographic attributes such as gender, age, and health care utilisation pattern was studied and compared with conventional primary care. METHODS: The study was performed as a cross-sectional survey including 11932 adult patients seeking complementary or conventional primary care. Patients were asked to document their self-perceived health status by completing a questionnaire in the waiting room. Physicians were performing conventional medicine and/or various forms of complementary primary care such as homeopathy, anthroposophic medicine, neural therapy, herbal medicine, or traditional Chinese medicine. Additional information on patient demographics and yearly consultation rates for participating physicians was obtained from the data pool of all Swiss health insurers. These data were used to confirm the survey results. RESULTS: We observed considerable and significant differences in demographic attributes of patients seeking complementary and conventional care. Patients seeking complementary care documented longer lasting and more severe main health problems than patients in conventional care. The number of previous physician visits differed between patient groups, which indicates higher consumption of medical resources by CAM patients. CONCLUSIONS: The study supports the hypothesis of differences in socio-demographic and behavioural attributes of patients seeking conventional medicine or CAM in primary care. The study provides empirical evidence that CAM users are requiring more physician-based medical services in primary care than users of conventional medicine.

Studying Effects of Primary Care Physicians and Patients on the Trade-Off Between Charges for Primary Care and Specialty Care Using a Hierarchical Multivariate Two-Part Model

Objective. To examine effects of primary care physicians (PCPs) and patients on the association between charges for primary care and specialty care in a point-of-service (POS) health plan. Data Source. Claims from 1996 for 3,308 adult male POS plan members, each of whom was assigned to one of the 50 family practitioner-PCPs with the largest POS plan member-loads. Study Design. A hierarchical multivariate two-part model was fitted using a Gibbs sampler to estimate PCPs' effects on patients' annual charges for two types of services, primary care and specialty care, the associations among PCPs' effects, and within-patient associations between charges for the two services. Adjusted Clinical Groups (ACGs) were used to adjust for case-mix. Principal Findings. PCPs with higher case-mix adjusted rates of specialist use were less likely to see their patients at least once during the year (estimated correlation: –.40; 95% CI: –.71, –.008) and provided fewer services to patients that they saw (estimated correlation: –.53; 95% CI: –.77, –.21). Ten of 11 PCPs whose case-mix adjusted effects on primary care charges were significantly less than or greater than zero (p < .05) had estimated, case-mix adjusted effects on specialty care charges that were of opposite sign (but not significantly different than zero). After adjustment for ACG and PCP effects, the within-patient, estimated odds ratio for any use of primary care given any use of specialty care was .57 (95% CI: .45, .73). Conclusions. PCPs and patients contributed independently to a trade-off between utilization of primary care and specialty care. The trade-off appeared to partially offset significant differences in the amount of care provided by PCPs. These findings were possible because we employed a hierarchical multivariate model rather than separate univariate models.

Human and embodied energy analysis applied to water source protection and household water treatment interventions used in Mali, West Africa

As water quality interventions are scaled up to meet the Millennium Development Goal of halving the proportion of the population without access to safe drinking water by 2015 there has been much discussion on the merits of household- and source-level interventions. This study furthers the discussion by examining specific interventions through the use of embodied human and material energy. Embodied energy quantifies the total energy required to produce and use an intervention, including all upstream energy transactions. This model uses material quantities and prices to calculate embodied energy using national economic input/output-based models from China, the United States and Mali. Embodied energy is a measure of aggregate environmental impacts of the interventions. Human energy quantifies the caloric expenditure associated with the installation and operation of an intervention is calculated using the physical activity ratios (PARs) and basal metabolic rates (BMRs). Human energy is a measure of aggregate social impacts of an intervention. A total of four household treatment interventions – biosand filtration, chlorination, ceramic filtration and boiling – and four water source-level interventions – an improved well, a rope pump, a hand pump and a solar pump – are evaluated in the context of Mali, West Africa. Source-level interventions slightly out-perform household-level interventions in terms of having less total embodied energy. Human energy, typically assumed to be a negligible portion of total embodied energy, is shown to be significant to all eight interventions, and contributing over half of total embodied energy in four of the interventions. Traditional gender roles in Mali dictate the types of work performed by men and women. When the human energy is disaggregated by gender, it is seen that women perform over 99% of the work associated with seven of the eight interventions. This has profound implications for gender equality in the context of water quality interventions, and may justify investment in interventions that reduce human energy burdens.

Can outcome prediction data change patient outcomes and organizational outcomes?

PURPOSE OF REVIEW: Intensive care medicine consumes a high share of healthcare costs, and there is growing pressure to use the scarce resources efficiently. Accordingly, organizational issues and quality management have become an important focus of interest in recent years. Here, we will review current concepts of how outcome data can be used to identify areas requiring action. RECENT FINDINGS: Using recently established models of outcome assessment, wide variability between individual ICUs is found, both with respect to outcome and resource use. Such variability implies that there are large differences in patient care processes not only within the ICU but also in pre-ICU and post-ICU care. Indeed, measures to improve the patient process in the ICU (including care of the critically ill, patient safety, and management of the ICU) have been presented in a number of recently published papers. SUMMARY: Outcome assessment models provide an important framework for benchmarking. They may help the individual ICU to spot appropriate fields of action, plan and initiate quality improvement projects, and monitor the consequences of such activity.