A recent joint report from the Institute of Medicine and the National Academy of Engineering, highlights the benefits of--indeed, the need for--mathematical analysis of healthcare delivery. Tools for such analysis have been developed over decades by researchers in Operations Research (OR). An OR perspective typically frames a complex problem in terms of its essential mathematical structure. This article illustrates the use and value of the tools of operations research in healthcare. It reviews one OR tool, queueing theory, and provides an illustration involving a hypothetical drug treatment facility.
Queueing Theory (QT) is the study of waiting lines. The theory is useful in that it provides solutions to problems of waiting and its relationship to key characteristics of healthcare systems. More generally, it illustrates the strengths of modeling in healthcare and service delivery.
Queueing theory offers insights that initially may be hidden. For example, a queueing model allows one to incorporate randomness, which is inherent in the actual system, into the mathematical analysis. As a result of this randomness, these systems often perform much worse than one might have guessed based on deterministic conditions. Poor performance is reflected in longer lines, longer waits, and lower levels of server utilization.
As an illustration, we specify a queueing model of a representative drug treatment facility. The analysis of this model provides mathematical expressions for some of the key performance measures, such as average waiting time for admission.
We calculate average occupancy in the facility and its relationship to system characteristics. For example, when the facility has 28 beds, the average wait for admission is 4 days. We also explore the relationship between arrival rate at the facility, the capacity of the facility, and waiting times.
One key aspect of the healthcare system is its complexity, and policy makers want to design and reform the system in a way that affects competing goals. OR methodologies, particularly queueing theory, can be very useful in gaining deeper understanding of this complexity and exploring the potential effects of proposed changes on the system without making any actual changes.
Recent studies have focused on gender differences in movement patterns as risk factors for ACL injury. Understanding intrinsic and extrinsic factors which contribute to movement patterns is critical to ACL injury prevention efforts. Isometric lower-extremity muscular strength, anthropometrics, and jump-landing technique were analyzed for 2,753 cadets (1,046 female, 1,707 male) from the U.S. Air Force, Military and Naval Academies. Jump-landings were evaluated using the Landing Error Scoring System (LESS), a valid qualitative movement screening tool. We hypothesized that distinct anthropometric factors (Q-angle, navicular drop, bodyweight) and muscle strength would predict poor jump-landing technique in males versus females, and that female cadets would have higher scores (more errors) on a qualitative movement screen (LESS) than males. Mean LESS scores were significantly higher in female (5.34 ± 1.51) versus male (4.65 ± 1.69) cadets (P<.001). Qualitative movement scores were analyzed using factor analyses, yielding five factors, or “patterns”, contributing to poor landing technique. Females were significantly more likely to have poor technique due to landing with less hip and knee flexion at initial contact (P<.001), more knee valgus with wider landing stance (P<.001), and less flexion displacement over the entire landing (P<.001). Males were more likely to have poor technique due to landing toe-out (P<.001), with heels first, and with an asymmetric foot landing (P<.001). Many of the identified factor patterns have been previously proposed to contribute to ACL injury risk. However, univariate and multivariate analyses of muscular strength and anthropometric factors did not strongly predict LESS scores for either gender, suggesting that changing an athlete’s alignment, BMI, or muscle strength may not directly improve his or her movement patterns.
jump-landing; ACL injury risk; motor patterns; qualitative movement screen
The U.S. Institute of Medicine (IOM) much publicized report in “To Err is Human” (2000, National Academy Press) stated that as many as 98 000 hospitalized patients in the U.S. die each year due to preventable medical errors. This revelation about medical error and patient safety focused the public and the medical community's attention on errors in healthcare delivery including laboratory and point-of-care-testing (POCT). Errors introduced anywhere in the POCT process clearly can impact quality and place patient's safety at risk. While POCT performed by or near the patient reduces the potential of some errors, the process presents many challenges to quality with its multiple tests sites, test menus, testing devices and non-laboratory analysts, who often have little understanding of quality testing. Incoherent or no regulations and the rapid availability of test results for immediate clinical intervention can further amplify errors. System planning and management of the entire POCT process are essential to reduce errors and improve quality and patient safety.
Mechanical forces can regulate various functions in living cells. The cytoskeleton is a crucial element for the transduction of forces in cell-internal signals and subsequent biological responses. Accordingly, many studies in cellular biomechanics have been focused on the role of the contractile acto-myosin system in such processes. A widely used method to observe the dynamic actin network in living cells is the transgenic expression of fluorescent proteins fused to actin. However, adverse effects of GFP-actin fusion proteins on cell spreading, migration and cell adhesion strength have been reported. These shortcomings were shown to be partly overcome by fusions of actin binding peptides to fluorescent proteins. Nevertheless, it is not understood whether direct labeling by actin fusion proteins or indirect labeling via these chimaeras alters biomechanical responses of cells and the cytoskeleton to forces. We investigated the dynamic reorganization of actin stress fibers in cells under cyclic mechanical loading by transiently expressing either egfp-Lifeact or eyfp-actin in rat embryonic fibroblasts and observing them by means of live cell microscopy. Our results demonstrate that mechanically-induced actin stress fiber reorganization exhibits very different kinetics in EYFP-actin cells and EGFP-Lifeact cells, the latter showing a remarkable agreement with the reorganization kinetics of non-transfected cells under the same experimental conditions.
Lower Extremities Committee of Korean Academy of Medical Sciences Guideline for Impairment Rating develops new guidelines which are based on McBride method, American Medical Association Guides, Disability evaluation by The Korean Orthopaedic Association, The Korean Neurosurgery Society, and Korean Academy of Rehabilitation Medicine. The committee analyzed and discussed to create an ideal method practical in Korea. Our committee endeavors to develop new methods which are easy to use, but are suitable for professional use and also independent from the examinee's intentions. The lower extremities are evaluated on the basis of anatomic change, functional change, and diagnosis based evaluation. Nine methods are used to assess the lower extremities. Anatomic assessment includes leg length discrepancy, ankylosis, amputation, skin loss, peripheral nerve injury, and vascular disease. In functional assessment, range of motion and muscle strength are included. Diagnosis-based assessments are used to evaluate impairment caused by specific fractures, deformities, ligament instability, meniscectomies, post-traumatic arthritis, fusion of the foot, and lower extremity joint replacements.
Disability Evaluation; Lower Extremity; Impairment
Background: Supplemental educational reading material is of no value to patients if it is not read and comprehended. Objective: Using standardized research tools, online patient education materials were comparatively assessed for readability and length in words to identify the strengths and weaknesses of widely utilized sources. Methods: Three sources of patient-education material on the internet (WebMD.com, Wikipedia.org, and MedicineOnline.com) were compared with materials produced by the American Academy of Dermatology for readability utilizing Flesch-Kincaid Grade Level and Flesch Reading Ease Scale. Automated word counts were used to determine the length of each educational piece. Results: The information presented in American Academy of Dermatology electronic pamphlets on the internet is significantly harder to comprehend than MedicineOnline.com, but easier than Wikipedia.org. The latter site proved significantly harder to comprehend than all other sources. The American Academy of Dermatology electronic pamphlets and MedicineOnline.com materials were the most concise, averaging 1,200 words or less, although this was not a statistically significant difference in length compared to other online patient-education resources. No single source of online patient-education material demonstrates optimal features with regard to each of these parameters. Limitations: Only 15 topic areas in the four most commonly accessed sources of patient information were analyzed in this study. Conclusion: No single source of commonly used internet patient-education material demonstrates optimal features with regard to readability, length, and presence of photographic illustrations. These educational materials should target a length of 1,200 words, be illustrated with clinical images, and readability should correspond with the national average reading level.
Nepal the “Shangri-La” in the lap of the Himalayas is gearing up for modern times as it starts rebuilding after a decade of senseless violence and destruction. The nation one of the poorest in the global development index is rich in natural resources and biodiversity. Reports of medicinal plants far exceeding those recorded and reported so far are encouraging and at the same time concerns for medicinal plants under threat as a result of overexploitation are emerging from Nepal. The harsh mountain terrains, lack of industrialization and harnessing potentiality of its areas of strength; water; natural resources and tourism make it poor in per capita income which averages ~ 300 US$, with half the population living under >1$ a day. Nepal is beginning to realize that the way ahead is only possible through the path of Science and Technology (ST). Nepal Academy of Science and Technology formerly known as Royal Academy of Science and Technology organized the fifth national conference held every 4 years that took place in the capital Kathmandu during November 10-12, 2008. The ST initiation event saw the participation of ~ 1400 people representing over 150 organizations from the country and experts from abroad. The theme for the fifth national meet was “Science, Technology and Innovation for Prosperous Nepal”. Complementary and Alternative Medicine (CAM) was an important theme in the event as the realization for the need of ST research focused in CAM for harnessing the chemo diversity potential was univocally approved.
It is widely recognised that many patients do not take prescribed medicines as advised.
Research in this field has commonly focused on the role of the patient in non-adherence;
however, healthcare professionals can also have a major influence on patient behaviour
in taking medicines. This study examines the perceptions, beliefs and behaviours of
healthcare professionals—doctors, pharmacists and nurses—about patient
Methods and analysis
This paper describes the study protocol and online questionnaire used in a
cross-sectional survey of healthcare professionals in Europe. The participating
countries include Austria, Belgium, France, Greece, The Netherlands, Germany, Poland,
Portugal, Switzerland, Hungary, Italy and England. The study population comprises
primary care and community-based doctors, pharmacists and nurses involved in the care of
adult patients taking prescribed medicines for chronic and acute illnesses.
Knowledge of the nature, extent and variability of the practices of healthcare
professionals to support medication adherence could inform future service design,
healthcare professional education, policy and research.
A protocol for a cross-sectional survey of healthcare professionals in Europe to
examine the perceptions, beliefs and behaviours of healthcare
professionals—doctors, pharmacists and nurses—about patient medication
The questionnaire used in the survey of healthcare professionals is described in
There is an acute need for evidence regarding healthcare professionals'
beliefs, perceptions and behaviour with regard to patient non-adherence to
This protocol describes a study to address this need.
The results of this study could guide healthcare professionals as they support
patients with taking medicine in their day-to-day clinical practice.
Strengths and limitations of this study
The survey is the largest cross-national survey of healthcare professionals'
approach to medication adherence.
Reliance on self-report data may raise concerns regarding the validity of the
Hydrodynamic, spectroscopic, and chemical crosslinking studies on monomer chromatin subnits are reported as a function of ionic strength, pH, and temperature. In earlier studies, two salt-dependent conformational transitions were described (Gordon et al., Proceedings of the National Academy of Science, 75, 660, 1978). Transition one occurred between 0.7 and 2.0 mM ionic strength and transition two occurred between 5.0 and 11.0 mM ionic strength. Crosslinking at 11 mM ionic strength with formaldehyde suppressed both transitions. In this communication we report that the second transition was characterized by changes in the circular dichroism spectra in the 260--320 nm region as well as by changes in the hydrodynamic properties. As the ionic strength was increased from 5.0 to 11.0 mM, [theta]282 decreased from 2000 TO 1500 DEG CM2/DMOLE AND [THETA]295 decreased from 0 to -400 deg cm2/dmole. Both transitions occurred in the pH range from pH 6.0 to 9.2. At pH 5.0, the two ionic strength-dependent transitions were no longer observed and the characteristic changes in the circular dichroism spectra were suppressed. The spectra of the monomer subunits at pH 5.0 showed only small changes with ionic strength and resembled the spectra of the subunits at 11 mM ionic strength above pH 6.0. In order to characterize the transitions in thermodynamic terms an ionic strength near the midpoint of each transition was selected. Then, changes in s20,w and D20,w were measured as a function of temperature. These data allow an estimation to be made of the enthalpies and entropies of the transitions.
The European Association of Communication in Healthcare (EACH) Early Career Researchers Network (ECRN) aims are to (1) promote international collaboration among young investigators and (2) provide a support network for future innovative communication research projects. In October 2009, Miami, USA at a workshop facilitated by the ECRN at the International Conference on Communication in Healthcare (ICCH) hosted by the American Academy of Communication in Healthcare we explored common facilitators and challenges faced by early career researchers in health communication research.
Attendees introduced themselves, their research area(s) of interest, and listed one facilitator and one barrier for their career development. EACH ECRN members then led a discussion of facilitators and challenges encountered in communication research projects and career development. We discussed potential collaboration opportunities, future goals, and activities.
Having supportive collegial relationships, institutional support, job security, and funding are critical facilitators for early career investigators. Key challenges include difficulty with time management and prioritizing, limited resources, and contacts.
International collaboration among early career researchers is a feasible and effective means to address important challenges, by increasing opportunities for professional support and networking, problem-solving, discussion of data, and ultimately publishing.
Future AACH-EACH Early Career Researcher Networks should continue to build collaborations by developing shared research projects, papers, and other scholarly products.
Early career development; collaboration; communication research; EACH, AACH
The methods for healthcare reform are strikingly underdeveloped, with much reliance on political power. A methodology that combined methods from sources such as clinical trials, experience-based wisdom, and improvement science could be among the aims of the upcoming work in the USA on comparative effectiveness and on the agenda of the Center for Medicare and Medicaid Innovation in the Centers for Medicare and Medicaid Services. Those working in quality improvement have an unusual opportunity to generate substantial input into these processes through professional organisations such as the Academy for Healthcare Improvement and dominant leadership organisations such as the Institute for Healthcare Improvement.
Public policy; quality improvement; comparative effectiveness research; continuous quality improvement; health policy; leadership; randomised controlled trial; research
Realist synthesis is an increasingly popular approach to the review and synthesis of evidence, which focuses on understanding the mechanisms by which an intervention works (or not). There are few published examples of realist synthesis. This paper therefore fills a gap by describing, in detail, the process used for a realist review and synthesis to answer the question ‘what interventions and strategies are effective in enabling evidence-informed healthcare?’ The strengths and challenges of conducting realist review are also considered.
The realist approach involves identifying underlying causal mechanisms and exploring how they work under what conditions. The stages of this review included: defining the scope of the review (concept mining and framework formulation); searching for and scrutinising the evidence; extracting and synthesising the evidence; and developing the narrative, including hypotheses.
Based on key terms and concepts related to various interventions to promote evidence-informed healthcare, we developed an outcome-focused theoretical framework. Questions were tailored for each of four theory/intervention areas within the theoretical framework and were used to guide development of a review and data extraction process. The search for literature within our first theory area, change agency, was executed and the screening procedure resulted in inclusion of 52 papers. Using the questions relevant to this theory area, data were extracted by one reviewer and validated by a second reviewer. Synthesis involved organisation of extracted data into evidence tables, theming and formulation of chains of inference, linking between the chains of inference, and hypothesis formulation. The narrative was developed around the hypotheses generated within the change agency theory area.
Realist synthesis lends itself to the review of complex interventions because it accounts for context as well as outcomes in the process of systematically and transparently synthesising relevant literature. While realist synthesis demands flexible thinking and the ability to deal with complexity, the rewards include the potential for more pragmatic conclusions than alternative approaches to systematic reviewing. A separate publication will report the findings of the review.
The role of nursing in the delivery of health care has emerged as a complex and cross-cutting issue ripe for inquiry and multidisciplinary research. Indeed, problems in the nursing workforce have risen high on the agendas on many influential organizations, including the American Academy of Nursing, the Institute of Medicine, the National Quality Forum, The Robert Wood Johnson Foundation, and others. In an effort to clarify current research issues and advance an agenda for future investigations, Dr. Peter Buerhaus at Vanderbilt University organized a round table focused on the working conditions of the nursing workforce at the AcademyHealth 2003 Annual Research Meeting in Nashville, Tenn. Chaired by the University of California, Los Angeles, School of Public Health's Jack Needleman, the “Working Conditions of the Nursing Workforce” roundtable proved to be a provocative exchange of views among researchers and users of research. Participants shared background about their role in advancing the research, identified gaps in current research, and suggested specific areas for further research. What follows is an edited transcript of the Roundtable that, in addition to Dr. Needleman, included Ellen Kurtzman, National Quality Forum; Barbara Mark, University of North Carolina, Chapel Hill; Lori Melichar, The Robert Wood Johnson Foundation; and Donald Steinwachs, Johns Hopkins University.
During 19–20 October 2009, the Royal Swedish Academy of Sciences arranged the international symposium Energy 2050 in Stockholm. The symposium was held in association with the Swedish EU presidency in autumn 2009. Internationally renowned scientists assessed the energy issue in a broad perspective, with particular emphasis on the possibilities of a fossil-free future. The symposium focused on key topics emanating from the in-depth energy studies carried through by the Academy´s Energy Committee since 2005. The world community is facing a challenge of historic proportions to define a new energy paradigm based on fossil-energy substitutes. This article gives an overview of the current global energy situation (2007) and of the technologies which have the major potential for supplying energy up to year 2050 without jeopardizing the CO2 emission targets.
Energy; Fossilfree energy; Paradigm; Renewable energy; Geothermal energy
Damage to motor areas of the brain, caused by stroke, can produce devastating motor deficits, including aberrant control of force. Reorganization of brain function has been identified as one of the fundamental mechanisms involved in recovery of motor control after stroke, and recent advances in neuroimaging have enabled study of this brain reorganization. This review focuses on neuroimaging studies that have examined reorganization of brain function during force production and force modulation after stroke. Type and extent of reorganization after stroke was characterized via three factors: severity of injury, time after stroke and the impact of therapeutic interventions on brain activation during force production. Twenty-six studies meeting the inclusion criteria could be identified in MEDLINE (1980 to 2007). Relevant characteristics of studies (lesion location, chronicity of stroke, motor task) and mapping techniques varied widely. During force production, increased activation in secondary motor areas occurred in persons with more severe strokes. Also, reduced recruitment of secondary motor areas during force production was found as a function of increased time since stroke. During force modulation, increased activation in motor areas occurred with greater force generation. In addition, persons with more severe stroke showed relatively greater activation with rising force as compared to persons with less severe stroke. Lastly, alteration of brain activation during and after rehabilitative interventions in persons with stroke occurred in some studies. This systematic review establishes that reorganization of brain function during force production and force modulation can occur after stroke. These findings imply that therapeutic strategies that may be able to target brain reorganization to improve force control and functional recovery after stroke.
PMID: 19265770 CAMSID: cams1877
To describe the American Academy on Communication in Healthcare’s (AACH) Faculty Development Course on Teaching the Medical Interview and report a single year’s outcomes.
We delivered a Faculty Development course on Teaching the Medical Interview whose theme was relationship-centered care to a national and international audience in 1999. Participants completed a retrospective pre-post assessment of their perceived confidence in performing interview, clinical, teaching, and self-awareness skills.
PARTICIPANTS AND SETTING
A total of 79 participants in the 17th annual AACH national faculty development course at the University of Massachusetts Medical School in June 1999.
A 5-day course utilized the principles of learner-centered learning to teach a national and international cohort of medical school faculty about teaching the medical interview.
MEASUREMENTS AND MAIN RESULTS
The course fostered individualized, self-directed learning for participants, under the guidance of AACH faculty. Teaching methods included a plenary session, small groups, workshops, and project groups all designed to aid in the achievement of individual learning goals. Course outcomes of retrospective self-assessed confidence in interview, clinical, teaching, self-awareness, and control variables were measured using a 7-point Likert scale. Participants reported improved confidence in interview, clinical, teaching, and self-awareness variables. After controlling for desirability bias as measured by control variables, only teaching and self-awareness mean change scores were statistically significant (p < .001).
The AACH Faculty Development course on Teaching the Medical Interview utilized learner-centered teaching methods important to insure learning with experienced course participants. Perceived teaching and self-awareness skills changed the most when compared to other skills.
medical interview; physician–patient relations; faculty development; educational methods
All public systems look for the best organizational structure to funnel part of their national income into healthcare services. Appropriate policies may differ widely across country settings. Most healthcare systems fall under one of two broad categories, either Bismark or Beveridge systems. There is no simple ideal model for the organization of health services, but most healthcare systems that follow the Beveridge healthcare model are poor performers. The Libyan Health system is a low responsive, inefficient and underperforming system that lacks goals and/or SMART. (Specific, Measurable, Achievable, Realistic, Time specific) objectives. A look at different organization models in the world would reinforce efforts to reorganize and improve the performance of the Libyan National Healthcare services. The French Health Care System (FHCS) ranked first according to the WHO and the European Health Consumer Powerhouse. The FHCS was described to have a technically efficient, generous healthcare system that provides the best overall health care. This makes the FHCS a practical model of organization having many of the essential aspects of a modern national health service. In this review, we describe the main features of the FHCS, current challenges and future trends with particular attention paid to aspects that could be of importance to the Libyan Healthcare System.
Health service; Health crises; Reform; French Health System; Libyan Health System
Patellofemoral pain syndrome (PFPS) is one of the most common chronic knee injuries; however, little research has been done to determine the risk factors for this injury.
Altered lower extremity kinematics and kinetics, decreased strength, and altered postural measurements will be risk factors.
1597 participants were enrolled in this investigation and prospectively followed from the date of their enrollment (July 2005, July 2006, or July 2007) through January 2008. Each participant underwent baseline data collection during their pre-freshman summer at the United States Naval Academy. Baseline data collection included three-dimensional motion analysis during a jump-landing task, six lower extremity isometric strength tests, and postural alignment measurements (navicular drop and Q-angle). Participants were prospectively followed from their date of enrollment to January 2008 (maximum of 2.5 years of follow up).
Risk factors for the development of PFPS included decreased knee flexion angle, decreased vertical ground reaction force, and increased hip internal rotation angle during the jump-landing task. Additionally, decreased quadriceps and hamstring strength, increased hip external rotator strength, and increased navicular drop were risk factors for the development of PFPS.
Multiple modifiable risk factors for PFPS pain have been identified in this investigation. In order to decrease the incidence of this chronic injury, the risk factors for PFPS need to be targeted in injury prevention programs.
Prevention programs should focus on increasing strength of the lower extremity musculature along with instructing proper mechanics during dynamic movements in order to decrease the incidence of PFPS.
incidence; anterior knee pain; risk factors
“Diabetes and Oral Disease: Implications for Health Professionals” was a one-day conference convened by the Columbia University College of Dental Medicine, the Columbia University College of Physicians and Surgeons, and the New York Academy of Sciences on May 4, 2011in New York City. The program included an examination of the bidirectional relationship between oral disease and diabetes and the inter-professional working relationships for the care of people who have diabetes. The overall goal of the conference was to promote discussion among the healthcare professions who treat people with diabetes, encourage improved communication and collaboration among them and ultimately, improve patient management of the oral and overall effects of diabetes. Attracting over 150 members of the medical and dental professions from eight different countries, the conference included speakers from academia and government and was divided into four sessions. This report summarizes the scientific presentations of the event.
diabetes; oral disease; meeting report
This needs assessment, initiated by the Academy for Healthcare Education Inc. in cooperation with AXDEV Group Inc., explored the knowledge, attitudes, behavior, and skills of community-based and academic-affiliated U.S. cardiologists in the area of CV risk assessment, treatment, and management from July 2006 to December 2006.
The needs assessment used a multistage, mixed-method approach to collect, analyze, and verify data from two independent sources. The exploratory phase collected data from a representative sampling of U.S. cardiologists by means of qualitative panel meetings, one-on-one interviews, and quantitative questionnaires. In the validation phase, 150 cardiologists from across the United States completed a quantitative online questionnaire. Data were analyzed with standardized statistical methods.
The needs assessment found that cardiologists have areas of weakness pertaining to their interpersonal skills, which may influence patient-physician communication and patient adherence. Cardiologists appeared to have little familiarity with or lend little credence to the concept of relative CV risk. In daily clinical practice, they faced challenges with regard to optimal patient outcome in areas of patient referral from primary-care providers, CV risk assessment and treatment, and patient monitoring. Community-based and academic-affiliated cardiologists appeared to be only moderately interested in educational interventions that pertain to CV risk-reduction strategies.
Educational interventions that target cardiologists' interpersonal skills to enhance their efficacy may benefit community-based and academic-affiliated specialists. Other desirable educational initiatives should address gaps in the patient referral process, improve patient knowledge and understanding of their disease, and provide supportive educational tools and materials to enhance patient-physician communication.
One of the goals of the American Academy of Orthopaedic Surgeons (AAOS) is to disseminate patient education materials that suit the readability skills of the patient population. According to standard guidelines from healthcare organizations, the readability of patient education materials should be no higher than the sixth-grade level. We hypothesized the readability level of patient education materials available on the AAOS Web site would be higher than the recommended grade level, regardless when the material was available online. Readability scores of all articles from the AAOS Internet-based patient information Web site, “Your Orthopaedic Connection,” were determined using the Flesch-Kincaid grade formula. The mean Flesch-Kincaid grade level of the 426 unique articles was 10.43. Only 10 (2%) of the articles had the recommended readability level of sixth grade or lower. The readability of the articles did not change with time. Our findings suggest the majority of the patient education materials available on the AAOS Web site had readability scores that may be too difficult for comprehension by a substantial portion of the patient population.
In September 2000, the Agency for Healthcare Quality and Research and the American Academy of Pediatrics Center for Child Health Research sponsored a meeting of experts and knowledgeable stakeholders to identify 1) the special information needs of pediatric care and 2) health service research questions related to the use of information technology in children's health care. Technologies that support the care of children must address issues related to growth and development, children's changing physiology, and the unique diseases of children and interventions of pediatric care. Connectivity and data integration are particular concerns for child health care workers. Consumer health information needs for this population extend beyond the needs of one individual to the needs of the family. Recommendations of the attendees include rapid implementation of features in electronic health information systems that support pediatric care and involvement of child health experts in policy making, standards setting, education, and advocacy. A proposed research agenda should address both effectiveness and costs of information technology, with special consideration for the needs of children, the development and evaluation of clinical decision support in pediatric settings, understanding of the epidemiology of iatrogenic injury in childhood, supplementation of vocabulary standards with pediatrics-specific terminology, and improvement in health care access for children, using telemedicine.
Guidelines translate best evidence into best practice. A well-crafted guideline promotes quality by reducing healthcare variations, improving diagnostic accuracy, promoting effective therapy, and discouraging ineffective – or potentially harmful – interventions. Despite a plethora of published guidelines, methodology is often poorly defined and varies greatly within and among organizations.
This manual describes the principles and practices used successfully by the American Academy of Otolaryngology – Head and Neck Surgery to produce quality-driven, evidence-based guidelines using efficient and transparent methodology for action-ready recommendations with multi-disciplinary applicability. The development process, which allows moving from conception to completion in twelve months, emphasizes a logical sequence of key action statements supported by amplifying text, evidence profiles, and recommendation grades that link action to evidence.
As clinical practice guidelines become more prominent as a key metric of quality healthcare, organizations must develop efficient production strategies that balance rigor and pragmatism. Equally important, clinicians must become savvy in understanding what guidelines are – and are not – and how they are best utilized to improve care. The information in this manual should help clinicians and organizations achieve these goals.
Dietary supplement use is common in the United States, with more than half of the population using such products. Nutrition authorities consistently advocate a "food first" approach to achieving nutritional adequacy but some, including the Academy of Nutrition and Dietetics (formerly the American Dietetic Association), also recognize that dietary supplements have a role to play in improving nutrient intake to support health and wellness. Surveys show that many health professionals use dietary supplements themselves and also recommend dietary supplements to their patients or clients.
As one component of a series of surveys of healthcare professionals (the "Life...supplemented" HCP Impact Studies), 300 registered dietitians were surveyed in 2009 regarding their personal use of dietary supplements and whether they recommend dietary supplements to their clients. Respondents were registered dietitians whose business involved seeing clients in a private practice or at a clinic.
Seventy-four percent of the dietitians surveyed said they were regular users of dietary supplements, while 22% said they used dietary supplements occasionally or seasonally. The primary reasons for using dietary supplements were for bone health (58%), overall health and wellness (53%), and to fill nutrient gaps (42%). When asked if they "ever recommend dietary supplements to clients," 97% of the respondents said they did. The primary reasons were for bone health (70%), to fill nutrient gaps (67%), and overall health and wellness (49%). Eighty-seven percent of the dietitians agreed with the statement, "There are gaps in clients' diets that could effectively be addressed with dietary supplements." The dietitians surveyed said they followed healthy habits including eating a balanced diet (96%), managing stress (92%), visiting their own healthcare professional regularly (86%), exercising regularly (83%), maintaining a healthy weight (80%), and getting a good night's sleep (72%). Nearly all respondents (95%) expressed an interest in continuing education about dietary supplements on a variety of topics.
Many dietitians, like other health professionals, use dietary supplements regularly as part of their own approach to a healthy diet and lifestyle. They also recommend dietary supplements to their clients or patients, to promote health.
Dietary supplements; Supplement surveys; Dietitians' health habits
Acute gastroenteritis remains a common condition among infants and children throughout the world. In 1996, The American Academy of Pediatrics (AAP) revised its recommendations for the treatment of infants and children with acute gastroenteritis.
The purpose of this survey was to determine how closely current treatment among Lebanese pediatricians compares with the AAP recommendations and to determine the impact of such management on the healthcare system.
Patients and Methods:
The outline of the study was based on a telephone questionnaire that addressed the management of healthy infants and children below five years of age with acute gastroenteritis complicated by mild to moderate dehydration. In addition, the costs of medical treatment and requested laboratory studies were calculated.
A total of 238 pediatricians completed the questionnaire. Most pediatricians prescribed Oral Rehydration Solutions (ORS) for rehydration (92.4%), advised breastfeeding during acute gastroenteritis (81.5%), and avoided parenteral rehydration for mild to moderate dehydration (89.1%). In addition to ORS, oral fluids such as soda, juices, and rice water were allowed for rehydration by 43.7% of pediatricians. Thirty-one percent of pediatricians delayed re-feeding for more than 6 hours after initiation of rehydration. Only 32.8% of pediatricians kept their patients on regular full-strength formulas, and only 21.8% permitted full-calorie meals for their patients. 75.4% of pediatricians did not order any laboratory studies in cases of mild dehydration and 50.4% did not order any laboratory studies for moderate dehydration. Stool analysis and culture were ordered by almost half of the pediatricians surveyed. Seventy-seven percent prescribed anti-emetics, 61% prescribed probiotics, 26.3% prescribed antibiotics systematically and local antiseptic agents, 16.9% prescribed zinc supplements, and 11% percent prescribed antidiarrheal agents.
Pediatricians in Lebanon are aware of the importance of ORS and the positive role of breastfeeding in acute gastroenteritis. However, they do not follow optimal recommendations from the AAP concerning nutrition, laboratory examinations and drug prescriptions. Consequently, this poses significant financial losses and economic burden.
Acute gastroenteritis; Lebanese pediatricians; laboratory studies in acute gastroenteritis in children; oral rehydration solutions