Strengthening implementation success using large-scale consensus decision-making - A new approach to creating medical practice guidelines

A study involving over 2000 stoma care nurses in the development of best practice guidelines for the assessment of peristomal body profiles, patient engagement and patient follow-up was conducted in 2018. The study was designed to develop guidelines for stoma care treatment and product selection and to decrease the evidence to implementation gap. The project built on research evidence from a literature review of 77 articles. The results of the literature review were then used to inform a series of Delphi surveys sent out to stoma care nurses through Association and industry list-serves in 11 languages. The Delphi surveys were followed by a face2face professionally facilitated discussions among nurse-research experts. The project concluded with a facilitated consensus dialogue among 960 stoma care nurses from 25 countries, resulting in an implementation plan to ensure the guidelines become a normal part of routine patient care. The study resulted in a set of medical practice guidelines for stoma care nurses, designed to improve patient outcomes and patient quality of life, that were accepted and adopted into routine medical practice across 25 countries. This article describes the study and how the process used, coined the ‘Modified Delphi Process’ by the process designer, led to faster implementation than is generally experienced in the medical community.     

Treatment Choice With Trial Data: Statistical Decision Theory Should Supplant Hypothesis Testing

Abstract

A central objective of empirical research on treatment response is to inform treatment choice. Unfortunately, researchers commonly use concepts of statistical inference whose foundations are distant from the problem of treatment choice. It has been particularly common to use hypothesis tests to compare treatments. Wald’s development of statistical decision theory provides a coherent frequentist framework for use of sample data on treatment response to make treatment decisions. A body of recent research applies statistical decision theory to characterize uniformly satisfactory treatment choices, in the sense of maximum loss relative to optimal decisions (also known as maximum regret). This article describes the basic ideas and findings, which provide an appealing practical alternative to use of hypothesis tests. For simplicity, the article focuses on medical treatment with evidence from classical randomized clinical trials. The ideas apply generally, encompassing use of observational data and treatment choice in nonmedical contexts.     

Institutional antecedents of subsidiary external embeddedness: Coping with regulatory competitive constraints

We investigate institutional antecedents to subsidiary external embeddedness and relate regulation constraining competition in local service sectors to subsidiary embeddedness with local partners in complementary sectors. Combining research on business networks with arguments derived from transaction cost economics, we argue that subsidiary external embeddedness depends on the extent of transaction costs originating from small numbers bargaining, which regulatory competitive constraints in local service sectors are a source of. Based on this logic, we suggest that low and high levels of regulatory competitive constraints are associated with greater subsidiary external embeddedness. We also suggest that this U-shaped relationship is more pronounced for subsidiaries that are centers of excellence within the multinational enterprise because these subsidiaries heavily depend on the local context as a source of their competitive advantage over their sister subsidiaries.     

Center–periphery relations,local governance and conflicts in Ethiopia: the experience of Metekel province

In Ethiopia, the study and issue of center–periphery relations is not an easy task. It has remained complex and dynamics as it has been dictated and shaped by ever changing socio-economic relations, state ideology and structure. A case in point is Metekel region, which had been characterized by under development, lowland, hot climate and traditional way of life. Until post-1991developments, Metekel was peripheral in relation to the central state. It was an area of confrontation and conflict. Owing to the structural weakness of the centre, successive rulers of the area did not command effective control over it. Focusing on Gumuz, a Nilo-Saharan family, on one hand, and highlanders and new settlers, on the other, this essay examined the main features and dynamics of center–periphery relations, governance and conflicts in Metekel area. The sources, both primary and secondary, have been carefully examined based on the objectives of the study.     

Nonparametric Comparison for Multivariate Panel Count Data

Multivariate panel count data often occur when there exist several related recurrent events or response variables defined by occurrences of related events. For univariate panel count data, several nonparametric treatment comparison procedures have been developed. However, it does not seem to exist a nonparametric procedure for multivariate cases. Based on differences between estimated mean functions, this article proposes a class of nonparametric test procedures for multivariate panel count data. The asymptotic distribution of the new test statistics is established and a simulation study is conducted. Moreover, the new procedures are applied to a skin cancer problem that motivated this study.     

北洋政府时期的农村与农民———以战乱和灾荒为研究视角

北洋政府时期,军阀为维护统治,满足其军费开支,过度剥削农民,田赋杂税猛如虎。由于军阀的割据战争和泛滥的匪患,中国农村俨如一个兵匪的王国。 加之该时期天灾不断,而预防、救济皆不到位,农村遍地灾荒、连年灾荒。 天灾人祸相交,致使北洋政府时期农村经济普遍衰落,农民命悬一线。知识分子、国民党等尝试提出了各自振兴农村的方案和策略,但都以失败而告终。 直到中国共产党诞生后,提出土地革命政策,才寻找到了一条真正能解放农村的新道路,农村社会才迎来了发展的新时机。     

Social Work and Complex Care Systems: The Case of People Hospitalised with a Disability

Health and hospital system reforms prioritise efficiency. However, initiatives can impact on people with new or existing disabilities who require time to maximise functional independence. With greater demands for shorter hospital stays social workers face increasing pressure to facilitate discharge. This paper reports findings from research identifying factors contributing to extended stays for adults with disabilities. We sought to better understand patient characteristics and discharge planning challenges by analysing a clinical dataset of 80 patients and qualitative interviews with five experienced hospital social workers. Three key factors are identified: issues around rehabilitation services; assessment and planning for community care; and availability of and access to discharge options. Strategies to reduce length of stay are reported. We argue that building collaborative partnerships and working across multiple, complex systems and disciplines are vital to ensure these patients access appropriate community-based resources within the current health reform environment.     

医疗保险对农村居民家庭消费的影响分析--基于不同收入层级的跨地区比较

利用2009、2010农村固定观察点数据，分析了医疗保险对不同地区、不同收入层级的农村居民家庭医疗消费支出和非医疗消费支出的影响。实证结果表明：医疗保险对农村居民家庭的医疗类消费不存在显著影响，对非医疗类消费支出则存在显著的正向促进作用。分地区来看，医疗保险对东西部地区农村居民家庭医疗类消费的影响差异显著，对东中部地区农村居民家庭非医疗类消费支出的影响同样差异显著；分收入层级来看，医疗保险对家庭医疗类消费的影响在不同收入层级的农村居民家庭之间不存在显著差异，但对非医疗类消费支出的影响在不同收入层级之间差异显著。此外，商业医疗保险作为医疗保险体系的重要组成部分，对促进农村消费起到带动作用。最后，本文从加大政府补贴和完善保障机制两个方面提出政策建议以期有效降低农村居民家庭超常的预防性储蓄，促进农村居民家庭消费。     

试论日本医疗体制改革的具体举措及绩效分析

日本医疗体制改革在坚持全民医疗保险制度和非营利性医疗机构为主体的医疗服务提供制度的前提下,以增加患者的负担比例、优化医疗机构、提高医疗质量、扩大医疗资金财源为主要内容,进行了一系列改革。日本医疗体制改革虽然还面临很多困境,但是从长期来看对控制医疗费的持续增长,恢复国民对医疗体制的信赖,减轻政府财政负担有一定作用。