Institutional Resource Allocation Research Articles

Priority-setting for hospital funding of high-cost innovative drugs and therapeutics: A qualitative institutional case study.

Rising costs of innovative drugs and therapeutics (D&Ts) have led to resource allocation challenges for healthcare institutions. There is limited evidence to guide priority-setting for institutional funding of high-cost D&Ts. This study sought to identify and elaborate on the substantive principles and procedures that should inform institutional funding decisions for high-cost off-formulary D&Ts through a case study of a quaternary care paediatric hospital. Semi-structured, qualitative interviews, both virtual and in-person, were conducted with institutional stakeholders (i.e. staff clinicians, senior leadership, and pharmacists) (n = 23) and two focus groups at The Hospital for Sick Children in Toronto, Canada. Participants involved in, and impacted by, high-cost off-formulary drug funding decisions were recruited through stratified, purposive sampling. Participants were approached for study involvement between July 27, 2020 and June 7, 2022. Data was analysed through reflexive thematic analysis. Institutional resource allocation for high-cost D&Ts was identified as ethically challenging but critical to sustainable access to novel therapies. Important substantive principles included: 1) clinical evidence of safety and efficacy, 2) economic considerations (direct costs, opportunity costs, value for money), 3) ethical principles (social justice, professional/organizational responsibility), and 4) disease-specific considerations. Multidisciplinary deliberation was identified as an essential procedural component of decision-making. Participants identified tension between innovation and the need for evidence-based decision-making; clinician and institutional responsibilities; and value for money and social justice. Participants emphasized the role of health system-level funding allocation in alleviating the financial and moral burden of decision-making by institutions. This study identifies values and processes to aid in the development and implementation of institutional resource allocation frameworks for high-cost innovative D&Ts.

Mapping Patient Encounters in Breast Cancer Care: An Analysis of 8800 Clinical Encounters Among Patients Undergoing Mastectomy.

Transitions toward value-based systems require a comprehensive definition of the complexity and duration of provider effort required for a given diagnosis. This study modeled the numbers of clinical encounters involved in various treatment pathways among breast cancer patients undergoing mastectomy. Clinical encounters with medical oncologists, radiation oncologists, breast surgeons, or plastic surgeons ≤4 years after diagnosis among all patients undergoing mastectomy from 2017 to 2018 were reviewed. Relative encounter volumes were modeled each 90-day period after diagnosis. A total of 8807 breast cancer-related encounters from 221 patients were analyzed, with mean (SD) encounter volume 39.9 (27.2) encounters per patient. Most encounters occurred in the first year after diagnosis (70.0%), with years 2, 3, and 4 representing 15.8%, 9.1%, and 3.5% of encounters, respectively. Overall stage was associated with encounter volume, with higher encounter volume with increasing stage (stages 0: 27.4 vs I: 28.5 vs II: 48.4 vs III: 61.1 vs IV: 80.8 mean encounters). Body mass index (odds ratio [OR], 0.22), adjuvant radiation (OR, 6.8), and receipt of breast reconstruction (OR, 3.5) were also associated with higher encounter volume (all P 's < 0.01). Duration of encounter volume varied by treatment phases, with medical oncology and plastic surgery sustaining high clinical encounter volume 3 years after diagnosis. Encounter utilization in breast cancer care persists 3 years after index diagnosis and is influenced by overall stage and treatment characteristics, including receipt of breast reconstruction. These results may inform the design of episode durations within value-based models and institutional resource allocation for breast cancer care.

The Value of Pharmacogenetics to Reduce Drug-Related Toxicity in Cancer Patients.

Many anticancer drugs cause adverse drug reactions (ADRs) that negatively impact safety and reduce quality of life. The typical narrow therapeutic range and exposure-response relationships described for anticancer drugs make precision dosing critical to ensure safe and effective drug exposure. Germline mutations in pharmacogenes contribute to inter-patient variability in pharmacokinetics and pharmacodynamics of anticancer drugs. Patients carrying reduced-activity or loss-of-function alleles are at increased risk for ADRs. Pretreatment genotyping offers a proactive approach to identify these high-risk patients, administer an individualized dose, and minimize the risk of ADRs. In the field of oncology, the most well-studied gene-drug pairs for which pharmacogenetic dosing recommendations have been published to improve safety are DPYD-fluoropyrimidines, TPMT/NUDT15-thiopurines, and UGT1A1-irinotecan. Despite the presence of these guidelines, the scientific evidence showing the benefits of pharmacogenetic testing (e.g., improved safety and cost-effectiveness) and the development of efficient multi-gene genotyping panels, routine pretreatment testing for these gene-drug pairs has not been implemented widely in the clinic. Important considerations required for widespread clinical implementation include pharmacogenetic education of physicians, availability or allocation of institutional resources to build an efficient clinical infrastructure, international standardization of guidelines, uniform adoption of guidelines by regulatory agencies leading to genotyping requirements in drug labels, and development of cohesive reimbursement policies for pretreatment genotyping. Without clinical implementation, the potential of pharmacogenetics to improve patient safety remains unfulfilled.

Financing Higher Education in Germany and Europe: Performance-oriented Models of State Funding and Institutional Resource Allocation

Financing Higher Education in Germany and Europe: Performance-oriented Models of State Funding and Institutional Resource Allocation

Analysis of a Novel Inpatient Acute Limb Ischemia Alert System

Acute limb ischemia (ALI) is a surgical emergency that generally develops in the outpatient setting. Hospitalized patients are also at risk for acute limb ischemia, but their presentation may be atypical or altered by medical therapy. Our institution developed an alert system to facilitate the prompt recognition and treatment of ALI that occurs in the inpatient population. We aimed to evaluate the usage of the system after the first 2 years of operation. All ALI alerts from October 2017 to December 2019 were collected from paging records and analyzed for location, timing, and the need for intervention. Alerts undergoing vascular intervention were classified as urgent (within 8 hours) or delayed (after 8 hr). Time and location data were evaluated to determine patterns of usage and true-positive rate of the system. From October 2017 to December 2019, there were 237 ALI alerts obtained from paging records containing time and location information for the alert. More alerts originated from ICUs relative to non-ICU floors (68% vs. 33%, P< 0.001), however a greater proportion of non-ICU floor alerts required intervention compared to ICU alerts (32.0% vs. 5.1%, P < .0001). The highest number of ALI alerts were from the Medical ICU (MRICU) (45.9%) and medical/surgical floors (33.3%), followed by Surgical ICU (20.2%). Alerts were more common within 3 hr of morning and evening nursing shift changes (47.3%, P < 0.001). From the 237 total alerts, the patient was able to be identified retrospectively in 186 cases, and of these 27 resulted in operative interventions (14.5%, positive predictive value), with 11 patients (40.7%) requiring urgent intervention with a median time to intervention of 3.5 hr (range 2.2-4.8), and 16 (59%) alerts undergoing a delayed intervention at a mean of 3 days (range 2-4). A total of 73 (39.2%) alert patients died during their admission, of which 65 (89.0%) were in an ICU, and no deaths were directly related to ALI. The median time to death was 2 days (range 0-95 days), and in 22 cases death occurred <24 hr from time of alert. Our novel hospital-wide ALI alert system demonstrates a 14.5% positive predictive value for ischemia that resulted in an intervention. Alerts were more likely to originate from the ICU setting and during nursing shift changes. Alerts originating from non-ICU floors were 5 times more likely to undergo surgical intervention for ALI. Further analysis is required to assess the effect of this system on patient safety, outcome, and allocation of institutional resources.

A global dataset of inland fisheries expert knowledge

Inland fisheries and their freshwater habitats face intensifying effects from multiple natural and anthropogenic pressures. Fish harvest and biodiversity data remain largely disparate and severely deficient in many areas, which makes assessing and managing inland fisheries difficult. Expert knowledge is increasingly used to improve and inform biological or vulnerability assessments, especially in data-poor areas. Integrating expert knowledge on the distribution, intensity, and relative influence of human activities can guide natural resource management strategies and institutional resource allocation and prioritization. This paper introduces a dataset summarizing the expert-perceived state of inland fisheries at the basin (fishery) level. An electronic survey distributed to professional networks (June-September 2020) captured expert perceptions (n = 536) of threats, successes, and adaptive capacity to fisheries across 93 hydrological basins, 79 countries, and all major freshwater habitat types. This dataset can be used to address research questions with conservation relevance, including: demographic influences on perceptions of threat, adaptive capacities for climate change, external factors driving multi-stressor interactions, and geospatial threat assessments.

Duration of Supplemental Oxygen Requirement and Predictors in Severe COVID-19 Patients in Ethiopia: A Survival Analysis.

With the rising number of new cases of COVID-19, understanding the oxygen requirement of severe patients assists in identifying at risk groups and in making an informed decision on building hospitals capacity in terms of oxygen facility arrangement. Therefore, the study aimed to estimate time to getting off supplemental oxygen therapy and identify predictors among COVID-19 patients admitted to Millennium COVID-19 Care Center in Ethiopia. A prospective observational study was conducted among 244 consecutively admitted COVID-19 patients from July to September, 2020. Kaplan Meier plots, median survival times and Log-rank test were used to describe the data and compare survival distribution between groups. Cox proportional hazard survival model was used to identify determinants of time to getting off supplemental oxygen therapy, where hazard ratio (HR), P-value and 95%CI for HR were used for testing significance and interpretation of results. Median time to getting off supplemental oxygen therapy among the studied population was 6 days (IQR,4.3-20.0). Factors that affect time to getting off supplemental oxygen therapy were age group (AHR=0.52,95%CI=0.32,0.84, p-value=0.008 for ≥70 years) and shortness of breath (AHR=0.71,95%CI=0.52,0.96, p-value=0.026). Average duration of supplemental oxygen therapy requirement among COVID-19 patients was 6 days and being 70 years and older and having shortness of breath were found to be associated with prolonged duration of supplemental oxygen therapy requirement. This result can be used as a guide in planning institutional resource allocation and patient management to provide a well-equipped care to prevent complications and death from the disease.

Perioperative blood transfusions in hip and knee arthroplasty: a retrospective assessment of combined risk factors.

Accurate identification of patients at risk of blood transfusion can reduce complications and improve institutional resource allocation. Probabilistic models are used to detect risk factors and formulate patient blood management strategies. Whether these predictors vary among institutions is unclear. We aimed to identify risk factors among our patients who underwent total hip (THA) or knee (TKA) arthroplasty, and combine these predictors to improve our model. We retrospectively assessed risk factors among 531 adults who underwent elective THA or TKA from January 2016 to November 2018. Using relevant surgical and patient characteristics gathered from electronic medical records, we conducted univariable and multivariable analyses. For our logistic regression model, we measured the impact of independent variables (age, gender, operation type (THA or TKA) and preoperative hemoglobin concentration) on the need for a transfusion. Of the 531 patients, 321 had THA (uncemented) and 210 had TKA. For the selected period, our transfusion rate of 8.1% (10.6% THA and 4.3% TKA) was low. Univariable analyses showed that lower BMI (p < 0.001) was associated with receiving a transfusion. Important factors identified through logistic regression analyses were age (estimated effect of an interquartile range increase in age: OR 3.89 [CI 95% 1.96-7.69]), TKA (OR -0.77 [CI 95% -1.57-0.02]), and preoperative hemoglobin levels (estimated effect of interquartile range increase in hemoglobin: OR 0.47 [CI 95% 0.31-0.71]). Contrary to findings from previous reports, gender was not associated with transfusion. Previously published predictors such as advanced age, low preoperative hemoglobin, and procedure type (THA) were also identified in our analysis. However, gender was not a predictor, and BMI showed the potential to influence risk. We conclude that, when feasible, the determination of site-specific transfusion rates and combined risk factors can assist practitioners to customize care according to the needs of their patient population. Level 3, retrospective cohort study.

Implementation of an Alert System for Acute Limb Ischemia in the Inpatient Setting: Success and Failures

Acute limb ischemia (ALI) most commonly occurs in outpatients, but the inpatient population is also at risk. Many inpatients are not able to elicit the usual symptoms of ALI and may have a delayed diagnosis resulting in poor outcomes. Our institution created a novel alert program to facilitate the rapid diagnosis and treatment of ALI in the inpatient population. All ALI alerts from October 2017 to December 2019 were collected from our institution’s paging records and analyzed for location, timing, and the need for intervention. Alerts undergoing vascular intervention were classified as urgent (within 8 hours from alert) or delayed (after 8 hours from alert). Time and location data were evaluated to determine patterns of usage and the true-positive rate of the system. From October 2017 to December 2019, there were 237 ALI alerts. Operative intervention was required in 27 patients (11.3%, positive predictive value). Of these, 11 patients (41%) required urgent surgery with a mean time to intervention of 4.1 ± 1.8 hours, and 16 (59%) alerts received a delayed intervention at a mean of 5.6 ± 8.0 days. Two patients ultimately required major amputation. More alerts came from intensive care units (ICUs) (67%) compared to non-ICU floors (33%); however, a higher number of non-ICU floor alerts (32%, 19/60) required intervention compared to ICU alerts (5%, 8/150). The highest number of ALI alerts were from the cardiology ICU (24.9%) and medical ICU (21.1%), followed by trauma surgery ICU (12.2%). The 3 hours after morning and evening nursing shift changes accounted for a disproportionate volume of alerts (47.3%). A total of 73 (30.6%) alert patients died during their admission. The median time to death was 2 days (range, 0-95 days), and in 22 cases death occurred less than 24 hours from time of alert. No deaths were directly related to ALI. The ALI alert system at our hospital demonstrates a low positive predictive value, which is consistent with the low threshold for initiating an alert. The increased frequency of alerts after nursing shift changes may indicate a discrepancy in the handoff between staff or decreased staffing ratios in the evenings. Given the large number of false alerts in the ICU setting, a review of the protocol in that context is warranted. Future work will assess the affect this alert system has on patient safety, patient outcomes, the development of alert fatigue, and the allocation of institutional resources.

AGS Position Statement: Resource Allocation Strategies and Age‐Related Considerations in the COVID‐19 Era and Beyond

Coronavirus disease 2019 (COVID‐19) continues to impact older adults disproportionately, from severe illness and hospitalization to increased mortality risk. Concurrently, concerns about potential shortages of healthcare professionals and health supplies to address these needs have focused attention on how resources are ultimately allocated and used. Some strategies misguidedly use age as an arbitrary criterion, inappropriately disfavoring older adults. This statement represents the official policy position of the American Geriatrics Society (AGS). It is intended to inform stakeholders including hospitals, health systems, and policymakers about ethical considerations to consider when developing strategies for allocating scarce resources during an emergency involving older adults. Members of the AGS Ethics Committee collaborated with interprofessional experts in ethics, law, nursing, and medicine (including geriatrics, palliative care, emergency medicine, and pulmonology/critical care) to conduct a structured literature review and examine relevant reports. The resulting recommendations defend a particular view of distributive justice that maximizes relevant clinical factors and deemphasizes or eliminates factors placing arbitrary, disproportionate weight on advanced age. The AGS positions include (1) avoiding age per se as a means for excluding anyone from care; (2) assessing comorbidities and considering the disparate impact of social determinants of health; (3) encouraging decision makers to focus primarily on potential short‐term (not long‐term) outcomes; (4) avoiding ancillary criteria such as “life‐years saved” and “long‐term predicted life expectancy” that might disadvantage older people; (5) forming and staffing triage committees tasked with allocating scarce resources; (6) developing institutional resource allocation strategies that are transparent and applied uniformly; and (7) facilitating appropriate advance care planning. The statement includes recommendations that should be immediately implemented to address resource allocation strategies during COVID‐19, aligning with AGS positions. The statement also includes recommendations for post‐pandemic review. Such review would support revised strategies to ensure that governments and institutions have equitable emergency resource allocation strategies, avoid future discriminatory language and practice, and have appropriate guidance to develop national frameworks for emergent resource allocation decisions. J Am Geriatr Soc 68:1136–1142, 2020.

Collegiate varsity versus club sport: Comparison of student outcomes

ABSTRACTStudent engagement in collegiate sport consists of both student involvement and institutional support, which varies across varsity and club sport programs. Though greater engagement is found in varsity athletics, there is a need to examine whether the additional time and resources invested are maximizing student outcomes. Therefore, the current study sought to compare the perceived social, intellectual, and fitness benefits associated with varsity athletic and club sport participation at a large university in the United States. A multivariate analysis of variance demonstrated significantly greater perceived intellectual and fitness benefits associated with participation in varsity athletics in comparison to club sport, with a non-significant difference in perceived social benefits associated with participation in varsity and club sport programs. These findings support the return on investment in varsity athletics; however, invite reconsideration of institutional resource allocation given the comparable student outcomes associated with club sport.

Time-Driven, Activity-Based Cost Analysis of Radiation Treatment Options for Spinal Metastases.

Several treatment options for spinal metastases exist, including multiple radiation therapy (RT) techniques: three-dimensional (3D) conventional RT (3D-RT), intensity-modulated RT (IMRT), and spine stereotactic radiosurgery (SSRS). Although data exist regarding reimbursement differences across regimens, differences in provider care delivery costs have yet to be evaluated. We quantified institutional costs associated with RT for spinal metastases, using a time-driven activity-based costing model. Comparisons were made between (1) 10-fraction 3D-RT to 30 Gy, (2) 10-fraction IMRT to 30 Gy, (3) 3-fraction SSRS (SSRS-3) to 27 Gy, and (4) single-fraction SSRS (SSRS-1) to 18 Gy. Process maps were developed from consultation through follow-up 30 days post-treatment. Process times were determined through panel interviews, and personnel costs were extracted from institutional salary data. The capacity cost rate was determined for each resource, then multiplied by activity time to calculate costs, which were summed to determine total cost. Full-cycle costs of SSRS-1 were 17% lower and 17% higher compared with IMRT and 3D-RT, respectively. Full-cycle costs for SSRS-3 were only 1% greater than 10-fraction IMRT. Technical costs for IMRT were 50% and 77% more than SSRS-3 and SSRS-1. In contrast, personnel costs were 3% and 28% higher for SSRS-1 than IMRT and 3D-RT, respectively (P < .001). Resource utilization varies significantly among treatment options. By quantifying provider care delivery costs, this analysis supports the institutional resource efficiency of SSRS-1. Incorporating clinical outcomes with such resource and cost data will provide additional insight into the highest value modalities and may inform alternative payment models, operational workflows, and institutional resource allocation.

Development of a specialty pharmacy productivity benchmarking model

Background: Benchmarking in healthcare is used to evaluate productivity on the basis of workflows, policies and performance in hopes of optimizing current practices and improving patient outcomes. Benchmarking has long been used in pharmacy practice, whether in tracking dispensing activities or optimizing clinical workflows. Internal benchmarking allows organizations to examine internal processes to determine allocation of institutional resources. Currently there is no validated model to evaluate productivity in specialty pharmacy workflows. Aims: To develop and validate a specialty pharmacy productivity benchmarking tool. Methods: A timer tool was developed to allow pharmacists to track the time spent performing activities which we identified as key performance indicators. Key performance indicators were identified as: prior authorizations, appeals of coverage denial, financial assistance activities, clinical onboarding activities, care plan activities and clinical assessments. These times were utilized to establish benchmarks for each key performance indicator. Raw activity number was tracked for each branch utilizing data from specialty management software database, Therigy. From these data, benchmark standards were derived, and all branches were evaluated. Results: Benchmarking standardized to the inflammatory diseases branch showed a near 2.5 fold elevation in workload in the hematology and oncology branch. The pulmonary branch showed a decreased workload compared to inflammatory diseases by approximately 35%. Neurology and infectious diseases within the 20% relative workload range of inflammatory diseases and are considered to have an equal productivity level. Conclusions: Results from this study provide a solid foundation for this benchmarking tool. Moving forward with this model the addition of technician metrics and a broader collection of performance indicators across a larger data collection period will be required to more fully develop the model.

Implementation and impact of indigenous health curricula: a systematic review.

The effectiveness of cultural competency education in improving health practitioner proficiency and addressing health inequities for minoritised patient groups is uncertain. Identification of institutional factors that shape or constrain development of indigenous health curricula may provide insights into the impact of these factors on the broader cultural competency curricula. We undertook a systematic review using actor-network theory to inform our interpretive synthesis of studies that reported indigenous health curricula evaluated within medical, nursing and allied health education. We searched the MEDLINE, OVID Nursing, Educational Resources Information Center (ERIC), PsycINFO, EMBASE, Web of Science and PubMed databases to December 2017 using exploded MeSH terms 'indigenous' and 'medical education' and 'educational professional' and 'health professional education'. We included studies involving undergraduate or postgraduate medical, nursing or allied health students or practitioners. Studies were eligible if they documented indigenous health learning outcomes, pedagogical practices and student evaluations. Twenty-three studies were eligible for the review. In an interpretive synthesis informed by actor-network theory, three themes emerged from the data: indigenous health as an emerging curriculum (drivers of institutional change, increasing indigenous capacity and leadership, and addressing deficit discourse); institutional resource allocation to indigenous health curricula (placement within the core curriculum, time allocation, and resources constraining pedagogy), and impact of the curriculum on learners (acceptability of the curriculum, learner knowledge, and learner behaviour). Systemic barriers acting on and within educational networks have limited the developmental capacity of indigenous health curricula, supported and sustained hidden curricula, and led to insufficient institutional investment to support a comprehensive curriculum. Future research in health professional education should explore these political and network intermediaries acting on cultural competence curricula and how they can be overcome to achieve cultural competency learning outcomes.

Structural Analysis of Strategic Variables through MICMAC Use: Case Study

The technique of structural analysis in foresight study from the Faculty of Economic and Administrative Sciences of Instituto Tecnologico Metropolitano- ITM Medellin, Colombia allowed defining the strategic variables that will guide its strengthening in 2020. The aim of this article is to present the conceptual references of the technique and results of the implementation of MICMAC to determine the degree of influence and dependence variables. The methodology used to achieve the objective was the analysis of 55 key variables that were prioritized because of their importance to determine the 15 strategic variables that have to project the future actions taking into account the situation of autonomy, power, conflict and output. In this regard, it is concluded on the relevance of the variables in the power quadrant corresponding to the mobility, physical and technological infrastructure as they are those that enable participation and interaction with other academic, productive and governmental entities; and in the quadrant of link variables of strategic direction, teachers, students, research, partnerships, academic management, financial resources and innovation have the greatest influence on future variables that have an effect on capacity building and the effective allocation of institutional resources. DOI: 10.5901/mjss.2016.v7n4p11

Appropriately Targeting Group Interventions for Academic Success Adopting the Clinical Model and PAR Profiles

Prevalence of academic risk (PAR) group profiles provide data enabling empirically based group-specialized prescriptions for targeted academic success interventions to increase student retention, completion, and graduation rates, while improving allocation of institutional resources. Postsecondary student attrition engenders student debt, shortages of highly trained professionals, and inadequate workforce diversity. Diagnostic PAR profiles, employing a proactive Diagnosis ⇒ Prescription ⇒ Intervention ⇒ Evaluation Model adapted from clinical medicine, enable empirically targeted, group-specialized, student-success interventions. Two-step cluster analysis of survey responses from 512 students entering first-semester urban health science community college differentiated three PAR-profile groups: (a) traditional, (b) language/education/financially challenged, and (c) older/supporting families/financially challenged. The latter two groups’ end-of-first-semester odds of adverse academic status events were, respectively, 1.73 ( p = .016) and 2.08 ( p = .002) times the traditional group’s. PAR profiles enable empirically based group-tailored interventions for increasing student retention, completion, and graduation rates, while improving allocation of institutional resources.

Who should get the last PICU bed?

Administrators sometimes face ethical dilemmas about the allocation of institutional resources. One such situation is when elective surgery cases require reserved ICU beds and the ICU is full. Such situations arise frequently in children's hospitals today. They are sometimes complicated by questions about whether every patient in the ICU belongs there. We present such a situation and responses from Mark Del Becarro, Vice President for Medical Affairs at Seattle Children's Hospital; Aaron Wightman, a nephrology fellow and bioethicist at Seattle Children's Hospital; and Emily Largent, a doctoral student in the joint JD/PhD Program in Health Policy at Harvard University.

Results sky high: “DAMN”ing marking forever

PurposeThe aim of this paper is to stimulate further discussion on divergent institutional and academic needs for effective marking processes to evaluate student work in Australian universities. This is in specific response to institutional stated goals and emerging policies under current economic realities. After identifying the three significant areas of marking that must be addressed: content, consistency and cost; the author proposes that the use of the AERO‐dynamic model of marking will reduce academic workloads and provide institutions with an effective marking process to meet corporate budgets.Design/methodology/approachThis conceptual paper is a synthesis of researcher participation and discourse interpretation. It is based on a cynical response to changing realities and resides in the arena of the “Theatre of the Absurd”.FindingsThe AERO‐dynamic model of marking was found to be highly cost effective for institutions with large student cohorts and ever diminishing budgets. Critical analysis identified areas of concern in marking consistency and assignment content and recommends specific actions to address these but also identifies that no process will be perfect and that some tradeoffs between cost, consistency and content need to be made. The role of the academic within this marking process is redefined and the implications of this for both institution and individual acknowledged.Originality/valueThis paper offers a starting point for further debate into the widening gap between student expectations on assignment marking and institutional resource allocation and support.

Reconfiguring the Academic Dance: A Critique of Faculty’s Responses to Administrative Practices in Canadian Universities

This article explores and critiques Canadian academics’ responses to new administrative practices in a variety of areas, including resource allocation, performance assessment and the regulation of academic work. The main argument is that, for the most part, faculty are responding to what administrative practices appear to be, rather than to what they do or accomplish institutionally. That is, academics are seeing and responding to these practices as isolated developments that interfere with or add to their work, rather than as reorganizers of social relations that fundamentally transform what academics do and are. As a result, their responses often serve to entrench and advance these practices’ harmful effects. This problem can be remedied by attending to how new administrative practices reconfigure institutional relations in ways that erode the academic mission, and by establishing new relations that better serve academics’—and the public’s—interests and needs. Drawing on the work of various academic and other activists, this article offers a broad range of possible strategies to achieve the latter goal. These include creating faculty-run “banks” to transform the allocation of institutional resources, producing new means and processes to assess—and support—academic performance, and establishing alternative policy-making bodies that operate outside of, and variously interrupt, traditional policy-making channels.

Automated generation of patient-tailored electronic care pathways by translating computer-interpretable guidelines into hierarchical task networks

This paper describes a methodology which enables computer-aided support for the planning, visualization and execution of personalized patient treatments in a specific healthcare process, taking into account complex temporal constraints and the allocation of institutional resources. To this end, a translation from a time-annotated computer-interpretable guideline (CIG) model of a clinical protocol into a temporal hierarchical task network (HTN) planning domain is presented. The proposed method uses a knowledge-driven reasoning process to translate knowledge previously described in a CIG into a corresponding HTN Planning and Scheduling domain, taking advantage of HTNs known ability to (i) dynamically cope with temporal and resource constraints, and (ii) automatically generate customized plans. The proposed method, focusing on the representation of temporal knowledge and based on the identification of workflow and temporal patterns in a CIG, makes it possible to automatically generate time-annotated and resource-based care pathways tailored to the needs of any possible patient profile. The proposed translation is illustrated through a case study based on a 70 pages long clinical protocol to manage Hodgkin's disease, developed by the Spanish Society of Pediatric Oncology. We show that an HTN planning domain can be generated from the corresponding specification of the protocol in the Asbru language, providing a running example of this translation. Furthermore, the correctness of the translation is checked and also the management of ten different types of temporal patterns represented in the protocol. By interpreting the automatically generated domain with a state-of-art HTN planner, a time-annotated care pathway is automatically obtained, customized for the patient's and institutional needs. The generated care pathway can then be used by clinicians to plan and manage the patients long-term care. The described methodology makes it possible to automatically generate patient-tailored care pathways, leveraging an incremental knowledge-driven engineering process that starts from the expert knowledge of medical professionals. The presented approach makes the most of the strengths inherent in both CIG languages and HTN planning and scheduling techniques: for the former, knowledge acquisition and representation of the original clinical protocol, and for the latter, knowledge reasoning capabilities and an ability to deal with complex temporal and resource constraints. Moreover, the proposed approach provides immediate access to technologies such as business process management (BPM) tools, which are increasingly being used to support healthcare processes.