Potential and limits of health management reform in Chile

Includes bibliography

Management of primary ciliary dyskinesia in European children: recommendations and clinical practice

The European Respiratory Society Task Force on primary ciliary dyskinesia (PCD) in children recently published recommendations for diagnosis and management. This paper compares these recommendations with current clinical practice in Europe. Questionnaires were returned by 194 paediatric respiratory centres caring for PCD patients in 26 countries. In most countries, PCD care was not centralised, with a median (interquartile range) of 4 (2-9) patients treated per centre. Overall, 90% of centres had access to nasal or bronchial mucosal biopsy. Samples were analysed by electron microscopy (77%) and ciliary function tests (57%). Nasal nitric oxide was used for screening in 46% of centres and saccharine tests in 36%. Treatment approaches varied widely, both within and between countries. European region, size of centre and the country's general government expenditure on health partly defined availability of advanced diagnostic tests and choice of treatments. In conclusion, we found substantial heterogeneity in management of PCD within and between countries, and poor concordance with current recommendations. This demonstrates how essential it is to standardise management and decrease inequality between countries. Our results also demonstrate the urgent need for research: to simplify PCD diagnosis, to understand the natural history and to test the effectiveness of interventions.

Spawning and habitat management in salmonid populations at the southern edge of their natural ranges = Reproducción y gestión del hábitat en poblaciones de salmónidos en el extremo meridional de sus distribuciones naturales

Las poblaciones de salmónidos en la Península Ibérica (trucha común, Salmo trutta; y salmón atlántico, Salmo salar) se encuentran cerca del límite meridional de sus distribuciones naturales, y por tanto tienen una gran importancia para la conservación de estas especies. En la presente Tesis se han investigado algunos aspectos de la reproducción y de la gestión del hábitat, con el objeto de mejorar el conocimiento acerca de estas poblaciones meridionales de salmónidos. Se ha estudiado la reproducción de la trucha común en el río Castril (Andalucía, sur de España), donde se ha observado que la freza ocurre desde diciembre hasta abril con el máximo de actividad en febrero. Este hecho representa uno de los periodos reproductivos más tardíos y con mayor duración de toda la distribución natural de la especie. Además, actualmente se sabe que el resto de poblaciones andaluzas tienen periodos de reproducción similares (retrasados y extendidos). Análisis en la escala de la distribución natural de la trucha común, han mostrado que la latitud explica parcialmente tanto la fecha media de reproducción (R2 = 62.8%) como la duración del periodo de freza (R2 = 24.4%) mediante relaciones negativas: a menor latitud, la freza ocurre más tarde y durante más tiempo. Es verosímil que un periodo de freza largo suponga una ventaja para la supervivencia de las poblaciones de trucha en hábitats impredecibles, y por tanto se ha propuesto la siguiente hipótesis, que deberá ser comprobada en el futuro: la duración de la freza es mayor en hábitats impredecibles que en aquellos más predecibles. La elevada tasa de solapamiento de frezaderos observada en el río Castril no se explica únicamente por una excesiva densidad de reproductores. Las hembras de trucha eligieron lugares específicos para construir sus frezaderos en vez de dispersarse aleatoriamente dentro del hábitat adecuado para la freza que tenían disponible. Estas observaciones sugieren que las hembras tienen algún tipo de preferencia por solapar sus frezaderos. Además, en ríos calizos como el Castril, las gravas pueden ser muy cohesivas y difíciles de excavar, por lo que el solapamiento de frezaderos puede suponer una ventaja para la hembra, porque la excavación en sustratos que han sido previamente removidos por frezas anteriores requerirá menos gasto de energía que en sustratos con gravas cohesivas que no han sido alteradas. Por tanto, se ha propuesto la siguiente hipótesis, que deberá ser comprobada en el futuro: las hembras tienen una mayor preferencia por solapar sus frezaderos en ríos con sustratos cohesivos que en ríos con sustratos de gravas sueltas. En el marco de la gestión del hábitat, se han empleado dos enfoques diferentes para la evaluación del hábitat físico, con el objeto de cuantificar los cambios potenciales en la disponibilidad de hábitat, antes de la implementación real de determinadas medidas sobre el hábitat. En primer lugar, se ha evaluado el hábitat físico del salmón atlántico en el río Pas (Cantabria, norte de España), en la escala del microhábitat, empleando la metodología IFIM junto con un modelo hidráulico bidimensional (River2D). Se han simulado una serie de acciones de mejora del hábitat y se han cuantificado los cambios en el hábitat bajo estas acciones. Los resultados mostraron un aumento muy pequeño en la disponibilidad de hábitat, por lo que no sería efectivo implementar estas acciones en este tramo fluvial. En segundo lugar, se ha evaluado el hábitat físico de la trucha común en el río Tajuña (Guadalajara, centro de España), en la escala del mesohábitat, empleando la metodología MesoHABSIM. Actualmente, el río Tajuña está alterado por los usos agrícolas de sus riberas, y por tanto se ha diseñado una restauración para mitigar estos impactos y para llevar al río a un estado más natural. Se ha cuantificado la disponibilidad de hábitat tras la restauración planteada, y los resultados han permitido identificar los tramos en los que la restauración resultaría más eficaz. ABSTRACT Salmonid populations in the Iberian Peninsula (brown trout, Salmo trutta; and Atlantic salmon, Salmo salar) are close to the southern limit of their natural ranges, and therefore they are of great importance for the conservation of the species. In the present dissertation, some aspects of spawning and habitat management have been investigated, in order to improve the knowledge on these southern salmonid populations. Brown trout spawning have been studied in the river Castril (Andalusia, southern Spain), and it has been observed that spawning occurs from December until April with the maximum activity in February. This finding represents one of the most belated and protracted spawning periods within the natural range of the species. Furthermore, it is now known that the rest of Andalusian populations show similar (belated and extended) spawning periods. Broad-scale analyses throughout the brown trout natural range showed that latitude partly explained both spawning mean time (R2 = 62.8%) and spawning duration (R2 = 24.4%) by negative relationships: the lower the latitude, the later the spawning time and the longer the spawning period. It is plausible that a long spawning period would be an advantage for survival of trout populations in unpredictable habitats, and thus the following hypothesis has been proposed, which is yet to be tested: spawning duration is longer in unpredictable than in predictable habitats. High rate of redd superimposition observed in the river Castril was not only caused by high density of spawners. Trout females chose specific sites for redd construction instead of randomly dispersing over the suitable spawning habitat. These observations suggest that female spawners have some kind of preference for superimposing redds. Moreover, in limestone streams such as Castril, unused gravels can be very cohesive and hard to dig, and thus redd superimposition may be an advantage for female, because digging may require less energy expenditure in already used redd sites than in cohesive and embedded unused sites. Hence, the following hypothesis has been proposed, which is yet to be tested: females have a higher preference for superimposing redds in streambeds with cohesive and embedded substrates than in rivers with loose gravels. Within the topic of habitat management, two different approaches have been used for physical habitat assessment, in order to quantify the potential change in habitat availability, prior to the actual implementation of proposed habitat measures. Firstly, physical habitat for Atlantic salmon in the river Pas (Cantabria, northern Spain) has been assessed at the microhabitat scale, using the IFIM approach along with a two dimensional hydraulic model (River2D). Proposed habitat enhancement actions have been simulated and potential habitat change has been quantified. Results showed a very small increasing in habitat availability and therefore it is not worth to implement these measures in this stream reach. Secondly, physical habitat for brown trout in the river Tajuña (Guadalajara, central Spain) has been assessed at the mesohabitat scale, using the MesoHABSIM approach. The river Tajuña is currently impacted by surrounding agricultural uses, and thus restoration was designed to mitigate these impacts and to drive the river to a more natural state. Habitat availability after the planned restoration has been quantified, and the results have permitted to identify in which sites the restoration will be more effective.

Resting energy expenditure is lower than predicted in people taking atypical antipsychotic medication

Resting energy expenditure (REE) is lower than predicted in persons taking atypical antipsychotic medication, and weight management is a significant clinical challenge for some of them. However, to date there have been no published guidelines to assist clinicians in choosing appropriate prediction equations to estimate energy expenditure in persons taking atypical antipsychotic medications. The objectives of this study were to measure REE in a group of men taking the atypical antipsychotic clozapine and to determine whether REE can be accurately predicted for this population using previously published regression equations. REE was measured using indirect calorimetry via a ventilated hood on eight men who had completed at least 6 months of treatment with clozapine. Comparisons between measured REE and predicted REE using five different equations were undertaken. The commonly-used Harris-Benedict and Schofield equations systematically overestimated REE. Predictions of REE from other equations were too variable for clinical use. When estimating energy requirements as part of a weight-management program in men who have been taking clozapine for 6 months, predictions of REE from the equations of Harris-Benedict and Schofield should be reduced by 280 kcal/day.

A heat metering system for energy management on an industrial site

Faced with a future of rising energy costs there is a need for industry to manage energy more carefully in order to meet its economic objectives. A problem besetting the growth of energy conservation in the UK is that a large proportion of energy consumption is used in a low intensive manner in organisations where they would be responsibility for energy efficiency is spread over a large number of personnel who each see only small energy costs. In relation to this problem in the non-energy intensive industrial sector, an application of an energy management technique known as monitoring and targeting (M & T) has been installed at the Whetstone site of the General Electric Company Limited in an attempt to prove it as a means for motivating line management and personnel to save energy. The objective energy saving for which the M & T was devised is very specific. During early energy conservation work at the site there had been a change from continuous to intermittent heating but the maintenance of the strategy was receiving a poor level of commitment from line management and performance was some 5% - 10% less than expected. The M & T is concerned therefore with heat for space heating for which a heat metering system was required. Metering of the site high pressure hot water system posed technical difficulties and expenditure was also limited. This led to a ‘tin-house' design being installed for a price less than the commercial equivalent. The timespan of work to achieve an operational heat metering system was 3 years which meant that energy saving results from the scheme were not observed during the study. If successful the replication potential is the larger non energy intensive sites from which some 30 PT savings could be expected in the UK.

Budgeting, budgetary control and management information in the highways departments

The need for an adequate information system for the Highways Departments in the United Kingdom has been recognised by the report of a committee presented to the Minister of Transport in 1970, (The Marshall Report). This research aims to present a comprehensive information system on a sound theoretical basis which should enable the different levels of management to execute their work adequately. The suggested system presented in this research covers the different functions of the Highways Department, and presents a suggested solution for problems which may occur during the planning and controlling of work in the different locations of the Highways Department. The information system consists of:- 1. A coding system covering the cost units, cost centres and cost elements. 2. Cost accounting records for the cost units and cost centres. 3. A budgeting and budgetary control system covering, the different planning methods and procedures which are required for preparing the capital expenditure budget, the improvement and maintenance operation flexible budgets and programme of work, the plant budget, the administration budget, and the purchasing budget. 4. A reporting system which ensures that the different levels of management are receiving relevant and timely information. 5. The flow of documents which covers the relationship between the prime documents, the cost accounting records, budgets, reports and their relation to the different sections and offices within the department. A comprehensive cost units, cost centres, and cost elements codes together with a number of examples demonstrating the results of the survey, and examples of the application and procedures of the suggested information system have been illustrated separately as appendices. The emphasis is on the information required for internal control by management personnel within the County Council.

The use of presidential executive orders to control the management and administration of the federal government

As long as governmental institutions have existed, efforts have been undertaken to reform them. This research examines a particular strategy, coercive controls, exercised through a particular instrument, executive orders, by a singular reformer, the president of the United States. The presidents studied-- Johnson, Nixon, Ford, Carter, Reagan, Bush, and Clinton--are those whose campaigns for office were characterized to varying degrees as against Washington bureaucracy and for executive reform. Executive order issuance is assessed through an examination of key factors for each president including political party affiliation, levels of political capital, and legislative experience. A classification typology is used to identify the topical dimensions and levels of coerciveness. The portrayal of the federal government is analyzed through examination of public, media, and presidential attention. The results show that executive orders are significant management tools for the president. Executive orders also represent an important component of the transition plans for incoming administrations. The findings indicate that overall, while executive orders have not increased in the aggregate, they are more intrusive and significant. When the factors of political party affiliation, political capital, and legislative experience are examined, it reveals a strong relationship between executive orders and previous executive experience, specifically presidents who served as a state governor prior to winning national election as president. Presidents Carter, Reagan, and Clinton (all former governors) have the highest percent of executive orders focusing on the federal bureaucracy. Additionally, the highest percent of forceful orders were issued by former governors (41.0%) as compared to their presidential counterparts who have not served as governors (19.9%). Secondly, political party affiliation is an important, but not significant, predictor for the use of executive orders. Thirdly, management strategies that provide the president with the greatest level of autonomy--executive orders--redefine the concept of presidential power and autonomous action. Interviews of elite government officials and political observers support the idea that executive orders can provide the president with a successful management strategy, requiring less expenditure of political resources, less risk to political capital, and a way of achieving objectives without depending on an unresponsive Congress. ^

The use of presidential executive orders to control the management and administration of the federal government

As long as governmental institutions have existed, efforts have been undertaken to reform them. This research examines a particular strategy, coercive controls, exercised through a particular instrument, executive orders, by a singular reformer, the president of the United States. The presidents studied- Johnson, Nixon, Ford, Carter, Reagan, Bush, and Clinton-are those whose campaigns for office were characterized to varying degrees as against Washington bureaucracy and for executive reform. Executive order issuance is assessed through an examination of key factors for each president including political party affiliation, levels of political capital, and legislative experience. A classification typology is used to identify the topical dimensions and levels of coerciveness. The portrayal of the federal government is analyzed through examination of public, media, and presidential attention. The results show that executive orders are significant management tools for the president. Executive orders also represent an important component of the transition plans for incoming administrations. The findings indicate that overall, while executive orders have not increased in the aggregate, they are more intrusive and significant. When the factors of political party affiliation, political capital, and legislative experience are examined, it reveals a strong relationship between executive orders and previous executive experience, specifically presidents who served as a state governor prior to winning national election as president. Presidents Carter, Reagan, and Clinton (all former governors) have the highest percent of executive orders focusing on the federal bureaucracy. Additionally, the highest percent of forceful orders were issued by former governors (41.0%) as compared to their presidential counterparts who have not served as governors (19.9%). Secondly, political party affiliation is an important, but not significant, predictor for the use of executive orders. Thirdly, management strategies that provide the president with the greatest level of autonomy-executive orders redefine the concept of presidential power and autonomous action. Interviews of elite government officials and political observers support the idea that executive orders can provide the president with a successful management strategy, requiring less expenditure of political resources, less risk to political capital, and a way of achieving objectives without depending on an unresponsive Congress.

Pressure ulcer management in Oman: nurses’ knowledge and views

Background: Pressure ulcers (PrUs) have a significant impact on health system expenditure and patient’s quality of life. It is a global problem. Many studies were undertaken in regard to PrU prevention and management. In Oman, no studies have been conducted to investigate nurses’ knowledge on prevention and management of PrUs. The purpose of this descriptive sequential explanatory mixed-method study was to explore the nurses’ level of knowledge in relation to prevention and management of PrUs in Oman. Methods: A mixed method design was used and the study was conducted over two Phases. In Phase I, a questionnaire was developed to explore nurses’ knowledge on PrU, policy, and resources. The main section of the questionnaire was the Pieper-Zulkowski Pressure Ulcer knowledge test (PZ-PUKT) which tests the knowledge on PrU. Another two sections were developed including questions about wound policy and resources available for PrU prevention and management in Oman. The questionnaire was distributed to nurses who were working in surgical, medical, orthopaedic, CCU, and ICU wards/units in seven hospitals. In Phase II study, semi-structured qualitative interviews were conducted with 16 of the questionnaire respondents. Interviews took approximately 30 minutes, were recorded and transcribed verbatim. Qualitative data were analysed using the Knowledge, Attitudes and Practice (KAP) model as the a priori framework. Results: In Phase I, 478 questionnaires were analysed. The knowledge test results showed the overall mean percent score for correctly answered questions was 51% suggesting a low level of knowledge. There was a significant relationship between nurses’ knowledge and age (P=0.001) and between knowledge and years of experience (P=0.001) with knowledge increasing with age and years of experience. In Phase II, four themes were identified from the interviews: knowledge, attitude, and practice (framework themes) and perception of role. Findings indicated positive and negative attitudes towards the care of PrUs. Some nurses stated feeling rewarded when they see wounds improving while others said they could not work with patients independently because they lacked the knowledge and the skills needed. There was variation in the management of PrU between hospitals. Both studies indicated that the wound management policy did not include enough information to guide nurses. Conclusion: Overall the nurses’ level of knowledge on PrU was relatively low. Most nurses were not familiar with wound management policy or different PrU prevention and management strategies. Nurses are aware of the risk of PrUs and try their best to manage them with the available resources however more training is required.

Beyond community-based diabetes management and the COAG coordinated care trial

OBJECTIVE: This article describes the patient management processes developed during the Council of Australian Governments (COAG) coordinated care trial and use of health outcome measures to monitor changes in utilisation patterns and patient well-being over time for a subgroup of 398 patients with type 2 diabetes. DESIGN: The Eyre component of the South Australian (SA) HealthPlus coordinated care trial was a matched geographically controlled study in which the outcomes for the intervention group of 1350 patients were compared with those of a similar control group of 500 patients in another rural health region in SA. SETTING: The trial was carried out on Eyre Peninsula in SA across populations in rural communities and in the main centres of Whyalla, Port Lincoln and Ceduna. Care planning was organised through general practitioner practices and services negotiated with allied health services and hospitals to meet patient needs. SUBJECTS: The SA HealthPlus trial included 1350 patients with chronic and complex illness. A subset of this group comprising 398 patients with type 2 diabetes is described in this report. Patients recruited into the three-year trial were care planned using a patient centred care planning model through which patient goals were generated along with medical management goals developed by clinicians and primary health care professionals. Relevant health services were scheduled in line with best practice and care plans were reviewed each year. Patient service utilisation, progress towards achieving health related goals and patient health outcomes were recorded and assessed to determine improvements in health and well-being along with the cost and profile of the services provided. RESULTS: Significant numbers of patients experienced improved health outcomes as a consequence of their involvement in the trial, and utilisation data showed reductions in hospital and medical expenditure for some patients. These results suggest that methods applied in the SA HealthPlus coordinated care trial have led to improvements in health outcomes for patients with diabetes and other chronic illnesses. In addition, the processes associated with the COAG trial motivated significant organisational change in the Regional Health Service as well as providing an opportunity to study the health and well-being outcomes resulting from a major community health intervention. CONCLUSIONS: The importance of the SA HealthPlus trial has been the demonstrated link between a formal research trial and significant developments in the larger health system with the trial not only leading to improvements in clinical outcomes for patients, but also acting as a catalyst for organisational reform. We now need to look beyond the illness focus of health outcome research to develop population based health approaches to improving overall community well-being.

Assessment of resting energy expenditure in pediatric mitochondrial diseases with indirect calorimetry

Mitochondrial diseases (MD) are the most frequent inborn errors of metabolism. In affected tissues, MD can alter cellular oxygen consumption rate leading to potential decreases in whole-body resting energy expenditure (REE), but data on pediatric children are absent. We determined, using indirect calorimetry (IC), whole-body oxygen consumption (VO2), carbon dioxide production (VCO2), respiratory quotient (RQ) and REE in pediatric patients with MD and healthy controls. Another goal was to assess the accuracy of available predictive equations for REE estimation in this patient population. IC data were obtained under fasting and resting conditions in 20 MD patients and 27 age and gender-matched healthy peers. We determined the agreement between REE measured with IC and REE estimated with Schofield weight and FAO/WHO/UNU equations. Mean values of VO2, VCO2 (mL·min-1·kg-1) or RQ did not differ significantly between patients and controls (P = 0.085, P = 0.055 and P = 0.626 respectively). Accordingly, no significant differences (P = 0.086) were found for REE (kcal·day-1 kg-1) either. On the other hand, although we found no significant differences between IC-measured REE and Schofield or FAO/WHO/UNU-estimated REE, Bland-Altman analysis revealed wide limits of agreement and there were some important individual differences between IC and equation-derived REE. VO2, VCO2, RQ and REE are not significantly altered in pediatric patients with MD compared with healthy controls. The energy demands of pediatric patients with MD should be determined based on IC data in order to provide the best possible personalized nutritional management for these children.