Health service accreditation reinforces a mindset of high-performance human resource management: lessons from an Australian study

OBJECTIVE

To investigate whether an accreditation program facilitates healthcare organizations (HCOs) to evolve and maintain high-performance human resource management (HRM) systems.

DESIGN

Cross-sectional multimethod study.

SETTING AND PARTICIPANTS

Healthcare organizations participating in the Australian Council on Healthcare Standards Evaluation and Quality Improvement Program (EQuIP 4) between 2007 and 2011.

MAIN OUTCOME MEASURES

Ratings across the EQuIP 4 HRM criteria, a clinical performance measure, surveyor reports (HRM information) and interview data (opinions and experiences regarding HRM and accreditation).

RESULTS

Healthcare organizations identified as high performing on accreditation HRM criteria seek excellence primarily because of internal motivations linked to best practice. Participation in an accreditation program is a secondary and less significant influence. Notwithstanding, the accreditation program provides the HCO opportunity for internal and external review and assessment of their performance; the accreditation activities are reflective learning and feedback events.

CONCLUSIONS

This study reveals that HCOs that pursue highly performing HRM systems use participation in an accreditation program as an opportunity. Their organizational mindset is to use the program as a tool by which to reflect and obtain feedback on their performance so to maintain or improve their management of staff and delivery of care.

A method for the automated long-term monitoring of three-spined stickleback Gasterosteus aculeatus shoal dynamics

This paper describes and evaluates a flexible, non-invasive tagging system for the automated identification and long-term monitoring of individual three-spined sticklebacks Gasterosteus aculeatus. The system is based on barcoded tags, which can be reliably and robustly detected and decoded to provide information on an individual's identity and location. Because large numbers of fish can be individually tagged, it can be used to monitor individual- and group-level dynamics within fish shoals.

Anaerobic digestion of corn ethanol thin stillage in batch and by high-rate down-flow fixed film reactors

Thin stillage (CTS) from a dry-grind corn ethanol plant was evaluated as a carbon source for anaerobic digestion (AD) by batch and high rate semi-continuous down-flow stationary fixed film (DSFF) reactors. Biochemical methane potential (BMP) assays were carried out with CTS concentrations ranging from approximately 2,460-27,172 mg total chemical oxygen demand (TCOD) per litre, achieved by diluting CTS with clean water or a combination of clean water and treated effluent. High TCOD, SCOD and volatile solids (VS) removal efficiencies of 85 ± 2, 94 ± 0 and 82 ± 1% were achieved for CTS diluted with only clean water at an organic concentration of 21,177 mg TCOD per litre, with a methane yield of 0.30 L methane per gram TCOD(removed) at standard temperature and pressure (STP, 0 °C and 1 atmosphere). Batch studies investigating the use of treated effluent for dilution showed promising results. Continuous studies employed two mesophilic DSFF anaerobic digesters treating thin stillage, operated at hydraulic retention times (HRT) of 20, 14.3, 8.7, 6.3, 5 and 4.2 d. Successful digestion was achieved up to an organic loading rate (OLR) of approximately 7.4 g TCOD L(-1)d(-1) at a 5 d HRT with a yield of 2.05 LCH(4) L(-1)d(-1) (at STP) and TCOD and VS removal efficiencies of 89 ± 3 and 85 ± 3%, respectively.

Docetaxel for the adjuvant treatment of early node-positive breast cancer: a single technology appraisal

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of docetaxel for the adjuvant treatment of early node-positive breast cancer based upon the manufacturer's submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturer's scope restricts the intervention to docetaxel in combination with doxorubicin and cyclophosphamide (TAC), and the comparator to anthracycline-based chemotherapy. Based on the BCIRG 001 trial, the submitted evidence shows that TAC is associated with superior disease-free and overall survival at 5 years compared with the anthracycline-based regimen FAC. The absolute risk reduction in patients treated with TAC compared with those treated with FAC was 7% for disease-free survival and 6% for overall survival. However, TAC was associated with significantly greater toxicity than FAC. There is also evidence that docetaxel, in an unlicensed sequential regimen FEC100-T, is associated with superior disease-free and overall survival at 5 years compared with FEC100. An economic model was developed by the manufacturer based on the BCIRG 001 trial. This generated central estimates of the cost per life-year gained and cost per quality-adjusted life-year (QALY) gained of TAC compared with FAC of 7900 pounds and 9800 pounds respectively. The manufacturer's submission predicts a cost-effectiveness of 15,000 pounds to 20,000 pounds per QALY gained for TAC compared with E-CMF (epirubicin in sequential therapy with cyclophosphamide, methotrexate, and fluorouracil), and estimates the cost-effectiveness of FEC100-T to be 8200 pounds per QALY compared with FEC100. Taking into account a number of issues identified by the ERG this may generate higher estimates of cost-effectiveness, but these are unlikely to exceed 35,000 pounds per QALY gained. Importantly, FAC is not commonly used in clinical practice in the UK and, therefore, the submitted evidence does not indicate whether TAC is superior to the anthracycline-based regimens that are in common use (FEC or E-CMF). The indirect comparisons presented suggest that the economic case for TAC in comparison to current UK practice may not be proven. The manufacturer's submission failed to record evidence of three serious adverse events in patients receiving docetaxel with doxorubicin or to mention the concern of the European Medicines Agency regarding TAC's long-term adverse events. The guidance issued by NICE in June 2006 as a result of the STA states that docetaxel, when given concurrently with doxorubicin and cyclophosphamide (the TAC regimen), is recommended as an option for the adjuvant treatment of women with early node-positive breast cancer.

Asynchronous, out-of-sequence, transcontinental chain kidney transplantation: a novel concept

The organ donor shortage has been the most important hindrance in getting listed patients transplanted. Living kidney donors who are incompatible with their intended recipients are an untapped resource for expanding the donor pool through participation in transplant exchanges. Chain transplantation takes this concept further, with the potential to benefit even more recipients. We describe the first asynchronous, out of sequence transplant chain that was initiated by transcontinental shipment of an altruistic donor kidney 1 week after that recipient's incompatible donor had already donated his kidney to the next recipient in the chain. The altruistic donor kidney was transported from New York to Los Angeles and functioned immediately after transplantation. Our modified-sequence asynchronous transplant chain (MATCH) enabled eight recipients, at four different institutions, to benefit from the generosity of one altruistic donor and warrants further exploration as a promising step toward addressing the organ donor shortage.

Docetaxel for the adjuvant treatment of early nodepositive breast cancer: a single technology appraisal

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of docetaxel for the adjuvant treatment of early node-positive breast cancer based upon the manufacturer’s submission to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The manufacturer’s scope restricts the intervention to docetaxel in combination with doxorubicin and cyclophosphamide (TAC), and the comparator to anthracycline-based chemotherapy. Based on the BCIRG 001 trial, the submitted evidence shows that TAC is associated with superior disease-free and overall survival at 5 years compared with the anthracycline-based regimen FAC. The absolute risk reduction in patients treated with TAC compared with those treated with FAC was 7% for disease-free survival and 6% for overall survival. However, TAC was associated with significantly greater toxicity than FAC. There is also evidence that docetaxel, in an unlicensed sequential regimen FEC100-T, is associated with superior diseasefree and overall survival at 5 years compared with FEC100. An economic model was developed by the manufacturer based on the BCIRG 001 trial. This generated central estimates of the cost per life-year gained and cost per quality-adjusted lifeyear (QALY) gained of TAC compared with FAC of £7900 and £9800 respectively. The manufacturer’s submission predicts a cost-effectiveness of £15,000–£20,000 per QALY gained for TAC compared with E-CMF (epirubicin in sequential therapy with cyclophosphamide, methotrexate, and fluorouracil), and estimates the cost-effectiveness of FEC100-T to be £8200 per QALY compared with FEC100. Taking into account a number of issues identified by the ERG this may generate higher estimates of cost-effectiveness, but these are unlikely to exceed £35,000 per QALY gained. Importantly, FAC is not commonly used in clinical practice in the UK and, therefore, the submitted evidence does not indicate whether TAC is superior to the anthracycline-based regimens that are in common use (FEC or E-CMF). The indirect comparisons presented suggest that the economic case for TAC in comparison to current UK practice may not be proven. The manufacturer’s submission failed to record evidence of three serious adverse events in patients receiving docetaxel with doxorubicin or to mention the concern of the European Medicines Agency regarding TAC’s long-term adverse events. The guidance issued by NICE in June 2006 as a result of the STA states that docetaxel, when given concurrently with doxorubicin and cyclophosphamide (the TAC regimen), is recommended as an option for the adjuvant treatment of women with early nodepositive breast cancer.

Use of classical and novel biomarkers as prognostic risk factors for localised prostate cancer: a systematic review

OBJECTIVES

To provide an evidence-based perspective on the prognostic value of novel markers in localised prostate cancer and to identify the best prognostic model including the three classical markers and investigate whether models incorporating novel markers are better.

DATA SOURCES

Eight electronic bibliographic databases were searched during March-April 2007. The reference lists of relevant articles were checked and various health services research-related resources consulted via the internet. The search was restricted to publications from 1970 onwards in the English language.

METHODS

Selected studies were assessed, data extracted using a standard template, and quality assessed using an adaptation of published criteria. Because of the heterogeneity regarding populations, outcomes and study type, meta-analyses were not undertaken and the results are presented in tabulated format with a narrative synthesis of the results.

RESULTS

In total 30 papers met the inclusion criteria, of which 28 reported on prognostic novel markers and five on prognostic models. A total of 21 novel markers were identified from the 28 novel marker studies. There was considerable variability in the results reported, the quality of the studies was generally poor and there was a shortage of studies in some categories. The marker with the strongest evidence for its prognostic significance was prostate-specific antigen (PSA) velocity (or doubling time). There was a particularly strong association between PSA velocity and prostate cancer death in both clinical and pathological models. In the clinical model the hazard ratio for death from prostate cancer was 9.8 (95% CI 2.8-34.3, p < 0.001) in men with an annual PSA velocity of more than 2 ng/ml versus an annual PSA velocity of 2 ng/ml or less; similarly, the hazard ratio was 12.8 (95% CI 3.7-43.7, p < 0.001) in the pathological model. The quality of the prognostic model studies was adequate and overall better than the quality of the prognostic marker studies. Two issues were poorly dealt with in most or all of the prognostic model studies: inclusion of established markers and consideration of the possible biases from study attrition. Given the heterogeneity of the models, they cannot be considered comparable. Only two models did not include a novel marker, and one of these included several demographic and co-morbidity variables to predict all-cause mortality. Only two models reported a measure of model performance, the C-statistic, and for neither was it calculated in an external data set. It was not possible to assess whether the models that included novel markers performed better than those without.

CONCLUSIONS

This review highlighted the poor quality and heterogeneity of studies, which render much of the results inconclusive. It also pinpointed the small proportion of models reported in the literature that are based on patient cohorts with a mean or median follow-up of at least 5 years, thus making long-term predictions unreliable. PSA velocity, however, stood out in terms of the strength of the evidence supporting its prognostic value and the relatively high hazard ratios. There is great interest in PSA velocity as a monitoring tool for active surveillance but there is as yet no consensus on how it should be used and, in particular, what threshold should indicate the need for radical treatment.

Evolution of the concept of self-care and implications for nurses: a literature review

BACKGROUND

Worldwide, the increasing prevalence of chronic disease evokes concern on a number of levels, including quality of life, health care costs and workforce issues to meet increasing demands on services. One response has been a shift in governmental health policy to encourage greater involvement of the chronically ill individual in their health care through participation in self-management programmes. Embedded in self-management programmes is the underlying concept of self-care, a complex and multidimensional phenomenon.

OBJECTIVE

This paper explores the development of the concept of self-care through health related literature and reviews the factors that have shaped the concept.

DESIGN

A comprehensive search of the literature was undertaken drawing principally on key electronic databases of the health literature, augmented with reference list searching.

DATA SOURCES

English language publications indexed in CINAHL, EMBASE, AMED, MEDLINE and PsycInfo with no limit on date of publication.

REVIEW METHODS

Abstracts were reviewed against the inclusion criteria and quality appraisal undertaken. Twenty-two studies were reviewed.

RESULTS

Many definitions of self-care exist and a consensual definition has not been reached. The current concept of self-care has been shaped by many different social, economic and political factors and is embedded in diverse theoretical perspectives and paradigms.

CONCLUSION

An understanding of the underlying theoretical perspectives and paradigms embedded within acute and chronic disease management will facilitate nurses' engagement in the debate, practice within appropriate ethical boundaries and support individuals, families and communities more effectively in managing chronic disease.