Impact of a hospice rapid response service on preferred place of death, and costs

Background: Many people with a terminal illness would prefer to die at home. A new palliative rapid response service (RRS) provided by a large hospice provider in South East England was evaluated (2010) to provide evidence of impact on achieving preferred place of death and costs. The RRS was delivered by a team of trained health care assistants and available 24/7. The purpose of this study was to (i) compare the characteristics of RRS users and non-users, (ii) explore differences in the proportions of users and non-users dying in the place of their choice, (iii) monitor the whole system service utilisation of users and non-users, and compare costs. Methods: All hospice patients who died with a preferred place of death recorded during an 18 month period were included. Data (demographic, preferences for place of death) were obtained from hospice records. Dying in preferred place was modelled using stepwise logistic regression analysis. Service use data (period between referral to hospice and death) were obtained from general practitioners, community providers, hospitals, social services, hospice, and costs calculated using validated national tariffs. Results: Of 688 patients referred to the hospice when the RRS was operational, 247 (35.9 %) used it. Higher proportions of RRS users than non-users lived in their own homes with a co-resident carer (40.3 % vs. 23.7 %); more non-users lived alone or in residential care (58.8 % vs. 76.3 %). Chances of dying in the preferred place were enhanced 2.1 times by being a RRS user, compared to a non-user, and 1.5 times by having a co-resident carer, compared to living at home alone or in a care home. Total service costs did not differ between users and non-users, except when referred to hospice very close to death (users had higher costs). Conclusions: Use of the RRS was associated with increased likelihood of dying in the preferred place. The RRS is cost neutral

The Rise and Fall of the Zaibatsu: Japan\u27s Industrial and Economic Modernization

Throughout the past century, the rise and fall of the zaibatsu and the operations of their direct successors has not only shaped Japan’s economic and financial landscape but also has been instrumental in the modernization of the world economy. Many of these corporations traced their roots to Japan’s premodern era, and were directly responsible for the transformation of a nation of rice farmers into an industrial powerhouse in the years prior to World War II. Following Japan’s defeat, these monopolistic corporations were dismantled by the Keynesian economists of the Allied occupation and were reorganized into the keiretsu system, which exists in Japan to this day. The paper examines the roots of the modern Japanese economy and the zaibatsu themselves, and goes on to follow their history and impact on Japan to the present day

Economic impact of hospitalisations among patients in the last year of life: An observational study

Background: Hospital admissions among patients at the end of life have a significant economic impact. Avoiding unnecessary hospitalisations has the potential for significant cost savings and is often in line with patient preference. Objective: To determine the extent of potentially avoidable hospital admissions among patients admitted to hospital in the last year of life and to cost these accordingly. Design: An observational retrospective case note review with economic impact assessment. Setting: Two large acute hospitals in the North of England, serving contrasting socio-demographic populations. Patients: A total of 483 patients who died within 1 year of admission to hospital. Measurements: Data were collected across a range of clinical, demographic, economic and service use variables and were collected from hospital case notes and routinely collected sources. Palliative medicine consultants identified admissions that were potentially avoidable. Results: Of 483 admissions, 35 were classified as potentially avoidable. Avoiding these admissions and caring for the patients in alternative locations would save the two hospitals £5.9 million per year. Reducing length of stay in all 483 patients by 14% has the potential to save the two hospitals £47.5 million per year; however, this cost would have to be offset against increased community care costs. Limitations: A lack of accurate cost data on alternative care provision in the community limits the accuracy of economic estimates. Conclusions: Reducing length of hospital stay in palliative care patients may offer the potential to achieve higher hospital cost savings than preventing avoidable admissions. Further research is required to determine both the feasibility of reducing length of hospital stay for patients with palliative care needs and the economic impact of doing so

Understanding the UK hospital supply chain in an era of patient choice

Author Posting © Westburn Publishers Ltd, 2011. This is a post-peer-review, pre-copy-edit version of an article which has been published in its definitive form in the Journal of Marketing Management, and has been posted by permission of Westburn Publishers Ltd for personal use, not for redistribution. The article was published in Journal of Marketing Management, 27(3-4), 401 - 423, doi:10.1080/0267257X.2011.547084 http://dx.doi.org/10.1080/0267257X.2011.547084The purpose of this paper is to investigate the UK hospital supply chain in light of recent government policy reform where patients will have, inter alia, greater choice of hospital for elective surgery. Subsequently, the hospital system should become far more competitive with supply chains having to react to these changes as patient demand becomes less predictable. Using a qualitative case study methodology, hospital managers are interviewed on a range of issues. Views on the development of the hospital supply chain in different phases are derived, and are used to develop a map of the current hospital chain. The findings show hospital managers anticipating some significant changes to the hospital supply chain and its workings as Patient Choice expands. The research also maps the various aspects of the hospital supply chain as it moves through different operational phases and highlights underlying challenges and complexities. The hospital supply chain, as discussed and mapped in this research, is original work given there are no examples in the literature that provide holistic representations of hospital activity. At the end, specific recommendations are provided that will be of interest to service to managers, researchers, and policymakers

Effects of mesenchymal stromal cells versus serum on tendon healing in a controlled experimental trial in an equine model

Abstract Background Mesenchymal stromal cells (MSC) have shown promising results in the treatment of tendinopathy in equine medicine, making this therapeutic approach seem favorable for translation to human medicine. Having demonstrated that MSC engraft within the tendon lesions after local injection in an equine model, we hypothesized that they would improve tendon healing superior to serum injection alone. Methods Quadrilateral tendon lesions were induced in six horses by mechanical tissue disruption combined with collagenase application 3 weeks before treatment. Adipose-derived MSC suspended in serum or serum alone were then injected intralesionally. Clinical examinations, ultrasound and magnetic resonance imaging were performed over 24 weeks. Tendon biopsies for histological assessment were taken from the hindlimbs 3 weeks after treatment. Horses were sacrificed after 24 weeks and forelimb tendons were subjected to macroscopic and histological examination as well as analysis of musculoskeletal marker expression. Results Tendons injected with MSC showed a transient increase in inflammation and lesion size, as indicated by clinical and imaging parameters between week 3 and 6 (p < 0.05). Thereafter, symptoms decreased in both groups and, except that in MSC-treated tendons, mean lesion signal intensity as seen in T2w magnetic resonance imaging and cellularity as seen in the histology (p < 0.05) were lower, no major differences could be found at week 24. Conclusions These data suggest that MSC have influenced the inflammatory reaction in a way not described in tendinopathy studies before. However, at the endpoint of the current study, 24 weeks after treatment, no distinct improvement was observed in MSC-treated tendons compared to the serum-injected controls. Future studies are necessary to elucidate whether and under which conditions MSC are beneficial for tendon healing before translation into human medicine

End of life care: The experiences of advance care planning amongst family caregivers of people with advanced dementia - A qualitative study

Background: End of life decisions for people with advanced dementia are reported as often being difficult for families as they attempt to make appropriate and justified decisions. Aim: To explore the experiences of advance care planning amongst family caregivers of people with advanced dementia. Design: Qualitative research including a series of single cases (close family relatives). Methods: A purposive sample of 12 family caregivers within a specialist dementia unit was interviewed about their experiences of advance care planning between August 2009 and February 2010. Results/Findings: Family caregivers need encouragement to ask the right questions during advance care planning to discuss the appropriateness of nursing and medical interventions at the end of life. Conclusions: Advance care planning can be facilitated with the family caregiver in the context of everyday practice within the nursing home environment for older people with dementia

The effects of integrated care: a systematic review of UK and international evidence

BACKGROUND: Healthcare systems around the world have been responding to the demand for better integrated models of service delivery. However, there is a need for further clarity regarding the effects of these new models of integration, and exploration regarding whether models introduced in other care systems may achieve similar outcomes in a UK national health service context. METHODS: The study aimed to carry out a systematic review of the effects of integration or co-ordination between healthcare services, or between health and social care on service delivery outcomes including effectiveness, efficiency and quality of care. Electronic databases including MEDLINE; Embase; PsycINFO; CINAHL; Science and Social Science Citation Indices; and the Cochrane Library were searched for relevant literature published between 2006 to March 2017. Online sources were searched for UK grey literature, and citation searching, and manual reference list screening were also carried out. Quantitative primary studies and systematic reviews, reporting actual or perceived effects on service delivery following the introduction of models of integration or co-ordination, in healthcare or health and social care settings in developed countries were eligible for inclusion. Strength of evidence for each outcome reported was analysed and synthesised using a four point comparative rating system of stronger, weaker, inconsistent or limited evidence. RESULTS: One hundred sixty seven studies were eligible for inclusion. Analysis indicated evidence of perceived improved quality of care, evidence of increased patient satisfaction, and evidence of improved access to care. Evidence was rated as either inconsistent or limited regarding all other outcomes reported, including system-wide impacts on primary care, secondary care, and health care costs. There were limited differences between outcomes reported by UK and international studies, and overall the literature had a limited consideration of effects on service users. CONCLUSIONS: Models of integrated care may enhance patient satisfaction, increase perceived quality of care, and enable access to services, although the evidence for other outcomes including service costs remains unclear. Indications of improved access may have important implications for services struggling to cope with increasing demand. TRIAL REGISTRATION: Prospero registration number: 42016037725

National Security in the Information Age: Are We Heading Toward Big Brother?

Symposium Welcome: Alexander McDaniel, Symposium Editor, University of Richmond Law Review, and Wendy C. Perdue, Dean of the University of Richmond School of Law. (9:00 a.m. - 9:15 a.m.) “How Does the Government Collect Data Through Surveillance?” Panel Discussion: William C. Banks, Distinguished Professor of Law at Syracuse University College of Law and Founding Director of the Institute for National Security and Counterterrorism, and Jake Laperruque, Privacy Fellow with The Constitution Project. Professor Paul D. Crane, Associate Professor at the University of Richmond School of Law, served as moderator. (9:15 a.m. - 10:30 a.m.) “How Does the Government Retain and Destroy Data?” lecture: Douglas Cox, Associate Professor at CUNY School of Law. (10:45 a.m. - 11:45 a.m.) “How Does Data Impact the Courtroom?” Panel: Lt. Colonel Jeffrey Addicott (U.S. Army, ret.), Professor of Law and Director of the Center for Terrorism Law at St. Mary’s University School of Law, and Paul Gill, Assistant Federal Public Defender for the Federal Public Defender, Eastern District of Virginia. Douglas A. Ramseur, Capital Defender with the Office of the Capital Defender in Central Virginia, served as moderator. (1:00 p.m.- 2:15 p.m.) Keynote Address: Thomas J. Ridge, former Pennsylvania Governor and the first U.S. Secretary of Homeland Security. (2:30 p.m. – 3:30 p.m.

Terrorism and Assassination: Political Assassination as an Instrument of National Policy - An Inquiry into Operations, Expediency, Morality, and the Law

The 2002 Symposium opened on Thursday, April 11, with a role-playing exercise and town meeting: Assassination of a Terrorist Enemy. In this session, a group of nationally prominent political leaders, policy makers, scholars, and members of the intelligence, military, religious and civil liberties communities engaged in a role-playing exercise exploring a fictional scenario posing the question of whether the United States should undertake an operation to assassinate the leader of a terrorist organization deemed responsible for acts of violence against the United States. The issue was explored through historical, moral, religious, operational, political, diplomatic, and legal perspectives. The final segment of the program included a town meeting discussion in which members of the audience participated in the debate and deliberation. These issues were explored the next day of the conference in a series of more specifically focused sessions. The opening session, on Thursday, April 11 from 6:30-9:00 p.m., featured Jeff Addicott; June Aprille; William C. Banks; Azizah al-Hibri, professor of Law at the University of Richmond School of Law; Julie Laskaris, Professor of Classical Studies at the University of Richmond; Peter Raven-Hansen, Gary Solis, Porcher Taylor, and Robert Turner. Rodney A. Smolla, the Allen Professor of Law at the University of Richmond School of Law, served as moderator. The “Roundtable Session I: Policy, Politics, and Operations” session, held on Friday, April 12 from 9:00-10:15 a.m., was led by Jeff Addicott, William C. Banks, Peter Raven-Hansen, Gary Solis, and Robert Turner. John Paul Jones, Professor of Law at the University of Richmond School of Law, served as moderator. “Roundtable Session II: Moral and Religious Perspectives,” held on Friday, April 12 from 10:30-11:45 a.m., was led by Azizah al-Hibri, Professor of Law at the University of Richmond School of Law. Julie Laskaris, Professor of Classical Studies at the University of Richmond, served as moderator. “Roundtable Session III: Assassination as an Instrument of Policy and the Law,” held on Friday, April 12 from 1:30- 2:45 p.m., was led by Jeff Addicott, William C. Banks, Peter Raven-Hansen, Gary Solis, Professor John Paul Jones, and Robert Turner. Porcher Taylor served as moderator

Biodiversity offsets perform poorly for both people and nature, but better approaches are available

Sustainability requires that we restore biodiversity and wider ecosystem services, yet developments such as new housing inevitably cause environmental impacts. Accordingly, developers are increasingly required to resource offset projects, delivering biodiversity or wider environmental net gains. However, analyses of offsets in England show that the large majority are conducted within development sites rather than targeted toward better opportunities for net gains elsewhere. Here, we compare current and alternative approaches to offsetting considering the biodiversity gains, ecosystem service co-benefits, and economic costs they generate. The results confirm that the current practice performs relatively poorly across all criteria. Analysis shows that by incorporating ecological and economic information into the targeting of offsets, they can provide a significant contribution to addressing the challenge of biodiversity loss or deliver substantial ecosystem service co-benefits to disadvantaged communities. The analytical methods and results presented here could support a substantial improvement in the operation and outcomes of biodiversity offsetting globally