Karen Clarke

Do women with acute myocardial infarction receive the same treatment as men

Abstract Objective : To determine whether women with acute myocardial infarction in the Nottingham health district receive the same therapeutic interventions as their male counterparts. Design : Retrospective study. Setting : University and City Hospitals,20Nottingham. Patients : All patients admitted with a suspected myocardial infarction during 1989 and 1990. Main outcome measures : Route and timing of admission to hospital, ward of admission, treatment, interventions in hospital, and mortality. Results - Women with myocardial infarction took longer to arrive in hospital than men. They were less likely to be admitted to the coronary care unit and20were therefore also less likely to receive thrombolytic treatment. They seemed to have more severe infarcts, with higher Killip classes, and had a slightly higher mortality during admission. They were less likely than men to receive secondary prophylaxis by being discharged taking ß blockers or aspirin. Conclusion : Survival chances both in hospital and after discharge in women with acute myocardial infarction are reduced because they do not have the same opportunity for therapeutic intervention as men.

The anti‐social model of disability

Social theories are usually developed to enable a clearer understanding of a situation or problem. The ‘Social Model’ in various forms is currently the dominant model for researching disability, addressing disability from within a socio‐political framework that draws substantially on a ‘social constructionist’ perspective. This article critiques some of the core sociological assumptions of the Social Model, questioning what ‘work’ this kind of theory does in informing a set of practical concerns around the design of assistive technologies, suggesting an alternative framework of analysis, supported by extensive ethnomethodologically informed ethnographic research

A Dependability Model for Domestic Systems

Technically-based models of dependability such as Laprie’s model suggest that there are attributes that should be reflected in the design of a system. These attributes tend to be attributes of the software or hardware and the models assume that system operators can be treated in the same way as software or hardware components. While this approach may be valid for some control systems with tightly specified operational processes, we argue that it must be extended if it is to be applied to systems where there is significant discretion on the part of the user as to how they will use the system. In particular, for systems in the home, we argue that the notion of dependability should be broadened This paper suggests that through the design of assistive technology (AT) systems for older people we can demonstrate the user should be placed at the centre of the process when considering system dependability.

The Defined Daily Dose as a Tool in Pharmacoeconomics

The application of economic principles and evaluation techniques to the analysis of healthcare problems· looks attractive to every cash-limited healthcare system seeking to improve outcomes while containing costs. While economic studies can never be the sole basis for a given decision, they are influential for healthcare decision makers)l) The purpose of economic analysis is to describe options or alternatives (whether for a medical treatment or broader health programme) and to estimate the costs and outcomes of those interventions.(2) More specifically, where drugs and services are involved, pharrnacoeconomics (a relative newcomer to the analysis of efficiency of healthcare services) identifies, measures and compares the costs (in terms of resources consumed) and consequences of pharmaceutical products,(3) and so has an important role to play in determining the most efficient use of available resources. It is important to continue to develop techniques that might add to the pharmacoeconomic armamentarium. It may be possible to devise new tools,(4) but existing tools should be explored first. Defined daily doses (DDDs) have been around for over 10 years, IS) but are they methodologically sound enough for key healthcare issues in pharmacoeconomics?

The electronic medical record and everyday medical work

The deployment of the electronic medical record (EMR) is widely seen by healthcare policy makers and service managers as a key step in the achievement of more efficient and integrated healthcare services. However, our studies of medical work practices reveal important discrepancies between the presumptions of EMR and the ways in which healthcare professionals actually use and communicate information. These lead us to conclude it may be some time before technologies like the EMR can deliver promised benefits, and will do so only if they are allowed to evolve via user-led design and development processes.

Designing assistive technologies for medication regimes in care settings

This paper presents some early design work of the Care in the Digital Community research project begun under the EPSRC IRC Network project Equator. Gaining a comprehensive understanding of user requirements in care settings poses interesting methodological challenges. This paper details some methodological options for working in the domestic domain and documents the translation of research into design recommendations. We report on the importance of medication issues in a hostel for former psychiatric patients and present an early prototype of a medication manager designed to be sensitive to the particular requirements of the setting.

Dependability and Trust in Organisational and Domestic Computer Systems

Ian Sommerville, Guy Dewsbury, Karen Clarke, Mark Rouncefield Computing Department, Lancaster University. Our economy and national infrastructures are dependent on a range of socio-technical systems and, by and large, these systems can be trusted to provide a dependable service. For example, electricity and telecommunication systems are generally reliable, the bank ATM network can usually deliver cash to authorised customers and automated stock control systems have meant that large stores and supermarkets rarely run out of specific products. In essence, at least in Western societies, the vast majority of people trust the services that are provided through the physical and economic infrastructure. This trust is engendered because, these services almost always meet the expectations of their external users. In order to meet these expectations, complex socio-technical systems have to be put in place by the service providers and these now, universally, rely on computer-based information systems. These information systems are essential elements of the socio-technical systems so both the organisations running these systems and the system users depend on them. The information systems that support the socio-technical systems that run the national and business infrastructure have two important characteristics: 1. They are situated in organisations (banks, telephone companies, electricity generators) that have a history of service provision and that have well-established processes for managing the delivery of these services. External users of organisational systems trust these organisations to use their best endeavours to ensure that their computer systems deliver correct information. Furthermore, it can be assumed that the people in these organisations follow the defined operational processes when it is appropriate to do so and react in a contingent way when they are faced with exceptional situations not covered by these processes. 2. They are essential for the effective provision of organisational services and the people within the organisation who are involved in the process do not have the authority to decide whether or not the automated systems should be used. It can be assumed that the operators have received some training in the use of the software and also that, whatever

Healthcare information giving services: technologies and everyday practicalities

This paper presents findings from observational studies of work practice in two ‘information giving’ services – a poisons information service and a mental health helpline – as a precursor to informing the design of such services. Our work high- lights the interactions that constitute the requesting and giving of information and the role of intermediaries in the delivery of recipient-designed information. We propose a shift of focus from the logic of information in system design to one that encompasses the practicalities of information giving.

Home technology systems

This paper considers the design of technology in domestic, or home, settings. The systems themselves have become increasingly complex and the need for dependable systems correspondingly important. The design problem is concerned less with the creation of new technical artefacts than with their effective configuration and integration. Inadequate understanding of the lived reality of use and user needs is often responsible for lack of dependability. The paper illuminates and highlights some fields for future investigation.

Improving ‘knife to skin time’: process modelling and new technology in medical work:

As healthcare becomes information intensive technology increasingly plays an important role in managing patient care; information gathering and dissemination; and co-ordinating work. One approach to ensuring resources, staff and systems are allocated and used efficiently is process modelling. This paper presents some findings from the Dependability Interdisciplinary Research Collaboration (DIRC) project, on ‘process modelling’ as an aspect of managerial activity and the work involved in both creating and implementing process maps or models. Our ethnographic investigations document some of the problems in developing process maps of medical activity as part of a desire to ‘improve knife to skin time’. We suggest that process maps are not systematic, rational, scientific deductions of the most efficient process. Process maps are locally sensible versions of best practice, and problems may arise where such locally sensible versions are exported throughout an organization to other settings where other relevances may apply.