Measuring value in cancer-related health care: A case study in head and neck cancer

In the current climate of escalating health care costs, defining value and accurately measuring it are two critical issues affecting not only the future of cancer care in particular but also the future of health care in general. Specifically, measuring and improving value in cancer-related health care are critical for continued advancements in research, management, and overall delivery of care. However, in oncology, most of this research has focused on value as it relates to insurance industry and payment reform, with little attention paid to value as the output of clinical interventions that encompass integrated clinical teams focusing on the entire cycle of care and measuring objective outcomes that are most relevant to patients. ^ In this study, patient-centered value was defined as health outcomes achieved per dollar spent, and calculated using objective functional outcomes and total care costs. The analytic sample comprised patients diagnosed with three common head and neck cancers—cancer of the larynx, oral cavity, and oropharynx—who were treated in an integrated tertiary care center over an approximately 10-year period. The results of this study provide initial empirical data that can be used to assess and ultimately to help improve the quality and value of head and neck cancer care, and more importantly they can be used by patients and clinicians to make better-informed decisions about care, particularly what therapeutic services and outcomes matter the most to patients.^

Impact of racial differences in medical care on breast cancer survival: Findings from a large nationwide and retrospective cohort study

Background: No studies have attempted to determine whether nodal surgery utilization, time to initiation and completion of chemotherapy or surveillance mammography impact breast cancer survival. ^ Objectives and Methods: To determine whether receipt of nodal surgery, initiation and completion of chemotherapy, and surveillance mammography impact of racial disparities in survival among breast cancer patients in SEER areas, 1992-2005. ^ Results: Adjusting for nodal surgery did not reduce racial disparities in survival. Patients who initiated chemotherapy more than three months after surgery were 1.8 times more likely to die of breast cancer (95% CI 1.3-2.5) compared to those who initiated chemotherapy less than a month after surgery, even after controlling for known confounders or controlling for race. Despite correcting for chemotherapy initiation and completion and known predictors of outcome, African American women still had worse disease specific survival than their Caucasian counterparts. We found that non-whites underwent surveillance mammography less frequently compared with whites and mammography use during a one- or two-year time interval was associated with a small reduced risk of breast-cancer-specific and all-cause mortality. Women who received a mammogram during a two-year interval could expect the same disease-specific survival benefit or overall survival benefit as women who received a mammogram during a one-year interval. We found that while adjustment for surveillance mammography receipt and physician visits reduced differences in mortality between blacks and whites, these survival disparities were eliminated after adjusting for the number of surveillance mammograms received. ^ Conclusions: The disparities in survival among African American and Hispanic women with breast cancer are not explained by nodal surgery utilization or chemotherapy initiation and chemotherapy completion. Surveillance mammograms, physician visits and number of mammograms received may play a major role in achieving equal outcomes for breast cancer-specific mortality for women diagnosed with primary breast cancer. Racial disparities in all-cause mortality were explained by racial differences in surveillance mammograms to certain degree, but were no longer significant after controlling for differences in comorbidity. Focusing on access to quality care and post treatment surveillance might help achieve national goals to eliminate racial disparities in healthcare and outcomes. ^

Packages of interventions for family planning, safe abortion care, maternal, newborn and child health

The evidence shows that high maternal, perinatal, neonatal and child mortality rates are associated with inadequate and poor quality health services. Evidence also suggests that explicit, evidence-based, cost effective packages of interventions can improve the processes and outcomes of health care when appropriately implemented. This document describes the key effective interventions organized in packages across the continuum of care through pre-pregnancy, pregnancy, childbirth, postpartum, newborn care and care of the child. The packages are defined for community and/or facility levels in developing countries and provide guidance on the essential components needed to assure adequacy and quality of care

Quantitative analysis of chromosomal CGH in human breast tumors associates copy number abnormalities with p53 status and patient survival

We present a general method for rigorously identifying correlations between variations in large-scale molecular profiles and outcomes and apply it to chromosomal comparative genomic hybridization data from a set of 52 breast tumors. We identify two loci where copy number abnormalities are correlated with poor survival outcome (gain at 8q24 and loss at 9q13). We also identify a relationship between abnormalities at two loci and the mutational status of p53. Gain at 8q24 and loss at 5q15-5q21 are linked with mutant p53. The 9q and 5q losses suggest the possibility of gene products involved in breast cancer progression. The analytical techniques are general and also are applicable to the analysis of array-based expression data.

Colaboração interprofissional na Estratégia Saúde da Família e a produção do cuidado em saúde durante o pré-natal

Introdução: Uma das mudanças mais importantes na produção do cuidado à saúde é a reorganização do processo de trabalho para a atuação de equipes multiprofissionais com abordagens interdisciplinares. A colaboração interprofissional tem sido apontada como um recurso que pode ser mobilizado para elevar a efetividade dos sistemas de saúde, e como estratégia inovadora, ela pode desempenhar um importante papel para enfrentar problemas do modelo de atenção e da força de trabalho em saúde. Objetivo: Descrever as percepções e atitudes de profissionais de saúde da Estratégia de Saúde da Família sobre as relações interprofissionais na atenção ao pré-natal, construir coletivamente e testar um protocolo de atenção à gestante para impulsionar as competências no trabalho colaborativo com vistas ao incremento da qualidade do cuidado. Métodos: Para isso, realizou-se previamente um estudo observacional descritivo para seleção de duas unidades de saúde. Na sequência foi realizado um estudo de intervenção do tipo antes e depois, com um grupo de controle pós-teste, incluindo métodos mistos. A população do estudo compreendeu oito profissionais de saúde (médicos, dentistas, enfermeiros e técnicos em saúde bucal) e 60 gestantes cadastradas em duas unidades de saúde da família do município de Uberlândia, sendo 36 incluídas no grupo intervenção e 24 no grupo controle. Dados numéricos, narrativas provenientes de entrevistas e registros de diário de campo foram usados para identificar mudanças na autoavaliação da saúde bucal, na qualidade de vida relacionada à saúde bucal medida pelo OHIP-14, na percepção das gestantes sobre o trabalho em equipe e nas práticas profissionais. Testes estatísticos para detectar diferenças de significância e análise temática de conteúdo foram empregados para interpretar os desfechos. Resultados: Em geral, observou-se percepção/atitude favorável dos profissionais em relação à colaboração interprofissional. Diferenças entre as categorias profissionais podem representar uma barreira subjetiva à implementação de protocolos que demandariam maior grau de trabalho colaborativo. Diferenças entre as unidades de atenção primária mostraram que a interação entre membros das equipes multiprofissionais pode sobrepujar dificuldades decorrentes do modo isolado e distinto no qual cada categoria profissional é formada. Foi produzido um Protocolo de Atenção à Gestante abrangendo o fluxo e a dinâmica dos processos de trabalho dentro de uma perspectiva de colaboração interprofissional. Segundo os profissionais, a intervenção apesar do seu caráter desafiador, estimulou o comprometimento da equipe para reorientar o processo de trabalho resultando em maior interação profissional colaborativa. Em relação às gestantes, a maioria era jovem (menos de 26 anos de idade) e tinha ensino médio incompleto ou completo sem diferenças significativas entre os grupos teste e controle. Gestantes do grupo intervenção perceberam que os profissionais trabalhavam mais em equipe do que as gestantes do grupo controle. De modo geral, as gestantes avaliaram que a saúde bucal e a qualidade de vida decorrente da saúde bucal melhoraram após a intervenção. Conclusões: Concluiu-se que apesar da percepção geral dos profissionais favorável à colaboração interprofissional, recursos formais e organizacionais não estavam sendo empregados. O método ZOPP se mostrou flexível e adequado para o desenvolvimento de competências para o trabalho colaborativo e para a construção de um protocolo de organização de serviços na atenção primária à saúde. O Protocolo de Atenção à Gestante testado provocou tensões e produziu efeitos positivos na colaboração interprofissional e na qualidade de vida relacionada à saúde bucal contribuindo para qualificar a atenção ao pré-natal oferecido.

Responses to Domestic Violence Public Service Ads: Memory, Attitudes, Affect, and Individual Differences

Public service ads (PSAs) are an increasingly visible part of efforts to decrease the occurrence and consequences of domestic violence. Like other advertising, domestic violence PSAs are designed to grab attention, influence attitudes, and enhance memory for ad content. Over the years, images in domestic violence PSAs have changed substantially; agencies have started using pictures that generate emotions - either vivid negative images (bruised faces or body parts), or positive images (smiling faces) that contrast with the negative text. It is not clear, however, how different types of ad images influence memory for the message and attitudes about domestic violence, and what role affect may play in such responses. Moreover, the extent to which individual differences (trauma history, posttraumatic distress - PTSD symptoms) influence outcomes is not known. In three studies with undergraduate and community samples, using methods ranging from psychophysiology to self-report, the impact of images on attitudes and memory for ad content are investigated, also considering affect and individual differences. Results indicate graphic negative images enhanced memory for ad content, are rated as more persuasive, and are more likely to compel the viewer to act. Affective responses to ads also differed based on image type, and in some cases, partially mediated the relationship between ads and outcomes. Trends in the data suggest further study of the role of individual differences (trauma history, PTSD symptoms) is needed. This research provides information specifically relevant to the design of domestic violence public service campaigns and broadly relevant to understanding the role of emotional responses and individual differences on outcomes associated with public service ads.

Development of The Readiness To Teach Online Scale

Despite the growing importance of online education, faculty acceptance has remained unchanged. Training programs developed for faculty to teach online have often focused on assessing their cognitive rather than affective and behavioral outcomes. The Readiness To Teach Online scale was developed as part of a multiphase mixed method research project to measure faculty perceptions and motivations toward teaching online. Items in the subcategory Teaching and Learning measured perceptions of technology and online teaching, and motivations regarding resources and other external factors. Items in the subcategories Social and Student Engagement, Faculty and Technology Support, Course Development and Instructional Design, and Evaluation and Assessment collected baseline data for current practices. The pilot study of this scale demonstrated strong internal consistency reliability estimates and support for validity, showing moderately to highly correlated significant relationships between faculty perceptions and motivation to teach online; both perception and motivation constructs were moderately to highly correlated with Social and Student Engagement.

Evaluation of hybrid and distance education learning environments in Spain

This article describes the adaptation and validation of the Distance Education Learning Environments Survey (DELES) for use in investigating the qualities found in distance and hybrid education psycho-social learning environments in Spain. As Europe moves toward post-secondary student mobility, equanimity in access to higher education, and more standardised degree programs across the European Higher Education Area (EHEA) the need for a high quality method for continually assessing the excellence of distance and hybrid learning environments has arisen. This study outlines how the English language DELES was adapted into the new Spanish-Distance Education Learning Environments Survey (S-DELES) for use with a Bachelor of Psychology and Criminology degree program offering both distance and hybrid education classes. We present the relationships between psycho-social learning environment perceptions and those of student affect. We also present the asynchronous aspects of the environment, scale means, and a comparison between the perceptions of distance education students and their hybrid education counterparts that inform the university about the baseline health of the information and communication technologies (ICT) environment within which the study was conducted.

Mechanisms that Trigger a Good Health-Care Response to Intimate Partner Violence in Spain. Combining Realist Evaluation and Qualitative Comparative Analysis Approaches

Background. Health care professionals, especially those working in primary health-care services, can play a key role in preventing and responding to intimate partner violence. However, there are huge variations in the way health care professionals and primary health care teams respond to intimate partner violence. In this study we tested a previously developed programme theory on 15 primary health care center teams located in four different Spanish regions: Murcia, C Valenciana, Castilla-León and Cantabria. The aim was to identify the key combinations of contextual factors and mechanisms that trigger a good primary health care center team response to intimate partner violence. Methods. A multiple case-study design was used. Qualitative and quantitative information was collected from each of the 15 centers (cases). In order to handle the large amount of information without losing familiarity with each case, qualitative comparative analysis was undertaken. Conditions (context and mechanisms) and outcomes, were identified and assessed for each of the 15 cases, and solution formulae were calculated using qualitative comparative analysis software. Results. The emerging programme theory highlighted the importance of the combination of each team’s self-efficacy, perceived preparation and women-centredness in generating a good team response to intimate partner violence. The use of the protocol and accumulated experience in primary health care were the most relevant contextual/intervention conditions to trigger a good response. However in order to achieve this, they must be combined with other conditions, such as an enabling team climate, having a champion social worker and having staff with training in intimate partner violence. Conclusions. Interventions to improve primary health care teams’ response to intimate partner violence should focus on strengthening team’s self-efficacy, perceived preparation and the implementation of a woman-centred approach. The use of the protocol combined with a large working experience in primary health care, and other factors such as training, a good team climate, and having a champion social worker on the team, also played a key role. Measures to sustain such interventions and promote these contextual factors should be encouraged.

THE DARK PERSONALITY AND JOB SUCCESS IN THE UNITED STATES ARMY: USE OF INTERPERSONAL MANIPULATION IN THE WORKPLACE

This dissertation relates job desires and outcomes to the Dark Personality (Psychopathy, Machiavellianism, Narcissism, Low Agreeableness, Low Honesty-Humility) in the United States Army. It purports that individuals high on the Dark Personality desire more power, money, and status, and that they obtain jobs that afford them these luxuries by using manipulation at work. Two pilot studies used samples of United States Army members to create and test index variables: Dark Personality, Total Manipulation in the workplace, Desire for Job Success, and Total Job Success in the Army. Individual personality traits, manipulation tactics, and job desires were examined in secondary analyses. Using a sample of 468 United States Army Members, central analyses indicated that Army members high on the Dark Personality desired Job Success. Likewise, army members higher on the Dark Personality used more Manipulation tactics at work, including the egregious tactics. Yet, using more Manipulation tactics at work predicted lower levels of Job Success in the Army. Most manipulation tactics had a negative impact on Job Success, with the exception of soft tactics like Reason and Responsibility Invocation. Together, these results indicate that selective use of soft manipulation predicted Job Success, but use of more manipulation tactics predicted less Job Success in the Army. Curvilinear results indicated that being either very low or very high on the Dark Personality predicted more Job Success in the Army, whereas having intermediate levels of the Dark Personality predicted less Job Success. Finally, possessing the Dark Personality and using more Manipulation tactics at work, together, predicted less Job Success in the Army. Collectively, the results indicate that army members with intermediate levels of the Dark Personality want more powerful and high paying jobs, yet their strategy of manipulating their coworkers to move up the job ladder does not result in higher ranking, higher paying Army positions. However, Army members highest on the Dark Personality achieved job success, defying the maladaptive influence that antisocial personality traits and manipulative behaviour had on job success for most Army members. Therefore, this dissertation indicates that successful corporate scoundrels exist in the Army, but there are few of them.

Revisiting a series of epithelial salivary gland tumors in children and adolescents in southern Portugal

Trabalho Final do Curso de Mestrado Integrado em Medicina, Faculdade de Medicina, Universidade de Lisboa, 2014

Caesarean Birth vs. Vaginal Delivery: Effects upon Maternal Satisfaction, Maternal Confidence and Maternal Perception of the Newborn Behaviour

In order to test the hypothesis that caesarean birth has negative consequences upon newly mothers’ satisfaction and perceptions, women delivering by caesarean birth (WCB) were compared with women delivering by vaginal birth (WVB). Subjects: 180 newly mothers; 93 WCB and 87 WVB. Instruments: A Socio-Demographic Questionnaire developed for this research, the Childbirth Perceptions Questionnaire and the Mother and Baby Scales. Results: WCB had significantly lower scores in perceptions of baby as alert/responsive and nearly significant lower scores for baby as alert during feeds. WVB showed a significantly higher level of satisfaction with delivery and conduct during labour, as also had significantly lower scores for perceptions of baby as irritable during feeds and for lack of confidence in feeds. After controlling for the kind of anesthesia received in labour, three conclusions must be taken into account: 1) between WCB with regional anaesthesia and WCB with general anaesthesia there is only one significant difference, with the former having higher scores for perception of baby as alert during feeds; 2) between WVB with regional anaesthesia and WVB with no anaesthesia there are only two significant differences, with the former having higher scores for lack of confidence in feeding and having lower scores for global confidence; 3) between WCB with regional anaesthesia and WVB with regional anaesthesia four significant differences emerge, with the former having a lower level of satisfaction with delivery and conduct in labour and having lower scores for perception of baby as alert responsive, and also having higher scores of perception of baby as irritable in feeds and higher scores for lack of confidence in feeding. Data seem compatible with the hypothesis that caesarean birth has some negative consequences upon mothers’ satisfaction and perceptions and, for this reason, psychological surveys should constitute a routine procedure in maternity hospitals, especially when newly mothers pertain to families affected by risks of psychological or social nature.

The EU's Group-to-Group Dialogue with the Southern Mediterranean and ASEAN – How much have they achieved? A Comparative Analysis. EU Centre Singapore Working Paper No, 18, December 2013

Four decades of the EU's group-to-group dialogues with the Southern Mediterranean grouping of countries and with ASEAN have produced different dynamics and outcomes, despite the EU’s common strategy to use economic soft power to achieve their goals for the partnerships. Diverging conditions in the two regions created inconsistency in the EU's application of the common approach. The EU's neighbourhood security concerns forced it to relax its political stand with their Southern Mediterranean partners. For ASEAN, geographical distance dilutes the EU’s security concerns it that region and has afforded the EU to be more ideological and assertive on democracy and human rights practices. These issues have provoked disagreements in EU-ASEAN dialogues, but both sides have also tried to remain pragmatic in order to achieve some progress in the partnership. In contrast, the protracted the Arab-Israeli conflict continues to hamper the Euro-Mediterranean dialogue, resulting in little progress. Social upheavals in the Southern Mediterranean also brought their partnership to a standstill. The EU's cooperation with former authoritarian regimes like Libya and Syria have only caused damage to its credibility in the Southern Mediterranean, and future Euro-Mediterranean dialogues are likely to be affected by it.

Towards a Fragmented Neighbourhood: Policies of the EU and Russia and their consequences for the area that lies in between. CEPS Essay No. 17, 17 October 2014

In the current volatile climate, the EU needs a strategy towards Russia that goes beyond sanctions. In reviewing the European Neighbourhood Policy and the Eastern Partnership, the EU’s incoming leadership should be more sensitive towards the existing political, diplomatic, economic, energy and military ties between Russia and the countries in the common neighbourhood. After all, it is by exploiting these ties that Russia was able to turn this neighbourhood into an area of destructive competition − the primary victim of which is Ukraine. Understanding Russia’s perceptions and being sensitive to these longstanding ties does not mean justifying their use by the Kremlin. Nevertheless, factoring these ties into the EU’s policies vis-à-vis its Eastern neighbourhood is a prerequisite for more reflective, responsive and effective EU policies.