Systematic Evaluation of Two Years of Ethics Reflection Groups. Changes Over Time Regarding Employees’ Attitudes, User Involvement, Team Cooperation and the Handling of Disagreement

Abstract Background: Research on the impact of ethics reflection groups (ERG) or moral case deliberations (MCD) is complex and scarce. Within a larger study, ERG has been used as an intervention for stimulating critical ethical reflection and improved team cooperation while observing changes over time.Research question: Are there – during and after two years of ERGs - changes over time regarding employees’ normative attitudes regarding the use of coercion and how employees perceive user involvement, team cooperation and the handling of disagreement in teams?Methods: Repeated cross-sectional survey to multidisciplinary employees at seven wards within three Norwegian mental health care institutions (T0-T1-T2). Changes in normative attitudes over time were estimated using linear mixed models.Results: In total, 817 surveys (from employees that did and did not participate in ERG) were included in the analyses. Of these, 7.6 % (N=62) responded at all three points in time, 15.5% (N=127) at two points, and 76.8 % (N= 628) once. On average, over time, respondents who participated in ERG agreed less that coercion can be seen a form of care or security. ERG participants more often reported that they involved users and that they handled disagreement within the team constructively. Furthermore, more frequent ERG participation was associated with a more critical attitude towards coercion and higher scores for user involvement, the coercion competence of the team and the constructive handling of disagreement within their teams.Conclusions: Structural ERGs or MCDs seem to contribute to employees reporting a more critical attitude towards coercion, more user involvement around coercion and a more constructive handling of disagreement. Differences were generally small in absolute terms possibly due to the low amount of longitudinal data and the relative low frequency of ERG’s during the two years. Studying changes over time in clinical practice and trying to find a relationship between CES interventions and CES outcomes is difficult yet important and needs to be further developed in future CES evaluation studies. This explorative quantitative study may be a first step from qualitative evidence towards more robust quantitative evidence of the contribution of CES to clinical practice and quality of care.

This chapter investigates the phenomenon of remarriage in nineteenth-century eastern Europe, demonstrating its significance in Jewish marital behaviour. Patterns of remarriage deserve attention for a number of reasons: they influenced fertility levels, affected family structure, played a role in networking, and served as an indicator of the importance of marriage in a given society. Remarriage is highly revealing of group characteristics and behaviour, but remarriage in late nineteenth-century eastern Europe merits attention for an additional reason. Patterns of remarriage and their changes over time significantly diverged among various population groups. Eastern Europe is thus an excellent context for examining the impact of significant variables on remarriage by means of a comparative approach. The chapter then evaluates modes of remarriage among four major religious-national groups: Russian Orthodox, Catholics, Protestants, and Jews. It also considers important differences between Jews and Christians in specific patterns of remarriage.

Background: Chronic myeloid leukemia (CML) treatment improved considerably after introduction of oral tyrosine kinase inhibitors (TKI). As a result, the number of patients living with CML may reach 250,000 by 2040. We track changes in TKI treatment adherence since 2001 and provide an early assessment of treatment costs following the availability of second-generation TKIs and generic imatinib. Methods: A retrospective cohort from the OptumLabs Data Warehouse, which includes claims data for privately insured and Medicare Advantage (MA) enrollees in a large private U.S. health plan with medical and pharmacy benefits, was used. Patients with CML initiated TKI treatment between May 2001 and October 2016 and were continuously enrolled in the health plan 6 months prior through 12 months following TKI start. Adherence was defined by medication possession ratio (MPR1=total days’ supply of imatinib in 1st year divided by 365, 1=perfect adherence). Total health care costs include medical and prescription medication benefits. MPR1 was modeled using ordinary least squares regression. The association between MPR1 and healthcare costs was estimated using a generalized linear model specified with a gamma error distribution and a log link. Results: We identified 1,793 eligible patients. First-line TKI has changed over time (dasatinib and nilotinib represent 45% of all 2016 starts; imatinib 55%). From 2001 to 2016, adherence increased (Table 1). MPR1 was higher in men and increased with age until age ∼62 after which it declined. MPR1 was lower for patients with more comorbid conditions prior to treatment. Overall, MPR1 was inversely associated with total health care costs (medical and pharmacy) among privately insured (P<.001) but not MA enrollees. The net impact of MPR1 on total healthcare costs diminished over time (P<.001) where a 10% point decrease in MPR1 was associated with 12% and 4% lower total costs, prior to and following availability of 2nd generation TKIs, respectively. When examining medical costs only, MPR1 was inversely associated with medical costs for both privately insured (P<.001) and MA enrollees (P=.016). Conclusions: We found that adherence to TKI treatment increased over time. While imatinib is still used more frequently than other TKIs as first-line therapy, second-generation TKIs are becoming increasingly used as first-line agents. Possible cost-offsets are decreasing over time but it may be too early to formally evaluate the impact of generic imatinib.

Party battles for control of government are seen as efforts to reshape public policy. In prior decades, the impact of parties was limited by divided control of branches of government. The impact of party control was also limited because neither party had a distinctive constituency with clear and different policy goals. Over time, realignment has produced parties with very different electoral bases. Republicans now are more unified and willing to cut government while Democrats are more supportive of government programs. This chapter reviews our expectations of the impact of parties, the changes that have made party control mean more, and how these changes affect policy areas like economic policy, welfare, and health care.

In the installation process of lifting tower cranes, background is complex, the impact of light on the characteristics of the target also changes over time very differently, which led to the installation of monitoring is not easy identified from the characteristics of the separate target in the changing off context. Based on this, this paper presents a model using bitmap which is based on the model of background subtraction to approach to background modeling adding morphological processing; the target feature can be more obvious. This method can identify the characterized target well from the complex background.

Nowadays, due to the complexity of the relationships with external entities, along with the importance that traditional media and the innovative social media have in creating competitive advantages, it is necessary for companies to collaborate in order to create Intellectual Capital (IC). Although collaboration is crucial to create IC, there is a paucity in literature regarding the effects that a specific type of collaboration may have on the IC of an organisation, specifically a franchising with a mediatic actor. Moreover, literature addressing IC creation and destruction over time is scarce, especially when applied to the construction industry. This paper’s goal is twofold: understanding the longitudinal changes of a construction SME’s Intellectual Capital, regarding its creation and destruction; analysing the impact that a specific inter-organisational collaboration franchising—with a mediatic actor may have on such IC. A single in-depth case study was conducted, allowing to conclude that the actions of an organisation can develop both Intellectual Assets and Intellectual Liabilities. It was also concluded that inter-organisational collaboration, through a franchise with an actor with experience in communication, can generate, in the long term, positive and innovative effects regarding the different IC components, namely the Relational one. More specifically, the paper allowed to ascertain that an organisation’s IC changes over time in a dynamic fashion, i.e., Intellectual Liabilities which emerged before an innovative collaboration can be transformed into Intellectual Assets and create competitive advantages. This paper contributes to stress the importance of managing IC, not only when it is created, but namely in when it can be destroyed, in a context of inter-organisational collaborations applied to a construction SME.

Abstract The FlourishCare Model (FCM) transforms primary care sites by addressing all determinants of health and focusing on helping patients to flourish. The FlourishCare Index (FCI) is a clinical measure to assess the effectiveness of the FCM to address all determinants of health. We will present data on the effectiveness of the FCM serving 159 older adults with MCCs. The sample was mostly female (77%), White (64%), retired (54%), married (30%) or widowed (20%) and living in urban areas (64%). The mean age was 69 (SD=15), with 13 years education (SD=3). Patients changed significantly over time on total FCI scores (57%-72%;□=3.80,SE=0.63). Results show significant growth over time for individual health behaviors (58%-67%;□=2.14,SE=0.84), health care access (71%-89%;□=4.43,SE=1.00) and social determinants (62%-85%;□=5.54,SE=1.02) with psychological determinants (54%-61%;□=1.74,SE=0.95) and environmental determinants (70%-81%;□=2.81,SE=1.62) showing a trend to significance. Interaction effects with time show that the FCM supported patients with lower education attainment to improve at a higher rate than those with higher education attainment, for the total FCI score (□=-0.59,SE=0.24) and health care access (□=-0.94,SE=0.38). Receiving mental health counseling resulted in more improvement in psychological determinants than those who did not receive counseling (□=3.43,SE=2.04). The FCM was able to support rural patients at a higher rate than urban patients to gain access to health care (□=4.13,SE=2.02). The FCM supported Hispanic patients the most in improving social determinants of health (□=8.40,SE=3.93). This study showed the importance of a systems approach to care using measures that focus on what matters most to older adults who value quality-of-life outcomes.

Abstract Background Populations with high needs often have poor health care access. Defining need is challenging, with no agreed-upon indicator of health need for primary care based spatial equity research in New Zealand. We examined seven potential indicators and tested for evidence of the Inverse Care Law in the Waikato region. Methods Indicators were identified through a systematic literature review and scored according to ten selection criteria. Indicators were mapped and analysed using GIS. Spearman’s correlations were calculated between indicators, and clusters of high need identified through spatial autocorrelation. The impact of incorporating indicator-based-weightings into an accessibility model was tested using ANOVA and Spearman’s correlations. GP service spatial equity was assessed by comparing clusters of access and need, and quantified through the Gini coefficient. Results While smoking rates met the most selection criteria, ambulatory sensitive hospitalisation (ASH) rates were significantly correlated with all indicators. Health needs were significantly clustered, but incorporating indicator weightings into the spatial accessibility analysis did not impact accessibility scores. A misalignment of access and need, and Gini coefficient of 0.281 suggests that services are not equitably distributed. Conclusions ASH rates seem a robust indicator of health need. However, data access issues may restrict their use. High need clusters vary spatially according to the indicator used. Key messages GIS techniques can identify ‘hot-spots’ of need, but these can be masked in accessibility models. Indicators should be carefully selected according to the research question.

Abstract Background An ethics reflection group (ERG) is one of a number of ethics support services developed to better handle ethical challenges in healthcare. The aim of this article is to evaluate the significance of ERGs in psychiatric and general hospital departments in Denmark. Methods This is a qualitative action research study, including systematic text condensation of 28 individual interviews and 4 focus groups with clinicians, ethics facilitators and ward managers. Short written descriptions of the ethical challenges presented in the ERGs also informed the analysis of significance. Results A recurring ethical challenge for clinicians, in a total of 63 cases described and assessed in 3 ethical reflection groups, is to strike a balance between respect for patient autonomy, paternalistic responsibility, professional responsibilities and institutional values. Both in psychiatric and general hospital departments, the study participants report a positive impact of ERG, which can be divided into three categories: 1) Significance for patients, 2) Significance for clinicians, and 3) Significance for ward managers. In wards characterized by short-time patient admissions, the cases assessed were retrospective and the beneficiaries of improved dialogue mainly future patients rather than the patients discussed in the specific ethical challenge presented. In wards with longer admissions, the patients concerned also benefitted from the dialogue in the ERG. Conclusion This study indicates a positive significance and impact of ERGs; constituting an interdisciplinary learning resource for clinicians, creating significance for themselves, the ward managers and the organization. By introducing specific examples, this study indicates that ERGs have significance for the patients discussed in the specific ethical challenge, but mostly indirectly through learning among clinicians and development of clinical practice. More research is needed to further investigate the impact of ERGs seen from the perspectives of patients and relatives.