WORKLOAD AND PERFORMANCE FACTORS ASSOCIATED WITH MULTIMEDIA JOB AIDS FOR COMMUNITY HEALTH WORKERS

This dissertation focuses on factors of multimedia job aids that modify workload, protocol adherence and clinical errors in community health workers. Literature shows that community health workers performance is not acceptable even with support of paper job aids. There are cognitive theories that try to explain reasons why the performance of community health workers is poor regardless of the access to paper based-job aid. Based on cognitive science and multimedia design theories an intervention was designed to compare alternative representations for the information contained on paper job aids and the capability of this new designed job aids to enhance community health workers performance. The dissertation is divided in 5 main parts: 1. identification and description of the problem, 2. a methodological approach to create and evaluate an intervention, 3. Presentation of results of the intervention evaluation, 4. Discussion of findings and 5. Conclusions

Response of B-type natriuretic pepticle to exercise in hypertensive patients with suspected diastolic heart failure: Correlation with cardiac function, hemodynamics, and workload

Background Diastolic heart failure (DHF) is characterized by dyspnea due to increased left ventricular (LV) filling pressures during stress. We sought the relationship of exercise-induced increases in B-type natriuretic peptide (BNP) to LV filling pressures and parameters of cardiovascular performance in suspected DHF. Methods Twenty-six treated hypertensive patients with suspected DHF (exertional dyspnea, LV ejection fraction >50%, and diastolic dysfunction) underwent maximal exercise echocardiography using the Bruce protocol. BNP, transmitral Doppler, and tissue Doppler for systolic (So) and early (Ea) and late (Aa) diastolic mitral annular velocities were obtained at rest and peak stress. LV filling pressures were estimated with E/Ea ratios. Results Resting BNP correlated with resting pulse pressure (r=0.45, P=0.02). Maximal exercise performance (4.6 +/- 2.5min) was limited by dyspnea. Blood pressure increased with exercise (from 143 +/- 19/88 +/- 8 to 191 +/- 22/90 +/- 10 mm Hg); 13 patients (50%) had a hypertensive response. Peak exercise BNP correlated with peak transmitral E velocity (r = 0.41, P <.05) and peak heart rate (r = -0.40, P <.05). BNP increased with exercise (from 48 57 to 74 97 pg/mL, P =.007), and the increment of BNP with exercise was associated with maximal workload and peak exercise So, Ea, and Aa (P <.01 for all). Filling pressures, approximated by lateral E/Ea ratio, increased with exercise (7.7 +/- 2.0 to 10.0 +/- 4.8, P <.01). BNP was higher in patients with possibly elevated filling pressures at peak exercise (E/Ea >10) compared to those with normal pressures (123 +/- 124 vs 45 +/- 71 pg/mL, P =.027). Conclusions Augmentation of BNP with exercise in hypertensive patients with suspected DHF is associated with better exercise capacity, LV systolic and diastolic function, and left atrial function. Peak exercise BNP levels may identify exercise-induced elevation of filling pressures in DHF.

Skin cancer clinics in Australia: workload profile and performance indicators from an analysis of billing data

Objective: To describe the workload profile in a network of Australian skin cancer clinics. Design and setting: Analysis of billing data for the first 6 months of 2005 in a primary-care skin cancer clinic network, consisting of seven clinics and staffed by 20 doctors, located in the Northern Territory, Queensland and New South Wales. Main outcome measures: Consultation to biopsy ratio (CBR); biopsy to treatment ratio (BTR); number of benign naevi excised per melanoma (number needed to treat [NNT]). Results: Of 69780 billed activities, 34 622 (49.6%) were consultations, 19 358 (27.7%) biopsies, 8055 (11.5%) surgical excisions, 2804 (4.0%) additional surgical repairs, 1613 (2.3%) non-surgical treatments of cancers and 3328 (4.8%) treatments of premalignant or non-malignant lesions. A total of 6438 cancers were treated (116 melanomas by excision, 4709 non-melanoma skin cancers [NMSCs] by excision, and 1613 NMSCs non-surgically); 5251 (65.2%) surgical wounds were repaired by direct suture, 2651 (32.9%) by a flap (of which 44.8% were simple flaps), 42 (0.5%) by wedge excision and 111 (1.4%) by grafts. The CBR was 1.79, the BTR was 3.1 and the NNT was 28.6. Conclusions: In this network of Australian skin cancer clinics, one in three biopsies identified a skin cancer (BTR, 3.1), and about 29 benign lesions were excised per melanoma (NNT, 28.6). The estimated NNT was similar to that reported previously in general practice. More data are needed on health outcomes, including effectiveness of treatment and surgical repair.

Breast cancer teams:the impact of constitution, new cancer workload and methods of operation on their effectiveness

National guidance and clinical guidelines recommended multidisciplinary teams (MDTs) for cancer services in order to bring specialists in relevant disciplines together, ensure clinical decisions are fully informed, and to coordinate care effectively. However, the effectiveness of cancer teams was not previously evaluated systematically. A random sample of 72 breast cancer teams in England was studied (548 members in six core disciplines), stratified by region and caseload. Information about team constitution, processes, effectiveness, clinical performance, and members' mental well-being was gathered using appropriate instruments. Two input variables, team workload (P=0.009) and the proportion of breast care nurses (P=0.003), positively predicted overall clinical performance in multivariate analysis using a two-stage regression model. There were significant correlations between individual team inputs, team composition variables, and clinical performance. Some disciplines consistently perceived their team's effectiveness differently from the mean. Teams with shared leadership of their clinical decision-making were most effective. The mental well-being of team members appeared significantly better than in previous studies of cancer clinicians, the NHS, and the general population. This study established that team composition, working methods, and workloads are related to measures of effectiveness, including the quality of clinical care. © 2003 Cancer Research UK.

Informal caregiving and mental ill health – differential relationships by workload, gender, age and area-remoteness in a UK region

Informal caregiving can be a demanding role which has been shown to impact on physical, psychological and social wellbeing. Methodological weaknesses including small sample sizes and subjective measures of mental health have led to inconclusive evidence about the relationship between informal caregiving and mental health. This paper reports on a study carried out in a UK region which investigated the relationship between informal caregiving and mental ill health. The analysis was conducted by linking three datasets, the Northern Ireland Longitudinal Study, the Northern Ireland Enhanced Prescribing Database and the Proximity to Service Index from the Northern Ireland Statistics and Research Agency. Our analysis used both a subjective measure of mental ill health, i.e. a question asked in the 2011 Census, and an objective measure, whether the respondents had been prescribed antidepressants by a General Practitioner between 2010 and 2012. We applied binary logistic multilevel modelling to these two responses to test whether, and for what sub-groups of the population, informal caregiving was related to mental ill health. The results showed that informal caregiving per se was not related to mental ill health although there was a strong relationship between the intensity of the caregiving role and mental ill health. Females under 50, who provided over 19 hours of care, were not employed or worked part-time and who provided care in both 2001 and 2011 were at a statistically significantly elevated risk of mental ill health. Caregivers in remote areas with limited access to shops and services were also at a significantly increased risk as evidenced by prescription rates for antidepressants. With community care policies aimed at supporting people to remain at home, the paper highlights the need for further research in order to target resources appropriately.

Dynamic Workload Parallelization and System Calibration on Single-Chip Cloud Computer

Many-core systems are emerging from the need of more computational power and power efficiency. However there are many issues which still revolve around the many-core systems. These systems need specialized software before they can be fully utilized and the hardware itself may differ from the conventional computational systems. To gain efficiency from many-core system, programs need to be parallelized. In many-core systems the cores are small and less powerful than cores used in traditional computing, so running a conventional program is not an efficient option. Also in Network-on-Chip based processors the network might get congested and the cores might work at different speeds. In this thesis is, a dynamic load balancing method is proposed and tested on Intel 48-core Single-Chip Cloud Computer by parallelizing a fault simulator. The maximum speedup is difficult to obtain due to severe bottlenecks in the system. In order to exploit all the available parallelism of the Single-Chip Cloud Computer, a runtime approach capable of dynamically balancing the load during the fault simulation process is used. The proposed dynamic fault simulation approach on the Single-Chip Cloud Computer shows up to 45X speedup compared to a serial fault simulation approach. Many-core systems can draw enormous amounts of power, and if this power is not controlled properly, the system might get damaged. One way to manage power is to set power budget for the system. But if this power is drawn by just few cores of the many, these few cores get extremely hot and might get damaged. Due to increase in power density multiple thermal sensors are deployed on the chip area to provide realtime temperature feedback for thermal management techniques. Thermal sensor accuracy is extremely prone to intra-die process variation and aging phenomena. These factors lead to a situation where thermal sensor values drift from the nominal values. This necessitates efficient calibration techniques to be applied before the sensor values are used. In addition, in modern many-core systems cores have support for dynamic voltage and frequency scaling. Thermal sensors located on cores are sensitive to the core's current voltage level, meaning that dedicated calibration is needed for each voltage level. In this thesis a general-purpose software-based auto-calibration approach is also proposed for thermal sensors to calibrate thermal sensors on different range of voltages.

Aging and semantic integration in sentence processing: Testing the cognitive workload of wrap-up

The current study investigated the cognitive workload of sentence and clause wrap-up in younger and older readers. A large number of studies have demonstrated the presence of wrap-up effects, peaks in processing time at clause and sentence boundaries that some argue reflect attention to organizational and integrative semantic processes. However, the exact nature of these wrap-up effects is still not entirely clear, with some arguing that wrap-up is not related to processing difficulty, but rather is triggered by a low-level oculomotor response or the implicit monitoring of intonational contour. The notion that wrap-up effects are resource-demanding was directly tested by examining the degree to which sentence and clause wrap-up affects the parafoveal preview benefit. Older and younger adults read passages in which a target word N occurred in a sentence-internal, clause-final, or sentence-final position. A gaze-contingent boundary change paradigm was used in which, on some trials, a non-word preview of word N+1 was replaced by a target word once the eyes crossed an invisible boundary located between words N and N+1. All measures of reading time on word N were longer at clause and sentence boundaries than in the sentence-internal position. In the earliest measures of reading time, sentence and clause wrap-up showed evidence of reducing the magnitude of the preview benefit similarly for younger and older adults. However, this effect was moderated by age in gaze duration, such that older adults showed a complete reduction in the preview benefit in the sentence-final condition. Additionally, sentence and clause wrap-up were negatively associated with the preview benefit. Collectively, the findings from the current study suggest that wrap-up is cognitively demanding and may be less efficient with age, thus, resulting in a reduction of the parafoveal preview during normal reading.