Systems thinking, complexity and managerial decision-making: an analytical review.

One feature that characterizes the organization and delivery of health care is its inherent complexity. All too often, with so much information and so many activities involved, it is difficult for decision-makers to determine in an objective fashion an appropriate course of action. It would appear that a holistic rather than a reductionist approach would be advantageous. The aim of this paper is to review how formal systems thinking can aid decision-making in complex situations. Consideration is given as to how the use of a number of systems modelling methodologies can help in gaining an understanding of a complex decision situation. This in turn can enhance the possibility of a decision being made in a more rational, explicit and transparent fashion. The arguments and approaches are illustrated using examples taken from the public health arena.

Characteristics of chiropractic practitioners, patients, and encounters in Massachusetts and Arizona.

OBJECTIVE: To describe chiropractic care using data collected at the time of each patient visit. METHODS: Random samples of chiropractors licensed in Arizona and Massachusetts were recruited to participate in interviews about their training, demographics, and practice characteristics. Interviewees were then recruited to record information about patient condition, evaluation, care, and visit disposition on 20 consecutive patient visits. RESULTS: Data for 2550 chiropractic patient visits were recorded. Care for low back, head and neck pain accounted for almost three quarters of visits. Extremity conditions and wellness care accounted for approximately half of the remaining visits. Spinal and soft tissue examinations were the most frequently reported diagnostic procedures (80% and 56% of visits, respectively), and high-velocity spinal manipulation techniques were the most frequently reported therapeutic procedures (almost 85% of visits). Rehabilitation exercises, thermal modalities, electric stimulation, and counseling/education/self-care were each performed during approximately 25% of visits. Approximately 85% of patients seen were self-referred, whereas only approximately 5% came from medical physicians. Approximately 35% of visits had an expected source of payment directly from the patient. Approximately 80% of visits ended with a plan for the patient to return at a specified time. CONCLUSION: These findings are consistent with the findings of previous studies and confirm that chiropractors use conventional patient assessment approaches with specific attention to spinal and musculoskeletal procedures, infrequently incorporating interventions commonly associated with other complimentary and alternative care providers. These findings illustrate that diagnostic assessment and follow-up are integral to chiropractic clinical encounters and offer a baseline for best practices development. The data also offer insight into chiropractic use and may be of interest to chiropractic leaders and education planners for professional development purposes.

Isolation and characterization of a novel gene close to the human phosphoinositide-specific phospholipase C beta 3 gene on chromosomal region 11q13.

We describe the isolation, characterization, and genomic structure of a gene, Phospholipase C beta 3 Neighboring gene (PNG), located on chromosome 11q13. The cDNA was isolated using a cosmid that also contains the phospholipase C beta 3 gene (PLCB3). PNG does not have any marked similarity to other known genes on the DNA level. However, analysis of hybridization to a panel of somatic cell hybrids indicates the existence of related sequences on chromosomes 2, 4, 7, and 22. PNG showed expression of a 1-kb message in multiple tissues. The predicted protein is 199 amino acids. The gene spans approximately 2.5 kb, divided into four exons and three introns. It is located 4.4 kb upstream of PLCB3, with the 5' ends facing each other. The intergenic region has been completely sequenced, revealing separate CpG islands at both ends of this region. The islands are separated by a stretch of 2 kb, characterized by periodic alteration of the GC content. The 5'-flanking region of PNG does not contain TATA or CCAAT, suggesting a housekeeping promoter structure.

Transfusion therapy in cardiac surgery: impact of the Paul Gann Blood Safety Act in California.

The Paul Gann Blood Safety Act became law in California on January 1, 1990, mandating that patients be informed of the risks and alternatives of blood transfusions. To evaluate the impact of this legislation, the authors compared transfusion therapy in patients undergoing cardiac surgery during 1990 to previous years (1986 to 1987 and 1989). Surgical techniques were unchanged. Homologous component usage was 8.7 +/- 0.6 (mean +/- SE) units/patient in 1986 to 1987 (n = 373), 8.2 +/- 0.9 in 1989 (n = 219) and 4.3 +/- 0.6 in 1990 (n = 222), P less than .001 by ANOVA. Erythrocyte transfusions were 3.5 +/- 0.2, 3.2 +/- 0.2, and 2.2 +/- 0.2 units/patient (P less than .001); platelet/plasma usage was 5.2 +/- 0.5, 4.9 +/- 0.7 and 2.1 +/- 0.4 units/patient (P less than .001). The number of patients not requiring transfusions increased from 28 per cent in 1989 (61 of 219) to 47 per cent in 1990 (104 of 222). A slight but significant decrease in cardiopulmonary bypass time and perioperative blood loss occurred. The authors conclude that this legislation stimulated the surgical team to control blood loss during surgery and to avoid the anticipatory use of component transfusions.