Productivity and Services – Safety Telephone Services for the Elderly

Previous research on productivity is often associated with manufacturing or uses manufacturing definitions of productivity. Marketing research on services has not been satisfied with the manufacturing definitions. No universal definition for service productivity exists. The lack of a universal definition highlights the complexity entailed in the concept of productivity. The objective of this study was to investigate service productivity in situations, where traditional ways are in some cases even not possible or are not enough. In one definition of the productivity of service organisations there is the efficiency of the organisation on the input side and on the output side the customers’ perceived quality or value-in-use. To learn about value-in-use, many methods have been developed. A common practice is to make customer opinion surveys in the form of customer questionnaires and interviews. However, customers cannot always be asked directly, for example, because of impaired cognitive abilities. Such cases include the elderly and children. Furthermore, customer opinion surveys are time consuming. In addition, customers do not always know what kind of services they would benefit from. For the empirical part of the study, a business area was identified where traditional ways of measuring value-in-use are difficult or in some cases even not possible. This business area is safety telephone services. These services are most often used by the elderly. The way to define value-in-use here was to assess how well the services offered met customer expectations. Comparing the services customers asked for and the services provided to them indicated whether customer expectations were met. This study showed that customers had their ideas concerning the contents of the services but many times the services provided did not meet these expectations. Organisational efficiency aspirations can decrease customers’ value-in-use. This study found a solution, in which increasing organisational efficiency would go hand-in-hand with increasing customers’ value-in-use; the result being that the organisations’ needs and the service users’ expectations were in line. Value creation for customers produced organisational efficiency and thus increased productivity. In this study, customer expectations were observed by means of wellness technology. With the help of modern technology, customer expectations can be followed quickly and easily and customers can co-create with the organisation. This type of an approach could be useful even in the development of other services for other ages and in different contexts. If a service organisation decreases the number of personnel and, at the same time, tries to offer services to the same or a larger clientele, customers easily notice the change, which is often negative. To avoid harmful decrease in value-in-use, limitations to the aspiration of efficiency should be implemented – one of such is that the organisation is required to meet certain quality standards defined by experts. The aim is to secure that, as a result of efficiency aspirations in the organisation, the quality of the service offerings does not diminish below mutually agreed standards. Traditionally, when productivity in services has been estimated, organisational efficiency has not been combined with both customer expectations and an expert assessment of quality. This study contributes with novel thinking entitled ‘Relationship Management of the Elderly’. This study handles productivity, expert defined quality and value-in-use in an organisational context, which is practically untouched in previous research studies.

EMQAL: Erasmus Mundus Master in Quality in Analytical Laboratories

The Erasmus Mundus Master in Quality in Analytical Laboratories (EMQAL) is a two-year Joint Master Degree. The course is funded by the European Commission through the Erasmus Mundus Programme, providing a number of attractive scholarships for European and non-European students. EMQAL prepares professionals for analytical laboratories, focusing on laboratory management and quality systems, along with complementing their technical knowledge. The EMQAL aims at training students in the most relevant issues concerning quality systems and management in analytical laboratories, and to become an expert in: Quality management, Analytical methods and Data Analysis. EMQAL promotes mobility. The students will attend one academic year of lectures in one of the European universities of the EMQAL consortium, and a 12 months master thesis at other European university, with the possibility to spend three-months in one of the non-EU partners. The language of instruction and examination is English. Further information is available at www.emqal.org.

A Communication Middleware Quality Enhancement with Qt Framework

In this thesis, a Peer-to-Peer communication middleware for mobile environment is developed using the Qt framework and the Qt Mobility extension. The Peer-to-Peer middleware – called as PeerHood – is for service sharing in network neighborhood. In addition, the PeerHood enables service connectivity and device monitoring functionalities. The concept of the PeerHood is already available in native C++ implementation on Linux platform using services from the platform. In this work, the PeerHood concept is remade to be based on use of the Qt framework. The objective of the new solution is to increase PeerHood quality with using functionalities from the Qt framework and the Qt Mobility extension. Furthermore, by using the Qt framework, the PeerHood middleware can be implemented to be portable cross-platform middleware. The quality of the new PeerHood implementation is evaluated with defined quality factors and compared with the existing PeerHood. Reliability, CPU usage, memory usage and static code analysis metrics are used in evaluation. The new PeerHood is shown to be more reliable and flexible that the existing one.

The ISSA Pedagogical Standards: a tool to influence quality in early childhood programs

The ISSA Pedagogical Standards were first published in 2001 as a network-developed tool that defined quality in teaching practices and the classroom environment and captured the changes that had occurred in the region since 1994 when the Step by Step Program, an initiative to promote democratic principles in early childhood development and education, was launched. The Program was built on belief that each child has the right to receive maximum support for the development of his or her full potential, and this work should be done in partnership and close cooperation with families, communities and professionals

Juror need for cognition and sensitivity to methodological flaws in expert evidence

Two studies investigated the influence of juror need for cognition on the systematic and heuristic processing of expert evidence. U.S. citizens reporting for jury duty in South Florida read a 15-page summary of a hostile work environment case containing expert testimony. The expert described a study she had conducted on the effects of viewing sexualized materials on men's behavior toward women. Certain methodological features of the expert's research varied across experimental conditions. In Study 1 (N = 252), the expert's study was valid, contained a confound, or included the potential for experimenter bias (internal validity) and relied on a small or large sample (sample size) of college undergraduates or trucking employees (ecological validity). When the expert's study included trucking employees, high need for cognition jurors in Study 1 rated the expert more credible and trustworthy than did low need for cognition jurors. Jurors were insensitive to variations in the study's internal validity or sample size. Juror ratings of plaintiff credibility, plaintiff trustworthiness, and study quality were positively correlated with verdict. In Study 2 (N = 162), the expert's published or unpublished study (general acceptance) was either valid or lacked an appropriate control group (internal validity) and included a sample of college undergraduates or trucking employees (ecological validity). High need for cognition jurors in Study 2 found the defendant liable more often and evaluated the expert evidence more favorably when the expert's study was internally valid than when an appropriate control group was missing. Low need for cognition jurors did not differentiate between the internally valid and invalid study. Variations in the study's general acceptance and ecological validity did not affect juror judgments. Juror ratings of expert and plaintiff credibility, plaintiff trustworthiness, and study quality were positively correlated with verdict. The present research demonstrated that the need for cognition moderates juror sensitivity to expert evidence quality and that certain message-related heuristics influence juror judgments when ability or motivation to process systematically is low. ^

Implementação do Sistema de Gestão de Qualidade NP EN ISO 9001:2008

Com as dificuldades económicas que se fazem sentir nos últimos anos, tanto em Portugal como no resto do mundo, em qualquer área de negócio, a qualidade tornou-se um dos fatores de sucesso. Com um mercado cada vez com mais concorrência, os clientes procuram frequentemente a melhor qualidade do produto ou do serviço da empresa. Para isso as empresas cada vez mais apostam em fornecer um produto de qualidade através de um sistema da qualidade bem delineado, bem gerido e certificado. O presente trabalho que foi desenvolvido nesta dissertação de Mestrado consistiu na conceção e acompanhamento da Implementação do Sistema de Gestão da Qualidade (SGQ) segundo a norma NP EN ISO 9001:2008 realizada numa indústria de componentes de calçado, designada NEWCOMP, Componentes para Calçado, LDA. (NCP), localizada em S. João da Madeira. Será uma ferramenta bastante útil e estratégica para a empresa a certificação, com inúmeras vantagens e benefícios para a sua imagem. As principais razões que levaram a empresa a interessar-se pela certificação do SGQ foi, principalmente, a melhoria da qualidade dos seus produtos, satisfação dos clientes e alcançar novos mercados. A documentação elaborada do SGQ inclui a política e objetivos da qualidade, esquemas dos principais processos, manual de funções entre outros documentos considerados necessários, para utilização de todas as partes envolvidas.

Precision of tibial tunnel placement under arthroscopic control alone in posterior cruciate ligament reconstruction: A radiological study

Introduction: Accurate and reproducible tibial tunnel placement minimizing the risk of neurovascular damage is a crucial condition for successful arthroscopic reconstruction of the posterior cruciate ligament (PCL). This step is commonly performed under fluoroscopic control. Hypothesis: Performing the tibial tunnel under exclusive arthroscopic control allows accurate and reliable tunnel placement according to recommendations in the literature. Materials and Methods: Between February 2007 and December 2009, 108 arthroscopic single bundle PCL reconstructions in tibial tunnel technique were performed. The routine postoperative radiographs were screened according to previously defined quality criterions. After critical analysis, the radiographs of 48 patients (48 knees) were enrolled in the study. 10 patients had simultaneous ACL reconstruction and 7 had PCL revision surgery. The tibial tunnel was placed under direct arthroscopic control through a posteromedial portal using a standard tibial aming device. Key anatomical landmarks were the exposed tibial insertion of the PCL and the posterior horn of the medial meniscus. First, the centre of the posterior tibial tunnel outlet on the a-p view was determined by digital analysis of the postoperative radiographes. Its distance to the medial tibial spine was measured parallel to the tibia plateau. The mediolateral position was expressed by the ratio between the distance of the tunnel outlet to the medial border and the total width of the tibial plateau. On the lateral view the vertical tunnel position was measured perpendicularly to a tangent of the medial tibial plateau. All measurement were repeated at least twice and carried out by two examiners. Results: The mean mediolateral tunnel position was 49.3 ± 4.6% (ratio), 6.7 ± 3.6 mm lateral to the medial tibial spine. On the lateral view the tunnel centre was 10.1 ± 4.5 mm distal to the bony surface of the medial tibial plateau. Neurovascular damage was observed in none of our patients. Conclusion: The results of this radiological study confirm that exclusive arthroscopic control for tibial tunnel placement in PCL reconstruction yields reproducible and accurate results according to the literature. Our technique avoids radiation, facilitates the operation room setting and enables the surgeon to visualize the anatomic key landmarks for tibial tunnel placement.

Subclinical thyroid dysfunction and the risk of stroke: a systematic review and meta-analysis

Subclinical thyroid dysfunction has been associated with coronary heart disease, but the risk of stroke is unclear. Our aim is to combine the evidence on the association between subclinical thyroid dysfunction and the risk of stroke in prospective cohort studies. We searched Medline (OvidSP), Embase, Web-of-Science, Pubmed Publisher, Cochrane and Google Scholar from inception to November 2013 using a cohort filter, but without language restriction or other limitations. Reference lists of articles were searched. Two independent reviewers screened articles according to pre-specified criteria and selected prospective cohort studies with baseline thyroid function measurements and assessment of stroke outcomes. Data were derived using a standardized data extraction form. Quality was assessed according to previously defined quality indicators by two independent reviewers. We pooled the outcomes using a random-effects model. Of 2,274 articles screened, six cohort studies, including 11,309 participants with 665 stroke events, met the criteria. Four of six studies provided information on subclinical hyperthyroidism including a total of 6,029 participants and five on subclinical hypothyroidism (n = 10,118). The pooled hazard ratio (HR) was 1.08 (95 % CI 0.87-1.34) for subclinical hypothyroidism (I (2) of 0 %) and 1.17 (95 % CI 0.54-2.56) for subclinical hyperthyroidism (I (2) of 67 %) compared to euthyroidism. Subgroup analyses yielded similar results. Our systematic review provides no evidence supporting an increased risk for stroke associated with subclinical thyroid dysfunction. However, the available literature is insufficient and larger datasets are needed to perform extended analyses. Also, there were insufficient events to exclude clinically significant risk from subclinical hyperthyroidism, and more data are required for subgroup analyses.

Diseño metodológico para la creación y desarrollo de organizaciones innovadoras, basadas en un modelo de liderazgo que genere entornos facilitadores de la creatividad, implantación de procesos de innovación y creación de productos y servicios innovadores

La presente investigación tiene como objetivo el desarrollo de una metodología que favorezca la innovación en las empresas a través de la actividad directiva, analizando a su vez, su influencia a nivel macro, en los sistemas de innovación, en las políticas de innovación y en el capital intelectual y a nivel micro, en la innovación, en el desempeño y en el clima organizacional. Se estima importante realizar un estudio sobre este tema debido a que la innovación se considera un pilar crítico para el desarrollo social a través de la competitividad de las empresas, así como, una fuente importante de ventaja competitiva. Existe abundante literatura sobre la influencia de la innovación en la gestión empresarial y el papel que el liderazgo desempeña en términos generales. Sin embargo, la literatura presenta diversos estilos de liderazgo sin mostrar una línea consistente de interrelación entre ellos, por lo que finalmente no existe una relación sólida entre el liderazgo, la gestión empresarial y la innovación. Este hecho se debe, como se muestra en la tesis, a que la literatura analiza las organizaciones y el liderazgo desde una perspectiva sociológica u organizacional, y otra desde la perspectiva psicológica sin aportar una línea de articulación entre ambas. Es decir, la literatura analiza el comportamiento organizacional pero no su causa. A lo largo de la tesis se van desarrollando diferentes líneas de trabajo que se convierten en aportaciones empíricas y académicas. Así, una de las aportaciones de la tesis es la sustitución de la figura del líder como persona, por la de un directivo con una doble función; por un lado, la función de liderazgo cuyo objetivo es generar cambio y por el otro, la función de gestionar el día a día o desempeño. Sustituir la figura del líder por una doble funcionalidad directiva facilita la comprensión del concepto liderazgo, lo que permite a su vez, establecer estrategias para su desarrollo, haciendo una realidad el que el liderazgo puede ser aprendido. Este resultado constituye la primera aportación de la tesis. Así mismo, a través de un exhaustivo análisis de la literatura, se desarrolla una propuesta de liderazgo integrado de acuerdo con el modelo Stuart-Kotze, el cual se describe también ampliamente. Encontrar un modelo único de liderazgo supone la piedra angular para el desarrollo de la metodología. Esta propuesta de liderazgo integrado da lugar a la segunda aportación de la tesis. Del mismo modo, se realiza un estudio en profundidad de la perspectiva psicológica de las organizaciones desarrollando el constructo Miedo al Error (ME) que resulta ser un rasgo de la personalidad existente en todos los seres humanos y que presenta una influencia negativa tanto en el desempeño, como en la innovación empresarial. Este resultado permite identificar cuales son las verdaderas barreras para el ejercicio del liderazgo, señalando que la disminución del ME debe ser considerada como una competencia de la Inteligencia Emocional a ser desarrollada por los directivos. Este resultado constituye la tercera aportación de la tesis. Una vez desarrollado el modelo de gestión empresarial expuesto, se procede a su validación, analizando la relación entre los constructos que definen el modelo de gestión: el desempeño, la innovación y el ME. Para identificar las influencias o relaciones de causalidad que subyacen entre los constructos, se utilizó la técnica del modelo de ecuaciones estructurales (SEM). La población objeto de estudio estuvo constituida por 350 profesionales con responsabilidad directiva, procedentes de empresas del sector servicios repartidas por toda la geografía española. Como fuente primaria de recolección de información se utilizó el cuestionario desarrollado por Stuart-Kotze M-CPI (Momentum Continuous Performance Improvement). En primer lugar se procedió a evaluar las propiedades psicométricas del modelo de medida, llevándose a cabo un análisis factorial exploratorio (AFE) y un análisis factorial confirmatorio (AFC) de segundo orden. Los resultados obtenidos ponen de manifiesto que el constructo desempeño (D) viene determinado por dos dimensiones, (DOP), desempeño orientado hacia la planificación y (DORT), desempeño orientado hacia la realización de la tarea. Es decir, la muestra de directivos no percibe que la planificación en el día a día y la realización de la tarea estén articuladas. Posteriormente se procede a realizar el contraste del modelo a través del método de ecuaciones estructurales. Los resultados muestran que la relación de influencia de la dimensión DOP no es significativa, por lo que el constructo D queda representado únicamente por la dimensión DORT. Los resultados de la investigación proporcionan conclusiones e hipótesis para futuras investigaciones. Si bien la muestra de directivos realiza un plan estratégico, éste no se tiene en cuenta en el día a día. Este hecho podría explicar el alto grado de administración por crisis tan frecuente en la empresa española. A su vez, el ME presenta una influencia negativa en la innovación, lo que concuerda con la literatura. Al respecto, considerar el ME como un rasgo de la personalidad, presente tanto en directivos como en colaboradores, facilita la comprensión de las barreras de la organización hacia la comunicación abierta a la vez, que una dirección de trabajo para la mejora de la capacidad innovadora de la organización. Por último, los resultados establecen la existencia de una relación causal entre el desempeño diario y la innovación. Con respecto a este segundo resultado y analizando los comportamientos que identifican el constructo D surgen también varias conclusiones e hipótesis para futuras investigaciones. Los resultados ponen de manifiesto que la muestra de directivos genera iniciativas de cambio con la finalidad de que el trabajo diario salga adelante según los estándares de calidad definidos. Sin embargo, estas iniciativas sólo proceden de los directivos, sin participación alguna de los colaboradores, los cuales son sólo responsables de la implementación produciéndose la consiguiente desmotivación y pérdida de oportunidades. Esta conclusión pone de manifiesto que la innovación de las empresas de la muestra sucede para garantizar la eficiencia de los procesos existentes, pero en ningún caso surge de la iniciativa de buscar una mejor eficacia empresarial. Este hecho plantea un origen doble de la innovación en los procesos. La innovación proactiva que buscaría la mejora de la eficacia de la organización y una innovación de carácter reactiva que buscaría la salvaguarda de la eficiencia. Quizás sea esta la causa del gap existente entre la innovación en España y la innovación de los países que ocupan los primeros puestos en el ranking de producción de innovación lo que constituye un importante punto de partida para una investigación futura. ABSTRACT This research aims to develop a methodology that supports innovation in companies through the managers’ activity, analysing in turn its influence at the macro level: innovation systems, innovation policies and Intellectual capital and at the micro level: innovation itself, performance and organizational climate. It is considered important to conduct a study on this subject due to the fact that innovation is considered a critical pillar for the development and future of the enterprise and an important source of competitive advantage. There is abundant literature about the influence of innovation in business management and the role that leadership plays in general terms. However, the literature presents various styles of leadership without showing a consistent relationship among them, so finally there is not a strong relationship among leadership, business management and innovation. As shown in the thesis, this is due to the fact that the literature analyses organizations and leadership from a sociological or organizational perspective and from a psychological perspective, without providing a hinge line between the two. That is, the existing literature discusses organizational behaviour but not its cause. Throughout the thesis, different lines of work that become empirical and academic contributions have been developed. Thus, one of the contributions of the thesis is replacing the figure of the leader as a person, by a manager with a dual function. Firstly, we have the leadership role which aims to generate change and, on the other hand, the function to manage the day-to-day task or performance. Replacing the figure of the leader by a dual managerial functionality facilitates the understanding of the leadership concept, allowing in turn, to establish development strategies and making true that leadership can be learned. This outcome is the first contribution of the thesis. Likewise, through a comprehensive literature review, an integrated leadership proposal is developed, according to the Kotze model, which is also described widely. Finding a specific leadership model represents the cornerstone for the development of the methodology. This integrated leadership proposal leads to the second contribution of the thesis. Similarly, an in-depth study was conducted about the psychological perspective of the organizations disclosing the construct Fear of Failure. This construct is a personality trait that exists in all human beings and has a negative influence on both performance and business innovation. This outcome allows identifying which are the real barriers to the exercise of leadership, noting that the decrease in fear of failure must be considered as an Emotional Intelligence competence to be developed by managers. This outcome represents the third contribution of the thesis. Once a business management model has been developed, we proceed to its validation by analysing the relationship among the model constructs: management, innovation and fear of failure. To identify the influence or causal relationships underlying the constructs, a structural equation model (SEM) technique was used. The study population consisted of 350 professionals with managerial responsibility, from companies in the services sector scattered throughout the Spanish geography. As a primary source for gathering information a questionnaire developed by Kotze M-CPI (Continuous Performance Improvement Momentum) was used. First we proceeded to evaluate the psychometric properties of the measurement model, carrying out an exploratory factorial analysis (EFA) and a confirmatory factorial analysis (CFA) of second order. The results show that the performance construct D is determined by two-dimensions (DOP: performance oriented to planning) and (DORT: aiming at the realization of the task). That is, the sample of managers does not perceive that planning and the daily task are articulated. Then, we proceeded to make the contrast of the model through a structural equation model SEM. The results show that the influence of the DOP dimension is not significant, so that only the DORT dimension finally represents the construct D. The research outcomes provide conclusions and hypotheses for future research. Although the managers in the sample develop a strategic plan, it seems that managers do not take it into account in their daily tasks. This could explain the high degree of crisis management so prevalent in the Spanish companies. In turn, the fear of failure has a negative influence on innovation, consistent with the literature. In this regard, the fear of failure is considered as a personality trait, present in both managers and employees, which enables the understanding of organizational barriers to open communication and provides a direction to improve the organization’s innovative capacity as well. Finally, the results establish a causal relationship between daily performance and innovation. Regarding this second outcome and analysing the behaviours that identify the construct D, several conclusions and hypotheses for future research arise as well. The results show that the managers in the sample show initiatives of change in order to make everyday work go ahead, according to defined quality standards. However, these initiatives only come from managers without any participation of coworkers, which are only responsible for the implementation, and this produces discouragement and loss of opportunities. This finding shows that the innovation by the companies in the sample happens to guarantee the efficiency of existing processes, but do not arise from an initiative that seeks better business efficacy. This raises two sources of innovation in processes. The first source would be a proactive innovation that would seek improved organizational efficacy. The second one is a reactive innovation that would seek to safeguard efficiency. Perhaps this is the cause of the existing gap between the innovation activity in Spain and the innovation activity in those countries that occupy the top positions in the ranking of innovation outcomes. The Spanish companies seek process efficiency and the top innovators business efficacy. This is an important starting point for future research.

UncertML: an XML schema for exchanging uncertainty

Authors from Burrough (1992) to Heuvelink et al. (2007) have highlighted the importance of GIS frameworks which can handle incomplete knowledge in data inputs, in decision rules and in the geometries and attributes modelled. It is particularly important for this uncertainty to be characterised and quantified when GI data is used for spatial decision making. Despite a substantial and valuable literature on means of representing and encoding uncertainty and its propagation in GI (e.g.,Hunter and Goodchild 1993; Duckham et al. 2001; Couclelis 2003), no framework yet exists to describe and communicate uncertainty in an interoperable way. This limits the usability of Internet resources of geospatial data, which are ever-increasing, based on specifications that provide frameworks for the ‘GeoWeb’ (Botts and Robin 2007; Cox 2006). In this paper we present UncertML, an XML schema which provides a framework for describing uncertainty as it propagates through many applications, including online risk management chains. This uncertainty description ranges from simple summary statistics (e.g., mean and variance) to complex representations such as parametric, multivariate distributions at each point of a regular grid. The philosophy adopted in UncertML is that all data values are inherently uncertain, (i.e., they are random variables, rather than values with defined quality metadata).

Nichtmedikamentöse Sekundärprävention der koronaren Herzkrankheit (KHK)

Hintergrund: Die koronare Herzkrankheit (KHK) ist eine häufige und potenziell tödliche Erkrankung mit einer Lebenszeitprävalenz von über 20%. Allein in Deutschland wird die Zahl der durch die ischämische Herzerkrankung und des akuten Myokardinfarkts jährlich verursachten Todesfälle auf etwa 140.000 geschätzt. Ein Zusammenhang eng mit dem Lebensstil verbundener Risikofaktoren mit Auftreten und Prognose der KHK ist nachgewiesen. Durch Maßnahmen der nichtmedikamentösen Sekundärprävention wird versucht, diese Risikofaktoren positiv zu verändern sowie die KHK im Gegensatz zu palliativen interventionellen Therapiestrategien kausal zu behandeln. Zur Wirksamkeit der nichtmedikamentösen sekundärpräventiven Maßnahmen liegt eine ganze Reihe von Einzelstudien und -untersuchungen vor, eine systematische Analyse, die die Evidenz aller hauptsächlich angewandten Sekundärpräventionsstrategien zusammenfasst, fehlt unseres Wissens nach bislang jedoch. Auch eine Auswertung vorhandener Studien zur Kosten-Effektivität der Maßnahmen ist hierbei zu integieren. Fragestellung: Ziel dieses HTA-Berichts (HTA=Health Technology Assessment) ist die Erstellung einer umfassenden Übersicht der aktuellen Literatur zu nichtmedikamentösen Sekundärpräventionsmaßnahmen in der Behandlung der KHK, um diese Maßnahmen und deren Komponenten bezüglich ihrer medizinischen Wirksamkeit sowie Wirtschaftlichkeit zu beurteilen. Weiterhin sollen die ethischen, sozialen und rechtlichen Aspekte der nichtmedikamentösen Sekundärprävention und die Übertragbarkeit der Ergebnisse auf den deutschen Versorgungsalltag untersucht werden. Methodik: Relevante Publikationen werden über eine strukturierte und hochsensitive Datenbankrecherche sowie mittels Handrecherche identifiziert. Die Literaturrecherche wird in vier Einzelsuchen zu medizinischen, gesundheitsökonomischen, ethischen und juristischen Themen am 18.09.2008 durchgeführt und erstreckt sich über die vergangenen fünf Jahre. Die methodische Qualität der Publikationen wird von jeweils zwei unabhängigen Gutachtern unter Beachtung von Kriterien der evidenzbasierten Medizin (EbM) systematisch geprüft. Ergebnisse: Von insgesamt 9.074 Treffern erfüllen 43 medizinische Publikationen die Selektionskriterien, mit einem Nachbeobachtungszeitraum zwischen zwölf und 120 Monaten. Insgesamt ist die Studienqualität zufriedenstellend, allerdings berichtet nur ca. die Hälfte der Studien differenziert die Gesamtmortalität, während die übrigen Studien andere Outcomemaße verwenden. Die Wirksamkeit einzelner Sekundärpräventionsmaßnahmen stellt sich als sehr heterogen dar. Insgesamt kann langfristig eine Reduktion der kardialen sowie der Gesamtmortalität und der Häufigkeit kardialer Ereignisse sowie eine Erhöhung der Lebensqualität beobachtet werden. Vor allem für trainingsbasierte und multimodale Interventionen ist eine effektive Reduktion der Mortalität zu beobachten, während psychosoziale Interventionen besonders in Bezug auf eine Erhöhung der Lebensqualität effektiv zu sein scheinen. Für die ökonomischen Auswertungen werden 26 Publikationen identifiziert, die von ihrer Themenstellung und Studienart dem hier betrachteten Kontext zugeordnet werden können. Insgesamt kann festgestellt werden, dass sich die Studienlage zur multimodalen Rehabilitation sowohl bezüglich ihrer Menge als auch Qualität der Analysen besser darstellt, als dies für Evaluationen von Einzelmaßnahmen beobachtet werden kann. Die internationale Literatur bestätigt den multimodalen Ansätzen dabei zwar ein gutes Verhältnis von Kosten und Effektivität, untersucht jedoch nahezu ausschließlich ambulante oder häuslichbasierte Maßnahmen. Die Auswertung der Studien, die einzelne sich mit präventiven Maßnahmen in Hinblick auf ihre Kosten-Effektivität beschäftigen, ergibt lediglich positive Tendenzen für Interventionen der Raucherentwöhnung und des körperlichen Trainings. Im Hinblick auf psychosoziale Maßnahmen sowie auch die Ernährungsumstellung können aufgrund der unzureichenden Studienlage jedoch keine Aussagen über die Kosten-Effektivität getroffen werden. Insgesamt werden im Rahmen der Betrachtung sozialer Aspekte der nichtmedikamentösen Sekundärprävention elf Publikationen einbezogen. Die relativ neuen Studien bestätigen, dass Patienten mit niedrigem sozioökonomischen Status insgesamt schlechtere Ausgangsbedingungen und demnach einen spezifischen Bedarf an rehabilitativer Unterstützung haben. Gleichzeitig sind sich die Forscher jedoch uneinig, ob gerade diese Patientengruppe relativ häufiger oder seltener an den Rehabilitationsmaßnahmen teilnimmt. Bezüglich der Barrieren, die Patienten von der Teilnahme an den präventiven Maßnahmen abhalten, werden psychologische Faktoren, physische Einschränkungen aber auch gesellschaftliche und systemisch-orientierte Einflüsse genannt. Diskussion: Nichtmedikamentöse Sekundärpräventionsmaßnahmen sind sicher und in der Lage eine Reduktion der Mortalität sowie der Häufigkeit kardialer Ereignisse zu erzielen sowie die Lebensqualität zu erhöhen. Da nur wenige der methodisch verlässlichen Studien Teilnehmer über einen längeren Zeitraum von mindestens 60 Monaten nachverfolgen, müssen Aussagen über die Nachhaltigkeit als limitiert angesehen werden. Verlässliche Angaben in Bezug auf relevante Patientensubgruppen lassen sich nur sehr eingeschränkt machen ebenso wie im Hinblick auf die vergleichende Beurteilung verschiedener Maßnahmen der Sekundärprävention, da diese von eingeschlossenen Studien nur unzureichend erforscht wurden. Zukünftige methodisch verlässliche Studien sind notwendig, um diese Fragestellungen zu untersuchen und zu beantworten. Bezogen auf die Kosten-Effektivität nichtmedikamentöser sekundärpräventiver Maßnahmen kann aus den internationalen Studien eine insgesamt positive Aussage zusammengefasst werden. Einschränkungen dieser resultieren jedoch zum einen aus den Besonderheiten des deutschen Systems der stationären Rehabilitationsangebote, zum anderen aus den qualitativ mangelhaften Evaluationen der Einzelmaßnahmen. Studien mit dem Ziel der Bewertung der Kosten-Effektivität stationärer Rehabilitationsangebote sind ebenso erforderlich wie auch qualitativ hochwertige Untersuchungen einzeln erbrachter Präventionsmaßnahmen. Aus sozialer Perspektive sollte insbesondere untersucht werden, welche Patientengruppe aus welchen Gründen von einer Teilnahme an Rehabilitations- bzw. präventiven Maßnahmen absieht und wie diesen Argumenten begegnet werden könnte. Schlussfolgerung: Nichtmedikamentöse sekundärpräventive Maßnahmen sind in der Lage eine Reduktion der Mortalität und der Häufigkeit kardialer Ereignisse zu erzielen sowie die Lebensqualität zu erhöhen. Eine Stärkung des Stellenwerts nichtmedikamentöser Maßnahmen der Sekundärprävention erscheint vor diesem Hintergrund notwendig. Auch kann für einige Interventionen ein angemessenes Verhältnis von Effektivität und Kosten angenommen werden. Es besteht allerdings nach wie vor erheblicher Forschungsbedarf bezüglich der Wirksamkeitsbeurteilung nichtmedikamentöser Maßnahmen der Sekundärprävention in wichtigen Patientensubgruppen und der Effizienz zahlreicher angebotener Programme. Darüber hinaus ist weitere Forschung notwendig, um die Nachhaltigkeit der Maßnahmen und Gründe für die Nichtinanspruchnahme detailliert zu untersuchen. Vor allem gilt es jedoch den Versorgungsalltag in Deutschland, wie er sich für Ärzte, Patienten und weitere Akteure des Gesundheitswesens darstellt, zu untersuchen und den heutigen Stellenwert nichtmedikamentöser Maßnahmen aufzuzeigen.

Expert study: A bolus calculator improves glycemic control and quality of life of type 1 diabetic patients (T1DM) (preliminary results)

Aims: To evaluate the impact on glycemic control and quality of life of a bolus calculator. Methods: Multicentre randomized prospective crosssectional study. Patients were randomized to control phase (3 months; calculation of prandial insulin according to insulinto-carbohydrate ratio and insulin sensitivity factor using a single strip meter) or intervention phase (3 months; calculation of prandial insulin with a bolus advisor), with a washout period (3 months). Patients wore a continuous glucosensor (7 days) and answered a quality of life questionnaire at the beginning and at the end of each phase. A questionnaire of satisfaction was obtained at the end of both phases. Inclusion criteria: Adults; T1DM> 1 year, HbA1c > 7.5%, basal-bolus therapy with insulin analogs, experience with carbohydrate Results: Data from the first 32 subjects with at least 1 ended phase (27 females, age 38 – 11 years, diabetes duration 16.8 – 7.5 years). Basal characteristics were comparable independently of the starting phase. No differences were found between phases in terms of mean blood glucose, standard deviation (from meter neither from sensor) and satisfaction. Conclusions: The use of a bolus calculator improves glycemic control and quality of life of T1DM subjects.

The appropriateness of renal angioplasty: the ANPARIA software: a multidisciplinary expert panel approach

Percutaneous transluminal renal angioplasty (PTRA) is an invasive technique that is costly and involves the risk of complications and renal failure. The ability of PTRA to reduce the administration of antihypertensive drugs has been demonstrated. A potentially greater benefit, which nevertheless remains to be proven, is the deferral of the need for chronic dialysis. The aim of the study (ANPARIA) was to assess the appropriateness of PTRA to impact on the evolution of renal function. A standardized expert panel method was used to assess the appropriateness of medical treatment alone or medical treatment with revascularization in various clinical situations. The choice of revascularization by either PTRA or surgery was examined for each clinical situation. Analysis was based on a detailed literature review and on systematically elicited expert opinion, which were obtained during a two-round modified Delphi process. The study provides detailed responses on the appropriateness of PTRA for 1848 distinct clinical scenarios. Depending on the major clinical presentation, appropriateness of revascularization varied from 32% to 75% for individual scenarios (overal 48%). Uncertainty as to revascularization was 41% overall. When revascularization was appropriate, PTRA was favored over surgery in 94% of the scenarios, except in certain cases of aortic atheroma where sugery was the preferred choice. Kidney size [7 cm, absence of coexisting disease, acute renal failure, a high degree of stenosis (C70%), and absence of multiple arteries were identified as predictive variables of favorable appropriateness ratings. Situations such as cardiac failure with pulmonary edema or acute thrombosis of the renal artery were defined as indications for PTRA. This study identified clinical situations in which PTRA or surgery are appropriate for renal artery disease. We built a decision tree which can be used via Internet: the ANPARIA software (http://www.chu-clermontferrand.fr/anparia/). In numerous clinical situations uncertainty remains as to whether PTRA prevents deterioration of renal function.

Early detection of lung cancer: a statement from an expert panel of the Swiss university hospitals on lung cancer screening.

The discussion about setting up a program for lung cancer screening was launched with the publication of the results of the National Lung Screening Trial, which suggested reduced mortality in high-risk subjects undergoing CT screening. However, important questions about the benefit-harm balance and the details of a screening program and its cost-effectiveness remain unanswered. A panel of specialists in chest radiology, respiratory medicine, epidemiology, and thoracic surgery representing all Swiss university hospitals prepared this joint statement following several meetings. The panel argues that premature and uncontrolled introduction of a lung cancer screening program may cause substantial harm that may remain undetected without rigorous quality control. This position paper focuses on the requirements of running such a program with the objective of harmonizing efforts across the involved specialties and institutions and defining quality standards. The underlying statement includes information on current evidence for a reduction in mortality with lung cancer screening and the potential epidemiologic implications of such a program in Switzerland. Furthermore, requirements for lung cancer screening centers are defined, and recommendations for both the CT technique and the algorithm for lung nodule assessment are provided. In addition, related issues such as patient management, registry, and funding are addressed. Based on the current state of the knowledge, the panel concludes that lung cancer screening in Switzerland should be undertaken exclusively within a national observational study in order to provide answers to several critical questions before considering broad population-based screening for lung cancer.