Statistical issues in the prospective monitoring of health outcomes across multiple units

Summary.  Following several recent inquiries in the UK into medical malpractice and failures to deliver appropriate standards of health care, there is pressure to introduce formal monitoring of performance outcomes routinely throughout the National Health Service. Statistical process control (SPC) charts have been widely used to monitor medical outcomes in a variety of contexts and have been specifically advocated for use in clinical governance. However, previous applications of SPC charts in medical monitoring have focused on surveillance of a single process over time. We consider some of the methodological and practical aspects that surround the routine surveillance of health outcomes and, in particular, we focus on two important methodological issues that arise when attempting to extend SPC charts to monitor outcomes at more than one unit simultaneously (where a unit could be, for example, a surgeon, general practitioner or hospital): the need to acknowledge the inevitable between-unit variation in 'acceptable' performance outcomes due to the net effect of many small unmeasured sources of variation (e.g. unmeasured case mix and data errors) and the problem of multiple testing over units as well as time. We address the former by using quasi-likelihood estimates of overdispersion, and the latter by using recently developed methods based on estimation of false discovery rates. We present an application of our approach to annual monitoring 'all-cause' mortality data between 1995 and 2000 from 169 National Health Service hospital trusts in England and Wales.     

An Assessment of EU 2020 Strategy: Too Far to Reach?

In 2010, EU adopted a new growth strategy which includes three growth priorities and five headline targets to be reached by 2020. The aim of this paper is to investigate the current performance of the EU member and candidate states in achieving these growth priorities and the overall strategy target by allocating the headline targets into the priorities and the priorities into the strategy by the use of a composite indicator methodology. The paper determines how far away each member and candidate state is from the targeted levels of the priorities and the strategy by making a distinction between EU 15 and relatively new member states as well. The developed composite indices enable the observation of the performances of the member and candidate states in a single indicator for the overall strategy and each growth priority. The results of the strategy index and three growth priority indices show that Nordic states possess the highest index scores already having reached many of the targets; many new member states performed as good as EU 15 and some EU 15 states are placed at the bottom of the ranking with quite poor performance in reaching the EU 2020 strategy.     

Consulting in industry: Moving beyond traditional interventions

Despite increased efforts to address musculoskeletal disorders (MSDs) in the work place, these injuries continue significantly impact the bottom line financial performance of companies, not to mention the health and safety of their most important resource - their workers. As MSD costs continue to rise, rehabilitation professionals must approach effective injury management and prevention processes from an onsite perspective. A paradigm shift is in order. Successful practitioners need to transform themselves from a clinical specialist to an onsite consultant. This article introduces various elements that are critical to the successful transformation of an onsite consultant. Effective onsite injury management and prevention concepts are discussed. Case studies are also presented to further illustrate the value of the onsite consultant approach.     

Correlates of infant pointing frequency in the first year

This study examines the emergence of concurrent correlates of infant pointing frequency with the aim of contributing to its ontogenetic theories. We measured monthly from 8 to 12 months infants' (N = 56) index-finger pointing frequency along with several candidate correlates: (1) family socioeconomic status (SES), (2) mothers' pointing production, and (3) infants' point following to targets in front of and behind them. Results revealed that (1) infants increased their pointing frequency across age, but high-SES infants had a steeper increase, and a higher pointing frequency than low-SES infants from 10 months onward, (2) maternal pointing frequency was not associated with infant pointing frequency at any age, (3) infants' point following abilities to targets behind their visual fields was positively associated with their pointing frequency at 12 months, after pointing had already emerged around 10 months. Findings suggest that family SES impacts infants' pointing development more generally, not just through maternal pointing. The association between pointing and following points to targets behind, but not in front, suggests that a higher level of referential understanding emerges after, and perhaps through the production of pointing.