The great epidemiological significance and costs associated with chronic heart failure pose a challenge to health systems in Western industrial countries. In the past few years, controlled randomised studies have shown that patients with chronic heart failure benefit from telemedical monitoring; specifically, telemonitoring of various vital parameters combined with a review of the symptoms, drug compliance and patient education. In Germany, various telemedical monitoring projects for patients with chronic heart failure have been initiated in the past few years; seven of them are presented here. Currently 7220 patients are being monitored in the seven selected projects. Most patients (51.1%) are in NYHA stage II, 26.3% in NYHA stage III, 14.5% in NYHA stage I and only 6.6% in NYHA stage IV respectively. Most projects are primarily regional. Their structure of telemedical monitoring tends to be modular and uses stratification according to the NYHA stages. All projects include medical or health economics assessments. The future of telemedical monitoring projects for patients with chronic heart failure will depend on the outcome of these assessments. Only of there is statistical evidence for medical benefit to the individual patient as well as cost savings will these projects continue. In the Western industrial nations, chronic heart failure has great epidemiological significance due to the rising number of patients, particularly elderly ones . This de1-receptor blockers, aldosterone antagonists, or beta-receptor blockers) and medical devices , the prognosis for chronic heart failure has improved in the past few years [Due to both, drug therapy , the most important partner in a complex telemonitoring system is the telemedical service centre. All data is collected here and integrated into the electronic patient records and constitutes the central core of case management. The patients transmit various vital parameters, either at intervals or continuously, to the telemedical service centre. The transmission of the vital parameters can be conducted via telephone or mobile phone. In Germany, one limiting factor seems to be the missing internet access, particularly in primary care practices.The relevant monitoring parameters are heart rate, ECG (arrhythmias), blood pressure, and body weight. For instance, it was shown in a clinical study that atrial fibrillation worsens the prognosis for patients with chronic heart failure . Body weIn the past few years, much international experience has been gathered in this regard on telemonitoring in patients with chronic heart failure, also in the context of randomised controlled studies. In the following, we report on selected projects in Germany.The German health system has traditionally been structured according to sector, namely, the outpatient and inpatient sectors. Government policy has made various attempts in the last few years to overcome this division to some extent. One important mean to achieve this is contracts for integrated care .In the past few years, a number of, mostly regional, model projects on telemonitoring patients with chronic heart failure have been conducted in Germany. These projects brought forth signs of cooperation between the hospitals and practising physicians, as the providers of medical care, and various health insurance organisations. In addition, providers of telemedical services and industrial partners were included in the cooperation.Currently 7220 patients are being monitored in seven selected telemonitoring projects for patients with chronic heart failure. Most patients (51.1%) are in NYHA stage II, 26.3% in NYHA stage III, 14.5% in NYHA stage I, only 6.6% of patients were in NYHA stage IV, and in 1.6% of the Patients the NYHA stage was unknown.The selected projects are presented in greater detail in the following sections.The telemedical care of patients with heart failure in the context of the HeiTel project makes it possible, through monitoring, to institute and adjust therapy optimised for the individual patient. The patient transmits by telephone certain prescribed vital parameters  via modem to the telemedical centre in an automated manner. If individually defined threshold values are not reached or exceeded, an alarm is immediately triggered in the monitoring centre so that therapeutic measures can be started immediately. Independent of any alarm responses, a patient in NYHA stages III-IV is contacted proactively at least once a week, while a stage II patient is contacted at least twice a month; they are asked questions according to a standardised form. The goal of these contacts is to promote medication adherence and to recognize telltale changes in a patient's health status as early as possible. Patients can reach the telemedical centre around the clock every day of the year to report cardiopulmonary symptoms and serious complaints. Training sessions on nutrition, movement and pharmacotherapy complete the programme and reinforce the patient's self-reliance in dealing with himself and his illness. After hospitalisation or after the conclusion of the individual titration phase during the initiation of drug therapy, which generally lasts about 6 months, there is a de-escalation of the device-based home monitoring, as part of a modular plan, which then becomes care provision by means of training sessions on nutrition, movement and monitoring of pharmacotherapy using a nurse call system. The purpose of this is to reinforce the patient's self-reliance in coping with himself and his illness and to perpetuate the success of treatment.This modular plan offers the opportunity of establishing telemedical care as a cost-efficient module that is integrated into a chain of medical services. More than 200 general practitioners and cardiologists are currently actively participating in this plan.n = 210) in comparison to a control group (n = 12 000) over a period of 2 years. This justifies the assumption that the intervention has a lasting effect. Although the plan was only designed for 12 months, these results led to an extension of the contract for integrated care.The accompanying evaluation of the project documented a high-level of satisfaction among the participants. It moreover, also demonstrated the plan's efficiency in terms of health economics by means of a significant reduction both in the overall costs and in the number of days of hospitalisation for the HeiTel patients  was established in 2004 by the Municipal Hospital Brandenburg in Brandenburg/Havel. Its aim is to improve the care for chronic cardiac patients in the federal state of Brandenburg. In cooperation with getemed, a medical technology company, and with funding by the European Union and by the Ministry of Economics of the state of Brandenburg a telemonitoring unit was developed which daily records and transmits all noninvasively parameters and information regarding clinical symptoms, drug compliance, and desired contact. The promising results of a self-financed pilot study led to a contract with the AOK Brandenburg  for integrated medical care for patients with chronic heart failure.Cooperations with various hospitals were established, including the German Heart Centre in Berlin, and numerous hospitals in the state of Brandenburg, as well as consulting cardiologists and general practitioners. The telemedical monitoring allows surveillance of patients from far distance, which is advantageous in a large, sparsely populated state with a low density of physicians.Inclusion criteria are chronic heart failure NYHA stages III-IV, an ejection fraction ≤40%, and a history of hospitalization for acute decompensated heart failure. At the moment, 300 patients of NYHA stages III and IV participate in the program.The patients receive a telemonitoring device, developed by getemed, Teltow, a scale, ECG electrodes, and a blood pressure gauge. The patient daily measures weight, blood pressure, ECG, thorax impedance and breathing rate, and for certain indications also oxygen saturation. Patients also provide information regarding the severity of dyspnea, their subjective well-being, medication intake, and preference regarding desired personal contact. The data is encoded and transmitted by internet to the TMBZ, where it is analysed weekdays with regard to newly manifested arrhythmias, heart rate, body weight, and blood pressure using individually determined threshold values, breathing rate, and, if indicated, the oxygen saturation. The patient's subjective comments regarding dyspnea, peripheral edema, well-being, and drug compliance are evaluated to detect worsening symptoms. If deterioration has been detected, the patient's physician is informed by fax or, in urgent cases, via telephone by the tmzb. A summary of the reported results is included. This objective data enables better adjustment of the patient's medication according to individually changing health status.The patient is contacted by the tmzb if: (i) suspicious changes of parameters are recorded, (ii) the patient requested contact, (iii) no data was transmitted, or (iv) the preceding intervention was not successful. The closer collaboration between the individual patients and their individual care givers  allows for an optimal care. The acceptance of telemonitoring among patients is very high, as indicated by the fact that the compliance with data transfer is 95%. Patients indicate that they feel secure. No serious technical problems have been encountered. Preliminary analyses of the data show a significant reduction both in number and days of hospitalisations for acutely decompensated heart failure .The “CorBene” project was developed as a contract for providing integrated care between practicing cardiologists, the Ford and Rhineland company health insurance programme, and the companies Vitaphone (Mannheim) and Medtronic (Düsseldorf). The goal is a transsectoral, stage-specific therapy of patients with chronic heart failure that is based on telemonitoring and is conducted according to guidelines. The participating doctors profit from a uniform documentation, improved exchange of information, and integrated quality management. This prevents, for example, redundant examinations. The telemedical concept of monitoring consists of four modules. This guarantees that the telemonitoring is appropriate to the NYHA stage and is individual. In module 1, the patient is given an ECG monitoring card to record his heart frequency and detect cardiac arrhythmias. Module 2 consists of weight monitoring. ECG and weight monitoring are linked together in modules 3 and 4. All reported data is integrated into an electronic patient record by the telemedical service centre Vitaphone, which is certified according to ISO and the Association for Engineering/Electronics/Information Technology (VDE) rules of application for telemonitoring , 24. In The “CorBene” project is being evaluated in terms of health economics. Initial data from 306 patients show that 81.2% of the patients included in the project are being treated according to the guidelines. 10.8% of these patients show clear improvement of clinical symptoms since they have been included in the project . The finIn the meantime, “CorBene”, which initially was a regional project, has been extended to cover all of North Rhine Westphalia (NRW) and Saarland. Currently more than 2900 patients with chronic heart failure are monitored by the project.Integrated concepts of providing medical care that utilize telemedicine have been proven to be appropriate instruments for improving current deficits for patients with cardiac failure. For this reason the Techniker Krankenkasse health insurance company and the German Foundation for the Chronically Ill developed the integrated programme of medical care called “Telemedicine for the Heart”. Patients from throughout Germany with NYHA stages II-IV who are insured with the Techniker Krankenkasse have profited from this programme since January 1st, 2006.The modularly structured programme for providing care, collecting data, interpreting data and training patients allows the participants to deal with their illness in a safer more self-empowered manner. It is also an important adjuvant to the treatment provided by their physicians. The goal of the patient-centred programme is to help the participating patients gain patient empowerment, to understand their illness better, to make the influencing factors between chronic heart failure, the prescribed medicine and their own life style more transparent. It also increases patient awareness of warning signs and symptoms, that indicate imminent decompensation. The analysis of life style with reference to the patient's own health situation encourages participants to reduce risk factors and expand health-promoting factors. By means of close coordination with the locally responsible physician, the programme aims to reduce the frequency and length of inpatient hospitalisations, at decreasing mortality, and at offering participants coordinated and high-quality medical care . The programme is set to run for 27 months, which are divided into three phases. The first 6-month is the training phase. It familiarises the patients with the procedures of the programme and, by means of telephone-based training, provides specific knowledge about the complex topics associated with chronic heart failure. The second phase is the 3-month stabilisation phase. It promotes a consolidation of the behavioural patterns taught during the first phase and attempts to teach how to deal with the illness independently on a daily basis. The third phase consists of an 18-month refresher phase, aiming to anchor the behavioural patterns that promote better health in daily routines of participating patients, through constant repetition. This should allow, the results that have been achieved to be maintained after the participants have left the programme. The care and training given to patients is provided by a telemedical service centre . An electronic record is maintained for each patient at the telemedical service centre. For patients in NYHA stages III and IV, telemedical monitoring of body weight, blood pressure, and the pulse is also planned. During the programme, necessary interventions are made by the telemedical service centre team in coordination with the general practitioners and/or the cardiologists if a threshold is crossed.P = .03, t-test). This means that it was possible to avoid approximately every fifth hospitalisation as the result of this intervention (i) an improved level of knowledge among the participating patients, (ii) an early warning function of the telemedical monitoring, and (iii) close coordination between the telemedical centre and the responsible physicians. In the context of a health economics evaluation conducted by the chair of health management at the University of Erlangen-Nuremberg, the data of 281 participants in the programme “Telemedicine for the Heart” (treatment group) were compared to the data of a matched control group that was three times larger in size. Examination of the number of hospitalisations per patient and year, showed that for the participants in the programme there were 21.5% fewer hospitalisations  reduction in mortality within the first year, that is, that with the most intensive training and support phases. Even if the analysis is extended to the maximum period of time (including the last phase of the programme with a low intensity of care provision), the mortality was reduced by 35.1% , a value more than one third lower than the mortality in the comparison group.The evaluation also provides a clearly positive result with regard to mortality. In the group of programme participants, there was a 51.7%  as well as over the maximum period of time observed normalised per year . These data make it clear that the complete 27-month programme fully paid for itself in its first year of work, while the effects of the care provision—especially the effect of the training sessions—were maintained over a much longer period of time.The medical effects reported above were achieved in a cost-efficient manner, as is shown by the overall costs. There are substantial differences in favour of the treatment group, both after 1 year of programme membership  and follows patients for a period of at least 12 months. In the telemedical group, there is daily monitoring of blood pressure, ECG, oxygen saturation, and body weight. Furthermore the patients' physical activity is evaluated by an activity sensor and the patient himself evaluates his own health status. The study is financed and supported logistically by the Barmer and Bosch health insurance companies. The primary end point of the study is the period of survival. Secondary end points of the study are overall mortality, cardiovascular mortality, frequency of any kind of nonelective hospitalisation, frequency of hospitalisations for cardiovascular reasons, the plasma level of NT-proBNP over time and the quality of life over time, An evaluation from the perspective of health economics is planned , 28.The project “HeartAs” was established in combination with an integrated-care contract. Until now, 516 patients have been included in the project, 96 of which have already concluded the program. The majority of patients are in NYHA stage II and III. In this project, body weight, ECG (12-channel or 1-channel), pulse, and blood pressure are transmitted. The project consists of a modular character. In addition to compliance management and emergency management modules, regular telephoneadvice calls are given. A medical, academic, and economic  evaluation will follow.Some initial experience regarding the telemedical monitoring of patients with chronic heart failure has been gathered in a project organised by the health insurance company “Kaufmännische Krankenkasse” and the Almeda company in Munich. The idea behind this project was similar to that of the ProHeart project. Participants were contacted regularly by telephone by specially trained medical personnel. On the one hand, the use of specially developed software meant that the telephone conversations were very standardized, while on the other, there was always an opportunity to discuss the patient's situation in detail in an individual and problem-oriented manner. The telephone contacts were supplemented by written training material . There wDuring the observation period, 14.7% of the participating patients died, compared to 27.1% in the control group. This difference was statistically significant .The project “ProHeart” is currently conducted by Almeda company and the Allianz health insurance. Up to now, 1545 patients in NYHA stages I–IV have been included in the projectThe German projects on telemedical monitoring of patients with chronic heart failure that are described individually above exhibit different approaches and plans for improving the situation of these patients. Nonetheless, they share some fundamental strategies. The goals are, besides monitoring the patients' status , to remind patients of their medication, to monitor symptoms indicative of imminent cardiac decompensation, and to train patients on topics relevant to heart failure. A significant concern of all the programmes is increasing the ability of the patients themselves to manage their own illness. Most programmes are planned for a limited time period. The timely limitations of this program have to be discussed critically. Most of the projects described were established and conducted within the confines of integrated-care-contracts over a predefined frame of time. Undisputed is the fact that chronic heart failure can improve only with consistent surveillance, for which reason patients need further long-term monitoring. This poses the question of which patients (NYHA stage) derive the most benefit from telemonitoring and which intensity  should be adjusted to individual patient needs. As a foundation, consistent definition and measures of goals needs to be defined . The discussed projects demonstrate the heterogeneous of patients included according to differences in NYHA stages. In a meta-analysis of 14 randomised controlled studies on telemonitoring of patients with heart failure, Clark et al. demonstrated there was a 20% reduction in overall mortality . The effRoth  and assoThe results clearly show that telemonitoring and telephone support programmes are beneficial with regard to mortality and the rehospitalisation rates for patients with chronic heart failure –17. The The reasons discussed for this include the high level of standard treatment for heart failure and intermittent data transmission (once a week) . The telThe electronic patient record is the central component of telemedical patient monitoring. Recognising deviations from established alarm thresholds allows both patients and the treating physician  to be alerted promptly. This permits close coordination between the partners and early intervention in the patient. In addition, personal telephone contact to the patient is established through the telemedical service centre. By means of this, enquiries can be made about symptoms and complaints, it can be checked whether medication is being taken, and patient education can be coordinated. The quality of the telemedical care systems depends significantly on the work of the employees in the telemedical service centre. The aim here must be to standardise procedures and certification of the telemedical service centres in the context of quality assurance . To thisAnother essential concern in telemedical monitoring is intercommunication between general practitioners, cardiologists in private practice, hospitals and rehabilitation facilities. This aspect is of great importance in Germany since here there is traditionally a great division between outpatient and inpatient sectors. Most telemedical monitoring programmes were conducted for this reason in the context of contracts for integrated care. In doing this, in addition to physicians, medical insurance companies and telemedical providers would be directly included in the projects.The greatest challenge at the moment is the reimbursement of telemedical services. This applies both to the service providers  and the telemedical providers. At the moment in Germany, telemedicine for monitoring patients with chronic heart failure is not a component of standard treatment. Thus it can also be explained why most projects are regional in character. In the next few years, it will be necessary to more strongly develop the evidence of the benefits of telemedical monitoring in patients with heart failure. For this, in addition to medical and economic evaluations , health-economic evaluations are also necessary. The programmes presented here have this health-economic evaluation integrated into them as a fixed component of the programmes. Proof of the cost efficiency of the programmes will be a crucial point for the future of telemedical monitoring programmes. Currently, none of the described projects have been completed, so that final results are not yet available.In Germany, various projects on telemedical monitoring of patients with chronic heart failure could have been set up in the past few years. Most of these projects were initiated in the context of contracts of integrated care and are mostly regional in nature. The telemedical monitoring programmes differ in terms of their choice of monitored vital parameters, sequence and frequency of data transmission, and duration. This makes a comparison only possible to a limited extent. In addition, most of the programmes are not yet completed, so that no final assessment of the medical-economic or health-economic evaluation is yet possible. The further acceptance of patients and sponsors of projects on telemedical monitoring of patients with chronic heart failure will depend in the future on the evidence for improvement of the medical variables  as well as evidence of cost efficiency. Standardization is required of the programmes for telemedical monitoring of patients with chronic heart failure according to defined quality criteria. For the context of further studies some basic questions, such as which patients (NYHA stage) derive the most benefit at which degree of intensity of telemonitoring, need to be considered, in order to achieve lasting improvements for these patients. In addition, attention need to be given to the affects of the physical separation of telemonitoring on the doctor-patient relationship in order to increase the physician's and patient's acceptance of telemonitoring.


Youth Check Your Risk, on chlamydia testing rates among young people attending general practices. The secondary aim was to test the acceptability of the tool among general practitioners and young people.Targeted chlamydia screening has been advocated to reduce chlamydia associated reproductive sequelae. General practitioners are well positioned to play a major role in chlamydia control. The primary aim of this pilot study was to measure the effect of offering an online sexual health assessment tool, Youth Check Your Risk http://www.checkyourrisk.org.au for use post-consultation between March to October 2007. The proportion of young people tested for chlamydia before and during the implementation of the tool was compared. Acceptability was assessed through a structured interviewer-administered questionnaire with general practitioners, and anonymous online data provided by Youth Check Your Risk users.General practitioners at three practices in Melbourne, Australia, referred patients aged 16 to 24 years to Youth Check Your Risk and 120 used it (13.8%). Major reasons for low referral rates reported by practitioners included lack of time, discomfort with raising the issue of testing, and difficulty in remembering to refer patients.The intervention did not result in any significant increases in the proportion of 16 to 24 year old males (2.7% to 3.0%) or females (6.3% to 6.4%) tested for chlamydia. A small increase in the proportion of 16 to 19 year old females tested was seen (4.1% to 7.2%). Of the 2997 patients seen during the intervention phase, 871 (29.1%) were referred to Youth Check Your Risk. Future interventions aimed at increasing chlamydia screening in general practice with the aid of an online risk assessment tool need to identify and overcome barriers to testing.Offering an online sexual risk assessment tool in general practice did not significantly increase the proportion of young people tested for chlamydia, with GPs identifying a number of barriers to referring young people to  Chlamydia trachomatis is the most common bacterial sexually transmitted infection (STI) worldwide  but in the end we've got 15 minutes and I spend longer and I'm always running late, but still it's that time issue.2) Discomfort raising the issue of sexual health, particularly where patients had not presented for sexual health reasons.3) Difficulty in remembering to refer patients in the target age group.To bypass these issues, the majority of GPs at one clinic reported leaving referral to YCYR to reception staff.On the whole, GPs reported that they did not hand out the referral cards or offer chlamydia screening opportunistically to all young patients, but did so when young people presented with high risk behaviours or issues related to sexual health, such as cervical screening, screening for sexually transmitted infections, contraception or genital symptoms. The majority of GPs reported that they did not feel that their testing practices had changed as a result of YCYR; however, participation in the study did raise their awareness and reminded them of the need to opportunistically screen young people for chlamydia.really negative' and 'indifferent' to 'fairly responsive' and 'interested'. Of the GPs interviewed, only two encountered patients who provided feedback on YCYR. One patient provided general feedback on the service to their GP at a later consultation, while another patient returned to their GP with the printed recommendations. Practices indicated that patients seemed reluctant to use YCYR on site, particularly in the practice in which the computer was set up in the 'staff only' area.GPs reported mixed reactions from patients they referred to YCYR, from 'We found that opportunistically offering an online sexual risk assessment tool in general practice to young people did not significantly increase the proportion of young people tested for chlamydia, although a small increase in the proportion of 16 to 19 year old women tested was seen. While GPs generally had a favourable view of the tool, a number of barriers prevented them from referring young people to YCYR and consequently, less than a third of young patients were referred to the site, and of these, few accessed it.The provision of onsite computers by practices did not seem to improve access by young people, and while no young people provided feedback about this, the location of the computers could have been a deterrent along with the fact that the only reason patients would access them was to use YCYR, hence potentially leaving young people feeling exposed or embarrassed. At a system level, practices may not be equipped to provide patients with a private area in which they can confidentially source online resources.This study has some limitations. First, we do not know if the small increase in chlamydia testing among younger women was as a direct result of offering YCYR through general practice. In order to protect the confidentiality of patients accessing the website, it was not possible to track health service use of individual patients accessing the site, therefore we do not know how many of the patients who accessed the website actually returned to a GP for chlamydia testing. Nor can we determine which chlamydia tests were the result of the patient accessing the website and being exposed to the recommendations for chlamydia screening. It is possible that testing increased because of a greater awareness of chlamydia screening due to the practices' involvement in the study or because of exposure to the educational package provided to GPs as part of the intervention, rather than as a direct result of referral to YCYR. Secondly, although their views were sought, only a small number of YCYR users provided online feedback and none provided detailed interview feedback despite the incentive offered, so we do not know how most young patients felt about being referred to the website, its on-site access, use of the site or whether they followed up on the advice. Thirdly, as two of the practices were affiliated with universities and serviced high numbers of young people and international students, it is uncertain how generalizable the results are to other practice populations.Reviews of interventions aimed at change in primary care show that while no intervention is effective in all circumstances, systematically developed, multi faceted interventions tailored to and engaging the target group and addressing barriers and facilitators to change are more likely to be effective -17. A reIt is possible that a more rigorous methodological approach in this study may have better addressed the existing barriers. In saying this, in a study by Merritt et al , despiteWhile engaging and increasing GPs knowledge around chlamydia testing is likely to go some way towards facilitating chlamydia screening, it is unlikely to increase opportunistic screening to the levels required to have an impact on chlamydia transmission in the population. Enhancing GPs communication skills, particularly around sexual history taking, may also help, however, as previous research has shown, GPs often do not feel comfortable raising the issue of sexual health during unrelated consultations ,9 and arFurthermore, GPs' perceptions that patient's are embarrassed discussing their sexual health is associated with a reduced likelihood of taking a sexual history and thus assessing a patient's risk . Recent Offering an online sexual risk assessment tool in general practice did not significantly increase the proportion of young people tested for chlamydia, with GPs identifying a number of barriers in referring young people to YCYR.It is possible that the intervention required more rigorous development to overcome these barriers. However, before the intervention can be considered ineffective, the way in which it was implemented must also be considered . The lowThe use of YCYR in general practice therefore should not be discounted altogether. However, given the issues and barriers evident in this study and reflected in other current research, the development of any future interventions, including YCYR, must first address these barriers if they are to effectively increase screening in general practice.CYR: Check Your Risk; GP: General Practitioner; HPV: Human papillomavirus; MSHC: Melbourne Sexual Health Centre; STI: Sexually transmitted infection; YCYR: Youth Check Your Risk.The authors declare that they have no competing interests.JEB was responsible for data collection, analysis and interpretation, and prepared the first draft of the manuscript. LAS contributed to the conception and design of the study, interpretation of data and writing of manuscript. CKF contributed to the conception and design of the study, interpretation of data and writing of manuscript. JSH was involved in study design, assisted in the statistical analysis and critically reviewed the manuscript. DM was involved in study design and critically reviewed the manuscript. DJH was involved in study design, assisted in youth focus group recruitment and critically reviewed the manuscript. SMS was involved in study design and critically reviewed the manuscript. MJW was involved in study design and critically reviewed the manuscript. DAW was involved in study design, assisted in the GP reference group recruitment and critically reviewed the manuscript. MYC contributed to the conception and design of the study, interpretation of data and writing of manuscriptAll authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2334/9/29/prepub


This manuscript presents an initial description of doctoral level core competencies for health services research (HSR). The competencies were developed by a review of the literature, text analysis of institutional accreditation self-studies submitted to the Council on Education for Public Health, and a consensus conference of HSR educators from US educational institutions. The competencies are described in broad terms which reflect the unique expertise, interests, and preferred learning methods of academic HSR programs. This initial set of core competencies is published to generate further dialogue within and outside of the US about the most important learning objectives and methods for HSR training and to clarify the unique skills of HSR training program graduates. Health services research (HSR) is a scientific field that examines the structures, functions, policies, and outcomes of health services delivered to individuals and populations. Its purIn the 1995 Institute of Medicine report, Health Services Research: Training and Workforce Issues , four elHSR incorporates a wide range of disciplines, notably biomedicine, economics, epidemiology, informatics, management sciences, political science, psychology, sociology, and statistics. Application of these disciplines to problems confronting health systems requires a workforce with a diverse skill set. The field has specific journals, professional societies, employers, sponsors, and training programs; however, the competencies common to all doctoral-trained HSR professionals have not been well-defined.Graduates of HSR training programs pursue a wide variety of careers in academia, research, healthcare delivery, and policy analysis. Despite the success of these graduates, they complete their respective training programs unsure what it means to be a health services researcher, how they are distinguished from other professionals, and what professional roles their advanced training has prepared them to undertake. Our inability to clearly articulate the skill set that is unique to health services research is an unsatisfactory response to these talented students, and highlights the need to develop a common set of HSR competencies.This manuscript describes an initial set of core competencies ("Version 1") for individuals trained at the doctoral level in HSR. The goal was to define the essential knowledge- and skills-based competencies expected of all HSR trainees, irrespective of areas of content specialization, method or disciplinary focus. Defining HSR doctoral competencies will (1) assist educators with developing and identifying the most important learning objectives for HSR training, (2) clarify for employers the skills and abilities of graduates of HSR training programs, and (3) give HSR trainees a unique professional identity.Ideally, designing a training program begins with defining its competencies, delineating learning objectives specific to each competency, and then developing a structure for delivering educational experiences that fulfills the objectives . The aimEach competency has a set of learning objectives, which describe the approach for achieving the competency. Although the end-results  of training programs may be similar, the approaches used to attain them  may differ. This manuscript does not propose specific learning objectives, curricula, or methods that could be used for each competency.We developed the core competencies by reviewing the literature and conducting a text analysis of accreditation self-studies submitted to the Council on Education for Public Health. Based on common themes identified in the self-studies, an initial draft of core competencies was developed and subsequently discussed at a conference of HSR educators. The Version 1 competencies presented in this manuscript are the result of this consensus conference. It should be emphasized that the methods used to generate these competencies were based on review of US training programs.A search of the peer- and non-peer reviewed literature was conducted for all articles and reports that describe competencies or learning objectives in health services research  . LiteratBecause the focus of this project was on health services researchers, programs designed to train managers of health systems were considered outside the project scope -8, as weThe project team obtained accreditation self-studies of all schools of public health doctoral and master's level programs in health services research from the Council on Education for Public Health (CEPH) – a total of 27 schools and 55 programs. Masters programs were included in this review, because many programs did not distinguish in the accreditation self-study between doctoral and masters level training. Approximately 650 learning objectives were extracted from the self-studies, and then sorted into learning objective clusters using text analysis software that may be used to derive themes from text-heavy data . The intBased on this categorization of learning objectives, the project team drafted an initial set of core competencies that summarized the learning objective clusters. For example, scientific method and theory, literature review methods, and proposal development were three clusters that were ultimately associated with a single core competency: "pose innovative and important research questions, informed by systematic reviews of the literature, stakeholder needs, and relevant theoretical and conceptual models."The draft version of the core competencies and their associated learning objective clusters were reviewed by the health services research faculties from the University of Washington and the Johns Hopkins Schools of Public Health. Their comments were used to produce a revised version. These materials were submitted to a geographically diverse batch of leaders of HSR training programs from across the United States in order to obtain the input of their faculty. These leaders and their programs were selected in consultation with staff responsible for HSR training programs funded by the Agency for Healthcare Research and Quality. The specific programs were selected to represent the major census divisions in the US, programs with and without CEPH-accreditation, and others that were or were not funded by the Agency for Healthcare Research and Quality.The conference was held in the fall of 2005 and included 10 directors of HSR training programs, doctoral students, and representatives from AcademyHealth, AHRQ, CEPH, and public and private sector stakeholder organizations that are employers of HSR trainees. The group used a consensus conference process to revise the specific knowledge- and skills-based competencies that are common to all health services research professionals. A final version of competencies resulted from this consensus process, and is presented in this manuscript.The specific wording of each competency was intended to reflect the level of mastery and to identify the specific asset that HSR doctoral training should develop among its trainees. Table The list of 14 core competencies should be viewed in its entirety as a reflection of values and teaching goals of the HSR doctoral training programs, professional societies, and stakeholder organizations that contributed to this project. While some academic programs may emphasize specific core competencies more than others, it is the totality of the core competencies that makes the list unique to HSR. Individual core competencies are written in broad terms to allow individual variation and interpretation among programs. Some are expressed in such general language that they may be relevant to disciplines other than HSR. This is appropriate since some competencies  are central to conducting research in all fields, but this should not minimize the relevance of their inclusion in the core competencies for HSR.The competencies presented in this manuscript are a first step towards explicating the common knowledge and skill sets of health services researchers. They are presented to generate dialogue and debate both in the US and globally on the essential competencies for HSR. It is possible that non-US programs would view other competencies as core to the educational experience, such as comparative health systems research. Lack of inclusion of these international programs should be seen as a limitation of this work.Further work is necessary to clearly identify the field's unique conceptual and methodological contributions to scientific inquiry. These efforts will undoubtedly help refine the HSR core competencies. Within the past two years, these competencies have been discussed and debated at a supplemental meeting to the 2007 Annual Research Meeting of AcademyHealth. At a 2008 conference sponsored by the Agency for Healthcare Research and Quality, approaches to how a particular program would deliver and evaluate them were examined by a group of HSR training program directors. They are published now to extend this dialogue to the global audience of health services research programs, employers of HSR trainees, and students.Competencies can be an effective tool to guide the design of health services doctoral training programs and can contribute to the definition of the field of health services research. Stakeholder debates can elucidate HSR strengths and identify areas for further development – e.g. development of theories of organizational change to improve quality or better methods to take selection bias into account. To maximize the utility of core competencies, they should be embedded in experiential training as well as courses. Didactic course work is only a small part of doctoral education and much learning takes place during seminars, independent studies with faculty, research assistantships, and research field experiences. One of the next steps in thinking about curriculum development with the competencies will include suggestions for implementing experiential learning in doctoral training. This first foray into competency development should not indicate that HSR is ready for an accreditation process, as accreditation may have the unintended effect of stifling innovation in HSR training. However, this emerging framework could serve as a possible template for continuing education of HSR professionals as the specificity of HSR competence increases with further work.The application of these competencies should not result in a set of "cookie cutter" training programs. In implementing the competencies, we expect that programs will consider the characteristics of their students, the expertise and interests of their faculty, and the opportunities presented by their research partners for field experiences. Programs should continue to offer training with emphasis in specific methods or topic areas. For example, one program may specialize in qualitative methods such as community-based participatory research, while another may concentrate on health economics.The 14 core competencies provide an overview of the breadth of expertise that can be expected of all graduates of US-based HSR doctoral training programs and a minimum level of depth . The specific level of competence in each educational domain, however, is a topic for each training program to grapple with. For example, we did not find unanimity that all HSR trainees should acquire an independent mastery level for primary and secondary data gathering studies. Instead, these competencies were worded to reflect an expectation of an intermediate level of competence – i.e., know how to apply or do something in a supervised setting. It would be expected that individual trainees would choose one of the two types of methodological approaches to gain independent expertise during their doctoral training.The Version 1 core competencies presented in this paper are a product of work done in 2005 and should be considered a first draft. The competencies should be dynamic, changing as the field of health services research changes. For this reason it is likely that the core competencies will need to be revised on a periodic basis. We are publishing Version 1 of the HSR core competencies to generate discussion among a wider group of health services research professionals.The pre-publication history for this paper can be accessed here:


To examine the appropriateness of admissions and in-patient stay for patients with long term neurological conditions (LTNCs). To identify variables predictive of appropriateness and explore management alternatives.Adults admitted as acute patients to Derby Hospitals NHS Foundation Trust (England). Data were collected prospectively and examined by a multi-disciplinary expert panel to determine the appropriateness of admission and length of stay (LoS). Management alternatives were discussed.A total of 119 participants were recruited. 32 admissions were inappropriate and 83 were for an inappropriate duration. Whether a participant lived in their own home was predictive of an inappropriate admission. The number of LTNCs, number of presenting complaints and whether the participant lived alone in their own home were predictive of an inappropriate LoS. For admissions judged to be inappropriate, the panel suggested management alternatives.Patients with LTNCs are being admitted to hospital when other services, e.g. ambulatory care, are available which could meet their needs. Inefficiencies in hospital procedures, such as discharge planning and patient transfers, continue to exist. Recognition of the need to plan for discharge at admission and to ensure in-patient services are provided in a timely manner may contribute towards improved efficiency. People with long term neurological conditions (LTNCs) sometimes have acute episodes of illness that may necessitate hospital admission. The need for hospital admission and continued hospital stay should be dependent on the type of assessment, observation and intervention required for the presenting condition. However, studies from the UK and elsewhere have shown that a number of patients are admitted to hospital, and/or remain in hospital when their needs  can be met more effectively elsewhere -6. AlthoThe age, health and functional status of the patient and the speciality of care admitted to have all been shown to be associated with inappropriate admissions ,11. LiviA systematic review that examined delayed discharge showed that: poor communication between hospital and community services; lack of assessment and discharge planning; inadequate notice of discharge; inadequate consultation with patients and their carers; over-reliance on informal support and lack of (or slow) statutory service provision; and inattention to the special needs of vulnerable groups are problems that characterise delayed hospital discharge .A limited number of studies have examined acute neurological conditions, such as a stroke, and have shown a proportion of the admission is medically inappropriate in 21–50% of patients and 36% of all in-patient days are inappropriate . In one Any person admitted to hospital is placed at risk of hospital acquired infection (often multi-resistant organisms), increased immobility, increased dependency and social isolation -30. For The study aimed to identify1. the prevalence of inappropriate admissions and lengths of in-patient stay amongst patients with LTNCs2. the form(s) of care that would be the most suitable alternative when an admission was deemed inappropriate3. the actions that would have facilitated an appropriate length of stay when the length of stay was deemed inappropriate4. variables predictive of inappropriatenessPatients were recruited from the Medical Assessment Unit (MAU) of Derby Hospitals NHS Foundation Trust. The Trust comprises two acute hospitals which have 56 assessment and 352 general medical beds. Collectively, the hospitals serve a population of approximately 600,000 people.Patients meeting the following criteria were eligible for inclusion in the study:1. Admission to a medical ward in an acute trust2. Patients aged 18 years or above3. A diagnosis, made by a physician, of one or more LTNC present for 12 months or more4. Acute stroke Participants were recruited from two acute hospital sites in Derby  between June 2006 and January 2007. The health records of patients admitted to the MAU were reviewed to determine those who were eligible for recruitment . Those who were eligible for recruitment were approached  within one to two days of being admitted and were provided with a copy of the relevant study documentation (an information sheet and consent form). A clinician involved in the care of the patient, i.e. a nurse or physician, provided their professional opinion as to whether or not they felt the patient was able to provide informed consent. In line with the Mental Capacity Act 2005 permission was sought to recruit patients who were unable to provide informed consent. For those patients who were unable to give informed consent, a member of their family or a friend was approached to provide assent on the patient's behalf. Where there were no family members or friends visiting, ethical permission was given to collect basic information from the patient's health records. Ethical approval was obtained from the Derbyshire NHS Research Ethics Committee (06/q2401/60).A researcher collected data from the health records which included: demographics, use of community health services, medical history and the admitting problem, in-patient management and outcomes of admission. In addition, structured interviews were carried out with patients at the bedside and data collected by this method included: use of community health services, the availability of formal or informal care, the circumstances surrounding the admission, level of functional ability, dependence and cognitive status. Information regarding the participant's functional abilities, level of dependence and cognitive status were assessed using three tools, namely the Guy's Neurological Disability Scale (GDNS), the Functional Independence Measure (FIM), and the Mini Mental State Examination (MMSE) -33.The appropriateness of the admission and LoS was assessed by an expert panel. In contrast to 'appropriateness tools'  the 'exThe panel consisted of a neurological rehabilitation physician, an acute care physician and a general practitioner. In order to standardise the process and maintain parity between cases, panel members adhered to a working definition when determining whether or not the admission/length of stay was appropriate.'Admissions and lengths of stay are deemed appropriate when the level of care required by the patient can only be provided in a hospital e.g. they require access to specialist equipment, treatment administration such as intravenous antibiotics, or urgent specialist input.'Each panel member was presented with the data collected . Expert panel members commented on the medical necessity of the admission/length of stay. When an admission was judged to be inappropriate the length of stay was also classified as inappropriate. Therefore, the lengths of stay of only those who had been admitted appropriately were taken forward for analysis. Members examined the in-patient case notes of each participant and identified if the discharges were premature or delayed. Due to time constraints, the appropriateness of each in-patient day could not be assessed during the panel meetings. Therefore, the panel examined the in-patient case notes relating to the last three to four days of admission to determine the appropriateness of continued admission (and to identify causes of delay where relevant). As the panel did not examine the whole length of stay (for patients whose stay was greater than three/four days) it was not possible to determine the number of days in which a delay occurred. The expert panel therefore assessed the appropriateness of the final day spent in hospital.To minimise bias, panel members were asked to consider the appropriateness of the admission independently and without examining in-patient case notes. They were also asked to reach their decision prior to the panel meeting and to provide the researcher with their preliminary decision. During panel meetings, members discussed their preliminary findings and provided their final decision regarding the appropriateness of each admission and LoS. The decision of the majority was taken forward as the final panel decision.The inter-rater reliability of decisions made independently and prior to the panel meetings showed that there was moderate agreement between raters (range: 0.419–0.444) when judging the appropriateness of admissions, as measured by the Kappa statistic . The intOnce the appropriateness of the acute admission and length of stay had been assessed, alternative forms of care were examined. In addition to the three physicians, a community matron, a social services manager, a neurological rehabilitation nurse specialist, an occupational therapist and a physiotherapist worked together to suggest alternative services or management strategies for the cases discussed. The inclusion of these additional members ensured that clinicians central to the admission, management and discharge of patients with LTNCs were represented and those selected had relevant clinical experience and current knowledge of the problems prevalent amongst patients with LTNCs. Involvement of a multi-disciplinary group ensured that alternative management strategies/services were examined from a variety of perspectives, thereby overcoming some of the limitations in knowledge that single clinicians may encounter (e.g. unfamiliarity with primary and secondary services).Data from acute stroke studies were used to determine the sample size ,24. BaseDescriptive statistics,  were used to describe participants and the outcomes of expert panel meetings. A Chi-Squared Test or Fisher Exact Test was used, where appropriate, to determine whether a difference existed in the proportion of participants admitted appropriately/inappropriately or whose last in-patient day was appropriate/inappropriate for specific categorical variables. The distribution of variables was examined for normality using the Kolmogorov-Smirnov test and histograms. The Mann Whitney U test was used to examine continuous variables between the two cohorts (appropriate/inappropriate admission or length of stay). Logistic regression was used to model variables predictive of an inappropriate admission and length of stay. Variables that were associated significantly with an inappropriate admission/length of stay after the Univariate analysis were entered into the logistic regression model separately for estimating the unadjusted Odds Ratios (OR) and 95% confidence intervals (CI). All the variables that were associated significantly with an inappropriate admission/length of stay were entered into one logistic regression model for estimating the adjusted OR and 95% CI. Using a Forward Stepwise Likelihood ratio selection method, variables were tested for significance. Entry of variables to the model was determined using the Log-Likelihood ratio test, with p < 0.05. The Hosmer-Lemeshow test was used for examining the goodness of fit for the model. Variables were deemed significant if the p-value was less than 0.05.A total of 298 patients met the eligibility criteria and of these 119 were recruited. The most common reason for failure to recruit eligible patients was that the patient was discharged before consent/assent could be obtained , followed by the patient declining . The calculated sample size was therefore not achieved. The confidence intervals of the proportion of patients who were admitted inappropriately/had an inappropriate length of in-patient stay and of the variables predictive of appropriateness are therefore less precise. However, aims one to three are unaffected.Participants were recruited over an eight month period (June 06–January 07). Half of the sample were male, the majority were white (97%), living in their own home (79%) and had a median age of 73 years (58–82). The majority of participants had one LTNC , however, approximately one fifth of the participants had multiple LTNCs . The most frequent LTNC was a stroke , followed by epilepsy n = 31, 21%) Parkinson's disease (PD) , dementia , multiple sclerosis , Alzheimer's disease , sub-arachnoid haemorrhage , peripheral neuropathy . Chest pain , shortness of breath , collapse  and a fall  were the most common presenting complaints. Additional complaints included epileptic fit , reduced mobility , diarrhoea  and participants being described as 'off their legs' . In total, there were 39 different presenting complaints . The most frequent reasons (sometimes more than one per participant) for an admission to be deemed inappropriate were that the participant's concern could have been managed by primary care services (40%); required attendance rather than admission to hospital (40%); required admission to a non-acute facility (13%); could have been managed by an outpatient service (8%). Of the alternative forms of care suggested by the expert panel, 15 cases (38%) were thought to be suitable for assessment or monitoring in a clinical decision unit only (without acute admission), 11 cases (28%) for health or social care at home, seven cases (15%) for respite or palliative care in a nursing home and four cases (13%) for a non acute hospital admission.The LoS of those participants who were found to have been admitted to hospital appropriately (n = 81) were analysed. The expert panel was unable to provide a definitive answer regarding the appropriateness of three in-patient stays and these were therefore excluded from the analysis. A total of 51 out of 81 participants  were admitted to hospital for an inappropriate duration and 46 (90%) of these admissions were too long.Prolonged LoS was frequently caused by a number of problems. Delays relating to the undertaking of investigations, planning for discharge ; treatment initiation; and failure to discharge the patient when medically fit were the most frequent causes of prolonged stays , prompt referrals to other services and completing investigations at an early stage in the admission were suggested. Also, faster access to the results of investigations, prompt provision of in-patient specialist health or therapeutic services and increased capacity of long term rehabilitation and sub-acute facilities would have facilitated the timely discharge of several participants.Participants diagnosed with multiple sclerosis (MS), Parkinson's disease (PD) or dementia were most frequently admitted inappropriately . No other variables were found to be significantly associated with an inappropriate admission  to statistics obtained previously in studies of other adult or older adult populations ,4,5. TheOne risk factor for an inappropriate admission, living in your own home compared to a residential/nursing home, was identified and this may relate to the availability of support for those who live in long term care facilities (where care is available 24 hours a day) compared to those who live in their own home. For an inappropriate LoS, a number of risk factors were identified relating to the health status of the participant (number of LTNCs and number of presenting complaints) and the social circumstances of the participant . Although participants who required transfer were not at significantly greater risk, the majority who were transferred from hospital to a rehabilitation or long term care facility had an inappropriate LoS, indicating that ensuring the timely transfer of patients to these facilities can be a difficult task.There are a number of limitations of this study. Firstly, the optimum sample size for the study was not achieved, therefore, the confidence intervals produced are less precise (8% compared to 5%). However, the logistic models have been checked for a goodness of fit using their residuals against fitted value plots, the factors included in the models were statistically significant; therefore, the analysis is valid. Failure to recruit the desired number of patients was primarily due to difficulties in recruiting patients when neither consent nor assent could be obtained. For such patients, ethical permission was given for a clinician involved in the patient's care to collect information from their health records. However, prior to this it was necessary to establish that neither a family member or friend was visiting and a minimum time period of three days was given to determine this. Patients were frequently discharged during this time. Also, whilst recruitment took place at two hospitals only one researcher was available to recruit patients. A large proportion of eligible patients were therefore discharged before the researcher could meet with the patient's family/friends to discuss the study. It is possible that such patients had greater levels of impairment (reflected in their inability to give informed consent) and would have been more dependent on services. The population recruited may be skewed towards those who were less physically and cognitively impaired, thus, the possibility of selection bias cannot be ruled out. Secondly, assessment of cognition, activities of daily living and neurological disability were only completed for those who were physically and mentally able to take part in an interview, or where a relative was able to give the information. The scores may not, therefore, reflect the LTNC population accurately. Thirdly, the number of inappropriate in-patient days was not examined due to time constraints. Lengths of stay that were deemed inappropriate therefore had a minimum of one day delay. Given the restricted capacity of acute beds and the potential risk of hospitalising patients inappropriately, it was felt that even a one day delay had great clinical significance. In order to justify rearrangement of services and examine cost savings, future research in this area would be required.It is also noteworthy that in this study an expert panel method was used. Whilst this method best served the study aims, the limitations must be noted. In any group situation there may be psychosocial influences, for example those who are less confident in their answers may choose to conform with more confident group members . Also, tThis study highlights several areas where interventions may reduce the incidence of inappropriate admissions and/or LoS. A large number of patients required assessment/observation in an ambulatory setting rather than an admission to hospital. It is important to ensure, therefore, that clinical decision unit models are equipped, designed and resourced to allow detailed assessments whilst preventing Emergency Departments and hospital wards from becoming congested. Also, for the participants studied, prompt access to specialist neurological advice would have been advantageous. Such advice may have prevented participants being admitted to wait for this advice, however, further research would be needed to confirm this. Also, this would help to meet the quality requirements laid out in the National Service Framework for Long Term Conditions, i.e. that people admitted with a neurological emergency should be assessed and treated in a timely manner by teams with the appropriate neurological skills  and that specialist clinicians should be consulted when patients with LTNCs are admitted  . It appeA proportion of patients with LTNCs have been shown to be admitted to hospital when it was not medically necessary and to have remained in hospital for an inappropriate period. Patients with LTNCs may be at increased risk of developing hospital associated complications. In many cases ambulatory services or alternative community services exist which could have met the needs of participants and would have eliminated the need for admission. Increased access to ambulatory services such as clinical decision units and same day access to nursing home beds or emergency home care is needed. Identification of specific barriers which prevent services being accessed, from both the secondary and primary care perspective, to prevent inappropriate admission is required to determine where specific intervention is most needed. Organisational inefficiencies such as poor discharge planning and failure to recognise when patients are ready for discharge continue to exist. Increased frequency of senior medical review, early identification of requirements with timely referral to in-patient services and development of discharge plans are practical suggestions which could improve efficiency of discharge procedures.The authors declare that they have no competing interests.CLH designed the study, collected study data, performed the analysis and interpretation of data and produced the first draft of the manuscript. MFP provided assistance with the design of the study, provided support to CLH during the collection of data, and assisted with the revision of the manuscript. LLP provided assistance with the design of the study and assisted with the revision of the manuscript. BJP provided assistance with the design of the study, provided support to CLH during the collection of data, and assisted with the revision of the manuscript. AF provided assistance with the statistical design of the study, performed the sample size calculation, assisted with the analysis and interpretation of the data and assisted with the revision of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:


Despite the development of several models of care delivery for patients with chronic illness, consistent improvements in outcomes have not been achieved. These inconsistent results may be less related to the content of the models themselves, but to their underlying conceptualization of clinical settings as linear, predictable systems. The science of complex adaptive systems (CAS), suggests that clinical settings are non-linear, and increasingly has been used as a framework for describing and understanding clinical systems. The purpose of this study is to broaden the conceptualization by examining the relationship between interventions that leverage CAS characteristics in intervention design and implementation, and effectiveness of reported outcomes for patients with Type II diabetes.We conducted a systematic review of the literature on organizational interventions to improve care of Type II diabetes. For each study we recorded measured process and clinical outcomes of diabetic patients. Two independent reviewers gave each study a score that reflected whether organizational interventions reflected one or more characteristics of a complex adaptive system. The effectiveness of the intervention was assessed by standardizing the scoring of the results of each study as 0 (no effect), 0.5 (mixed effect), or 1.0 (effective).Out of 157 potentially eligible studies, 32 met our eligibility criteria. Most studies were felt to utilize at least one CAS characteristic in their intervention designs, and ninety-one percent were scored as either "mixed effect" or "effective." The number of CAS characteristics present in each intervention was associated with effectiveness (p = 0.002). Two individual CAS characteristics were associated with effectiveness: interconnections between participants and co-evolution.The significant association between CAS characteristics and effectiveness of reported outcomes for patients with Type II diabetes suggests that complexity science may provide an effective framework for designing and implementing interventions that lead to improved patient outcomes. Although the cost of managing patients with chronic disease is high, and is predicted to rise to 80% of US health care dollars by 2020 , identifTo facilitate implementation, several models for delivery of care for patients with chronic disease have emerged. These include the "self-management" and "collaborative management" models, the "chronic care model," and the "disease management" approach -9. RecenOne possible reason for the modest effects of organizational intervention outcomes is suggested by the recent application of complex adaptive system (CAS) theory to the organization of health care delivery -17. A CACAS theory has been used to describe clinical settings, such as primary care clinics . Howeveri.e., differences in the workflow of test ordering, ease of access of recommended care, patient population served, or provider beliefs).Complexity science suggests that inconsistent outcomes may result from an implicit assumption of linear, mechanistic relationships between cause and effect in implementing organizational interventions. This linear viewpoint implies that a specific intervention should lead to consistent, reproducible results across clinical settings. In contrast, nonlinearity, self-organization, and co-evolution suggest that each clinical setting is unique, and that outcomes of interventions may be greatly affected by small situational differences. ,19. For The goal of this study is to build on the current literature related to using CAS to observe and understand clinical settings, to begin to examine the extent to which CAS theory is useful as a tool for designing and/or implementing organizational interventions. We hypothesize that interventions that leverage the characteristics of complex adaptive systems, intentionally or not, and regardless of the particular model of chronic care delivery on which the intervention was based, will consistently lead to improved outcomes over those that do not. To test this hypothesis, we conducted a systematic review of organizational interventions for patients with Type II diabetes and examine these interventions through the lens of complexity science.We defined organizational interventions as those that explicitly attempt to affect or change organizational structures or processes to implement evidence-based practice. We searched Medline from 1989 through 29 December 2005, after developing a search strategy based on four components: 1) the strategy developed by the Effective Practice and Organization of Care (EPOC) Group of the Cochrane Collaboration and updated for a recent systematic review of Medicare-funded preventive services ,22; (2) Inclusion criteria were randomized, quasi-randomized, or controlled clinical trials published in English and conducted in economically developed countries as identified by the International Monetary Fund or the Organization for Economic Cooperation and Development . We exclFour investigators independently reviewed overlapping groups of differing halves of the citations' titles and abstracts generated by the full literature search to assess agreement regarding potentially eligible publications. Raw agreement was 94%. If eligibility was uncertain after review of the title and abstract, the full article was reviewed. Eligible studies were independently reviewed and jointly abstracted in detail by teams of two investigators. Disagreements were resolved by consensus of the group of investigators.Eligible publications were independently evaluated by two raters with content expertise in complexity science to assess the extent to which the intervention utilized any of the following characteristics of a CAS: individuals' capacity/ability to learn; the interconnections between individuals; the ability of participants to self-organize; and the tendency of participants to co-evolve. These are representative of critical elements of CAS ,19. The Because of the heterogeneity across study outcomes, we did not use effect size as the outcome variable. The most commonly used outcome was change in hemoglobin A1c, but this was used in only 14 studies of variable duration, four of which contained unit of allocation error, or mismatch between the unit of randomization and unit of analysis. Additionally, some studies compared change in hemoglobin A1c with baseline values, rather than with controls. To overcome this, a rating scale was used to assess the efficacy of the intervention. The outcomes of each study were assessed by two independent raters on a scale of 0 (no effect), 0.5 (mixed results), and 1 (intervention effective) based on the type (process versus outcome), number, and statistical significance of outcomes reported. The specific criteria used for each rating, along with specific examples of the reported outcomes for each rating, are shown in Table Because of the small number of studies identified, we used Fisher's exact test to test the significance of the relationship between total number of characteristics of complex adaptive systems being leveraged by an organizational intervention and the strength of outcomes reported, as well as between each individual characteristic and the strength of outcomes. Because a mismatch between the unit of allocation and analysis may bias a study toward positive results, we divided studies into two groups based on whether a unit of analysis error was present. A second analysis using Fisher's exact test was performed including only those studies that did not contain a unit of analysis error. Finally, a third analysis using logistic regression was performed to weight studies based on both sample size and duration of intervention. All statistical analyses were performed using Stata 8.0 .The search identified 5,590 publications; 157 were potentially eligible by review of title and abstract. After full review of these published studies, 32 met our eligibility criteria -56. FiguThe distribution of characteristics of complex adaptive systems utilized by a study intervention and the intervention efficacy for all studies is shown in Table Of the four CAS characteristics assessed for each intervention, two were individually significantly associated with effectiveness. Interventions that affected interconnections in the organization or allowed participants to co-evolve were significantly associated with intervention effectiveness . When studies with unit of analysis error were excluded, these associations remained significant (p = 0.05 and 0.003). The associations between interventions affecting participants' ability to learn or self-organize were not statistically significant (p = 0.06 and 0.58).Consistent with prior literature, this systematic review found that many studies of organizational interventions do not improve process or outcome measures for patients with the chronic illness diabetes -5. Only Specifically, the finding that interventions incorporating features of CAS were more effective suggests that a dynamic approach to the design of organizational interventions to improve patient outcomes may be helpful. Rather than designing one-size-fits-all interventions that require adherence to a rigid, pre-set course of action, allowing participants to have input and control that reflect their local environment, as well as allowing them to adapt or deviate from a set plan as results evolve, may lead to more effective change. In short, we suggest that thinking about the intervention as a participatory, adaptive process rather than a set blueprint will lead to more effective interventions. These approaches currently exist; one example includes the Institute for Healthcare Improvement's Framework for Spread . Howeveri.e., the interventions should consider the holistic nature of practices. The number of studies was too small to allow for this analysis.Two individual characteristics, co-evolution  and interconnections (changing the pattern of communication between participants) had the strongest relationship with intervention effect. It is difficult to interpret the lack of a relationship between other individual characteristics and strength of outcomes, as the number of studies included in this analysis was small, particularly after those with level of analysis error were excluded. However, the significant association between the overall number of characteristics of CAS and the intervention effectiveness, in the absence of a clear association for all individual characteristics, could imply that combinations of characteristics are more effective,The association between interventions that influenced the interconnections between participants and intervention effectiveness may suggest that interventions that focus on the quality and pattern of relationships between participants in a clinical setting may be superior to those that focus on trying to change the behavior of a single participant. What sets this apart from other theories of organizational change is the scope of this approach to allow consideration of multiple aspects of the clinical setting, and the nonlinearity of the relationships between them. This inherent nonlinearity implies that inputs and outputs are unlikely to be proportional, particularly across clinical settings and over time, and suggests the need for the following specific approaches: involvement of more than one type of participant in both intervention design and implementation, use of more than one method of connecting agents in an organization, and continual reassessment of the effect of an intervention coupled with a willingness to make changes based on this reassessment. In fact, this may explain why multi-faceted organizational interventions may be more effective than those with a focus on a single strategy .e.g., positive studies being more likely to be published), or the possibility that studies with negative outcomes did not provide sufficient detail regarding interventions, could potentially impact these results. However, regarding the latter potential bias, the inter-rater consistency on characteristic ratings indicates that reported methods were sufficient to reliably assess the interventions. We did not identify studies in the management literature or seek out unpublished information or "grey literature." Our intention was to focus on studies in the peer-reviewed medial literature as the most simple, direct, and universally accepted approach to studying whether an association between interventions with features that reflect CAS and outcome effectiveness exists. If this association had not been found, our next step might have been to identify these additional sources.Several other limitations besides the small sample size deserve mention. All of the studies included related only to the chronic care of diabetic patients. Confirmation of these findings for patients with other chronic diseases is necessary. In addition, while we were able to address the potential bias inherent in studies with unit of allocation error, publication bias  declare that they have no competing interests.LKL conceived this analysis using the database conceived by VL, PN, and JP, rated studies, performed preliminary statistical analysis, and drafted the manuscript. JP participated in the design of the study and helped to draft the manuscript. VL conceived the systematic review and database, rated studies, and helped to draft the manuscript. MP rated studies and helped to draft the manuscript. PN conceived the systematic review and database and helped to draft the manuscript. JC performed statistical analysis and helped to draft the manuscript. RMcD participated in the design of the study, provided theoretical expertise, and helped to draft the manuscript.All authors have read and approved the final manuscript.Search strategy for organizational interventions to improve outcomes of patients with Type II diabetes. Medline search strategy to identify studies of organizational interventions to improve outcomes for patients with Type II diabetes, as described in Leykum, et al, Organizational interventions employing principles of complexity science have improved outcomes for patients with Type II diabetes. Search completed December 2005.Click here for fileSummary of included studies. Summary of eligible studies of organizational interventions on outcomes of patients with type 2 diabetes, as described in Leykum, et al, Organizational interventions employing principles of complexity science have improved outcomes for patients with Type II diabetes.Click here for file


Millions of children die every year in developing countries, from preventable diseases such as pneumonia and diarrhoea, owing to low levels of investment in child health. Investment efforts are hampered by a general lack of adequate information that is necessary for priority setting in this sector. This paper measures the health system costs of providing inpatient and outpatient services, and also the costs associated with treating pneumonia and diarrhoea in under-five children at a health centre in Zambia.Annual economic and financial cost data were collected in 2005-2006. Data were summarized in a Microsoft excel spreadsheet to obtain total department costs and average disease treatment costs.The total annual cost of operating the health centre was US$1,731,661 of which US$1 284 306 and US$447,355 were patient care and overhead departments costs, respectively. The average cost of providing out-patient services was US$3 per visit, while the cost of in-patient treatment was US$18 per bed day. The cost of providing dental services was highest at US$20 per visit, and the cost of VCT services was lowest, with US$1 per visit. The cost per out-patient visit for under-five pneumonia was US$48, while the cost per bed day was US$215. The cost per outpatient visit attributed to under-five diarrhoea was US$26, and the cost per bed day was US$78.In the face of insufficient data, a cost analysis exercise is a difficult but feasible undertaking. The study findings are useful and applicable in similar settings, and can be used in cost effectiveness analyses of health interventions. The challenge to meet the millennium development goal of reducing under-five mortality with two thirds by 2015 has prompted the need for increased investment in child health in low income countries, where about 4.8 million children die every year from preventable diseases .Morbidity and mortality due to these and other diseases impose a huge economic burden on individuals, families and on society at large. This economic burden is more acute in developing countries, where the opportunity costs of resources are very high. This necessitates the need for priority setting in the allocation of resources.However, priority setting in most developing countries is hampered by lack of sufficient information . Little A literature search was conducted between June 2006 and February 2007, for English language articles on healthcare costs and the costs of pneumonia and diarrhoea in the following databases: MEDLINE (January 1966 to date), Cochrane Controlled Trials Register (CENTRAL), the Cochrane economic evaluation database (NHS EED), EMBASE-Medicine (January 1985 to date) and the ISI Web of Science. The search did not yield any studies undertaken in Zambia to measure health care costs or treatment costs of pneumonia and diarrhoea in children. Limited data are also available on the costs of general healthcare services .In an effort to document information that is potentially beneficial to priority setting in the health sector, we set out to measure the health system costs of providing inpatient and outpatient healthcare services to an urban population in Zambia. We demonstrated how our findings can be used to measure disease specific costs by calculating average treatment costs of pneumonia and diarrhoea in under-five children. This was also done in order to justify the adoption of cost-effective disease prevention measures. Research has shown the efficacy of rotavirus and pneumococcal vaccines in preventing diarrhoea and pneumonia in children ,13, and Lusaka district, in which the capital of Zambia is situated, has a population of about 2 million people. Healthcare for the district is provided by the central Government and private for profit institutions, which are mainly situated in urban areas. The public health institutions are classified into health posts, health centres, district referral centres, general hospitals and central hospitals. Health posts are intended to cater for a population of about 500 to 100 households, while health centres serve a population of about 50,000 people in urban areas and 10,000 people in rural areas. District referral centres, general and central hospitals are meant to cater for populations of 200,000; 800,000 and above 800,000 respectively. Lusaka district has 8 health posts, 22 health centres and 2 central hospitals.We undertook the costing study at Kanyama health centre, in Kanyama Township in the capital, Lusaka. The health centre is a public institution funded by the Ministry of Health (MOH), under the Lusaka District Health Management Team (DHMT). Its catchment area includes all the households in Kanyama Township and some other households in surrounding areas. The centre provides both outpatient and inpatient services, and has about 700 visits daily, and a total of 41 beds.Kanyama Township had an estimated population of over 130,000 in 2006 . ApproxiThe study was undertaken from the health provider perspective, and as such, only costs borne by the health centre were taken into consideration. We did not include the costs to households and social costs such as quality of life reductions caused by disease.Cost Analysis in Primary Health Care: A Manual for Programme Managers [Data collection was guided by the Managers . Cost anManagers . The HMIData on the prices and quantities of drugs and other recurrent medical supplies provided to the health centre were obtained from the DHMT pharmacy, which supplies all such items to government health centres in Lusaka District. It has a well developed system of delivery with updated documentation of all transactions to health centres. We were able to access these records to obtain updated information on supplies to Kanyama health centre, and accurate prices of most of the items provided. The prevailing market price was used as proxy for items whose prices were unavailable in the records of both the health centre and the DHMT. All costs were adjusted to 2006 prices using the 2006 Gross Domestic Products (GDP) deflator, valued at K1,175 . Items wCosts were classified as either economic or financial. Economic costs reflected the opportunity cost of resource use, while financial costs considered only expenditures incurred in the purchase of items. Costs were further classified as capital or recurrent. Capital costs included items such as buildings, equipment and vehicles, who's useful life was more than one year. Recurrent costs included items such as personnel and supplies, which could be replaced within a year. Items such as cutlery, buckets and garden implements, which could last for more than a year but cost less than US$100 were regarded as recurrent costs.A physical count of all capital items such as furniture and equipment was undertaken to ascertain the exact number and condition. Only items that were functional were included for costing. The floor areas and costs of buildings were obtained from the Buildings Department at the Ministry of Works and Supply, which is the custodian of all information on government buildings. Where such costs were not available, the floor space of the buildings was measured physically and an estimated value was attached by a Quantity Surveyor at the Department.Capital costs were annuitized to take into account the fact that such resources are bought in one year, but their useful life spans over several years . The annData were, however, sometimes not readily available and had to be estimated using proxies. For example, we did not have access to the original records of some capital and recurrent outlays, which made it difficult to obtain their original purchase prices. We therefore, made estimates which could have been over or under the true value. This was the case also for utilities, for which we did not find any records on bills paid towards water and electricity. We decided to use fixed monthly charges of US$2.78 for water  and US$6In some cases, the records were available but not in order, and the researcher could not sort them due to inadequate time and resources. It was not possible, for example, to allocate some medical supplies received by the health centre's pharmacy to the various wards or departments, as usage of these items was not specified by ward. It was thus decided to treat all such items as overhead costs, to be allocated to each of the wards according to an estimated allocation factor. The supplies that were 'ward or department specific', e.g. family planning drugs and some antibiotics were allocated directly to the necessary wards or departments.Further, it was not immediately possible to allocate certain items, such as staff time to certain departments, as their usage between departments was not clearly defined. The same personnel who tended to the paediatric ward also serviced the male and female wards. As a result, it was not easy to distinguish to which ward/department some of the staff time belonged. It was thus decided to allocate time equally to those departments that were serviced by the same personnel, as there was no clearly defined pattern of work. The same was done for equipment, where percent usage was divided equally between wards.Figure The health centre's departments were classified into 9 patient care and 6 overhead departments. The patient care departments included all units or wards where patients directly received treatment, such as the inpatient and outpatient wards and the laboratory. The overhead departments were those that serviced the patient care departments and whose activities were not immediately identified with disease treatment ,20. ThesIn each department, costs were categorised as follows: Personnel cost, including salaries, benefits and allowances. Capital costs, including buildings, vehicles, furniture and equipment such as x-ray machines. Supplies, including cleaning supplies, medical and surgical supplies. Maintenance, for buildings, vehicles and general repairs. For inpatient costs, we included beds, inpatient maintenance and supplies and length of stay for each disease.The costs were further divided into patient care costs, which were costs incurred in the patient care departments, and overhead costs, incurred in the overhead departments. Overhead departments' costs were shared by all the patient care units. These costs were allocated to each patient care department according to the estimated proportion of number of visits, bed days, personnel or floor space.The intermediate outputs were the services provided by each patient care department. The units of analysis used to measure the output were bed days for the inpatient department and visits for the outpatient department. In the laboratory, the units of measurement were the total number of lab tests conducted in the study period. In the labour/maternity ward, the units used were visits instead of bed days. This is because the majority of the women spent a day or less in this ward before being discharged. The total number of visits and admissions included both persons attending the health centre for the first time (new attendees) and re-attendees.Total costs were divided by total outputs to obtain average costs. The average cost of inpatient care, for example, was obtained by dividing the total cost in the paediatric ward by the total number of bed days in the reference period. Average costs of service provision are presented for all the patient care departments except Anti Retroviral Treatment (ART), for which information on usage was not available.To decide on the introduction of pneumococcal and rotavirus vaccines, the economic burden of pneumonia and diarrhoea is needed for inclusion in cost-effectiveness studies. Our result can help estimate these costs. To do this, we measured the average treatment costs of pneumonia and diarrhoea, using total under-five pneumonia and diarrhoea visits and bed days recorded in the health centre's records, and the total outpatient and in-patient costs for treating these diseases. All resources related to the treatment of childhood pneumonia, including personnel, buildings, medical supplies, laboratory equipment and utilities were costed. Unit costs for each disease were calculated by dividing the total outpatient and inpatient costs by the corresponding visits or bed days for the condition. The average healthcare costs provided for both pneumonia and diarrhoea thus include the outpatient (cost per visit) and inpatient (cost per bed day) costs.The annual costs incurred in the patient care departments are presented in table The outpatient ward had the highest total cost at US$426,847 (33%), while the Voluntary Counselling and Testing Ward (VCT) ward had the lowest at US$9,659 (1%). The outpatient ward also had the highest recurrent cost (35%), while the inpatient ward had the highest capital cost (28%).Table There were an estimated 14 outpatient visits per day per medical personnel for the entire study period. The health centre's bed occupancy rate, defined as the bed days per number of beds was 82%; while the bed turnover, defined as the number of admissions per number of beds was 71%. The average length of stay was 4 days.Table The average costs per unit of service in all the departments are given in table Table This paper provides information on the average outpatient and inpatient treatment costs in an urban health centre in Zambia, and also measures the average cost of pneumonia and diarrhoea treatment in children under the age of 5 years. The average costs incurred in the patient care departments ranged from US$1 to US$20, with the highest cost observed in the dental department. Except for dental services, all out-patient services costs were relatively much lower than in-patient costs. This is reflective of the severity of inpatient cases, which require relatively more care and consequently more resources to manage. Additional costs such as lodging facilities and meals tend to increase admission costs [We estimated the total annual cost of operating the health centre at US$1,284,305. It was however not possible to isolate the government budget for Kanyama health centre and compare it with our result. Most of the budget components were financed through various departments, and aggregated together with information from other clinics and health centres. The salaries, for example were paid through MOH and the health centre's supplies and equipment were provided by DHMT.The government per capita expenditure on health was US$17 in 2005 . Taking The annual per capita cost of providing healthcare calculated in this paper is lower than the cost estimated by the World Bank , but is In comparison to a study undertaken in Kenya, which recently reported costs of in-patient pneumonia treatment in children, ranging from about US$46 to US$172 , our estA limitation of this study is that it did not measure the supervisory costs incurred by the Ministry of Health, and the costs of support incurred by non-governmental organisations and the donor community, thereby underestimating the true health systems cost of service provision to Kanyama Township. Furthermore, our exclusion of family costs incurred in accessing healthcare does not give a true reflection of the burden of disease and healthcare. It is necessary for social planning to also have an insight into the cost structures of individuals, households and society at large. Future research should consider both the direct and indirect costs of treatment, and the long term effects of quality of life reductions due to illness. This perspective is more informative to policy makers as it helps them plan for a wider section of the community.The paper, however, fills a large gap in the literature on the cost of healthcare provision in Zambia, particularly on the cost of childhood pneumonia and diarrhoea to the health system. It underscores the challenge of undertaking a cost analysis in the face of unavailability of reliable, consistent and accurate data, which is the case in many developing countries ,20. In ZThe study provides information that is potentially useful for planning in the area of child health. It documents the procedures for undertaking cost analyses of healthcare services which can be used in similar settings. Our experiences in this study could be a guide for others as far as highlighting what is expected in the course of undertaking such work.This study was undertaken in a particular institutional and epidemiological setting. Although generalization must be made with great caution, the study can still be useful in similar Zambian settings since the costs of large items such as staff, equipment and drugs are fairly standard. The costs of medication, treatment and other facility costs may also be generally comparable.The authors declare that they have no competing interests.Both authors participated in the design and planning of the study. Field work was conducted by LC; the analysis and write-up was carried out mainly by LC. Both authors read and approved the final manuscript.