Referral patterns and proximity to palliative care inpatient services by level of socio-economic disadvantage : a national study using spatial analysis

Background: A range of health outcomes at a population level are related to differences in levels of social disadvantage. Understanding the impact of any such differences in palliative care is important. The aim of this study was to assess, by level of socio-economic disadvantage, referral patterns to specialist palliative care and proximity to inpatient services. Methods: All inpatient and community palliative care services nationally were geocoded (using postcode) to one nationally standardised measure of socio-economic deprivation – Socio-Economic Index for Areas (SEIFA; 2006 census data). Referral to palliative care services and characteristics of referrals were described through data collected routinely at clinical encounters. Inpatient location was measured from each person’s home postcode, and stratified by socio-economic disadvantage. Results: This study covered July – December 2009 with data from 10,064 patients. People from the highest SEIFA group (least disadvantaged) were significantly less likely to be referred to a specialist palliative care service, likely to be referred closer to death and to have more episodes of inpatient care for longer time. Physical proximity of a person’s home to inpatient care showed a gradient with increasing distance by decreasing levels of socio-economic advantage. Conclusion: These data suggest that a simple relationship of low socioeconomic status and poor access to a referral-based specialty such as palliative care does not exist. Different patterns of referral and hence different patterns of care emerge.

Retrospective observational study of patients who present to Australian rural emergency departments with undifferentiated chest pain

Aim To identify the demographic and clinical characteristics of patients who present to Australian rural emergency departments with chest pain. Design Retrospective, observational study Setting Rural emergency departments (ED) in Queensland, Australia Participants 337 consecutive adult patients with undifferentiated chest pain that presented between 1st September 2013 and 30th November 2013. Main outcome measures Service indicators, discharge diagnoses and disposition Results Presentations for undifferentiated chest pain represented 3.5% of all patient presentations during the sampling period. The mean age of patients was 48 years and 54% were male. Overall, 92% of patients left the ED within the 4-hour NEAT target. The majority of presentations were related to cardiac concerns (39%), followed by non-cardiac chest pain (17%), musculoskeletal (15%) and respiratory (10%) conditions. More than half of these patients were discharged at the completion of the ED service (52.8%), 40.6% were admitted, 3.3% left at own risk, 2.4% did not wait and less than 1% of patients required transfer to another hospital directly from the ED. Conclusions This study has provided information on the characteristics and processes of care for patients presenting to Australian rural EDs with undifferentiated chest pain that will inform service planning and further research to evaluate the effectiveness of care for these patients.

Managing knowledge for asset management : shifting from process to relational frames

The purpose of this paper is to review existing knowledge management (KM) practices within the field of asset management, identify gaps, and propose a new approach to managing knowledge for asset management. Existing approaches to KM in the field of asset management are incomplete with the focus primarily on the application of data and information systems, for example the use of an asset register. It is contended these approaches provide access to explicit knowledge and overlook the importance of tacit knowledge acquisition, sharing and application. In doing so, current KM approaches within asset management tend to neglect the significance of relational factors; whereas studies in the knowledge management field have showed that relational modes such as social capital is imperative for ef-fective KM outcomes. In this paper, we argue that incorporating a relational ap-proach to KM is more likely to contribute to the exchange of ideas and the devel-opment of creative responses necessary to improve decision-making in asset management. This conceptual paper uses extant literature to explain knowledge management antecedents and explore its outcomes in the context of asset man-agement. KM is a component in the new Integrated Strategic Asset Management (ISAM) framework developed in conjunction with asset management industry as-sociations (AAMCoG, 2012) that improves asset management performance. In this paper we use Nahapiet and Ghoshal’s (1998) model to explain antecedents of relational approach to knowledge management. Further, we develop an argument that relational knowledge management is likely to contribute to the improvement of the ISAM framework components, such as Organisational Strategic Manage-ment, Service Planning and Delivery. The main contribution of the paper is a novel and robust approach to managing knowledge that leads to the improvement of asset management outcomes.

Youth programs in remote Indigenous communities: Context matters

A diversity of programs oriented to young people seek to develop their capacities and their connection to the communities in which they live. Some focus on ameliorating a particular issue or ‘deficit’ whilst others, such as sporting, recreation and youth groups are more grounded in the community. This article reports a qualitative study undertaken in three remote Indigenous communities in Central Australia. Sixty interviews were conducted with a range of stakeholders involved in a diversity of youth programs. A range of critical challenges for and characteristics of remote Indigenous youth programs are identified if such programs are to be ‘fit for context’. ‘Youth centred-context specific’ provides a positive frame for the delivery of youth programs in remote Central Australia, encouraging an explicit focus on program logic; program content and processes; and relational, temporal, and, spatial aspects of the practice context. These provide lenses with which youth program planning and delivery may be enhanced in remote communities. Culturally safe service planning and delivery suggests locally determined processes for decision-making and community ownership. In some cases, this may mean a community preference for all ages to access the service to engage in culturally relevant activities. Where activities are targeted at young people, yet open to and inclusive of all ages, they provide a medium for cross-generational interaction that requires a high degree of flexibility on the part of staff and funding programs. Although the findings are focused in Central Australia, they may be relevant to similar contexts elsewhere.

NHS Wales user needs study including knowledgebase tools report. Report for Informing Healthcare Strategy implementation programme.

Thomas, R., Spink, S., Durbin, J. & Urquhart, C. (2005). NHS Wales user needs study including knowledgebase tools report. Report for Informing Healthcare Strategy implementation programme. Aberystwyth: Department of Information Studies, University of Wales Aberystwyth. Sponsorship: Informing Healthcare, NHS Wales

UK RRT Incidence in 2009: national and centre-specific analyses

Introduction: This chapter describes the characteristics of
adult patients on renal replacement therapy (RRT) in the
UK in 2009. The prevalence rates per million population
(pmp) were calculated for Primary Care Trusts in England,
Health and Social Care Areas in Northern Ireland, Local
Health Boards in Wales and Health Boards in Scotland.
These areas will be referred to in this report as ‘PCT/HBs’.
Methods: Data were electronically collected from all 72
renal centres within the UK. A series of cross-sectional and
longitudinal analyses were performed to describe the
demographics of prevalent RRT patients in 2009 at centre
and national level. Age and gender standardised ratios for
prevalence rates in PCT/HBs were calculated. Results:
There were 49,080 adult patients receiving RRT in the UK
on 31st December 2009, equating to a UK prevalence of
794 pmp. This represented an annual increase in prevalent
numbers of approximately 3.2% although there was significant
variation between centres and PCT/HB areas. The
growth rate from 2008 to 2009 for prevalent patients by
treatment modality in the UK was 4.2% for haemodialysis
(HD), a fall of 7.2% for peritoneal dialysis (PD) and a
growth of 4.4% with a functioning transplant. There has
been a slow but steady decline in the proportion of PD
patients from 2000 onwards. Median RRT vintage was 5.4
years. The median age of prevalent patients was 57.7
years (HD 65.9 years, PD 61.2 years and transplant 50.8
years). For all ages, prevalence rates in males exceeded
those in females: peaks for males were in the 75–79 years
age group at 2,632 pmp and for females in the 70–74
years age group at 1,445 pmp. The most common identifiable
renal diagnosis was biopsy-proven glomerulonephritis
(16.0%), followed by diabetes (14.7%). Transplantation was
the most common treatment modality (48%), HD in 44%
and PD 8%. However, HD was increasingly common with
increasing age and transplantation less common. Conclusions:
The HD and transplant population continued to
expand whilst the PD population contracted. There were
national, regional and dialysis centre level variations in
prevalence rates. This has implications for service planning
and ensuring equity of care for RRT patients.

Realist synthesis: Critical care rapid response systems.

Background Rapid Response Systems (RRS) consist of four interrelated and interdependent components; an event detection and trigger mechanism, a response strategy, a governance structure and process improvement system. These multiple components of the RRS pose problems in evaluation as the intervention is complex and cannot be evaluated using a traditional systematic review. Complex interventions in healthcare aimed at changing service delivery and related behaviour of health professionals require a different approach to summarising the evidence. Realist synthesis is such an approach to reviewing research evidence on complex interventions to provide an explanatory analysis of how and why an intervention works or doesn’t work in practice. The core principle is to make explicit the underlying assumptions about how an intervention is suppose to work (ie programme theory) and then use this theory to guide evaluation. Methods A realist synthesis process was used to explain those factors that enable or constrain the success of RRS programmes. Results The findings from the review include the articulation of the RRS programme theories, evaluation of whether these theories are supported or refuted by the research evidence and an evaluation of evidence to explain the underlying reasons why RRS works or doesn’t work in practice. Rival conjectured RRS programme theories were identified to explain the constraining factors regarding implementation of RRS in practice. These programme theories are presented using a logic model to highlight all the components which impact or influence the delivery of RRS programmes in the practice setting. The evidence from the realist synthesis provided the foundation for the development of hypothesis to test and refine the theories in the subsequent stages of the Realist Evaluation PhD study [1]. This information will be useful in providing evidence and direction for strategic and service planning of acute care to improve patient safety in hospital. References: McGaughey J, Blackwood B, O’Halloran P, Trinder T. J. & Porter S. (2010) Realistic Evaluation of Early Warning Systems and the Acute Life-threatening Events – Recognition and Treatment training course for early recognition and management of deteriorating ward-based patients: research protocol. Journal of Advanced Nursing 66 (4), 923-932.

A realistic evaluation of track and trigger systems and acute care training for early recognition and treatment of deteriorating ward-based patients: research protocol.

Aim The aim of the study is to evaluate factors that enable or constrain the implementation and service delivery of early warnings systems or acute care training in practice. Background To date there is limited evidence to support the effectiveness of acute care initiatives (early warning systems, acute care training, outreach) in reducing the number of adverse events (cardiac arrest, death, unanticipated Intensive Care admission) through increased recognition and management of deteriorating ward based patients in hospital [1-3]. The reasons posited are that previous research primarily focused on measuring patient outcomes following the implementation of an intervention or programme without considering the social factors (the organisation, the people, external influences) which may have affected the process of implementation and hence measured end-points. Further research which considers the social processes is required in order to understand why a programme works, or does not work, in particular circumstances [4]. Method The design is a multiple case study approach of four general wards in two acute hospitals where Early Warning Systems (EWS) and Acute Life-threatening Events Recognition and Treatment (ALERT) course have been implemented. Various methods are being used to collect data about individual capacities, interpersonal relationships and institutional balance and infrastructures in order to understand the intended and unintended process outcomes of implementing EWS and ALERT in practice. This information will be gathered from individual and focus group interviews with key participants (ALERT facilitators, nursing and medical ALERT instructors, ward managers, doctors, ward nurses and health care assistants from each hospital); non-participant observation of ward organisation and structure; audit of patients' EWS charts and audit of the medical notes of patients who deteriorated during the study period to ascertain whether ALERT principles were followed. Discussion & progress to date This study commenced in January 2007. Ethical approval has been granted and data collection is ongoing with interviews being conducted with key stakeholders. The findings from this study will provide evidence for policy-makers to make informed decisions regarding the direction for strategic and service planning of acute care services to improve the level of care provided to acutely ill patients in hospital. References 1. Esmonde L, McDonnell A, Ball C, Waskett C, Morgan R, Rashidain A et al. Investigating the effectiveness of Critical Care Outreach Services: A systematic review. Intensive Care Medicine 2006; 32: 1713-1721 2. McGaughey J, Alderdice F, Fowler R, Kapila A, Mayhew A, Moutray M. Outreach and Early Warning Systems for the prevention of Intensive Care admission and death of critically ill patients on general hospital wards. Cochrane Database of Systematic Reviews 2007, Issue 3. www.thecochranelibrary.com 3. Winters BD, Pham JC, Hunt EA, Guallar E, Berenholtz S, Pronovost PJ (2007) Rapid Response Systems: A systematic review. Critical Care Medicine 2007; 35 (5): 1238-43 4. Pawson R and Tilley N. Realistic Evaluation. London; Sage: 1997

Needs assessment of people with severe mental illnesses and their families in Azerbaijan

RESUMO: Os indivíduos com doença mental grave, assim como os seus familiares, podem ser caracterizados como uma população em que ocorre uma combinação complexa de necessidades médicas e psicossociais, nomeadamente a nível do diagnóstico e do acesso aos serviços de saúde mental. A avaliação de necessidades pode fornecer informações importantes para o desenvolvimento de intervenções eficazes, tanto a nível da população como a nível individual. Este estudo teve como objetivo determinar as diferentes necessidades reportadas pelos pacientes com doença mental grave e seus familiares , assim como investigar as possíveis relações entre o estado de necessidades e as variáveis sócio-demográficas e clínicas. Simultaneamente, o estudo teve como objetivo avaliar a sobrecarga familiar e a satisfação dos utentes com os serviços de saúde mental. Foi elaborado um estudo transversal, realizado numa amostra de conveniência de cinquenta díades de paciente/membro da família, seguidos em regime de ambulatório no Centro Nacional de Saúde Mental. Foram utilizados como instrumentos de avaliação um questionário sociodemográfico, a Escala Breve de Avaliação Psiquiátrica (BPRS), o questionário de Avaliação de Necessidades de Camberwell (CAN), o Questionário de Avaliação do Envolvimento (IEQ) e a Escala de Verona de Satisfação com os Serviços (VSSS). As mais frequentes necessidades não-satisfeitas foram o ‘sofrimento psicológico’, as ‘atividades sociais’ e os ‘benefícios sociais’. O estudo mostrou uma sobrecarga significativa nas famílias que cuidam de pessoas com doença mental grave, que se correlacionou com as suas opiniões sobre as necessidades dos pacientes e teve um impacto negativo sobre o bem-estar psicológico. Os três mais importantes predictores de sofrimento psíquico em familiares foram o sexo, a situação laboral e a relação com o paciente. A avaliação da satisfação com os serviços revelou a existência de um hiato significativo entre os serviços prestados e os serviços desejados, reportados pelos pacientes e seus familiares. A maioria dos participantes do estudo desejavam ter um trabalho protegido, ou receber ajuda para encontrar emprego. Os resultados deste estudo poderão ser usados para fins de planeamento desenvolvimento e avaliação de serviços de saúde mental no Azerbeijão. Algumas recomendações sobre a melhoria dos serviços de saúde mental para pacientes com doença mental grave e suas famílias são feitas na secção final do trabalho.----------ABSTRACT: Patients suffering from severe mental illness, in addition to their family members, may be characterized as a population with a complex combination of medical and psychosocial needs, which are under-recognized and under-addressed by mental health services. At the same time, needs assessment provides important information necessary for developing effective interventions at both population and individual level. The study was aimed to determine various needs perceived by patients with SMI and their family members, as well as to find out possible relations between the needs and socio-demographic and clinical variables. Similarly the study was intended to evaluate family burden and users’ satisfaction with services. This was a cross-sectional study conducted on a convenience sample. Fifty dyads of a patient and family member applying for out-patient services to the National Mental Health Centre participated in the study. Sociodemographic questionnaire, Brief Psychiatric Rating Scale, Camberwell Assessment of Need, Involvement Evaluation Questionnaire, and Verona Service Satisfaction Scale were used as assessment tools. The most prominent unmet needs reported by people with SMI and their relatives were psychological distress, social activities and welfare benefits. The study showed significant burden in families caring for people with SMI, which correlated with their views about patients’ needs and had a negative impact on the psychological well-being. The three most important predictors of psychological distress in family members were gender, employment status and relationship to patient. Evaluation of satisfaction with services pointed out the gap between provided and desired services reported by patients and their relatives. Most of study participants wished to have sheltered work, or receive help in finding employment. The results of this study may be used for the purposes of mental health service planning, development and evaluation in our country. Some recommendations on improvement of mental health services for patients with SMI and their families have been made in the conclusion.

Management of Traffic Control — A Computer Oriented Approach

Traffic Management system (TMS) comprises four major sub systems: The Network Database Management system for information to the passengers, Transit Facility Management System for service, planning, and scheduling vehicle and crews, Congestion Management System for traffic forecasting and planning, Safety Management System concerned with safety aspects of passengers and Environment. This work has opened a rather wide frame work of model structures for application on traffic. The facets of these theories are so wide that it seems impossible to present all necessary models in this work. However it could be deduced from the study that the best Traffic Management System is that whichis realistic in all aspects is easy to understand is easy to apply As it is practically difficult to device an ideal fool—proof model, the attempt here has been to make some progress-in that direction.

Relationship between body mass index and the use of healthcare services in Australia

Objective: To examine the relationship between body mass index (BMI) and the use of medical and preventive health services. Research Methods and Procedures: This study involved secondary analysis of weighted data from the Australian 1995 National Health Survey. The study was a population survey designed to obtain national benchmark information about a range of health-related issues. Data were available from 17,033 men and 17,174 women, 20 years or age. BMI, based on self-reported weight and height, was analyzed in relation to the use of medical services and preventive health services. Results: A positive relationship was found between BMI and medical service use, such as medication use, visits to hospital accident and emergency departments (for women only); doctor visits, visits to a hospital outpatient clinics; and visits to other health professionals (for women only). A negative relationship was found in women between BMI and preventive health services. Underweight women were found to be significantly less likely to have Papanicolaou smear tests, breast examinations, and mammograms. Discussion: This research shows that people who fall outside the healthy weight range are more likely to use a range of medical services. Given that the BMI of industrialized populations appears to be increasing, this has important ramifications for health service planning and reinforces the need for obesity prevention strategies at a population level.

Cost of stroke in Australia from a societal perspective: results from the north east Melbourne stroke incidence study (NEMESIS)

Background and Purpose—— Accurate information about resource use and costs of stroke is necessary for informed health service planning. The purpose of this study was to determine the patterns of resource use among stroke patients and to estimate the total costs (direct service use and indirect production losses) of stroke (excluding SAH) in Australia for 1997.

Methods—— An incidence-based cost-of-illness model was developed, incorporating data obtained from the North East Melbourne Stroke Incidence Study (NEMESIS). The costs of stroke during the first year after stroke and the present value of total lifetime costs of stroke were estimated.

Results—— The total first-year costs of all first-ever-in-a lifetime strokes (SAH excluded) that occurred in Australia during 1997 were estimated to be A$555 million (US$420 million), and the present value of lifetime costs was estimated to be A$1.3 billion (US$985 million). The average cost per case during the first 12 months and over a lifetime was A$18 956 (US$14 361) and A$44 428 (US$33 658), respectively. The most important categories of cost during the first year were acute hospitalization (A$154 million), inpatient rehabilitation (A$150 million), and nursing home care (A$63 million). The present value of lifetime indirect costs was estimated to be A$34 million.

Conclusions—— Similar to other studies, hospital and nursing home costs contributed most to the total cost of stroke (excluding SAH) in Australia. Inpatient rehabilitation accounts for {approx}27% of total first-year costs. Given the magnitude of these costs, investigation of the cost-effectiveness of rehabilitation services should become a priority in this community.

The management of depressed elderly care recipients : family perspectives on the skills of professional carers

Recent studies have identified high levels of depression among older people, both those in their own homes and those in residential care. With the world's population ageing, it is timely for health service providers to consider how the escalating population of depressed elderly people will be managed. Although treating general practitioners may be the health professionals most expected to detect, treat, and monitor depression among the elderly, professional carers are well placed to assist in the detection and monitoring of the disorder. This study conducted individual interviews with 15 family members of depressed aged-care recipients to determine their perceptions of the skills and knowledge of depression of professional carers. Family members reported that carers are more likely to avoid than engage with their clients about depressive symptomatology and do not communicate their concerns with managers or general practitioners (GPs). Family members believed that, in general, professional carers were undertrained in these areas. The implications of these findings for health service planning and staff training are discussed.

The psychoanalytic treatment of psychosis

The authors provide a brief review of the role of psychoanalysis in current mental health practice, psychoanalytic perspectives on the aetiology of the psychoses and analytic approaches to nosology and diagnosis as a framework for a structural approach to the various manifestations of psychosis. The paper then moves on to the discussion of appropriate techniques for the treatment of psychoses which depart from the exploratory treatment used in neurotic patients. The final section of the paper examines the results of recent outcome studies of psychoanalysis and addresses some of the consequences for service planning and delivery.