Effectiveness of Community versus Hospital Eye Service follow-up for patients with neovascular age-related macular degeneration with quiescent disease (ECHoES): a virtual non-inferiority trial

OBJECTIVES: To compare the ability of ophthalmologists versus optometrists to correctly classify retinal lesions due to neovascular age-related macular degeneration (nAMD).

DESIGN: Randomised balanced incomplete block trial. Optometrists in the community and ophthalmologists in the Hospital Eye Service classified lesions from vignettes comprising clinical information, colour fundus photographs and optical coherence tomographic images. Participants' classifications were validated against experts' classifications (reference standard).

SETTING: Internet-based application.

PARTICIPANTS: Ophthalmologists with experience in the age-related macular degeneration service; fully qualified optometrists not participating in nAMD shared care.

INTERVENTIONS: The trial emulated a conventional trial comparing optometrists' and ophthalmologists' decision-making, but vignettes, not patients, were assessed. Therefore, there were no interventions and the trial was virtual. Participants received training before assessing vignettes.

MAIN OUTCOME MEASURES: Primary outcome-correct classification of the activity status of a lesion based on a vignette, compared with a reference standard. Secondary outcomes-potentially sight-threatening errors, judgements about specific lesion components and participants' confidence in their decisions.

RESULTS: In total, 155 participants registered for the trial; 96 (48 in each group) completed all assessments and formed the analysis population. Optometrists and ophthalmologists achieved 1702/2016 (84.4%) and 1722/2016 (85.4%) correct classifications, respectively (OR 0.91, 95% CI 0.66 to 1.25; p=0.543). Optometrists' decision-making was non-inferior to ophthalmologists' with respect to the prespecified limit of 10% absolute difference (0.298 on the odds scale). Optometrists and ophthalmologists made similar numbers of sight-threatening errors (57/994 (5.7%) vs 62/994 (6.2%), OR 0.93, 95% CI 0.55 to 1.57; p=0.789). Ophthalmologists assessed lesion components as present less often than optometrists and were more confident about their classifications than optometrists.

CONCLUSIONS: Optometrists' ability to make nAMD retreatment decisions from vignettes is not inferior to ophthalmologists' ability. Shared care with optometrists monitoring quiescent nAMD lesions has the potential to reduce workload in hospitals.

TRIAL REGISTRATION NUMBER: ISRCTN07479761; pre-results registration.

The political economy of co-ordination challenges in the National Health Service: a postpositivist evaluation of diabetes policy and governance

The present PhD thesis develops and applies an evaluative methodology suited to the evaluation of policy and governance in complex policy areas. While extensive literatures exist on the topic of policy evaluation, governance evaluation has received less attention. At the level of governance, policymakers confront choices between different policy tools and governance arrangements in their attempts to solve policy problems, including variants of hierarchy, networks and markets. There is a need for theoretically-informed empirical research to inform decision-making at this level. To that end, the PhD develops an approach to evaluation by combining postpositivist policy analysis with heterodox political economy. Postpositivist policy analysis recognises that policy problems are often contested, that choices between policy options can involve significant trade-offs and that knowledge of policy options is itself dispersed and fragmented. Similarly, heterodox economics combines a concept of incommensurable values with an appreciation of the strengths and weaknesses of different institutional arrangements to realise them. A central concept of the field is coordination, which orientates policy analysis to the interactions of stakeholders in policy processes. The challenge of governance is to select the appropriate policy tools and arrangements which facilitate coordination. Via a postpositivist exploration of stakeholder ‘frames’, it is possible to ascertain whether coordination is occurring and to identify problems if it is not. Evaluative claims of governance can be made where arrangements can be shown to frustrate the realisation of shared values and objectives. The research makes a contribution to knowledge in a number of ways a) a distinctive evaluative approach that could be applied to other areas of health and public policy b) greater appreciation of the strengths and weaknesses of different forms of evidence in public policy and in particular health policy and c) concrete policy proposals for the governance and organisation of diabetes services, with implications for the NHS more broadly.

Professional service productization and its implications to knowledge transfer in internationalization processes –Case: Company X in Finnish, Swedish and Norwegian markets

As a result of globalization, two thirds of the world’s business takes place nowadays in the service sector. In line, professional service firms are growing their share of the global service production. However, saturation of the professional service sector has forced professional service firms to search for more heuristic ways to conduct business in the international markets. By leveraging effectively the firm’s professionals, a professional service firm can lower its costs to clients and simultaneously generate additional value for the company and thus gain competitive advantage. Even though the academic field has shown growing interest towards services for decades, the fields of service productization and service internationalization are heavily understudied even today. Hence, the objective of this study was to contribute to the research on professional service internationalization and productization. The study concentrated on examining the impact that productization has on knowledge sharing and leveraging in professional service firms operating internationally. The research question focused on examining what implications productization has on knowledge transfer and leveraging during professional service internationalization by leaning on the existing research and on an empirical research. The empirical research was conducted as a single case study within a professional service firm operating in debt-related administrative service business. The case company is one of the leading operators in its field of business and therefore offered a fruitful environment to observe and analyze the topics in question. Additionally, the case company has a strong international presence and a large scale of operations in the selected markets, Finland, Norway and Sweden. Based on the previous literature and on the empirical research, this study found that for professional service firms to efficiently utilize individual, tacit knowledge, in its internationalization processes, it must be shared with the whole organization. By exploiting productization as a knowledge leveraging mechanism, a PSF can apply and transfer knowledge profoundly during its internationalization processes that would otherwise be difficult to tap into. Productization might not be sufficient alone, but by complementing it with a favorable organizational structure and culture, and by encouraging open communication, a PSF may take advantage of the whole potential that productization has to offer.

Quality improvement within nonprofit social service providers

As a relatively new phenomenon in 2009, Swedish nonprofit social service providers proposed quality improvement as a way to reduce mistakes, use resources more effectively and meet the needs and expectations of clients in a better way. Although similar experiences have been studied in health care, the transfer of quality improvement to nonprofit social services gives a possibility for more knowledge on what enables, and constrains, systematic quality improvement in this specific context. This thesis is based on five years of supporting quality improvement in the Swedish nonprofit welfare sector. Specifically, it builds knowledge on which active mechanisms and enabling or constraining structures exist for nonprofit social service quality improvement. By studying quality improvement projects that have been conducted in the development program Forum for Values, critical cases and broad overviews are found valuable. These cases have resulted in four papers on quality improvement in nonprofit social services. The papers include: critical cases from a nursing home for elderly and a daycare for disabled children (Paper I); a critical case from a sheltered housing (Paper II); an overview of performance measurements in 127 quality improvement projects (Paper III); and an analytical model of how improvement policy and practice are bridged by intermediaries (Paper IV). In this thesis, enabled or constrained events and activities related to Deming's system of profound knowledge are identified from the papers and elaborated upon. As a basis for transforming practice into continuous improvement, profound knowledge includes the four knowledge domains: appreciation of a system, theory of knowledge, understanding of variation and psychology of change. From a realist perspective, the identified events are seen as enabled or constrained by mechanisms and underlying regularities, or structures, in the context of nonprofit social services. The emerging mechanisms found in this thesis are: describing and reflecting upon project relations; forming and testing a theory of action; collecting and displaying measurable results over time; and engaging and participating in a development program. The structures that enable these mechanisms are: connecting projects to shared values such as client needs; local ownership of what should be measured; and translating quality improvement into a single practice. Constraining structures identified are: a lack of generalizable scientific knowledge and inappropriate or missing infrastructure for measurements. Reflecting upon the emergent structures of nonprofit social services, the role of political macro structures, reflective practice, competence in statistical methods and areas of expertise becomes important. From this discussion and the findings some hypotheses for future work can be formulated. First, the identified mechanisms and structures form a framework that helps explain why intended actions of quality improvement occur or not. This frameworkcan be part of formulating a program theory of quality improvement in nonprofit social services. With this theory, quality improvement can be evaluated, reflected upon and further developed in future interventions. Second,new quality improvement interventions can be reproduced more regularly by active work with known enablers and constraints from this program theory. This means that long-lasting interventions can be performed and studied in a second generation of improvement efforts. Third, if organizations integrate quality improvement as a part of their everyday practice they also develop context-specific knowledge about their services. This context-specific knowledge can be adopted and further developed through dedicated management and understanding of variation. Thus, if enabling structures are invoked and constraining structures handled, systematic quality improvement could be one way to integrate generalizable scientific knowledge as part of an evidence-creating practice.

[principles Of Universality, Comprehensiveness And Equity In A Hearing Health Care Service].

This article analyzed whether the practices of hearing health care were consistent with the principles of universality, comprehensiveness and equity from the standpoint of professionals. It involved qualitative research conducted at a Medium Complexity Hearing Health Care Center. A social worker, three speech therapists, a physician and a psychologist constituted the study subjects. Interviews were conducted as well as observation registered in a field diary. The thematic analysis technique was used in the analysis of the material. The analysis of interviews resulted in the construction of the following themes: Universality and access to hearing health, Comprehensive Hearing Health Care and Hearing Health and Equity. The study identified issues that interfere with the quality of service and run counter to the principles of Brazilian Unified Health System. The conclusion reached was that a relatively simple investment in training and professional qualification can bring about significant changes in order to promote a more universal, comprehensive and equitable health service.

A retrospective study of Traumatic Dental Injuries in a Brazilian dental urgency service

Epidemiologic aspects of traumatic dental injuries (TDI) were evaluated in the permanent dentition in a sample of 847 patients treated at the Dental Urgency Service of the Dental School of the Federal University of Goiás, Brazil, between May 2000 and May 2008. The statistical treatment analyzed data from frequency distribution and chi-square test. The level of significance was set at 5% for all analyses. The results showed a higher incident among males (610; 72.01%) with mean age of 6-10 year-old. Uncomplicated crown fracture (without pulp exposure) (502; 26.95%), avulsion (341; 18.30%) and complicated crown fracture (with pulp exposure) (330; 17.71%) were the most prevalent TDI. The prevalence of trauma throughout the years showed proportionality, being observed a larger number of cases between July and September (249; 29.39%). The most affected teeth were the maxillary central incisors (65.65%), followed by the maxillary left lateral incisors (19.67%). In 311 participants (18.25%), only one tooth was involved, while in most patients (536; 81.75%), TDI occurred in more than one tooth. Significant proportion (82.27%) of traumatized teeth presented completely formed root apex. The main etiologic factors involved in TDI were falls (51.71%), traffic accidents (22.90%) and violence (5.67%). Based on the obtained data, it may be concluded that accurate policies of TDI prevention must be established, capable of stimulating the exposure of appropriate protocols for management of these lesions. The prevalence of TDI in Goiânia subpopulation is compared to the prevalence reported in epidemiological studies in others populations.

Atenção domiciliar como mudança do modelo tecnoassistencial

OBJETIVO: Analisar práticas de atenção domiciliar de serviços ambulatoriais e hospitalares e sua constituição como rede substitutiva de cuidado em saúde. PROCEDIMENTOS METODOLÓGICOS: Estudo qualitativo que analisou, com base na metodologia de caso traçador, quatro serviços ambulatoriais de atenção domiciliar da Secretaria Municipal de Saúde e um serviço de um hospital filantrópico do município de Belo Horizonte, MG, entre 2005 e 2007. Foram realizadas entrevistas com gestores e equipes dos serviços de atenção domiciliar, análise de documentos e acompanhamento de casos com entrevistas a pacientes e cuidadores. A análise foi orientada pelas categorias analíticas integração da atenção domiciliar na rede de saúde e modelo tecnoassistencial. ANÁLISE DOS RESULTADOS: A implantação da atenção domiciliar foi precedida por decisão político-institucional tanto com orientação racionalizadora, buscando a diminuição de custos, quanto com vistas à reordenação tecnoassistencial das redes de cuidados. Essas duas orientações encontram-se em disputa e constituem dificuldades para conciliação dos interesses dos diversos atores envolvidos na rede e na criação de espaços compartilhados de gestão. Pôde-se identificar a inovação tecnológica e a autonomia das famílias na implementação dos projetos de cuidado. As equipes mostraram-se coesas, construindo no cotidiano do trabalho novas formas de integrar os diferentes olhares para transformação das práticas em saúde. Foram observados desafios na proposta de integrar os diferentes serviços de caráter substitutivo do cuidado ao limitar a capacidade da atenção domiciliar de mudar o modelo tecnoassistencial. CONCLUSÕES: A atenção domiciliar possui potencial para constituição de uma rede substitutiva ao produzir novos modos de cuidar que atravessam os projetos dos usuários, dos familiares, da rede social e dos trabalhadores da atenção domiciliar. A atenção domiciliar como modalidade substitutiva de atenção à saúde requer sustentabilidade política, conceitual e operacional, bem como reconhecimento dos novos arranjos e articulação das propostas em curso.

Efetividade de programa de agentes comunitários na promoção da saúde bucal

OBJETIVO:Avaliar mudanças em conhecimentos, atitudes e acesso/utilização de serviços odontológicos decorrentes de um programa de promoção da saúde bucal com agentes comunitários de saúde. MÉTODOS:Um projeto de capacitação combinando ensino-aprendizagem, apoio e supervisão, foi desenvolvido entre os meses de julho de 2003 a agosto de 2004. As mudanças foram avaliadas por meio de entrevistas estruturadas em que participaram 36 agentes comunitários de saúde e uma amostra de 91 mulheres e mães, representativa de donas de casa com 25 a 39 anos de idade, alfabetizadas e residentes em domicílios de três a seis cômodos no município de Rio Grande da Serra (SP). Foram colhidos dados sobre conhecimentos de saúde-doença bucal, práticas e capacidades auto-referidas em relação ao auto-exame, higiene bucal, número de residentes e de escovas dentais individuais e coletivas em cada domicílio e acesso e uso de serviços odontológicos. Por meio do teste t de Student pareado, foram comparadas as médias dos valores obtidos antes e depois do programa para cada um dos grupos estudados. As respostas foram analisadas adotando-se um nível de significância de 5%. RESULTADOS: Foram observadas diferenças estatisticamente significativas para questões relativas ao conhecimento de saúde bucal entre os agentes e entre as mulheres antes e depois da capacitação (p<0,05). Desequilíbrio entre o número de escovas e de indivíduos em cada família diminuiu. A freqüência da escovação e do uso do fio dental se elevou depois da atuação dos agentes. Os valores de auto-avaliação da higiene bucal aumentaram. Modificação nas práticas e capacidades auto-referidas mostrou significativa elevação da auto-confiança. O acesso ao serviço foi mais fácil (p<0,000) e seu uso mais regular (p<0,000) entre mulheres. CONCLUSÕES: Houve mudanças positivas na percepção em relação a aspectos de saúde bucal, na auto-confiança e no acesso e uso de serviços odontológicos. Tais mudanças po

The Process of Simulation Authoring/Creation by Chemistry Teachers: A Service Learning Experience

Two case studies are presented to describe the process of public school teachers authoring and creating chemistry simulations. They are part of the Virtual Didactic Laboratory for Chemistry, a project developed by the School of the Future of the University of Sao Paulo. the documental analysis of the material produced by two groups of teachers reflects different selection process for both themes and problem-situations when creating simulations. The study demonstrates the potential for chemistry learning with an approach that takes students' everyday lives into account and is based on collaborative work among teachers and researches. Also, from the teachers' perspectives, the possibilities of interaction that a simulation offers for classroom activities are considered.

Introdução ao uso dos protocolos SRU/SRW: ferramentas para a catalogação cooperativa

In this article the use of Search and Retrieve URL (SRU) / Search and Retrieve Web Service (SRW) protocols, both developed and maintained by the Library of Congress in the United States, is presented and discussed. The SRU/SRW is a new draft protocol based on the already widespread Z39.50 protocol, whose purpose is to facilitate the development of solutions for shared cooperative cataloging of bibliographic information. Some examples of applications are also shown and the lack of production on the subject in specialized journals is pointed out.

Shared information in stationary states of stochastic processes

We present four estimators of the shared information (or interdepency) in ground states given that the coefficients appearing in the wave function are all real non-negative numbers and therefore can be interpreted as probabilities of configurations. Such ground states of Hermitian and non-Hermitian Hamiltonians can be given, for example, by superpositions of valence bond states which can describe equilibrium but also stationary states of stochastic models. We consider in detail the last case, the system being a classical not a quantum one. Using analytical and numerical methods we compare the values of the estimators in the directed polymer and the raise and peel models which have massive, conformal invariant and nonconformal invariant massless phases. We show that like in the case of the quantum problem, the estimators verify the area law with logarithmic corrections when phase transitions take place.

MODELING OF AN INFORMATION SYSTEM FOR WINE TRACEABILITY BASED ON A SERVICE ORIENTED ARCHITECTURE

The purpose is to present a scientific research that led to the modeling of an information system which aimed at the maintenance of traceability data in the Brazilian wine industry, according to the principles of a service-oriented architecture (SOA). Since 2005, traceability data maintenance is an obligation for all producers that intend to export to any European Union country. Also, final customers, including the Brazilian ones, have been asking for information about food products. A solution that collectively contemplated the industry was sought in order to permit that producer consortiums of associations could share the costs and benefits of such a solution. Following an extensive bibliographic review, a series of interviews conducted with Brazilian researchers and wine producers in Bento Goncalves - RS, Brazil, elucidated many aspects associated with the wine production process. Information technology issues related to the theme were also researched. The software was modeled with the Unified Modeling Language (UML) and uses web services for data exchange. A model for the wine production process was also proposed. A functional prototype showed that the adopted model is able to fulfill the demands of wine producers. The good results obtained lead us to consider the use of this model in other domains.

Application of the essential work of fracture method in ranking the performance in service of high-density polyethylene resins employed in pressure pipes

High-density polyethylene resins have increasingly been used in the production of pipes for water- and gas-pressurized distribution systems and are expected to remain in service for several years, but they eventually fail prematurely by creep fracture. Usual standard methods used to rank resins in terms of their resistance to fracture are expensive and non-practical for quality control purposes, justifying the search for alternative methods. Essential work of fracture (EWF) method provides a relatively simple procedure to characterize the fracture behavior of ductile polymers, such as polyethylene resins. In the present work, six resins were analyzed using the EWF methodology. The results show that the plastic work dissipation factor, beta w(p), is the most reliable parameter to evaluate the performance. Attention must be given to specimen preparation that might result in excessive dispersion in the results, especially for the essential work of fracture w(e).

Expo 1988 Information Service Centre, Brisbane

View to service centre during Expo 1988.

Perceptions of mental health service delivery among staff and Indigenous consumers: it's still about communication

Objective: A needs analysis was undertaken to determine the quality and effectiveness of mental health services to Indigenous consumers within a health district of Southern Queensland. The study focussed on identifying gaps in the service provision for Indigenous consumers. Tools and methodologies were developed to achieve this. Method: Data were collected through the distribution of questionnaires to the target populations: district health service staff and Indigenous consumers. Questionnaires were developed through consultation with the community and the Steering Committee in order to achieve culturally appropriate wording. Of prime importance was the adaptation of questionnaire language so it would be fully understood by Indigenous consumers. Both questionnaires were designed to provide a balanced perspective of current mental health service needs for Indigenous people within the mental health service. Results: Results suggest that existing mental health services do not adequately meet the needs of Indigenous people. Conclusions: Recommendations arising from this study indicate a need for better communication and genuine partnerships between the mental health service and Indigenous people that reflect respect of cultural heritage and recognises the importance of including Indigenous people in the design and management of mental health services. Attention to the recommendations from this study will help ensure a culturally appropriate and effective mental health service for Indigenous consumers.