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Road network performance (RNP) is a key element for urban sustainability as it has a significant impact on economy, environment, and society. Poor RNP can lead to traffic congestion, which can lead to higher transportation costs, more pollution and health issues regarding the urban population. To evaluate the effects of the RNP, the involved stakeholders need a real-world data base to work with. This paper develops a data collection approach to enable location-based RNP analysis using publicly available traffic information. Therefore, we use reachable range requests implemented by navigation service providers to retrieve travel times, travel speeds, and traffic conditions. To demonstrate the practicability of the proposed methodology, a comparison of four German cities is made, considering the network characteristics with respect to detours, infrastructure, and traffic congestion. The results are combined with cost rates to compare the economical dimension of sustainability of the chosen cities. Our results show that digitization eases the assessment of traffic data and that a combination of several indicators must be considered depending on the relevant sustainability dimension decisions are made from.
Virtual teams that use integrated communication platforms are ubiquitous in cross-border collaboration. This study explores the use of communication media and team outcomes—both social outcomes and task accomplishment—in multilingual virtual teams. Based on surveys from 96 virtual teams (with 578 team members), the research shows that the more time spent in rich communication channels, such as online conferences, increased inclusion and satisfaction, whereas the more time spent with written communication that is lower in richness increased the level of task accomplishment. Team members with lower language proficiency felt less included in all collaboration channels, whereas team members with higher language proficiency felt less satisfied with lean collaboration. In addition, limited language proficiency speakers were significantly less likely to view rich tools as helpful for their teams to reach a mutual decision. Our data support media richness theory in its original context for native and highly proficient English speakers. Our study extends the scope of the theory by applying it to the new context of team members with limited language proficiency. Management should implement a collaboration infrastructure consisting of communication platforms that integrate a variety of media to account for different tasks and different communication needs.
Each year, the Virtual Business Professional (VBP) program brings together professors and students from across the globe to engage in client projects. The VBP program of 2020 occurred from the beginning of March through the middle of April. In this article, we share how the COVID-19 pandemic affected VBP participants and their teams. We present post-project survey results (completed by 440 of 530 participants for an 83 percent response rate), professor comments, and student comments to demonstrate how VBP participants overcame many of the pandemic disruptions to work effectively in virtual teams, develop compassion and empathy for one another, and foster more global mindsets.
This study examines the impact of perceived foreign language proficiency on hybrid culture building in multicultural teams. Hybrid culture includes a mutually shared set of norms, communication patterns, problem-solving approaches, and synergistic task coordination that result from the diverse cultural backgrounds of the team members. Language is the main vehicle for communication and plays a major role in social interaction and therefore hybrid culture building. We argue that the level of perceived language proficiency of multicultural team members influences hybrid culture building; consequently, adequate language skills lead not only to an efficient task solution but are also an important factor in creating interpersonal relationships and building a shared culture. Our empirical analysis supports the positive influence of language proficiency in hybrid teams; however, foreign language proficiency is more influential on cognitively oriented areas of multicultural teamwork than on affective ones.
Oncologic patients are regarded as the population most at risk of developing a severe course of COVID-19 due to the fact that malignant diseases and chemotherapy often weaken the immune system. In the face of the ongoing SARS-CoV-2 pandemic, how particular patients deal with this infection remains an important question. In the period between the 15 and 26 April 2020, a total of 1227 patients were tested in one of seven oncologic outpatient clinics for SARS-CoV-2, regardless of symptoms, employing RT-qPCR. Of 1227 patients, 78 (6.4%) were tested positive of SARS-CoV-2. Only one of the patients who tested positive developed a severe form of COVID-19 with pneumonia (CURB-65 score of 2), and two patients showed mild symptoms. Fourteen of 75 asymptomatic but positively tested patients received chemotherapy or chemo-immunotherapy according to their regular therapy algorithm (±4 weeks of SARS-CoV-2 test), and 48 of 78 (61.5%) positive-tested patients received glucocorticoids as co-medication. None of the asymptomatic infected patients showed unexpected complications due to the SARS-CoV-2 infection during the cancer treatment. These data clearly contrast the view that patients with an oncologic disease are particularly vulnerable to SARS-CoV-2 and suggest that compromising therapies could be continued or started despite the ongoing pandemic. Moreover the relatively low appearance of symptoms due to COVID-19 among patients on chemotherapy and other immunosuppressive co-medication like glucocorticoids indicate that suppressing the response capacity of the immune system reduces disease severity.
Objective: Functioning is an important outcome for rheumatoid arthritis (RA) management. Heterogeneity of respective patient-reported outcome measures (PROMs) challenges direct comparisons between their results. This study aimed to standardize reporting of such PROMs measuring functioning in RA to facilitate comparability.
Methods: Common Item Non-Equivalent Groups Design (NEAT) with the Health Assessment Questionnaire (HAQ) as a common scale across data sets from various countries (incl. UK, Turkey and Germany) to establish a common metric. Other PROMs included are the Physical Function items of the Multidimensional Health Assessment Questionnaire (MDHAQ), Disabilities of Arm, Shoulder and Hand (DASH), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), World Health Organization Disability Assessment Schedule Version 2.0 (WHODAS 2.0), and four short forms (20, 10, 6, and 4 physical function items) from the Patient-Reported Outcomes Measurement Information System (PROMIS). As the HAQ includes mobility, self-care and domestic life items, this study focuses on these three domains. PROMs were described using Standard Error of Measurement (SEM) and Smallest Detectable Difference (SDD). Rasch Measurement model was used to create the common metric.
Results: Range of SEM is 0.2 (MDHAQ) to 7.4 (SF36-PF). SDD revealed a range from 9.7 % (WOMAC-RAT) to 33.5 % (WHODAS-PF). PROMs co-calibration revealed fit to the Rasch measurement model. A transformation table was developed to allow exchange between PROMs scores.
Discussion: Scores between the Daily Activity PROMs commonly used in RA can now be compared. Factors such as SEM and SDD help determine choice of PROM in clinical practice and research.
Providing a subset of previously studied information as a retrieval cue can impair memory for the remaining information. Previous work with adults has shown that such part-list cuing impairment (PLCI) can be transient or lasting, depending on study condition. Here, we investigated the persistence of PLCI in children. Three age groups (7- and 8-year-olds, 9- and 10-year-olds, and 12- to 14-year-olds) learned a list of items, either through a single study trial (1-study condition) or through two study-test cycles (2-study-test condition). Subsequently, two recall tests were administered, with part-list cues being provided in the first (critical) test but not in the second (final) test. Of primary interest was whether the detrimental effect of part-list cuing induced in the critical test would persist to the uncued final test. In 12- to 14-year-olds, we found an adult-like pattern of results, with lasting impairment in the 1-study condition but transient impairment in the 2-study-test condition. In contrast, in the two younger age groups, we found PLCI to be lasting in both study conditions, suggesting age differences in the persistence of PLCI. The results are discussed in light of a recently proposed two-mechanism account of PLCI that attributes lasting impairment to retrieval inhibition and transient impairment to strategy disruption. Following this account, the results suggest that whereas 12- to 14-year-olds’ PLCI was caused by (lasting) retrieval inhibition in the 1-study condition and by (transient) strategy disruption in the 2-study-test condition, 7- and 8-year-olds’ and 9- and 10-year-olds’ PLCI was caused by (lasting) retrieval inhibition in both study conditions.
Background
Vertigo, dizziness and balance disorders (VDB) are among the most relevant contributors to the burden of disability among older adults living in the community and associated with immobility, limitations of activities of daily living and decreased participation. The aim of this study was to identify the quality of evidence of physical therapy interventions that address mobility and participation in older patients with VDB and to characterize the used primary and secondary outcomes.
Methods
A systematic search via MEDLINE (PubMed), Cochrane Library, CINAHL, PEDro, forward citation tracing and hand search was conducted initially in 11/2017 and updated in 7/2019. We included individual and cluster-randomized controlled trials and trials with quasi-experimental design, published between 2007 and 2017/2019 and including individuals ≥65 years with VDB. Physical therapy and related interventions were reviewed with no restrictions to outcome measurement. Screening of titles, abstracts and full texts, data extraction and critical appraisal was conducted by two independent researchers. The included studies were heterogeneous in terms of interventions and outcome measures. Therefore, a narrative synthesis was conducted.
Results
A total of 20 randomized and 2 non-randomized controlled trials with 1876 patients met the inclusion criteria. The included studies were heterogeneous in terms of complexity of interventions, outcome measures and methodological quality. Vestibular rehabilitation (VR) was examined in twelve studies, computer-assisted VR (CAVR) in five, Tai Chi as VR (TCVR) in three, canal repositioning manoeuvres (CRM) in one and manual therapy (MT) in one study. Mixed effects were found regarding body structure/function and activities/participation. Quality of life and/or falls were assessed, with no differences between groups. VR is with moderate quality of evidence superior to usual care to improve balance, mobility and symptoms.
Conclusion
To treat older individuals with VDB, VR in any variation and in addition to CRMs seems to be effective. High-quality randomized trials need to be conducted to inform clinical decision making.
Trial registration
PROSPERO 2017 CRD42017080291.
Faults in Heating, Ventilation and Air Conditioning (HVAC) systems affect the energy efficiency of buildings. To date, there rarely exist methods to detect and diagnose faults during the operation of buildings that are both cost-effective and sufficient accurate. This study presents a method that uses artificial intelligence to automate the detection of faults in HVAC systems. The automated fault detection is based on a residual analysis of the predicted total heating power and the actual total heating power using an algorithm that aims to find an optimal decision rule for the determination of faults. The data for this study was provided by a detailed simulation of a residential case study house. A machine learning model and an ARX model predict the building operation. The model for fault detection is trained on a fault-free data set and then tested with a faulty operation. The algorithm for an optimal decision rule uses various statistical tests of residual properties such as the Sign Test, the Turning Point Test, the Box-Pierce Test and the Bartels-Rank Test. The results show that it is possible to predict faults for both known faults and unknown faults. The challenge is to find the optimal algorithm to determine the best decision rules. In the outlook of this study, further methods are presented that aim to solve this challenge.
The objective of this study was to catalogue items from instruments used to measure functioning, disability, and contextual factors in patients with low back pain (LBP) treated with manual medicine (manipulation and mobilization) according to the International Classification of Functioning, Disability and Health (ICF). This catalogue will be used to inform the development of an ICF-based assessment schedule for LBP patients treated with manual medicine. In this scoping review we systematically searched MEDLINE, Embase, PsycINFO and CINAHL. We identified instruments (questionnaires, clinical tests, single questions) used to measure functioning, disability and contextual factors, extracted the relevant items and then linked these items to the ICF. We included 95 articles and identified 1510 meaningful concepts. All but 70 items were linked to the ICF. Of the concepts linked to the ICF, body functions accounted for 34.7%, body structures accounted for 0%, activities and participation accounted for 41%, environmental factors accounted for 3.6%, and personal factors accounted for 16%. Most items used to measure functioning and disability in LBP patient treated with manual medicine focus on body functions, and activities and participation. The lack of measures that address environmental factors warrants further investigation.
Objective: Functioning is an important outcome for rheumatoid arthritis (RA) management. Heterogeneity of respective patient-reported outcome measures (PROMs) challenges direct comparisons between their results. This study aimed to standardize reporting of such PROMs measuring functioning in RA to facilitate comparability.
Methods: Common Item Non-Equivalent Groups Design (NEAT) with the Health Assessment Questionnaire (HAQ) as a common scale across data sets from various countries (incl. UK, Turkey and Germany) to establish a common metric. Other PROMs included are the Physical Function items of the Multidimensional Health Assessment Questionnaire (MDHAQ), Disabilities of Arm, Shoulder and Hand (DASH), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), World Health Organization Disability Assessment Schedule Version 2.0 (WHODAS 2.0), and four short forms (20, 10, 6, and 4 physical function items) from the Patient-Reported Outcomes Measurement Information System (PROMIS). As the HAQ includes mobility, self-care and domestic life items, this study focuses on these three domains. PROMs were described using Standard Error of Measurement (SEM) and Smallest Detectable Difference (SDD). Rasch Measurement model was used to create the common metric.
Results: Range of SEM is 0.2 (MDHAQ) to 7.4 (SF36-PF). SDD revealed a range from 9.7 % (WOMAC-RAT) to 33.5 % (WHODAS-PF). PROMs co-calibration revealed fit to the Rasch measurement model. A transformation table was developed to allow exchange between PROMs scores.
Discussion: Scores between the Daily Activity PROMs commonly used in RA can now be compared. Factors such as SEM and SDD help determine choice of PROM in clinical practice and research.
Keywords: Common metric; DASH; Disability and Health; HAQ; International Classification of Functioning; Multidimensional HAQ; PROMIS-SF; Rasch measurement model; Scale banking; WHODAS 2.0; WOMAC.
Driving forest machines on wet soils causes irreversible soil compaction, often associated with intensive rut formation and inaccessibility of wheeled forest machines for future forest operations. The German forestry equipment manufacturer FHS, Forsttechnik Handel & Service GmbH, engineered a forwarder, the Trac 81/11, equipped with conventional, well-proved bogie-axles embraced by a closed rubber track. At the center of the bogie-axle, four additional supportive rollers are placed to increase the load-carrying section between the tires of the bogie-axle. The study aimed to characterize the principle concept and the trafficability of the forwarder by analyzing the footprint area, the contact pressure, the rut formation on forest sites and the slippage during driving. Therefore, the effective contact area was measured on steel plates and rut formation was analyzed on a case study basis. Results showed that the supportive rollers increase the contact surface area by about 1/3. By this, a decrease of peak loads below the wheels and a more homogenous load distribution were observed. However, the contact surface area is still clearly divided into three parts; the area between the supportive rollers and the wheels does not take any load. Results of the rut formation were diverse: After 20 passes with 26,700 kg total mass, rut depth varied between 12.6 and 212.5 mm. Overall, the new undercarriage concept of FHS demonstrated a generally positive performance. The engineered forwarder contributes to reduce the environmental impact associated with log extraction.
Introduction: In Germany, all new, innovative medicines are subject to an early benefit assessment by the German Federal Joint Committee with subsequent price negotiation and optional arbitration. The purpose of this study was to identify drivers of negotiated (including arbitrated) prices of new, non-orphan innovative medicines in Germany.
Methods: The analysis considered all non-orphan drugs that underwent a benefit appraisal between January 2011 and June 2016, and displayed a reimbursement price in the German Drug Directory (Lauer-Taxe®) in November 2017. Negotiated annual treatment costs were analyzed with respect to 11 explanatory variables in regression models.
Results: The total sample included 106 non-orphan drugs. The analysis showed a significant and positive association of log-transformed negotiated annual treatment cost of new medicines with log-transformed annual treatment cost of its comparator(s), extent of added benefit, and log-transformed size of the target population. Analyzing the effects of specific endpoints instead of the overall added benefit revealed that the single endpoint with the largest impact on price is adverse events (AEs). Surprisingly, an increase in AEs significantly increased the price. Various subgroup and sensitivity analyses demonstrated the robustness of the results. The adjusted R squared for all models was above 80%.
Conclusions: The analysis was able to confirm that variables whose consideration is mandated by law are, in fact, the key drivers of negotiated prices. Somewhat puzzling, the analysis also found an increase in AEs to move prices significantly upward.
A DDR3 SDRAM test setup implemented on the Griffin III test system from HILEVEL Technologies is used to analyse the row hammer bug. Row hammer pattern experiments are compared to standard retention tests for different manufacturing technologies. The row hammer effect is depending on the number of stress activation cycles. The analysis is extended to an avoidance scheme with refreshes similar to the Target Row Refresh scheme for the DDR4 SDRAM technology.
Plastic waste is one of the biggest growing factors contributing to environmental pollution. So far there has been no established method to detect and identify plastics in environmental matrices. Thus, a method based on their characteristic fluorescence behavior is used to investigate whether plastics can be detected and identified in tap water under laboratory conditions. The experiments show that the identification of plastics as a function of water depth is possible. As the identification becomes more difficult with higher water depths, investigations with a highly sensitive imaging method were carried out to obtain an areal integration of the fluorescent light and thus better results.
Hintergrund: Die COVID-19-Pandemie ist eine Ausnahmesituation ohne Präzedenz und erforderte zahlreiche Ad-hoc-Anpassungen in den Strukturen und Prozessen der akutstationären Versorgung.
Ziel: Ziel war es zu untersuchen, wie aus Sicht von Führungspersonen und Hygienefachkräften in der Pflege die stationäre Akutversorgung durch die Pandemiesituation beeinflusst wurde und welche Implikationen sich daraus für die Zukunft ergeben.
Methoden: Qualitative Studie bestehend aus semistrukturierten Interviews mit fünf Verantwortlichen des leitenden Pflegemanagements und drei Hygienefachkräften in vier Krankenhäusern in Deutschland. Die Interviews wurden mittels qualitativer Inhaltsanalyse ausgewertet.
Ergebnisse: Die Befragten beschrieben den auf die prioritäre Versorgung von COVID-19-Fällen hin umstrukturierten Klinikalltag. Herausforderungen waren Unsicherheit und Angst bei den Mitarbeiter_innen, relative Ressourcenknappheit von Material und Personal und die schnelle Umsetzung neuer Anforderungen an die Versorgungleistung. Dem wurde durch gezielte Kommunikation und Information, massive Anstrengungen zur Sicherung der Ressourcen und koordinierte Steuerung aller Prozesse durch bereichsübergreifende, interprofessionelle Task Forces begegnet.
Schlussfolgerungen: Die in der COVID-19-Pandemie vorgenommenen Anpassungen zeigen Entwicklungspotenziale für die zukünftige Routineversorgung auf, z. B. könnten neue Arbeits- und Skill Mix-Modelle aufgegriffen werden. Für die Konkretisierung praktischer Implikationen sind vertiefende Analysen der Daten mit zeitlichem Abstand erforderlich.
Objective: Many different assessment tools are used to assess functioning in rehabilitation; this limits the comparability and aggregation of respective data. The aim of this study was to outline the development of an International Classification of Functioning, Disability and Health (ICF)-based interval-scaled common metric for 2 assessment tools assessing activities of daily living: the Functional Independence Measure (FIMTM) and the Extended Barthel Index (EBI), used in Swiss national rehabilitation quality reports.
Methods: The conceptual equivalence of the 2 tools was assessed through their linking to the ICF. The Rasch measurement model was then applied to create a common metric including FIMTM and EBI.
Subjects: Secondary analysis of a sample of 265 neurological patients from 5 Swiss clinics.
Results: ICF linking found conceptual coherency of the tools. An interval-scaled common metric, including FIMTM and EBI, could be established, given fit to the Rasch model in the related analyses.
Conclusion: The ICF-based and interval-scaled common metric enables comparison of patients and clinics functioning outcomes when different activities of daily living tools are used. The common metric can be included in a Standardized Assessment and Reporting System for functioning information in order to enable data aggregation and comparability.
Keywords: Barthel Index; Functional Independence Measure; Rasch Measurement Model; activities of daily living; outcome assessment (healthcare); psychometrics; quality in healthcare; rehabilitation.
Aquifers are typically perceived as rather stable habitats, characterized by low biogeochemical and microbial community dynamics. Upon contamination, aquifers shift to a perturbed ecological status, in which specialized populations of contaminant degraders establish and mediate aquifer restoration. However, the ecological controls of such degrader populations, and possible feedbacks between hydraulic and microbial habitat components, remain poorly understood. Here, we provide evidence of such couplings, via 4 years of annual sampling of groundwater and sediments across a high-resolution depth-transect of a hydrocarbon plume. Specialized anaerobic degrader populations are known to be established at the reactive fringes of the plume. Here, we show that fluctuations of the groundwater table were paralleled by pronounced dynamics of biogeochemical processes, pollutant degradation, and plume microbiota. Importantly, a switching in maximal relative abundance between dominant degrader populations within the Desulfobulbaceae and Desulfosporosinus spp. was observed after hydraulic dynamics. Thus, functional redundancy amongst anaerobic hydrocarbon degraders could have been relevant in sustaining biodegradation processes after hydraulic fluctuations. These findings contribute to an improved ecological perspective of contaminant plumes as a dynamic microbial habitat, with implications for both monitoring and remediation strategies in situ.
Implementation of robotic devices in nursing care. Barriers and facilitators: an integrative review
(2020)
Background: Robots in healthcare are gaining increasing attention; however, their implementation is challenging due to the complexity of both interventions themselves and the contexts in which they are implemented. The objective of this integrative review is to identify barriers to and facilitators of the implementation of robotic systems in nursing.
Methods: Articles published from 2002 to 2019 reporting on projects to implement robotic devices in nursing care were searched on Medline (via PubMed), CINAHL and databases on funded research projects (Community Research and Development Information Services and Technische Informationsbibliothek) and in journals for robotic research in November 2017 and July 2019 for an update. No restrictions regarding study designs were imposed. All included articles underwent quality assessments with design-specific critical appraisal tools. Barriers to and facilitators of implementation were classified using the Context and Implementation of Complex Interventions framework.
Results: After removing all duplicates, the search revealed 11 204 studies, of which 17 met the inclusion criteria and were included in the synthesis. The majority of the studies dealt with the implementation of robots designed to support individuals, either living at home or in nursing homes (n=11). The studies were conducted in Europe, the USA and New Zealand and were carried out in nursing homes, individual living environments, hospital units and laboratories. The quality of reporting and quality of evidence were low in most studies. The most frequently reported barriers were in socioeconomic and ethical domains and were within the implementation outcomes domain. The most frequently reported facilitators were related to the sociocultural context, implementation process and implementation strategies.
Discussion: This review identified barriers to and facilitators of the implementation of robotic devices in nursing within different dimensions. The results serve as a basis for the development of suitable implementation strategies to reduce potential barriers and promote the integration of elements to facilitate implementation.
PROSPERO registration number: CRD42018073486.
Abstract
Objectives: To develop a common reference metric of functioning, incorporating generic and health condition-specific disability instruments, and to test whether this reference metric is invariant across 2 health conditions.
Design: Psychometric study using secondary data analysis. Firstly, the International Classification of Functioning, Disability and Health (ICF) Linking Rules were used to examine the concept equivalence between the World Health Organization Disability Assessment Schedule (WHODAS 2.0), Health Assessment Questionnaire (HAQ), and Functional Independence Measure (FIMTM). Secondly, a scale-bank was developed using a reference metric approach to test-equating, based on the Rasch measurement model.
Participants: Secondary analysis was performed on data from 487 people; 61.4% with rheumatoid arthritis and 38.6% with stroke.
Results: Three sub-domains of the WHODAS 2.0 and all items of the HAQ and FIMTM motor mapped on to the ICF chapters d4 Mobility, d5 Self-care and d6 Domestic life. Test-equating of these scales resulted in good model fit, indicating that a scale bank and associated reference metric across these 3 instruments could be created.
Conclusion: This study provides a transformation table to enable direct comparisons among instruments measuring physical functioning commonly used in rheumatoid arthritis (HAQ) and stroke (FIMTM motor scale), as well as in people with disability in general (WHODAS 2.0).
Keywords: FIM; Functional Independence Measure; HAQ; Health Assessment Questionnaire; WHODAS 2.0; World Health Organization Disability Assessment Schedule; outcome assessment; rheumatoid arthritis; stroke; psychometrics.
Background
Joint contractures in frail older people are associated with serious restrictions in participation. We developed the Participation Enabling CAre in Nursing (PECAN) intervention, a complex intervention to enable nurses to promote participation in nursing home residents with joint contractures. The aim of this study was to examine the feasibility of the implementation strategy and to identify enablers and barriers for a successful implementation.
Methods
The implementation of PECAN was investigated in a 6-month pilot cluster-randomised controlled trial (c-RCT). As a key component of the implementation strategy, nominated nurses were trained as facilitators in a one-day workshop and supported by peer-mentoring (visit, telephone counselling). A mixed-methods approach was conducted in conjunction with the pilot trial and guided by a framework for process evaluations of c-RCTs. Data were collected using standardised questionnaires (nursing staff), documentation forms, problem-centred qualitative interviews (facilitators, therapists, social workers, relatives, peer-mentors), and a group discussion (facilitators). A set of predefined criteria on the nursing home level was examined. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed using directed content analysis.
Results
Seven nursing homes (n = 4 intervention groups, n = 3 control groups) in two regions of Germany took part in the study. Facilitators responded well to the qualification measures (workshop participation: 14/14; workshop rating: “good”; peer-mentor visit participation: 10/14). The usage of peer-mentoring via telephone varied (one to seven contacts per nursing home). Our implementation strategy was not successful in connection with supplying the intervention to all the nurses. The clear commitment of the entire nursing home and the respect for the expertise of different healthcare professionals were emphasised as enablers, whereas a lack of impact on organisational conditions and routines and a lack of time and staff competence were mentioned as barriers.
Conclusion
The PECAN intervention was delivered as planned to the facilitators but was unable to produce comprehensive changes in the nursing homes and subsequently for the residents. Strategies to systematically include the management and the nursing team from the beginning are needed to support the facilitators during implementation in the main trial.
Trial registration
German clinical trials register, DRKS00010037. Registered 12 February 2016.
Background:
Care pathways (CPWs) are complex interventions that have the potential to reduce treatment errors and optimize patient outcomes by translating evidence into local practice. To design an optimal implementation strategy, potential barriers to and facilitators of implementation must be considered.
The objective of this systematic review is to identify barriers to and facilitators of the implementation of CPWs in primary care (PC).
Methods:
A systematic search via Cochrane Library, CINAHL, and MEDLINE via PubMed supplemented by hand searches and citation tracing was carried out. We considered articles reporting on CPWs targeting patients at least 65 years of age in outpatient settings that were written in the English or German language and were published between 2007 and 2019. We considered (non-)randomized controlled trials, controlled before-after studies, interrupted time series studies (main project reports) as well as associated process evaluation reports of either methodology. Two independent researchers performed the study selection; the data extraction and critical appraisal were duplicated until the point of perfect agreement between the two reviewers. Due to the heterogeneity of the included studies, a narrative synthesis was performed.
Results:
Fourteen studies (seven main project reports and seven process evaluation reports) of the identified 8154 records in the search update were included in the synthesis. The structure and content of the interventions as well as the quality of evidence of the studies varied.
The identified barriers and facilitators were classified using the Context and Implementation of Complex Interventions framework. The identified barriers were inadequate staffing, insufficient education, lack of financial compensation, low motivation and lack of time. Adequate skills and knowledge through training activities for health professionals, good multi-disciplinary communication and individual tailored interventions were identified as facilitators.
Conclusions:
In the implementation of CPWs in PC, a multitude of barriers and facilitators must be considered, and most of them can be modified through the careful design of intervention and implementation strategies. Furthermore, process evaluations must become a standard component of implementing CPWs to enable other projects to build upon previous experience.
Living with spinal cord injury in Mongolia: A qualitative study on perceived environmental barriers
(2020)
Context: Environmental factors play a key role in the lives of individuals with a spinal cord injury (SCI). This study identifies environmental barriers and their impacts on daily lives as perceived by individuals living with SCI in Mongolia.
Design: A qualitative study with semi-structured interviews was conducted. A topic guide for the interviews was structured around the components of the International Classification of Functioning, Disability, and Health.
Setting: Urban and rural areas of Mongolia.
Participants: A purposive sample of 16 persons with traumatic SCI.
Interventions: Not applicable.
Outcome Measures: Not applicable.
Results: Seven categories of environmental barriers were mentioned, such as poor access to the physical environment, absence of wheelchair-friendly transportation, negative societal attitudes, inadequate health and rehabilitation services, lack of access to assistive devices and medicines, limited financial resources for healthcare, and inaccurate categorization of disabilities in laws. These barriers were claimed to have an impact on physical and psychological health, limit activities, and restrict participation in almost all areas of life.
Conclusion: This study contributes to the identification of targets for interventions aimed at improving the lived experience of persons with SCI in a low-resource context. The findings reveal that while the Mongolian government already has laws and policies in place to improve access to the physical environment, transportation, assistive devices and employment, much more has to be done in terms of enforcement. Specialized SCI care and rehabilitation services are highly demanded in Mongolia.
Background
Modification of the home environment, together with rehabilitative interventions, is important for maximizing the level of functioning after an individual with disability undergoes rehabilitation in the hospital.
Objectives
We developed a simple screening scale – the home environment checklist (HEC) – to identify any mismatch between an individual's abilities and their home environment to help clinicians monitor the appropriateness of the home environment to which individuals with disability will be discharged. We also examined the psychometric properties of the HEC.
Methods
The HEC was developed by a multidisciplinary panel of rehabilitation experts using information routinely collected in rehabilitation clinics before discharge. The reliability of the checklist was assessed in 60 individuals undergoing rehabilitation. The inter-rater agreement and internal consistency of the scale were assessed by weighted kappa statistics and Cronbach's alpha, respectively. Rasch analysis was performed with 244 rehabilitation individuals to evaluate the internal construct validity, and the known-groups validity was confirmed by a comparison of the daily activity levels of 30 individuals with disabilities under rehabilitation to the HEC score.
Results
The HEC was developed as a simple, 10-item checklist. The weighted kappa statistics ranged from 0.73 to 0.93, indicating excellent inter-rater reliability. Cronbach's alpha was 0.92, indicating high internal consistency. Rasch analysis with a testlet approach on 3 subscales demonstrated a good fit with the Rasch model (χ2 = 13.2, P = 0.153), and the demonstrated unidimensionality and absence of differential item functioning supported the internal construct validity of the HEC. HEC scores were significantly different (P < .01) among individuals with disability and 3 levels of restrictions in their activities (no limitation, home-bound, and bed-bound), which demonstrates the known-groups validity of the HEC.
Conclusions
The HEC has good reliability and validity, which supports its utility in rehabilitation clinics.
Making one's own choices is an important part of leading a fulfilling life within society. However, people with IDs often face significant obstacles when making their own decisions. Article 12 (Equal recognition before the law) of the United Nations Convention on the Rights of Persons with Disabilities (CRPD) aims to ensure firstly that people with IDs and others with compromised capacity are nonetheless recognized as legal individuals, and secondly that assistance is provided in the form of supported decision‐making in order to exercise this resulting legal capacity. It is unclear whether current national legislation in any country satisfies these requirements in practice. This study utilizes institutional ethnography to reveal how decision‐making is coordinated in practice for people with mild to moderate IDs living in supported residential environments in England, and to determine whether these processes are compliant with Article 12 of the CRPD. Data collection was based on observations, semi‐structured interviews, and documentary analysis, involving 29 participants including people with mild to moderate IDs. The results point to the complexity of supported decision‐making and identify three main categories of decision‐making: spontaneous decisions, mid‐term decisions, and strategic decisions. The data also show that people with mild to moderate IDs are able to exercise their legal capacity through support decision‐making in their everyday life. Immediate and informal supported decision‐making exists in daily practice for people with mild to moderate IDs living in supported residential environments. Although there are structures in place for implementing supported decision‐making, various barriers persist that limit the overall efficacy and consistency of the realization of supported decision‐making, for example, multiple use of mental capacity assessments. Such practices move away from the supported decision‐making model toward substituted decision‐making.
Background
The World Health Organization developed the International Classification of Functioning, Disability, and Health (ICF) in 2001 and has been in the process of implementing it in clinics since then. Current international efforts to implement ICF in rehabilitation clinics include the implementation of ICF Core Sets and the development of simple, intuitive descriptions for the ICF Generic-30 Set (also called Rehabilitation Set). The present study was designed to operationalize these ICF tools for clinical practice in Japan. This work included 1) the development of the Japanese version of the simple, intuitive descriptions for the ICF Generic-30 Set, 2) the development of a rating reference guide for Activity and Participation categories, and 3) the examination of the interrater reliability of rating Activity and Participation categories.
Methods
The Japanese version of the simple, intuitive descriptions for the ICF Generic-30 Set was developed following the process employed to develop the Chinese and Italian versions.
For further operationalization of this ICF Set in practice, a rating reference guide was developed. The development of the rating reference guide involved the following steps: 1) a trial of rating patients by several raters, 2) cognitive interviewing of the raters to analyse the thinking process involved in rating, 3) drafting of the rating reference guide, and 4) review by ICF specialists to confirm consistency with the original ICF concepts.
After the rating reference guide was developed, interrater reliability of the rating with the reference guide was determined. Interrater reliability was examined using weighted kappa statistics with linear weight.
Results
Through the pre-defined process, the Japanese version of the simple, intuitive descriptions for 30 categories of the ICF Generic-30 Set and the rating reference guides for 21 Activity and Participation categories were successfully developed. The weighted kappa statistics ranged from 0.61 to 0.85, showing substantial to excellent agreement of the ratings between raters.
Conclusions
The present study demonstrates that ICF categories can be translated into clinical practice. Collaboration between clinicians and researchers would further enhance the implementation of the ICF in Japan.
Impact of spasticity on functioning in spinal cord injury: an application of graphical modelling
(2020)
Abstract
Objective: To identify the impact of moderate-to-severe spasticity on functioning in people living with spinal cord injury.
Design: Secondary analysis of cross-sectional survey data using graphical modelling.
Subjects: Individuals (n = 1,436) with spinal cord injury aged over 16 years with reported spasticity problems.
Methods: Spasticity and 13 other impairments in body functions were assessed using the spinal cord injury Secondary Conditions Scale. Impairments in mental functions were assessed using the Mental Health subscale of the 36-item Short Form (SF-36). Independence in activities was measured with the Spinal Cord Injury Independence Measure Self-Report. Restrictions in participation were measured with the Utrecht Scale for Evaluation Rehabilitation – Participation.
Results: Fifty-one percent of participants reported moderate-to-severe spasticity. Graphical modelling showed that Chronic pain, Contractures, Tiredness, Doing housework, and Respiratory functions were associated with spasticity and were the top 5 potential targets for interventions to improve the experience of spasticity. The associations and intervention targets were dependent on the level and completeness of the lesion.
Conclusion: This is the first application of graphical modelling in studying spasticity in people living with spinal cord injury. The results can be used as a basis for studies aiming to optimize rehabilitation interventions in people with moderate-to-severe spasticity.
Lay Abstract
Spasticity is one of the most common complications of spinal cord injury. It influences limitations in functioning. Comprehensive evidence on the impact of spasticity on all domains of functioning may be beneficial to optimize rehabilitation interventions aimed at reducing the effects of spasticity. This is the first application of graphical modelling to study and visualize the impact of moderate-to-severe spasticity on functioning in people living with spinal cord injury. The results show that chronic pain, contractures, tiredness, doing housework, and respiratory functions were the functioning domains associated with spasticity. These are therefore the top 5 potential targets for interventions to improve the experience of spasticity. In addition, the level and completeness of lesions should be considered when studying spasticity in relation to all domains of functioning. These results should be used as a basis for studies aiming to optimize rehabilitation interventions in people with moderate-to-severe spasticity.
Objective
To demonstrate the influence and added value of a Standardized Assessment and Reporting System (StARS) upon the reporting of functioning outcomes for national rehabilitation quality reports. A StARS builds upon an ICF-based (International Classification of Functioning, Disability and Health) and interval-scaled common metric.
Design
Comparison of current ordinal-scaled Swiss national rehabilitation outcome reports including an expert-consensus-based transformation scale with StARS-based reports through descriptive statistical methods and content exploration of further development areas of the reports with relevant ICF Core Sets.
Setting
Swiss national public rehabilitation outcome quality reports on the clinic level.
Participants
A total of 29 Swiss rehabilitation clinics provided their quality report datasets including 18 047 patients.
Interventions
Neurological or musculoskeletal rehabilitation.
Main outcome measures
Functional Independence Measure™ or Extended Barthel Index.
Results
Outcomes reported with a StARS tended to be smaller but more precise than in the current ordinal-scaled reports, indicating an overestimation of achieved outcomes in the latter. The comparison of the common metric’s content with ICF Core Sets suggests to include ‘energy and drive functions’ or ‘maintaining a basic body position’ to enhance the content of functioning as an indicator.
Conclusions
A StARS supports the comparison of outcomes assessed with different measures on the same interval-scaled ICF-based common metric. Careful consideration is needed whether an ordinal-scaled or interval-scaled reporting system is applied as the magnitude and precision of reported outcomes is influenced. The StARS’ ICF basis brings an added value by informing further development of functioning as a relevant indicator for national outcome quality reports in rehabilitation.
Study design
Cross-sectional.
Objectives
To examine the associations between activities, body structures and functions, and their relationship with aetiology, age and sex in persons with spinal cord injury (SCI) at discharge from first rehabilitation.
Setting
Swiss SCI Cohort Study (SwiSCI).
Methods
The study included 390 participants with newly acquired SCI and the International Classification of Functioning, Disability and Health (ICF) as conceptual frame of reference. Body structures were represented by injury level and severity; body functions by cardiovascular, pulmonary, skin, bowel and urinary functions and pain; mental functions by anxiety, depression, optimism and self-esteem; and activities by independence in performing activities of daily living (ADL). Using structural equation modelling (SEM), indirect effects of body structures and functions on independence in performing ADL through mental functions were tested for each mental function separately. For each structural model, fit was assessed using several indices and differences in aetiology, age and sex groups were explored.
Results
The structural model about optimism showed good fit in all indices; the models about anxiety, depression and self-esteem showed conflicting fit indices, respectively. Within all models, effects on independence in performing ADL were mainly direct. Pain showed significant (P < 0.05) indirect effects on independence in performing ADL within the depression, optimism and self-esteem models. The model about anxiety showed differences in aetiology groups.
Conclusions
Using an ICF-based modelling approach, this study presents an attempt towards a more comprehensive understanding of functioning in first rehabilitation of persons with SCI, which might be fundamental for rehabilitation planning.
Study design
Case study.
Objective
To present a framework for developing an International Classification of Functioning, Disability and Health (ICF)-based documentation system in spinal cord injury (SCI)-specific rehabilitation.
Setting
Data collection took place at Maharaj Hospital, Thailand. The preparatory studies and analysis were performed at Swiss Paraplegic Research, Switzerland.
Methods
Data collected from interviews and health records of four SCI cases across the continuum of care (acute, post-acute, early and late long term) were linked to ICF categories using established ICF linking rules. The resulting categories were compared with selected ICF sets (ICF Generic-30, ICF core sets for SCI and multiple sclerosis) to determine the extent of coverage. Furthermore, the context of applicable services was described systematically.
Results
Less than half of the ICF categories in the defined ICF sets were covered by clinical assessment tools. Low correspondence was found predominantly in acute and late long-term phase. Least well covered were categories of activities and participations and environmental factors. The correspondence of categories increased when considering the additional ICF categories identified from patient interviews. The description of rehabilitation services provided in each case classified according to the dimensions of service provider, funding, and service delivery.
Conclusions
There is a need to promote the systematic and standardized assessment of functioning among health professionals working in the field of SCI in developing countries. This study describes basic steps toward developing a standardized ICF-based system for assessing and reporting functioning outcomes in SCI rehabilitation and across the continuum of care.
A quantitative physical model for potential induced degradation of the shunting type (PID-s) in solar modules is introduced. Based on a drift and diffusion approach for sodium ions and atoms, it gives insight into the kinetics of degradation and the corresponding regeneration. A simple drift/source term is used to describe the time-dependent flux of Na-ions towards stacking faults at the surface of the solar cell. The assumed transport mechanism for Na+ ions through the SiN-layer uses the modified Stern-Eyring rate theory but our approach can also be adapted to other mechanisms. Several PID-s and regeneration curves of one-cell solar modules at T = 49°C and T = 90°C with 1000V potential difference between modul frame and cell were measured and least-square fits of the in-situ measured parallel resistance Rsh to the model were performed giving very good accordance.
Based on a few measurements, the model can predict PID-s and regeneration characteristics of solar modules under different conditions.
1. Understanding and explaining the structure of communities in response to environmental gradients is a central goal in ecology. Trait‐based approaches are promising but yet rarely applied to understand community dynamics in response to changing environmental conditions.
2. Here, we investigate seasonal succession patterns of functional traits in phytoplankton communities and how nutrient reductions (oligotrophication) alter these patterns. We used phytoplankton data from 40 years of observation from the Rappbode Reservoir (Germany), which underwent a strong shift in trophic conditions, and translated taxonomic composition into functional traits by assigning trait values compiled from the literature.
3. All studied traits (morphological, behavioural and physiological traits) responded to changing environmental conditions and showed consistent, reoccurring seasonal developments. The seasonal succession of phytoplankton communities was shaped by a trade‐off between small‐celled, fast‐growing species that are able to rapidly incorporate existing resources (r ‐strategists) and large‐celled species with more complex and efficient mechanisms to exploit scarce mineral nutrients or acquire previously unexploited nutrient pools (k ‐strategists). In summer, when nutrients were scarce, the k ‐strategy was prevailing (important traits: phosphate affinity, nitrogen fixation, motility and mixotrophy). During the rest of the year, nutrients and turbulence were high and r ‐strategists dominated (important traits: maximum growth rate and light affinity).
4. A comparison between eutrophic and oligotrophic years revealed that the main features of functional trait succession were largely preserved, but intra‐annual fluctuations from spring to summer were stronger during eutrophic years. Nutrient reductions mainly affected functional traits and biomass in spring, while in summer the functional community composition changed little.
5. Synthesis. This study provides for the first time a quantitatively supported functional template for trait‐based succession patterns in lakes under different nutrient conditions. By translating taxonomic composition into trait information, we demonstrate that the quantification of functional characteristics enables ecological interpretation of observed community dynamics and provides not only a testable template but also a powerful tool towards a more mechanistic understanding. The quantification of functional traits further improves the predictability of community shifts in response to changing environmental conditions and thus opens new perspectives for predictive limnology using lake ecosystem models.