Customer Driven Service Development – Technology-based Care and Services for the Elderly

The objective of this master’s thesis was to examine technology-based smart home devices and services. Topic was approached through basic theories, transaction cost theory and resource-based view in order to build basis for this thesis. Conceptual framework was discussed by means of networks, value networks and service systems which provide a useful framework for service development. The needs of the elderly living at home were discussed in order to find out which technology-based services could be used to satisfy the needs. Segmentation and need data collected previously during proactive home visits was exploited and additionally a survey targeted to experts and professionals of social and health care sector was done to verify the needs. Finally, the results of the survey were analyzed using quality function deployment method to figure out the most important and suitable service offerings for the elderly. As a conclusion of analysis, social media and monitoring services are the most useful technology-based services. However, traditional home services will still maintain their necessity too.

Kuulla vai kuunnella – käyttäjää osallistavan palveluinnovoinnin lähestymistavan toteuttamisen haasteita julkisella sektorilla

Julkisen sektorin itsensä synnyttämien innovaatioiden ja innovoinnin näkökulma on verrattain tuore innovaatiotutkimuksen tutkimuskohde. Vielä uudempaa lähestymistapaa edustaa käyttäjälähtöinen ja käyttäjää osallistava palveluinnovaatiotutkimus julkisella sektorilla. Käyttäjälähtöisen ja käyttäjää osallistavan palveluinnovoinnin lähestymistavan toteuttamisesta ollaan kiinnostuneita, mutta tieteelliseen tutkimukseen perustuva tieto lähestymistavasta on vielä kohtuullisen niukkaa. Tämän käyttäjälähtöiseen palvelujen innovointiin keskittyvän väitöskirjatutkimuksen päätavoitteena on mikrotasolla tunnistaa ja ryhmitellä käyttäjää osallistavan palveluinnovoinnin lähestymistavan toteuttamisen haasteita julkisella sektorilla. Väitöskirjatutkimuksen alatavoitteena on tutkimuksesta saatavan tiedon avulla muodostaa kysymyslista tukemaan lähestymistavan käyttöönottamista ja toteuttamista julkisen sektorin palveluorganisaatioissa ja -verkostoissa. Julkisen palvelusektorin ohella väitöskirjan tutkimustuloksia voivat soveltuvin osin hyödyntää myös yksityisen ja kolmannen sektorin palveluorganisaatiot ja -verkostot sekä käyttäjälähtöisen innovaatiopolitiikan suunnitteluun ja sen jalkauttamiseen osallistuvat tahot. Haasteita lähestytään tutkimuksessa käyttäjälähtöisen ja käyttäjää osallistavan palveluinnovoinnin lähestymistavan piirteiden kautta ja haasteita tarkastellaan kehittäjäviranomaisten (ryhmätaso) näkökulmasta. Kuntasektori on valittu tutkimukseen edustamaan julkista sektoria. Lähestymistavan piirteiksi tutkimuksessa määritellään käyttäjänäkökulman ohjaava rooli organisaation innovaatiotoiminnan strategisella tasolla ja palvelujen uudistamisprosessien tasoilla, avoimuus (erityisesti käyttäjärajapinta) ja tulkinnallisuus innovaatioprosessien varhaisessa vaiheessa sekä laaja-alainen käsitys innovaatioiden lähteistä käyttäjänäkökulmaa muodostettaessa. Tutkimuksen kohteena on hyvinvointipalveluinnovaatioprosessien varhainen vaihe, jolloin keskeisessä asemassa on uusien ideoiden sekä uuden tiedon ja ymmärryksen hankinta hyödynnettäväksi innovaatioprosessien seuraavissa vaiheissa. Tutkimuksessa rajaudutaan käyttäjälähtöisen palveluinnovoinnin muotoon, jossa käyttäjät intentionaalisesti ja konkreettisesti osallistetaan kehittäjäviranomaisjohtoisiin palveluinnovaatioprosesseihin. Käyttäjiksi tutkimuksessa ymmärretään palvelun loppukäyttäjät palvelujen ”ulkoisina hyödyntäjinä” ja yli sektorialisten palveluprosessien henkilöstö palvelujen ”sisäisinä hyödyntäjinä”. Hyvinvointipalveluista tutkimuksessa ovat edustettuina sosiaali- ja terveyspalvelut sekä ikäihmisten palvelukeskusten tarjoamat palvelut. Kuntasektorin innovaatiotoiminnan kenttä ymmärretään tutkimuksessa verkostomaisena kokonaisuutena, joka ylittää kuntien hallinnolliset rajat. Artikkeliväitöskirjana toteutetun väitöskirjatutkimuksen metodologia perustuu usean tapauksen tapaustutkimukseen (multiple case-studies) ja kvalitatiiviseen tutkimusotteeseen. Työn empiirinen osuus koostuu viidestä artikkelina julkaistusta osatutkimuksesta. Osatutkimuksissa käytetään tapaustutkimuksen eri variaatioita, ja tutkimusaineistot on kerätty kolmesta eri perustutkimusympäristöstä. Osatutkimuksien tapaukset on valittu palvelun käyttäjien ”äänen jatkumon” (the voice of the customer) eri kohdista. Käyttäjän ääntä käytetään tutkimuksessa metodisena ratkaisuna ja metaforana. Lisäksi käyttäjän ääni ymmärretään tutkimuksessa paremminkin kollektiivisena ja laajemmista palvelujen kehittämisnäkökulmista kertovana tekijänä kuin yksittäisten palvelun käyttäjien tarpeista ja toiveista kertovana metaforana. Käyttäjää osallistavan palveluinnovoinnin lähestymistavan toteuttamisen haasteiksi julkisella sektorilla tutkimuksessa tunnistetaan viisi haastetta. Tiivistetysti haasteena on 1. palvelujen käyttäjien subjektiuteen perustuva käyttäjälähtöisyys palvelujen uudistamisessa 2. tunnistaa palvelun käyttäjät innovaatiotoiminnan voimavarana ja rohkaistua heidän osallistamiseensa 3. sitoutuminen yhteistoiminnallisuuteen käyttäjä- ja muita rajapintoja ylittävissä palvelujen uudistamisprosesseissa ja innovaatiohakuisuus työskentelyssä 4. oivaltaa palvelutoivelistoja ja asiakaspalautteita laajempia kehittämisnäkökulmia 5. synnyttää luottamukseen perustuva hyvä kierre palvelun käyttäjien ja kehittäjien välille. Tutkimustuloksena syntyneet haasteet paikannetaan tutkimuksessa käyttäjän äänen jatkumolle erilaisin painotuksin. Lisäksi tutkimustulosten pohjalta tehdään kolme keskeistä johtopäätöstä. Ensinnäkin palvelun kehittäjätahon sekä palvelun loppukäyttäjien ja palvelujen sisäisten hyödyntäjien väliltä on tunnistettavissa innovaatiopotentiaalia sisältäviä rakenteellisia aukkoja. Toiseksi kehittäjäviranomaistahon valmius ja halu laajentaa tiedonmuodostustaan palvelujen uudistamisessa palvelun käyttäjien kanssa yhteisöllisen tiedonmuodostuksen suuntaan on puutteellinen. Kolmanneksi palvelujen kehittäjätaho ei ole sisäistänyt riittävässä määrin käyttäjää osallistavan palveluinnovoinnin lähestymistavan metodologisia perusajatuksia. Tutkimuksessa tunnistetut viisi haastetta osoittavat, että käyttäjää osallistavan palveluinnovoinnin lähestymistavan käyttöönotto hyvinvointipalveluorganisaation tai -verkoston palvelujen innovoinnin lähestymistavaksi ei ole mekaaninen toimenpide. Lähestymistavan käyttöönottoa tukeva kysymyslista perustuu tutkimuksessa tunnistettuihin haasteisiin. Kysymyslista on laadittu siten, että kysymykset liittyvät laajasti julkisten palveluorganisaatioiden ja -verkostojen innovaatiokulttuuriin. Kaksiosaisen kysymyslistan ensimmäisen osan kysymykset käsittelevät innovointia ohjaavia mentaalisia malleja. Ensimmäisessä osassa esitetään esimerkiksi seuraava kysymys: ”Millaista käsitystäpalvelun käyttäjistä (kuntalaisista) sekä käyttäjien ja kehittäjien (viranomaisten) välisestä suhteesta ilmennämme palvelujen innovoinnissa; onko palvelujen käyttäjä (kuntalainen) kohde, jolle kehitetään palveluja, vai onko hän jopa välttämätön kehittämiskumppani?”. Kysymyslistan toisen osan kysymykset liittyvät innovaatiokäytänteisiin ja valmiuksiin. Esimerkkinä voidaan mainita seuraava kaksiosainen kysymys: ”Tukevatko innovaatiokäytänteemme käyttäjärajapinnan ylittäviä innovaatioprosesseja ja sitoudummeko avoimin mielin työskentelyyn palvelun käyttäjien, potentiaalisten käyttäjien tai ei-käyttäjien kanssa? Mitä hyötyjä koemme yhteistoiminnallisuudesta koituvan meille ja käyttäjille sekä innovaation laatuominaisuuksiin?”. Mitä tulee tutkimuksen otsikon alkuosaan ”kuulla vai kuunnella”, vastaus on, että pääpaino on sanalla ”kuulla”. Pohdintaluvussa tuodaan myös esille tarve – tai ainakin kriittisen tarkastelun tarve – käyttäjälähtöisen ja käyttäjää osallistavan palveluinnovoinnin käsitteen ja sen luonteen sekä tavoitteiden määrittelemiselle julkisen sektorin ominaispiirteistä käsin vastapainona alkuperältään yksityisen sektorin liiketoimintakontekstista lähtöisin oleville määrittelyille.

Competence in intensive and critical care nursing - development of a basic assessment scale for graduating nursing students

Intensive and critical care nursing is a speciality in its own right and with its own nature within the nursing profession. This speciality poses its own demands for nursing competencies. Intensive and critical care nursing is focused on severely ill patients and their significant others. The patients are comprehensively cared for, constantly monitored and their vital functions are sustained artificially. The main goal is to win time to cure the cause of the patient’s situation or illness. The purpose of this empirical study was i) to describe and define competence and competence requirements in intensive and critical care nursing, ii) to develop a basic measurement scale for competence assessment in intensive and critical care nursing for graduating nursing students, and iii) to describe and evaluate graduating nursing students’ basic competence in intensive and critical care nursing by seeking the reference basis of self-evaluated basic competence in intensive and critical care nursing from ICU nurses. However, the main focus of this study was on the outcomes of nursing education in this nursing speciality. The study was carried out in different phases: basic exploration of competence (phase 1 and 2), instrumentation of competence (phase 3) and evaluation of competence (phase 4). Phase 1 (n=130) evaluated graduating nursing students’ basic biological and physiological knowledge and skills for working in intensive and critical care with Basic Knowledge Assessment Tool version 5 (BKAT-5, Toth 2012). Phase 2 focused on defining competence in intensive and critical care nursing with the help of literature review (n=45 empirical studies) as well as competence requirements in intensive and critical care nursing with the help of experts (n=45 experts) in a Delphi study. In phase 3 the scale Intensive and Critical Care Nursing Competence Scale (ICCN-CS) was developed and tested twice (pilot test 1: n=18 students and n=12 nurses; pilot test 2: n=56 students and n=54 nurses). Finally, in phase 4, graduating nursing students’ competence was evaluated with ICCN-CS and BKAT version 7 (Toth 2012). In order to develop a valid assessment scale of competence for graduating nursing students and to evaluate and establish the competence of graduating nursing students, empirical data were retrieved at the same time from both graduating nursing students (n=139) and ICU nurses (n=431). Competence can be divided into clinical and general professional competence. It can be defined as a specific knowledge base, skill base, attitude and value base and experience base of nursing and the personal base of an intensive and critical care nurse. Personal base was excluded in this self-evaluation based scale. The ICCN-CS-1 consists of 144 items (6 sum variables). Finally, it became evident that the experience base of competence is not a suitable sum variable in holistic intensive and critical care competence scale for graduating nursing students because of their minor experience in this special nursing area. ICCN-CS-1 is a reliable and tolerably valid scale for use among graduating nursing students and ICU nurses Among students, basic competence of intensive and critical care nursing was self-rated as good by 69%, as excellent by 25% and as moderate by 6%. However, graduating nursing students’ basic biological and physiological knowledge and skills for working in intensive and critical care were poor. The students rated their clinical and professional competence as good, and their knowledge base and skill base as moderate. They gave slightly higher ratings for their knowledge base than skill base. Differences in basic competence emerged between graduating nursing students and ICU nurses. The students’ self-ratings of both their basic competence and clinical and professional competence were significantly lower than the nurses’ ratings. The students’ self-ratings of their knowledge and skill base were also statistically significantly lower than nurses’ ratings. However, both groups reported the same attitude and value base, which was excellent. The strongest factor explaining students’ conception of their competence was their experience of autonomy in nursing. Conclusions: Competence in intensive and critical care nursing is a multidimensional concept. Basic competence in intensive and critical care nursing can be measured with self-evaluation based scale but alongside should be used an objective evaluation method. Graduating nursing students’ basic competence in intensive and critical care nursing is good but their knowledge and skill base are moderate. Especially the biological and physiological knowledge base is poor. Therefore in future in intensive and critical care nursing education should be focused on both strengthening students’ biological and physiological knowledge base and on strengthening their overall skill base. Practical implications are presented for nursing education, practice and administration. In future, research should focus on education methods and contents, mentoring of clinical practice and orientation programmes as well as further development of the scale.

Palveluasumisen markkinapotentiaali Suomessa asuvien venäjänkielisten ikäihmisten keskuudessa - Analyysi markkinoista ja kuluttajakäyttäytymisestä

Tutkimus on toimeksianto Yritykseltä X, joka halusi selvitettävän, millaista markkinapotentiaalia on nähtävissä ikäihmisten palveluasumisessa Suomessa asuville venäjänkielisille. Markkinoiden analysoinnin lisäksi tutkimuksessa on selvitetty kohderyhmän kuluttajakäyttäytymistä ja ostokykyä. Tutkimuksen tavoitteena ei ole antaa toimeksiantajalle valmista investointipäätöstä, vaan tuoda tietoa markkinoista ja kohderyhmästä päätöksenteon tueksi. Käytössä on ollut neljä empiiristä aineistoa. Primääriaineistona ovat asiantuntija¬haastattelut sekä kyselyt Yrityksen X venäjänkielisille työntekijöille ja maksaja-asiakkaille – eli kuntien ja sairaanhoitopiirien edustajille. Sekundääriaineistona on joukko suomalaisten Venäjä-asiantuntijoiden viime vuosien tutkimuksia. Pro gradun teoriaosuus on tiivis. Teorian on auttanut kirjoittajaa tarkastelemaan palveluasumisen markkinoita kansainvälisellä vivahteella sekä suomalaisittain uuden kuluttajaryhmän kuluttajakäyttäytymistä ja ostokykyä. Suomessa asuvia venäjänkielisiä ikäihmisiä ei ole aikaisemmassa tutkimuksessa tarkasteltu omana kohderyhmänään, mutta heistä on tehty paljon yhteiskunnallista tutkimusta. Tätä on hyödynnetty muun muassa tarkasteltaessa kohderyhmän kulttuurisia piirteitä, sosiaalisia tapoja, kieltä ja uskontoa. Suomessa asuvista venäjänkielisistä ikäihmistä ei voi puhua yhtenäisenä ryhmänä. Osa yli 65-vuotiaista on suomen kielen taitoisia ja työssään menestyneitä, mutta monen maahanmuuttajan sosiaalinen asema laski heidän muuttaessaan Suomeen. Neuvostoliitossa asuneet ovat tottuneet niukkoihin olosuhteisiin, siihen että samassa taloudessa asui jopa kolme sukupolvea, ja että perhe piti huolta yhteiskunnan tuen ollessa niukkaa. Vaikka venäläisessä kulttuurissa vanhainkodeilla on huono maine, voidaan Suomessa asuvien ikäihmisten keskuudessa nähdä positiivista suhtautumista palveluasumista ja suomalaisia julkispalveluja kohtaan. Mikäli Yritys X rakentaa yksikön Lappeenrantaan, kannattaa potentiaalisina asiakkaina nähdä myös venäläiset terveysmatkailijat ja suunnitella palvelutarjonta laajemmin kuin vain Suomessa asuville venäjänkielisille. Mikäli yksikkö tulee Helsinkiin, on kilpailijana ortodokseille ja venäjänkielisille vanhuksille tarkoitettu Helenan vanhainkoti.

Cost-effectiveness analysis in South Karelia Central Hospital

The target organization of this study, otherwise South-Karelia Social and Health Care District (Eksote) provides health, senior, family and social welfare services. South Karelia Central Hospital provides special health care and offers health services from all of the most important medical specialties. Eksote has in use 15D instrument to measure the health-related quality of life (HRQoL) of their patients before and after their interventions for observing the health effects of the medical care. Furthermore, 15D allows measuring the effectiveness and cost-effectiveness of health care when comparing these before and after results of the 15D measurements and adding the costs of the interventions into this research. The main purposes of this study were to analyze the effectiveness and cost-effectiveness of medical care in South Karelia Central Hospital by using the gathered 15D data to calculate effectiveness and cost-effectiveness ratios and to analyze the reliability and availability of the data. Study has been conducted using literature review and quantitative research methods. The results indicate that from the patients within the eight units selected to this study the 15D change information was available from the 52 %, the 15D change and the cost information from 38 % and the information of quality-adjusted life years (QALYs) produced and the cost information from 35 %. The effectiveness and cost-effectiveness of medical care were greatest at the units of Pain Outpatient Clinic and Rheumatic Diseases Outpatient Clinic. The most effective medical care is given in the unit where the average price of one produced QALY is the highest (Orthopedics). However, the calculated standard deviations pointed out that there are great variances in the effectiveness and cost-effectiveness within the units also.

Continuity of patient care in day surgery

Continuity is a part of high-quality patient care. The purpose of this study was to analyse what factors are important in the continuity of patients’ care, and how well continuity is achieved in different stages of the care of day surgical patients. Day surgery has become significantly more prevalent in the past few decades, and in order for it to be carried out successfully, continuity in care is particularly essential. The study was carried out in two stages. In the first stage (2001–2005) of the study, continuity was examined through a review of literature from the perspective of critical pathways, naming the continuity categories of time flow, coordination flow, caring relationship flow, and information flow. The first stage also entailed an analysis of matters important to the patient and problems concerning the achievement of care continuity, carried out by interviewing 25 day surgical patients. In the second stage (2006–2015), the degree to which the continuity of day surgical patient care was achieved was analysed from the perspective of patients (n=203, 58%) and nurses working in day surgery units (n=83, 69%), and suggestions for developing the continuity of day surgery patient care were made. In this study continuity of care was examined through a review of literature from the perspective of critical pathways, naming the continuity categories of time flow, coordination flow, caring relationship flow, and information flow. Within these categories, several important factors for the patient were found. According to both patients and nurses, continuity of care is generally achieved to a high degree. Continuity of care is improved by patients being acquainted with and meeting the staff attending to them (nurse and surgeon) before and after the operation. From patients’ perspective, there is room for improvement especially in terms of being admitted to care and in the carer-patient relationship. From nurses’ perspective, there is room for improvement in terms of the smoothness of care. Nurses evaluated the continuity of care to be the least successful before and after the operation. An extensive social and health care reform is planned in Finland in the coming years, aiming to enhance social and health care services and to create smoothly functioning service and care. As a topic of further study supporting the development of the service system, it is important to follow the patient’s progress throughout the entire chain of care, e.g. as a case study. On the other hand, there is also a need to study the views of nurses and other health care professionals in health care, e.g. in primary health care.

Disability as a determinant of access to health care services in Colombia

The relationship between disability and poverty has been described in different contexts. Nevertheless, the basic characteristics of this relationship have not yet been fully established. The social exclusion and discrimination against people with disabilities increase the risk of poverty and reduce the access to basic opportunities such as health and education. This study examines the impact of a health limitation and poverty in the access to health care services in Colombia. Data from the Colombian National Health Survey (2007) was used in the analysis. Variables related with health condition and socio economic characteristics were first generated. Then interactions between health limitations and the lower levels of the asset index were created. This variable gave information related to the relationship between disability and poverty. A probabilistic model was estimated to examine the impact of a health condition and the relation between poverty and disability on the access to health care. The results suggest that living with a physical limitation increases by 10% the probability of access to health care services in Colombia. However, people with a disability and in the lowest quartile of the asset index have a 5% less probability of access to health care services. We conclude that people who live with a physical, mental or sensorial limitation have a higher probability of access to health care services. However, poor and disabled people have a lower probability in access, which increases the risk of having a severe disease and become chronically poor.

Health care network formation and policyholders' welfare

We develop a model in which two insurers and two health care providers compete for a fixed mass of policyholders. Insurers compete in premium and offer coverage against financial consequences of health risk. They have the possibility to sign agreements with providers to establish a health care network. Providers, partially altruistic, are horizontally differentiated with respect to their physical address. They choose the health care quality and compete in price. First, we show that policyholders are better off under a competition between conventional insurance rather than under a competition between integrated insurers (Managed Care Organizations). Second, we reveal that the competition between a conventional insurer and a Managed Care Organization (MCO) leads to a similar equilibrium than the competition between two MCOs characterized by a different objective i.e. private versus mutual. Third, we point out that the ex ante providers’ horizontal differentiation leads to an exclusionary equilibrium in which both insurers select one distinct provider. This result is in sharp contrast with frameworks that introduce the concept of option value to model the (ex post) horizontal differentiation between providers.

Calories, obesity and health in OECD countries

Theoretical models suggest that decisions about diet, weight and health status are endogenous within a utility maximization framework. In this article, we model these behavioural relationships in a fixed-effect panel setting using a simultaneous equation system, with a view to determining whether economic variables can explain the trends in calorie consumption, obesity and health in Organization for Economic Cooperation and Development (OECD) countries and the large differences among the countries. The empirical model shows that progress in medical treatment and health expenditure mitigates mortality from diet-related diseases, despite rising obesity rates. While the model accounts for endogeneity and serial correlation, results are affected by data limitations.

Robots with a gentle touch: advances in assistive robotics and prosthetics

As healthcare costs rise and an aging population makes an increased demand on services, so new techniques must be introduced to promote an individuals independence and provide these services. Robots can now be designed so they can alter their dynamic properties changing from stiff to flaccid, or from giving no resistance to movement, to damping any large and sudden movements. This has some strong implications in health care in particular for rehabilitation where a robot must work in conjunction with an individual, and might guiding or assist a persons arm movements, or might be commanded to perform some set of autonomous actions. This paper presents the state-of-the-art of rehabilitation robots with examples from prosthetics, aids for daily living and physiotherapy. In all these situations there is the potential for the interaction to be non-passive with a resulting potential for the human/machine/environment combination to become unstable. To understand this instability we must develop better models of the human motor system and fit these models with realistic parameters. This paper concludes with a discussion of this problem and overviews some human models that can be used to facilitate the design of the human/machine interfaces.

Assessing feasibility and acceptability of study procedures : getting ready for implementation of national stroke guidelines in out-patient health care

BACKGROUND: Even though Swedish national guidelines for stroke care (SNGSC) have been accessible for nearly a decade access to stroke rehabilitation in out-patient health care vary considerably. In order to aid future interventions studies for implementation of SNGSC, this study assessed the feasibility and acceptability of study procedures including analysis of the context in out-patient health care settings. METHODS: The feasibility and acceptability of recruitment, observations and interviews with managers, staff and patients were assessed, as well as the feasibility of surveying health care records. RESULTS: To identify patients from the the hospitals was feasible but not from out-patient care where a need to relieve clinical staff of the recruitment process was identified. Assessing adherence to guidelines and standardized evaluations of patient outcomes through health care records was found to be feasible and suitable assessment tools to evaluate patient outcome were identified. Interviews were found to be a feasible and acceptable tool to survey the context of the health care setting. CONCLUSION: In this feasibility study a variety of qualitative and quantitative data collection procedures and measures were tested. The results indicate what can be used as a set of feasible and acceptable data collection procedures and suitable measures for studying implementation of stroke guidelines in an out-patient health care context.

Knowledge and practice of women regarding cervical cancer in a primary health care unit

Objectives: evaluating the level of information about the examination of uterine cervical cancer and its association with sociodemographic variables in women of a health care unit in the city of Bauru, São Paulo, Brazil. Methods: we conducted a cross-sectional descriptive study with 370 women aged 25 to 59, through structured interviews in their own homes; we used descriptive statistics and the χ2 test. Results: 40.5% of the women had not undergone the Papanicolaou test at the recommended frequency; 58.2% incorrectly defined the test, and 69.5% did not know about the risk factors for the development of cervical cancer; the knowledge about the test showed statistically significant association with schooling and family income of the studied population. Conclusions: women present deficiencies on the proper practice of the Papanicolaou test, on knowledge about the test, risk factors and prevention methods. Therefore, it is necessary to develop primary health actions for the most vulnerable population.

Reproduction and maternal health care among young women in Kenya: geographic and socio-economic determinants

Many factors influence the propensity of young women to seek appropriate maternal healthcare, and they need to be considered when analyzing these women’s reproductive behavior. This study aimed to contribute to the analysis concerning Kenyan young women’s determinants on maternal healthcare-seeking behavior for the 5 years preceding the 2008/9 Kenya Demographic and Health Survey. The specific objectives were to: investigate the individual and contextual variables that may explain maternal healthcare habits; measure the individual, household and community effect on maternal healthcare attitudes in young women; assess the link between young women’s characteristics and the use of facilities for maternal healthcare; find a relationship between young women’s behavior and the community where they live; examine how the role of the local presence of healthcare facilities influences reproductive behavior, and if the specificity of services offered by healthcare facilities affects their inclination to use healthcare facilities, and measure the geographic differences that influence the propensity to seek appropriate maternal healthcare. The analysis of factors associated with maternal healthcare-seeking behavior for young women in Kenya was investigated using multilevel models. We performed three major analyses, which concerned the individual and contextual determinants influencing antenatal care (discussed in Part 6), delivery care (Part 7), and postnatal care (Part 8). Our results show that there is a significant variation in antenatal, delivery and postnatal care between communities, even if the majority of variability is explained by individual characteristics. There are differences at the women’s level on the probability of receiving antenatal care and delivering in a healthcare facility instead of at home. Moreover, community factors and availability of healthcare facilities on the territory are also crucial in influencing young women’s behavior. Therefore, policies addressed to youth’s reproductive health should also consider geographic inequalities and different types of barriers in access to healthcare facilities.

Estimating the prevalence of comorbid conditions and their effect on health care costs in patients with diabetes mellitus in Switzerland.

BACKGROUND Estimating the prevalence of comorbidities and their associated costs in patients with diabetes is fundamental to optimizing health care management. This study assesses the prevalence and health care costs of comorbid conditions among patients with diabetes compared with patients without diabetes. Distinguishing potentially diabetes- and nondiabetes-related comorbidities in patients with diabetes, we also determined the most frequent chronic conditions and estimated their effect on costs across different health care settings in Switzerland. METHODS Using health care claims data from 2011, we calculated the prevalence and average health care costs of comorbidities among patients with and without diabetes in inpatient and outpatient settings. Patients with diabetes and comorbid conditions were identified using pharmacy-based cost groups. Generalized linear models with negative binomial distribution were used to analyze the effect of comorbidities on health care costs. RESULTS A total of 932,612 persons, including 50,751 patients with diabetes, were enrolled. The most frequent potentially diabetes- and nondiabetes-related comorbidities in patients older than 64 years were cardiovascular diseases (91%), rheumatologic conditions (55%), and hyperlipidemia (53%). The mean total health care costs for diabetes patients varied substantially by comorbidity status (US$3,203-$14,223). Patients with diabetes and more than two comorbidities incurred US$10,584 higher total costs than patients without comorbidity. Costs were significantly higher in patients with diabetes and comorbid cardiovascular disease (US$4,788), hyperlipidemia (US$2,163), hyperacidity disorders (US$8,753), and pain (US$8,324) compared with in those without the given disease. CONCLUSION Comorbidities in patients with diabetes are highly prevalent and have substantial consequences for medical expenditures. Interestingly, hyperacidity disorders and pain were the most costly conditions. Our findings highlight the importance of developing strategies that meet the needs of patients with diabetes and comorbidities. Integrated diabetes care such as used in the Chronic Care Model may represent a useful strategy.

Premature Discontinuation of Randomized Trials in Critical and Emergency Care: A Retrospective Cohort Study.

OBJECTIVES Randomized clinical trials that enroll patients in critical or emergency care (acute care) setting are challenging because of narrow time windows for recruitment and the inability of many patients to provide informed consent. To assess the extent that recruitment challenges lead to randomized clinical trial discontinuation, we compared the discontinuation of acute care and nonacute care randomized clinical trials. DESIGN Retrospective cohort of 894 randomized clinical trials approved by six institutional review boards in Switzerland, Germany, and Canada between 2000 and 2003. SETTING Randomized clinical trials involving patients in an acute or nonacute care setting. SUBJECTS AND INTERVENTIONS We recorded trial characteristics, self-reported trial discontinuation, and self-reported reasons for discontinuation from protocols, corresponding publications, institutional review board files, and a survey of investigators. MEASUREMENTS AND MAIN RESULTS Of 894 randomized clinical trials, 64 (7%) were acute care randomized clinical trials (29 critical care and 35 emergency care). Compared with the 830 nonacute care randomized clinical trials, acute care randomized clinical trials were more frequently discontinued (28 of 64, 44% vs 221 of 830, 27%; p = 0.004). Slow recruitment was the most frequent reason for discontinuation, both in acute care (13 of 64, 20%) and in nonacute care randomized clinical trials (7 of 64, 11%). Logistic regression analyses suggested the acute care setting as an independent risk factor for randomized clinical trial discontinuation specifically as a result of slow recruitment (odds ratio, 4.00; 95% CI, 1.72-9.31) after adjusting for other established risk factors, including nonindustry sponsorship and small sample size. CONCLUSIONS Acute care randomized clinical trials are more vulnerable to premature discontinuation than nonacute care randomized clinical trials and have an approximately four-fold higher risk of discontinuation due to slow recruitment. These results highlight the need for strategies to reliably prevent and resolve slow patient recruitment in randomized clinical trials conducted in the critical and emergency care setting.