A comparative analysis of outpatient costs in HIV treatment programs

OBJECTIVE: To analyze the costs of human immunodeficiency virus (HIV) outpatient treatment for individuals with different CD4 cell counts in the Brazilian public health system, and to compare to costs in other national health systems. METHODS: A retrospective survey was conducted in five public outpatient clinics of the Brazilian national HIV program in the city of São Paulo. Data on healthcare services provided for a period of one year of HIV outpatient treatment were gathered from randomly selected medical records. Prices of inputs used were obtained through market research and public sector databases. Information on costs of HIV outpatient treatment in other national health systems were gathered from the literature. Annual costs of HIV outpatient treatment from each country were converted into 2010 U.S. dollars. RESULTS: Annual cost of HIV outpatient treatment for the Brazilian national public program was US$ 2,572.92 in 2006 in São Paulo, ranging from US$ 1,726.19 for patients with CD4 cell count > 500 to US$ 3,693.28 for patients with 51 < CD4 cell count < 200. Antiretrovirals (ARVs) represented approximately 62.0% of annual HIV outpatient costs. Comparing among different health systems during the same period, HIV outpatient treatment presented higher costs in countries where HIV treatment is provided by the private sector. CONCLUSION: The main cost drivers of HIV outpatient treatment in different health systems were: ARVs, other medications, health professional services, and diagnostic exams. Nevertheless, the magnitude of cost drivers varied among HIV outpatient treatment programs due to health system efficiency. The data presented may be a valuable tool for public policy evaluation of HIV treatment programs worldwide.

Systems medicine and integrated care to combat chronic noncommunicable diseases

We propose an innovative, integrated, cost-effective health system to combat major non-communicable diseases (NCDs), including cardiovascular, chronic respiratory, metabolic, rheumatologic and neurologic disorders and cancers, which together are the predominant health problem of the 21st century. This proposed holistic strategy involves comprehensive patient-centered integrated care and multi-scale, multi-modal and multi-level systems approaches to tackle NCDs as a common group of diseases. Rather than studying each disease individually, it will take into account their intertwined gene-environment, socio-economic interactions and co-morbidities that lead to individual-specific complex phenotypes. It will implement a road map for predictive, preventive, personalized and participatory (P4) medicine based on a robust and extensive knowledge management infrastructure that contains individual patient information. It will be supported by strategic partnerships involving all stakeholders, including general practitioners associated with patient-centered care. This systems medicine strategy, which will take a holistic approach to disease, is designed to allow the results to be used globally, taking into account the needs and specificities of local economies and health systems.

Torque efficiency of different archwires in 0.018- and 0.022-inch conventional brackets.

OBJECTIVE To compare the archwires inserted during the final stages of the orthodontic treatment with the generated moments at 0.018- and 0.022-inch brackets. MATERIALS AND METHODS The same bracket type, in terms of prescription, was evaluated in both slot dimensions. The brackets were bonded on two identical maxillary acrylic resin models, and each model was mounted on the orthodontic measurement and simulation system. Ten 0.017 × 0.025-inch TMA and ten 0.017 × 0.025-inch stainless steel archwires were evaluated in the 0.018-inch brackets. In the 0.022-inch brackets, ten 0.019 × 0.025-inch TMA and ten 0.019 × 0.025-inch stainless steel archwires were measured. A 15° buccal root torque (+15°) and then a 15° palatal root torque (-15°) were gradually applied to the right central incisor bracket, and the moments were recorded at these positions. A t-test was conducted to compare the generated moments between wires within the 0.018- and 0.022-inch bracket groups separately. RESULTS The 0.017 × 0.025-inch archwire in the 0.018-inch brackets generated mean moments of 9.25 Nmm and 14.2 Nmm for the TMA and stainless steel archwires, respectively. The measured moments in the 0.022-inch brackets with the 0.019 × 0.025-inch TMA and stainless steel archwires were 6.6 Nmm and 9.3 Nmm, respectively. CONCLUSION The 0.017 × 0.025-inch stainless steel and β-Ti archwires in the 0.018-inch slot generated higher moments than the 0.019 × 0.025-inch archwires because of lower torque play. This difference is exaggerated in steel archwires, in comparison with the β-Ti, because of differences in stiffness. The differences of maximum moments between the archwires of the same cross-section but different alloys were statistically significant at both slot dimensions.

Uptake efficiency of surface modified gold nanoparticles does not correlate with functional changes and cytokine secretion in human dendritic cells in vitro.

Engineering nanoparticles (NPs) for immune modulation require a thorough understanding of their interaction(s) with cells. Gold NPs (AuNPs) were coated with polyethylene glycol (PEG), polyvinyl alcohol (PVA) or a mixture of both with either positive or negative surface charge to investigate uptake and cell response in monocyte-derived dendritic cells (MDDCs). Inductively coupled plasma optical emission spectrometry and transmission electron microscopy were used to confirm the presence of Au inside MDDCs. Cell viability, (pro-)inflammatory responses, MDDC phenotype, activation markers, antigen uptake and processing were analyzed. Cell death was only observed for PVA-NH2 AuNPs at the highest concentration. MDDCs internalize AuNPs, however, surface modification influenced uptake. Though limited uptake was observed for PEG-COOH AuNPs, a significant tumor necrosis factor-alpha release was induced. In contrast, (PEG+PVA)-NH2 and PVA-NH2 AuNPs were internalized to a higher extent and caused interleukin-1beta secretion. None of the AuNPs caused changes in MDDC phenotype, activation or immunological properties.

Exercise efficiency relates with mitochondrial content and function in older adults

Chronic aerobic exercise has been shown to increase exercise efficiency, thus allowing less energy expenditure for a similar amount of work. The extent to which skeletal muscle mitochondria play a role in this is not fully understood, particularly in an elderly population. The purpose of this study was to determine the relationship of exercise efficiency with mitochondrial content and function. We hypothesized that the greater the mitochondrial content and/or function, the greater would be the efficiencies. Thirty-eight sedentary (S, n = 23, 10F/13M) or athletic (A, n = 15, 6F/9M) older adults (66.8 ± 0.8 years) participated in this cross sectional study. V˙O2peak was measured with a cycle ergometer graded exercise protocol (GXT). Gross efficiency (GE, %) and net efficiency (NE, %) were estimated during a 1-h submaximal test (55% V˙O2peak). Delta efficiency (DE, %) was calculated from the GXT. Mitochondrial function was measured as ATPmax (mmol/L/s) during a PCr recovery protocol with (31)P-MR spectroscopy. Muscle biopsies were acquired for determination of mitochondrial volume density (MitoVd, %). Efficiencies were 17% (GE), 14% (NE), and 16% (DE) higher in A than S. MitoVD was 29% higher in A and ATPmax was 24% higher in A than in S. All efficiencies positively correlated with both ATPmax and MitoVd. Chronically trained older individuals had greater mitochondrial content and function, as well as greater exercise efficiencies. GE, NE, and DE were related to both mitochondrial content and function. This suggests a possible role of mitochondria in improving exercise efficiency in elderly athletic populations and allowing conservation of energy at moderate workloads.

Time-Efficiency Analysis Comparing Digital and Conventional Workflows for Implant Crowns: A Prospective Clinical Crossover Trial

PURPOSE To compare time-efficiency in the production of implant crowns using a digital workflow versus the conventional pathway. MATERIALS AND METHODS This prospective clinical study used a crossover design that included 20 study participants receiving single-tooth replacements in posterior sites. Each patient received a customized titanium abutment plus a computer-aided design/computer-assisted manufacture (CAD/CAM) zirconia suprastructure (for those in the test group, using digital workflow) and a standardized titanium abutment plus a porcelain-fused-to-metal crown (for those in the control group, using a conventional pathway). The start of the implant prosthetic treatment was established as the baseline. Time-efficiency analysis was defined as the primary outcome, and was measured for every single clinical and laboratory work step in minutes. Statistical analysis was calculated with the Wilcoxon rank sum test. RESULTS All crowns could be provided within two clinical appointments, independent of the manufacturing process. The mean total production time, as the sum of clinical plus laboratory work steps, was significantly different. The mean ± standard deviation (SD) time was 185.4 ± 17.9 minutes for the digital workflow process and 223.0 ± 26.2 minutes for the conventional pathway (P = .0001). Therefore, digital processing for overall treatment was 16% faster. Detailed analysis for the clinical treatment revealed a significantly reduced mean ± SD chair time of 27.3 ± 3.4 minutes for the test group compared with 33.2 ± 4.9 minutes for the control group (P = .0001). Similar results were found for the mean laboratory work time, with a significant decrease of 158.1 ± 17.2 minutes for the test group vs 189.8 ± 25.3 minutes for the control group (P = .0001). CONCLUSION Only a few studies have investigated efficiency parameters of digital workflows compared with conventional pathways in implant dental medicine. This investigation shows that the digital workflow seems to be more time-efficient than the established conventional production pathway for fixed implant-supported crowns. Both clinical chair time and laboratory manufacturing steps could be effectively shortened with the digital process of intraoral scanning plus CAD/CAM technology.

Analysis of community health worker utilization in El Paso County, Texas

Community health workers (CHWs) are an accepted, viable component of health systems worldwide. Most often they are utilized in developing regions where health care access is limited and/or health care practitioners are scarce. In this way community health workers have been used to extend the reach of primary care delivery to whole nations, and can be used to reduce health disparities in disadvantaged populations or minority groups as well. In the United States, utilization of CHWs is fragmented, and an amalgam of programs exist which are usually only community-specific. These programs are often burdened by financial un-sustainability. The Community Health Worker National Workforce Study (2007) was markedly the first effort to compile a profile of the CHW workforce in all 50 states. El Paso County, as a uniquely bi-national setting, provided a prime locale to assess CHW utilization on a localized scale, and in a distinctively Latino population and medically underserved area. ^ Results gleaned from this study of 45 CHWs and 5 administrators demonstrate commonalities between El Paso County CHWs and the national CHW workforce; differences were found in average education level, wages for experienced CHWs, as well as primary target populace and target health issues. Future research should focus on cost-effectiveness of CHW utilization.^

Evaluating the U.S. Global Health Policy Initiative

In understanding that the efforts made in improving global health affects the health of U.S. citizens, a policy analysis of President Barak Obama's Global Health Initiative was conducted. Using materials gathered from experts in the field of health and their findings and recommendations, paired with the current policies of other G8 countries that pledged to support the efforts of improving global health, the analysis was conducted using four specifically defined criteria. The set criteria determine the appropriateness, responsiveness, effectiveness and equity of Obama's GHI in comparison to other G8 country health policies and overall global health priorities. G8 countries without a specific global health policy, or with a policy that was not in English were excluded from this study and Switzerland, headquarters of the World Health Organization, was added due to its membership in the OECD, and the fact that it has a specific foreign health policy. In evaluating the U.S. Global Health Initiative it is clear that in terms of implementing foreign policy specific to health, the United States is on the forefront alongside the United Kingdom and Switzerland. Other G8 Countries have pledged monies and in order to Millennium Development Health Goals by 2015. The U.S. Global Health Policy does not address issues necessary to meet Millennium Development Goals in Health. Instead the Global Health Initiative is focused narrowly on Fighting and rolling back the HIV/Aids Epidemic based on President Bush's PEPFAR policy. Policy recommendations for a more effective and efficient Global Health Initiative include building upon the PEPFAR policy foundation in order to strengthen health systems worldwide, allowing individuals and communities to combat unnecessary death and disease through research, education, and other preventative methods.^

Performance tiers: Implementing comparative effectiveness analysis in the health care setting through operations research and spatial methods

This dissertation develops and tests a comparative effectiveness methodology utilizing a novel approach to the application of Data Envelopment Analysis (DEA) in health studies. The concept of performance tiers (PerT) is introduced as terminology to express a relative risk class for individuals within a peer group and the PerT calculation is implemented with operations research (DEA) and spatial algorithms. The analysis results in the discrimination of the individual data observations into a relative risk classification by the DEA-PerT methodology. The performance of two distance measures, kNN (k-nearest neighbor) and Mahalanobis, was subsequently tested to classify new entrants into the appropriate tier. The methods were applied to subject data for the 14 year old cohort in the Project HeartBeat! study.^ The concepts presented herein represent a paradigm shift in the potential for public health applications to identify and respond to individual health status. The resultant classification scheme provides descriptive, and potentially prescriptive, guidance to assess and implement treatments and strategies to improve the delivery and performance of health systems. ^

Use of intranet and other interventions to increase influenza vaccination among health care workers

Influenza (the flu) is a serious respiratory illness that can cause severe complications, often leading to hospitalization and even death. Influenza epidemics occur in most countries every year, usually during the winter months. Despite recommendations from the Centers for Disease Control and Prevention (CDC) and efforts by health care institutions across the United States, influenza vaccination rates among health care workers in the United States remain low. How to increase the number of vaccinated health care workers is an important public health question and is examined in two journal articles included here. ^ The first journal article evaluates the effectiveness of an Intranet intervention in increasing the proportion of health care workers (HCWs) who received influenza vaccination. Hospital employees were required go to the hospital's Intranet and select "vaccine received," "contraindicated," or "declined" from the online questionnaire. Declining employees automatically received an online pop-up window with education about vaccination; managers were provided feedback on employees' participation rates via e-mail messages. Employees were reminded of the Intranet requirement in articles in the employee newsletter and on the hospital's Intranet. Reminders about the Intranet questionnaire were provided through managers and newsletters to the HCWs. Fewer than half the employees (43.7%) completed the online questionnaire. Yet the hospital witnessed a statistically significant increase in the percentage of employees who received the flu vaccine at the hospital – 48.5% in the 2008-09 season as compared to 36.5%, 38.5% and 29.8% in the previous three years (P < 0.05). ^ The second article assesses current interventions employed by hospitals, health systems and nursing homes to determine which policies have been the most effective in boosting vaccination rates among American health care workers. A systematic review of research published between January 1994 and March 2010 suggests that education is necessary but not usually sufficient to increase vaccine uptake. Education about the flu and flu vaccines is most effective when complemented with easy access and making the vaccine free, although this combination may not be sufficient to achieve the desired vaccination levels among HCWs. The findings point toward adding incentives for HCWs to get vaccinated and requiring them to record their vaccination status on a declination/consent form – either written or electronic. ^ Based on these findings, American health care organizations, such as hospitals, nursing homes, and long-term care facilities, should consider using online declination forms as a method for increasing influenza vaccination rates among their employees. These online forms should be used in conjunction with other policies, including free vaccine, mobile distribution and incentives. ^ To further spur health care organizations to adopt policies and practices that will raise influenza vaccination rates among employees, The Joint Commission – an independent, not-for- profit organization that accredits and certifies more than 17,000 health care organizations and programs in the United States – should consider altering its standards. Currently, The Joint Commission does not require signed declination forms from employees who eschew vaccination; it only echoes the CDC's recommendations: "Health care facilities should require personnel who refuse vaccination to complete a declination form." Because participation in Joint Commission accreditation is required for Medicare reimbursement, action taken by the Joint Commission to require interventions such as mandatory declination/consent forms might result in immediate action by health care organizations to follow these new standards and lead to higher vaccination rates among HCWs.^ 1“Frequently Asked Questions for H1N1 and Seasonal Influenza.” The Joint Commission - Infection Control: http://www.jointcommission.org/PatientSafety/InfectionControl/h1n1_faq.htm. ^

A platform for the development of patient applications in the domain of personalized health

Personalized health (p-health) systems can contribute significantly to the sustainability of healthcare systems, though their feasibility is yet to be proven. One of the problems related to their development is the lack of well-established development tools for this domain. As the p-health paradigm is focused on patient self-management, big challenges arise around the design and implementation of patient systems. This paper presents a reference platform created for the development of these applications, and shows the advantages of its adoption in a complex project dealing with cardio-vascular diseases.

A model to develop a platform for personalised health applications

Antecedentes Europa vive una situación insostenible. Desde el 2008 se han reducido los recursos de los gobiernos a raíz de la crisis económica. El continente Europeo envejece con ritmo constante al punto que se prevé que en 2050 habrá sólo dos trabajadores por jubilado [54]. A esta situación se le añade el aumento de la incidencia de las enfermedades crónicas, relacionadas con el envejecimiento, cuyo coste puede alcanzar el 7% del PIB de un país [51]. Es necesario un cambio de paradigma. Una nueva manera de cuidar de la salud de las personas: sustentable, eficaz y preventiva más que curativa. Algunos estudios abogan por el cuidado personalizado de la salud (pHealth). En este modelo las prácticas médicas son adaptadas e individualizadas al paciente, desde la detección de los factores de riesgo hasta la personalización de los tratamientos basada en la respuesta del individuo [81]. El cuidado personalizado de la salud está asociado a menudo al uso de las tecnologías de la información y comunicación (TICs) que, con su desarrollo exponencial, ofrecen oportunidades interesantes para la mejora de la salud. El cambio de paradigma hacia el pHealth está lentamente ocurriendo, tanto en el ámbito de la investigación como en la industria, pero todavía no de manera significativa. Existen todavía muchas barreras relacionadas a la economía, a la política y la cultura. También existen barreras puramente tecnológicas, como la falta de sistemas de información interoperables [199]. A pesar de que los aspectos de interoperabilidad están evolucionando, todavía hace falta un diseño de referencia especialmente direccionado a la implementación y el despliegue en gran escala de sistemas basados en pHealth. La presente Tesis representa un intento de organizar la disciplina de la aplicación de las TICs al cuidado personalizado de la salud en un modelo de referencia, que permita la creación de plataformas de desarrollo de software para simplificar tareas comunes de desarrollo en este dominio. Preguntas de investigación RQ1 >Es posible definir un modelo, basado en técnicas de ingeniería del software, que represente el dominio del cuidado personalizado de la salud de una forma abstracta y representativa? RQ2 >Es posible construir una plataforma de desarrollo basada en este modelo? RQ3 >Esta plataforma ayuda a los desarrolladores a crear sistemas pHealth complejos e integrados? Métodos Para la descripción del modelo se adoptó el estándar ISO/IEC/IEEE 42010por ser lo suficientemente general y abstracto para el amplio enfoque de esta tesis [25]. El modelo está definido en varias partes: un modelo conceptual, expresado a través de mapas conceptuales que representan las partes interesadas (stakeholders), los artefactos y la información compartida; y escenarios y casos de uso para la descripción de sus funcionalidades. El modelo fue desarrollado de acuerdo a la información obtenida del análisis de la literatura, incluyendo 7 informes industriales y científicos, 9 estándares, 10 artículos en conferencias, 37 artículos en revistas, 25 páginas web y 5 libros. Basándose en el modelo se definieron los requisitos para la creación de la plataforma de desarrollo, enriquecidos por otros requisitos recolectados a través de una encuesta realizada a 11 ingenieros con experiencia en la rama. Para el desarrollo de la plataforma, se adoptó la metodología de integración continua [74] que permitió ejecutar tests automáticos en un servidor y también desplegar aplicaciones en una página web. En cuanto a la metodología utilizada para la validación se adoptó un marco para la formulación de teorías en la ingeniería del software [181]. Esto requiere el desarrollo de modelos y proposiciones que han de ser validados dentro de un ámbito de investigación definido, y que sirvan para guiar al investigador en la búsqueda de la evidencia necesaria para justificarla. La validación del modelo fue desarrollada mediante una encuesta online en tres rondas con un número creciente de invitados. El cuestionario fue enviado a 134 contactos y distribuido en algunos canales públicos como listas de correo y redes sociales. El objetivo era evaluar la legibilidad del modelo, su nivel de cobertura del dominio y su potencial utilidad en el diseño de sistemas derivados. El cuestionario incluía preguntas cuantitativas de tipo Likert y campos para recolección de comentarios. La plataforma de desarrollo fue validada en dos etapas. En la primera etapa se utilizó la plataforma en un experimento a pequeña escala, que consistió en una sesión de entrenamiento de 12 horas en la que 4 desarrolladores tuvieron que desarrollar algunos casos de uso y reunirse en un grupo focal para discutir su uso. La segunda etapa se realizó durante los tests de un proyecto en gran escala llamado HeartCycle [160]. En este proyecto un equipo de diseñadores y programadores desarrollaron tres aplicaciones en el campo de las enfermedades cardio-vasculares. Una de estas aplicaciones fue testeada en un ensayo clínico con pacientes reales. Al analizar el proyecto, el equipo de desarrollo se reunió en un grupo focal para identificar las ventajas y desventajas de la plataforma y su utilidad. Resultados Por lo que concierne el modelo que describe el dominio del pHealth, la parte conceptual incluye una descripción de los roles principales y las preocupaciones de los participantes, un modelo de los artefactos TIC que se usan comúnmente y un modelo para representar los datos típicos que son necesarios formalizar e intercambiar entre sistemas basados en pHealth. El modelo funcional incluye un conjunto de 18 escenarios, repartidos en: punto de vista de la persona asistida, punto de vista del cuidador, punto de vista del desarrollador, punto de vista de los proveedores de tecnologías y punto de vista de las autoridades; y un conjunto de 52 casos de uso repartidos en 6 categorías: actividades de la persona asistida, reacciones del sistema, actividades del cuidador, \engagement" del usuario, actividades del desarrollador y actividades de despliegue. Como resultado del cuestionario de validación del modelo, un total de 65 personas revisó el modelo proporcionando su nivel de acuerdo con las dimensiones evaluadas y un total de 248 comentarios sobre cómo mejorar el modelo. Los conocimientos de los participantes variaban desde la ingeniería del software (70%) hasta las especialidades médicas (15%), con declarado interés en eHealth (24%), mHealth (16%), Ambient Assisted Living (21%), medicina personalizada (5%), sistemas basados en pHealth (15%), informática médica (10%) e ingeniería biomédica (8%) con una media de 7.25_4.99 años de experiencia en estas áreas. Los resultados de la encuesta muestran que los expertos contactados consideran el modelo fácil de leer (media de 1.89_0.79 siendo 1 el valor más favorable y 5 el peor), suficientemente abstracto (1.99_0.88) y formal (2.13_0.77), con una cobertura suficiente del dominio (2.26_0.95), útil para describir el dominio (2.02_0.7) y para generar sistemas más específicos (2_0.75). Los expertos también reportan un interés parcial en utilizar el modelo en su trabajo (2.48_0.91). Gracias a sus comentarios, el modelo fue mejorado y enriquecido con conceptos que faltaban, aunque no se pudo demonstrar su mejora en las dimensiones evaluadas, dada la composición diferente de personas en las tres rondas de evaluación. Desde el modelo, se generó una plataforma de desarrollo llamada \pHealth Patient Platform (pHPP)". La plataforma desarrollada incluye librerías, herramientas de programación y desarrollo, un tutorial y una aplicación de ejemplo. Se definieron cuatro módulos principales de la arquitectura: el Data Collection Engine, que permite abstraer las fuentes de datos como sensores o servicios externos, mapeando los datos a bases de datos u ontologías, y permitiendo interacción basada en eventos; el GUI Engine, que abstrae la interfaz de usuario en un modelo de interacción basado en mensajes; y el Rule Engine, que proporciona a los desarrolladores un medio simple para programar la lógica de la aplicación en forma de reglas \if-then". Después de que la plataforma pHPP fue utilizada durante 5 años en el proyecto HeartCycle, 5 desarrolladores fueron reunidos en un grupo de discusión para analizar y evaluar la plataforma. De estas evaluaciones se concluye que la plataforma fue diseñada para encajar las necesidades de los ingenieros que trabajan en la rama, permitiendo la separación de problemas entre las distintas especialidades, y simplificando algunas tareas de desarrollo como el manejo de datos y la interacción asíncrona. A pesar de ello, se encontraron algunos defectos a causa de la inmadurez de algunas tecnologías empleadas, y la ausencia de algunas herramientas específicas para el dominio como el procesado de datos o algunos protocolos de comunicación relacionados con la salud. Dentro del proyecto HeartCycle la plataforma fue utilizada para el desarrollo de la aplicación \Guided Exercise", un sistema TIC para la rehabilitación de pacientes que han sufrido un infarto del miocardio. El sistema fue testeado en un ensayo clínico randomizado en el cual a 55 pacientes se les dio el sistema para su uso por 21 semanas. De los resultados técnicos del ensayo se puede concluir que, a pesar de algunos errores menores prontamente corregidos durante el estudio, la plataforma es estable y fiable. Conclusiones La investigación llevada a cabo en esta Tesis y los resultados obtenidos proporcionan las respuestas a las tres preguntas de investigación que motivaron este trabajo: RQ1 Se ha desarrollado un modelo para representar el dominio de los sistemas personalizados de salud. La evaluación hecha por los expertos de la rama concluye que el modelo representa el dominio con precisión y con un balance apropiado entre abstracción y detalle. RQ2 Se ha desarrollado, con éxito, una plataforma de desarrollo basada en el modelo. RQ3 Se ha demostrado que la plataforma es capaz de ayudar a los desarrolladores en la creación de software pHealth complejos. Las ventajas de la plataforma han sido demostradas en el ámbito de un proyecto de gran escala, aunque el enfoque genérico adoptado indica que la plataforma podría ofrecer beneficios también en otros contextos. Los resultados de estas evaluaciones ofrecen indicios de que, ambos, el modelo y la plataforma serán buenos candidatos para poderse convertir en una referencia para futuros desarrollos de sistemas pHealth. ABSTRACT Background Europe is living in an unsustainable situation. The economic crisis has been reducing governments' economic resources since 2008 and threatening social and health systems, while the proportion of older people in the European population continues to increase so that it is foreseen that in 2050 there will be only two workers per retiree [54]. To this situation it should be added the rise, strongly related to age, of chronic diseases the burden of which has been estimated to be up to the 7% of a country's gross domestic product [51]. There is a need for a paradigm shift, the need for a new way of caring for people's health, shifting the focus from curing conditions that have arisen to a sustainable and effective approach with the emphasis on prevention. Some advocate the adoption of personalised health care (pHealth), a model where medical practices are tailored to the patient's unique life, from the detection of risk factors to the customization of treatments based on each individual's response [81]. Personalised health is often associated to the use of Information and Communications Technology (ICT), that, with its exponential development, offers interesting opportunities for improving healthcare. The shift towards pHealth is slowly taking place, both in research and in industry, but the change is not significant yet. Many barriers still exist related to economy, politics and culture, while others are purely technological, like the lack of interoperable information systems [199]. Though interoperability aspects are evolving, there is still the need of a reference design, especially tackling implementation and large scale deployment of pHealth systems. This thesis contributes to organizing the subject of ICT systems for personalised health into a reference model that allows for the creation of software development platforms to ease common development issues in the domain. Research questions RQ1 Is it possible to define a model, based on software engineering techniques, for representing the personalised health domain in an abstract and representative way? RQ2 Is it possible to build a development platform based on this model? RQ3 Does the development platform help developers create complex integrated pHealth systems? Methods As method for describing the model, the ISO/IEC/IEEE 42010 framework [25] is adopted for its generality and high level of abstraction. The model is specified in different parts: a conceptual model, which makes use of concept maps, for representing stakeholders, artefacts and shared information, and in scenarios and use cases for the representation of the functionalities of pHealth systems. The model was derived from literature analysis, including 7 industrial and scientific reports, 9 electronic standards, 10 conference proceedings papers, 37 journal papers, 25 websites and 5 books. Based on the reference model, requirements were drawn for building the development platform enriched with a set of requirements gathered in a survey run among 11 experienced engineers. For developing the platform, the continuous integration methodology [74] was adopted which allowed to perform automatic tests on a server and also to deploy packaged releases on a web site. As a validation methodology, a theory building framework for SW engineering was adopted from [181]. The framework, chosen as a guide to find evidence for justifying the research questions, imposed the creation of theories based on models and propositions to be validated within a scope. The validation of the model was conducted as an on-line survey in three validation rounds, encompassing a growing number of participants. The survey was submitted to 134 experts of the field and on some public channels like relevant mailing lists and social networks. Its objective was to assess the model's readability, its level of coverage of the domain and its potential usefulness in the design of actual, derived systems. The questionnaires included quantitative Likert scale questions and free text inputs for comments. The development platform was validated in two scopes. As a small-scale experiment, the platform was used in a 12 hours training session where 4 developers had to perform an exercise consisting in developing a set of typical pHealth use cases At the end of the session, a focus group was held to identify benefits and drawbacks of the platform. The second validation was held as a test-case study in a large scale research project called HeartCycle the aim of which was to develop a closed-loop disease management system for heart failure and coronary heart disease patients [160]. During this project three applications were developed by a team of programmers and designers. One of these applications was tested in a clinical trial with actual patients. At the end of the project, the team was interviewed in a focus group to assess the role the platform had within the project. Results For what regards the model that describes the pHealth domain, its conceptual part includes a description of the main roles and concerns of pHealth stakeholders, a model of the ICT artefacts that are commonly adopted and a model representing the typical data that need to be formalized among pHealth systems. The functional model includes a set of 18 scenarios, divided into assisted person's view, caregiver's view, developer's view, technology and services providers' view and authority's view, and a set of 52 Use Cases grouped in 6 categories: assisted person's activities, system reactions, caregiver's activities, user engagement, developer's activities and deployer's activities. For what concerns the validation of the model, a total of 65 people participated in the online survey providing their level of agreement in all the assessed dimensions and a total of 248 comments on how to improve and complete the model. Participants' background spanned from engineering and software development (70%) to medical specialities (15%), with declared interest in the fields of eHealth (24%), mHealth (16%), Ambient Assisted Living (21%), Personalized Medicine (5%), Personal Health Systems (15%), Medical Informatics (10%) and Biomedical Engineering (8%) with an average of 7.25_4.99 years of experience in these fields. From the analysis of the answers it is possible to observe that the contacted experts considered the model easily readable (average of 1.89_0.79 being 1 the most favourable scoring and 5 the worst), sufficiently abstract (1.99_0.88) and formal (2.13_0.77) for its purpose, with a sufficient coverage of the domain (2.26_0.95), useful for describing the domain (2.02_0.7) and for generating more specific systems (2_0.75) and they reported a partial interest in using the model in their job (2.48_0.91). Thanks to their comments, the model was improved and enriched with concepts that were missing at the beginning, nonetheless it was not possible to prove an improvement among the iterations, due to the diversity of the participants in the three rounds. From the model, a development platform for the pHealth domain was generated called pHealth Patient Platform (pHPP). The platform includes a set of libraries, programming and deployment tools, a tutorial and a sample application. The main four modules of the architecture are: the Data Collection Engine, which allows abstracting sources of information like sensors or external services, mapping data to databases and ontologies, and allowing event-based interaction and filtering, the GUI Engine, which abstracts the user interface in a message-like interaction model, the Workow Engine, which allows programming the application's user interaction ows with graphical workows, and the Rule Engine, which gives developers a simple means for programming the application's logic in the form of \if-then" rules. After the 5 years experience of HeartCycle, partially programmed with pHPP, 5 developers were joined in a focus group to discuss the advantages and drawbacks of the platform. The view that emerged from the training course and the focus group was that the platform is well-suited to the needs of the engineers working in the field, it allowed the separation of concerns among the different specialities and it simplified some common development tasks like data management and asynchronous interaction. Nevertheless, some deficiencies were pointed out in terms of a lack of maturity of some technological choices, and for the absence of some domain-specific tools, e.g. for data processing or for health-related communication protocols. Within HeartCycle, the platform was used to develop part of the Guided Exercise system, a composition of ICT tools for the physical rehabilitation of patients who suffered from myocardial infarction. The system developed using the platform was tested in a randomized controlled clinical trial, in which 55 patients used the system for 21 weeks. The technical results of this trial showed that the system was stable and reliable. Some minor bugs were detected, but these were promptly corrected using the platform. This shows that the platform, as well as facilitating the development task, can be successfully used to produce reliable software. Conclusions The research work carried out in developing this thesis provides responses to the three three research questions that were the motivation for the work. RQ1 A model was developed representing the domain of personalised health systems, and the assessment of experts in the field was that it represents the domain accurately, with an appropriate balance between abstraction and detail. RQ2 A development platform based on the model was successfully developed. RQ3 The platform has been shown to assist developers create complex pHealth software. This was demonstrated within the scope of one large-scale project, but the generic approach adopted provides indications that it would offer benefits more widely. The results of these evaluations provide indications that both the model and the platform are good candidates for being a reference for future pHealth developments.

El análisis de la construcción sin pérdidas (Lean Construction) y su relación con el Project & Construction Management : propuesta de regulación en España y su inclusión en la ley de la ordenación de la edificación

El presente trabajo se basa en la filosofía de la Construcción sin Pérdidas (“Lean Construction”), analizando la situación de esta filosofía en el sector de la edificación en el contexto internacional y español, respondiendo las siguientes preguntas: 1. ¿Cómo surge el “Lean Construction”? 2. ¿Cuáles son sus actividades, funciones y cometidos? 3. ¿Existe regulación del ¨Lean Construction” en otros países? 4. ¿Existe demanda del ¨Lean Construction” en España? 5. ¿Existe regulación del ¨Lean Construction” en España? 6. ¿Cómo debería ser la regulación ¨Lean Construction” en España? 7. ¿Cuál es la relación del “Lean Construction” con el “Project & Construction Management”? 8. ¿Cómo debería ser la regulación de “Lean Construction” en España considerando su relación con el “Project & Construction Management”? Las preguntas indicadas las hemos respondido detalladamente en el presente trabajo, a continuación se resume las respuestas a dichas preguntas: 1. El “Lean Construction” surge en agosto de 1992, cuando el investigador finlandés Lauri Koskela publicó en la Universidad de Stanford el reporte TECHNICAL REPORT N° 72 titulado “Application of the New Production Philosophy to Construction”. Un año más tarde el Dr. Koskela invitó a un grupo de especialistas en construcción al primer workshop de esta materia en Finlandia, dando origen al International Group for Lean Construction (IGLC) lo que ha permitido extender la filosofía a EEUU, Europa, América, Asia, Oceanía y África. “Lean Construction” es un sistema basado en el enfoque “Lean Production” desarrollado en Japón por Toyota Motors a partir de los años cincuenta, sistema que permitió a sus fábricas producir unidades con mayor eficiencia que las industrias americanas, con menores recursos, en menor tiempo, y con un número menor de errores de fabricación. 2. El sistema “Lean Construction” busca maximizar el valor y disminuir las pérdidas de los proyectos generando una coordinación eficiente entre los involucrados, manejando un proyecto como un sistema de producción, estrechando la colaboración entre los participantes de los proyectos, capacitándoles y empoderándoles, fomentando una cultura de cambio. Su propósito es desarrollar un proceso de construcción en el que no hayan accidentes, ni daños a equipos, instalaciones, entorno y comunidad, que se realice en conformidad con los requerimientos contractuales, sin defectos, en el plazo requerido, respetando los costes presupuestados y con un claro enfoque en la eliminación o reducción de las pérdidas, es decir, las actividades que no generen beneficios. El “Last Planner System”, o “Sistema del Último Planificador”, es un sistema del “Lean Construction” que por su propia naturaleza protege a la planificación y, por ende, ayuda a maximizar el valor y minimizar las pérdidas, optimizando de manera sustancial los sistemas de seguridad y salud. El “Lean Construction” se inició como un concepto enfocado a la ejecución de las obras, posteriormente se aplicó la filosofía a todas las etapas del proyecto. Actualmente considera el desarrollo total de un proyecto, desde que nace la idea hasta la culminación de la obra y puesta en marcha, considerando el ciclo de vida completo del proyecto. Es una filosofía de gestión, metodologías de trabajo y una cultura empresarial orientada a la eficiencia de los procesos y flujos. La filosofía “Lean Construction” se está expandiendo en todo el mundo, además está creciendo en su alcance, influyendo en la gestión contractual de los proyectos. Su primera evolución consistió en la creación del sistema “Lean Project Delivery System”, que es el concepto global de desarrollo de proyectos. Posteriormente, se proponen el “Target Value Design”, que consiste en diseñar de forma colaborativa para alcanzar los costes y el valor requerido, y el “Integrated Project Delivery”, en relación con sistemas de contratos relacionales (colaborativos) integrados, distintos a los contratos convencionales. 3. Se verificó que no existe regulación específica del ¨Lean Construction” en otros países, en otras palabras, no existe el agente con el nombre específico de “Especialista en Lean Construction” o similar, en consecuencia, es un agente adicional en el proyecto de la edificación, cuyas funciones y cometidos se pueden solapar con los del “Project Manager”, “Construction Manager”, “Contract Manager”, “Safety Manager”, entre otros. Sin embargo, se comprobó la existencia de formatos privados de contratos colaborativos de Integrated Project Delivery, los cuales podrían ser tomados como unas primeras referencias para futuras regulaciones. 4. Se verificó que sí existe demanda del ¨Lean Construction” en el desarrollo del presente trabajo, aunque aún su uso es incipiente, cada día existe más interesados en el tema. 5. No existe regulación del ¨Lean Construction” en España. 6. Uno de los objetivos fundamentales de esta tesis es el de regular esta figura cuando actúe en un proyecto, definir y realizar una estructura de Agente de la Edificación, según la Ley de Ordenación de la Edificación (LOE), y de esta manera poder introducirla dentro de la Legislación Española, protegiéndola de eventuales responsabilidades civiles. En España existe jurisprudencia (sentencias de los tribunales de justicia españoles) con jurisdicción civil basada en la LOE para absolver o condenar a agentes de la edificación que son definidos en los tribunales como “gestores constructivos” o similares. Por este motivo, en un futuro los tribunales podrían dictaminar responsabilidades solidarias entre el especialista “Lean Construction” y otros agentes del proyecto, dependiendo de sus actuaciones, y según se implemente el “Lean Project Delivery System”, el “Target Value Design” y el “Integrated Project Delivery”. Por otro lado, es posible que el nivel de actuación del especialista “Lean Construcción” pueda abarcar la gestión del diseño, la gestión de la ejecución material (construcción), la gestión de contratos, o la gestión integral de todo el proyecto de edificación, esto último, en concordancia con la última Norma ISO 21500:2012 o UNE-ISO 21500:2013 Directrices para la dirección y gestión de proyectos. En consecuencia, se debería incorporar adecuadamente a uno o más agentes de la edificación en la LOE de acuerdo a sus funciones y responsabilidades según los niveles de actuación del “Especialista en Lean Construction”. Se propone la creación de los siguientes agentes: Gestor del Diseño, Gestor Constructivo y Gestor de Contratos, cuyas definiciones están desarrolladas en este trabajo. Estas figuras son definidas de manera general, puesto que cualquier “Project Manager” o “DIPE”, gestor BIM (Building Information Modeling), o similar, puede actuar como uno o varios de ellos. También se propone la creación del agente “Gestor de la Construcción sin Pérdidas”, como aquel agente que asume las actuaciones del “gestor de diseño”, “gestor constructivo” y “gestor de contratos” con un enfoque en los principios del Lean Production. 7. En la tesis se demuestra, por medio del uso de la ISO 21500, que ambos sistemas son complementarios, de manera que los proyectos pueden tener ambos enfoques y ser compatibilizados. Un proyecto que use el “Project & Construction Management” puede perfectamente apoyarse en las herramientas y técnicas del “Lean Construction” para asegurar la eliminación o reducción de las pérdidas, es decir, las actividades que no generen valor, diseñando el sistema de producción, el sistema de diseño o el sistema de contratos. 8. Se debería incorporar adecuadamente al agente de la edificación “Especialista en Lean Construction” o similar y al agente ¨Especialista en Project & Construction Management” o DIPE en la Ley de Ordenación de la Edificación (LOE) de acuerdo a sus funciones y responsabilidades, puesto que la jurisprudencia se ha basado para absolver o condenar en la referida Ley. Uno de los objetivos fundamentales de esta tesis es el de regular la figura del “Especialista en Lean Construction” cuando actúa simultáneamente con el DIPE, y realizar una estructura de Agente de la Edificación según la LOE, y de esta manera protegerlo de eventuales responsabilidades solidarias. Esta investigación comprueba que la propuesta de definición del agente de edificación DIPE, según la LOE, presentada en la tesis doctoral del Doctor Manuel Soler Severino es compatible con las nuevas definiciones propuestas. El agente DIPE puede asumir los roles de los diferentes gestores propuestos en esta tesis si es que se especializa en dichas materias, o, si lo estima pertinente, recomendar sus contrataciones. ABSTRACT This work is based on the Lean Construction philosophy; an analysis is made herein with regard to the situation of this philosophy in the building sector within the international and Spanish context, replying to the following questions: 1. How did the concept of Lean Construction emerge? 2. Which are the activities, functions and objectives of Lean Construction? 3. Are there regulations on Lean Construction in other countries? 4. Is there a demand for Lean Construction in Spain? 5. Are there regulations on Lean Construction in Spain? 6. How should regulations on Lean Construction be developed in Spain? 7. What is the relationship between Lean Construction and the Project & Construction Management? 8. How should regulations on Lean Construction be developed in Spain considering its relationship with the Project & Construction Management? We have answered these questions in detail here and the replies are summarized as follows: 1. The concept of Lean Construction emerged in august of 1992, when Finnish researcher Lauri Koskela published in Stanford University TECHNICAL REPORT N° 72 entitled “Application of the New Production Philosophy to Construction”. A year later, Professor Koskela invited a group of construction specialists to Finland to the first workshop conducted on this matter; thus, the International Group for Lean Construction (IGLC) was established, which has contributed to extending the philosophy to the United States, Europe, the Americas, Asia, Oceania, and Africa. Lean Construction is a system based on the Lean Production approach, which was developed in Japan by Toyota Motors in the 1950s. Thanks to this system, the Toyota plants were able to produce more units, with greater efficiency than the American industry, less resources, in less time, and with fewer manufacturing errors. 2. The Lean Construction system aims at maximizing the value of projects while reducing waste, producing an effective coordination among those involved; it manages projects as a production system, enhancing collaboration between the parties that participate in the projects while building their capacities, empowering them, and promoting a culture of change. Its purpose is to develop a construction process free of accidents, without damages to the equipment, facilities, environment and community, flawless, in accordance with contractual requirements, within the terms established, respecting budgeted costs, and with a clear approach to eliminating or reducing waste, that is, activities that do not generate benefits. The Last Planner System is a Lean Construction system, which by its own nature protects planning and, therefore, helps to maximize the value and minimize waste, optimizing substantially the safety and health systems. Lean Construction started as a concept focused on the execution of works, and subsequently the philosophy was applied to all the stages of the project. At present it considers the project’s total development, since the time ideas are born until the completion and start-up of the work, taking into account the entire life cycle of the project. It is a philosophy of management, work methodologies, and entrepreneurial culture aimed at the effectiveness of processes and flows. The Lean Construction philosophy is extending all over the world and its scope is becoming broader, having greater influence on the contractual management of projects. It evolved initially through the creation of the Lean Project Delivery System, a global project development concept. Later on, the Target Value Design was developed, based on collaborative design to achieve the costs and value required, as well as the Integrated Project Delivery, in connection with integrated relational (collaborative) contract systems, as opposed to conventional contracts. 3. It was verified that no specific regulations on Lean Construction exist in other countries, in other words, there are no agents with the specific name of “Lean Construction Specialist” or other similar names; therefore, it is an additional agent in building projects, which functions and objectives can overlap those of the Project Manager, Construction Manager, Contract Manager, or Safety Manager, among others. However, the existence of private collaborative contracts of Integrated Project Delivery was confirmed, which could be considered as first references for future regulations. 4. There is a demand for Lean Construction in the development of this work; even though it is still emerging, there is a growing interest in this topic. 5. There are no regulations on Lean Construction in Spain. 6. One of the main objectives of this thesis is to regulate this role when acting in a project, and to define and develop a Building Agent structure, according to the Building Standards Law (LOE by its acronym in Spanish), in order to be able to incorporate it into the Spanish law, protecting it from civil liabilities. In Spain there is jurisprudence in civil jurisdiction based on the LOE to acquit or convict building agents, which are defined in the courts as “construction managers” or similar. For this reason, courts could establish in the future joint and several liabilities between the Lean Construction Specialist and other agents of the project, depending on their actions and based on the implementation of the Lean Project Delivery System, the Target Value Design, and the Integrated Project Delivery. On the other hand, it is possible that the level of action of the Lean Construction Specialist may comprise design management, construction management and contract management, or the integral management of the entire building project in accordance with the last ISO 21500:2012 or UNE-ISO 21500:2013, guidelines for the management of projects. Accordingly, one or more building agents should be appropriately incorporated into the LOE according to their functions and responsibilities and based on the levels of action of the Lean Construction Specialist. The creation of the following agents is proposed: Design Manager, Construction Manager, and Contract Manager, which definitions are developed in this work. These agents are defined in general, since any Project Manager or DIPE, Building Information Modeling (BIM) Manager or similar, may act as one or as many of them. The creation of the Lean Construction Manager is also proposed, as the agent that takes on the role of the Design Manager, Construction Manager and Contract Manager with a focus on the Lean Production principles. 7. In the thesis it is demonstrated that through the implementation of the ISO 21500, both systems are supplementary, so projects may have both approaches and be compatible. A project that applies the Project & Construction Management may perfectly have the support of the tools, techniques and practices of Lean Construction to ensure the elimination or reduction of losses, that is, those activities that do not generate value, thus designing the production system, the design system, or the contract system. 8. The Lean Construction Specialist or similar and the Specialist in Project & Construction Management should be incorporated appropriately into the LOE according to their functions and responsibilities, since jurisprudence has been based on such Law to acquit or convict. One of the main objectives of this thesis is the regulate the role of the Lean Construction Specialist when acting simultaneously with the DIPE, and to develop a structure of the building agent, according to the LOE, and in this way protect such agent from joint and several liabilities. This research proves that the proposal to define the DIPE building agent, according to the LOE, and presented in the doctoral dissertation of Manuel Soler Severino, Ph.D. is compatible with the new definitions proposed. The DIPE agent may assume the roles of the different managers proposed in this thesis if he specializes in those topics or, if deemed pertinent, recommends that they be engaged.

The health care needs of UK pensioners living in Spain: an agenda for research

There is a growing interest in learning how older migrants adapt to their new country of residence, in understanding their motivations for migration and the factors that influence international retirement migration patterns. However, there has been little research into the health and health care needs of international migrants retiring to other countries. This paper presents findings on health status and utilisation of health services with a particular focus on UK pensioners retiring to Spain. Future research should focus on the health needs of pensioners and their perspectives as to whether and how these health needs are met.

A metasynthesis of qualitative studies regarding opinions and perceptions about barriers and determinants of health services’ accessibility in economic migrants

Background: Access to health services is an important health determinant. New research in health equity is required, especially amongst economic migrants from developing countries. Studies conducted on the use of health services by migrant populations highlight existing gaps in understanding which factors affect access to these services from a qualitative perspective. We aim to describe the views of the migrants regarding barriers and determinants of access to health services in the international literature (1997–2011). Methods: A systematic review was conducted for Qualitative research papers (English/Spanish) published in 13 electronic databases. A selection of articles that accomplished the inclusion criteria and a quality evaluation of the studies were carried out. The findings of the selected studies were synthesised by means of metasynthesis using different analysis categories according to Andersen’s conceptual framework of access and use of health services and by incorporating other emergent categories. Results: We located 3,025 titles, 36 studies achieved the inclusion criteria. After quality evaluation, 28 articles were definitively synthesised. 12 studies (46.2%) were carried out in the U.S and 11 studies (42.3%) dealt with primary care services. The participating population varied depending mainly on type of host country. Barriers were described, such as the lack of communication between health services providers and migrants, due to idiomatic difficulties and cultural differences. Other barriers were linked to the economic system, the health service characteristics and the legislation in each country. This situation has consequences for the lack of health control by migrants and their social vulnerability. Conclusions: Economic migrants faced individual and structural barriers to the health services in host countries, especially those with undocumented situation and those experimented idiomatic difficulties. Strategies to improve the structures of health systems and social policies are needed.