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Selected AbstractsDecentralisation, Governance and Health-System Performance: ,Where You Stand Depends on Where You Sit'DEVELOPMENT POLICY REVIEW, Issue 6 2010Andrew Mitchell Advocates of local government often argue that when decentralisation is accompanied by adequate mechanisms of accountability, particularly those responsive to local preferences, improved service delivery will result. From the perspective of the health sector, the appropriate degree of decentralisation and the necessary mechanisms of accountability depend upon the achievement of health system goals. Drawing on evidence from six countries (Bolivia, Chile, India, Pakistan, Philippines, Uganda), this article comes to the conclusion that a balance between centralisation of some functions and decentralisation of others, along with improved mechanisms of accountability, is needed to achieve health system objectives. [source] Real options for precautionary fisheries managementFISH AND FISHERIES, Issue 2 2008Eli P Fenichel Abstract The 1996 Food and Agriculture Organization's (FAO) ,Guidelines on the Precautionary Approach to Fisheries and Species Introduction' raise important issues for fisheries managers, but fail to prescribe an approach for risk management. The distinguishing characteristics of the ,precautionary approach' are the inclusion of uncertainty and ,an elaboration on the burden of proof'. The FAO precautionary approach emphasizes that managers should be risk-averse, but does not provide tools for determining the appropriate degree of risk aversion. Consequently, application of the precautionary approach often leads to decision-making based on ad hoc safety margins. These safety margins are seldom chosen with explicit consideration of trade-offs. If the emphasis was shifted to choosing between competing uncertainties, then managers could manage risk. By attempting to avoid risk, managers may gain exposure to other risks and perhaps miss valuable opportunities. We place fishery management problems within the rubric of ,real investment' problems, and compare and contrast the consideration of risk by alternative investment frameworks. We show that traditional investment frameworks are inappropriate for fishery management, and furthermore, that traditional precautionary approaches are arbitrary and without basis in decision theory. Quantitative decision-making techniques, such as formal decision analysis (FDA), enable integration of competing hypotheses that help alleviate burden-of-proof issues. These techniques help analysts consider sources of uncertainty. FDA, however, can still be subject to arbitrary safety margins because such analyses often focus on determining which strategies best achieve, or avoid, targets that have been established without complete consideration of trade-offs. A managerial finance approach, real options analysis (ROA), is an alternative and complementary decision-making technique that enables managers to compute precautionary adjustments that couple the size of the ,safety margin' with the amount of uncertainty, thereby optimizing risk exposure and avoiding the need for arbitrary safety margins. We illustrate the advantages of an approach that combines FDA and ROA, using a heuristic example about a decision to re-introduce Atlantic salmon (Salmo salar L.) into Lake Ontario. Finally, we provide guidance on applying ROA to other fishery problems. The precautionary approach requires that managers consider risk, but considering risk is not the same as managing it. Here ROA is useful. [source] Improving Australian pharmacists' attitudes to internet use in community pharmacy practiceINTERNATIONAL JOURNAL OF PHARMACY PRACTICE, Issue 2 2005Margaret Bearman Lecturer Objective The internet now provides a significant part of consumers' healthcare information. While little is known about how community pharmacists regard the internet, there is some suggestion that issues of confidence and motivation may provide significant barriers to appropriate use. The objectives of this study were to measure any changes in pharmacists' attitudes towards the internet after completing a four-module educational course, ,Advanced web skills for pharmacists: finding quality on the internet'. Method We developed a 30-item instrument measuring pharmacists' attitudes toward the internet. Pharmacists completed the survey upon enrolment, then again on completion of the CD ROM course and for a third time three months after completing the course. Key findings The instrument was completed prior to the course by 147 participating pharmacists. The numbers of responses at the end of the course and 3,4 months post-course were 104 and 88 respectively. We established a reliable measure of pharmacists' attitudes to the internet with an appropriate degree of face validity. There was a significant improvement in attitude after course completion (P <0.005) and a further significant improvement in attitude three months after course completion (P <0.01). Conclusions A short distance education programme in internet skills can markedly improve community pharmacists' attitudes to the internet. [source] Supplementing desflurane with intravenous anesthesia reduces fetal cardiac dysfunction during open fetal surgeryPEDIATRIC ANESTHESIA, Issue 8 2010ANNE BOAT MD Summary Objective:, To lower the incidence and severity of fetal cardiovascular depression during maternal fetal surgery under general anesthesia. Aim:, We hypothesized that supplemental intravenous anesthesia (SIVA) with propofol and remifentanil would lower the need for high-dose inhalational anesthesia and provide adequate maternal depth of anesthesia and uterine relaxation. SIVA technique would minimize prolonged fetal exposure to deep inhalational anesthetics and significant intraoperative fetal cardiovascular depression. Background:, Fetal hypoxia and significant fetal hemodynamic changes occur during open fetal surgery because of the challenges such as surgical manipulation, hysterotomy, uterine contractions, and effects of anesthetic drugs. Tocolysis, a vital component of fetal surgery, is usually achieved using volatile anesthetic agents. High concentrations of volatile agents required to provide an appropriate degree of uterine relaxation may cause maternal hypotension and placental hypoperfusion, as well as direct fetal cardiovascular depression. Methods:, We reviewed medical records of 39 patients who presented for ex utero intrapartum treatment and mid-gestation open fetal surgery between April 2004 and March 2009. Out of 39 patients, three were excluded because of the lack of echocardiographic data; 18 patients received high-concentration desflurane anesthesia and 18 patients had SIVA with desflurane for uterine relaxation. We analyzed the following data: demographics, fetal medical condition, anesthetic drugs, concentration and duration of desflurane, maternal arterial blood pressure, intraoperative fetal echocardiogram, presence of fetal bradycardia, and need for intraoperative fetal resuscitation. Results:, Adequate uterine relaxation was achieved with about 1.5 MAC of desflurane in the SIVA group compared to about 2.5 MAC in the desflurane only anesthesia group (P = 0.0001). More fetuses in the high-dose desflurane group compared to the SIVA group developed moderate-severe left ventricular systolic dysfunction over time intraoperatively (P = 0.02). 61% of fetuses in the high-dose desflurane group received fetal resuscitative interventions compared to 26% of fetuses in the SIVA group (P = 0.0489). Conclusion:, SIVA as described provides adequate maternal anesthesia and uterine relaxation, and it allows for decreased use of desflurane during open fetal surgery. Decreased use of desflurane may better preserve fetal cardiac function. [source] A quantitative approach to benefit-risk assessment of medicines , part 1: the development of a new model using multi-criteria decision analysis,PHARMACOEPIDEMIOLOGY AND DRUG SAFETY, Issue S1 2007Filip Mussen PhD Abstract Purpose One of the most important uses of benefit-risk assessment pertains to approval of new medicines by regulatory authorities and the subsequent review of these products during their life-cycle when new safety and/or efficacy data becomes available. At present, there exist no validated, well-accepted models for benefit-risk assessment that have the appropriate degree of sophistication, and as a consequence no models are widely used by regulatory authorities or industry. The aim of the study was therefore to develop a new model for benefit-risk assessment of medicines using multi-criteria decision analysis (MCDA). Methods The MCDA methodology was used for a systematic approach to assess the benefit risk ratio of medicines. The reasons for adopting this approach were (1) taking multiple benefit and risk criteria into account, (2) making a judgement on the evidence and potential uncertainty because of the incompleteness of evidence, and (3) making trade-offs of the benefits against risks. Results It was demonstrated through a seven-step approach how MCDA is used to construct the model. Ten benefit and ten risk criteria were identified to form a value tree. Then fixed scales were established for all criteria and options on the criteria were scored. Weights were assigned for each criteria using swing-weighting. Finally sensitivity analysis was carried. Conclusions This novel approach based on MCDA has the potential for being applied as a new tool for judging and deciding on the benefits and risks, thereby helping regulators and industry in the development and approval of new medicines and their adequate use. Copyright © 2007 John Wiley & Sons, Ltd. [source] | ||||||||||