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PubMed2002

What will it take to lead the continual improvement and innovation of health care in the twenty-first century?

We have witnessed the separation of the care for an individual patient and the concern for the health of a population. As we anticipate the twenty-first century, we see the wisdom of reconnecting these concerns. The knowledge and skills that we will address can help bridge the gap. First, we offer background to seminal work during the twentieth century that set the foundation for the improvement of health care. Next, we describe two major challenges for the continual improvement of health care that lie ahead. Third, we suggest an approach that leaders might use to address major challenges. Fourth, we offer a set of knowledge domains that outline the knowledge and skills that leaders of the improvement of health care will need. Finally, we provide two special issues that require additional mention and should not be overlooked. We believe that the combination of these ideas can provide a framework for knowledge building, action taking, and reflection needed by health care leaders in the coming century.

Delivery of Health Care↗
PubMed2004

Is rural medicine a separate discipline?

BACKGROUND: The Australian College of Rural and Remote Medicine was established in 1997 to meet what rural doctors perceived as their unmet educational and professional needs. However, the issue of just how different rural practice is from urban practice remains a topic of debate. METHODS: This paper explores the scope of rural medical practice, through the use of clinical scenarios and a synthesis of the research literature, to determine if rural medical practice is emerging as a distinct discipline in Australia. CONCLUSION: Rural and remote medical practice is different, and additional, to urban practice, in the context, content and process of care. Three of the four criteria for determining rural medical practice as a distinct discipline exist in Australia. The fourth criteria: sufficient external recognition of rural medicine as a distinct discipline, awaits resolution. WHAT THIS PAPER ADDS: This paper examines a key issue that has been a source of conflict between the relevant stakeholders for a decade. By placing the differences between rural and urban medical practice within a framework, supported by published work, this paper describes what is required to justify rural medical practice as a distinct discipline for the first time.

Australia↗
PubMed1996

The concept of family resilience: crisis and challenge.

The concept of resilience, the ability to withstand and rebound from crisis and adversity, has valuable potential for research, intervention, and prevention approaches aiming to strengthen couples and families. Resilience has been viewed as residing within the individual, with the family often dismissed as dysfunctional This article advances a systemic view of resilience in ecological and developmental contexts and presents the concept of family resilience, attending to interactional processes over time that strengthen both individual and family hardiness. Extending our understanding of normal family functioning, the concept of family resilience offers a useful framework to identify and fortify key processes that enable families to surmount crises and persistent stresses. There are many pathways in relational resilience, varying to fit diverse family forms, psychosocial challenges, resources, and constraints. Shared beliefs and narratives that foster a sense of coherence, collaboration, competence, and confidence are vital in coping and mastery. Interventions to strengthen family resilience have timely relevance for weathering the rapid social changes and uncertainties facing families today.

Adaptation, Psychological↗
PubMed2005

Genomics in nursing education.

PURPOSE: To review international efforts to incorporate genetics content into nursing education curricula. ORGANIZING FRAMEWORK: A discussion of the progress in nursing education programs in selected countries to educate students for genomics-based health care. Information is based on review of the literature and curriculum change efforts by the authors. CONCLUSIONS: The lack of agreed-upon minimum competencies impedes efforts to educate nurses for genomics-based health care. Nationally and internationally recognized documents are useful for collaborative efforts to establish minimal competencies in knowledge, skills, and attitudes for nurses with basic and advanced education. Curriculum change that incorporates minimum competencies will require nursing faculty to improve their knowledge base in genomics-based health care. Partnerships among nurses in different countries are needed for successful genomics education programs for faculty.

Attitude of Health Personnel↗
PubMed2002

Emerging factors shaping the future of the Veterans' Health Administration: a strategic analysis.

In response to societal and industry-wide forces, the Veterans' Health Administration (VHA) has undertaken a re-engineering process, changing the operational and management structure from individual, independent, and often competing large hospital centres into 22 integrated service networks or VISNs to provide structural incentives for efficiency, quality and improved access as well as transitioning the system to one that is grounded in ambulatory and primary care (Ashton et al., 1998). This paper presents a framework for evaluating the successes and/or failures of the recent re-organization efforts of the VHA in bringing together this multitude of medical care 'parts' or modules into an integrated, cost-effective healthcare delivery system. In total, this paper attempts to delineate an analytical framework by which the threats and opportunities as well as the strengths and weaknesses of the VHA are identified. More specifically, this paper addresses the external pressures driving reform in the VHA system and how the Veterans' Administration can respond to these pressures. Implications for the future of the VHA if its reform efforts are not successful are examined.

Delivery of Health Care, Integrated↗
PubMed2002

The psychopathology of K. Jaspers and K. Schneider as a fundamental method for psychiatry.

The paper is intended to answer the question whether and to what extent the psychopathology in the direction of Karl Jaspers and Kurt Schneider is still meaningful for contemporary psychiatry. K. Schneider developed gradually his "Clinical Psychopathology", proceeding from Jaspers' 4th edition of the "General Psychopathology" (1946). The Jaspersian-Schneiderian approach, aiming more at the elucidation of the patient's own inner experiences than at the observation of behaviour, has overcome the overly objectifying psychiatry of Kraepelin. The history and bearing of Jaspersian-Schneiderian psychopathology on psychiatry, its tenets, positions and concepts, as well as findings and results obtained with the approach are outlined. Recent developments in psychiatry, underestimating or even neglecting the psychopathological approach, are in danger of resulting in a loss of psychopathological competence in research and practice. The essay shows that this psychopathology is far from over, but remains relevant for clinical and biological psychiatry and should lead now, as ever, all other special and basic sciences in psychiatry. The critical methodological reflection and the fundamental psychopathological framework, created by Jaspers and modified and adapted to the requirements of clinical psychiatry by K. Schneider, are also today practically useful and heuristically fruitful. That we need psychopathology for diagnostics, therapy and primary and secondary prevention of schizophrenic psychoses, and also for biological psychiatric research, has been demonstrated by means of a long string of contributions of the last decades. The Jaspersian-Schneiderian approach does not mean definite conclusion and codification, but leaves enough room for new developments, completing, correcting and changing many aspects of classical and present psychiatric views. In ensues that the view of European psychiatrists that we need psychopathology, according to the axiom: "First things first" (Gross and Huber 1993a, 2000a), and the call of Andreasen (Andreasen 1998) for a serious investment in training a new generation of psychiatrists in psychopathology, seem to be well founded and entirely justified.

Humans↗
PubMed1991

Staff development through analysis of practice.

Dreyfus and Dreyfus's (1986) five-stage model of skill acquisition is integrated with findings from the American Occupational Therapy Association/American Occupational Therapy Foundation Clinical Reasoning Study. This model is presented as an organizing framework for staff development. Strategies for the recognition and retention of experienced clinicians who can serve as mentors for newer colleagues are identified.

Clinical Competence↗
PubMed2005

[A comparison of special and traditional inpatient care of people with dementia].

Recent studies reveal that approximately two thirds of the residents in German nursing homes suffer from some type of moderate to severe dementia. In addition to cognitive impairments, other psychiatric symptoms and behavior problems frequently impact the quality of life of the affected residents, their fellow residents and the nursing staff. Novel concepts of nursing care for dementia patients with behavior problems have been developed against this backdrop, e. g. within the framework of the program of special care for dementia patients in Hamburg. A comprehensive course study (follow-up period: approximately six months) of a sample population of nursing home residents and consecutive admissions focused upon:the degree to which the quality of life and care for dementia patients in Hamburg differs according to the type of care given, i. e. segregative (domus philosophy), or partially segregative (integration philosophy), and the differences between the special care of dementia patients as provided in Hamburg, as opposed to the traditionally integrative care of dementia patients as practiced in the city of Mannheim. In order to gain the most complete picture possible-also for persons with severe cognitive impairments-information was collected primarily on the basis of the assessments made by qualified nursing staff. In the city of Hamburg there were advantages and disadvantages, respectively, between segregative care (domus philosophy) and partially segregative care (integration philosophy): the activity rates were higher for care in integrative than in domus environments, and could be maintained better over time. Moreover, the number of visits from relatives and their involvement in the nursing and social care was also higher for the integrative, as opposed to the domus setting. Among the residents of domus-care homes, however, significantly more biographical information was collected, and the proportion of dementia patients receiving gerontopsychiatric care also was higher. Dementia patients in these homes also received more psychotropic medication, with antidementia drugs and antidepressants being prescribed significantly more frequently and antipsychotic drugs less frequently.The comparison of the special dementia care available in Hamburg with the traditional, integrative care available to dementia patients in Mannheim revealed a number of visible indicators for the quality of life that point in favor of the model program in Hamburg. This is apparent in the more frequent expression of positive feelings, the greater number of activities fostering competency, the significant involvement of relatives and volunteers, the greater number of social contacts with the staff, fewer use of physical restraint, and better gerontopsychiatric care. Contradictory to our expectation, however, dementia patients cared for in the traditional setting exhibited fewer behavior problems over time than did their counterparts cared for within the framework of the Hamburg model.

Aged↗
PubMed1996

Relationships among children's beliefs, perceptions of their parents' beliefs, and their moderate-to-vigorous physical activity.

The purposes of this study were to (a) examine the relationship between children's beliefs (value, competence, and goal orientations) pertaining to fitness-oriented activities and their participation in moderate-to-vigorous physical activity (MVPA), (b) determine whether children's own beliefs are related to their perceptions of their parents' beliefs about them (value, competence, goal orientations, expectancies), and (c) examine the relationship between children's perceptions of their parents' beliefs and their MVPA. Self-report questionnaires and structured interviews were administered to children (N = 81, ages 11-15) in a one-on-one situation in their homes to tap their own beliefs, their perceptions of their parents' beliefs, and to assess children's level of MVPA through the use of two-day recall and peer comparison measures. Multivariate multiple-regression analyses revealed that children's beliefs about their MVPA could predict a significant amount of the variance in their self-reported MVPA and that children's perceptions of their parents' beliefs were unrelated to their MVPA. Follow-up canonical correlation analyses showed that the most significant and positive predictors of MVPA were children's perceptions of competence and the degree to which they endorse a task and ego orientation. S second multivariate multiple-regression analysis revealed that children's perceptions of their parents' beliefs about them and their own beliefs about MVPA were significantly related. These findings are discussed within the framework of a Family Influence Model for understanding children's MVPA participation.

Adolescent↗
PubMed2001

Through the years: a longitudinal study of physical education teachers from a research-based preparation program.

This study investigated factors that enhanced and constrained the career development of six teachers, who had graduated from the same university teacher education program, in their induction years (Woods & Earls, 1995) and again later in their career cycles. Three participants were physical education teachers (PETs), and three were former physical education teachers (FPETs). Fessler's (1985) Teacher Career Stage Model provided the theoretical framework. Data sources were: interviews with teachers and their teacher educators and direct observations of lessons. Results indicated that the PETs continued to have skill development as their primary teaching objective. The teachers maintained many of their teaching skills, and shifted between the career cycles of "competency building" and "enthusiastic and growing." All three FPETs left their physical education positions during the career frustration stage and at the time of publication were in the career exit stage.

Adult↗
PubMed2003

Risk modeling, assessment, and management of lahar flow threat.

The 1991 eruption of Mount Pinatubo in the Philippines is considered one of the most violent and destructive volcanic activities in the 20th century. Lahar is the Indonesian term for volcanic ash, and lahar flows resulting from the massive amount of volcanic materials deposited on the mountain's slope posed continued post-eruption threats to the surrounding areas, destroying lives, homes, agricultural products, and infrastructures. Risks of lahar flows were identified immediately after the eruption, with scientific data provided by the Philippine Institute of Volcanology, the U.S. Geological Survey, and other research institutions. However, competing political, economic, and social agendas subordinated the importance of scientific information to policy making. Using systemic risk analysis and management, this article addresses the issues of multiple objectives and the effective integration of scientific techniques into the decision-making process. It provides a modeling framework for identifying, prioritizing, and evaluating policies for managing risk. The major considerations are: (1) applying a holistic approach to risk analysis through hierarchical holographic modeling, (2) applying statistical methods to gain insight into the problem of uncertainty in risk assessment, (3) using multiobjective trade-off analysis to address the issue of multiple decisionmakers and stakeholders in the decision-making process, (4) using the conditional expected value of extreme events to complement and supplement the expected value in quantifying risk, and (5) assessing the impacts of multistage decisions. Numerical examples based on ex post data are formulated to illustrate applications to various problems. The resulting framework from this study can serve as a general baseline model for assessing and managing risks of natural disasters, which the Philippines' lead agency-the National Disaster Coordinating Council (NDCC)-and other related organizations can use for their decision-making processes.

Journal Article↗
PubMed2006

The ComFor: an instrument for the indication of augmentative communication in people with autism and intellectual disability.

BACKGROUND: The ComFor (Forerunners in Communication) is an instrument to explore underlying competence for augmentative communication. More specifically, it measures perception and sense-making of non-transient forms of communication at the levels of presentation and representation. The target group consists primarily of individuals with autism and intellectual disability (ID) without or with only limited verbal communication. The ComFor is suitable for children and adults with a developmental level between 12 and 60 months. This paper describes the theoretical framework and structure of the ComFor, the results of a study on its psychometric properties and its clinical uses. METHOD: The ComFor was tested on a sample of 623 children and adults from the Netherlands and Flanders: a group with autism and ID (n = 310); a group with ID without autism (n = 174); and a control group of typically developing children (n = 139). RESULTS: The data generally support the reliability and validity of the ComFor. Internal consistency, inter-rater and test-retest reliability were found to be good. Construct validity (internal structure, convergent and divergent patterns) was established in different ways. The criterion-related validity has yet to be established, as predictive data are not available at the moment. CONCLUSION: Taken together, the results indicate that the ComFor is a promising instrument to explore underlying competence for augmentative communication. Areas for future research are outlined and the clinical relevance is discussed.

Adolescent↗
PubMed1998

Pharmacologic treatment of geriatric depression: key issues in interpreting the evidence.

OBJECTIVE: A framework for critical appraisal of antidepressant trial literature involving geriatric subjects is presented. Among older adults, treatment decisions are complicated by comorbid medical and cognitive illness, the variable course of recovery, and the overlap of depressive symptoms with other disease symptoms. Consumers of the literature on competing antidepressant therapies for older adults must consider disease and population-specific outcome assessment issues. DESIGN: An appraisal guide, adapted for geriatric depression, is developed from literature on methodological challenges of outcome assessment and published clinical trials comparing competing antidepressant therapies in older subjects. CONCLUSIONS: The clinical utility of pharmacologic treatment of depression can be difficult to assess because depression scales in current use provide an important but limited perspective on treatment outcome and because the scales vary in actual content and ability to detect change. The use of indicators of function, independence, and self-perceived well-being as outcomes offers additional patient relevance and should be included. Key considerations involve (1) general characteristics: whether the depression outcome measure is valid and reproducible for the aged population under study, whether the outcome measure is sensitive to treatment-related change, and whether the time-frame of outcome assessment is appropriate for the treatment goal; (2) cognitive impairment: how subjects with dementia are assessed, and whether the impact of the intervention on caregivers and healthcare systems is considered as a relevant outcome; (3) pharmacologic issues: whether the comparator agent is a reasonable usual-care standard in the older adult and whether ascertainment for adverse effects is similar for all agents under study; and (4) broader general health status issues: whether functional or quality of life measures are used as outcome indicators.

Aged↗
PubMed1999

Treatment of musculoskeletal pain with traditional Chinese herbal medicine.

Traditional Chinese herbal medicine (TCHM) uses naturally occurring plant, animal, and mineral substances to treat or assist in the treatment of the full spectrum of human disease. With the rise in popularity of alternative or complementary medicine, all physicians will encounter patients using TCHMs. TCHM should be taken under the supervision of a provider whose herbal training and competence is commensurate with the intensity of the herbal regimen and the severity of the clinical condition. TCHM can be valuable in the treatment of all kinds of pain: either as primary or adjunctive therapy depending on the clinical situation. TCHM therapies are prescribed in the framework of a unique diagnostic approach, and are highly specific with regard to type of pain and location of pain.

Drugs, Chinese Herbal↗
PubMed2026

iMTSS: an integrated framework for biology- and patient-driven prognosis in myelofibrosis undergoing transplantation.

BACKGROUND: Allogeneic hematopoietic cell transplantation is the only curative treatment for myelofibrosis, but failure occurs by two mechanistically distinct routes: relapse of the neoplasm, which reflects its underlying genetics, and non-relapse mortality, which reflects whether the patient and graft tolerate the procedure. Established prognostic systems either lack molecular granularity or were derived in the non-transplant setting, and all collapse these two routes into a single survival estimate. None can indicate why an individual patient is at risk, or which class of intervention might reduce that risk. OBJECTIVE: To determine why an individual patient is at risk and to develop and validate an integrated framework that quantifies biology- and patient-driven prognosis. STUDY DESIGN: We analyzed 1,550 adults undergoing first allogeneic transplantation for primary or secondary myelofibrosis across international centers, the largest genomically annotated transplant cohort in this disease. The cohort was split into development (n=930) and validation (n=620) sets. Overall survival was modeled by Cox regression; relapse and non-relapse mortality were modeled as competing events by Fine-Gray subdistribution-hazard regression at 2 years. Discrimination was assessed by the concordance index with bootstrap confidence intervals. The molecular contribution was quantified by variance decomposition of, and robustness to the analytic choices was examined by resampling. RESULTS: A genetically defined disease-intrinsic axis, including TP53 allelic state, RAS pathway mutations, ASXL1 and driver genotype, blasts and blood counts, predicted 2 year relapse incidence (validation concordance 0.69, 95% CI 0.63 to 0.74), whereas a non-overlapping host and structural axis, including portal vein thrombosis, donor type, patients' performance status, and age predicted 2-year non-relapse mortality (0.63, 95% CI 0.59 to 0.68). The two scores shared only 3.4% of their variance, indicating that a patient's disease genetics carried almost no information about non-relapse mortality. Variance decomposition showed that TP53 allelic state alone accounted for 30% of the relapse score. Recombined, the framework discriminated overall survival (concordance 0.640, 95% CI 0.616 to 0.662) better than every established prognostic system. For proof of concept, 3 risk groups separated in the validation cohort, with 5 year survival of 72%, 58%, and 39% (P<0.001), and the models were well calibrated. CONCLUSIONS: Relapse and non-relapse mortality after transplantation for myelofibrosis are governed by distinct dimensions. Estimating both outcomes independently with genetic and clinical information, in addition to overall survival, establishes an individualized basis for transplant decision-making. The calculator is openly available (https://imtss-calculator.com).

mortality↗
PubMed2002

[Analysis of preliminary conditions for the implementation of health training programs within the framework of humanitarian aid].

NGOs must be able to ensure the appropriate design and quality of their training programmes for health workers implemented in developing countries. It is a question of empowering those countries to become more autonomous, and the purpose of this study is to identify factors that can improve the sustainable management of the population's health through the long-term training of competent health workers. A literature review validated by experts distinguished three main characteristics necessary for the success of such programmes; relevance, feasibility and functionality from an educational perspective. Moreover, in addition to the three aforementioned criteria, a fourth transversal attribute was noted: sustainability. The objective of the programme designer is to assess the presence of these conditions in order to decide whether or not the training programme should be implemented.

Delivery of Health Care↗
PubMed2003

Prediction of resource use during acute pediatric illnesses.

BACKGROUND: Significant resources are used for acute illnesses in children. Identifying predictors of resource use can focus interventions to reduce this use. OBJECTIVE: To determine the relative effects of maternal, infant, social milieu, and demographic characteristics, the mother-child interaction, and perception of illness severity on the use of resources during acute illnesses in children. DESIGN: At the 2-week and 6-, 15-, and 24-month well-child care visits of a cohort of mother-infant dyads, the mother-well-child interaction was assessed by using the Biringen Emotional Availability Scales, and data were gathered regarding maternal depression and sense of competence, infant temperament, maternal social support, the home environment, and demographic characteristics. At each of the cohort's 1983 ill-child care visits during 30 months of follow-up, the mother-ill-child interaction was assessed by using the Emotional Availability Scales, and mothers and pediatricians independently assessed illness severity using the Acute Illness Observation Scales. Resources used during the illnesses-over-the-counter and prescription medications, tests, hospitalizations, follow-up visits, and the emergency department-were assessed. SETTING: A hospital primary care center and an urban and a suburban private practice. Patients Between February 1, 1995, and March 30, 1998, a consecutive sample of 380 dyads were asked to enroll at the 2-week well-child care visit; 316 (83.2%) consented, and complete data were available for analysis of 243 dyads. MAIN OUTCOME MEASURES: A path analytic framework using a structural equation model assessed the presence and strength of predictive relationships between demographic, maternal, infant, and social milieu data, the Biringen Emotional Availability Scales, and the Acute Illness Observation Scales and the main outcome measure, resource use. RESULTS: Three variables predicted greater mean resource use during each acute illness episode: a less optimal mother-child interaction (beta = -.53), lower scores for parenting sense of competence (beta = -.26), and greater perception of illness severity by mothers (beta =.33). By using the coefficient of determination (R2), these 3 predictors account for 55% of the reliable variance in resource use during acute illnesses. CONCLUSION: The quality of the mother-child interaction, maternal sense of competence, and maternal assessment of severity of the illness are major predictors of resource use during acute pediatric illnesses, and should be important foci of interventions to reduce resource use.

Acute Disease↗