Steffen Bayer

A systematic review of the benefits of home telecare for frail elderly people and those with long-term conditions

We have conducted a systematic review of home telecare for frail elderly people and for patients with chronic conditions. We searched 17 electronic databases, the reference lists of identified studies, conference proceedings and Websites for studies available in January 2006. We identified summaries of 8666 studies, which were assessed independently for relevance by two reviewers. Randomized controlled trials of any size and observational studies with 80 or more participants were eligible for inclusion if they examined the effects of using telecommunications technology to (a) monitor vital signs or safety and security in the home, or (b) provide information and support. The review included 68 randomized controlled trials (69%) and 30 observational studies with 80 or more participants (31%). Most studies focused on people with diabetes (31%) or heart failure (29%). Almost two-thirds (64%) of the studies originated in the US; more than half (55%) had been published within the previous three years. Based on the evidence reviewed, the most effective telecare interventions appear to be automated vital signs monitoring (for reducing health service use) and telephone follow-up by nurses (for improving clinical indicators and reducing health service use). The cost-effectiveness of these interventions was less certain. There is insufficient evidence about the effects of home safety and security alert systems. It is important to note that just because there is insufficient evidence about some interventions, this does not mean that those interventions have no effect.

Flexible Homes, Flexible Care, Inflexible Organisations? The Role of Telecare in Supporting Independence

‘Telecare’ involves the use of information and communications technologies to provide support for vulnerable individuals living in the community. The UK government wishes to make telecare available in all homes that need it by 2010. This expansion is seen as central to the improvement of older peoples independence and quality of life by enabling them to live at home whenever possible. The paper discusses the range of initiatives now in place to facilitate the introduction of telecare in the UK. It argues that while there is now experience of telecare through pilot and demonstration schemes, moving to mainstream service delivery is far from straightforward. Using a case study of a telecare scheme, along with supplementary data from other schemes, the paper explores the reasons why it may be hard to meet government objectives. These include the organisational and cultural characteristics of local care institutions and the complexity of scheme objectives. It draws conclusions on the challenges in meeting aspirations for mass telecare over the next decade and on the future role of the housing stock in care provision.

Meeting government objectives for telecare in moving from local implementation to mainstream services

The UK government wishes to deploy a mainstream telecare service by 2010. We believe that it will be necessary to overcome the organizational and structural barriers to such an implementation. A better understanding of the effect of telecare across the care system as a whole will also be needed. In the absence of rigorous data from trials and because of the time taken for systemic effects to emerge, the evidence for the benefits of telecare needs to be explored through simulation modelling.

Facilitating stroke care planning through simulation modelling

Stroke is a leading cause of death and long-term severe disability. A major difficulty facing stroke care provision in the UK is the lack of service integration between the many authorities, professionals and stakeholders involved in the process. The objective of this article is to describe a prototype model to support integrative planning for local stroke care services.The model maps the flow of care in the acute and community segments of the care pathway for stroke patients and allows exploring alternatives for care provision. Simulation modelling can help to develop an understanding of the systemic impact of service change and improve the design and targeting of future services.

Innovation and the dynamics of capability accumulation in project–based firms

Summary Project-based firms face particular difficulties in managing innovation. This paper builds on the literature on concepts of project-based firms to develop an approach to innovation management linking work acquisition, execution and learning. The conceptual framework is expressed in diagrammatic form, providing a succinct representation of the complex relationships and a starting point for analysis of the opportunities and challenges facing the management of project-based firms, including those impeding success, in particular the role of time pressures. The analysis helps to elucidate findings from prior in-depth studies of a large number of engineering and design firms. The paper also provides pointers for future research.

Projection of Young-Old and Old-Old with Functional Disability: Does Accounting for the Changing Educational Composition of the Elderly Population Make a Difference?

This study compares projections, up to year 2040, of young-old (aged 60-79) and old-old (aged 80+) with functional disability in Singapore with and without accounting for the changing educational composition of the Singaporean elderly. Two multi-state population models, with and without accounting for educational composition respectively, were developed, parameterized with age-gender-(education)-specific transition probabilities (between active, functional disability and death states) estimated from two waves (2009 and 2011) of a nationally representative survey of community-dwelling Singaporeans aged ≥60 years (N=4,990). Probabilistic sensitivity analysis with the bootstrap method was used to obtain the 95% confidence interval of the transition probabilities. Not accounting for educational composition overestimated the young-old with functional disability by 65 percent and underestimated the old-old by 20 percent in 2040. Accounting for educational composition, the proportion of old-old with functional disability increased from 40.8 percent in 2000 to 64.4 percent by 2040; not accounting for educational composition, the proportion in 2040 was 49.4 percent. Since the health profiles, and hence care needs, of the old-old differ from those of the young-old, health care service utilization and expenditure and the demand for formal and informal caregiving will be affected, impacting health and long-term care policy.

Perceptions and experiences of financial incentives: a qualitative study of dialysis care in England.

Objective The objective of the study was to understand the extent to which financial incentives such as Payment by Results and other payment mechanisms motivate kidney centres in England to change their practices. Design The study followed a qualitative design. Data collection involved 32 in-depth semistructured interviews with healthcare professionals and managers, focusing on their subjective experience of payment structures. Participants Participants were kidney healthcare professionals, clinical directors, kidney centre managers and finance managers. Healthcare commissioners from different parts of England were also interviewed. Setting Participants worked at five kidney centres from across England. The selection was based on the prevalence of home haemodialysis, ranging from low (<3%), medium (5–8%) and high (>8%) prevalence, with at least one centre in each one of these categories at the time of selection. Results While the tariff for home haemodialysis is not a clear incentive for its adoption due to uncertainty about operational costs, Commissioning for Quality and Innovation (CQUIN) targets and the Best Practice Tariff for vascular access were seen by our case study centres as a motivator to change practices. Conclusions The impact of financial incentives designed at a policy level is influenced by the understanding of cost and benefits at the local operational level. In a situation where costs are unclear, incentives which are based on the improvement of profit margins have a smaller impact than incentives which provide an additional direct payment, even if this extra financial support is relatively small.

Future requirements for and supply of ophthalmologists for an aging population in Singapore

BackgroundSingapore’s population, as that of many other countries, is aging; this is likely to lead to an increase in eye diseases and the demand for eye care. Since ophthalmologist training is long and expensive, early planning is essential. This paper forecasts workforce and training requirements for Singapore up to the year 2040 under several plausible future scenarios.MethodsThe Singapore Eye Care Workforce Model was created as a continuous time compartment model with explicit workforce stocks using system dynamics. The model has three modules: prevalence of eye disease, demand, and workforce requirements. The model is used to simulate the prevalence of eye diseases, patient visits, and workforce requirements for the public sector under different scenarios in order to determine training requirements.ResultsFour scenarios were constructed. Under the baseline business-as-usual scenario, the required number of ophthalmologists is projected to increase by 117% from 2015 to 2040.Under the current policy scenario (assuming an increase of service uptake due to increased awareness, availability, and accessibility of eye care services), the increase will be 175%, while under the new model of care scenario (considering the additional effect of providing some services by non-ophthalmologists) the increase will only be 150%. The moderated workload scenario (assuming in addition a reduction of the clinical workload) projects an increase in the required number of ophthalmologists of 192% by 2040.Considering the uncertainties in the projected demand for eye care services, under the business-as-usual scenario, a residency intake of 8–22 residents per year is required, 17–21 under the current policy scenario, 14–18 under the new model of care scenario, and, under the moderated workload scenario, an intake of 18–23 residents per year is required.ConclusionsThe results show that under all scenarios considered, Singapore’s aging and growing population will result in an almost doubling of the number of Singaporeans with eye conditions, a significant increase in public sector eye care demand and, consequently, a greater requirement for ophthalmologists.

Teleconsultations reduce greenhouse gas emissions

Objectives Health services contribute significantly to greenhouse gas emissions. New models of delivering care closer to patients have the potential to reduce travelling and associated emissions. We aimed to compare the emissions of patients attending a teleconsultation – an outpatient appointment using video-conferencing equipment – with those of patients attending a face-to-face appointment. Methods We estimated the total distances travelled and the direct and indirect greenhouse gas emissions for 20,824 teleconsultations performed between 2004 and 2011 in Alentejo, a Portuguese region. These were compared to the distances and emissions that would have resulted if teleconsultations were not available and patients had to attend face-to-face outpatient appointments. Estimates were calculated using survey data on mode of transport, and national aggregate data for car engine size and fuel. A sensitivity analysis using the lower and upper quartiles for survey distances was performed. Results Teleconsultations led to reductions in distances and emissions of 95%. 2,313,819 km of travelling and 455 tonnes of greenhouse gas emissions were avoided (22 kg of carbon dioxide equivalent per patient). The incorporation of modes of transport and car engine size and fuel in the analysis led to emission estimates which were 12% smaller than those assuming all patients used an average car. Conclusions The availability of remote care services can significantly reduce road travel and associated emissions. At a time when many countries are committed to reducing their carbon footprint, it is desirable to explore how these reductions could be incorporated into technology assessments and economic evaluations.

Towards a DNA Barcode Reference Database for Spiders and Harvestmen of Germany

As part of the German Barcode of Life campaign, over 3500 arachnid specimens have been collected and analyzed: ca. 3300 Araneae and 200 Opiliones, belonging to almost 600 species (median: 4 individuals/species). This covers about 60% of the spider fauna and more than 70% of the harvestmen fauna recorded for Germany. The overwhelming majority of species could be readily identified through DNA barcoding: median distances between closest species lay around 9% in spiders and 13% in harvestmen, while in 95% of the cases, intraspecific distances were below 2.5% and 8% respectively, with intraspecific medians at 0.3% and 0.2%. However, almost 20 spider species, most notably in the family Lycosidae, could not be separated through DNA barcoding (although many of them present discrete morphological differences). Conspicuously high interspecific distances were found in even more cases, hinting at cryptic species in some instances. A new program is presented: DiStats calculates the statistics needed to meet DNA barcode release criteria. Furthermore, new generic COI primers useful for a wide range of taxa (also other than arachnids) are introduced.