A Decision Simulation Model for Health Services Management

This article examines transformations associated with changes in resource use and land cover dynamics in the community of Sao Manoel, Maranhao state, in the eastern Brazilian Amazon. The shifting cultivator peasants in Sao Manoel integrate swidden fields for annual cropping, the extraction of babassu palm products, and pastures for cattle ranching. Since the early twentieth century, predominant vegetative cover patterns have been altered from species-rich mature forests to secondary succession with babassu dominant to pasture or swidden fields containing palm stands of various densities. A grounded political ecology of resource use in the area suggests that management strategies and the resulting land cover dynamics integrate site-specific decisions of peasant producers. I discuss the trajectory of production strategies in Sao Manoel since the establishment of the community in the 1920s, and identify the multiple dimensions affecting resource use and environmental outcomes, with an emphasis on the period following land struggles and the recovery of peasant tenure rights in the mid-1980s. The analysis indicates that socionatural trajectories that optimize resource use and address the socioeconomic needs of the community include the maintenance of palm/pastures associations.

This study examined the impact of caring for children with medical complexity (CMC) and high resource use on family quality of life (QoL). Families of CMC enrolled in a complex care program completed the PedsQL Family Impact module (PedsQL FIM) and Healthcare Satisfaction module (PedsQL HCS) at enrollment then 1 and 2 years after enrollment. Tertiary center resource utilization and staff care coordination time were collected for the two years. PedsQL FIM scores were low at enrollment and did not improve over time. Social Functioning, Worry, and Daily Activities were the lowest domains. PedsQL HCS scores were higher at enrollment, but also failed to improve over the two years. Changes in resource use were not associated with changes in PedsQL FIM or HCS scores. Staff care coordination time was highest for patients with ≥ 10 hospital days per year. CMC families' low QoL did not appear to be related to healthcare satisfaction or a shift from inpatient to outpatient resource use. Less staff support for families of CMC who spent more time at home may have contributed to their continued low QoL. Further study is required to identify causes of and strategies for improving the low QoL of families of CMC.

In a prospective study of gall stone related deaths in a single Health District, the biliary tract was examined at necropsy in 1701 cases and 8078 death certificates were searched. Gall stones were identified as the cause of death in only 21 cases (0.26%) but in 291 subjects found to have gall stones or cholecystectomy at necropsy, the mortality was 3.4%. The necropsy prevalence of gall stones in the adult population was 17.1% but nine out of 10 subjects with gall stones had not had a cholecystectomy and women were three times more likely to have had their gall stones removed than men. There were five postoperative deaths (mean age 60 years) with an operative mortality for cholecystectomy in the district of 1.2%. Death due to unoperated gall stones was identified in 16 subjects, most of whom were very elderly women (mean age 81) but carcinoma of the gall bladder was only found in one woman of 90 with gall stones. The prevalence of gall stones rose with age in both sexes but the cholecystectomy rate per head of population at-risk declined sharply in the seventh decade in women and the eighth decade in men. There are a large number of people with unoperated gall stones in the population but gall stone related deaths are very uncommon. The cholecystectomy rate in Britain, however, seems to be rising and it is suggested that if this trend continues there may be an increased number of deaths.

Competitive relationships were estimated for plants from young and old pasture populations. Experimental treatments were conducted under both common garden field station conditions and actual grazed pasture conditions. The results suggest four conclusions. (1) Grazing and other ‘pasture’ conditions did not prevent plant competition. (2) Interspecific competition appears to promote the use of different resources (niche divergence). (3) Intraspecific competition may lead to a broadening of resource use by a species and, thus, indirectly increase both niche overlap and interspecific competition. No evidence was found to support an alternative theory of co-existence in which interspecific competition is argued to promote a balancing of competitive abilities without changes to relative niche overlap. (4) Changes in resource use appears to occur within a few decades after pasture formation.

The compression hypothesis predicts that when two species occur together in narrow sympatry, individuals in the overlap zone will use a smaller range of habitats and a larger or unchanged range of prey than individuals in allopatry. This report attempts to validate the assumptions underlying this hypothesis, and describes two tests of the predicted resource shifts using narrowly sympatric species of predatory marsupials (Antechinus spp.). In the first test, using A. stuartii and A. flavipes, there was little correspondence between observed and predicted changes in diet and habitat use (as measured by indices of niche breadth) for populations of either species. One index of niche breadth (Levins' B) revealed no trends in resource use, but a proportional similarity index relating resource use to resource abundance consistently indicated that the niche breadths of each species were greater in allopatry than in narrow sympatry. In the second test, using A. stuartii where it occurred alone and in narrow sympatry with A. swainsonii, there was again little correspondence between observed and predicted changes in resource use for seasonal or overall data. Differences in magnitudes of niche breadths between allopatric and narrowly sympatric A. stuartii were smaller in this test than in the first.While these findings provided no support for the compression hypothesis, they suggested three situations in which the predictions of the hypothesis may generally not apply. These are: when the predators are active, dietary generalists (diet cannot expand in sympatry); when one species is a markedly superior competitor to the other (the dominant species suffers little or no niche compression in sympatry); and when the species compete by interference rather than exploitation (one species is evicted from sympatry or both show compression in habitat use and diet).

This investigation examines the impact of intensive farm management advice on levels and productivities of resource use on samples of farms. A total of 60 members of 13 farm management advisory services and 60 non‐members, matched by locality, were studied in two farming regions of Western Australia. A production model has been formulated and analysed which discriminates between effects of differences and changes in resource use and productivity over time and between members and non‐members. Major differences between members and non‐members over time have been rates of growth of inputs and outputs rather than systematic changes of production relationships.

Background:A scheme to train paramedics to undertake a greater role in the care of older people following a call for an emergency ambulance was developed in a large city in...

Attention-deficit hyperactivity disorder (ADHD) is the most common mental health disorder in youths. Stimulants are the drugs of first choice in the treatment of ADHD. It has been suggested that full costs associated with the treatment of ADHD may be reduced by once-daily administration regimens of stimulants. To estimate the cost effectiveness of treatment with long-acting methylphenidate osmotic release oral system (OROS) [Concerta] for youths with ADHD for whom treatment with immediate-release (IR) methylphenidate is suboptimal. We developed a Markov model to obtain an incremental cost-effectiveness ratio (ICER). The analysis covered 10 years, with a Markov cycle of 1 day. Costs (in 2005 euros ) included medication, consultations and treatment interventions, and additional costs for attending special education. Quality-adjusted life-years (QALYs) were used as the effectiveness measure. Outcome probabilities were taken from the medical literature and an expert panel of five child psychiatrists and paediatricians. Univariate sensitivity analyses were performed to assess the robustness of the base-case estimate. Multivariate sensitivity analysis was used to estimate a worst- and best-case ICER. The ICER of methylphenidate-OROS treatment in youths with ADHD for whom treatment with IR methylphenidate is suboptimal was euro 2004 per QALY. Total costs after 10 years were euro 15,739 for the IR methylphenidate pathway and euro 16,015 for the methylphenidate-OROS pathway. In the univariate sensitivity analysis, the ICER was sensitive to changes in resource use and the probability of stopping stimulant treatment in favour of IR methylphenidate. An ICER of 0 was reached with a 6.2% price reduction of methylphenidate-OROS. Methylphenidate-OROS is a cost-effective treatment for youths with ADHD for whom treatment with IR methylphenidate is suboptimal. Higher medication costs of methylphenidate-OROS were compensated for by savings on resource use, yielding similar 10-year costs compared with treatment with IR methylphenidate. Our analysis is sensitive to both clinical parameters and (differences in) resource utilization and costs between the groups modelled, warranting further research within clinical trials and observational databases, and into the full scope of costs.

Despite the progress made in explaining trophic interactions through the stoichiometric interplay between consumers and resources, it remains unclear how the number of species in a trophic group influences the effects of elemental imbalances in food webs. Therefore, we conducted a laboratory experiment to test the hypothesis that multispecies producer assemblages alter the nutrient dynamics in a pelagic community. Four algal species were reared in mono- and polycultures under a 2 x 2 factorial combination of light and nutrient supply, thereby contrasting the stoichiometry of trophic interactions involving single vs. multiple producer species. After 9 d, these cultures were fed to the calanoid copepod Acartia tonsa, and we monitored biomass, resource use, and C:N:P stoichiometry in both phyto- and zooplankton. According to our expectations, light and N supply resulted in gradients of phytoplankton biomass and nutrient composition (C:N:P). Significant net diversity effects for algal biomass and C:N:P ratios reflected the greater responsiveness of the phytoplankton polyculture to altered resource supply compared to monocultures. These alterations of elemental ratios were common, and were partly triggered by changes in species frequency in the mixtures and partly by diversity-related changes in resource use. Copepod individual biomass increased under high light (HL) and N-reduced (-N) conditions, when food was high in C:N but low in C:P and N:P, whereas copepod growth was obviously P limited, and copepod stoichiometry was not affected by phytoplankton elemental composition. Correspondingly, copepod individual biomass reflected significant net diversity effects: compared to expectations- derived from monocultures, copepod individuals feeding on algal polycultures remained smaller than predicted under HL and N-sufficient (+N) conditions but grew larger than predicted under HL, -N and low light +N conditions. In conclusion, multiple producer species altered the stoichiometry of trophic interactions between phyto- and zooplankton, with divergent effects under high and low resource supply.

Evaluating performance of regional wildlife habitat models: Implications to resource planning

Russian SARS-CoV-2 vaccineRelease without phase III trial entails numerous risks

Satisfaction with and acceptability of training is clearly very important but not sufficient for change in practice. Outcomes from education and training are often related to patient morbidityor mortality, but there might be other outcomes such as staff retention or change in resource use. Evaluation overlaps with research, although evaluation is about the specific education and training whilst research is about generalisable findings. Perhaps the most well-known structure of evaluation is the Kirkpatrick model, which proposes that there are few ‘levels’ of evaluation of training. Assessing motivation for example may include establishing whether the trainees' plans and/or confidence to implement the new behaviour has increased following the training. A complex intervention is one that targets several behaviours and has multiple, interacting components and education and training is sometimes such an intervention, particularly when it forms part of a wider project.

Changes in physical activity and short-term changes in health care charges: a prospective cohort study of older adults

Ontogenetic changes in resource use often delimit transitions between life stages. Ecological and individual factors can cause variation in the timing and consistency of these transitions, ultimately affecting community and population dynamics through changes in growth and survival. Therefore, it is important to document and understand behavioral and life history polymorphisms, and the processes that drive intraspecific variation in them. To evaluate juvenile loggerhead sea turtle (Caretta caretta) life history variation and to detect shifts in habitat and diet that occur during an oceanic‐to‐neritic ontogenetic shift, we sequentially analyzed the stable isotope composition of humerus bone growth increments from turtles that stranded dead on Southeastern U.S. beaches between 1997 and 2013 (n = 84). In one‐half of the sampled turtles, growth increment‐specific nitrogen stable isotope (δ15N) data showed significant increases in δ15N values over each turtle's life. These data were used to provide a new line of evidence that juvenile Northwest Atlantic loggerheads exhibit two major ontogenetic shift patterns: discrete shifts (n = 24), which were completed within one year, and facultative shifts (n = 14), which were completed over multiple years (up to five). The mean difference in pre‐ and post‐ontogenetic shift δ15N values was 4.3‰. Differences in isotopic baselines between neritic and oceanic habitats of the Northwest Atlantic Ocean make it likely these patterns are driven by a coupled change in both habitat and diet, and that facultative shifters utilize both neritic and oceanic resources within transitional growth years. Mean size and age at transition between habitats (54.2 cm straightline carapace length, SCL; 11.98 yr) was within the range of previous estimates and did not differ between discrete and facultative shifters. Our results further expand our understanding of loggerhead sea turtle life history polymorphisms and demonstrate the value of bone tissue analysis to the study of this variation. Sequential analysis of annual skeletal growth increments provides a valuable method for reconstructing long‐term ontogenetic changes in foraging ecology and habitat use in long‐lived, cryptic marine species.

Cost-variance analysis by DRGs; a technique for clinical budget analysis