Analyse de la logique d’intervention d’une adaptation québécoise d’un modèle de soins centré sur le patient appuyé par un dossier médical personnel dans les suivis pédiatriques au sein d’un groupe de médecine de famille

Dans l'optique d'améliorer la performance des services de santé en première ligne, un projet d'implantation d'une adaptation québécoise d'un modèle de soins centré sur le patient appuyé par un dossier médical personnel (DMP) a été mis sur pied au sein d'un groupe de médecine familiale (GMF) de la région de Montréal. Ainsi, ce mémoire constitue une analyse comparative entre la logique de l'intervention telle qu'elle est décrite dans les données probantes concernant les modèles de soins centrés sur le patient et le dossier médical personnel ainsi que la logique de l'intervention issue de nos résultats obtenus dans le cadre de ce projet au sein d'un GMF. L'analyse organisationnelle se situe durant la phase de pré-déploiement de l'intervention. Les principaux résultats sont que la logique d'intervention appliquée dans le cadre du projet est relativement éloignée de ce qui se fait de mieux dans la littérature sur le sujet. Ceci est en partie explicable par les différentes résistances en provenance des acteurs du projet (ex. médecins, infirmières, fournisseur technologique) dans le projet, mais aussi par l'absence de l'interopérabilité entre le DMP et le dossier médical électronique (DME). Par ailleurs, les principaux effets attendus par les acteurs impliqués sont l'amélioration de la continuité informationnelle, de l’efficacité-service, de la globalité et de la productivité. En outre, l’implantation d’un modèle centré sur le patient appuyé par un DMP impliquerait la mise en œuvre d’importantes transformations structurelles comme une révision du cadre législatif (ex. responsabilité médicale) et des modes de rémunérations des professionnels de la santé, sans quoi, les effets significatifs sur les dimensions de la performance comme l’accessibilité, la qualité, la continuité, la globalité, la productivité, l’efficacité et la réactivité pourraient être limités. Ces aménagements structuraux devraient favoriser la collaboration interprofessionnelle, l'interopérabilité des systèmes, l’amélioration de la communication multidirectionnelle (patient-professionnel de la santé) ainsi qu'une autogestion de la santé supportée (ex. éducation, prévention, transparence) par les professionnels de la santé.

The Financial Statement Insurance Alternative to Auditor Liability

These articles evaluate using financial statement insurance (FSI) to reduce the frequency and magnitude of audit failure. The FSI concept was pioneered by Josh Ronen, NYU Accounting Professor, who has modeled its economic aspects. My paper examines FSI’s efficacy from policy and legal perspectives. I conclude that while the model is not perfect, it promises considerable advantages over the current model. While some of the existing system’s imperfections are sustained or reappear in different guises, none of the existing imperfections appears to be aggravated and the rest likely are mitigated significantly. So I prescribe a framework to permit companies, on an experimental-basis and with investor approval, to use FSI as an optional alternative to financial statement auditing backed by auditor liability.

Towards the development of a new wavelet for ECG classification

In this paper an attempt has been made to determine the number of Premature Ventricular Contraction (PVC) cycles accurately from a given Electrocardiogram (ECG) using a wavelet constructed from multiple Gaussian functions. It is difficult to assess the ECGs of patients who are continuously monitored over a long period of time. Hence the proposed method of classification will be helpful to doctors to determine the severity of PVC in a patient. Principal Component Analysis (PCA) and a simple classifier have been used in addition to the specially developed wavelet transform. The proposed wavelet has been designed using multiple Gaussian functions which when summed up looks similar to that of a normal ECG. The number of Gaussians used depends on the number of peaks present in a normal ECG. The developed wavelet satisfied all the properties of a traditional continuous wavelet. The new wavelet was optimized using genetic algorithm (GA). ECG records from Massachusetts Institute of Technology-Beth Israel Hospital (MIT-BIH) database have been used for validation. Out of the 8694 ECG cycles used for evaluation, the classification algorithm responded with an accuracy of 97.77%. In order to compare the performance of the new wavelet, classification was also performed using the standard wavelets like morlet, meyer, bior3.9, db5, db3, sym3 and haar. The new wavelet outperforms the rest

Delimitation of the Right to Life by Healthcare Professionals: Up to what point should the right to life be protected?

This article explores the medical care standard required by law for terminally illpatients and the possibility of limiting therapeutic efforts while respecting the duediligence expected from doctors. To this end, circumstances are identified in whichthe doctor is forced to choose between two possible actions: to guarantee the right tolife by continuing treatment, or to limit the right to healthcare by limiting therapeuticefforts. Two cases taken from English Common Law were reviewed that decided onthe factual problem at hand. In our country, the Constitutional Court established aline of jurisprudence on the role of the doctor in deciding whether or not to continuetreatment for a terminally ill person. Lastly, jurisprudence precedents are presentedalong with a comparative analysis of the solutions given in Great Britain andin Colombia.

Small-area variation in health care affecting the choice of cesarean delivery: the case of a Colombian health insurer

In the midst of health care reform, Colombia has succeeded in increasing health insurance coverage and the quality of health care. In spite of this, efficiency continues to be a matter of concern, and small-area variations in health care are one of the plausible causes of such inefficiencies. In order to understand this issue, we use individual data of all births from a Contributory-Regimen insurer in Colombia. We perform two different specifications of a multilevel logistic regression model. Our results reveal that hospitals account for 20% of variation on the probability of performing cesarean sections. Geographic area only explains 1/3 of the variance attributable to the hospital. Furthermore, some variables from both demand and supply sides are found to be also relevant on the probability of undergoing cesarean sections. This paper contributes to previous research by using a hierarchical model and by defining hospitals as cluster. Moreover, we also include clinical and supply induced demand variables.

Doctors´ remuneration schemes and hospital competition in two-sided markets with common network externalities

This paper uses a two-sided market model of hospital competition to study the implications of di§erent remunerations schemes on the physiciansí side. The two-sided market approach is characterized by the concept of common network externality (CNE) introduced by Bardey et al. (2010). This type of externality occurs when occurs when both sides value, possibly with di§erent intensities, the same network externality. We explicitly introduce e§ort exerted by doctors. By increasing the number of medical acts (which involves a costly e§ort) the doctor can increase the quality of service o§ered to patients (over and above the level implied by the CNE). We Örst consider pure salary, capitation or fee-for-service schemes. Then, we study schemes that mix fee-for-service with either salary or capitation payments. We show that salary schemes (either pure or in combination with fee-for-service) are more patient friendly than (pure or mixed) capitations schemes. This comparison is exactly reversed on the providersíside. Quite surprisingly, patients always loose when a fee-for-service scheme is introduced (pure of mixed). This is true even though the fee-for-service is the only way to induce the providers to exert e§ort and it holds whatever the patientsívaluation of this e§ort. In other words, the increase in quality brought about by the fee-for-service is more than compensated by the increase in fees faced by patients.

An integrated assessment of carbon dioxide capture and storage in the UK

Geological carbon dioxide storage (CCS) has the potential to make a significant contribution to the decarbonisation of the UK. Amid concerns over maintaining security, and hence diversity, of supply, CCS could allow the continued use of coal, oil and gas whilst avoiding the CO2 emissions currently associated with fossil fuel use. This project has explored some of the geological, environmental, technical, economic and social implications of this technology. The UK is well placed to exploit CCS with a large offshore storage capacity, both in disused oil and gas fields and saline aquifers. This capacity should be sufficient to store CO2 from the power sector (at current levels) for a least one century, using well understood and therefore likely to be lower-risk, depleted hydrocarbon fields and contained parts of aquifers. It is very difficult to produce reliable estimates of the (potentially much larger) storage capacity of the less well understood geological reservoirs such as non-confined parts of aquifers. With the majority of its large coal fired power stations due to be retired during the next 15 to 20 years, the UK is at a natural decision point with respect to the future of power generation from coal; the existence of both national reserves and the infrastructure for receiving imported coal makes clean coal technology a realistic option. The notion of CCS as a ‘bridging’ or ‘stop-gap’ technology (i.e. whilst we develop ‘genuinely’ sustainable renewable energy technologies) needs to be examined somewhat critically, especially given the scale of global coal reserves. If CCS plant is built, then it is likely that technological innovation will bring down the costs of CO2 capture, such that it could become increasingly attractive. As with any capitalintensive option, there is a danger of becoming ‘locked-in’ to a CCS system. The costs of CCS in our model for UK power stations in the East Midlands and Yorkshire to reservoirs in the North Sea are between £25 and £60 per tonne of CO2 captured, transported and stored. This is between about 2 and 4 times the current traded price of a tonne of CO2 in the EU Emissions Trading Scheme. In addition to the technical and economic requirements of the CCS technology, it should also be socially and environmentally acceptable. Our research has shown that, given an acceptance of the severity and urgency of addressing climate change, CCS is viewed favourably by members of the public, provided it is adopted within a portfolio of other measures. The most commonly voiced concern from the public is that of leakage and this remains perhaps the greatest uncertainty with CCS. It is not possible to make general statements concerning storage security; assessments must be site specific. The impacts of any potential leakage are also somewhat uncertain but should be balanced against the deleterious effects of increased acidification in the oceans due to uptake of elevated atmospheric CO2 that have already been observed. Provided adequate long term monitoring can be ensured, any leakage of CO2 from a storage site is likely to have minimal localised impacts as long as leaks are rapidly repaired. A regulatory framework for CCS will need to include risk assessment of potential environmental and health and safety impacts, accounting and monitoring and liability for the long term. In summary, although there remain uncertainties to be resolved through research and demonstration projects, our assessment demonstrates that CCS holds great potential for significant cuts in CO2 emissions as we develop long term alternatives to fossil fuel use. CCS can contribute to reducing emissions of CO2 into the atmosphere in the near term (i.e. peak-shaving the future atmospheric concentration of CO2), with the potential to continue to deliver significant CO2 reductions over the long term.

Patients' understanding of risk associated with medication use: impact of European Commission guidelines and other risk scales

Patients want and need comprehensive and accurate information about their medicines so that they can participate in decisions about their healthcare: In particular, they require information about the likely risks and benefits that are associated with the different treatment options. However, to provide this information in a form that people can readily understand and use is a considerable challenge to healthcare professionals. One recent attempt to standardise the Language of risk has been to produce sets of verbal descriptors that correspond to specific probability ranges, such as those outlined in the European Commission (EC) Pharmaceutical Committee guidelines in 1998 for describing the incidence of adverse effects. This paper provides an overview of a number of studies involving members of the general public, patients, and hospital doctors, that evaluated the utility of the EC guideline descriptors (very common, common, uncommon, rare, very rare). In all studies it was found that people significantly over-estimated the likelihood of adverse effects occurring, given specific verbal descriptors. This in turn resulted in significantly higher ratings of their perceived risks to health and significantly lower ratings of their likelihood of taking the medicine. Such problems of interpretation are not restricted to the EC guideline descriptors. Similar levels of misinterpretation have also been demonstrated with two other recently advocated risk scales (Caiman's verbal descriptor scale and Barclay, Costigan and Davies' lottery scale). In conclusion, the challenge for risk communicators and for future research will be to produce a language of risk that is sufficiently flexible to take into account different perspectives, as well as changing circumstances and contexts of illness and its treatments. In the meantime, we urge the EC and other legislative bodies to stop recommending the use of specific verbal labels or phrases until there is a stronger evidence base to support their use.

The ethical challenges of ubiquitous healthcare

Ubiquitous healthcare is an emerging area of technology that uses a large number of environmental and patient sensors and actuators to monitor and improve patients’ physical and mental condition. Tiny sensors gather data on almost any physiological characteristic that can be used to diagnose health problems. This technology faces some challenging ethical questions, ranging from the small-scale individual issues of trust and efficacy to the societal issues of health and longevity gaps related to economic status. It presents particular problems in combining developing computer/information/media ethics with established medical ethics. This article describes a practice-based ethics approach, considering in particular the areas of privacy, agency, equity and liability. It raises questions that ubiquitous healthcare will force practitioners to face as they develop ubiquitous healthcare systems. Medicine is a controlled profession whose practise is commonly restricted by government-appointed authorities, whereas computer software and hardware development is notoriously lacking in such regimes.

General care of the older cancer patient.

With increasing age, there are greater numbers of older people who will be diagnosed with cancer. It must be remembered that such individuals have increased frailty and have a number of geriatric syndromes and conditions particularly pertinent to older age, including incontinence, poor cognition and impaired nutrition. It is often difficult to define the effects of cancer and its treatment or complications, and separate these from the effects of normal ageing and geriatric syndromes. The documentation of poor nutrition and its management must combine knowledge from both geriatric medicine and oncology. Nutrition serves to identify key healthcare professionals who are all essential in any patient at risk or suffering from malnutrition. Incontinence must be actively sought, its cause identified and efforts made to either 'cure' it or, in certain circumstances, 'manage' it. Older patients with cancer are cared for predominantly by older relations and informal care mechanisms and special consideration of their physical and practical needs are paramount. In this area, nurses, doctors, therapists and social workers should work to identify formal and informal mechanisms to support particularly the older carer.

Care homes’ use of medicines study: prevalence, causes and potential harm of medication errors in care homes for older people

Introduction: Care home residents are at particular risk from medication errors, and our objective was to determine the prevalence and potential harm of prescribing, monitoring, dispensing and administration errors in UK care homes, and to identify their causes. Methods: A prospective study of a random sample of residents within a purposive sample of homes in three areas. Errors were identified by patient interview, note review, observation of practice and examination of dispensed items. Causes were understood by observation and from theoretically framed interviews with home staff, doctors and pharmacists. Potential harm from errors was assessed by expert judgement. Results: The 256 residents recruited in 55 homes were taking a mean of 8.0 medicines. One hundred and seventy-eight (69.5%) of residents had one or more errors. The mean number per resident was 1.9 errors. The mean potential harm from prescribing, monitoring, administration and dispensing errors was 2.6, 3.7, 2.1 and 2.0 (0 = no harm, 10 = death), respectively. Contributing factors from the 89 interviews included doctors who were not accessible, did not know the residents and lacked information in homes when prescribing; home staff’s high workload, lack of medicines training and drug round interruptions; lack of team work among home, practice and pharmacy; inefficient ordering systems; inaccurate medicine records and prevalence of verbal communication; and difficult to fill (and check) medication administration systems. Conclusions: That two thirds of residents were exposed to one or more medication errors is of concern. The will to improve exists, but there is a lack of overall responsibility. Action is required from all concerned.

The effects of a soft drink tax in the UK

The majority of the UK population is either overweight or obese. Health economists, nutritionists and doctors are calling for the UK to follow the example of other European countries and introduce a tax on soft drinks as a result of the perception that high intakes contribute to diet-related disease. We use a demand model estimated with household-level data on beverage purchases in the UK to investigate the effects of a tax on soft drink consumption. The model is a Quadratic Almost Ideal Demand System, and censoring is handled by applying a double hurdle. Separate models are estimated for low, moderate and high consumers to allow for a differential impact on consumption between these groups. Applying different hypothetical tax rates, we conclude that understanding the nature of substitute/complement relationships is crucial in designing an effective policy as these relationships differ between consumers depending on their consumption level. The overall impact of a soft drink tax on calorie consumption is likely to be small.

Political culture and corporate homicide liability in the UK and Europe

This chapter outlines recent developments in the emergence within Europe of systems of criminal law designed to hold corporate bodies liable where they cause the deaths of workers or members of the public. These changes point to the emergence of a new, more punitive, legal culture in relation to corporate crime. At the same time, however, there is evidence to suggest that this punitive culture is not uniform; different national jurisdictions reflect it to differing degrees. The chapter explores the degree to which the UK’s willingness to criminalise work-related deaths is mirrored elsewhere in Europe, and identifies some factors that might account for variations in this regard. In particular, attention is paid to the influence that social and political culture have on practices in this area. It is written as part of a research handbook on corporate crime in Europe, so has an eye on a more generalist audience in some regards.