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Health Care Delivery - Science topic

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Processes required to manage an effective health care organization.
Focusing on U.S. health care delivery systems, how to manage in health care organizations including management processes organizational structures and types of governance and management issues of U.S.-based health care delivery systems.
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Indeed, a lack of awareness about management science (MS) and operations management (OM) principles is one of the root causes of inferior healthcare leaders' management decisions for delivery of care, such as new/old lines of service, staffing and scheduling, financial and equipment allocation, bed capacity, etc.
Traditional OM is based on past experience, intuition, educated guesses, simple linear projections with the average values of input variables. In contrast, management science is based on comparative outcomes of validated simulation models of organizations' functioning and their operations. Traditional management does not have a proper means to take into account the inevitable process variability, uncertainty, scale, and interconnections that are critical for making sustainable and justified managerial decisions. The fundamentals of management science for healthcare organizations have been developed. They play a role of the laws of physics in natural sciences. While the laws of physics cannot be violated, management science principles can and are frequently violated. Unfortunately, many organizations pay a heavy price for doing so. Thus, the problem is not a lack of knowledge of the MS fundamentals and methods. The problem is a dearth of the practical application of this knowledge in the real hospital and clinic settings.
You may find useful, e.g. the following resources for details:
1. Kolker, A. Springer_Briefs series in Healthcare Management & Economics "Healthcare Management Engineering: What Does This Fancy Term Really Mean? The Use of Operations Management in Healthcare Settings". NY, 2012
2. Hopp, W., & Lovejoy, W. (2013). Hospital operations: Principles of high efficiency health care. New York: FT Press.
3. Reid, P., Compton, W, Grossman, J., Fanjiang, G., Eds., (2005). Building A Better Delivery System: A new Engineering / Healthcare Partnership. National Academy of Engineering and Institute of Medicine. Washington, DC. The National Academy Press
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I am seeing so many different titles for nurses in primary care practices who are doing care coordination - which is also defined in a number of different ways. I would love to get some feedback around what people think may be the differences.
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In my PhD, I identified 9 different professions delivering case management. The specific training of each brought an eclectic range of expertise and challenges to the role. However, in nursing poor role definitions and inconsistent use of titles have complicated understanding for the practitioner and the patient. In addition, there may be intra and inter-professional differences in explaining how case management should be delivered and by whom.
The academic and grey literature terms interchangeably including care management, case management, activity, approach and interventions - sometimes, this variation arises within the same article, adding more confusion. Sue Lukersmith’s work has been very helpful but the terminology used still differs within and across various professions adding further misunderstanding between different professional disciplines. EG social workers refer to "care " rather than case management.
Therefore, a sensible approach in defining a case management service should first clarify its purpose and the needs of the people it aims to serve. This will point toward the knowledge and skills needed for the conduct of the role. Have a look at my thesis on : https://eprints.soton.ac.uk/421176/1/Saltrese_A_Final_Thesis_2018_April.pdf
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Dear colleagues,
The VAS is a commonly used tool in health outcome studies, when using it to assess importance of certain action or intervention, how we can interpret the results, for example on 1 to 10 line (where 1; the least and the 10; the highest), the average of importance was 4 out of 10, what does that mean? and if we want to identify the level of importance (very important, important, somewhat important, not important), where are the cut off point for each level? to say for example, one third of student view this intervention is very important.
Can we interpret the result as 1-5 is not important and 6 to 10 is important.
Thank you.   
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nice ihformation
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Cost is always a concern in the present health care delivery, even in developed countries. The prevalence of such disease is quite low (in most of the area of the world). In such scenario, doing these tests in all patients costs billion. Is this cost-effective? if it should be done mandatorily, why? Or, should these tests be done based on history and examination?
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No, all patients should be considered as infectious. as there is a window period during which the patient is more infectious inspite of testing negative.
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we are looking like minded people/organisation working on the issue to strengthen decentralize primary health care delivery in rural India
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Definitely,VHND important to involve community for promotion of health and prevention of diseases.Rather can say health care services at door steps.
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Nursing documentation methods for patients receiving bladder instillations of BCG. Which methods are used in the urology outpatients department
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There are two categories of documentation methods in nursing such as documentation by inclusion and documentation by exception. In the former, nurse practitioners make note of all assessment findings, nursing interventions and client outcomes on an ongoing, regular basis. In the latter, they make note of negative findings and this documentation is completed when review findings, nursing interventions or client outcomes show a variation from the established assessment norms / standards of care prevailing in a particular practice setting. The common documentation methods in these categories are focus charting, SOAP charting and narrative charting. Nurse practitioners can select any of these methods, but ensure that the selected method reflects client care needs and the context of practice. Focus Charting This documentation method focuses on particular client concerns/behaviors, a change in the client’s condition/behavior, or a significant event in the client’s treatment determined during the assessment. In the documentation, three columns are utilized for focus charting or F-DAR chartin.
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Increasing unexpected healthcare utilisation in developed countries has led to several questions from the stakeholders, especially the health policy makers. Critics say unexpected healthcare utilisation cannot be prevented, while others say unscheduled utilisation can be avoided if adequate measures are put in place.
I believe, if the root cause of unexpected healthcare utilisation is known, there may be significant reduction to the high influx of patients to the health centres.
Question: In your opinion, what are the factors responsible for sudden utilisation of our health centres?
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Dear Aramide
You raised a question on a complex and complicate aspect of health care, that is utilization. Utilization(actual use of health care services) expressed as rates or proportions or frequency  is a measure of the degree of accommodation between health care systems and population characteristics. Why do people use health care services?. The answer is not straight forward. But we assume that they use the services because they need them and these services are available. The major determinants of services utilization in brief are: Health need, cost and income, distance between residence and location of source of care, degree of awareness, satisfaction and expectation, organizational aspects like referral and waiting lists, sociodemographic characteristics and others. Therefore to understand the pattern of utilization and forces behind the pattern and variation over time and across populations requires careful analysis of available data and perhaps household surveys.
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Chiropractic pediatric treatment
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I looked in the normal places and only found the following linkk
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I have been unsuccessfully trying to find the $ costs of bladder cancer per person in Australia. Or just the yearly costs. This information is available for the US but I cannot find Australian information. Is this due to the differences in coding for various procedures?
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Hello Susan,
I have not found any information either on sites relating to Australia.
However, this paper is authored by a ResearchGate members who perhaps could be of assistance:
Arianayagam, R., Arianayagam, M., & Rashid, P. (2011). Bladder cancer: Current management. Australian family physician, 40(4), 209.
I also found find this link - Australia Urology Associates - that could maybe be of help:
This is the website for an Australian urological surgeon who treats bladder cancer; whether his team could point you in the right direction to find the answer to your question:
I hope you find the information that you need.
Very best wishes for your PhD,
Mary
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Hello everyone,
I need help with the scheduling in Anylogic.
I will describe the process
1.       A patient comes in a clinic [newly created agent]
2.       After his visit, he/she is given a future date for a following appointment (appointment 1)
3.       He/she goes home [I created a zone – rectangular node – for this]
4.       Day of the Appointment 1 arrives, he/she needs to go to the clinic [from home]
5.       Point 2, 3, 4 repeat
My difficulty is that for the date and time for appointment 1 needs to be done dynamically (not predetermined). This means that the decision of the future appointment needs to happen at the end of the clinic visit, and it may be different for different patients.
How can I create such a schedule, attach it to each individual patient, and make sure that the patients come back at the clinic on the date of their appointment?
Much appreciated any help received.
Regards,
Alex
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Hello Zakaria,
This was a bit tricky. After the patients get out of the clinic (and go home - i.e. they are not destroyed or exit the system), they go though a bloc that gives them the next appointment. i had to create java classes for this. Anylogic does not directly support this type of schedules. when created, the patients are looking for an available appointment with a doctor [the docs have each their own schedule/timetable]; once the patients gets one, then that patient is always attached to that specific doctor. So, next time that the patient needs an appointment, it will only look at the timetable of his own doc. When it finds an empty slot, it occupies it, calculates how far in time it is, and that is the value of the delay bloc HOME. 
So, it is a fist come first served idea, but, it also checks for availability of the doc. I have some probabilities that also ensure that patients do not need to see the doc every time they come in.
Do not get me wrong, it is not an easy thing to do. And i do not know why no simulation platform incorporated [more complex and complete] schedules.
Hope that helps ;)
Alex 
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I am looking into the required skills and competences of applied theatre practitioners in healthcare environments.
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This could create a psychological help
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Dear Sir/ Madam,
I’m a business analyst working on an assignment to identify problems and prospect of Bangladesh Healthcare and Pharma industry.
For this I need information like, how many people/ patients are going abroad each year for medical treatment and what are the top destinations.
Could you please suggest, where I can get this information or whom to contact. Rough estimate may be okay.
Many thanks in advance for your cooperation.
Shaiful
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Thanks Mr. Bose
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I would like to conduct a study assessing clients' willingness to pay for quality maternal health care delivery. Can someone indicate me any literature about contiguous valuation method to assess willingness to pay? Please let me know if there is any validated questionnaire to carry out willingness to pay study using contiguous valuation method.
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Please refer to the following information, more specifically, the examples of asking/assessing customers’ ‘willingness to pay’, for example: Andersson and Mossberg (2004, p. 173); Smith and Albaum (2013, p. 119 and 162).  
  • Andersson, T. D. and Mossberg, L. (2004) The dining experience: do restaurants satisfy customer needs?, Food Service Technology, 4, 4, pp. 171-178.
  • Homburg, C., Koschate, N. and Hoyer, W. D. (2005) Do Satisfied Customers Really Pay More? A Study of the Relationship Between Customer Satisfaction and Willingness to Pay, Journal of Marketing, 69, 2, pp. 84-96.
  • Morgan, R. M. and Hunt, S. D. (1994) The commitment-trust theory of relationship marketing, Journal of Marketing, 58, 3, pp. 20-38.
  • Smith, S. M. and Albaum, G. S., (2013) Measuring Customer Satisfaction, in Smith, S. M. and Albaum, G. S. (Eds.), Basic Marketing Research: Building Your Survey, Qualtrics Labs, Inc., Utah, USA,  pp. 109-121.
Regards, Kenneth
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Evidently, Accountability for reasonableness (A4R) is a widely accepted ethical framework that has been used internationally in previous studies for evaluating legitimacy and fairness in priority setting in hospitals. According to ‘accountability for reasonableness’, a fair priority setting process meets four conditions: relevance, publicity, appeals, and enforcement. Like A4R, is there a widely accepted conceptual framework that has been used in priori studies to evaluate effectiveness in budget management (the whole budgetary process from budget preparation to implementation, and monitoring and evaluation) in case of hospitals? Thank you. 
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Dear Gedion,
I found interesting the publication from the World Bank that I am attaching. It does not fit with the detailed vision that you are asking, but maybe it could give some highlights about a global budget perspective for hospitals.
The author provides a guide for reforming global budgets in the hospital sector. Many countries with publicly funded systems adopted global budgets as a key funding mechanism, which could  combine  administrative simplicity with performance incentives. For countries with poor HIS, global budgets are less complex to implement and required less sophisticated data and reports. However, because that global budgets do not provide strong performance incentives as do some other output based payments systems. Policymakers who are aware of these constraints can use global budgets effectively in combination with other monitoring and evaluation instruments to access a more accurate effectiveness analysis of the budget management processes .
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Are anyone aware of studies assessing patient satisfaction and quality of treatment in people with diabetes, comparing a standard structured out patient structure with pre-planned visits to an on-demand structure, where the patient demands all services?
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Hello Claus
   I am not aware of any such studies but I work at a retail pharmacy in a medical building and we have a diabetes center in the building staffed by nurses and dietitians that are certified diabetes educators. Both pharmacists on staff are certified in diabetes management.. Patients can only be seen at the diabetes center with an appointment but we can see them at the pharmacy whenever is convenient for them by appointment or as walk-ins. We have not done any studies comparing participant satisfaction levels between on demand services and standard appointment based services.
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We are developing a MOOC around this challenge to service delivery and want to hear from anyone who has evidence, service models, service user stories etc that could contribute to the MOOC material. we want to be as globally inclusive as possible so would welcome your input, especially if you want to contribute videos, presentations, podcasts and your research. please get in touch with us. 
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 Harshvardhan and Rebecca
thank you very much for these. they will be very useful
Lucy
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Indian Council of Medical Research's study at West Bengal revealed that quacks are an integral part of rural health care delivery services because of various reasons such as available even at midnight, practices within the community itself thus saving time/money, approachable etc. Govt. health care delivery services has lot of barriers such as distance, long waiting time, unfriendly behavior of many doctors posted there etc. This has serious health implications. Existing health care delivery service in rural & backward community needs to address these issues.
My question is what could be an alternative model of health care delivery services? Should we train the quacks & monitor there services to have a better impact? Pls find attached the research article.
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Thanks a lot for ur response,  Ms Claudia
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Hello all
i am currently doing a research paper for an english class on the AHCA in terms of mental health care and its delivery. I am currently having trouble finding articles that do not have a political bias on the AHCA. is there any websites or sources that you have found that could be considered as a reliable source for such a politically sensitive topic?
thank you,
Brianna Burke
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Thank you for sharing our article, Robert. Brianna, we also have another one published which was based on focus groups by age group. I attached it to this response.
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Many site teams demonstrate on displayed charts consistence of good performance for a period of over six months and would want to drop the QI project so that they commence on a new area needing improvement. Experience has showed that because of high staff attrition and turn over, sustainability of good practices is not realized since you've got to retrain and re-couch new providers.
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Diana and William, thank you for sharing your submissions and experiences. Site QI teams adopt changes for testing from consolidated change package harvested from previous QI efforts , on few patients, for a period of three months. If the change works for a team after that action period, they adapt it and scale up the QI efforts for the particular process to cover all patients in care. The site-providers are encouraged to track thier performance using documentation journals and displayed charts [simple run charts that incorporates a median to determine if the change was significant] as part of thier self evidence based evaluation. This might take a year or so depending on the team's commitment. There should be a six points consistence in the performance above the median line to declare an effective change. This does not mean that the team drops focusing on the process. It becomes a routine to monitor the improved process and ensures maintenance of the continued good/best practices. Graduation, therefore here means the team change thier focus to another process that needs improvement and initiates QI projects.
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abdominal obesity is risk factor for certain diseases
what is causes and how can be avoided and reduced? 
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Dear Amar,
Here are 6 evidence-based ways to lose belly fat.
1. Don’t Eat Sugar… and Avoid Sugar-Sweetened Beverages Like The Plague
Added sugar is extremely unhealthy.
Studies show that it has uniquely harmful effects on metabolic health.
Sugar is half glucose, half fructose… and fructose can only be metabolized by the liver in any significant amount.
When you eat a lot of refined sugar, the liver gets flooded with fructose, and is forced to turn it all into fat.
Numerous studies have shown that excess sugar, mostly due to the large amounts offructose, can lead to increased accumulation of fat in the belly.
Some believe that this is the primary mechanism behind sugar’s harmful effects on health… it increases belly fat and liver fat, which leads to insulin resistance and a host of metabolic problems.
Liquid sugar is even worse in this regard. Liquid calories don’t get “registered” by the brain in the same way as solid calories, so when you drink sugar-sweetened beverages, you end up eating more total calories.
Studies show that sugar-sweetened beverages are linked to a 60% increased risk of obesity in children… per each daily serving.
Make a decision to minimize the amount of sugar in your diet, and considercompletely eliminating sugary drinks.
This includes sugar-sweetened beverages, fruit juices, various sports drinks, as well as coffees and teas with sugar added to them.
Keep in mind that none of this applies to whole fruit, which are extremely healthy and have plenty of fiber that mitigates the negative effects of fructose.
The amount of fructose you get from fruit is negligible compared to what you get from a diet high in refined sugar.
Btw… if you want to cut back on refined sugar, then you must start reading labels. Even foods marketed as health foods can contain huge amounts of sugar.
Bottom Line: Excess sugar consumption may be the primary driver of belly fat accumulation, especially sugary beverages like soft drinks and fruit juices.
2. Eating More Protein May be The Best Long-Term Strategy to Reduce Belly Fat
Protein is the most important macronutrient when it comes to losing weight.
It has been shown to reduce cravings by 60%, boost metabolism by 80-100 calories per day and help you eat up to 441 fewer calories per day.
If weight loss is your goal, then adding protein to your diet is perhaps the single most effective change you can do.
Not only will it help you lose… it can also help you avoid re-gaining weight if you ever decide to abandon your weight loss efforts.
There is also some evidence that protein is particularly effective against belly fat.
One study showed that the amount and quality of protein consumed was inversely related to fat in the belly. That is, people who ate more and better protein had much less belly fat.
Another study in Denmark showed that protein, especially animal protein, was linked to significantly reduced risk of belly fat gain over a period of 5 years.
This study also showed that refined carbs and vegetable oils were linked to increased amounts of belly fat, but fruits and vegetables linked to reduced amounts.
Many of the studies showing protein to be effective had protein at 25-30% of calories. That’s what you should aim for.
So… make an effort to increase your intake of unprocessed eggs, fish, seafood,meats, poultry and dairy products. These are the best protein sources in the diet.
If you struggle with getting enough protein in your diet, then a quality protein supplement (like whey protein) is a healthy and convenient way to boost your total intake.
If you’re a vegetarian, check out this article on how to increase your protein intake.
Bonus tip: Consider cooking your foods in coconut oil… some studies have shownthat 30 mL (about 2 tablespoons) of coconut oil per day reduces belly fat slightly.
Bottom Line: Eating enough protein is a very effective way to lose weight. Some studies suggest that protein is particularly effective against belly fat accumulation.
3. Cut Carbs From Your Diet
Carb restriction is a very effective way to lose fat.
This is supported by numerous studies… when people cut carbs, their appetite goes down and they lose weight.
 Over 20 randomized controlled trials have now shown that low-carb diets lead to 2-3 times more weight loss than low-fat diets.
This is true even when the low-carb groups are allowed to eat as much as they want, while the low-fat groups are calorie restricted and hungry.
Low-carb diets also lead to quick reductions in water weight, which gives people near instant results… a major difference on the scale is often seen within a few days.
There are also studies comparing low-carb and low-fat diets, showing that low-carb diets specifically target the fat in the belly, and around the organs and liver.
What this means is that a particularly high proportion of the fat lost on a low-carb dietis the dangerous and disease promoting abdominal fat.
Just avoiding the refined carbs (white breads, pastas, etc) should be sufficient, especially if you keep your protein high.
However… if you need to lose weight fast, then consider dropping your carbs down to 50 grams per day. This will put your body into ketosis, killing your appetite and making your body start burning primarily fats for fuel.
Of course, low-carb diets have many other health benefits besides just weight loss. They can have life-saving effects in type 2 diabetics, for example.
Bottom Line: Studies have shown that low-carb diets are particularly effective at getting rid of the fat in the belly area, around the organs and in the liver.
4. Eat Foods Rich in Fiber… Especially Viscous Fiber
Dietary fiber is mostly indigestible plant matter.
It is often claimed that eating plenty of fiber can help with weight loss.
This is true… but it’s important to keep in mind that not all fiber is created equal.
It seems to be mostly the viscous fibers that can have an effect on your weight.
These are fibers that bind water and form a thick gel that “sits” in the gut.
This gel can dramatically slow the movement of food through your stomach and small bowel, and slow down the digestion and absorption of nutrients. The end result is a prolonged feeling of fullness and reduced appetite.
One review study found that an additional 14 grams of fiber per day were linked to a 10% decrease in calorie intake and weight loss of 2 kg (4.5 lbs) over 4 months.
In one 5-year study, eating 10 grams of soluble fiber per day was linked to a 3.7% reduction in the amount of fat in the abdominal cavity, but it had no effect on the amount of fat under the skin.
What this implies, is that soluble fiber may be particularly effective at reducing the harmful belly fat.
The best way to get more fiber is to eat a lot of plant foods like vegetables and fruit. Legumes are also a good source, as well as some cereals like oats.
Then you could also try taking a fiber supplement like glucomannan. This is one of the most viscous dietary fibers in existence, and has been shown to cause weight loss in many studies.
Bottom Line: There is some evidence that soluble dietary fiber may lead to reduced amounts of belly fat, which should cause major improvements in metabolic health.
5. Aerobic Exercise is Very Effective at Reducing Belly Fat
Exercise is important for various reasons.
It is among the best things you can do if you want to live a long, healthy life and avoid disease.
Getting into all of the amazing health benefits of exercise is beyond the scope of this article, but exercise does appears to be effective at reducing belly fat.
However… keep in mind that I’m not talking about abdominal exercises here. Spot reduction (losing fat in one spot) is not possible, and doing endless amounts of crunches will not make you lose fat from the belly.
In one study, 6 weeks of training just the abdominal muscles had no measurable effect on waist circumference or the amount of fat in the abdominal cavity.
That being said, other types of exercise can be very effective.
Aerobic exercise (like walking, running, swimming, etc) has been shown to cause major reductions in belly fat in numerous studies.
Another study found that exercise completely prevented people from re-gaining abdominal fat after weight loss, implying that exercise is particularly important during weight maintenance.
Exercise also leads to reduced inflammation, blood sugar levels and all the other metabolic abnormalities that are associated with central obesity.
Bottom Line: Exercise can be very effective if you are trying to lose belly fat. Exercise also has a number of other health benefits.
6. Track Your Foods and Figure Out Exactly What and How Much You Are Eating
What you eat is important. Pretty much everyone knows this.
However… surprisingly, most people actuallydon’t have a clue what they are really eating.
People think they’re eating “high protein,” “low-carb” or whatever… but tend to drastically over- or underestimate.
I think that for anyone who truly wants to optimize their diet, tracking things for a while is absolutely essential.
It doesn’t mean you need to weigh and measure everything for the rest of your life, but doing it every now and then for a few days in a row can help you realize where you need to make changes.
If you want to boost your protein intake to 25-30% of calories, as recommended above, just eating more protein rich foods won’t cut it. You need to actually measure and fine tune in order to reach that goal.
Hoping this will be helpful,
Rafik
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A major trend for medical advice, given the growing trend of sick patients living longer, is to look for advice on the web from sources such as HEALTHPAD, etc, I am now intrigued by the comparative effectiveness of those sources of MEDICAL help.
I am wondering on serious research that would compare,let us say, 100 patients with a serious flu or stomach infection, and put them in a situation to consult an actual physician face to face and 3 or 5 web medical advice places and then compare the results of the advice . 
My last book was on orgnizational culture in clinics and hospitals. Now I am asking what if the local culture is taken away (can it be done?) and we look for medical advice  outside the brick and mortar locations.
Any advice of reserach on this topics is WELCOME.
I am fully aware that the results might be contradictory in many cases or fully wrong methodologies in others.  But this is a topic of huge implications for every and all countries health systems.
Please advice with your views but more important with serious research citations on this techno-social topic. Probably one with major social implications.
MUCHAS GRACIAS AMIGOS
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Looks like Cochrane has been investigating that for awhile http://www.cochrane.org/search/site/internet
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Need references for a paper on the chiropractic adjustment.
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Thank you, Dr. Ewalds-Kvist, for mentioning my paper (titled, "Reduction of resting pulse rate following chiropractic adjustment of atlas subluxation"). Here is another paper that may be of interest:
Zhang J, Dean D, Nosco D, Strathopulos D, Floros M. Effect of chiropractic care on heart rate variability and pain in a multisite clinical study. J Manipulative Physiol Ther 2006; 29:267-274. PMID: 16690380.
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How can gamification contributes to health care delivery?
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There are a lot of applications for gamification in healthcare settings. This is especially true with all of the influence of electronic health records in the U.S. in the past 10 years. With the emphasis shifting from EMR adoption to EMR optimization there will be ample opportunity to explore the role of gamification on outcomes. There is a journal "Games for Health" that has started to publish articles in the area. Here is a link of the latest issue. http://online.liebertpub.com/toc/g4h/5/1 All the best in your pursuit, I think it is a fertile research area. 
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A colleague of mine has requested assistance in attaining international evidence demonstrating how up-skilling paramedics improves quality/patient care and the economic value of doing so, to continue to strengthen the case for change at a strategic level.
I am "putting it out there" to call on the international pool of knowledge and information, that may not have been published, but undoubtedly exists. Even small individual case studies are as important as large scale projects to bring about and support change.
Thanks so much for your consideration and look forward to hearing all you have to offer. 
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Yes, up-skilling would mean to teach or learn additional paramedic skills, based on current paramedicine curriculum.
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Consider cost effectiveness of the approach and applicability in rural Kenya
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Thank Dung Pham
The paper is helpful however, I have to work from a Kenyan cultural perspective. But all is quite helpful
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Hello and good day.
I am wondering whether it is possible to use the Theory of Planned Behavior to predict a "behavior" that may comprised of several constructs. 
For example, the behavior of "providing care to patients by a health care professional". This behavior may consists of several constructs such as (1) educating patients; (2) provide counseling; (3) provide monitoring; and (4) evaluation of health.
Kindly share your valuable knowledge
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Dear Bounmy, I agree with the previous answers. It is possible, but needs some carefully consideration of possible implications for measurement and data analysis.As Dean already mentioned, a lot of social and health-related behavior is rather a behavioral category than a single behavior (e.g. "exercising"). You can aggregate your constructs (1)-(3) in a single behavior labelled "providing care to patients by a health care professional". In my opinion it is of prevailing importance to clearly define the behavioral category in terms of your intended constructs. You need to ensure that all study participants have the same understanding of the behavior under investigation. 
However, I recommend to study Fishbein & Ajzen's recent book: Predicting and Changing Behavior (2010). The authors discuss the role of "behavioral categories" in detail.
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Educational, emotional, policy and legislation, housing, medical care? Can anyone add to or expand on these?
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This paper raises a number of key issues relevant to your question:
Laverack, G. and Whipple, A. (2010) The Sirens’ Song of Empowerment:  A case study of health promotion and the New Zealand Prostitutes Collective. Global Health promotion. Vol 17(1): 33-38.
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Beyond stratifying for health literacy, we are interested in controlling for an individual's total exposure to/encounters/interaction with healthcare delivery.  This could be thought of as duration of exposure as well as intensity for unit time.
Is anyone aware of a validated method of measuring this?
thanks
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Hello.  I cannot specifically answer the appropriate validity method of measuring this.  However, you may want to approach validity incrementally.  That is, first think of the entire healthcare delivery process from a "linear" perspective; hence, the time a patient enters the healthcare system of delivery to their complete exit.  During each phase you may consider validity measures and developing a composite index with respect to the full linear process.  Obviously dynamic interactions across the clinical spectrum will impact and intervene with respect to a "dose" response; the fact still remains that it is a linear process -- walk in the door and leave through the door.  What happens in the "Black Box" is your "holy grail."  Good luck.
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In some countries, e.g. Germany and Switzerland, health care regulators tend to separate the funding of hospital (inpatient) treatment over ambulatory health care delivery. In some cases, taxpayers not only provide the funding for investment in hospital structures, but are called to co-finance directly individual per case funding via DRG. Under these circumstances, healthcare authorities simultaneously play multiple roles in planning, investing, controlling and providing health care. Insurance companies therefore are partially relieved of their responsability for health care delivery when patients are hospitalised, while their role for cost control is unlimited in the ambulatory setting. the result is a chronic conflict of interest among health care providers in the ambulatory setting vs. those working in an inpatient setting, and a disruption of the pathways of health care delivery between the two sectors. This disruption has particularly negative effects on the continuity and coherence of care in the  NCD (Non Communicable Disease) sector, e.g. cardiovascular diseases,  diabetes, and mental health. The subject should be of interest for both health economists and epidemologists.
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There only a possible comment: Dr. iselin is wright. The disruption he is referering to is deleterious for continuity and coherence of medical care. The laws have been mede from politicians with experience in legislatory rulse ansd without any feeleing or experiencve in medical care.
You may say:
Not chaos-like together, crush'd and bris'd, But, as the world, harmoniously confused: where order in variety we see, and where, tho' all things differ, all agree.
Alexander Pole, Windsor Forest.
Or, clearer and better:
It is said that every people has the Government it deserves. It is more to the point that every Government has the electorate it deserves, for the orators of the front bench can edify or debauch an ignorant electorate at will. Thus our democracy moves in a vicious circle of reciprocal worthiness and unworthiness.
Heartbreak House. Bernard Shaw
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We have already searched the published peer reviewed literature but would be interested in any unpublished reports or studies etc that describe models of care or service delivery models within primary healthcare services that provide care specifically to Indigenous peoples of any country.
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Northern medical service run from Winnipeg and based in Churchill, Manitoba - evaluative literature and initial gov reports setting it up
'Where there is no doctor' ---book written in the 80s based on Peruvian Andes
NAIHO - Nat Aboriginal and Islander Hlth Organisation - rich report literature- stewards at Redfern AMS or via Gary Foley (former leader)'
CAAC  - still operating hlth services in Central Aust
Commonwealth Gov reports (since 70s) - Parliament Library
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I am trying to create a study of this question in Miami-Dade and Broward (FL) counties. Most recent research by Krumholtz et al (2011) shows that risk-standardized mortality rates and readmission rates were not associated for patients admitted with acute MI or pneumonia and were only weakly associated, within a certain range, for patients admitted with heart failure. Previous literature searches have shown an inverse relation between the two, lower mortality, higher read admission. I know there is a subgroup of safety-net hospital factors here. How would I set up a a good research study on this and what tests could I use?
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Dear Dr. Hubball,
 I think this article may be useful for your question.
Regards,
JAMA. 2013 Feb 13;309(6):587-93. doi: 10.1001/jama.2013.333.
Relationship between hospital readmission and mortality rates for patients hospitalized with acute myocardial infarction, heart failure, or pneumonia.
Krumholz HM1, Lin Z, Keenan PS, Chen J, Ross JS, Drye EE, Bernheim SM, Wang Y, Bradley EH, Han LF, Normand SL.
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What influences decsion making amongst the interprofessional team
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ِDear Dr. Adu-anti,
Quality decision making is an essential component of good clinical practice. If we are to understand,critique and improve clinical decision making, it is imperative that, in addition to understanding the elements of the immediate clinical problem,
we make explicit the contextual factors that are taken into account when making decisions. When seeking to improve decision-making, a broad perspective needs to be adopted that considers factors such as the individual’s decision-making attributesand the influence of the external context on decision making.
Evidence-based practice is consistently advocatedas a means for improving the quality of clinicalpractice. A broader perspective of factorsinfluencing decision making illustrates how evidence-based practice needs to be integrated with
many other influences on practice. Considerationof social and organizational dimensions of contexts critical in optimizing the quality of clinical decision
making. Ifwe are to promote effective decisionmaking, we need to understand how we can bestteach decision making that considers and manages the multiplicity of factors that influence it, rather than focusing only on the immediate clinical decision-making tasks of diagnosis and intervention.
Regards,
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Want to start calculating the cost effective analysis of FIMNCI programme / COPTA ban on Guthka in Darbhanga District in Bihar. Need help as to where and how to start.
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Economic evaluation of the program using cost benefit analysis will involve comparison of the costs against the consequences.  Costs include those incurred in the healthcare sector(C1), patient and family (C2)and others (C3). You need to identify the consequences e.g. health state changed, measure the consequences i.e. effects (E) on the healthcare sector (S1), Patient and family (S2), and other sector (S3) and do valuations, based on "health-states preferences" (U) and "willingness to pay" (W). Also, identify other value created (V).
CBA = (W+V+S1+S2+S3)-(C1+C2+C3)
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Missing (or at least unremarked upon) in the debate about Obamacare in particular and health policy in general is the value/worth of continuity of care, i.e. more integrated systems vs less integrated systems
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The Executive Summary of this somewhat lengthy current study sponsored by WHO is informative "What is the Evidence on the Economic Impacts of Integrated Care?": http://www.euro.who.int/__data/assets/pdf_file/0019/251434/What-is-the-evidence-on-the-economic-impacts-of-integrated-care.pdf
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Or unintended consequences from false results? i.e. safety and accuracy, at what cost? Reference your favorite papers, but anecdotal opinions welcome too.
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Great question. If one starts with the premise that [value] = [quality] / [cost] and believes that we should focus on maximizing value, then the question can be re-focused as "when do we see incremental quality result from optimizing diagnostic accuracy?"  This relates to the patient population (diagnosing pre-malingnant colon polyps has a very different meaning for an 88 year old than for a 52 year-old), the illness (missing a diagnosis of iron deficiency is not as important as missing a diagnosis of HIV because of the seriousness of the illness and the public health implications), and the operating characteristics of the tests (over-screening for colon cancer with fecal occult blood testing might lead to unneccessary, expensive, and not-risk-free colonoscopies because there are a lot of false-positives). I believe, anecdotally, that the biggest errors we make in assessing the value of diagnostic tests are (1) focusing on sensitivity and specificity instead of likelihood ratios; after all, Bayes' theorem works with likelihood ratios, and (2) assuming that tests have similar operating characteristics in all patient populations. Using a ferritin value to detect iron deficiency makes sense in young healthy women, but not in hospitalized patients, but this type of issue has not been well characterized for many diagnostic tests that we assume work well in all populations but may not.
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I am looking into the compliance rate of asthma action plans in the pediatric patient population. How useful are they. Are there results from focus groups regarding asthma action plans?
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pediatrics asthma guidelines are to some extent similar to adults.you can use the following guideline too.
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Person Centered Medicine is an epochal change of Medicine, Medical Science and Medical Education whose destiny is to change the quality of Health Care delivery as we have seen in the first pilot investigation of Person Centered Medicine Clinical Method on clinical practice which depicted amazing results.
You could find it in
The Person Centered Medicine International Academy would like to spread this investigation all over the world.
If you are interested in it we could cooperate for realizing the research project we made in your country.
Prof. Giuseppe R.Brera
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It is recommended to correct the sample size when leading a community randomized controlled trial that considers the community as a research unit and not individuals or households. I would like to know if this recommendation is to be applied.
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Yes - you must allow for clustering by community in both the power calculation and the statistical analysis. There are plenty of papers available showing how this is done. try this web page:
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The surgical safety checklist has been mandated or strongly encouraged by several governments since Haynes et coauthors found it to reduce morbidity and mortality in a global population (N Engl J Med 2009;360:491-9). Recently Urbach et al, found conflicting results with the Introduction of surgical safety checklists in Ontario, Canada (N Engl J Med 2014;370:1029-38). What didn't work? Do we need to implement our checklist? Or do we need simply to change our practice and use the available checklists in the correct way?
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Dear Sergio
These 02 articles my be useful for you:
1) Am Surg. 2011 Sep;77(9):1131-7.
The surgical safety checklist: lessons learned during implementation.
Calland JF1, Turrentine FE, Guerlain S, Bovbjerg V, Poole GR, Lebeau K, Peugh J, Adams RB.
Abstract
Procedural checklists may be useful for increasing the reliability of safety-critical processes because of their potential capacity to improve teamwork, situation awareness, and error catching. To test the hypothesized utility and adaptability of checklists to surgical teams, we performed a randomized controlled trial of procedural checklists to determine their capacity to increase the frequency of safety-critical behaviors during 47 laparoscopic cholecystectomies. Ten attending surgeons at an academic tertiary care center were randomized into two equal groups - half of these surgeons received basic team training and used a preprocedural checklist whereas the other half performed standard laparoscopic cholecystectomies. All procedures were videotaped and scored by trained reviewers for the presence of safety-critical behaviors. There were no differences detected in patient outcomes, case times, or technical proficiency between groups. Cases performed by surgeons in the intervention (checklist) group were significantly more likely to involve positive safety-related team behaviors such as case presentations, explicit discussions of roles and responsibilities, contingency planning, equipment checks, and postcase debriefings. Overall, situational awareness did not significantly differ between the intervention and control groups. Participants in the intervention (checklist) group consistently rated their cases as involving less satisfactory subjective levels of comfort, team efficiency, and communication compared with those performed by surgeons in the control group. Surgical procedural safety checklists have the capacity to increase the frequency of positive team behaviors in the operating room during laparoscopic surgery. Adapting to the use of a procedural checklist may be initially uncomfortable for participants
2) Ann Surg. 2013 Dec;258(6):856-71.
Do safety checklists improve teamwork and communication in the operating room? A systematic review.
Russ S1, Rout S, Sevdalis N, Moorthy K, Darzi A, Vincent C.
Abstract
OBJECTIVES:
The aim of this systematic review was to assess the impact of surgical safety checklists on the quality of teamwork and communication in the operating room (OR).
BACKGROUND:
Safety checklists have been shown to impact positively on patient morbidity and mortality following surgery, but it is unclear whether this clinical improvement is related to an improvement in OR teamwork and communication.
METHODS:
A systematic search strategy of MEDLINE, EMBASE, PsycINFO, Google Scholar, and the Cochrane Database for Systematic Reviews was undertaken to obtain relevant articles. After de-duplication and the addition of limits, 315 articles were screened for inclusion by 2 researchers and all articles meeting a set of prespecified inclusion criteria were retained. Information regarding the type of checklist, study design, assessment tools used, outcomes, and study limitations was extracted.
RESULTS:
Twenty articles formed the basis of this systematic review. All articles described an empirical study relating to a case-specific safety checklist for surgery as the primary intervention, with some measure of change/improvement in teamwork and/or communication relating to its use. The methods for assessing teamwork and communication varied greatly, including surveys, observations, interviews, and 360° assessments. The evidence suggests that safety checklists improve the perceived quality of OR teamwork and communication and reduce observable errors relating to poor team skills. This is likely to function through establishing an open platform for communication at the start of a procedure: encouraging the sharing of critical case-related information, promoting team coordination and decision making, flagging knowledge gaps, and enhancing team cohesion. However, the evidence would also suggest that when used suboptimally or when individuals have not bought in to the process, checklists may conversely have a negative impact on the function of the team.
CONCLUSIONS:
Safety checklists are beneficial for OR teamwork and communication and this may be one mechanism through which patient outcomes are improved. Future research should aim to further elucidate the relationship between how safety checklists are used and team skills in the OR using more consistent methodological approaches and utilizing validated measures of teamwork such that best practice guidelines can
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I work in a rural town in Kenya and my heart bleeds each time there's a delay to patient care, either due to patient delays or because the hospital is not well equipped.
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There is no limit for financial requirements to meet the unmet needs of the poor. In this context, the government should plan the use of its resources better in such a way that the resources are spent on cost-effective services. Often, this is not the case. Governments allow their resources flow into developed places to serve the better-off even while keeping their policies targeted at the poor and primary healthcare. Unless there is a positive correlation between the policy priorities and budget spending, this kind of scenario is unfortunately unavoidable. The private not-for-profit sector attempts to bridge the healthcare gap to some extent in some areas in Africa, but they too face resource constraint.
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I am particularly interested to know what types of POCT have been in use at A&E, and whether there is any evidence on benefits and disadvantages.
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i believe my question has been misunderstood. By POCT, I mean conducting tests near the site of patient care. These may be simple medical blood tests which can be performed at the bedside rather than doing them in the main Lab at the hospital. Other examples include simple imaging for example using portable ultrasound device rather than using medical imaging department.
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When one measures hospital activity of individual clinicians, units, and departments, there is always the challenge of aiming for balancing workload. However, it is a known fact that there is a human level variation as regards speed, focus, and efficiency. Obviously, volume is not a measure of quality of care, for which we need key performance indicators. I am interested to know of evidence or experience whereby volume and quality can be effectively reconciled.
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This isn't an easy question to answer.
Firstly you have the planned operation and the expected complexity of that operation, then you have waht actually happened, part of which can be the result of the sugeon and part as a result of the patient.
Next you rightly say you have the quality. then you have the speed and the natural variation.
Then there is the issue of balancing workload. What is a balanced workload and why do we want to achieve this. Are we measuring for planning purposes or ....?
Personally, I would probably not focus on speed of operation too much. What we want is an operation that gives a good outcome for the patient in terms of clinical results aand quality of life, without rework.
Does that help at all?
mike
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Is it ok to use same values for calculation of catastrophic expenditure on health care for all diseases and health related conditions (5-20%) or should it be different for non-communicable/chronic illnesses?
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Thank you very much for this great questions.
I think there is no problem if you use the same threshold on health care for all diseases and health related conditions or specific illness.
Be careful about thresholds in-terms of denominators. To date researchers have failed to accept a unique threshold for defining catastrophic expenditure. However, the most common thresholds for household total consumption expenditure or income is more than 15%, for non-food expenditure is more than 25% or 40% and household capacity to pay is more than or equal to 40%.
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The Bio-psycho social theory has been proven to give us a comprehensive understanding of human behavior yet health practitioners and policy makers seem to still prefer medically biased conclusions. Why is this so and is there any research addressing such issues?
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Although it's tempting to say yes unequivocally or offer anecdotal support it is important to temper claims and support assertions by providing the evidence. The BMJ editorial by Marteau and colleagues outlines the contributions that health psychology / behavioural medicine have made to understanding health behaviour and patient care. There is little doubt that using a well-evidence approach to integrating psychology to medical practice is effective, the key being evidence-based. To quote Marteau and colleagues "too much behavioural research is based neither on valid theories of human behaviour nor on existing empirical evidence. Interventions that are theory based seem more effective in supporting behaviour change than those that are not, and can be more effectively generalised and disseminated. "
The study by Phillips and colleagues (attached) shows that good communication skills alone is not sufficient to improve outcomes with patients whereas using the Self-Regulatory (or Common-sense) Model in a medical consultation does seem to improve health outcomes. In addition, a structured approach to understanding and managing illness beliefs using Health Psychology models seems to offer more than supportive listening alone. Strategies to change behaviour do more than simply telling people to change that behaviour and especially when they target beliefs about health related to the behaviour.
We need more and better studies to demonstrate HOW health psychology can improve clinician patient interactions and then IF this translates to better health outcomes.
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I only got publication concerning the medical issues ....
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...is this helpful for you at all?
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Health Care systems based on compulsory social insurance alone tend to regulate access to care through control and rationing of human and material resources. As a consequence, motivation for developping and improving therapeutic concepts and procedures is often low. Economic growth and major disposability of financial resources for individual citizens enlarge the field of choice for treatment. Insurance companies and the medical profession are tempted to offer a broad spectrum of treatment options that tends to increase demand and might undermine the quality of indication, thereby causing an increase in complications and in cost for secondary repair which results in spoiling of resources. Measuring and managing quality under these conditions becomes a major concern, especially in mixed economies with both social and private health insurances schemes.
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Dear Colleague, thank you very much for your answer which will help me and others to address the question in a well structured way. I am not a pessimist but my personal experience as a clinician is biased by the fact that I have seen some very unpleasant and unfortunate decisions in high risk and therefore complication-prone diabetes patients that have been driven by incentives such as private insurance coverage and networking based on financial criteria alone. I shall be pleased to discuss the subject in more depth in the future.
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Currently we are faced with organ transplant scandals in Germany. We discovered a lack of data-driven quality management systems for solid organ transplantation. We currently develop such a system and would like to cooperate.
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As was stated by Mr. Huff UNOS is a source. Also "The Gift of Life" orgainzation in Philadelphia has Quality measurements, There is an independent laboratory that performs the testing for transplants LABS Inc. Cenntenial Co. They keep statistics and quality assuarance data on organ doners and transplant recepients. These might be additional respources you can tap. All the best.
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What the impact of current work-life balance policy may be having on dementia care, as care homes are mainly being staffed by part time care staff.
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Have you looked at the Cochrane Library ?
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There are macro factors such as cost, technology, user expectation, and demographics. What would the micro factors that affect a strategy be?
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Various factors may hinder implementation of nutritional strategy, first and foremost being the environment and situation in which the person is placed! Cultural background, family responsibilities, mental acceptance, financial condition, ate some of them! If maximum ate favourable, implementation becomes easy !
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Yet another question: looking at the decolonization of healthcare in tribal health, US and Canada. Thoughts? Very little in peer-reviewed journals.
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At the level of care (I am family doctor ) a part of the solution lies in the focus on the patient centered care under the classical principles:
Patient-centered concepts incorporate 6 interactive components. The first component is the physician’s exploration of both the patients’ disease and 4 dimensions of the illness experience including: their feelings about being ill, their ideas about what is wrong with them, the impact of the problem on their daily functioning, and their expectations of what should be done. The second component is the physician’s understanding of the whole person. The third component is the patient and physician finding common ground regarding management. In the fourth component the physician incorporates prevention and health promotion into the visit. The fifth component is the enhancement of the patient-physician relationship. Finally, the sixth component requires that patient-centered practice be realistic.
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When conducting health services analyses, it is often difficult to establish a cause-effect relationship between medical and behavioral health conditions. For example, if the rate for diabetes-related hospitalizations is being measured, to what extent do hospitalizations with primary or secondary diagnoses of behavioral health conditions or other medical conditions contribute to the primary condition's prevalence or acuity?
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To me, the answer should be articulated in three points:
1) Methodological/Research perspective: when you are exploring the relationship between two or multiple variables (e.g. one/multiple medical or behavioral conditions or their prevalence rates), you are actually doing a "correlation analysis", which be definition provides just a description of the rate of occurrence of a given or multiple events (e.g. prevalence rate of one condition in relationship to another one). So that you have a positive or negative "correlation" between two (bivariate) or multiple (multivariate) factors. But the interesting point is that correlation analysis do not give any sort of directional hypothesis (meaning that you can "read" that correlation in "round-way" just alternating "positive" or "negative" descriptions) and that you have no explanation (predictive hypothesis) or what factor should predict or drive one/more than one others. Also, a "third" variable problem should occur (meaning that you can't know "a priori" if you are controlling for additional factors which you may know or not know (yet) but that should still influence the correlation between two or multiple factors.
The only way to "control" for more factors is to perform a regression analysis, hopefully by implementing a model that is able to account for all "confounding" factors, if ever know. While in pharmacological trials a very good approach is to design a double-blind controlled (usually placebo or multiple arms) study (assuming the sample size is sufficient to allow for multiple comparisons without reducing the potency of the study), it is much more difficult to this in ecological or epidemiological naturalistic studies (prevalence studies for example).
Back in the 1950s, the preliminary research results on the correlation between the prevalence of lung cancer, caffeine consumption and smoking, lead to the apparent conclusion that coffee had a causative role in determining lung cancer. Which is not. The problem there, was that no Pearson, Spearman's or Kendall's tau regression was performed in order to reduce the chance of additional confounding factors, while, in real world, most people addicted to smoke, often is a hard-to-die coffee drinker. No more, no less.
So, about your question, who shouldn't expect to have an answer about the causative or directional effect of behavioral disturbances on medical disorders or vice-versa, simply because no correlation analysis is per se able to deal with this.
2) Biological perspective: I agree with Dr. Silverman here. The HPA axis and the neuro-endocrine-immune system is the common substrate for "medical" and "behavioral" conditions, so that even the distinction between the two makes no sense to me. Maybe, you should say that most "medical" disorders may also manifest with behavioral features (not a co-morbidity actually) and that all MEDICAL disorders should also be influenced by epigenetic factors, indipendenly on the presence of behavioral symptoms at a given point of the course of the illness.
3) A clinical perspecitve: you were mentioning mood and anxiety disorders. Indeed they are quite different if you are accounting just "simple" non-comorbid ones. By definitons, anxiety disorders follow a sort of "chronic", (almost "processual"-like) natural couse; when this is not the case, usually a medical or affective conditions is influencing the longitudinal presentation of the anxiety disorder(s). Mood disorders, are usually characterized by an episodic presentation. This has major implication for your research about the topic you are discussing here. In fact, you should ideally assess the continuous spectrum of affective disorders following a lifetime approach rather than an orthogonal "hic et nunc" one, which is the one that one should mistakenly follow focusing just on the hospitalization period of the patient (no matter the medical or "psychiatric" cause of the hospitalization). While there are relevant temperamental and trait states which are almost accounted as "candidate endophenotypes" for mood disorders (in the sense of stable personal features which are non influenced by the current episode/polarity of illness, medications and that are present and stable even in non-affected relatives), other features are not that stable. Cognitive status is also very relevant, especially in diabetic patients. And, clearly, bipolar patients with endocrine disorders (e.g. type-I diabetes), are often cognitively impaired in the long-term course, which further increase the risk of unreliable medical/behavioral recall history. Recall bias is also an intrinsic issue of BD, because most patients fail to recall previous (hypo-)manic episodes because they are "nostalgic" of missing "hights", which are the status the expect to experience again and that they consider "normal", and also because we live in a "depressocentric" world, where depression is "bad" and hyperactivity, mania and productivity is good (and also we live in "antidepressant" world by that consequence) [for reference, please see the work of Kleman or Ghaemi].
The topic is indeed complex, and to sum up, I would just recommend you to assess the prevalence and "correlation" of the factors, with no "demand" for explanation or causation. Also follow a lifetime, naturalistic approach. Then, if you are planning further explorations, try to implement a multivariate model, then a hypothesis-directed one-tailed model, and, finally, a factorial/cluster analysis.
By the way, I'm attaching here for your convenience a paper I published in the Journal of World Psychiatry about the "prevalence" of different newly-diagnosed endocrine disorders (including diabetes) in a large sample of major depressed women. As you'll notice, it is a very "plain" analysis, with just a prevalence report. Also, you'll see that most endocrine and anxiety disorders (e.g. panic for type-diabetes) largely co-occur. But please remember, when you are finding a lot of multiple co-morbidities or co-occurring phenomena, you are not actually reaching a good finding, rather you are probably witnessing at multiple phenomena sharing a common background or predicted by a common diathesis. So move on on further exploring your data... On the contrary, if you're going to search the community sample for the relationship between shoes size and depression, who may find that most depressed men may have 8.5 USA size. Maybe with a very strong positive correlation factor. But indeed this make no sense unless you're able to explain what you found and to further investigate that finding to discriminate for confounding factors!
Take care, Michele Fornaro, MD.