Assessment of the effects of methodological choice in continuity of care research: a real-world example with dyslipidaemia cohort

ObjectiveTo determine if the choice of methodological elements affects the results in continuity of care studies.DesignThis is a retrospective cohort study. The association between continuity of care and clinical outcome was investigated using the Continuity of Care Index. The association was explored in 12 scenarios based on four definitions of the relative timing of continuity and outcome measurements in three populations (three Ps × four Ts).SettingNational Health Insurance claims from all primary and secondary care facilities in South Korea between 2007 and 2015.ParticipantsParticipants were patients diagnosed with dyslipidaemia, made ≥2 ambulatory visits and were newly prescribed with ≥1 antihyperlipidaemic agent at an ambulatory setting in 2008. Three study populations were defined based on the number of ambulatory visits: 10 084 patients in population 1 (P1), 8454 in population 2 (P2) and 4754 in population 3 (P3).Main outcome measureHospitalisation related to one of the four atherosclerotic cardiovascular diseases, including myocardial infarction, stable or unstable angina, ischaemic stroke and transient ischaemic attack.ResultsConcurrent measure of continuity and outcome (T1) showed a significantly higher risk of hospitalisation (adjusted HRs: 2.73–3.07, p<0.0001) in the low continuity of care group, whereas T2, which measured continuity until the outcome occurred, showed no risk difference between the continuity of care groups. T3, which measured continuity as a time-varying variable, had adjusted HRs of 1.31–1.55 (p<0.05), and T4, measuring continuity for a predefined period and measuring outcomes in the remaining period, had adjusted HRs of 1.34–1.46 (p<0.05) in the low continuity of care. Within each temporal relationship, the effect estimates became more substantial as the inclusion criteria became stricter.ConclusionsThe study design in continuity of care studies should be planned carefully because the results are sensitive to the temporal relationship between continuity and outcome and the population selection criteria.

Addressing Spatial Inequality in Broadband Use and Community-Level Outcomes

This chapter considers the significance of place for broadband policy evaluation and examines long-term data on Chicago neighborhoods as an example of quasi-experimental design. Interventions are often targeted to low-income urban neighborhoods or rural communities, with goals for increased local employment, economic development, or community health. Measuring outcomes by place provides a way to aggregate impacts for individual residents and to suggest potential spillover benefits for communities. Evaluating broadband use (i.e., subscriptions) over time in communities can address issues of causation as well as long-term outcomes of use. Chicago’s Smart Communities program illustrates the benefits of conducting long-term evaluation, taking advantage of new American Community Survey data that allows tracking of broadband subscriptions in smaller or less-populated geographies such as neighborhoods or rural communities. Finally, the chapter discusses strategies for expanding community-level research through other quasi-experimental designs and the creation and utilization of community-level data on broadband adoption and use.

Strategic Human Resource: Enhancing Performance With Six Sigma Approach

Human resource (HR) is the backbone of an organization and hence, there is need to build its underlying capabilities for effective service delivery. Six Sigma aims at improving the effectiveness of processes by collecting data and then using advanced statistical analysis tools to solve the problems. Six Sigma deployment in HR provides consistency in operations and leads to quality excellence by providing better services at lower costs. Six Sigma approach adds more science to the art of HR, which is used to measuring outcomes it can control, rather than those it can influence. Six Sigma deployment in HR transforms typical HR practices with a proactive approach and leads to better, faster and more cost-effective services; improve internal customer satisfaction and greater motivation and job satisfaction of employees. The research develops various framework for Six Sigma deployment in HR and provides case studies of successful Six Sigma deployment in various areas of HR.

Utility of modified Rankin Scale for brain vascular malformations in hereditary hemorrhagic telangiectasia

Background Approximately 10% of hereditary hemorrhagic telangiectasia (HHT) patients harbour brain vascular malformations (VMs). Intracranial hemorrhage (ICH) from brain VMs can lead to death or morbidity, while treatment options for brain VMs also have associated morbidity. The modified Rankin Scale (mRS) may provide an approach to identifying HHT-brain VM patients with poor outcomes, and their predictors. We aimed to measure the relationship between mRS score and brain VM, brain VM number, as well as other aspects of HHT, at enrollment and during prospective follow-up. Methods 1637 HHT patients (342 with brain VMs) were recruited from 14 HHT centres of the Brain Vascular Malformation Consortium since 2010 and followed prospectively (mean = 3.4 years). We tested whether the presence of brain VM, other HHT organ involvement, and HHT mutation genotype were associated with worse mRS scores at baseline and during follow-up, using linear mixed models, adjusting for age, sex, and year of visit. Results Presence of brain VMs was not associated with worse mRS score at baseline and there was no significant worsening of mRS with prospective follow-up in these patients; 92% had baseline mRS of 0–2. HHT-related gastrointestinal (GI) bleeding was associated with worse mRS scores at baseline (0.37, 95% CI 0.26–0.47, p < 0.001), as were history of anemia (0.35, 95% CI 0.27–0.43, p < 0.001) and liver VMs (0.19, 95% CI 0.09–0.30, p < 0.001). Presence of pulmonary arteriovenous malformations (AVMs) was not associated with worse mRS scores at baseline. mRS score was not associated with either HHT genotype (Endoglin vs ACVRL1). Only GI bleeding was associated with a significantly worsening mRS during prospective follow-up (0.64, 95% CI 0.21–1.08, p = 0.004). Conclusion Most HHT-brain VM patients had good functional capacity (mRS scores 0–2) at baseline that did not change significantly over 3.4 mean years of follow-up, suggesting that mRS may not be useful for predicting or measuring outcomes in these patients. However, HHT patients with GI bleeding, anemia history or liver VMs had worse mRS scores, suggesting significant impact of these manifestations on functional capacity. Our study demonstrates the insensitivity of the mRS as an outcomes measure in HHT brain VM patients and reinforces the continued need to develop outcomes measures, and their predictors, in this group.

992 Infrared Thermal Imaging in The Diagnosis and Management of Upper Limb Trauma

Aim Trauma can affect perfusion and thereby the temperature of the injured area. Infrared thermal imaging (IRT) has been used as a non-invasive, non-ionising means of diagnosing and monitoring various pathologies. We aim to evaluate the role of IRT in upper limb trauma. Method A review of all literature from the Cochrane Database, PubMed, Medline and EMBASE was performed. All papers evaluating infrared thermal imaging in trauma of the upper limb were included. Exclusion criteria included animal or cadaveric studies, and studies not measuring outcomes related to thermal imaging. Results Six papers were included from a total of 149 papers. There were five observational studies (with limited population numbers) and one case report. Four studies (N = 217) identified significantly higher skin temperatures in fractured limbs compared to non-injured side (p ≤ 0.05). Two studies included follow-ups with skin temperature differences between injured and non-injured sides decreasing over time, consistent with fracture healing times (approximately 3-4 weeks for paediatrics and 6 weeks for adults). One study (N = 9) identified that the presence of activity-related chronic pain in the hand was consistent with higher mean skin temperatures, even at baseline (p = 0.00000795). Conclusions IRT has been successfully used as a means of diagnosis and monitoring fracture healing in the upper limb. It also shows potential for use in detecting fractures that may not be initially evident on x-ray in the acute setting e.g., scaphoid fractures. Further robust and higher quality studies with larger patient populations are required.