About 30% of patients drop out of cognitive-behavioural therapy (CBT), which has implications for psychiatric and psychological treatment. Findings concerning drop out remain heterogeneous.
This ...paper aims to compare different machine-learning algorithms using nested cross-validation, evaluate their benefit in naturalistic settings, and identify the best model as well as the most important variables.
The data-set consisted of 2543 out-patients treated with CBT. Assessment took place before session one. Twenty-one algorithms and ensembles were compared. Two parameters (Brier score, area under the curve (AUC)) were used for evaluation.
The best model was an ensemble that used Random Forest and nearest-neighbour modelling. During the training process, it was significantly better than generalised linear modelling (GLM) (Brier score: d = -2.93, 95% CI (-3.95, -1.90)); AUC: d = 0.59, 95% CI (0.11 to 1.06)). In the holdout sample, the ensemble was able to correctly identify 63.4% of cases of patients, whereas the GLM only identified 46.2% correctly. The most important predictors were lower education, lower scores on the Personality Style and Disorder Inventory (PSSI) compulsive scale, younger age, higher scores on the PSSI negativistic and PSSI antisocial scale as well as on the Brief Symptom Inventory (BSI) additional scale (mean of the four additional items) and BSI overall scale.
Machine learning improves drop-out predictions. However, not all algorithms are suited to naturalistic data-sets and binary events. Tree-based and boosted algorithms including a variable selection process seem well-suited, whereas more advanced algorithms such as neural networks do not.
Im Zuge der Weiterentwicklung der Palliativversorgung in Deutschland entstand im Jahr 2017 eine Vereinbarung zur „Besonders qualifizierten und koordinierten palliativmedizinischen Versorgung“ ...(BQKPMV). Hausärzt*innen nehmen bei der BQKPMV eine zentrale Rolle ein und sind u.a. für die Koordination der Versorgung zuständig. Es gibt Hinweise darauf, dass Hürden in der praktischen Umsetzung der BQKPMV bestehen und eine Anpassung erforderlich sein könnte. Diese Arbeit ist Teil des Projekts Polite (Analyse der Implementierung der ‚Besonders qualifizierten und koordinierten palliativmedizinischen Versorgung‘ in der Versorgungsrealität und Empfehlungen zur Weiterentwicklung) und verfolgt das Ziel, Empfehlungen zur Weiterentwicklung der BQKPMV zu konsentieren.
Zwischen Juni und Oktober 2022 erfolgte eine Online-Delphi-Befragung mit Expert*innen für die ambulante Palliativversorgung aus ganz Deutschland (Versorgende, Fachverbände, Kostenträger, Wissenschaft, Selbstverwaltung). Inhaltliche Basis für die Empfehlungen, über die im Rahmen der Delphi-Befragung abgestimmt wurde, waren Ergebnisse aus der ersten Projektphase sowie aus einem Expert*innen-Workshop. Teilnehmende konnten zu jeder Empfehlung auf einer vierstufigen Rangskala angeben, inwiefern sie a) der Deutlichkeit der Formulierung und b) der Relevanz für die Weiterentwicklung der BQKPMV zustimmen. Ein Konsens wurde angenommen, wenn 75% der Teilnehmenden einer Empfehlung bezüglich beider Kriterien (eher) zustimmten. Wurde kein Konsens erreicht, wurden die Empfehlungen mithilfe der Freitextanmerkungen angepasst und in der nächsten Runde erneut präsentiert. Die Analysen erfolgten deskriptiv.
An der ersten Befragungsrunde nahmen 45 Expert*innen teil, an der zweiten 31 und an der dritten 30 (43% weiblich, im Mittel 55 Jahre alt). In Runde 1 wurden sieben, in Runde 2 sechs und in Runde 3 drei Empfehlungen konsentiert. Diese insgesamt 16 Empfehlungen beziehen sich inhaltlich auf vier Themenkomplexe: Bekanntheit und Implementierung der BQKPMV (6 Empfehlungen), Rahmenbedingungen der BQKPMV (3), Abgrenzung der Versorgungsformen (5) und Zusammenarbeit an den Schnittstellen (2).
Mithilfe der Delphi-Methode konnten konkrete und für die Versorgungspraxis relevante Empfehlungen zur Weiterentwicklung der BQKPMV identifiziert werden. Im finalen Set von Empfehlungen liegt ein besonderer Fokus auf einer Steigerung der Bekanntheit und der Vermittlung von Informationen zu Leistungsumfang, Mehrwert und Rahmenbedingungen der BQKPMV.
Die Ergebnisse liefern eine empirisch fundierte Grundlage für die Weiterentwicklung der BQKPMV. Sie zeigen konkreten Veränderungsbedarf auf und unterstreichen, dass eine Optimierung der BQKPMV erforderlich ist.
In the course of the further development of palliative care in Germany, an agreement on an intermediate level of outpatient palliative care, the so-called BQKPMV (specially qualified and coordinated palliative homecare) was realised in 2017. Family physicians play a central role in the BQKPMV; among other things, they are responsible for the coordination of care. There are indications that barriers exist in the practical implementation of the BQKPMV and that an adjustment may be necessary. This work is part of the Polite project (analysis of the implementation of an intermediate level of outpatient palliative care in the reality of care and recommendations for further development) and aims at building consensus on recommendations for the further development of the BQKPMV.
Between June and October 2022, an online Delphi survey was conducted among experts for outpatient palliative care from all over Germany (providers, professional associations, funders, science, self-government). The content of the recommendations, which were voted on as part of the Delphi survey, was based on the results of both the first project phase and an expert workshop. Participants rated the extent to which they agree with a) the clarity of the wording, and b) the relevance for the further development of the BQKPMV on a four-point Likert scale. Consensus was assumed when 75% of the participants (rather) agreed to a recommendation with regard to both criteria. If no consensus was reached, the recommendations were adjusted using the free text comments and presented again in the next round. Descriptive analyses were applied.
Forty-five experts participated in the first Delphi round, 31 in the second, and 30 in the third round (43% female, average age 55). Consensus was obtained for seven recommendations in round 1, for six in round 2 and for three in round 3. These final 16 recommendations relate to four topics: awareness and implementation of the BQKPMV (6 recommendations), framework conditions of the BQKPMV (3), discrimination of forms of care (5), and cooperation at the interfaces of care (2).
The Delphi method was used to identify concrete recommendations for the further development of the BQKPMV that are relevant to health care practice. In the final set of recommendations, a particular focus lies on increasing awareness and communicating information about the scope of the health care service, added value and framework conditions of the BQKPMV.
The results provide an empirically sound basis for the further development of the BQKPMV. They show a concrete need for change and highlight that an optimisation of the BQKPMV is necessary.
In diesem Open-Access-Buch werden die politischen Ziele der Ambulantisierung und der sektorengleichen Vergütung den aktuellen Herausforderungen in der Chirurgie gegenübergestellt. Die unzureichend an ...die steigenden Kosten angepasste Vergütung spiegelt sich in einem signifikanten Rückgang des Reinertrags chirurgischer Einzelpraxen wider. Als Folge sinkt die Zahl ambulanter Operationen (AOPs). Die Ergebnisse der vorliegenden Studie zeigen, dass die Besondere Versorgung den Herausforderungen begegnen, die Ergebnisqualität verbessern und Sektorengrenzen aufbrechen sowie die Ambulantisierung bei geringerer Einflussnahme auf medizinische Entscheidungen und deutlich höherer Vergütung ausbauen kann. Als Handlungsempfehlung resultiert ein Ersatz der auf Soll-Werten basierenden Einzelleistungsvergütungen durch modifizierte Hybrid-DRGs mit regelmäßig aufwandsorientierten Vergütungsanpassungen für Krankenhäuser und Vertragsärzte mit/ohne Krankenhausanbindung. Findet eine Umsetzung in der Regelversorgung nicht statt und bestehen weiterhin keine finanziellen Anreize, können laufende Projekte der Besonderen Versorgung weiter ausgebaut werden.
Abstract The increased use of gait analysis has raised the need for a better understanding of how walking speed and demographic variations influence asymptomatic gait. Previous analyses mainly ...reported relationships between subsets of gait features and demographic measures, rendering it difficult to assess whether gait features are affected by walking speed or other demographic measures. The purpose of this study was to conduct a comprehensive analysis of the kinematic and kinetic profiles during ambulation that tests for the effect of walking speed in parallel to the effects of age, sex, and body mass index. This was accomplished by recruiting a population of 121 asymptomatic subjects and analyzing characteristic 3-dimensional kinematic and kinetic features at the ankle, knee, hip, and pelvis during walking trials at slow, normal, and fast speeds. Mixed effects linear regression models were used to identify how each of 78 discrete gait features is affected by variations in walking speed, age, sex, and body mass index. As expected, nearly every feature was associated with variations in walking speed. Several features were also affected by variations in demographic measures, including age affecting sagittal-plane knee kinematics, body mass index affecting sagittal-plane pelvis and hip kinematics, body mass index affecting frontal-plane knee kinematics and kinetics, and sex affecting frontal-plane kinematics at the pelvis, hip, and knee. These results could aid in the design of future studies, as well as clarify how walking speed, age, sex, and body mass index may act as potential confounders in studies with small populations or in populations with insufficient demographic variations for thorough statistical analyses.
Abstract
The increasing demand for minimal to noninvasive in situ analysis of body fluids, such as sweat, interstitial fluid, and tears, has driven rapid development of electrochemically active ...materials and wearable biosensors. The mechanically soft and deformable nature of these biosensors enables them to efficiently adapt to the geometric nonlinearity of a specific part of the human body. The integration of these biosensors with a fully miniaturized wireless telemetry system enables displaying real-time data in a mobile device and/or reporting to an encrypted server for post analysis. These features are essential for the long-term, unobtrusive monitoring of biochemical activity in ambulatory care settings for improved management of many chronic diseases, such as diabetes, gout, and Parkinson’s disease. Herein, we present the latest innovations of wearable electrochemical sensors tailored for human skin or eyes with a focus on their materials, designs, sensing mechanisms, and clinical implications.
•Ambulance dispatching and relocation decisions highly impact patients’ health.•A mathematical model and a pilot-method heuristic are proposed.•The goal is to provide an efficient response to current ...and future emergencies.•System’s preparedness is considered and relocations to any base are allowed.•The proposed strategy reduces in 2.3 minutes the average extra time per ambulance.
In the Emergency Medical Service (EMS) context, the decision-making process plays a very important role since some decisions highly impact patients’ health. This work focuses on the operational level by solving the dispatching and relocation ambulance problems. Dispatching decisions assign ambulances to emergencies and the relocation problem decides on the base to which available ambulances should be (re)assigned. To improve effectiveness and efficiency in the EMS response, integrated optimization approaches are proposed: a mathematical model and a pilot method heuristic. The aim is to maximize system’s coverage using a time-preparedness measure allowing relocations to any base.
Experiments are performed using EMS data from Lisbon, Portugal, where solving these problems is still a handmade task. The optimization approaches are adapted to compare the proposed strategy with the current Portuguese EMS strategy which dispatches the closest available ambulance for each emergency and relocates ambulances to their home bases. Results highlight the potential of the mathematical model and of the proposed strategy to be applied in real-time contexts since key performance indicators (KPIs) are, in general, better than the ones obtained through the heuristic and the current Portuguese EMS strategy. The heuristic should be used when more emergencies occur in the same time period since a solution can be obtained almost immediately in contrast to the MIP usage.
Powered ankle prostheses have been designed to reduce the energetic burden that individuals with transtibial amputation experience during ambulation. There is an open question regarding how much ...power the prosthesis should provide, and whether approximating biological ankle kinetics is optimal to reduce the metabolic cost of users. We tested 10 individuals with transtibial amputation walking on a treadmill wearing the BiOM powered ankle prosthesis programmed with 6 different power settings (0-100%), including a prosthetist-chosen setting, chosen to approximate biological ankle kinetics. We measured subjects' metabolic cost of transport (COT) and the BiOM's net ankle work during each condition. Across participants, power settings greater than 50% resulted in lower COT than 0% or 25%. The relationship between power setting, COT, and net ankle work varied considerably between subjects, possibly due to individual adaptation and exploitation of the BiOM's reflexive controller. For all subjects, the best tested power setting was higher than the prosthetist-chosen setting, resulting in a statistically significant and meaningful difference in COT between the best tested and prosthetist-chosen power settings. The results of this study demonstrate that individuals with transtibial amputation may benefit from prescribed prosthetic ankle push-off work that exceeds biological norms.
Introduction: Multidisciplinary obesity services at university hospitals usually treat patients with more complex and severe obesity. In addition, patients with Class 3 obesity, in particular, have ...different attitudes regarding the choices of therapy. Methods: This explorative study investigated the effect of patient attitudes towards bariatric surgery on body weight change (primary outcome) and psychological improvement (secondary outcomes: quality of life, depression, anxiety, and eating behaviour) in a 6-month moderate behavioural weight loss (BWL) programme in a university outpatient setting. Results: 297 patients with mostly Class 3 obesity participated in the programme. The patients did not yet have any indications for bariatric surgery. Of the participants, 37% had a positive attitude towards bariatric surgery (POS), whereas 38% had a negative attitude (NEG). The drop-out rate was 8%. NEG participants lost significantly more body weight than the POS participants (intention-to-treat population: 4.5 SD: 6.3 kg versus 0.4 SD: 5.8 kg; p < 0.001). In both subgroups, anxiety, depression, the mental score for quality of life, and eating behaviour improved. Conclusion: A BWL treatment in a clinical setting identified 2 distinct groups with different attitudes towards bariatric surgery that were associated with different body weight change outcomes. These groups may require differently targeted programmes to achieve the best body weight loss results.
Izhodišča: Večino bolnikov z nezapleteno arterijsko hipertenzijo obravnavamo zdravniki družinske medicine. Namen raziskave je bil ugotoviti, kako poteka obravnava bolnikov z arterijsko hipertenzijo v ...timu družinske medicine v Sloveniji ter oceniti urejenost krvnega tlaka.
Metode: V prospektivni opazovalni raziskavi smo v obdobju od 21. 11. 2017 do 28. 3. 2019 šest mesecev spremljali obravnavo dotlej še nezdravljenih bolnikov z esencialno arterijsko hipertenzijo v 158 ambulantah družinske medicine v Sloveniji. Ob koncu spremljanja smo ocenili urejenost krvnega tlaka (KT).
Rezultati: Vključenih je bilo 1.060 bolnikov, katerih povprečna starost je bila 58,6 ± 12,1 let. Med vključenimi bolniki je bilo 579 (55 %) moških in 481 (45 %) žensk. Povprečna vrednost sistoličnega KT ob vstopu je bila 165,2 ± 14,5 mm Hg, diastoličnega pa 96,2 ± 10,0 mm Hg. 751 bolnikov (70,8 %) je imelo pridružene dejavnike tveganja za bolezni srca in ožilja. 408 (38,5 %) bolnikov je imelo ocenjeno srčno-žilno tveganje kot veliko oz. zelo veliko. Antihipertenzivna zdravila so bila uvedena pri 1.046 (98,7 %) bolnikih; pri 418 bolnikih (39,4 %) je bilo uvedeno kombinacijsko zdravljenje dveh ali več učinkovin v prosti ali fiksni kombinaciji. 331 bolnikov (31,6 %) je med spremljanjem opravilo obisk pri diplomirani medicinski sestri.
Raziskavo je zaključilo 929 (87,6 %) bolnikov. Povprečna vrednost sistoličnega KT ob zaključku raziskave je bila 135,4 ± 10,9 mm Hg, diastoličnega pa 81,8 ± 8,0 mm Hg, ciljni KT je dosegalo 63,3 % bolnikov.
Zaključek: Prepoznali smo nekatere priložnosti za izboljšanje vodenja. V prihodnje bo potrebno še okrepiti timsko obravnavo bolnikov ter spodbujati zdravnike k uvajanju kombinacijskega zdravljenja, najbolje v obliki dveh oziroma treh zdravilnih učinkovin v eni tableti.
This paper explores the professionalization project of paramedics, based on an ethnographic study of UK National Health Service (NHS) ambulance personnel. Drawing on concepts derived from ...institutional theory and the sociology of professions, we argue that the project is enacted at two levels, namely a formal, structural and senior level reflecting changing legitimation demands made on NHS practitioners and pursued through institutional entrepreneurship, and an informal, agentic, ‘street level’ enacted by the practitioners themselves via ‘institutional work’. Focusing on this latter, front‐line level, our ethnographic data demonstrate that the overall impact of the senior level professionalization project on the working lives of paramedics has been somewhat muted, mostly because it has had limited power over the organizations that employ paramedics. Given the slow progress of the senior level professionalization project, paramedics at street level continue to enact subtle forms of institutional work which serve to maintain ‘blue‐collar professionalism’ – a form originally identified in Donald Metz's ethnography of ambulance work. Our analysis draws attention to the complex and contested nature of professionalization projects, in that their enactment at senior and street levels can be somewhat misaligned and possibly contradictory.
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