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At least 739 records · Page 41Linked to original sources
PubMed1996

Knowledge based commissioning: can a national clinical effectiveness policy be compatible with seeking local professional advice?

OBJECTIVES: To help develop a means, based on the views of purchasers and providers of health care, of incorporating national research on clinical effectiveness into local professional advisory mechanisms in order to inform health care purchasing and contracting. METHODS: Three geographically based multidisciplinary workshops attended by National Health Service (NHS) staff drawn from the principal purchaser and provider groups in one English region were organized around the discussion of three health care purchasing case studies: coronary artery disease, diabetes and management of clinical depression in general practice. The proceedings were transcribed and analyzed using content analysis methods. RESULTS: 95 people took part. There were major differences between the purchasers' and health care providers' views on the right balance between local and national information and advisory sources for purchasing. In general, providers wanted the provision of advice to purchasers to be local, in which their opinion was sought, either individually or collectively, acted on and the results fed back to them. In contrast, health authority purchasers considered that local professionals were only one source of professional advice, albeit an important one, to be utilized in coming to decisions. General practitioner fundholders as purchasers, however, preferred to rely on their own experiences and contacts with local providers in making purchasing decisions. CONCLUSIONS: Professional specialist advisory groups are necessary to inform the purchasing of health care, but should extend beyond advising on the placement of individual contracts. Involving health care providers in all short-term contracting is unlikely to be cost-effective given the time commitment required. The emphasis at purchaser/provider meetings should be on education: providing an opportunity for purchasers and providers to develop closer relationships to discuss political imperatives and financial constraints; increasing communication and understanding of providers' and purchasers' roles; and providing an environment for professionals and purchasers to share their views on purchasing. As currently presented, elements of the national policies in the NHS advocating the use of both national evidence on clinical effectiveness and local professional advice are contradictory and should be clarified.

Community Health Planning↗
PubMed2001

Perspectives on comorbidity and cancer in older patients: approaches to expand the knowledge base.

Not only do persons 65 years and older bear a disproportionate burden of cancer, advancing age is associated with increased vulnerability to other age-related health problems. Newly diagnosed older cancer patients who have lived into later years of life may have concurrent ailments (eg, diabetes, chronic obstructive pulmonary disease, heart disease, arthritis, and/or hypertension) that could affect treatment choice, prognosis, and survival. The clinician must often make cancer treatment decisions in the context of an older individual's pre-existing health problems (ie, comorbidity). Ways to produce reliable information on comorbidity that can be effectively used in evaluation of older cancer patients are urgently needed. What is the nature and severity of the older patient's comorbid health problems? How do other age-related conditions influence treatment decisions and the cancer course? How do already compromised older patients tolerate the stress of cancer and its treatment? How are concomitant comorbid conditions managed? At present, no established, valid way to assess comorbidity in older cancer patients exists. Such technology, with a solid conceptual and scientific base, promises a high positive clinical yield to assure quality cancer care for older patients if reliable and valid instruments can be integrated into oncology practice. Much preliminary scientific work must be performed. A synthesis of viewpoints on what to include in comorbidity assessment of older cancer patients and development approaches were expressed in a multidisciplinary working group convened by the National Institute on Aging and the National Cancer Institute. We share the key issues raised regarding complexities of comorbidity assessment and suggestions for scientific inquiry.

Aged↗
PubMed1996

The knowledge base of bee navigation

Navigation in honeybees is discussed against the background of the types of memories employed in the navigational task. Two questions are addressed. Do bees have goal-specific expectations, and when are novel routes travelled? Expectations are deduced from (1) context stimuli as determinants for local cue memories, (2) landmark-dependent path integration, (3) sequential learning of landmarks, and (4) motivation- and context-dependent memory retrieval. Novel routes are travelled under two conditions: (1) goal-cue-based piloting and (2) integration of simultaneously activated vector memories. Our data do not support the conclusion that memory integration in bees is organised by a cognitive map. The assumption of purely separate memories that are only retrieved according to the chain of events during navigational performance also appears to be inadequate. We favour the view that multiple memories are integrated using external and internal sources of information. Such configural memories lead to both specific expectations and novel routes.

Journal Article↗
PubMed1996

Dynamics of the upper limb during performance of the tasks of everyday living--a review of the current knowledge base.

This paper provides a brief review of the published literature on the subject of kinematics and kinetics of the human arm and shoulder mechanism, specifically when performing the tasks of everyday living. Surprisingly, only a small number of papers covering functional analysis of the arm were found, and the majority of these were concerned only with the kinematics of the elbow and lower arm. Differences in experimental method and a lack of consensus as to how to model the joint axes of the human arm make the results difficult to compare. Results are normally only presented in the form of angular excursion of the arm segments, with only one paper providing data on angular velocities and accelerations. The results of the different analyses suggest that the human arm is adaptive (due to its inherent mechanical redundancy), showing the ability to perform the same tasks using differing kinematic strategies. Therefore, the principal interest for the designer of upper limb orthoses should be the work-space defined by the start and end points of the hand, and the maintenance of the desired hand orientation when performing these tasks.

Activities of Daily Living↗
PubMed1994

Knowledge-based information management: implications for information services.

The 1994 Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) standards for information management will change the way health care librarians respond to JCAHO accreditation surveys and may affect the way libraries are managed. This article will highlight the changes in the standards and the new opportunities they offer. Implications for library operations and the challenges inherent in working with the new Accreditation Manual for Hospitals (AMH) are also explored. The long-awaited 1994 Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) Accreditation Manual for Hospitals (AMH) is now on most hospital library shelves. As expected, librarians will find that the section on Professional Library Services (the PR chapter) has disappeared and that the standards previously in that section are now incorporated in part into the new Management of Information, or IM chapter. Although this method of grouping standards may be new to many health sciences librarians, the incorporation of library services into IM may actually provide many more opportunities for librarians than the previous method of addressing library services separately.

Accreditation↗
PubMed1998

Antiretroviral therapy for HIV infection. A knowledge-based approach to drug selection and use.

In the absence of evidence that eradication of HIV from an infected individual is feasible, the established goal of antiretroviral therapy is to reduce viral load to as low as possible for as long as possible. Achieving this with the currently available antiretroviral agents involves appropriate selection of components of combination regimens to obtain an optimal antiviral response. In addition, consideration of a plan for a salvage or second-line regimen is required if initial therapy fails to achieve an optimal response or should loss of virological control occur despite effective initial therapy. Such a planned approach, based on consideration of the likely modes of therapeutic failure (viral resistance, cellular resistance, toxicity) could be called rational sequencing. Choice of therapy should never involve compromise in terms of activity. However, the choice of drug should also be guided by tolerability profiles and considerations of coverage of the widest range of infected cells, compartmental penetration, pharmacokinetic interactions and, importantly, the ability of an agent or combination to limit future therapeutic options through selection of cross-resistant virus. Available clinical end-point data clearly indicate that combination therapy is superior to monotherapy, with clinical and surrogate marker data supporting the use of triple drug (or double protease inhibitor) combinations over double nucleoside analogue combinations. Thus, 3-drug therapy should represent current standard practice in a nontrials setting. Treatment should be considered as early as practical, and may be best guided by measurement of viral load, with a range of other markers having potential utility in individualising treatment decisions. Therapeutic failure may be defined clinically, immunologically or, ideally, virologically, and should prompt substitution of at least 2, and preferably all, components of the treatment regimen. Drug intolerance may also be best managed by rational substitution.

Anti-HIV Agents↗