Costs and quality of medication reconciliation practice in primary care clinics

Medication reconciliation, with the aim to resolve medication discrepancy, is one of the Joint Commission patient safety goals. Medication errors and adverse drug events that could result from medication discrepancy affect a large population. At least 1.5 million adverse drug events and $3.5 billion of financial burden yearly associated with medication errors could be prevented by interventions such as medication reconciliation. This research was conducted to answer the following research questions: (1a) What are the frequency range and type of measures used to report outpatient medication discrepancy? (1b) Which effective and efficient strategies for medication reconciliation in the outpatient setting have been reported? (2) What are the costs associated with medication reconciliation practice in primary care clinics? (3) What is the quality of medication reconciliation practice in primary care clinics? (4) Is medication reconciliation practice in primary care clinics cost-effective from the clinic perspective? Study designs used to answer these questions included a systematic review, cost analysis, quality assessments, and cost-effectiveness analysis. Data sources were published articles in the medical literature and data from a prospective workflow study, which included 150 patients and 1,238 medications. The systematic review confirmed that the prevalence of medication discrepancy was high in ambulatory care and higher in primary care settings. Effective strategies for medication reconciliation included the use of pharmacists, letters, a standardized practice approach, and partnership between providers and patients. Our cost analysis showed that costs associated with medication reconciliation practice were not substantially different between primary care clinics using or not using electronic medical records (EMR) ($0.95 per patient per medication in EMR clinics vs. $0.96 per patient per medication in non-EMR clinics, p=0.78). Even though medication reconciliation was frequently practiced (97-98%), the quality of such practice was poor (0-33% of process completeness measured by concordance of medication numbers and 29-33% of accuracy measured by concordance of medication names) and negatively (though not significantly) associated with medication regimen complexity. The incremental cost-effectiveness ratios for concordance of medication number per patient per medication and concordance of medication names per patient per medication were both 0.08, favoring EMR. Future studies including potential cost-savings from medication features of the EMR and potential benefits to minimize severity of harm to patients from medication discrepancy are warranted. ^

Evaluating the Utility of Clinical Criteria for the Identification of Lynch Syndrome among Endometrial Cancer Patients

Background: Lynch Syndrome (LS) is a familial cancer syndrome with a high prevalence of colorectal and endometrial carcinomas among affected family members. Clinical criteria, developed from information obtained from familial colorectal cancer registries, have been generated to identify individuals at elevated risk for having LS. In 2007, the Society of Gynecologic Oncology (SGO) codified criteria to assist in identifying women presenting with gynecologic cancers at elevated risk for having LS. These criteria have not been validated in a population-based setting. Materials and Methods: We retrospectively identified 412, unselected endometrial cancer cases. Clinical and pathologic information were obtained from the electronic medical record, and all tumors were tested for expression of the DNA mismatch repair proteins through immunohistochemistry. Tumors exhibiting loss of MSH2, MSH6 and PMS2 were designated as probable Lynch Syndrome (PLS). For tumors exhibiting immunohistochemical loss of MLH1, we used the PCR-based MLH1 methylation assay to delineate PLS tumors from sporadic tumors. Samples lacking methylation of the MLH1 promoter were also designated as PLS. The sensitivity and specificity for SGO criteria for detecting PLS tumors was calculated. We compared clinical and pathologic features of sporadic tumors and PLS tumors. A simplified cost-effectiveness analysis was also performed comparing the direct costs of utilizing SGO criteria vs. universal tumor testing. Results: In our cohort, 43/408 (10.5%) of endometrial carcinomas were designated as PLS. The sensitivity and specificity of SGO criteria to identify PLS cases were 32.7 and 77%, respectively. Multivariate analysis of clinical and pathologic parameters failed to identify statistically significant differences between sporadic and PLS tumors with the exception of tumors arising from the lower uterine segment. These tumors were more likely to occur in PLS tumors. Cost-effectiveness analysis showed clinical criteria and universal testing strategies cost $6,235.27/PLS case identified and $5,970.38/PLS case identified, respectively. Conclusions: SGO 5-10% criteria successfully identify PLS cases among women who are young or have significant family history of LS related tumors. However, a larger proportion of PLS cases occurring at older ages with less significant family history are not detected by this screening strategy. Compared to SGO clinical criteria, universal tumor testing is a cost effective strategy to identify women presenting with endometrial cancer who are at elevated risk for having LS.

Cambio para optimizar la calidad de las prestaciones del Programa Oncológico Provincial

Considerando el alto costo farmacológico de los tratamientos oncológicos actuales y de los anticuerpos monoclonales pautados para diferentes terapias que están apareciendo y que serán prácticamente lo único que se use en el futuro para diferentes diagnósticos, el Programa Oncológico Provincial cubre sin cargo alguno las necesidades de los pacientes atendidos en Hospitales Estatales, cumpliendo una función social, dispensando los medicamentos solicitados por el médico tratante, en forma confiable, segura, y con equidad para recibir el tratamiento adecuado en el momento oportuno. Los recursos que pueden ser destinados al gasto farmacéutico son limitados, por lo que es necesario racionalizar el consumo y priorizar en la asignación de estos recursos a las opciones que presentan mayores ventajas económicas, basada en mantener una mejor relación costo/beneficio, repercutiendo de manera directa en los enfermos y en la sociedad en general. En este trabajo, se analiza el sistema de adquisición de drogas oncológicas usado por el Programa Oncológico Provincial realizando una comparación entre el sistema de compras original y el adoptado por el Programa en el año 2005. Se evalúa el periodo 2001-2007, en base a diversos indicadores y datos estadísticos, para determinar si ha mejorado la calidad de las prestaciones, si ha disminuido la demanda contenida y si se ha logrado mejorar la relación costo / beneficio, controlando así el gasto sanitario global lo que constituiría una inversión rentable para el sistema de salud. Los resultados indican que el nuevo sistema adoptado por el Programa Provincial de Oncología ha mejorado la provisión de medicamentos y garantiza mayor calidad en las prestaciones, pero estos resultados pueden ser superados. También muestra la gravedad del problema de la utilización de los nuevos fármacos monoclonales.

Intermodal exchange stations in the city of Madrid

The City of Madrid is putting into operation Intermodal Exchange Stations (IESs) to make connections between urban and suburban transportation modes easier for users of public transportation. The purpose of this article is to evaluate the actual effects that the implementation of IESs in the City of Madrid has on the affected stakeholders: users, public transportation operators, infrastructure managers, the government, the abutters and other citizens. We develop a methodology intended to help assess the welfare gains and losses for each stakeholder. Then we apply this methodology to the case study of the Avenida de América IES in the city of Madrid. We found that it is indeed possible to arrive at win–win solutions for the funding of urban transportation infrastructure, as long as the cost-benefit ratio of the project is high enough. Commuters save travel time. Bus companies diminish their costs of operation. The abutters gain in quality of life. The private operator of the infrastructure makes a fair profit. And the government is able to promote these infrastructure facilities without spending more of its scarce budgetary resources.

Análisis de la aplicación de Soldadura de acero de calidad "A" mediante láser de Neodimio-YAG en construcción naval

El proceso de soldadura por láser desarrollado en los últimos años ha puesto de manifiesto las posibilidades de aplicación de esta tecnología en diferentes sectores productivos, principalmente en la industria automovilística, en la cual se han demostrado sus ventajas en términos de productividad, eficiencia y calidad. El uso de la tecnología láser, ya sea híbrida o pura, reduce el input térmico al limitar la zona afectada por el calor, sin crear deformaciones y, por tanto, disminuye los re-trabajos post-soldadura necesarios para eliminarlas. Asimismo, se aumenta la velocidad de soldadura, incrementando la productividad y calidad de las uniones. En la última década, el uso de láseres híbridos, (láser + arco) de gran potencia de Neodimio YAG, (Nd: YAG) ha sido cada vez más importante. La instalación de este tipo de fuentes de láser sólido de gran potencia ha sido posible en construcción naval debido a sus ventajas con respecto a las instalaciones de láser de C02 existentes en los astilleros que actualmente utilizan esta tecnología. Los láseres de C02 están caracterizados por su gran potencia y la transmisión del haz a través de espejos. En el caso de las fuentes de Nd:YAG, debido a la longitud de onda a la cual se genera el haz láser, su transmisión pueden ser realizada a través de fibra óptica , haciendo posible la utilización del cabezal láser a gran distancia de la fuente, aparte de la alternativa de integrar el cabezal en unidades robotizadas. El proceso láser distribuye el calor aportado de manera uniforme. Las características mecánicas de dichas uniones ponen de manifiesto la adecuación de la soldadura por láser para su uso en construcción naval, cumpliendo los requerimientos exigidos por las Sociedades de Clasificación. La eficiencia energética de los láseres de C02, con porcentajes superiores al 20%, aparte de las ya estudiadas técnicas de su instalación constituyen las razones por las cuales este tipo de láser es el más usado en el ámbito industrial. El láser de gran potencia de Nd: YAG está presente en el mercado desde hace poco tiempo, y por tanto, su precio es relativamente mayor que el de C02, siendo sus costes de mantenimiento, tanto de lámparas como de diodos necesarios para el bombeo del sólido, igualmente mayores que en el caso del C02. En cambio, el efecto de absorción de parte de la energía en el plasma generado durante el proceso no se produce en el caso del láser de Nd: YAG, utilizando parte de esa energía en estabilizar el arco, siendo necesaria menos potencia de la fuente, reduciendo el coste de la inversión. En función de la aplicación industrial, se deberá realizar el análisis de viabilidad económica correspondiente. Dependiendo de la potencia de la fuente y del tipo de láser utilizado, y por tanto de la longitud de onda a la que se propaga la radiación electromagnética, pueden existen riesgos para la salud. El láser de neodimio se propaga en una longitud de onda, relativamente cercana al rango visible, en la cual se pueden producir daños en los ojos de los operadores. Se deberán establecer las medidas preventivas para evitar los riesgos a los que están expuestos dichos operadores en la utilización de este tipo de energía. La utilización del láser de neodimio: YAG ofrece posibilidades de utilización en construcción naval económicamente rentables, debido su productividad y las buenas características mecánicas de las uniones. Abstract The laser welding process development of the last years shows broad application possibilities in many sectors of industry, mostly in automobile production. The advantages of the laser beam process produce higher productivity, increasing the quality and thermal efficiency. Laser technology, arc-hybrid or pure laser welding, reduces thermal input and thus a smaller heat-affected zone at the work piece. This means less weldment distortion which reduces the amount of subsequent post-weld straightening work that needs to be done. A higher welding speed is achieved by use of the arc and the laser beam, increasing productivity and quality of the joining process. In the last decade use of hybrid technology (laser-GMA hybrid method) with high power sources Nd:YAG lasers, gained in importance. The installation of this type of higher power solid state laser is possible in shipbuilding industrial applications due to its advantages compare with the C02 laser sources installed in the shipyards which use this technology. C02 lasers are characterised by high power output and its beam guidance is via inelastic system of mirrors. In the case of Nd:YAG laser, due to its wavelength, the laser beam can be led by means of a flexible optical fibre even across large distances, which allows three dimensional welding jobs by using of robots. Laser beam welding is a process during which the heat is transferred to the welded material uniformly and the features of the process fulfilled the requirements by Classification Societies. So that, its application to the shipbuilding industry should be possible. The high quantum efficiency of C02 laser, which enabled efficiency factors up to 20%, and relative simple technical possibilities of implementation are the reasons for the fact that it is the most important laser in industrial material machining. High power Nd: YAG laser is established on the market since short time, so that its price is relatively high compared with the C02 laser source and its maintenance cost, lamp or diode pumped solid state laser, is also higher than in the case of C02 lasers. Nevertheless effect of plasma shielding does not exist with Nd:YAG lasers, so that for the gas-shielding welding process the optimal gases can be used regarding arc stability, thus power source are saved and the costs can be optimised. Each industrial application carried out needs its cost efficiency analysis. Depending on the power output and laser type, the dangerousness of reflected irradiation, which even in some meters distance, affects for the healthy operators. For the YAG laser process safety arrangements must be set up in order to avoid the laser radiation being absorbed by the human eye. Due to its wavelength of radiation, being relatively close to the visible range, severe damage to the retina of the eye is possible if sufficient precautions are not taken. Safety aspects are of vital importance to be able to shield the operator as well as other personal. The use of Nd:YAG lasers offers interesting and economically attractive applications in shipbuilding industry. Higher joining rates are possible, and very good mechanical/technological parameters can be achieved.

An extension of Mohring’s model for land rent distribution

In an early paper Herbert Mohring (J. Poi Et on , 49 (1961)) presented a model for land rent distribution yielding the well-known result that the price of land must fall with the distance from the city center to offset transportation costs. Our paper is an extension of Mohring's model in which we relax some of his drastic simplifying assumptions. This extended model has been incorporated in a method for economic evaluation of city master plans which has been applied to a Swedish city. In this method the interdependence among housing, heating, and transportation, the dura-bility of urban structures, and the uncertainty of future demand are explicitly considered within a cost-benefit approach. Some empirical results from this pilot study concerning land rent distributions are also presented here.

Incorporating equity into transport planning: utility, priority and sufficiency approaches

The analysis addresses the issue of transport equity and explores three different approaches to equity in transport: utilitarianism, sufficientarianism and prioritarianism. Each approach calls for a different treatment of the benefits reaped by different population groups in the assessment of transport investments or policies. In utilitarianism, which underlies much of the current practice of transport project appraisal, all benefits receive the same weight, irrespective of the recipient of the benefits. In both sufficientarianism and prioritarianism, benefits are weighed in distinct ways, depending on the characteristics of the recipients. The three approaches are illustrated using a fictive case study, in which three different transport investment are assessed and compared to each other. Finally, the assessment of transport investments will be explored using the cost-effectiveness analysis (CEA). The CEA assesses the distributional effects of transport investments for utilitarism, sufficientarism and prioritarism approaches and addresses distinct needs associated with different population groups in respect to their transport

Evaluación teórico experimental de la influencia de espumas de relleno metálicas como elementos de absorción de energía en perfiles tubulares de pequeño espesor. Su aplicación a vehículos para el transporte colectivo de personas

Los accidentes con implicación de autocares en los que se producen vuelcos ponen de manifiesto la especial agresividad de los mismos, como lo confirman las estadísticas. Como medida para mejorar la seguridad de los Vehículos de Grandes Dimensiones para el Transporte de Pasajeros (V.G.D.T.P.) frente a vuelco fue aprobado por las Naciones Unidas el Reglamento Nº 66 de Ginebra. Este reglamento establece los requisitos mínimos que las estructuras de los vehículos de grandes dimensiones deben cumplir con respecto a vuelco. El reglamento 66 ha supuesto un paso adelante muy importante en relación con la seguridad de los autocares, puesto que especifica por primera vez requerimientos estructurales a este tipo de vehículos, y en general ha supuesto una mejora del vehículo . Por otro lado, a consecuencia de la obligatoriedad de instalación de cinturones de seguridad, existe una unión entre pasajeros y vehículo, pero como no se trata de una unión rígida, hay que contemplar el porcentaje de la masa de los ocupantes que influye en la absorción de energía de la estructura. Además la retención de los ocupantes con cinturones de seguridad influye en la energía a absorber por la estructura del vehículo en dos aspectos, por un lado aumenta la masa del vehículo y en el otro se incrementa la altura el centro de gravedad. Esta situación a conducido a elaborar por parte de las Naciones Unidas la revisión 01 del Reglamento 66, en el que se considera que el 50 % de la masa total de los pasajeros posee una unión rígida con la estructura del vehículo, y por lo tanto debe ser tenida en cuenta si el vehículo posee sistemas de retención. En la situación actual, con limitaciones de peso del vehículo y peso por eje, los elementos de confort, seguridad y espacio para maleteros contribuyen a aumentar el peso del vehículo. Esto unido a la dificultad de introducción de cambios radicales en la concepción actual de fabricación de este tipo de vehículos por suponer unas pérdidas importantes para los fabricantes existentes, tanto en su conocimiento del producto como en su metodología de proceso, conlleva la necesidad cada vez más agobiante de analizar y evaluar otras alternativas estructurales que sin suponer grandes revoluciones a los productos actualmente en fabricación los complementen permitiendo adaptarse a los nuevos requerimientos en seguridad. Recientes desarrollos en la relación costo-beneficio de los procesos para la producción de materiales celulares metálicos de baja densidad, tales como las espumas metálicas, los posiciona como una alternativa de especial interés para la aplicación como elementos de absorción de energía para reforzar estructuras. El relleno con espumas metálicas puede ser más eficiente en términos de optimización de peso comparado con el aumento de espesor de los perfiles estructurales, dado que la absorción de energía se produce en una fracción relativamente pequeña de los perfiles, en las denominadas rótulas plásticas. La aplicación de espumas de relleno metálicas en estructuras de vehículos se está empezando a emplear en determinadas zonas de los vehículos de turismo, siendo totalmente novedosa cualquier intento de aplicación en estructuras de autobuses y autocares. Conforme a lo expuesto, y con el objeto de resolver estos problemas, se ha elaborado el presente trabajo de tesis doctoral, cuyos objetivos son: -Desarrollar un modelo matemático, que permita simular el ensayo de vuelco, considerando la influencia de los ocupantes retenidos con cinturones de seguridad para evaluar su influencia en la absorción de energía de la estructura. -Validar el modelo matemático de vuelco de la estructura mediante ensayos de secciones representativas de la estructura del vehículo y mediante el ensayo de un vehículo completo. -Realizar un estudio de las propiedades de las espumas metálicas que permitan incorporarlas como elemento de absorción de energía en el relleno de componentes de la superestructura de autobuses y autocares. -Desarrollar un modelo matemático para evaluar el aporte del relleno de espuma metálica en la absorción de energía ante solicitaciones por flexión estática y dinámica en componentes de la superestructura de autobuses o autocares. -Realizar un programa de ensayos a flexión estáticos y dinámicos para validar el modelo matemático del aporte del relleno de espuma metálica sobre componentes de la superestructura de autobuses y autocares. . -Incorporar al modelo matemático de vuelco de la estructura, los resultados obtenidos sobre componentes con relleno de espuma metálica, para evaluar el aporte en la absorción de energía. -Validar el modelo de vuelco de la estructura del autobús o autocar con relleno de espuma metálica, mediante ensayos de secciones de carrocería. ABSTRACT Accidents involving buses in which rollovers occur reveal the special aggressiveness thereof, as the statistics prove. As a measure to improve the safety of large vehicles for the transport of passengers to rollover, Regulation 66 of Geneva was approved by the United Nations. This regulation establishes the minimum requirements that structures of large vehicles must comply with respect to rollovers. The regulation 66 has been a major step forward in relation to the safety of coaches, since it specifies structural requirements to such vehicles and has been an improvement for the vehicle. In turn, as a result of compulsory installation of safety belts, there is contact between passengers and vehicle, but as it is not a rigid connection we must contemplate the percentage of the mass of the occupants that impacts on the energy absorption of the structure. Thus, the passengers’ restraining modifies the energy to absorb by the vehicle in two different aspects: On the one hand, it increases the vehicle weight and on the other the height of the center of gravity. This circumstance has taken the United Nations to elaborate Revision 01 of Regulation 66, in which it is considered that the 50 percent of passengers’ mass has a rigid joint together with the vehicle structure and, therefore, the passengers’ mass mentioned above should be highly considered if the vehicle has seat belts. In the present situation, in which limitations in vehicle weight and weight in axles are stricter, elements of comfort, safety and space for baggage are contributing to increase the weight of the vehicle. This coupled with the difficulty of introducing radical changes in the current conception of manufacturing such vehicles pose significant losses for existing manufacturers, both in product knowledge and process methodology, entails the overwhelming need to analyze and evaluate other structural alternatives without assuming relevant modifications on the products manufactured currently allowing them to adapt to the new safety requirements. Recent developments in cost-benefit processes for the production of metallic foams of low density, such as metal foams, place them as an alternative of special interest to be used as energy absorbers to strengthen structures. The filling with metal foams can be more efficient in terms of weight optimization compared with increasing thickness of the structural beams, since the energy absorption occurs in a relatively small fraction of the beams, called plastic hinges. The application of metal filling foams in vehicle structures is beginning to be used in certain areas of passenger cars, being an innovative opportunity in structures for application in buses and coaches. According to the mentioned before, and in order to come forward with a solution, this doctoral thesis has been prepared and its objectives are: - Develop a mathematical model to simulate the rollover test, considering the influence of the occupants held with seat belts to assess their influence on energy absorption structure. - Validate the mathematical model of the structure rollover by testing representative sections of the vehicle structure and by testing a complete vehicle. - Conduct a study of the properties of metal foams as possible incorporation of energy absorbing element in the filler component of the superstructure of buses and coaches. - Elaborate a mathematical model to assess the contribution of the metal foam filling in absorbing energy for static and dynamic bending loads on the components of buses or coaches superstructure. - Conduct a static and dynamic bending test program to validate the mathematical model of contribution of metal foam filling on components of the superstructure of buses and coaches bending. - To incorporate into the mathematical model of structure rollover, the results obtained on components filled with metal foam, to evaluate the contribution to the energy absorption. - Validate the rollover model structure of the bus or coach filled with metal foam through tests of bay sections. The objectives in this thesis have been achieved successfully. The contribution calculation model with metal foam filling in the vehicle structure has revealed that the filling with metal foam is more efficient than increasing thickness of the beams, as demonstrated in the experimental validation of bay sections.

Why do health economists promote technology adoption rather than the search for efficiency? A proposal for a change in our approach to economic evaluation in health care

Acknowledgments Financial Support: HERU and HSRU receive a core grant from the Chief Scientist’s Office of the Scottish Government Health and Social Care Directorates, and the Centre for Clinical epidemiology & Evaluation is funded by Vancouver Coastal Health Authority. The model used for the illustrative case study in this paper was developed as part of a NHS Technology Assessment Review, funded by the National Institute for Health Research (NIHR) Health Technology Assessment Program (project number 09/146/01). The views and opinions expressed in this paper are those of the authors and do not necessarily reflect those of the Scottish Government, NHS, Vancouver Coastal Health, NIHR HTA Program or the Department of Health. The authors wish to thank Kathleen Boyd and members of the audience at the UK Health Economists Study Group, for comments received on an earlier version of this paper. We also wish to thank Cynthia Fraser (University of Aberdeen) for literature searches undertaken to inform the manuscript, and Mohsen Sadatsafavi (University of British Columbia) for comments on an earlier draft

Gerenciamento da qualidade e do custo do transporte de cargas por ônibus interurbano de passageiros

Algumas empresas de transporte intermunicipal e interestadual de transporte rodoviário de passageiros, objetivando maiores lucros, têm se dedicado ao transporte de determinados tipos de cargas e encomendas, aproveitando-se do fato do bagageiro do ônibus ser uma oferta fixa para o transporte. No entanto, percebe-se algumas deficiências de caráter operacional que podem comprometer a qualidade e o custo do serviço prestado. Portanto, essa pesquisa tem por finalidade analisar o transporte de cargas executado por ônibus sob a ótica da qualidade e do custo. Partindo-se da adaptação do modelo clássico de Parasuraman, bem como da adoção de direcionadores de custo, de acordo com o método de custeio baseado em atividades, pretende-se apresentar como as principais atividades que compõem os processos do transporte rodoviário de cargas são afetadas durante a prestação do serviço. Para tanto, é apresentada uma análise crítica qualitativa que estabelece a forma como essas atividades são influenciadas pelos gaps do modelo de qualidade proposto e como as mesmas influenciam o custo operacional. Tal análise é resultado de duas pesquisas realizadas. A primeira pesquisa foi de profundidade numa empresa que atua no segmento. Foram obtidos alguns indicadores de desempenhos que são vitais para que as atividades sejam executadas de acordo com as conformidades previstas. A segunda pesquisa, via questionário, possibilitou identificar as principais expectativas dos clientes. Mesmo com o índice reduzido de respostas do questionário, foram levantados pontos que são extremamente fundamentais para a formação das expectativas dos clientes. Entre esses pontos destacam-se o tempo de atendimento, o treinamento dos funcionários e o cumprimento dos horários preestabelecidos. Dos processos que caracterizam o transporte de cargas, deve-se destacar o processo de entrega que além dos problemas provenientes da operação propriamente dita, sofre ainda a interferência, em algumas atividades, da participação direta do cliente e dos fatores externos da operação (ambiente não controlado).

Caracterização dos processos de manutenção em equipamentos eletromédicos hospitalares

Atualmente existe uma gama considerável de procedimentos assistenciais de saúde os quais, seja por cultura, ou por exigências legais, só podem ser realizados com aporte tecnológico. Logo reduzir o tempo de parada de um equipamento médico está diretamente associado à viabilização da assistência necessária ao paciente. Em outras palavras, prestar uma manutenção otimizada representa qualidade na prestação de serviço da unidade assistencial de saúde, podendo em alguns casos, até, evitar a morte do paciente. Para isso é muito importante que os defeitos sejam reconhecidos e tratados adequadamente, não se esquecendo da otimização dos recursos financeiros. Com base nesta premissa, este trabalho propõe estabelecer uma relação dos tipos de defeitos apresentados pelos equipamentos com sua ocorrência, utilizando para tal o método de Pareto, fornecendo uma ferramenta de análise de grande utilidade na estruturação de grupos de manutenção corretiva de um serviço de engenharia clínica. Assim foram tomados como amostra quatro tipos de equipamentos que são eletrocardiógrafos, monitores cardíacos, unidades eletrocirúrgicas e incubadoras neonatais; caracterizando a existência de defeitos que podem ser classificados em baixa, média e alta complexidade de resolução, o que reflete na necessidade de ferramentas gerais ou específicas ao reparo e do nível de qualificação da equipe técnica, além do universo de componentes, partes e peças envolvidas com cada etapa de manutenção. Foram qualificados e quantificados defeitos para cada tipo de equipamentos acima, onde se constatou que nos equipamentos médico-hospitalares estudados, a maioria das paradas requisitou intervenções simples, de baixa complexidade. Ou seja, poucos defeitos foram responsáveis por muitas ordens de serviço e que o corpo técnico de manutenção pode esperar e se programar para atuar em cada um deles de acordo com o gráfico de Pareto. Desta forma o serviço de engenharia clínica pode ser direcionado para as necessidades prioritárias do estabelecimento assistencial de saúde, sendo capaz de produzir resultados com melhor custo-benefício.

A presença do homo academicus na contabilidade: um olhar bourdieusiano sobre o contexto social do desenvolvimento da produção científica contábil brasileira

Esta pesquisa investiga o contexto social do desenvolvimento da produção científica contábil brasileira, defendendo a tese de que os agentes, no decorrer do processo de divulgação de suas investigações, estão priorizando aspectos produtivistas e quantitativos e, consequentemente, deixando em segundo plano a preocupação qualitativa e epistemológica [vigilância crítica] de tal produção. Fundamentado na Teoria de Campos de Pierre Bourdieu, este estudo busca relacionar a socialização acadêmica, o habitus dos agentes imbricados no campo, a distribuição do capital científico na área contábil e as características epistemológicas das publicações científicas da área, para obtenção das evidências sobre a problemática levantada. Trata-se de um levantamento operacionalizado por meio de entrevista semiestruturada, com uma amostra de 9 respondentes e estudo documental, com uma amostra de 43 artigos. Os dados foram analisados com emprego da técnica de análise de conteúdo. Apoiando-se em Bourdieu (2004, 2008, 2009, 2011, 2013) foram encontradas evidências de que as teorias, conceitos, metodologias, técnicas e demais escolhas realizadas pelos pesquisadores da área contábil, na maioria das vezes, não passam de manobras estratégicas que visam conquistar, reforçar, assegurar ou derrubar o monopólio da autoridade científica, visando a obtenção de maior poder simbólico no campo. Com relação ao habitus dos agentes pertencentes ao campo científico contábil, constatou-se uma tendência ao produtivismo em consequência das determinações dos órgãos reguladores da pesquisa em contabilidade (CAPES) e das lutas simbólicas travadas no campo para obtenção da autoridade científica. No tocante à socialização acadêmica, reforçou-se a presença de condutas produtivistas, por meio dos programas de pós-graduação stricto sensu, que repassam aos agentes as regras do jogo científico, doutrinando-os na maneira de publicar grande quantidade de comunicações em pouco tempo e com menos custos. As análises epistemológicas puderam triangular os dois últimos constructos, a fim de lhes dar validade, e evidenciaram uma preferência por temáticas que envolvem a contabilidade destinada aos usuários externos e procedimentos contábeis destinados ao mercado financeiro, privilegiando a utilização de dados secundários, por meio de pesquisas documentais. Em termos metodológicos, constatou-se a presença unânime de estudos positivistas, com alguns aspectos empiristas, mostrando uma ausência de inovação em termos de pesquisas norteadas por abordagens metodológicas alternativas e utilização de modelos econométricos para explicar a realidade observada sem teoria para embasar e explicar esses modelos. Por fim, a distribuição do capital simbólico no campo, mostrou que individualmente nenhum agente desponta com maior capital científico, mas, institucionalmente, a FEA/USP ocupa essa posição de destaque. Por conseguinte, pôde-se concluir que o campo científico contábil permanece estagnado e sem grandes modificações teóricas, pelo fato do produtivismo e das lutas simbólicas no interior do campo; fatos esses que, de certa maneira, motivaram a criação de uma espécie de \"receita mágica para publicar\" ou \"formato ideal\" legitimado, institucionalizado e difícil de ser modificado, a não ser que ocorra uma revolução científica que mude o paradigma existente

Modeling construction time in Spanish building projects

The literature states that project duration is affected by various scope factors. Using 168 building projects carried out in Spain, this paper uses the multiple regression analysis to develop a forecast model that allows estimating project duration of new builds. The proposed model uses project type, gross floor area (GFA), the cost/GFA relationship and number of floors as predictor variables. The research identified the logarithmic form of construction speed as the most appropriate response variable. GFA has greater influence than cost on project duration but both factors are necessary to achieve a forecast model with the highest accuracy. We developed an analysis to verify the stability of forecasted values and showed how a model with high values of fit and accuracy may display an anomalous behavior in the forecasted values. The sensitivity of the proposed forecast model was also analyzed versus the variability of construction costs.

Sugammadex : implicações farmacoeconómicas e consequências na prática clínica anestésica presente e futura

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

Mutual recognition in goods and services: an economic perspective. Bruges European Economic Policy (BEEP) Briefing 2/2002

Mutual recognition is a remarkable innovation facilitating economic intercourse across borders. In the EU's internal goods market it has been helpful in tackling or avoiding the remaining obstacles, namely, regulatory barriers between Member States. However, there is a curious paradox. Despite the almost universal acclaim of the great merits of mutual recognition the principle has, in and by itself, contributed only modestly to the actual realisation of free movement in the single market. It is also surprising that economists have not or hardly underpinned their widespread appreciation for the principle by providing rigorous analysis which could substantiate the case for mutual recognition for policy makers. Business in Europe has shown a sense of disenc hantment with the principle because of the many costs and uncertainties in its application in actual practice. The purpose of the present paper is to provide the economic and strategic arguments for employing mutual recognition much more systematically in the single market for goods and services. The strategic and the "welfare" gains are analysed and adetailed exposition of the fairly high information , transaction and compliance costs is provided. The information costs derive from the fact that mutual recognition remains a distant abstraction for day-to-day business life. Understandably, verifying the "equivalence" of objectives of health and safety between Member States is perceived as difficult and uncertain. This sentiment is exacerbated by the complications of interpreting the equivalence of "effects". In actual practice, these abstractions are expected to override clear and specific national product or services rules, which local inspectors or traders may find problematic without guidance. The paper enumerates several other costs including, inter alia, the absence of sectoral rule books and the next-to-prohibitive costs of monitoring of the application of the principle. The basic problems in applying mutual recognition in the entire array of services are inspected, showing why the principle can only be used in a limited number of services markets and even there it may contribute only modestly to genuine free movement and competitive exposure. A special section is devoted to a range of practical illustrations of the difficulties business experiences when relying on mutual recognition. Finally, the corollary of mutual recognition - regulatory competition - is discussed in terms of a cost/benefits analysis compared to what is often said to be the alternative , that is "harmonisation" , in EU parlance the "new approach" to approximation. The conclusion is that the manifold benefits of mutual recognition for Europe are too great to allow the present ambiguities to continue. The Union needs much more pro-active approaches to reduce the costs of mutual recognition as well as permanent monitoring structures for its application to services (analogous to those already successfully functioning in goods markets). Above all, what is required is a "mutual recognition culture" so that the EU can better enjoy the fruits of its own regulatory ingenuity.