Cost evaluation and comparison of three decision strategies for cardiac revascularization : results of the suspected CAD protocol of the European CMR registry

Background: The public health burden of coronary artery disease (CAD) is important. Perfusion cardiac magnetic resonance (CMR) is generally accepted to detect and monitor CAD. Few studies have so far addressed its costs and costeffectiveness. Objectives: To compare in a large CMR registry the costs of a CMR-guided strategy vs two hypothetical invasive strategies for the diagnosis and the treatment of patients with suspected CAD. Methods: In 3'647 patients with suspected CAD included prospectively in the EuroCMR Registry (59 centers; 18 countries) costs were calculated for diagnostic examinations, revascularizations as well as for complication management over a 1-year follow-up. Patients with ischemia-positive CMR underwent an invasive X-ray coronary angiography (CXA) and revascularization at the discretion of the treating physician (=CMR+CXA strategy). Ischemia was found in 20.9% of patients and 17.4% of them were revascularized. In ischemia-negative patients by CMR, cardiac death and non-fatal myocardial infarctions occurred in 0.38%/y. In a hypothetical invasive arm the costs were calculated for an initial CXA followed by FFR testing in vessels with ≥50% diameter stenoses (=CXA+FFR strategy). To model this hypothetical arm, the same proportion of ischemic patients and outcome was assumed as for the CMR+CXA strategy. The coronary stenosis - FFR relationship reported in the literature was used to derive the proportion of patients with ≥50% diameter stenoses (Psten) in the study cohort. The costs of a CXA-only strategy were also calculated. Calculations were performed from a third payer perspective for the German, UK, Swiss, and US healthcare systems.

Factors affecting a woman's decision to leave an abusive relationship : the theory of planned behaviour /

The present study tested the appHcabiUty of Ajzen's (1985) theory of planned behaviour (TPB), an extension of Fishbein and Ajzen's (1975) theory of reasoned action (TRA), for the first time, in the context of abused women's decision to leave their abusive relationships. The TPB, as a means of predicting women's decision to leave their abusive partners' was drawn from Strube's (1988, 1991) proposed decision-making model based on the principle that the decision-making process is a rational, deliberative process, and regardless of outcome, was a result of a logical assessment of the available data. As a means of predicting those behaviours not under volitional control, Ajzen's (1985) TPB incorporated a measure of perceived behavioural control. Data were collected in two phases, ranging from 6 months to 1 year apart. It was hypothesized that, to the extent that an abused woman held positive attitudes, subjective norms conducive to leaving, and perceived control over leaving, she would form an intention to leave and thus, increase the likelihood of actually leaving her partner. Furthermore, it was expected that perceptions of control would predict leaving behaviour over and above attitude and subjective norm. In addition, severity and frequency of abuse were assessed, as were demographic variables. The TPB failed to account significantly for variability in either intentions or leaving behaviour. All of the variance was attributed to those variables associated with the theory of reasoned action, with social influence emerging as the strongest predictor of a woman's intentions. The poor performance of this model is attributed to measurement problems with aspects of attitude and perceived control, as well as a lack of power due to the small sample size. The insufficiency of perceived control to predict behaviour also suggests that, on the surface at least, other factors may be at work in this context. Implications of these results, and recommendations such as, the importance of obtaining representative samples, the inclusion of self-esteem and emotions as predictor variables in this model, a reevaluation of the target behaviovu" as nonvolitional, and longitudinal studies spanning a longer time period for future research within the context of decision-making are discussed.

Modernizing human resource management : the importance of values-based leadership in the Canadian federal public service /

Over the past several decades, many theories have been advanced as to why efforts to reform the public service have met with only limited success. Clearly, the role of leadership with respect to reform must be examined, since successful organizational leaders should be extremely accomplished in the promotion and protection of the values that underlie decision-making. The issue of effective leadership is particularly significant for the future of the public service of Canada. Large numbers of public servants in the executive ranks are due to retire within the next five years. Given their central role, it is vital that there be enough dedicated and committed public servants to staff future vacancies. It is also essential that future public service leaders possess the competencies and values associated with a world-class public service and, a new type of public organization. Related to this point is the importance of people-management skills. People management in the public service is an issue that has historically faced - and will continue to face - major challenges with respect to recruiting and retaining the leaders it requires for its continued success. It is imperative that the public service not only be revitalized and be seen as an employer of choice, but also that the process by which it accomplishes this goal - the practice of human resource management - be modernized. To achieve the flexibility needed to remain effective, the public service requires the kind ofleadership that supports new public service values such as innovation and which emphasizes a "people- first" approach. This thesis examines the kind of public service leadership needed to modernize the human resource management regime in the federal public service. A historical examination of public service values is presented to help determine the values that are important for public service leaders with respect to modernizing human resource management. Since replenishing the 2 ranks of public service leaders is crucial to ensure the quality of service to Canadians, leadership that supports career planning will be a major focus of this paper. In addition, this thesis demonstrates that while traditional public service values continue to endure, innovative leaders must effectively reconcile new public service values with traditional values in order to increase the possibilities for successful reform as well as achieve business objectives. Much of the thesis is devoted to explaining the crucial role of post-bureaucratic leadership to successful reform. One of the major findings of the thesis is that leaders who demonstrate a blending of new public service values and traditional values are critical to creating effective employment relationships, which are key to modernizing human resource management in the federal public service. It will be apparent that public service leaders must ensure that an appropriate accountability framework is in place before embarking on reform. However, leaders who support new public service values such as innovation and empowerment and who emphasize the importance of people are essential to successful reform.

Gendered attitudes and family planning decision-making in Honduras

This study examines gendered attitudes and family planning in the Central American country of Honduras using a feminist perspective. Specifically, this study investigates the relationships between gendered attitudes (i.e., male oriented or non-male oriented attitudes) and who makes decisions about contraceptive use and family size among married and common-law Hondurans. This study also attempts to account for social elements such as gendered attitudes, education, economics, environment and demographics that may act to limit or enhance women's agency in reproductive decisionmaking. Furthermore, gender is examined to determine whether these relationships depend on the gender of the respondents. Two national Honduran surveys from 2001 are used in a secondary analysis, specifically muUinomial logisfic regression. Findings indicate that women reporting non-male oriented attitudes are significantly more likely to indicate that they (the wives) make the contraceptive decisions. Moreover, both men and women reporting non-male oriented attitudes are significantly more likely to indicate making contraceptive decisions together. Both of these effects remain significant when other social factors included in the analyses, though part of the effect is explained by education and economics. Similar effects are found in terms of family size decisions. Limitations and directions for future research are discussed.

A qualitative narrative inquiry of the experience of accessing community supports among women who have experienced trauma

Abuse related trauma can have serious consequences on individuals' health and their state of well-being and may result in decreased access to different determinants of health. The purpose of this qualitative narrative inquiry using secondary data was to explore the experience of accessing community supports among eight women who had experienced abuse-related trauma. A conceptual framework drawn from the literature on social inclusion and social exclusion and a narrative inquiry method were used to explore epiphanies, customs, routines, images, and everyday experiences (Clandinin & Connelly, 2000) among the women. A Three-Dimensional Space Narrative Structure was used to explore the participants' personal or internal conditions, feelings, hopes and reaction as well as their social experiences in interaction with others in community. The participants described experiencing the impact of trauma in their past and present circumstances, a lack of accommodation of difference, challenges in maintaining a sense of self in a world of assumption and labels, impact of trauma on the determinants of health, and uncertainty about the future. The findings from the study demonstrate experiences of social exclusion among the participants in the past, further isolation and social exclusion in the present when personal life issues were ignored by community support services, and uncertainty about what the future will bring for them. The findings indicate close relationships between the women's personal lives and their social connections which need to be considered to mitigate social exclusion and enhance social inclusion.

Why I am not a teacher: a self-study examining why I made the decision to exit the teaching profession /

A good teacher was once described as being like a candle; consuming itself to light the way for others (Author unknown). But as Knox (2005) says, far too many yoimg flames flicker out before they ever get the opportvmity to bum their brightest. This self-study explores the phenomenon of teacher attrition through the stories and lived experiences of one elementary teacher. I strive throughout this self-study to delve deeper into the significance of my story and lived experiences in order to enhance our understanding of why teachers exit the profession. As a result, the guiding question throughout the study is, "Why do teachers, particularly those who have only taught for a few years, leave the classrooms they worked so hard to enter?" Through the writing of a narrative entitled Sarah 's Story, I was able to identify and give voice to a story openly sharing the feelings of despair; disappointment, frustration and disillusionment. This study has identified areas of tension that lead to dissatisfaction, discontent, and teacher disillusionment. It confronts the issues of complexity, uncertainty, and conflict that are experienced in teaching. It discusses the puzzling, powerfiil and upsetting experiences, highlighting the importance of talk between all members of the education system.

An exploration of women elementary school teachers' perceptions of how their decision to return to teaching part-time from a maternity leave influences their professional and personal lives /

The purpose of this research was to explore women elementary teachers' perceptions of how their decision to return to teaching part-time from a maternity leave influences their professional and personal lives. The investigation focused on the decisions surrounding a mother's choice to reenter the teaching profession parttime in a field where each mother had previously been employed full-time. A collective case study was undertaken based on an in-depth interview with five mothers who had made the choice to return to the classroom part-time. The data collected in this study were analyzed and interpreted using qualitative methods. The following four major themes emerged from the interviews: decisionmaking process, challenges faced by mothers who teach part-time, the importance of support, and the enhancement of instructional practice from parenthood. Using these four themes, an analysis was conducted to examine the similarities and differences among the experiences of the participants. The mothers' reflections, my analysis, and the related literature were used at the conclusion of this report to compile implications for teaching practice, theory, and further research.

Decision analysis of the effectiveness of lung cancer screening using autofluorescence bronchoscopy and computed tomography

Background: Lung cancer (LC) is the leading cause of cancer death in the developed world. Most cancers are associated with tobacco smoking. A primary hope for reducing lung cancer has been prevention of smoking and successful smoking cessation programs. To date, these programs have not been as successful as anticipated. Objective: The aim of the current study was to evaluate whether lung cancer screening combining low dose computed tomography with autofluorescence bronchoscopy (combined CT & AFB) is superior to CT or AFB screening alone in improving lung cancer specific survival. In addition, the extent of improvement and ideal conditions for combined CT & AFB screening were evaluated. Methods: We applied decision analysis and Monte Carlo simulation modeling using TreeAge Software to evaluate our study aims. Histology- and stage specific probabilities of lung cancer 5-year survival proportions were taken from Surveillance and Epidemiologic End Results (SEER) Registry data. Screeningassociated data was taken from the US NCI Prostate, Lung, Colorectal and Ovarian Cancer Screening Trial (PLCO), National Lung Screening Trial (NLST), and US NCI Lung Screening Study (LSS), other relevant published data and expert opinion. Results: Decision Analysis - Combined CT and AFB was the best approach at Improving 5-year survival (Overall Expected Survival (OES) in the entire screened population was 0.9863) and in lung cancer patients only (Lung Cancer Specific Expected Survival (LOSES) was 0.3256). Combined screening was slightly better than CT screening alone (OES = 0.9859; LCSES = 0.2966), and substantially better than AFB screening alone (OES = 0.9842; LCSES = 0.2124), which was considerably better than no screening (OES = 0.9829; LCSES = 0.1445). Monte Carlo simulation modeling revealed that expected survival in the screened population and lung cancer patients is highest when screened using CT and combined CT and AFB. CT alone and combined screening was substantially better than AFB screening alone or no screening. For LCSES, combined CT and AFB screening is significantly better than CT alone (0.3126 vs. 0.2938, p< 0.0001). Conclusions: Overall, these analyses suggest that combined CT and AFB is slightly better than CT alone at improving lung cancer survival, and both approaches are substantially better than AFB screening alone or no screening.

A Study of role conflict, role ambiguity, locus of control, job satisfaction and participation in decision making among front-line vocational service workers for mentally retarded adults

This study was an investigation of individual and organizational factors, as perceived by front-line vocational service workers from Adult Rehabilitation Centres (ARC Industries) for mentally retarded adults. The specific variables which were measured included role conflict/role ambiguity (role factors), internal/external locus of control (individual differences), job satisfaction with work and supervision (job attitudes) and participation in deci~ion making (organizational factor). The exploration of these constructs was conducted by means of self-report questionnaires which were completed by sixty-nine out of a total of ninety front-line employees. The surveys were distributed in booklet form to nine distinct rehabilitation facilities from St. Catharines, West Lincoln, Greater Niagara, Port Colborne, WeIland, Fort Erie, Hamilton, Guelph and Brantford. The survey data was evaluated by the statisti.cal Package for the Social Sciences (SPSS) which used the Pearson Product Moment Correlation procedure and a compar~son of means test. A comparison of correlation coefficients test was also conducted. This statistical procedure was calculated mathematically. The results obtained from the statistical evaluation confirmed the prediction that self-reported measures of participation in decision making and satisfaction (work and supervision) would be negatively correlated with role conflict and role ambiguity. As well, the speculation that perceived satisfaction (work and supervision) would be positively correlated with participation in decision making was empirically supported. Internal and external locus of control did not contribute to a significant difference in r~sponses to role perceptions (conflict and ambiguity) , satisfaction (work and supervision) or the correlational relationship between participation in decision making and satisfaction (work and supervision). Overall, the findings from this study substantiated the importance of examining employee perceptions in the workplace and the interrelationships among individual and organizational variables. This research was considered a contribution to the general area of occupational stress and to the study of individuals in work organizations.

A study on the role of the parent in educational decision making from the perspective of parents and teachers

ADeweyan (1916) democratic theoty ofeducation called for the participation ofall citizens in deliberating important educational issues to improve overall student learning. Thus, the move to include parents in educational decision making can be considered to be rooted in democratic principles. To gain greater insight into the issue ofparent involvement in educational decision making, one elementary school was studied and a triangulization method was employed in an attempt to clarify the important issues surrolUlding the move to include parents in the governance ofschools. The three methods to gain information included surveys, interviews, and documentation ofsignificant school events and related work. All ofthe parents and teachers ofthe school were surveyed, 10 parents and 6teachers were interviewed, and related school events were recorded. The survey design was modeled on the Parent Involvement Questionnaire (PIQ) created and reported on by Chavkin and Williams (1987). The results ofthe surveys were used as a guide for the interview questions. An interview outline was developed based on Seidman's (1991) open-ended approach and Patton's (1980) standardized open-ended interview style in which parents and teachers were asked about their experiences and opinions on anmnber ofparent involvement issues. Parents and teachers in this school indicated agreater interest in becoming more aware ofeducational issues such as school budget and school discipline policies. Although the parents indicated agreater interest in school matters and the teachers indicated awillingness to include parents in school matters, both the parents and teachers in this study perceived the role ofthe parent as advisory, not decision making. It was concluded that to ensure ameaningful and functional role for parellts as tlleir p811icipatioll ill educational matters evolves, SCllools must have a clear vision ofthe primary goal ofall schools, namely, to foster and nourish democratic citizens for ademocratic society (Glickman, 1993). Furthennore, intentional practices such as Purkey's (ad) 5-P Relay approach, based on a democratic theory and practice of education, will have to be employed in order to give parents an authentic voice in educational matters and provide an avenue for parents to acquire the necessary skills and lmowledge needed to do so. As schools, school boards, and the Ministry ofEducation implement parent involvement guidelines and policies, developmental needs ofeach school need to be considered to ensure the employment ofdemocratic practices not authoritarian mandates. Parent interest and involvement, at whatever level, should be an important element in the overall move to make schools part ofthe democratic society they were meant to be.

Decision-making theory applied to India's explosion of a nuclear device in May, 1974

This essay reviews the decision-making process that led to India exploding a nuclear device in May, 1974. An examination of the Analytic, Cybernetic and Cognitive Theories of decision, will enable a greater understanding of the events that led up to the 1974 test. While each theory is seen to be only partially useful, it is only by synthesising the three theories that a comprehensive account of the 1974 test can be given. To achieve this analysis, literature on decision-making in national security issues is reviewed, as well as the domestic and international environment in which involved decisionmakers operated. Finally, the rationale for the test in 1974 is examined. The conclusion revealed is that the explosion of a nuclear device by India in 1974 was primarily related to improving Indian international prestige among Third World countries and uniting a rapidly disintegrating Indian societal consensus. In themselves, individual decision-making theories were found to be of little use, but a combination of the various elements allowed a greater comprehension of the events leading up to the test than might otherwise have been the case.

Factors affecting treatment decision making for women with breast cancer

This study examined the factors affecting treatment decision making for young women with early stage breast cancer. Thirty women, aged 35 to 52 years, were presented information about two equally effective chemotherapy treatments following surgery for breast cancer using an educational instrument called a "decision board." Although equally effective, the treatments differ with regards to side effects and treatment schedule. The purpose of this research was to investigate what factors affect the decision-making process. Following administration of the decision board, women were given a take-home version to review and asked to return one to two weeks later with a decision, at which time they completed a questionnaire. theoretical framework for this study was constructed from the literature on self-directed learning and critical thinking. The Overall, the factors rated most important to the treatment decision were related to quality of life, side effects, and length of treatment. Five factors were found to be rated significantly different by the women who chose one treatment versus the other in terms of importance to their decision. These were side effects in general, vomiting, hair loss, family role, and the number of trips to the cancer centre required for treatment.Implications and recommendations for patient education, research, and practice evolved from the findings of this study.

A study of ethical decision-making in hypothetical scenarios by secondary school principals /

The purpose of the study,was to investigate the ways in which secondary school principals make decisions that have an ethical dimension, and the reasons they use to justify their choices. The ethical principles and concepts, as well as the scenarios, were adapted from The Ethics ofSchool Administration by Strike, Haller, and Soltis (1998). In this study, 32 secondary principals from a school board in Ontario were asked to complete a descriptive survey which was designed to have principals make administrative decisions in response to 5 hypothetical scenarios. The open-ended questions were expected to elicit responses that were reflective of the principals' actual decision-making strategies. The survey also required them to justify and explain their reasons for each decision. The data were analyzed and 4 major categories ofjustifications emerged: pedagogy, legalism, moral code, and democracy. The results indicate that the decisions made by principals are grounded in various perspectives. While the data did not indicate any explicit knowledge of ethical principles and concepts, the principals' responses suggest sound and valid reasoning for their decision making, addressing the principles and concepts from a variety of viewpoints and using diverse justifications.

Youth Involvement in Organizational Decision Making: The Connection to Youth Initiative and Organizational Functioning

Studying positive adolescent development requires an examination of the mutually beneficial associations between youth and their environment. These youthcontext relations include both the contributions that youth make to others and society and the youth-context interactions that might predict positive youth outcomes. Community and youth-serving organizations, where youth may be involved in decision-making roles such as service delivery, advocacy, or on boards of directors, can provide one important context for youth contributions and for positive adolescent development. Research on the outcomes of youth involvement in organizational decision-making, however, is limited, and largely consists of exploratory qualitative studies. This dissertation is formatted as an integrated article dissertation. It begins with a review of the literature on contexts of structured youth activities and positive youth development. This review is intended to describe theory on development-context relations, in which development is considered an interactive process that occurs between individuals and their contexts, as it pertains the positive development of youth who are involved in various structured activities (e.g., volunteering). This description follows with a review of current research, and conclusions and rationale for the current studies. Following this theoretical and research background, the dissertation includes reports of two studies that were designed to address gaps in the research on youth involvement in organizational decision-making. The first was a qualitative research synthesis to elucidate and summarize the extant qualitative research on the outcomes of youth involvement in organizational decision making on adults and organizations. Results of this study suggested a number of outcomes for service provision, staff, and broader organizational functioning, including both benefits to organizations as well as some costs. The second study was a quantitative analysis of the associations among youth involvement, organizations' learning culture, and youth initiative, and relied on survey data gathered from adults and youth in community-based organizations with youth involvement. As expected, greater youth involvement in organizational decision making was associated with higher learning culture within the organization. Two dimensions of youth involvement, greater program engagement and relationships with adults, were related to greater youth initiative. A third dimension, sense of ownership, was not- .-.- associated with youth's level of initiative. Moreover, the association between relationships with adults and youth initiative was only significant in organizations with relatively low learning culture. Despite some limitations, these studies contribute to the research literature by providing some indication of the potential benefits and costs of youth involvement and by making an important contribution toward the early stages of context-level analyses of youth development. Findings have important implications for practitioners, funders, future research, and lifespan development theory.