We use historical particularities of pension funding law to investigate whether managers of U.S. corporate defined benefit pension plan sponsors strategically use regulatory freedom to lower the ...reported value of pension liabilities, and hence required cash contributions. For some years, pension plans were required to estimate two liabilities—one with mandated discount rates and mortality assumptions, and another where these could be chosen freely. Using a sample of 11,963 plans, we find that the regulated liability exceeds the unregulated measure by 10% and the difference further increases for underfunded pension plans. Underfunded plans tend to assume substantially higher discount rates and lower life expectancy. The effect persists both in the cross-section of plans and over time and it serves to reduce cash contributions. We further show that plan sponsor managers use the freed-up cash for corporate investment and that credit risk is unlikely to explain the finding.
When breast cancer is detected and treated early, the chances of survival are very high. However, women in many settings face complex barriers to early detection, including social, economic, ...geographic, and other interrelated factors, which can limit their access to timely, affordable, and effective breast health care services. Previously, the Breast Health Global Initiative (BHGI) developed resource‐stratified guidelines for the early detection and diagnosis of breast cancer. In this consensus article from the sixth BHGI Global Summit held in October 2018, the authors describe phases of early detection program development, beginning with management strategies required for the diagnosis of clinically detectable disease based on awareness education and technical training, history and physical examination, and accurate tissue diagnosis. The core issues address include finance and governance, which pertain to successful planning, implementation, and the iterative process of program improvement and are needed for a breast cancer early detection program to succeed in any resource setting. Examples are presented of implementation, process, and clinical outcome metrics that assist in program implementation monitoring. Country case examples are presented to highlight the challenges and opportunities of implementing successful breast cancer early detection programs, and the complex interplay of barriers and facilitators to achieving early detection for breast cancer in real‐world settings are considered.
Women in many settings face complex barriers to early detection, including social, economic, geographic, and other interrelated factors, which can limit her access to timely, affordable, and effective breast health care services. In this consensus manuscript, phases of an early detection program development are described, beginning with management strategies required for the diagnosis of clinically detectable disease, and core issues are described pertaining to successful planning, implementation, and the iterative process of program improvement needed for a breast cancer early detection program to succeed in any resource setting.
There is growing concern over the conservation status of sharks and relatives exposed to fishing mortality. The Food and Agriculture Organization of the United Nations in 1999 adopted the ...International Plan of Action for the Conservation and Management of Sharks (IPOA), which provides nations with advice on adopting and implementing national plans. An assessment of global national and regional plans of action on sharks (NPOAs) found: most are out of date; limited use of specific, measurable and timebound objectives and activities; no outcome objectives; and few performance assessments. This makes most NPOAs inadequate for planning and assessing efficacy. Over 33% of the annual retained catch of sharks and relatives was from countries without NPOAs and less than 12% was from countries with current NPOAs. NPOAs identified fisheries management framework deficits, ecology knowledge gaps, institutional capacity and coordination shortfalls, and budget constraints as the largest obstacles to implementation and are improvement priorities. We recommend how to amend the IPOA to better support the adoption and effective design and implementation of NPOAs for evidence‐informed conservation and management.
This study aimed to examine the financing of photovoltaics research and development by analyzing funding from public (European Union and national budgets) and private sources (enterprises), Strategic ...Energy Technology Plan participating countries being the main focus (European Union Member States plus Norway and Turkey). In the coming years, photovoltaics are expected to heavily contribute towards the achievement of audacious climate and energy objectives. Continuous monitoring of the effects is of great importance to assess a course of action taken at such a large scale. It will be revealed that the distribution of funding provided by national budgets highly concentrates on a few Member States, which is part of a general trend in Research and Development within Europe. Approximately 85% of the current European investment provided by the EU budget is administered in the framework of the Horizon 2020 (2014–2020) program; private investment behaves differently. The European photovoltaics manufacturing market has been obliterated by low-budget imported goods. A major characteristic is that the remaining companies are almost exclusively privately held. Gathering data has consequently been a challenge, as opposed to the readily available public datasets.
This article examines the funding of two key components of state government total compensation: pensions and other postemployment benefits (OPEB), the latter consisting primarily of retiree health ...care. A brief overview of the economic, political, and legal environments of state pensions and OPEB is followed by an analysis of the unfunded liabilities for these respective benefits. Regression results suggest the importance of state management capacity, per capita income, and public employee density in understanding differences in the states' pension and OPEB funding performance. Additionally, employers' level of pension contributions, legislative professionalism, and fiscal constraint are significantly related to pension funding, while political ideology and levels of state pension funding are significantly related to OPEB funding. The article concludes by discussing the tensions that states face in attempting to balance the fiscal imperative of funding retiree benefits liabilities with the human capital challenge of attracting and retaining a professional workforce. Failure on either could be costly to state government.
Do-not-attempt-cardiopulmonary-resuscitation (DNACPR) practice has been shown to be variable and sub-optimal. This paper describes the development of the Recommended Summary Plan for Emergency Care ...and Treatment (ReSPECT). ReSPECT is a process which encourages shared understanding of a patient’s condition and what outcomes they value and fear, before recording clinical recommendations about cardiopulmonary-resuscitation (CPR) within a broader plan for emergency care and treatment.
ReSPECT was developed iteratively, with integral stakeholder engagement, informed by the Knowledge-to-Action cycle. Mixed methods included: synthesis of existing literature; a national online consultation exercise; cognitive interviews with users; a patient-public involvement (PPI) workshop and a usability pilot, to ensure acceptability by both patients and professionals.
The majority (89%) of consultation respondents supported the concept of emergency care and treatment plans. Key features identified in the evaluation and incorporated into ReSPECT were: The importance of discussions between patient and clinician to inform realistic treatment preferences and clarity in the resulting recommendations recorded by the clinician on the form. The process is compliant with UK mental capacity laws. Documentation should be recognised across all health and care settings. There should be opportunity for timely review based on individual need.
ReSPECT is designed to facilitate discussions about a person’s preferences to inform emergency care and treatment plans (including CPR) for use across all health and care settings. It has been developed iteratively with a range of stakeholders. Further research will be needed to assess the influence of ReSPECT on patient-centred decisions, experience and health outcomes.
Background
A key function of health systems is implementing interventions to improve health, but coverage of essential health interventions remains low in low‐income countries. Implementing ...interventions can be challenging, particularly if it entails complex changes in clinical routines; in collaborative patterns among different healthcare providers and disciplines; in the behaviour of providers, patients or other stakeholders; or in the organisation of care. Decision‐makers may use a range of strategies to implement health interventions, and these choices should be based on evidence of the strategies' effectiveness.
Objectives
To provide an overview of the available evidence from up‐to‐date systematic reviews about the effects of implementation strategies for health systems in low‐income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on alternative implementation strategies and informing refinements of the framework for implementation strategies presented in the overview.
Methods
We searched Health Systems Evidence in November 2010 and PDQ‐Evidence up to December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well‐conducted systematic reviews of studies that assessed the effects of implementation strategies on professional practice and patient outcomes and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the review findings. Two overview authors independently screened reviews, extracted data and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence) and assessments of the relevance of findings to low‐income countries.
Main results
We identified 7272 systematic reviews and included 39 of them in this overview. An additional four reviews provided supplementary information. Of the 39 reviews, 32 had only minor limitations and 7 had important methodological limitations. Most studies in the reviews were from high‐income countries. There were no studies from low‐income countries in eight reviews.
Implementation strategies addressed in the reviews were grouped into four categories – strategies targeting:
1. healthcare organisations (e.g. strategies to change organisational culture; 1 review);
2. healthcare workers by type of intervention (e.g. printed educational materials; 14 reviews);
3. healthcare workers to address a specific problem (e.g. unnecessary antibiotic prescription; 9 reviews);
4. healthcare recipients (e.g. medication adherence; 15 reviews).
Overall, we found the following interventions to have desirable effects on at least one outcome with moderate‐ or high‐certainty evidence and no moderate‐ or high‐certainty evidence of undesirable effects.
1.Strategies targeted at healthcare workers: educational meetings, nutrition training of health workers, educational outreach, practice facilitation, local opinion leaders, audit and feedback, and tailored interventions.
2.Strategies targeted at healthcare workers for specific types of problems: training healthcare workers to be more patient‐centred in clinical consultations, use of birth kits, strategies such as clinician education and patient education to reduce antibiotic prescribing in ambulatory care settings, and in‐service neonatal emergency care training.
3. Strategies targeted at healthcare recipients: mass media interventions to increase uptake of HIV testing; intensive self‐management and adherence, intensive disease management programmes to improve health literacy; behavioural interventions and mobile phone text messages for adherence to antiretroviral therapy; a one time incentive to start or continue tuberculosis prophylaxis; default reminders for patients being treated for active tuberculosis; use of sectioned polythene bags for adherence to malaria medication; community‐based health education, and reminders and recall strategies to increase vaccination uptake; interventions to increase uptake of cervical screening (invitations, education, counselling, access to health promotion nurse and intensive recruitment); health insurance information and application support.
Authors' conclusions
Reliable systematic reviews have evaluated a wide range of strategies for implementing evidence‐based interventions in low‐income countries. Most of the available evidence is focused on strategies targeted at healthcare workers and healthcare recipients and relates to process‐based outcomes. Evidence of the effects of strategies targeting healthcare organisations is scarce.
Clinical implementation of pharmacogenomics (PGx) leads to personalized medicine, which improves the efficacy, safety, and cost-effectiveness of treatments. Although PGx-based research has been ...conducted for more than a decade, several barriers have slowed down its widespread implementation in clinical practice. Globally, there is an imbalance in programs and solutions required to empower the clinical implementation of PGx between countries. Therefore, we aimed to review these issues comprehensively, determine the major barriers, and find the best solutions. Through an extensive review of ongoing clinical implementation programs, scientific, educational, ethical, legal, and social issues, information technology, and reimbursement were identified as the key barriers. The pace of global implementation of genomic medicine coincided with the resource limitations of each country. The key solutions identified for the earlier mentioned barriers are as follows: building of secure and suitable information technology infrastructure with integrated clinical decision support systems along with increasing PGx evidence, more regulations, reimbursement strategies for stakeholder's acceptance, incorporation of PGx education in all institutions and clinics, and PGx promotion to all health care professionals and patients. In conclusion, this review will be helpful for the better understanding of common barriers and solutions pertaining to the clinical application of PGx.
Abstract More than 30% of the world's population are anemic with serious economic consequences including reduced work capacity and other obstacles to national welfare and development. Red blood cell ...transfusion is the mainstay to correct anemia, but it is also 1 of the top 5 overused procedures. Patient blood management (PBM) is a proactive, patient-centered, and multidisciplinary approach to manage anemia, optimize hemostasis, minimize iatrogenic blood loss, and harness tolerance to anemia. Although the World Health Organization has endorsed PBM in 2010, many hospitals still seek guidance with the implementation of PBM in clinical routine. Given the use of proven change management principles, we propose simple, cost-effective measures enabling any hospital to reduce both anemia and red blood cell transfusions in surgical and medical patients. This article provides comprehensive bundles of PBM components encompassing 107 different PBM measures, divided into 6 bundle blocks acting as a working template to develop institutions' individual PBM practices for hospitals beginning a program or trying to improve an already existing program. A stepwise selection of the most feasible measures will facilitate the implementation of PBM. In this manner, PBM represents a new quality and safety standard.
La figure, dans la sémiotique greimassienne, héritant d’une élaboration polysémique chez Hjelmslev, appartient tant au plan de l’expression qu’au plan du contenu. Sur le plan du contenu, elle ...s’introduit au niveau discursif et renvoie à un thème, qu’elle
. Par ailleurs, dans Sémantique Structurale, les traces d’information que nos cinq sens nous apportent sont aussi appelées figures, et c’est par leur intermédiaire que le monde naturel joue un rôle dans la naissance du sens. Ces figures engendrées par la perception sont des figures d’expression et appartiennent de ce fait au plan de l’expression. L’unification des deux types de figures en une figurativité générique, située au niveau discursif et subdivisée en figurativité
, dite de surface, et figurativité
, dite profonde (Landowski. 2017.
. São Paulo : Editora CPS e Estação das Letras e Cores) est discutée avec l’apport d’auteurs de la sémiotique française et la structure quadratique du signe due au Groupe µ (2015.
. Bruxelles : Les Impressions Nouvelles : 283–292). Cette discussion nous suggère la figurativité comme transversale au parcours génératif du sens et contribuant à l’opération de conversion, dans la mesure où des traces du monde naturel refont surface sous la forme de figures du monde, sur le plan du contenu discursif.
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