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PubMed1983

Effect of decentralized computer order entry on medication turnaround time.

The medication order turnaround times of two drug-distribution systems in the same hospital using either centralized or decentralized computer order entry were compared. A decentralized medication order entry satellite pharmacy equipped with a pharmacy computer terminal and a small supply of medications typically requested to be administered without delay was implemented on one floor of a 518-bed hospital. Pharmacist-verified medication orders for five of the hospital's 22 nursing units were entered into the satellite computer terminal and transmitted to the central pharmacy for processing. Initial doses of medication dispensed from the satellite's drug supply were noted in the central pharmacy. Pharmacy personnel recorded time they spent in various steps of the medication delivery cycle for routine medication orders handled by the decentralized pharmacy. The same measurements were made for the centralized pharmacy system before implementation of the pharmacy satellite. The mean turnaround time for routine medication orders in the decentralized system was 79.5 minutes, which was 52% less than that of the centralized system (167.3 minutes). Decentralized computer order entry appears to be an effective way of decreasing turnaround time for routine medication orders.

Computers↗
PubMed1990

In vivo measurement of posterior chamber intraocular lens decentration and tilt.

We report what to our knowledge is the first extensive in vivo clinical study of intraocular lens decentration and tilt. Measurements of posterior chamber intraocular lenses, all implanted by the same surgeon in 89 eyes, showed that decentration and tilt consistently differed between right and left eyes. Lenses tended to decenter superotemporally and tilt with their superonasal edges tipped forward. Decentration magnitude relative to the cornea light reflex axis and line of sight averaged 0.64 mm, with decentration increasing slightly with increased axial length. Average tilt was 6.75 degrees, and the average tilt-induced astigmatism was 0.27 diopter. Tilt magnitude decreased with increased axial length, as did tilt-induced astigmatism and plus sphere.

Adult↗
PubMedDate not supplied

The political economy of decentralization of health and social services in Canada.

A trend to decentralization in Canada's 'welfare state' has received support from the Left and from the Right. Some social critics of the Left expect decentralization to result in holistic services adjusted to local needs. Others, moreover, feel we are in the dawn of a new epoch in which major economic transformations are to bring about, through new class alliances and conflict, decentralization of power and a better quality of life in communities. These assumptions and their theoretical pitfalls are discussed here following an historical overview of the centralization/decentralization issue in Canadian social policy. It is argued that recent proposals of decentralization are a continuation of reactionary tendencies to constrain social expenditures, but not a path to better quality of life.

Canada↗
PubMedDate not supplied

Vertical or holistic decentralization of the health sector? Experiences from Zambia and Uganda.

Many countries in Africa have embarked on health sector reforms. The design of the reforms differs considerably. A key feature of the reforms is decentralization, of which Uganda and Zambia are implementing two different models. This paper analyses the two models of health sector reform, and their implications for ultimate development goals. In Uganda, the whole government has been decentralized, with a wide range of powers and resources transferred to the districts. The health care system is part of the political set up of the country. In Zambia, only the health sector has been decentralized. Power and resources for health care have been divested to new parallel organizations. While useful lessons can be drawn from the managerial and administrative experience in the two countries, not least concerning donor coordination, it seems that neither form of decentralization has so far led to a clear and appreciable improvement of health services and, ultimately, to a clear focus on development goals, such as poverty alleviation. The conditions for this to happen are discussed in this paper.

Female↗
PubMedDate not supplied

Financing indicators for health care decentralization in Latin America: information and suggestions for health planning.

This article presents the results from an evaluative longitudinal study with before-after design. The main objective was to determine the effects of health care decentralization on changes in health financing. Taking into account feasibility, political and technical criteria, three Latin American countries were selected as study populations: Mexico, Nicaragua and Peru. The methodology had two main phases. In the first phase, the study referred to secondary sources of data and documents to obtain information about the following variables: type of decentralization implemented, source of finance, funds of financing, providers, final use of resources and mechanisms for resource allocation. In the second phase, the study referred to primary data collected in a survey of key personnel from the health sectors of each country. Taking into account the changes implemented in the three countries, as well as the strengths and weaknesses of each country in financing and decentralization, a rule for decision-making is proposed that attempts to identify the main financial changes implemented in each country and the basic indicators that can be used in future years to direct the planning, assessment, adjustment and correction of health financing and decentralization.

Delivery of Health Care↗
PubMedDate not supplied

Decentralization, health care and policy process in the Punjab, Pakistan in the 1990s.

The Province of the Punjab underwent a number of attempts to decentralize the health sector in the 1990s. Among the most important were the decentralization of financial management within the district, the Sheikhupura PHC Pilot Project, the establishment of the District Health Authorities and District Health Management Teams, the creation of semi-autonomous hospitals and the programme of District Health Government (DHG). These usually received donor support and promotion, and emerged from within the provincial Department of Health, and more specifically the Secretariat and the internationally supported Second Family Health Project (FH2). Of particular significance was the DHG change, which involved a decentralization to the district, the appointment of powerful Chief Executives, the formation of District Management Committees and purchaser-provider separation. The paper reviews these proposals, focusing on the need to build on experiences and learning lessons from pilot projects, reform continuity, developing consultation and involvement and policy analysis. The latter indicates the importance of developing more in-depth policy analysis around the role of the central organization, the form of decentralization and the purchaser-provider separation. The paper concludes by underlining the need to ensure that political strategy and in-depth policy are appropriately coordinated in the policy process.

Developing Countries↗
PubMedDate not supplied

Implications of decentralization for the control of tropical diseases in Tanzania: a case study of four districts.

Decentralization has been and is still high on the agenda in contemporary health sector reforms. However, despite extensive literature on the topic, little is known about the processes and results of decentralization, including the relationship with the control of major public health problems caused by communicable diseases. This paper reports from a study of decentralization and control of tropical diseases in districts implementing health sector and local government reforms in Tanzania. The study was undertaken in four districts, involving interviews and discussions with key stakeholders from individual household members to the district commissioner, and a review of official health policy, planning and management documents. The study findings reveal devolution of financial, planning and managerial authority being theoretical rather than practical, as district health plans are largely directed by national and international priorities rather than by local priorities. Vertical programmes still exist, focusing narrowly on single diseases. The local mechanisms for multisectoral collaboration, as well as community participation functions, are far from optimal. Further, inappropriate and weak information systems prevent adequate local responsiveness in setting priorities. In conclusion, decentralization might have a large potential for improving health system performance, but problems of implementation pose serious challenges to releasing this potential.

Communicable Disease Control↗
PubMedDate not supplied

Decentralizing EPI services and prospects for increasing coverage: the case of Tanzania.

Primary health Care (PHC) strategies were adopted widely in 1978 after the Alma Ata declaration to improve accessibility to health services and the health of the people. Of the strategies of PHC was the decentralization of health services to lower levels in order to enhance participation and responsiveness of the health system to local problems. While PHC was being promoted vertical programmes such as the expanded programme on immunization (EPI) were also being promoted and achieved substantial benefits. However, almost 25 years later many countries have not been able to achieve these health goals. This study addressed the question: Can we make the process of health care decentralization more likely to support health system and EPI goals? This study analysed the experience of EPI decentralization at national, regional and district levels. Several stakeholders were identified who were supportive and others who were non-supportive of the process. Community support to EPI measured by using willingness to pay (WTP) for kerosene (to keep vaccines cool) was low. It was significantly (p < 0.05) associated with whether providers in the nearest health facility properly attended the target population and whether the providers in the facility were available when needed. There was a substantial stakeholder support and opposition to the process of decentralization at the district level. Community support was not high possibly due to the perceived non-availability of the service providers and their lack of awareness of the population they serve. It was proposed that reforms should give priority to the involvement of communities and peripheral health facility providers in the process.

Delivery of Health Care↗
PubMed1998

Does Decentralization Matter in Environmental Management?

/ Questionnaires from 39 state National Pollutant Discharge Elimination System (NPDES) agencies were analyzed using principal component analysis and multiple regression. Decentralized programs scored better in a fundamental indicator of efficiency (lower percentage of expired permits) and in the key effectiveness measure of unit-cost compliance achieved. In no case did centralized states score significantly better than decentralized ones. These results indicated support for the theory that superior local knowledge is the key mechanism. Case studies of five states suggested internal program adjustments may cause outcomes to converge towards efficiency and effectiveness, perhaps explaining the large number of variables showing no difference between centralized programs and decentralized ones.KEY WORDS: NPDES; Compliance; Decentralization; Outcome; Efficiency; Unit-cost analysis

Journal Article↗
PubMed1987

Distribution of neuropeptide-like immunoreactivity in intact and chronically decentralized middle cervical and stellate ganglia of dogs.

Neuropeptide-like immunoreactivity to antisera raised against Leu- and Met-enkephalin, vasoactive intestinal peptide (VIP), neuropeptide Y (NPY) and substance P (SP) have been studied immunohistochemically in middle cervical and stellate ganglia of dogs. To investigate the relationship of the peptides to one another as well as to preganglionic and postganglionic neurons, intact and chronically decentralized middle cervical and stellate ganglia were studied. Ganglia were processed for immunohistochemistry in unoperated dogs and in dogs two weeks after unilateral ganglionic decentralization. The immunoreactivity for each peptide had a characteristic distribution in the ganglia. These distributions differed from one another and from the distribution of cardiac postganglionic sympathetic neurons. Camera lucida drawings of peptide distributions were made to compare different peptides and counts were made to determine the percentages of cells immunoreactive for a given peptide. The results demonstrated that enkephalin-like immunoreactivity in axons was present in both the stellate and middle cervical ganglia, but was heaviest in the caudal 2/3 of the stellate ganglia. Enkephalin-like immunoreactive fibers formed pericellular baskets around stellate ganglion neurons. VIP-like immunoreactive cell bodies and processes were distributed sparsely, but widely, in the stellate ganglia and to a lesser extent in the middle cervical ganglia. One of two commercial antisera to SP resulted in immunoreactive staining of cell bodies and processes in the stellate ganglia. SP-like immunoreactivity in neurons represented about 10% or less of the cells in the stellate ganglia. At least 80-85% of the neurons in the stellate and middle cervical ganglia were immunoreactive for NPY antisera. Decentralization eliminated enkephalin-like immunoreactive staining in the middle cervical and stellate ganglia, but not the VIP-, NPY- and SP-like immunoreactive staining of neurons in these ganglia. In summary, the enkephalin-like immunoreactive axons in the thoracic autonomic ganglia appear to be derived from extrinsic neurons, most likely from preganglionic spinal neurons. VIP-, SP- and NPY-like immunoreactivity were not significantly affected by decentralization. The results provide anatomical evidence for substrates related to neuropeptidergic synaptic mechanisms in thoracic autonomic ganglia.

Animals↗
PubMed2005

Failure-tolerant performance stabilization of the generic large-scale system by decentralized linear output feedback.

Most of the existing results on the decentralized stabilization of large-scale systems consider systems in the input-output-decentralized form, i.e., systems whose input and output matrices are block diagonal. The controller synthesis for such systems is less involved than that for input-output-centralized ones. In this paper, a transformation is proposed for the input-output decentralization of the generic large-scale system. Using the transformed system, a sufficient condition for failure-tolerant performance stabilization of the original large-scale system in a desirable performance region under decentralized linear output feedback is established. The problem is then reformulated as a constrained nonlinear optimization problem. The proposed methodology results in the optimal reconciliation of failure-tolerant performance stabilization of the overall system, and reliability and low actuator gains of the isolated subsystems. The effectiveness of the proposed approach is demonstrated by an example.

Algorithms↗
PubMed1999

Intraocular lens tilt and decentration, anterior chamber depth, and refractive error after trans-scleral suture fixation surgery.

OBJECTIVES: To compare the extent of intraocular lens (IOL) tilt and decentration, as well as the anterior chamber depth after trans-scleral suture IOL fixation after either secondary out-of-the-bag or primary in-the-bag IOL implantation. DESIGN: Retrospective, comparative, nonrandomized, interventional study. PARTICIPANTS: Fifty-two eyes that underwent scleral suture fixation were compared with 51 eyes that underwent secondary out-of-the-bag implantation and 50 eyes that underwent in-the-bag implantation. INTERVENTION: One-piece polymethyl methacrylate IOL implantation by three different techniques. MAIN OUTCOME MEASURES: The tilt angle and decentration length of the IOL, as well as the anterior chamber depth, were measured by the Scheimpflug videophotography system. The spherical equivalent error from the predicted value was also examined. RESULTS: The mean tilt angle in the scleral suture fixation group was significantly greater than that in either the out-of-the-bag or the in-the-bag implantation group (P<0.0001). The mean decentration length was also largest in the suture group, followed by the out-of-the-bag group and the in-the-bag group (P<0.0001). The anterior chamber depth in the suture group and the out-of-the-bag group was significantly smaller than that in the in-the-bag group (P<0.0001). The spherical equivalent error in the suture group and the out-of-the-bag group was also greater than that in the in-the-bag group (P<0.0001). CONCLUSIONS: The extent of both tilt and decentration after scleral suture fixation was greater than that observed after either out-of-the-bag or in-the-bag implantation. The anterior chamber depth with the sutured or out-of-the-bag fixated IOL was shallower than that with the in-the-bag fixated IOL, which resulted in a significant myopic shift.

Adolescent↗
PubMed1999

Update on fixation of rigid and foldable posterior chamber intraocular lenses. Part I: Elimination of fixation-induced decentration to achieve precise optical correction and visual rehabilitation.

PURPOSE: Realizing that precise posterior chamber intraocular lens (PC-IOL) centration is needed to consistently achieve good optical results and visual rehabilitation after modern cataract surgery, the authors assessed the status and success rate of lens haptic fixation and its correlation with lens optic centration-decentration in a large series of eyes with PC-IOLs obtained postmortem. DESIGN: Prospective analysis of pseudophakic eyes obtained postmortem. PARTICIPANTS: A total of 3493 human eyes obtained postmortem, the largest database of such specimens available to date. METHODS: Miyake-Apple posterior photographic technique. MAIN OUTCOME MEASURES: The amount of decentration of rigid PC-IOLs and small-incision foldable PC-IOLs was analyzed, and the results were correlated with the type of fixation that had been achieved in each case. RESULTS: Determination of mean values revealed that capsular bag fixation was achieved in 52.05% of eyes, asymmetric bag-sulcus fixation in 34.21 % of eyes, and sulcus-sulcus fixation in 13.74% of eyes. Asymmetrically fixed lenses consistently showed significant decentration. During the past 5 years (1993-98), the overall rate of in-the-bag fixation increased to 59.2%; by 1998 it had increased to 64%. Most significantly, success in achieving bag-bag fixation of foldable IOLs implanted in association with modern capsular surgery with small incisions has surged to 90% over the past 4 years. CONCLUSIONS: The authors found a direct correlation of decentration in eyes with asymmetric fixation, and the results underscore the need for careful in-the-bag haptic placement. Although few surgeons today would dispute the goal to implanting haptics in the capsular bag, these findings show that the overall success rate over the years has, while improving, remained surprisingly low. The overall success rate of about 60% seen with all lens designs is probably as good as can be expected with classic large-incision extracapsular techniques. However, and most important and encouraging, the success rate of haptic fixation in cases with foldable lenses has improved dramatically during the past 4 years (up to the 90% range). This coincides with the present emphasis on modern capsular surgery and small-incision techniques used to insert these lenses.

Acrylic Resins↗
PubMed1997

A study on decentralizing from acute care to home care settings in Germany.

Although it is generally accepted in Germany that decentralizing towards home care settings can improve the efficiency and effectiveness of health care, a coherent policy toward decentralization has not been developed yet. A variety of elements of the traditional German health care system have limited the opportunities for decentralizing. Separation between health care and social services, separation between acute care and medical rehabilitation and separation between ambulatory care and hospital care were rather strict, prohibiting development of a comprehensive infrastructure of professional support for home care as well as the hospital financing scheme. Recent reform measures in Germany in the field of health care policy and social policy partly have tackled these problems. The introduction of long-term care insurance might provide the chance for a better infrastructure and more comprehensive usage of professional support for home care, although it is not without risks, and integration of long-term care insurance in the health policy sector lacks coherence. While reforms of the hospital financing scheme and an entitlement of hospitals to provide one-day-surgery and post-discharge treatment will decrease the likelihood that hospitals keep patients in order to fill their beds, the extent to which hospitals will make use of these new instruments remains doubtful at present. Increased competition between sickness funds could open opportunities for prudent 'managed care' as part of 'managed competition', and strengthening of home care might be part of managed care programs. At present it is not clear, however, whether sickness funds will be entitled to compete through usage of managed care mechanisms. Other elements of recent health care reforms were counterproductive as far as decentralizing towards home care is concerned. Especially global budgets on honorariums for office-based doctors and on volumes of prescribed drugs might create incentives for inefficient and ineffective referrals to hospitals.

Cost Control↗
PubMed2002

Effect of a capsular tension ring on intraocular lens decentration and tilting after cataract surgery.

PURPOSE: To evaluate the effect of a capsular tension ring (CTR) on the tilting and decentration of intraocular lenses (IOLs) after cataract surgery. SETTING: Department of Ophthalmology, Ilsan Paik Hospital, Inje University, Kyunggyi-do, Korea. METHODS: Cataract surgery was performed in both eyes of 20 patients ranging in age from 57 to 75 years. The 40 eyes were divided into 2 groups based on whether a CTR (Lucid Korea) was implanted. Each patient received a CTR in 1 eye only. All IOLs (AcrySof MA60BM, Alcon) were implanted in the capsular bag after a continuous curvilinear capsulorhexis smaller than the IOL optic was created and phacoemulsification performed. The extent of IOL tilting and decentration was measured with the EAS-1000 anterior eye segment analysis system 7, 30, and 60 days after surgery. RESULTS: The extent of IOL decentration was statistically significantly less in eyes with both an IOL and CTR than in those with an IOL only. The mean decentration in the CTR-IOL group was 0.38 mm +/- 0.16 (SD) at 7 days, 0.43 +/- 0.15 mm at 30 days, and 0.42 +/- 0.17 mm at 60 days. The mean values in the IOL-only group were 0.49 +/- 0.11 mm, 0.53 +/- 0.14 mm, and 0.57 +/- 0.16 mm, respectively. The amount of IOL tilting was also significantly less in the CTR-IOL group. The mean tilting in the CTR-IOL group was 2.22 +/- 0.46 degrees at 7 days, 2.36 +/- 0.50 degrees at 30 days, and 2.47 +/- 0.40 degrees at 60 days. The mean values in the IOL-only group were 3.14 +/- 0.65 degrees, 2.91 +/- 0.67 degrees, and 3.06 +/- 0.56 degrees, respectively. CONCLUSION: These results indicate that the CTR reduces undesirable postsurgical IOL movement for at least 60 days.

Aged↗
PubMed1992

Prospective experimental study of factors related to posterior chamber intraocular lens decentration.

The effect of posterior chamber intraocular lens (IOL) dimensions, design, style, loop fixation, and anterior capsular tears on decentration were investigated in an experimental model. Nine posterior chamber IOLs of various designs and styles with loop diameters between 12.0 and 14.0 mm and optic diameters between 5.0 and 7.0 mm were implanted in human eyes obtained post mortem. Symmetrical and asymmetrical fixation were investigated in eyes with and without radial tears using the Miyake posterior view technique. Location of IOL loops proved to be the most significant factor in IOL decentration. Decentration was least with symmetrical bag/bag fixation and no radial tears (mean = 0.20 +/- 0.05 mm). Asymmetrical bag/sulcus fixation in the presence of anterior capsular tears was associated with the highest decentration rate (mean 0.68 +/- 0.28 mm). Optic size and total loop diameter had no apparent effect on IOL centration in the immediate postoperative period.

Cataract Extraction↗
PubMed1993

Effect of anterior capsulotomy on decentration of a two-zone multifocal intraocular lens.

A study was undertaken to determine if can-opener (CO) or continuous curvilinear capsulorhexis (CCC) anterior lens capsulotomy influences decentration of a two-zone multifocal intraocular lens (IOL). Fifty IOLs (25 with polypropylene haptics and 25 with poly[methyl methacrylate] haptics) were implanted following CO, 42 with poly(methyl methacrylate) haptics, following CCC. The extent and direction of decentration was estimated using a photogeometric technique. The haptic material may influence decentration. Continuous curvilinear capsulorhexis was associated with less decentration than CO (0.36 mm and 0.43 mm, respectively). The difference, however, was not statistically significant.

Adult↗
PubMed1991

Tilt and decentration of the implanted posterior chamber intraocular lens.

Management of surgically induced astigmatism is an important problem for surgeons implanting intraocular lenses. Besides corneal astigmatism, the fixation status of the intraocular lens (IOL) may contribute to total astigmatism. This study was undertaken to evaluate the effect of tilt and decentration of the implanted posterior chamber IOL on the total astigmatism. The tilting angle of the IOL was measured by a method using the 3rd and 4th Purkinje images, and the grade of the decentration was obtained photogrammetrically. The average tilt angle was 7.53 +/- 3.03 degrees (SD). The average decentration was 0.68 +/- 0.33 mm (SD) from the corneal center. Based on these data, the astigmatic error induced by the tilt or decentration of the implanted IOL was calculated as within 0.4 diopter. These data suggest that the fixation status of the IOL implanted in the bag does not cause a serious astigmatic error.

Aged↗