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PubMed2027

Global Genomic Surveillance.

Global genomic surveillance has emerged as a foundational pillar of public health in the twenty-first century, enabling real-time tracking of pathogen evolution and informing outbreak response. This chapter examines the strategic architecture of global genomic surveillance, focusing on its application to arboviruses such as chikungunya virus (CHIKV). It explores the integration of genomic data with epidemiological, clinical, and environmental information within a One Health framework, while addressing critical challenges in governance, equity, and interoperability. The discussion covers the entire genomic surveillance workflow, from sample collection and sequencing to bioinformatic analysis and phylogenetic inference, and highlights the transformative role of artificial intelligence (AI) in predictive surveillance. By analyzing global initiatives, operational barriers, and emerging technologies, this chapter underscores the necessity of sustainable, equitable, and interoperable genomic systems to proactively address current and future infectious disease threats.

Humans↗

PubMed2004

An integrated comprehensive occupational surveillance system for health care workers.

BACKGROUND: Workers in the health care industry may be exposed to a variety of work-related stressors including infectious, chemical, and physical agents; ergonomic hazards; psychological hazards; and workplace violence. Many of these hazards lack surveillance systems to evaluate exposures and health outcomes. The development and implementation of a comprehensive surveillance system within the Duke University Health System (DUHS) that tracks occupational exposures and stressors as well as injuries and illnesses among a defined population of health care workers (HCWs) is presented. METHODS: Human resources job and work location data were used to define the DUHS population at risk. Outcomes and exposure data from existing occupational health and safety programs, health promotion programs, and employee health insurance claims, were linked with human resources data and de-identified to create the Duke Health and Safety Surveillance System (DHSSS). RESULTS: The surveillance system is described and four examples are presented demonstrating how the system has successfully been used to study consequences of work-related stress, hearing conservation program evaluation, risk factors for back pain and inflammation, and exposures to blood and body fluids (BBF). CONCLUSIONS: Utilization of existing data, often collected for other purposes, can be successfully integrated and used for occupational health surveillance monitoring of HCWs. Use of the DHSSS for etiologic studies, benchmarking, and intervention program evaluation are discussed.

Health Personnel↗

PubMed2002

Information and communication technology in health care: do we need feedback?

Applying information and communication technology (ICT) to a given medical domain is not merely adding a new technique. When applied to a medical domain, ICT has the potential to radically change processes in that domain. In their paper 'Health care in the information society: a prognosis for the year 2013' Haux and co-workers provide us with a set of predictions based on progress in three main areas: (1). patient-centred recording and use of medical data for collaborative care; (2). process-integrated decision support; and (3). comprehensive use of patient data for research and health care reporting. We complement their theses by predicting some of the feedback mechanisms that will develop as ICT is shaping health care. Feedback is return to the input of a part of the output of a mechanism; this part of the input constituting information that reports discrepancies between intended and actual operation and leads to a self-correcting action that can be utilised. We discuss feedback in the areas Haux identifies: the patient record, decision support, and the use of data for research and health care reporting. For each of these domains, we will discuss the output that serves as input, the discrepancies discovered, and the self-correction that will or should follow.

Cooperative Behavior↗

PubMed1998

Outpatient utilization patterns of integrated and split psychotherapy and pharmacotherapy for depression.

OBJECTIVE: This exploratory study examined utilization and costs among depressed patients in two treatment models-integrated treatment, in which psychotherapy and pharmacotherapy were provided by a psychiatrist, and split treatment, in which pharmacotherapy was provided by a psychiatrist and psychotherapy by a nonphysician psychotherapist. METHODS: A quasi-experimental retrospective design was used to compare claims data from a national managed mental health care organization for 191 patients in integrated treatment and 1,326 in split treatment. RESULTS: During the 18-month study, patients receiving integrated treatment used significantly fewer outpatient sessions and had significantly lower treatment costs, on average, than those in split treatment. Integrated treatment appeared to be associated with a pattern of utilization characterized by frequent treatment episodes in contrast to that of split treatment, which was characterized by more sessions with fewer breaks of 90 days or more. CONCLUSIONS: The results do not support the prevailing assumption that integrated treatment is more costly than split treatment in a managed care network. Despite limitations in the study methods, the strength of these preliminary findings poses a powerful challenge and invites further study.

Adolescent↗

PubMedDate not supplied

Effects of reorganization on laboratory quality: preliminary findings and lessons learned.

Reorganization and downsizing are common challenges for managers. This case study describes the implementation of a major restructuring of a clinical laboratory within a large, integrated medical-delivery organization. Economic trends prompted us to evaluate the effects of a major laboratory reorganization, with a significant shift from clinical laboratory scientists to lower waged, nonlicensed technical staff, on the analytic quality and other indicators of laboratory performance. Although a laboratory reorganization may be implemented slowly, this reorganization effort was completed quickly. Data were collected during both the pre- and post-reorganization period. Postimplementation performance indicators show no reductions in analytic quality. Effectively dealing with the human side of significant change appears to be the biggest challenge for managers, both in the short term and well after the reorganization. These results and qualitative information and insights might be of value to laboratory management contemplating a laboratory reorganization.

California↗

PubMed2001

Management of childhood illness at health facilities in Benin: problems and their causes.

OBJECTIVES: To prepare for the implementation of Integrated Management of Childhood Illness (IMCI) in Benin, we studied the management of ill children younger than 5 years at outpatient health facilities. METHODS: We observed a representative sample of consultations; after each consultation, we interviewed caregivers and reexamined children. Health workers' performance was evaluated against IMCI guidelines. To identify determinants of performance, statistical modeling was performed and 6 focus groups with health workers were conducted to solicit their opinions. RESULTS: Altogether, 584 children were enrolled and 101 health workers were observed; 130 health workers participated in focus group discussions. Many serious deficiencies were found: incomplete assessment of children's signs and symptoms, incorrect diagnosis and treatment of potentially life-threatening illnesses, inappropriate prescription of dangerous sedatives, missed opportunities to vaccinate, and failure to refer severely ill children for hospitalization. Quantitative and qualitative analyses showed various health facility-, health worker-, caregiver-, and child-related factors as possible determinants of health worker performance. CONCLUSIONS: Action is urgently needed. Our results suggest that to improve health care delivery, interventions should target both the health system and the community level.

Benin↗

PubMed2006

[Integrated health care at Recklinghausen].

This paper reports in detail on a project of Integrated Health Care in cardiology at Recklinghausen, Germany. Information on the structure of the contract, the participants, the agreed claiming of benefits and provision of services are provided as well as relevant figures and contact data.

Cardiology↗

PubMed2002

The impact of an integrated family planning program in Russia.

In 1995, the U.S. Agency for International Development implemented an integrated program of family planning education and services in six Russian cities to increase physicians' and women's contraceptive knowledge and change current contraceptive use. Large population-based surveys of women ages 15-44 were carried out at the beginning of project implementation (in 1996) and 3 years later in two project sites and a comparison site. Results from these surveys indicate that project activities affected women's knowledge of family planning methods, and caused women to have more favorable attitudes toward modern contraception. In addition, abortion rates decreased in project sites while remaining virtually unchanged in the comparison site. Because of uneven implementation of project interventions in the demonstration sites, however, the intervention's actual impact on abortion rates remains unclear.

Abortion, Legal↗

PubMed1999

The integration of comprehensive psychiatric/mental health care into the primary health system: diagnosis and treatment.

This research study was funded by the Health Systems Trust in Cape Town through the University of Natal in Durban. OBJECTIVES. The objectives of this study were to teach primary health care nurses to diagnose and treat common psychiatric conditions, to refer those patients whom they cannot handle, and to evaluate the implementation of these functions in their primary health care practice. METHODS. Twenty nurses from six clinics in one province of South Africa were trained, and implementation was studied. History taking, diagnosis, pharmacological treatment and referral were studied through record reviews. Record reviews were done by two independent psychiatrists, who achieved an inter-rater reliability of 0.68. RESULTS. Record reviews showed that at the end of the project nurses could take substantially complete psychiatric histories in 89% cases, five axis diagnoses were correct in 63% of cases, and when STAT medication was prescribed it was appropriate in 92% of cases. Appropriate long-term medication was prescribed in 60% of cases. ETHICAL ISSUES. Permission was obtained from the provincial office, the Municipal Offices and participating clinics. Informed consent was obtained by the registered nurses from all participating clients. LIMITATIONS. The sample for the clinics was not representative of all clinics in the Eastern Cape but a representation of rural-urban settings sampled from 20 clinics in a region. The sample of consumers was convenient and may not represent the client population in each clinic. For this reason the findings may not be a true reflection of the entire region, and generalization of the findings should be made at the utmost discretion of the reader.

Data Collection↗

PubMedDate not supplied

Towards a dynamic description of major depression epidemiology.

AIMS: The substantial impact of major depression on population health is widely acknowledged. To date, health system responses to this condition have been largely shaped by observational findings. In the future, health policy decisions will benefit from an increasingly integrated and dynamic understanding of the epidemiology of this condition. Policy decisions can also be supported by the development of decision-support tools that can simulate the impact of alternative policy decisions on population health. Markov models are useful both in epidemiological modelling and in decision analysis. METHODS: In this project, a Markov model describing major depression epidemiology was developed. The model employed a Markov Tunnel in order to depict the dependence of recovery probabilities on episode duration. Transition probabilities, including incidence, recovery and mortality were estimated from Canadian national survey data. RESULTS: Episode incidence was approximately 3% per year. Recovery rates declined exponentially over time. The model predicted point prevalence at slightly less than 1%, agreeing closely with observed prevalence data. CONCLUSIONS: Epidemiological models describing the dynamic relationships between major depression incidence, prevalence, recovery and mortality can help to integrate available epidemiological data. Such models offer an attractive option for support of health policy decisions.

Adolescent↗

PubMed1997

Integrating women's healthcare--serving the whole woman.

Health systems across the country are setting up centers to serve all the health needs of women. The driver for comprehensive care programs, they say, is expert intuition, not hard data, that integrated care will result in better outcomes than traditional fragmented care has produced. They point to women's preferences for "one-stop shopping" and government initiatives that encourage integration. And they offer six keys to successfully launching a comprehensive care program--insights gained in developing their programs.

Comprehensive Health Care↗

PubMed2001

A framework for monitoring maternal and infant health status.

The Mother and Infant Network (MINET) Program was established in South Western Sydney Area Health Service (SWSAHS) in 1997. MINET developed and implemented an integrated clinical data network as a key strategy to support and inform a Continuum of Care comprising hospital and community based services. There are good data sources within the MINET program. Its scope spans care for mothers and children, which begins with the first antenatal attendance and ends at school entry. This paper has three interrelated aims: to describe the development of the MINET program; to demonstrate the benefits of a sustainable Information Culture which can assist an Area Health Services in adopting a health outcomes based approach to service delivery; and to describe how MINET has the capacity to support Health Services Research.

Female↗

PubMed2005

Seniors' views on the use of electronic health records.

In the Mauricie and Centre-du-Québec region of the province of Quebec, Canada, an integrated services network has been implemented for frail seniors. It combines three of the best practices in the field of integrated services, namely: single-entry point, case management and personalized care plan. A shared interdisciplinary electronic health record (EHR) system was set up in 1998. A consensus on the relevance of using EHRs is growing in Quebec, in Canada and around the world. However, technology has out-paced interest in the notions of confidentiality, informed consent and the impact perceived by the clientele. This study specifically examines how frail seniors perceive these issues related to an EHR. The conceptual framework is inspired by the DeLone and McLean model whose main attributes are: system quality, information quality, utilisation modes and the impact on organisations and individuals. This last attribute is the focus of this study, which is a descriptive with quantitative and qualitative component. Thirty seniors were surveyed. Positive information they provided falls under three headings: (i) being better informed; (ii) trust and consideration for professionals; and (iii) appreciation of innovation. The opinions of the seniors are generally favourable regarding the use of computers and the EHR in their presence. Improvements in EHR systems for seniors can be encouraged.

Aged↗

PubMed2006

Mental health literacy in rural Queensland: results of a community survey.

OBJECTIVES: The aim of this study was to assess the awareness of, and attitudes to, mental health issues in rural dwelling Queensland residents. A secondary objective was to provide baseline data of mental health literacy prior to the implementation of Australian Integrated Mental Health Initiative--a health promotion strategy aimed at improving the health outcomes of people with chronic or recurring mental disorders. METHOD: In 2004 a random sample of 2% (2132) of the estimated adult population in each of eight towns in rural Queensland was sent a postal survey and invited to participate in the project. A series of questions were asked based on a vignette describing a person suffering major depression. In addition, questions assessed respondents' awareness and perceptions of community mental health agencies. RESULTS: Approximately one-third (36%) of those surveyed completed and returned the questionnaire. While a higher proportion of respondents (81%) correctly identified and labelled the problem in the vignette as depression than previously reported in Australian community surveys, the majority of respondents (66%) underestimated the prevalence of mental health problems in the community. Furthermore, a substantial number of respondents (37%) were unaware of agencies in their community to assist people with mental health issues while a majority of respondents (57.6%) considered that the services offered by those agencies were poor. CONCLUSION: While mental health literacy in rural Queensland appears to be comparable to other Australian regions, several gaps in knowledge were identified. This is in spite of recent widespread coverage of depression in the media and thus, there is a continuing need for mental health education in rural Queensland.

Adolescent↗

PubMed2026

A doubly robust framework for addressing outcome-dependent selection bias in multi-cohort EHR studies.

Selection bias can hinder accurate estimation of association parameters in binary disease risk models using non-probability samples like electronic health records (EHRs). The issue is compounded when participants are recruited from multiple clinics/centers with varying selection mechanisms that may depend on the disease/outcome of interest. Traditional inverse-probability-weighted (IPW) methods, based on constructed parametric selection models, often struggle with misspecifications when selection mechanisms vary across cohorts. This paper introduces a new Joint Augmented Inverse Probability Weighted (JAIPW) method, which integrates individual-level data from multiple cohorts collected under potentially outcome-dependent selection mechanisms, with data from an external probability sample. JAIPW offers double robustness by incorporating a flexible auxiliary score model to address potential misspecifications in the selection models. We outline the asymptotic properties of the JAIPW estimator, and our simulations reveal that JAIPW achieves up to 6 times lower relative bias and 5 times lower root mean square error (RMSE) compared to the best performing joint IPW methods under scenarios with misspecified selection models. Applying JAIPW to the Michigan Genomics Initiative (MGI), a multi-clinic EHR-linked biobank, combined with external national probability samples, resulted in cancer-sex association estimates closely aligned with national benchmark estimates. We also analyzed the association between cancer and polygenic risk scores (PRS) in MGI to illustrate a situation where the exposure variable is not measured in the external probability sample.

Selection Bias↗

PubMed1995

Modeling shared health and social care information.

The article describes an analysis of the detailed data used by different groups of health care professionals and their requirements to share data as part of an integrated information systems design project. This systematic recording of their data usage and sharing requirements led to the development of a novel analysis technique: the complex object grid. The use of the complex object grid facilitates the description of information usage and needs at several levels of detail.

Aged↗

PubMed2000

Responses of Canada's health care management education programs to health care reform initiatives.

Canada's provincial health care systems have been experiencing significant changes, mostly through horizontal integration achieved by merging hospitals, and, in a few cases, through vertical integration of public health, long term care, home care and hospital services. The government motivation for forcing these changes seems to have been primarily financial. In a few cases, the integration seems to have resulted in a stable and successful outcome, but, in most others, there has been destabilization, and in some, there has been chaos. The question posed in this research was how the five accredited Canadian graduate programs in health care management were responding to these changes. Two of the programs have recently made major changes in structure and/or delivery processes, following careful examination of their perceived environments. One has rationalized by subdividing courses. Another is repatriating courses from the business school in order to achieve more health-related content. Four of the five programs have added a number of courses in the last few years, or plan to do so in the next year or two, either because of accreditation criteria or student or faculty interest. The program directors viewed the educational requirements for clinicians and non-clinicians as being identical. In spite of the major structural changes, and the resulting destabilization of the health care organizations (and even governments), none of the programs emphasized the changes as factors in their plans for program changes. They expressed some concern about the possibility of fads as opposed to significant changes. It may be that these changes are dealt with in the content of individual courses. This aspect was not examined by the survey nor by interviews with the directors. Each of the programs has emphasized its own niche, with no consensus about changes required.

Canada↗

PubMed1994

The case against using the APACHE system to predict intensive care unit outcome in trauma patients.

The use of outcome indices as a means of evaluating institutional performance for delivery of medical care is at the forefront of federal health policy reforms. Because an enormous number of clinical and financial data are generated by ICU patients, it is inevitable that integrated bedside computers will be necessary to supply the type of information that is being sought by governmental and private insurance agencies involved in assessment of hospital performance. The Health Care Financing Administration already has adopted the APACHE data collection protocols and predictive models for the severity of illness adjustments that were used in assessing the 1986 hospital-specific death rate for acute myocardial infarction, congestive heart failure, stroke, and pneumonia. In our opinion, however, it is unlikely that any single system will be developed that can accurately estimate more than 50% of ICU deaths. The intention of the APACHE III system to include 78 diagnostic categories seems unrealistic. Furthermore, the number of data needed to document outcomes for both low- and high-risk admissions is impractical. We are evaluating APACHE III to determine whether the revisions to the definition for head trauma will represent a significant improvement in predicting outcomes for trauma patients. In the interim, the financial investment in the APACHE III automated bedside data collection system cannot be justified for trauma patients. Neither should it be used in ICUs that admit a large number of trauma patients as a tool for monitoring unit efficiency, guiding triage decisions, allocating staff and ICU beds, identifying risks of iatrogenic or other potential complications, or assessing quality of life, in spite of marketing efforts by the APACHE Corporation. We believe that using any of the APACHE systems for these purposes, at best, is premature, and potentially misrepresents the trauma patient population. Standards for patient classification already are in place for use in making determinations for institutional reimbursement from governmental and insurance agencies. The inequities for certain subgroups of patients, including trauma patients, could create situations in which care is rationed rather than allocated according to a plan that distributes resources efficiently. The APACHE system has several shortcomings and adds little, if anything, to the potential solutions for trauma quality assurance and resource allocation. Nor has the APACHE system established procedures for documenting institutional review of unexpected trauma deaths that would be equivalent, for example, to the type of audit filters applied by the American College of Surgeons in conjunction with the TRISS methodology.(ABSTRACT TRUNCATED AT 400 WORDS)

Bias↗