New KUSP Article
Practice sensitive quality indicators in RAI-MDS 2.0 nursing home data.
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Estabrooks CA, Knopp-Sihota JA, Norton PG.
BMC research notes 2013 Nov 13;6(1):460
In recent years, improving the quality of care for nursing home residents has generated a considerable amount of attention. In response, quality indicators (QIs), based on available evidence and expert consensus, have been identified within the Resident Assessment Instrument — Minimum Data Set 2.0 (RAI-MDS 2.0), and validated as proxy measures for quality of nursing home care. We sought to identify practice sensitive QIs; that is, those QIs believed to be the most sensitive to clinical practice. METHOD: We enlisted two experts to review a list of 35 validated QIs and to select those that they believed to be the most sensitive to practice. We then asked separate groups of practicing physicians, nurses, and policy makers to (1) rank the items on the list for overall “practice sensitivity” and then, (2) to identify the domain to which the QI was most sensitive (nursing care, physician care, or policy maker). RESULTS: After combining results of all three groups, pressure ulcers were identified as the most practice sensitive QI followed by worsening pain, physical restraint use, the use of antipsychotic medications without a diagnosis of psychosis, and indwelling catheters. When stratified by informant group, although the top five QIs stayed the same, the ranking of the 13 QIs differed by group. CONCLUSIONS: In addition to identifying a reduced and manageable set of QIs for regular reporting, we believe that focusing on these 13 practice sensitive QIs provides both the greatest potential for improving resident function and slowing the trajectory of decline that most residents experience.
Article recommended by Dr. Carole Estabrooks
Change and Shit Work: Empowering and Overpowering the Frail Elderly in Long-Term Care
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American Behavioral Scientist 2013
Drawing on a year of fieldwork in Heartland Community, a “culture-change” nonprofit nursing home, this article investigates dynamics of worker-client power relationships across departments. The analysis raises questions about power and inequality that invert the usual way of thinking about it: Rather than trying to explain why some workers or customers are treated better or worse than others, this article explores why the same people were treated very differently at different times of the day by staff in different departments of the same organization. The divergence in power relations across departments, I contend, flowed from the nursing home’s attempts to manage cross-cutting pressures to humanize care relationships without increasing costs. I suggest that that Heartland’s “solution” to these tensions preserves the routinely inhumane treatment of nursing home residents in the day-to-day activities of the nursing department while presenting a much different face to visitors, family members, policy makers, and the public. The article concludes by suggesting that these ethnographic findings may point not only to a widespread strategy in the nursing home industry but also more generally to the organizational impression management functions served by efforts to “humanize” worker-client relationships.
CALL FOR ABSTRACTS: AcademyHealth’s 2014 Annual Research Meeting (ARM)
San Diego CA 8-10 June 2014
DEADLINE 16 January 2014
AcademyHealth is seeking abstracts on 18 themes across multiple areas of study in health services research, as well as proposals for panels that present research or discuss key health policy topics. Abstracts submitted to the call for papers will also be considered for publication in JAMA and HSR.
CALL FOR ABSTRACTS: Clinical Decision Making in the Era of Personalized Medicine
Antwerp Belgium 8-10 June 2014
DEADLINE 10 February 2014
Clinical decision making got a great boast in the seventies, with the famous publications by Pauker and Kassirer. After a few decades of relative silence, interest in this discipline is again rising, especially in personalized medicine, shared decision making and undergraduate training. The threshold concept they conceived has been proven a cornerstone in clinical practice. Apart from the special focus, the broad field of medical decision making will be addressed in symposia, workshops, pre-conference courses, presentations and poster sessions.
CALL FOR ABSTRACTS: Summer Institutes on Quality Improvement
4-8 August 2014 San Antonio, TX
Clinicians, Educators and Researchers – share your EBP successes. Nurses, physicians, pharmacists, managers, and all health professionals are invited to submit for consideration, abstracts consistent with the theme of these national, interdisciplinary conferences.
Facilitating knowledge exchange between health-care sectors, organisations and professions: a longitudinal mixed-methods study of boundary-spanning processes and their impact on health-care quality
Nasir L, Robert G, Fischer M, Norman I, Murrells T, Schofield P.
Health Serv Deliv Res 2013 10/22;1(7).
Objectives To explore whether or not boundary-spanning processes stimulate the creation and exchange of knowledge between sectors, organisations and professions and whether or not this leads, through better integration of services, to improvements in the quality of care. Design A 2-year longitudinal nested case study design using mixed methods. Participants Health-care and non-health-care practitioners representing the range of staff participating in the Westpark Initiative (WI) and patients. Interventions The WI sought to improve services through facilitating knowledge exchange and collaboration between general practitioners, community services, voluntary groups and acute specialists during the period late 2009 to early 2012. We investigated the impact of the four WI boundary-spanning teams on services and the processes through which they produced their effects. Results The four teams varied in their ability to, first, exchange knowledge across boundaries and, second, implement changes to improve the integration of services. The study setting experienced conditions of flux and uncertainty in which known horizontal and vertical structures underwent considerable change and the WI did not run its course as originally planned. Although knowledge exchanges did occur across sectoral, organisational and professional boundaries, in the case of child and family health services, early efforts to improve the integration of services were not sustained. In the case of dementia, team leadership and membership were undermined by external reorganisations. The anxiety and depression in black and minority ethnic populations team succeeded in reaching its self-defined goal of increasing referrals from Westpark practices to the local well-being service. From October to December 2010 onwards, referrals have been generally higher in the six practices with a link worker than in those without, but the performance of Westpark and Coxford practices did not differ significantly on three national quality indicators. General practices in a WI diabetes ‘cluster’ performed better on three of 17 Quality and Outcomes Framework (QOF) indicators than practices in the remainder of Westpark and in the wider Coxford primary care trust. Surprisingly, practices in Westpark, but not in the diabetes cluster, performed better on one indicator. No statistically significant differences were found on the remaining 13 QOF indicators. The time profiles differed significantly between the three groups for elective and emergency admissions and bed-days.
Exchanging knowledge through healthcare manager placements in research teams
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Bullock A, Morris ZS, Atwell C.
Service Industries Journal 2013;33(13-14):1363-1380
This study contributes to service industry theory by revealing how employers in the health service understand knowledge exchange as ‘transaction’. Although under pressure to deliver better services without additional resource, health service providers do not seek customers, making them unlike commercial service industries. This paper reports a UK knowledge exchange programme designed to bring together healthcare managers and researchers. Case study data were gathered from 36 semi-structured interviews with health services managers (Fellows) embedded in research teams, research team leads, and Fellows’ workplace line-managers. Interviews were analysed thematically using a coding frame. The importance of personal contact in knowledge exchange mechanisms was confirmed but the knowledge model varied by interaction pairings (Fellow/research team; Fellow/health service). When with researchers, an exchange model was commonly in operation, marked by collaborative engagement. In contrast, line-managers tended to adopt a transactional approach, driven by instrumental motives. This transactional model merits further research.
Implementation of coherent, evidence-based pathways in Danish rehabilitation practice.
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Kristensen HK, Hounsgaard L.
Disability and rehabilitation 2013;35(23):2021-2028
Studies have shown that evidence-based practice improves outcomes, both for patients and for staff organisational systems. However, the incorporation of evidence-based guidelines in a health care practice requires a specific, targeted approach on all organisational levels. Purpose: To gain a deeper understanding of how to facilitate the implementation of coherent and evidence-based guidelines in Danish rehabilitation contexts. Method: The study was based on a phenomenological hermeneutic approach and on theories within knowledge translation. Fifteen municipalities and four hospitals volunteered to participate. Facilitators were appointed locally. Data concerning factors facilitating the implementation were generated in three focus group interviews. Results: Evidence-based rehabilitation was implemented with local adaptation for each participating setting, resulting in context-dependent variations. Conclusion: The PARIHS framework is based on concepts that capture factors of impact on clinical decision-making and interventions which enhance changes of daily practice in the participating rehabilitation settings. The rehabilitation pathways reinforced the foundation and ownership of the daily practice and created an impetus for raising the quality of clinical practice. The facilitators constituted important actors in anchoring the implementation. Moreover, it was important for the local implementation to be an integrated element of a common workforce agenda. Implications for Rehabilitation Evidence-based rehabilitation pathways updated the professional knowledge and reinforced the therapists’ ownership of the daily practice. Appointed facilitators are key stakeholders and important elements in anchoring an implementation. Local implementation processes being part of a cross-sectoral enhancement support successful implementation.
Factors influencing evidence-based practice among community nurses
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Gerrish K, Cooke J.
Journal of Community Nursing 2013 2013;27(4):98-101.
Nurses working in the community may have insufficient time to access, interpret and apply research, and, therefore, need information to be presented in a format that is easily accessible. As community nurses rise to the challenges outlined in recent health policy, it is increasingly important that they maximise their potential to deliver evidence-based practice. This article looks at a survey that aimed to identify factors influencing evidence-based practice among community nurses. The findings indicate that in order to make progress it is important to adopt a multifaceted approach, taking into account the real world in which nurses currently practice. While it is important to develop nurses’ skills in accessing and reviewing research information, constraints on time mean that it will be difficult to achieve a nursing workforce where all nurses are active in reviewing research evidence. © 2013 Wound Care People ltd.
Political and institutional influences on the use of evidence in public health policy. A systematic review.
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Liverani M, Hawkins B, Parkhurst JO.
PloS one 2013 Oct 30;8(10):e77404
We conducted a systematic review of empirical studies that examined the influence of key features of political systems and institutional mechanisms on evidence use, and contextual factors that may contribute to the politicisation of health evidence. Eligible studies were identified through searches of seven health and social sciences databases, websites of relevant organisations, the British Library database, and manual searches of academic journals. Relevant findings were extracted using a uniform data extraction tool and synthesised by narrative review. FINDINGS: 56 studies were selected for inclusion. Relevant political and institutional aspects affecting the use of health evidence included the level of state centralisation and democratisation, the influence of external donors and organisations, the organisation and function of bureaucracies, and the framing of evidence in relation to social norms and values. However, our understanding of such influences remains piecemeal given the limited number of empirical analyses on this subject, the paucity of comparative works, and the limited consideration of political and institutional theory in these studies.
Determinants for the effectiveness of implementing an occupational therapy intervention in routine dementia care
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Dopp CM, Graff MJ, Rikkert MG, van der Sanden MW, Vernooij-Dassen MJ.
Implementation science 2013 Nov 7;8(1):131
A multifaceted implementation (MFI) strategy was used to implement an evidence-based occupational therapy program for people with dementia (COTiD program). This strategy was successful in increasing the number of referrals, but not in improving occupational therapists’ (OTs) adherence. Therefore, a process evaluation was conducted to identify factors that influenced the effectiveness of the MFI strategy. METHODS: A mixed-method approach of qualitative and quantitative research was used to evaluate the implementation process. The MFI strategy as planned and as executed were reported and evaluated based on the framework of Hulscher et al. (2003; 2006). Data on OTs attitudes and expected barriers were collected at baseline from 94 OTs using a 19-item questionnaire. Data on the experiences were collected after finishing the implementation using focus groups with OTs and telephone interviews with physicians and managers. For quantitative data, frequencies and correlations were calculated and qualitative data were analyzed using inductive content analysis. RESULTS: The implementation strategy as executed had a stronger focus than planned on increasing OTs promotional skills due to an initial lack of referrals. This resulted in less attention for increasing OTs’ skills in using the COTiD program as initially intended. At baseline, OTs had a positive attitude toward the program, however, 75% did not feel experienced enough and only 14.3% felt competent in using the program. Focus groups and interviews revealed various determinants that influenced implementation. Most managers were positive about the program. However, the degree of operational support of managers for OTs regarding the implementation was not always adequate. Managers stated that a well-defined place for occupational therapy within the dementia care network was lacking although this was perceived necessary for successful implementation. Several physicians perceived psychosocial interventions not to be in their area of expertise or not their responsibility. All professionals perceived inter-professional collaboration to be a facilitator for effective implementation, and general practitioners were perceived as key partners in this collaboration. However, collaboration was not always optimal. OTs indicated that increasing the referral rate was most effective when promoting OT via other disciplines within a physician’s network. CONCLUSION: Our data suggests that a first step in successful implementation should be to make sure that individual and organizational barriers are resolved. In addition, implementation should be network-based and encourage inter-professional collaboration. Initial promotion of COTiD should focus on physicians that have a positive attitude toward non-pharmacological interventions.
Health Care Administration and Organization
“You’re Being Paged!” Outcomes of a Nursing Home On-Call Role-Playing and Longitudinal Curriculum
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Yuasa M, Bell CL, Inaba M, Tamura BK, Ahsan S, Saunders V, et al.
Journal of the American Geriatrics Society 2013 Nov;61(11):1976-1982
Effectively handling telephone calls about nursing home (NH) residents is an important skill for healthcare professionals, but little formal training is typically provided. The objective of the current study was to describe and evaluate the effectiveness of a novel structured role-playing didactic session followed by an on-call NH longitudinal clinical experience. The effectiveness of the structured role-playing didactic session was compared in different learners, including geriatric medicine fellows (n = 10), family medicine residents and faculty (n = 14), nurse practitioner students (n = 31), and other learners (n = 7). The curriculum focused on common problems encountered while caring for NH residents during on-call periods. Learners rated themselves using an 18-item pre/post questionnaire including five attitude and 13 skills questions, using a 1-to-5 Likert scale. T-tests were used to compare means before and after sessions. Significant improvements were found in overall mean attitudes and skills scores. For all learners, the greatest improvements were seen in “comfort in managing residents at the NH,” “managing feeding or gastrostomy tube dislodgement,” “identifying different availability of medications, laboratory studies, and procedures in NH,” and “describing steps to send NH residents to the emergency department.” Geriatric medicine fellows’ attitudes and skills improved significantly after the longitudinal clinical experience. The faculty survey demonstrated improved documentation, communication, and fellows’ management of on-call problems after curriculum implementation. This novel curriculum used role-playing to provide training for on-call management of NH residents.© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.
Leading from the middle: Constrained realities of clinical leadership in healthcare organizations.
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Martin GP, Waring J.
Health (London, England : 1997) 2013 Jul;17(4):358-374
In many developed-world countries, there have been efforts to increase the ‘leadership capacity’ of healthcare professionals, particularly lower-status staff without formal managerial power. Creating frontline ‘leaders’ is seen as a means of improving the quality of healthcare, but such efforts face considerable challenges in practice. This article reports on a qualitative, interview-based study of 23 staff in two UK operating theatre departments, mostly nurses by professional background, who were given formal leadership responsibilities by their hospitals and redesignated as ‘team leaders’ and ‘theatre co-ordinators’. While participants were familiar with leadership theory and could offer clear accounts of good leadership in practice, they were often limited in their ability to enact their leadership roles. Professional and managerial hierarchies constrained participants’ leadership capacity, and consequently the exercise of leadership rested on alignment with managerial relationships and mandates. The findings highlight difficulties with accounts of leadership as something to be distributed across organizations; in healthcare organizations, established institutional structures and norms render this approach problematic. Rather, if fostering leadership capacity is to have the transformational effect that policymakers desire, it may need to be accompanied by other, wider changes that attend to institutional, organizational and professional context.
Health Care Innovation and Quality Assurance
Viewpoint: Scaling up testing services for non-communicable diseases in Africa: Priorities for implementation research
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Jaffar S, Amberbir A, Kayuni N, Musicha C, Nyirenda M.
Tropical medicine & international health : TM & IH 2013 Sep 4
The burden of non-communicable diseases in Africa is rising rapidly and implementation of evidence-based control strategies is needed urgently. Testing people for hypertension and diabetes will be an important component in the fight against these diseases, as voluntary counselling and testing was for HIV-infection. We discuss the below the areas where we believe evidence is needed to inform policy. © 2013 John Wiley & Sons Ltd.
The effects of RN staffing hours on nursing home quality: A two-stage model.
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Lee HY, Blegen MA, Harrington C.
International journal of nursing studies 2013 Oct 14
Based on structure-process-outcome approach, this study examined the association of registered nurse (RN) staffing hours and five quality indicators, including two process measures (catheter use and antipsychotic drug use) and three outcome measures (pressure ulcers, urinary tract infections, and weight loss). SETTING/PARTICIPANTS: We used data on resident assessments, RN staffing, organizational characteristics, and market factors to examine the quality of 195 nursing homes operating in a rural state of United States – Colorado. RESULTS: Higher RN hours were associated with fewer pressure ulcers, but RN hours were not related to the other quality indicators. CONCLUSIONS: The study finding shows the importance of understanding the role of ‘nurse staffing’ under nursing home care, as well as the significance of associated/contextual factors with nursing home quality even in a small rural state. Copyright © 2013 Elsevier Ltd. All rights reserved.
Prevalence of chronic wounds and structural quality indicators of chronic wound care in Dutch nursing homes.
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Rondas AA, Schols JM, Stobberingh EE, Halfens RJ.
International wound journal 2013 Oct 24
The aim of this study was to measure the prevalence of (infected) chronic wounds in Dutch nursing homes and to explore which signs and symptoms are used to diagnose infected chronic wounds. Moreover, it was to determine which structural quality indicators related to chronic wound care at ward and institutional levels were fulfilled. In April 2012, as part of the annual National Prevalence Measurement of Care Problems of Maastricht University [Landelijke Prevalentiemeting Zorgproblemen (LPZ)], a multi-center cross-sectional point-prevalence measurement was carried out together with an assessment of relevant care quality indicators. The prevalence was 4·2%; 16 of 72 (22%) chronic wounds were considered to be infected. Increase of exudate (81·3%; n = 13), erythema (68·8%; n = 11), pain (56·3%; n = 9) and wound recalcitrance (56·3%; n = 9) were considered to be diagnostic signs and symptoms of a chronic wound infection. Although at institutional level most quality indicators were fulfilled, at ward level this was not the case. Despite the relatively low number of residents, we consider our population as representative for the nursing home population. It may be an advantage to appoint specific ward nurses and to provide them specifically with knowledge and skills concerning chronic wounds. © 2013 The Authors International Wound Journal © 2013 Medicalhelplines.com Inc and John Wiley & Sons Ltd.
One size does not fit all: evaluating an intervention to reduce antibiotic prescribing for acute bronchitis
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Ackerman SL, Gonzales R, Stahl MS, Metlay JP.
BMC health services research 2013 Nov 4;13(1):462
Overuse of antibiotics for upper respiratory tract infections (URIs) and acute bronchitis is a persistent and vexing problem. In the U.S., more than half of all patients with upper respiratory tract infections and acute bronchitis are treated with antibiotics annually, despite the fact that most cases are viral in etiology and are not responsive to antibiotics. Interventions aiming to reduce unnecessary antibiotic prescribing have had mixed results, and successes have been modest. The objective of this evaluation is to use mixed methods to understand why a multi-level intervention to reduce antibiotic prescribing for acute bronchitis among primary care providers resulted in measurable improvement in only one third of participating clinicians. METHODS: Clinician perspectives on print-based and electronic intervention strategies, and antibiotic prescribing more generally, were elicited through structured telephone surveys at high and low performing sites after the first year of intervention at the Geisinger Health System in Pennsylvania (n = 29). RESULTS: Compared with a survey on antibiotic use conducted 10 years earlier, clinicians demonstrated greater awareness of antibiotic resistance and how it is impacted by individual prescribing decisions—including their own. However, persistent perceived barriers to reducing prescribing included patient expectations, time pressure, and diagnostic uncertainty, and these factors were reported as differentially undermining specific intervention components’ effectiveness. An exam room poster depicting a diagnostic algorithm was the most popular strategy. CONCLUSIONS: Future efforts to reduce antibiotic prescribing should address multi-level barriers identified by clinicians and tailor strategies to differences at individual clinician and group practice levels, focusing in particular on changing how patients and providers make decisions together about antibiotic use.
Immediate versus sustained effects: interrupted time series analysis of a tailored intervention
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Hanbury A, Farley K, Thompson C, Wilson PM, Chambers D, Holmes H.
Implementation science 2013 Nov 5;8(1):130
This paper describes the development, delivery, and evaluation of a tailored intervention designed to increase primary health care professionals’ adoption of a national recommendation that women with mild to moderate postnatal depression (PND) are referred for psychological therapy as a first stage treatment. METHODS: Three factors influencing referral for psychological treatment were targeted using three related intervention components: a tailored educational meeting, a tailored educational leaflet, and changes to an electronic system data template used by health professionals during consultations for PND. Evaluation comprised time series analysis of monthly audit data on percentage referral rates and monthly first prescription rates for anti-depressants. Interviews were conducted with a sample of health professionals to explore their perceptions of the intervention components and to identify possible factors influencing intervention effectiveness. RESULTS: The intervention was associated with a significant, immediate, positive effect upon percentage referral rates for psychological treatments. This effect was not sustained over the ten month follow-on period. Monthly rates of anti-depressant prescriptions remained consistently high after the intervention. Qualitative interview findings suggest key messages received from the intervention concerned what appropriate antidepressant prescribing is, suggesting this to underlie the lack of impact upon prescribing rates. However, an understanding that psychological treatment can have long-term benefits was also cited. Barriers to referral identified before intervention were cited again after the intervention, suggesting the intervention had not successfully tackled the barriers targeted.
Research Practice & Methodology
How confidence intervals become confusion intervals
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McCormack J, Vandermeer B, Allan GM.
BMC medical research methodology 2013 Oct 31;13(1):134
In this paper, we review how researchers can look at very similar data yet have completely different conclusions based purely on an over-reliance of statistical significance and an unclear understanding of confidence intervals. The dogmatic adherence to statistical significant thresholds can lead authors to write dichotomized absolute conclusions while ignoring the broader interpretations of very consistent findings. We describe three examples of controversy around the potential benefit of a medication, a comparison between new medications, and a medication with a potential harm. The examples include the highest levels of evidence, both meta-analyses and randomized controlled trials. We will show how in each case the confidence intervals and point estimates were very similar. The only identifiable differences to account for the contrasting conclusions arise from the serendipitous finding of confidence intervals that either marginally cross or just fail to cross the line of statistical significance. SUMMARY: These opposing conclusions are false disagreements that create unnecessary clinical uncertainty. We provide helpful recommendations in approaching conflicting conclusions when they are associated with remarkably similar results.
Predictors of Response Rates to a Long Term Follow-Up Mail out Survey.
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Koloski NA, Jones M, Eslick G, Talley NJ.
PloS one 2013 Nov 4;8(11):e79179
Very little is known about predictors of response rates to long-term follow-up mail-out surveys, including whether the timing of an incentive affects response rates. We aimed to determine whether the timing of the incentive affects response rates and what baseline demographic and psychological factors predict response rates to a 12 year follow-up survey. STUDY DESIGN AND SETTING: Participants were 450 randomly selected people from the Penrith population, Australia who had previously participated in a mail-out survey 12 years earlier. By random allocation, 150 people received no incentive, 150 received a lottery ticket inducement with the follow-up survey and 150 received a lottery ticket inducement on the return of a completed survey. RESULTS: The overall response rate for the study was 63%. There were no significant differences in terms of response rates between the no incentive (58.8%;95%CI 49.8%,67.3%), incentive with survey (65.1%;95%CI 56.2%,73.3%) and promised incentive (65.3%;95%CI 56.1%,73.7%) groups. Independent predictors of responding to the 12 year survey were being older (OR=1.02, 95%CI 1.01,1.05,P=0.001) and being less neurotic as reported on the first survey 12 years earlier (OR=0.92, 95%CI 0.86,0.98, P=0.010).
A Core-Item Reviewer Evaluation (CoRE) System for Manuscript Peer Review
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Onitilo AA, Engel JM, Salzman-Scott S, Stankowski RV, Doi SAR.
Accountability in Research 2014 03/04; 2013/11;21(2):109-121
Manuscript peer review is essential for ensuring accountability to all involved in the publication process, including authors, journals, and readers. Lack of consensus regarding what constitutes an accountable manuscript peer review process has resulted in varying practices from one journal to the next. Currently, reviewers are asked to make global judgments about various aspects of a paper for review irrespective of whether guided by a review checklist or not, and several studies have documented gross disagreement between reviewers of the same manuscript. We have previously proposed that the solution may be to direct reviewers to concrete items that do not require global judgments but rather provide a specific choice, along with referee justification for such choices. This study evaluated use of such a system via an international survey of health care professionals who had recently reviewed a health care–related manuscript. Results suggest that use of such a peer review system by reviewers does indeed improve interreviewer agreement, and thus, has the potential to support more consistent and effective peer review, if introduced into journal processes for peer review.
Purposeful Sampling for Qualitative Data Collection and Analysis in Mixed Method Implementation Research.
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Palinkas LA, Horwitz SM, Green CA, Wisdom JP, Duan N, Hoagwood K.
Administration and Policy in Mental Health 2013 Nov 6
Purposeful sampling is widely used in qualitative research for the identification and selection of information-rich cases related to the phenomenon of interest. Although there are several different purposeful sampling strategies, criterion sampling appears to be used most commonly in implementation research. However, combining sampling strategies may be more appropriate to the aims of implementation research and more consistent with recent developments in quantitative methods. This paper reviews the principles and practice of purposeful sampling in implementation research, summarizes types and categories of purposeful sampling strategies and provides a set of recommendations for use of single strategy or multistage strategy designs, particularly for state implementation research.
Health Care in Canada
This report estimates the economic footprint of home and community care in Canada, highlighting the implications of caregiving employees for businesses, and shedding light on the potential spending implications of shifting some care from institutions to homes.
Development of EASY-Care, for Brief Standardized Assessment of the Health and Care Needs of Older People; With Latest Information About Cross-National Acceptability.
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Philip KE, Alizad V, Oates A, Donkin DB, Pitsillides C, Syddall SP, et al.
Journal of the American Medical Directors Association 2013 Oct 26
The EASY-Care system has been developed in the past 20 years in the United States and Europe as a brief standardized method for assessing the perceptions of older people about their health and care needs and priorities for a service response. More recently, it has been adapted and tested for use in poor, middle-income, and rich countries across the world. In this article we review its development and report the latest data for cross-cultural acceptability to older people and their clinicians in 6 countries across 4 continents. METHOD: We used a multicenter, mixed-method (quantitative and qualitative) approach to assess clinician (n = 37) and patient (n = 115) perspectives of acceptability of the EASY-Care Standard (2010) instrument.RESULTS: Key strengths identified included high levels of acceptability from both clinician and patient perspectives, with the tools seen as useful for identification of unmet need. Key recommendations included enhancing clarity in certain questions, ensuring it is not too long. Recommendations included minor context-specific adaptations, effective use of the screening questionnaire, and use of context-specific interviewer prompts. Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.
Preliminary Data from an Advanced Dementia Consult Service: Integrating Research, Education, and Clinical Expertise
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Catic AG, Berg AI, Moran JA, Knopp JR, Givens JL, Kiely DK, et al.
Journal of the American Geriatrics Society 2013 Nov;61(11):2008-2012
Hospitalized individuals with advanced dementia often receive care that is of limited clinical benefit and inconsistent with preferences. An advanced dementia consultation service was designed, and a pre and post pilot study was conducted in a Boston hospital to evaluate it. Geriatricians and a palliative care nurse practitioner conducted consultations, which consisted of structured consultation, counseling and provision of an information booklet to the family, and postdischarge follow-up with the family and primary care providers. Individuals aged 65 and older with advanced dementia who were admitted were identified, and consultations were solicited using pop-ups programmed into the computerized provider order entry (POE) system. In the initial 3-month period, 24 subjects received usual care. In the subsequent 3-month period, consultations were provided to five subjects for whom they were requested. Data were obtained from the electronic medical record and proxy interviews (admission, 1 month after discharge). Mean age of the combined sample (N = 29) was 85.4, 58.6% were from nursing homes, and 86.2% of their proxies stated that comfort was the goal of care. Nonetheless, their hospitalizations were characterized by high rates of intravenous antibiotics (86.2%), more than five venipunctures (44.8%), and radiological examinations (96.6%). Acknowledging the small sample size, there were trends toward better outcomes in the intervention group, including greater proxy knowledge of the disease, better communication between proxies and providers, more advance care planning, lower rehospitalization rates, and fewer feeding tube insertions after discharge. Targeted consultation for advanced dementia is feasible and may promote greater engagement of proxies and goal-directed care after discharge.© 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.
An Aging Population And Growing Disease Burden Will Require A Large And Specialized Health Care Workforce By 2025.
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Dall TM, Gallo PD, Chakrabarti R, West T, Semilla AP, Storm MV.
Health affairs (Project Hope) 2013 Nov;32(11):2013-2020
s the US population ages, the increasing prevalence of chronic disease and complex medical conditions will have profound implications for the future health care system. We projected future prevalence of selected diseases and health risk factors to model future demand for health care services for each person in a representative sample of the current and projected future population. Based on changing demographic characteristics and expanded medical coverage under the Affordable Care Act, we project that the demand for adult primary care services will grow by approximately 14 percent between 2013 and 2025. Vascular surgery has the highest projected demand growth (31 percent), followed by cardiology (20 percent) and neurological surgery, radiology, and general surgery (each 18 percent). Market indicators such as long wait times to obtain appointments suggest that the current supply of many specialists throughout the United States is inadequate to meet the current demand. Failure to train sufficient numbers and the correct mix of specialists could exacerbate already long wait times for appointments, reduce access to care for some of the nation’s most vulnerable patients, and reduce patients’ quality of life.
Predictors of Nursing Home Placement from Assisted Living Settings in Canada.
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Maxwell CJ, Soo A, Hogan DB, Wodchis WP, Gilbart E, Amuah J, et al.
Canadian journal on aging = La revue canadienne du vieillissement 2013 Nov 4:1-16
We sought to estimate the incidence of long-term care (LTC) placement and to identify resident- and facility-level predictors of placement among older residents of designated assisted living (AL) facilities in Alberta, Canada. Included were 1,086 AL residents from 59 facilities. Research nurses completed interRAI-AL resident assessments and interviewed family caregivers and administrators. Predictors of placement were identified with multivariable Cox proportional hazards models. The cumulative incidence of LTC admission was 18.3 per cent by 12 months. Significantly increased risk for placement was evident for older residents and those with poor social relationships, little involvement in activities, cognitive and/or functional impairment, health instability, recent falls and hospitalizations/emergency department visits, and severe bladder incontinence. Residents from larger facilities, with an LPN and/or RN on-site 24/7 and with an affiliated primary care physician, showed lower risk of placement. Our findings highlight clinical and policy areas where targeted interventions may delay LTC admissions.
Diagnostic data for neurological conditions in interRAI assessments in home care, nursing home and mental health care settings: a validity study.
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Foebel AD, Hirdes JP, Heckman GA, Kergoat MJ, Patten S, Marrie RA.
BMC health services research 2013 Nov 1;13(1):457
The interRAI suite of assessment instruments can provide valuable information to support person-specific care planning across the continuum of care. Comprehensive clinical information is collected with these instruments, including disease diagnoses. In Canada, interRAI data holdings represent some of the largest repositories of clinical information in the country for persons with neurological conditions. This study examined the accuracy of the diagnostic information captured by interRAI instruments designed for use in the home care, long-term care and mental health care settings as compared with national administrative databases. METHODS: The interRAI assessments were matched with an inpatient hospital record and emergency department (ED) visit record in the preceding 90 days. Diagnoses captured on the interRAI instruments were compared to those recorded in either administrative record for each individual. Diagnostic validity was examined through sensitivity, specificity and positive predictive value analysis for the following conditions: multiple sclerosis, epilepsy, Alzheimer’s disease and other dementias, Parkinson’s disease, traumatic brain injury, stroke, diabetes mellitus, heart failure and reactive airway disease. RESULTS: In the three large study samples (home care: n = 128,448; long-term care: n = 26,644; mental health: n = 13,812), interRAI diagnoses demonstrated high specificity when compared to administrative records, for both neurological conditions (range 0.80 — 1.00) and comparative chronic diseases (range 0.83 — 1.00). Sensitivity and positive predictive values (PPV) were more varied by specific diagnosis, with sensitivities and PPV for neurological conditions ranging from 0.23 to 0.94 and 0.14 to 0.77, respectively. The interRAI assessments routinely captured more cases of the diagnoses of interest than the administrative records. CONCLUSIONS: The interRAI assessment collected accurate information about disease diagnoses when compared to administrative records record within three months. Such information is likely relevant to day-to-day care in these three environments and can be used to inform care planning and resource allocation decisions.
Hospitalizations of nursing home residents in the last year of life: nursing home characteristics and variation in potentially avoidable hospitalizations.
Non UofA Access
Xing J, Mukamel DB, Temkin-Greener H.
Journal of the American Geriatrics Society 2013 Nov;61(11):1900-1908
OBJECTIVES: To examine the incidence of, variations in, and costs of potentially avoidable hospitalizations (PAHs) of nursing home (NH) residents at the end of life and to identify the association between NH characteristics and a facility-level quality measure (QM) for PAH. DESIGN: Retrospective. SETTING: Hospitalizations originating from NHs. PARTICIPANTS: Long-term care NH residents who died in 2007. RESULTS: Almost 50% of hospital admissions for NH residents in their last year of life were for potentially avoidable conditions, costing Medicare $1 billion. Five conditions were responsible for more than 80% of PAHs. PAH QM across facilities showed significant variation (mean 12.0 ± 142.3 per 1,000 person-years, range -399.48 to 398.09 per 1,000 person-years). Chain and hospital-based facilities were more likely to exhibit better performance (O-E < 0). Facilities with higher nursing staffing were more likely to have better performance, as were facilities with higher skilled staff ratio, those with nurse practitioners or physician assistants, and those with on-site X-ray services. CONCLUSION: Variations in facility-level PAHs suggest that a potential for reducing hospital admissions for these conditions may exist. Presence of modifiable facility characteristics associated with PAH performance could help us formulate interventions and policies for reducing PAHs at the end of life. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.
Quality of Life of and Quality of Care for People With Dementia Receiving Long Term Institutional Care or Professional Home Care: The European RightTimePlaceCare Study.
Non UofA Access
Beerens HC, Sutcliffe C, Renom-Guiteras A, Soto ME, Suhonen R, Zabalegui A, et al.
Journal of the American Medical Directors Association 2013 Nov 9
To explore how quality of life (QoL) and quality of care (QoC) for people with dementia (PwD) vary across 8 European countries; to explore how QoL and QoC for PwD vary across living arrangements; and to assess the association between QoL and QoC. DESIGN: Cross-sectional survey. SETTING: Institutional long term care and home care in 8 European countries (England, Estonia, Finland, France, Germany, the Netherlands, Spain, and Sweden). PARTICIPANTS: PwD receiving formal home care but at risk for admission to an institutional setting, and PwD who were recently admitted. MEASUREMENTS: QoL was assessed by the PwD and by their best informed proxies using the Quality of Life-Alzheimer’s Disease scale (QoL-AD) (range 13-52). QoC was measured using quality of care indicators (eg, the presence of depressive symptoms, the presence of pressure ulcers). RESULTS: A total of 1123 PwD living at home (mean age 82.2, 63%women) and 791 PwD living in institutional care (mean age 84.1, 74% women) participated. QoL of PwD was most often rated highest in Sweden and England and lowest in Estonia and Spain. No differences in QoL were detected among the settings. For the QoC indicators, no consistent patterns were visible in such a way that certain countries or settings scored “higher” or “lower.” The presence of depressive symptoms was most consistently associated with lower QoL (P ≤ .001). CONCLUSION: There is great variation in QoL and QoC scores among European countries and settings. To gain insight into the underlying causes of these differences, more knowledge is needed about the effect of different national health care systems and dementia strategies on QoL and QoC indicators. Depressive symptoms were associated with QoL, and executing longitudinal studies investigating which factors are associated with change in QoL is highly recommended. Copyright © 2013 American Medical Directors Association, Inc. Published by Elsevier Inc. All rights reserved.
Educational interventions to improve recognition of delirium: a systematic review.
Non UofA Access
Yanamadala M, Wieland D, Heflin MT.
Journal of the American Geriatrics Society 2013 Nov;61(11):1983-1993
Delirium is a common and serious condition that is underrecognized in older adults in a variety of healthcare settings. It is poorly recognized because of deficiencies in provider knowledge and its atypical presentation. Early recognition of delirium is warranted to better manage the disease and prevent the adverse outcomes associated with it. The purpose of this article is to review the literature concerning educational interventions focusing on recognition of delirium. The Medline and Cumulative Index to Nursing and Allied Health Literature (CINHAL) databases were searched for studies with specific educational focus in the recognition of delirium, and 26 studies with various designs were identified. The types of interventions used were classified according to the Predisposing, Reinforcing and Enabling Constructs in Educational Diagnosis and Evaluation (PRECEDE) model, and outcomes were sorted according to Kirkpatrick’s hierarchy. Educational strategies combining predisposing, enabling, and reinforcing factors achieved better results than strategies that included one or two of these components. Studies using predisposing, enabling, and reinforcing strategies together were more often effective in producing changes in staff behavior and participant outcomes. Based on this review, improvements in knowledge and skill alone seem insufficient to favorably influence recognition of delirium. Educational interventions to recognize delirium are most effective when formal teaching is interactive and is combined with strategies including engaging leadership and using clinical pathways and assessment tools. The goal of the current study was to systematically review the published literature to determine the effect of educational interventions on recognition of delirium. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.
Role of the nurse practitioner in providing palliative care in long-term care homes.
Non UofA Access
Kaasalainen S, Ploeg J, McAiney C, Schindel Martin L, Donald F, Martin-Misener R, et al.
International journal of palliative nursing 2013 Oct;19(10):477-485
The purpose of this study, which was part of a large national case study of nurse practitioner (NP) integration in long-term care (LTC), was to explore the NP role in providing palliative care in LTC. METHODS: Using a qualitative descriptive design, data was collected from five LTC homes across Canada using 35 focus groups and 25 individual interviews. In total, 143 individuals working in LTC participated, including 9 physicians, 20 licensed nurses, 15 personal support workers, 19 managers, 10 registered nurse team managers or leaders, 31 allied health care providers, 4 NPs, 14 residents, and 21 family members. The data was coded and analysed using thematic analysis. FINDINGS: NPs provide palliative care for residents and their family members, collaborate with other health-care providers by providing consultation and education to optimise palliative care practices, work within the organisation to build capacity and help others learn about the NP role in palliative care to better integrate it within the team, and improve system outcomes such as accessibility of care and number of hospital visits. CONCLUSIONS: NPs contribute to palliative care in LTC settings through multifaceted collaborative processes that ultimately promote the experience of a positive death for residents, their family members, and formal caregivers.
With support from Hawaii Community Foundation, NFF provided deep financial advice to nine nonprofits that provide Aging in Place (AIP) services, programs that allow seniors to receive community support while remaining in the comfort of their own homes. And through their stories, an urgent picture has emerged. By 2050, the population of American citizens over the age of 65 is expected to more than double. It has become increasingly imperative that our sector join forces to meet the needs of our seniors, lovingly called ‘kupuna’ in Hawaii. Among the services that will need to be scaled, AIP programs play a unique role in Hawaii. Applying a four-part methodology, NFF developed a step-by-step strategy outlining what the social sector in Hawaii must do to meet the future well prepared, so that Hawaii’s kupuna can age with the care they deserve.
22-24 November 2013 ECHA Cost: $30
Alberta’s first hackathon for health is looking for you! If you are a clinician, healthcare professional, developer, designer or researcher, you have skills and insights the healthcare system needs. Whether you’ve identified a problem, or have the expertise to find a solution, we need you. As a Hacking Health participant you will work on a team for one intense, highly-focused weekend to create digital health care solutions.
KUSP Brown Bag: Using RAI data for evidence based decision making and quality improvement initiatives.
Monday 18 November 2013 5-140 ECHA 12:00-13:00
Robert Jagodzinski will be presenting this session.
KUSP Brown Bag: Preparing for the CIHR Funding Reforms
Friday 22 November 2013 12:00-13:00 ECHA 4-001
Drs. Carole Estabrooks and Joanne Simila-Grant will be presenting this session.
Research informing policy: How to make an impact
Presenter: Dr. Mieke Koehoorn
Thursday, November 21, 2013 Toronto, ON 16:00
Join us for the 2013 Alf Nachemson Memorial Lecture, where you will hear Dr. Mieke Koehoorn—senior scientist at the Partnership for Work, Health and Safety at the University of British Columbia—talk about the contribution of research to worker health legislation and compensation policy in British Columbia.
KT Canada: Introduction to Systematic Review and Meta-Analysis Course
Begins 13 January 2014 Costs $1600
This is an introductory course on systematic reviews and meta-analyses and will be delivered online. It is co-taught by Sharon Straus (MD, MSc) and Andrea Tricco (MSc, PhD). The overall course objective is to teach about systematic reviews in general, as well as how to go about doing a systematic review. For more information and to register, please contact Gail Klein by email firstname.lastname@example.org
Three-Part Webcast Series from the EPPI-Centre
November 19, 20, 21, 2013
The Center on KTDRR is working with a number of national and international partners, and we are pleased to count the Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) among those partners. The EPPI-Centre is part of the Social Science Research Unit (SSRU) at the Institute of Education, University of London.
-EPPI Webcast #1: “The Work of the EPPI-Centre”
Tuesday 29 November 2013: 13:00-13:35 MT
Presenters: Ann Oakley, PhD and David Gough, PhD
The first webcast in the series describes how the EPPI-Centre got started. Also discussed are some benefits and problems of evidence-based policy and various types of research reviews that policymakers find most useful.
-EPPI Webcast #2: “Research for Real Life Problems”
Wednesday 20 November 2013 13:00-14:00 MT
Presenters: Sandy Oliver, PhD, and Rebecca Rees, MA, MSc
The second in the series of webcasts presented by staff from the EPPI-Centre focuses on why research results may not be used today, how to resolve the issue, and how to get more reliable and relevant research into use.
-EPPI Webcast #3: “Undertaking Reviews for Policy”
Thursday 21 November 2013 13:00-13:45 MT
Presenters: James Thomas, PhD, and Katy Sutcliffe, PhD
This webcast examines motivating policymakers to use research, the types of reviews are most useful in the policy arena, the impact of time constraints, and strategies for policy-focused reviews when the research is thin.
NCCDH Webinar: Knowledge translation frameworks & health equity- fast friends or perfect strangers?
Tuesday 19 November 2013 11:00-12:30 MT
Knowledge translation (KT) is about closing the gap between knowing and doing. Public health has been particularly interested in finding effective models for moving research into action. This webinar will discuss the application of a health equity support score to knowledge translation frameworks and highlight existing knowledge– to-action frameworks that can support equity focused knowledge translation.
IHSPR Policy Round Webinar: Physician Engagement and Leadership for Health System Improvement
Friday, November 29, 2013 10:30-12:00 MT
Presenters: Jean-Louis Denis,Brad Havervold
This webinar will highlight new leadership modalities (e.g. dyads of physician and manager leaders and other forms of distributed leadership) and processes (e.g. physician “compacts”) that are fostering what some refer to as “organized professionalism.” Strategies for successful physician leadership and engagement and critical success factors for change management approaches will be shared.
Age-Friendly Housing for an Older Population
Wed 27 November 2013 11:00–12:30 MT
-Understanding and Responding to a Housing Market for Older Canadians
Nina Romas, Canada Mortgage and Housing Corporation (CMHC)
-Building Lifelong Communities: The Rural Way
Lori Kovaks, Executive Director & Gwyn Butler, Operations Manager, The Rural Way, Alberta
-Imagining Housing Strategies to Age in Place: The Case of Postwar Suburbs
Carole Després, PhD, Professor and Director of Masters Program, Architectural Sciences and Urban Design, Université Laval
-Rising Tide: Housing Solutions for the Wave of Seniors in St. John’s Newfoundland
Scott Morton-Ninomiya, Affordable Housing Coordinator, City of St. John’s, Newfoundland
NCI Implementation Science: Reporting Guidelines, Measures and Harmonization: Following Up on the NIH D&I Working Meeting on Measures and Reporting
Tuesday 26 November 2013 13:00-16:00p ET
Drs. Borsika Rabin, Ross C. Brownson, and Chris R. Carpenter join us in follow up to the 6th NIH Meeting on Dissemination and Implementation Research in Health: A working meeting on Standardized Reporting and Measures Development. Drs. Rabin, Brownson, and Carpenter will present some of the key concepts discussed at the meeting and next steps. Central to their discussion are the key needs for measurement, reporting and issues of harmonization. Please note, that although this webinar is hosted by the NCI, this topic is not cancer specific and will be relevant to other health topics and disciplines. There are some background articles that should be read before attending this session. Follow the link for more information.
CDRAKE & ASC Webinar: Ambiguous Loss and Grief
Presenter: Betty Anderson
This is a recorded webinar and can be watched at any time.
Given that “Grief is the constant yet hidden companion of Alzheimer’s Disease and other related dementias” (Ken Doka, 2004), health-care providers and Alzheimer Society staff and volunteers who intentionally acknowledge and invite the carer to explore grief create a most powerful intervention indeed. Grieving the psychological changes of the person with dementia can be especially challenging for carers. Grieving for the person who is so changed by dementia, yet still alive, adds significantly to the stresses of caregiving.
“How are you feeling?” asked the doctor. His patient was suffering from semantic dementia, a condition in which damage to part of the brain’s temporal lobe disrupts the connection between words and their meanings. Her vocabulary had been reduced to just 3,000-4,000 words, fewer than what a four-year-old can use (the average adult English speaker knows 20,000–35,000).
There is a worrying rise in health-care spending in Canada, but it doesn’t have much to do with population aging. To stay with the oceanographic metaphor, aging might be, at most, a modest tidal wave. The real tsunami of health spending is the result of changes in the way all patients are treated in the system, resulting from both price inflation (drugs and doctors cost more than ever) and technical progress (new diagnostic tests, surgeries and drugs).
Includes a variety of short articles on the culture of care including one on health care aides by Drs. Estabrooks and Norton.
Several years ago, paramedics in Deep River, Ont., came to the realization that most of their 911 emergency calls were coming from seniors living alone. And so they decided to do something about it. Five years later, they have managed to cut the number of 911 calls from these individuals in half. The trick: a bit of preventive medicine.
Penalties will go into effect this month against local health agencies if they fail to place patients, preferably in their own homes, within eight days of being declared medically stable.
SUPPORT (Support for People and Patient-Oriented Research and Trials) Units are provincial or regional centres designed to support those engaged in patient-oriented research. They are locally accessible, multi-disciplinary clusters of research resources, policy knowledge, and patient perspective. They provide the necessary expertise to pursue patient-oriented research and help lead reforms in response to locally-driven health care needs.
Untangling Alzheimer’s is a dramatic and inspiring medical investigation driven by David Suzuki’s journey to understand the science of Alzheimer’s and the surprising new insights into its cause. David has a very personal interest in the disease because his mother, aunt and two uncles died of it. We join David on an intimate journey as he explores the newest breakthroughs in this devastating disease as well as his own chances of contracting the cruel condition.
Following another patient death, experts warn that long-term-care homes are housing more residents with behaviour issues, without enough specially trained staff.
Toronto prides itself on being in the urban vanguard, but it is ill-prepared for an aging population.
All G8 countries are being brought together in London on December 10-11, 2013 to focus on dementia research. This is the first Summit dedicated to seeking a heightened level of international collaboration in order to face the global challenge of dementia. n consultation with PHAC, CIHR has proposed responses to the questions informed by previous discussions with stakeholders during the inception and deployment of ICRSAD, as well as the development of the NPHSNC. We are sharing these responses with the community. The following is the link in order to access the “Proposed Responses to the UK Guided Questions” document. We invite you to contribute any additional information you would like to share with us by November 25th 2013. Please send all comments in confidence to email@example.com.
A brief article in Nature announces that 1/4 of studies that meet commonly used statistical cutoff may be false. The plague of non-reproducibility in science may be mostly due to scientists’ use of weak statistical tests, as shown by an innovative method developed by statistician Valen Johnson, at Texas A&M University in College Station.
Nursing home murders makes for splashy headlines. But the real dangers elderly residents face are incompetence, penny-pinching and casual neglect
Resource recommended by our own early adopter Ferenc Toth ActiveInbox
ActiveInbox allows you to organize your email so it’s not overwhelming and focused on tasks. On Ferenc’s recommendation, I have been using this for the past month and find it VERY useful but it does take about a week to get used to and you still have to do some work to organize emails.
This site provides a broad overview of various health data (wait times, life expectancy, hospital deaths, etc.) for areas across Canada.
In path analysis, researchers use models to map out relationships between many variables and test them for strength.
Many organizations would like to make better use of research, but aren’t sure where to start. Others feel they’re doing well, but would also like to know if there are areas they could improve. Through self-assessment, an organization can discover its strengths, identify gaps, and make plans for addressing priority areas in the future. We hope the tool will not only help in self-evaluation, but also provide ideas for where and how to enhance research use.
Marie-Curie Funded Research Fellowships
DEADLINE: 30 November 2013
CogNovo offers a choice of 14 focussed research projects. Each project is supervised by a multidisciplinary team of experts and offers opportunities for secondments to international academic and commercial partners. Please note: Marie-Curie Fellowships have specific eligibility requirements: candidates should not have a) been resident within the UK for more than 12 months within the 3 years prior to 1 April 2014, or b) undertaken more than 4 years of fulltime research subsequent to their qualifying (Bachelor’s or Master’s) degree. Project 14 would be of particular interest to readers of KUSP FYI since it involves investigating rationality of human decision making under time constraints; evaluate theoretical predictions of a new model of constrained decision making within a medical context.