Using simulation modelling to transform hospital planning and management to address health inequalities.

Health inequalities are a perennial concern for policymakers and in service delivery to ensure fair and equitable access and outcomes. As health inequalities are socially influenced by employment, income, and education, this impacts healthcare services among socio-economically disadvantaged groups, making it a pertinent area for investigation in seeking to promote equitable access. Researchers widely acknowledge that health equity is a multi-faceted problem requiring approaches to understand the complexity and interconnections in hospital planning as a precursor to healthcare delivery. Operations research offers the potential to develop analytical models and frameworks to aid in complex decision-making that has both a strategic and operational function in problem-solving. This paper develops a simulation-based modelling framework (SimulEQUITY) to model the complexities in addressing health inequalities at a hospital level. The model encompasses an entire hospital operation (including inpatient, outpatient, and emergency department services) using the discrete-event simulation method to simulate the behaviour and performance of real-world systems, processes, or organisations. The paper makes a sustained contribution to knowledge by challenging the existing population-level planning approaches in healthcare that often overlook individual patient needs, especially within disadvantaged groups. By holistically modelling an entire hospital, socio-economic variations in patients' pathways are developed by incorporating individual patient attributes and variables. This innovative framework facilitates the exploration of diverse scenarios, from processes to resources and environmental factors, enabling key decision-makers to evaluate what intervention strategies to adopt as well as the likely scenarios for future patterns of healthcare inequality. The paper outlines the decision-support toolkit developed and the practical application of the SimulEQUITY model through to implementation within a hospital in the UK. This moves hospital management and strategic planning to a more dynamic position where a software-based approach, incorporating complexity, is implicit in the modelling rather than simplification and generalisation arising from the use of population-based models.

An exploratory study of creating dementia-friendly businesses in the visitor economy: evidence from the UK.

Many governments have promoted the development of a civil society to encourage citizen involvement in addressing many of the grand social challenges such as the growing prevalence of dementia, as ageing becomes a major trend in developed societies. One outcome has been the development of Dementia Friendly Communities, created via Dementia Action Alliances (DAAs) in England, to enhance awareness, care and the experience of people with dementia in accessing services and facilities. These initiatives are based on engaging the business community and yet no research studies have examined this theme to date. Given the growing significance of leisure and tourism activities that people with dementia and family members engage in, this study examines the experience of business engagement with DAAs in the visitor economy in England. The notion of shared value articulated by Porter and Kramer (2011) is used as a basis for understanding the type of business engagement.

Interpreting Action Research Arm Test Assessment Scores to Plan Treatment.

Rasch keyforms can help interpret clinical assessment scores. The Action Research Arm Test (ARAT) is a commonly used assessment, yet no keyform currently exists. The aim is to provide a keyform for the ARAT and demonstrate how a clinician can use the keyform to design optimally challenging rehabilitation sessions. Secondary analysis of ARAT data ( n = 122) using confirmatory factor and Rasch analyses were used to examine the measurement properties and generate a keyform. The item standardized factor loadings were >0.40 (range = 0.82-0.96) and R2 values were >.60 (range = .65-.96). All items exhibited adequate infit statistics with point measure correlations >.60 (range = .72-.97). Person reliability was .98, and person separation was 7.07. Item-difficulty measures ranged from -2.78 logits to 2.64 logits. The ARAT has strong measurement properties, and a keyform was provided. We showed how the keyform can be utilized by clinicians to interpret scores, set goals, and plan treatment.

Psychometrics of the wrist stability and hand mobility subscales of the Fugl-Meyer assessment in moderately impaired stroke.

BACKGROUND: There remains a need for a quickly administered, stroke-specific, bedside measure of active wrist and finger movement for the expanding stroke population. The wrist stability and hand mobility scales of the upper extremity Fugl-Meyer Assessment (w/h UE FM) constitute a valid, reliable measure of paretic UE impairment in patients with active wrist and finger movement. OBJECTIVE: The aim of this study was to determine performance on the w/h UE FM in a stable cohort of survivors of stroke with only palpable movement in their paretic wrist flexors. DESIGN: A single-center cohort study was conducted. METHOD: Thirty-two individuals exhibiting stable, moderate upper extremity hemiparesis (15 male, 17 female; mean age=56.6 years, SD=10.1; mean time since stroke=4.6 years, SD=5.8) participated in the study, which was conducted at an outpatient rehabilitation clinic in the midwestern United States. The w/h UE FM and Action Research Arm Test (ARAT) were administered twice. Intraclass correlation coefficients (ICCs), Cronbach alpha, and ordinal alpha were computed to determine reliability, and Spearman rank correlation coefficients and Bland-Altman plots were computed to establish validity. RESULTS: Intraclass correlation coefficients for the w/h UE FM and ARAT were .95 and .99, respectively. The w/h UE FM intrarater reliability and internal consistency were greater than .80, and concurrent validity was greater than .70. This also was the first stroke rehabilitative study to apply ordinal alpha to examine internal consistency values, revealing w/h UE FM levels greater than .85. Concurrent validity findings were corroborated by Bland-Altman plots. CONCLUSIONS: It appears that the w/h UE FM is a promising tool to measure distal upper extremity movement in patients with little active paretic wrist and finger movement. This finding widens the segment of patients on whom the w/h UE FM can be effectively used and addresses a gap, as commonly used measures necessitate active distal upper extremity movement.

Ethinyl estradiol and other human pharmaceutical estrogens in the aquatic environment: a review of recent risk assessment data.

Interest in pharmaceuticals in the environment has increased substantially in recent years. Several studies in particular have assessed human and ecological risks from human pharmaceutical estrogens, such as 17α-ethinyl estradiol (EE2). Regulatory action also has increased, with the USA and other countries developing rules to address estrogens and other pharmaceuticals in the environment. Accordingly, the Center for Drug Evaluation and Research at the US Food and Drug Administration has conducted a review and analysis of current data on the long-term ecological exposure and effects of EE2 and other estrogens. The results indicate that mean-flow long-term predicted environmental concentrations (PECs) of EE2 in approximately 99% or more of US surface water segments downstream of wastewater treatment plants are lower than a predicted no-effect concentration (PNEC) for aquatic chronic toxicity of 0.1 ng/L. Exceedances are expected to be primarily in localized, effluent-dominated water segments. The median mean-flow PEC is more than two orders of magnitude lower than this PNEC. Similar results exist for other pharmaceutical estrogens. Data also suggest that the contribution of EE2 more broadly to total estrogenic load in the environment from all sources (including other human pharmaceutical estrogens, endogenous estrogens, natural environmental estrogens, and industrial chemicals), while highly uncertain and variable, appears to be relatively low overall. Additional data and a more comprehensive approach for data collection and analysis for estrogenic substances in the environment, especially in effluent-dominated water segments in sensitive environments, would more fully characterize the risks.

Psychometric properties and administration of the wrist/hand subscales of the Fugl-Meyer Assessment in minimally impaired upper extremity hemiparesis in stroke.

There is a need for time-efficient, valid measures of distal paretic upper extremity (UE) movement. The purposes of this study were to (1) determine the psychometric properties of the wrist stability and mobility and wrist/hand scale of the upper extremity Fugl-Meyer (w/h UE FM) as a "stand-alone" measure of distal UE movement; and (2) provide detailed instructions on w/h UE FM administration and scoring. The upper extremity Fugl Meyer (UE FM) and Action Research Arm Test (ARAT) were administered on 2 separate occasions to each of 29 subjects exhibiting stable, mild UE hemiparesis (23 men; mean age ± SD, 60.8±12.3 y; mean time since stroke onset for subjects in the sample, 36.0 mo). Fifty-eight observations were collected on each measure. w/h UE FM internal consistency levels (measured by Cronbach α) were high (.90 and .88 for first and second testing sessions, respectively). The intraclass correlation coefficient for the UE FM was .98, while the intraclass correlation coefficient for the w/h UE FM was .97. Concurrent validity measured by Spearman correlation was moderately high between the w/h UE FM and ARAT (.72, P<.001). From these data, it appears that the w/h UE FM is a promising tool to measure distal UE movement in minimally impaired stroke, although more research with a larger sample is needed. A standardized approach to UE test administration is critical to accurate score interpretation across patients and trials. Thus, the article also provides instructions and pictures for w/h UE FM administration and scoring.

Catheter ablation for atrial fibrillation on uninterrupted warfarin: can it be done without echo guidance?

INTRODUCTION: Catheter ablation for atrial fibrillation is an effective treatment for symptomatic patients who have failed drug therapy. Recent studies using intracardiac echocardiography have demonstrated that ablation can be performed safely on uninterrupted warfarin and may be superior to bridging low molecular weight heparin (LMWH). We sought to assess the safety of an uninterrupted warfarin protocol using a simplified ablation protocol in a prospective controlled study. METHODS: Two anticoagulation regimes for patients undergoing catheter ablation for atrial fibrillation were evaluated--a bridging LMWH group and an uninterrupted warfarin group. Bleeding complications were compared between the 2 groups. RESULTS: In total 198 patients were evaluated (109 bridging LMWH, 89 uninterrupted warfarin). The preprocedure INR in the LMWH group (mean age 60.6 years, 72% male) was 1.2 ± 0.3 compared to 2.3 ± 0.5 in the uninterrupted warfarin group (mean age 60.9 years, 69% male). The primary outcome (a composite of major and minor bleeding complications) was observed in 78% in the LMWH group compared to 56% in the warfarin group (P = 0.001), mainly due to increased pain at the venous access site (41% vs 16%, P = 0.001). Two patients undergoing ablation on warfarin required pericardiocentesis for cardiac tamponade. Drug costs were lower in the warfarin group ($64.77 ± 31.86 vs $20.76 ± 15.60, P = 0.005), but the overall cost of treatment per patient (including bed occupancy costs) was similar in the LMWH group compared to the warfarin group ($883.96 ± 278.78 vs $816.59 ± 182.72, P = 0.06). CONCLUSION: Catheter ablation for atrial fibrillation can be performed safely on uninterrupted warfarin without intracardiac echocardiography, with a reduced risk of bleeding complications.

Adventure tourism and adventure sports injury: the New Zealand experience.

The primary aims of this study were to establish a client injury baseline for the New Zealand adventure tourism and adventure sport sector, and to examine patterns and trends in claims for injury during participation in adventure activities. Content analysis of narrative text data for compensated injuries occurring in a place for recreation and sport over a 12-month period produced over 15,000 cases involving adventure tourism and adventure sport. As found in previous studies in New Zealand, highest claim counts were observed for activities that are often undertaken independently, rather than commercially. Horse riding, tramping, surfing and mountain biking were found to have highest claim counts, while hang gliding/paragliding/parasailing and jet boating injuries had highest claim costs, suggesting greatest injury severity. Highest claim incidence was observed for horse riding, with female claimants over-represented for this activity. Younger male claimants comprised the largest proportion of adventure injuries, and falls were the most common injury mechanism.

Sulphate, nitrogen and base cation budgets at 21 forested catchments in Canada, the United States and Europe.

To assess the concern over declining base cation levels in forest soils caused by acid deposition, input-output budgets (1990s average) for sulphate (SO(4)), inorganic nitrogen (NO(3)-N; NH(4)-N), calcium (Ca), magnesium (Mg) and potassium (K) were synthesised for 21 forested catchments from 17 regions in Canada, the United States and Europe. Trend analysis was conducted on monthly ion concentrations in deposition and runoff when more than 9 years of data were available (14 regions, 17 sites). Annual average SO(4) deposition during the 1990s ranged between 7.3 and 28.4 kg ha(-1) per year, and inorganic nitrogen (N) deposition was between 2.8 and 13.8 kg ha(-1) per year, of which 41-67% was nitrate (NO(3)-N). Over the period of record, SO(4) concentration in deposition decreased in 13/14 (13 out of 14 total) regions and SO(4) in runoff decreased at 14/17 catchments. In contrast, NO(3)-N concentrations in deposition decreased in only 1/14 regions, while NH(4)-N concentration patterns varied; increasing at 3/14 regions and decreasing at 2/14 regions. Nitrate concentrations in runoff decreased at 4/17 catchments and increased at only 1 site, whereas runoff levels of NH(4)-N increased at 5/17 catchments. Decreasing trends in deposition were also recorded for Ca, Mg, and K at many of the catchments and on an equivalent basis, accounted for up to 131% (median 22%) of the decrease in acid anion deposition. Base cation concentrations in streams generally declined over time, with significant decreases in Ca, Mg and K occurring at 8, 9 and 7 of 17 sites respectively, which accounted for up to 133% (median 48%) of the decrease in acid anion concentration. Sulphate export exceeded input at 18/21 catchments, likely due to dry deposition and/or internal sources. The majority of N in deposition (31-100%; median 94%) was retained in the catchments, although there was a tendency for greater NO(3)-N leaching at sites receiving higher (<7 kg ha(-1) per year) bulk inorganic N deposition. Mass balance calculations show that export of Ca and Mg in runoff exceeds input at all 21 catchments, but K export only exceeds input at 16/21 sites. Estimates of base cation weathering were available for 18 sites. When included in the mass balance calculation, Ca, Mg and K exports exceeded inputs at 14, 10 and 2 sites respectively. Annual Ca and Mg losses represent appreciable proportions of the current exchangeable soil Ca and Mg pools, although losses at some of the sites likely occur from weathering reactions beneath the rooting zone and there is considerable uncertainty associated with mineral weathering estimates. Critical loads for sulphur (S) and N, using a critical base cation to aluminium ratio of 10 in soil solution, are currently exceeded at 7 of the 18 sites with base cation weathering estimates. Despite reductions in SO(4) and H(+) deposition, mass balance estimates indicate that acid deposition continues to acidify soils in many regions with losses of Ca and Mg of primary concern.

Reconsidering the motor recovery plateau in stroke rehabilitation.

Termination of motor rehabilitation is often recommended as patients with cerebrovascular accident (CVA) become more chronic and/or when they fail to respond positively to motor rehabilitation (commonly termed a "plateau"). Managed-care programs frequently reinforce this practice by restricting care to patients responding to therapy and/or to the most acute patients. When neuromuscular adaptation occurs in exercise, rather than terminating the current regimen, a variety of techniques (eg, modifying intensity, attempting different modalities) are used to facilitate neuromuscular adaptations. After presenting the concepts of the motor recovery plateau and adaptation, we similarly posit that patients with CVA adapt to therapeutic exercise but that this is not indicative of a diminished capacity for motor improvement. Instead, like traditional exercise circumstances, adaptive states can be overcome by modifying regimen aspects (eg, intensity, introducing new exercises). Findings suggesting that patients with chronic CVA can benefit from motor rehabilitation programs that apply novel or different parameters and modalities. The objectives of this commentary are to (1) to encourage practitioners to reconsider the notion of the motor recovery plateau, (2) to reconsider chronic CVA patients' ability to recover motor function, and (3) to use different modalities when accommodation is exhibited.

How physicians' organizations compete: protectionism and efficiency.

This article develops a framework that distinguishes four types of competitive strategies that physicians' organizations can adopt in their interactions with health plans. Two types of strategies protect physicians' incomes and autonomy from incursion and control by insurers; the other two enhance the efficiency of health care markets by controlling costs and embedding physicians' caregiving in a community of professionals. The mix of strategies that each organization adopts at any given time depends on the market conditions and regulatory policies it faces, as well as its organizational capacity. The article reviews recent developments in the field that indicate that today's markets and regulations create neither the pressures nor the capacity for physicians' organizations to adopt strategies that enhance efficiency. The managed care backlash has led to a relaxation of pressures to control costs, and the lack of a business case for quality has discouraged embedded caregiving. These developments instead have encouraged and enabled physicians' organizations to adopt strategies that protect their members from the bargaining power and micromanagement of health plans. The article therefore proposes changes in purchasing and regulatory policies to alter the pressures and improve the capacity of physicians' organizations to pursue efficiency and eschew protectionism.

"Virtual" health care organizations and the challenges of improving quality.

This article examines the challenges of improving health care quality continuously within and across "virtual" provider organizations such as independent practice associations and physician-hospital organizations. It draws on recent research and theory about interorganizational networks in other fields to develop recommendations for securing physicians' commitment to quality improvement strategies in today's health care environment.