Non-standard Interventions Research Articles

Exercise interventions for adults with cancer receiving radiation therapy alone.

Exercise interventions for adults with cancer receiving radiation therapy alone.

A Clinical Response Team Providing Support to Long-Term Care Homes with COVID-19 Outbreaks in Eastern Ontario-a Cohort Study.

BackgroundThe greatest impact of the COVID-19 pandemic in Canada has been on long-term care facilities which have accounted for a large majority of the mortality seen in this country. We developed a clinical response team to perform mass assessment and provide support to long-term care facilities in Eastern Ontario with large outbreaks in the hope of reducing the impact of the outbreaks.MethodsThis is a retrospective cohort study of all residents of LTC facilities supported by our multidisciplinary clinical response team. We collected data about the timing of the outbreak and our deployment, as well as the total number of COVID-19 cases and deaths, and measured the correlation between the timing of our deployment and the observed mortality rate.ResultsOur clinical team was deployed to 14 long-term care facilities, representing 719 cases and 243 deaths (mean ± standard error of mortality 34% ± 4%). Our team was deployed a mean ± standard error of 16 ± 2 days after the declaration of an outbreak. There was a significant correlation between an earlier deployment of our clinical team and a lower mortality rate for that outbreak (Pearson’s r = 0.70, p < .01).InterpretationThis retrospective, uncontrolled study of a non-standardized intervention has many potential limitations. However, the data suggest that timely deployment of our clinical response team may improve outcomes in the event of a large outbreak. This clinical team may be useful in future pandemics.

Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy.

Hypertonicity of the pelvic floor (PFH) is a disabling condition with urological, gynecological and gastrointestinal symptoms, sexual problems and chronic pelvic pain, impacting quality of life. Pelvic floor physical therapy (PFPT) is a first-line intervention, yet no systematic review on the efficacy of PFPT for the treatment of PFH has been conducted. To systematically appraise the current literature on efficacy of PFPT modalities related to PFH. PubMed, Embase, Emcare, Web of Science, and Cochrane databases were searched from inception until February 2020. A manual search from reference lists of included articles was performed. Ongoing trials were reviewed using clinicaltrial.gov. Randomized controlled trials (RCTs), prospective - and retrospective cohorts and case-study analyses were included. Outcome measures were pelvic floor muscle tone and function, pain reports, sexual function, pelvic floor symptom scores, quality of life and patients' perceived effect. The literature search resulted in 10 eligible studies including 4 RCTs, 5 prospective studies, and 1 case study published between 2000 and 2019. Most studies had a high risk of bias associated with the lack of a comparison group, insufficient sample sizes and non-standardized interventions. Six studies were of low and 4 of medium quality. All studies were narratively reviewed. Three of 4 RCTs found positive effects of PFPT compared to controls on five out of 6 outcome measures. The prospective studies found significant improvements in all outcome measures that were assessed. PFPT seems to be efficacious in patients with chronic prostatitis, chronic pelvic pain syndrome, vulvodynia, and dyspareunia. Smallest effects were seen in patients with interstitial cystitis and painful bladder syndrome. The findings of this systematic review suggest that PFPT can be beneficial in patients with PFH. Further high-quality RCTs should be performed to confirm the effectiveness of PFPT in the treatment of PFH. van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, etal. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev 2022;10:209-230.

Outcomes of a Structured, Stepwise Approach to Endoscopic Necrosectomy.

Despite the increasing number of procedures being performed, there is no consensus on the optimal approach to performing direct endoscopic necrosectomy (DEN), which is a labor-intensive, nonstandardized intervention. We prospectively validated the usefulness of a predefined, structured, stepwise approach to DEN with the objective of improving procedural efficiency and resource use. A prospective study of patients with necrotizing pancreatitis who after endoscopic transluminal drainage did not have clinical improvement and required DEN. The study was undertaken in 2 phases. Phase I was a retrospective analysis of interventions performed using an unstructured, conventional approach. Median of 3 necrosectomy sessions (range, 2 to 3) were required to achieve 80% treatment success in 20 patients. On the basis of these observations, a structured approach that included 3 steps (debridement, necrosis extraction, and irrigation) was developed and validated prospectively in phase II in 39 patients. The main outcome was to compare procedural efficiency defined as a number of necrosectomy sessions to achieve treatment success. Although there was no significant difference in treatment success (phase I=80.0 vs. phase II=94.9%, P=0.17), the procedure was more efficient in phase II [median session, 2 (interquartile range=1 to 3) vs. 3 (interquartile range=2 to 3); P=0.003]. Multiple logistic regression analysis revealed that a structured, stepwise approach was associated with fewer necrosectomy sessions to achieve treatment success (odds ratio=4.7; 95% confidence interval=1.5-15.0; P=0.008) when adjusted for patient demographics, lab parameters, and disease characteristics. By decreasing the number of necrosectomy sessions, a structured, stepwise approach to endoscopic necrosectomy seems to improve procedural efficiency.

Possibilities of performance of nonstandard operative interventions in patients, suffering early gastric cancer

Objective. To study a possibility of performance of nonstandard organ-preserving operations in patients, suffering early gastric cancer, using application of the sentinel lymph nodes visualization procedures and the lymph node dissection procedure.&#x0D; Materials and methods. There were performed operative interventions in 35 patients, suffering early gastric cancer (Stages T1 and T2). For identification of sentinel lymph nodes a procedure of luminescence, using green indocyan, was applied.&#x0D; Results. In all the patients early gastric cancer was diagnosed (T1,T2). Possibility for performance of organ-preserving operations in early gastric cancer was shown. Miniinvasive interventions in a patient with severe concurrent diseases have appeared sufficiently effective and radical. The patients’ quality of life after laparoscopic pylorus-preserving and organ-preserving operations was significantly better, than quality of life in patients, to whom gastric resection with extended D2 lymph node dissection was done.&#x0D; Conclusion. There was established, that intraoperative lymphography constitutes he informative method, which helps to estimate the disease Stage in gastric cancer and to apply the adequate scheme of combined and complex treatment. More sensitive is a procedure of luminescence, using green indocyan. Determination of the affection degree of «sentinel lymph nodes» in gastric cancer may serve as an argument for change of the selection tactics while changing the tactics for the operative intervention volume choice.

Comprehensive Lifestyle Improvement Program for Prostate Cancer (CLIPP): Protocol for a Feasibility and Exploratory Efficacy Study in Men on Androgen Deprivation Therapy.

BackgroundAndrogen deprivation therapy (ADT) for prostate cancer is associated with adverse cardiometabolic effects such as reduced libido, hot flashes, metabolic syndrome, diabetes, myocardial infarction, and stroke. This reduces quality of life and potentially increases mortality. Several large clinical trials have demonstrated improvements in cardiometabolic risk with comprehensive multimodality lifestyle modification. However, there is a lack of data for such interventions in men on ADT for prostate cancer, and existing studies have used non-standardized interventions or lacked data on metabolic risk factors.ObjectiveThe Comprehensive Lifestyle Improvement Project for Prostate Cancer (CLIPP) is designed to address these gaps by using an intervention modeled on the Diabetes Prevention Program, a standardized multicomponent intervention with demonstrated effectiveness in reducing cardiometabolic risk factors that has been successfully adapted for multiple disease types including breast cancer.MethodsA single-arm unblinded clinical trial will be conducted to determine the feasibility of conducting a 24-week comprehensive lifestyle modification intervention that targets weight loss and increased physical activity modeled on the Diabetes Prevention Program in 30 men on ADT for prostate cancer. Secondary aims are to determine the effect of the intervention on cardiometabolic markers and quality of life. The tertiary aim is to determine the effect of the intervention on markers of inflammation and angiogenesis, important mechanisms for prostate cancer progression. Participants will be recruited from the University of Arizona Cancer Center and the surrounding community. The intervention will be delivered weekly in person and over the phone for 16 weeks. For Weeks 16-24, participants receive weekly phone calls from the study health coach to motivate them to continue their lifestyle modification. Questionnaire and biological data are collected at baseline, 12 weeks, and 24 weeks. Body composition using dual-energy x-ray absorptiometry scans will be performed at baseline and end of study.ResultsBased on a sample size of 30, the two-sided 95% confidence interval will not be wider than 0.373 standard deviations for the adherence rate and will not be wider than 0.374 for the retention rate. In addition, the study will have a power of 80% to detect a change of 0.47 standard deviations from baseline for each of the markers investigated in the secondary and tertiary aims assuming a within-subject correlation of 0.20 at a significance level of 5%. The recruitment period is from October 2018 to April 2019.ConclusionsThe aim of CLIPP is to determine the feasibility of conducting a Diabetes Prevention Program–style comprehensive lifestyle modification intervention in men with ADT for prostate cancer and its effects on cardiometabolic adverse effects, quality of life, as well as markers of inflammation and angiogenesis. Results will inform the development of future clinical trials in this population.International Registered Report Identifier (IRRID)DERR1-10.2196/12579

A REVIEW ON MINDFULNESS AND NURSING STRESS AMONG NURSES

&lt;p&gt;&lt;em&gt;Previous research has been done on mindfulness and nursing stress but no review has been done to highlight the most up-to-date findings, to justify the recommendation of mindfulness training for the nursing field. The present paper aims to review the relevant studies, derive conclusions, and discuss future direction of research in this field. A total of 19 research papers were reviewed. The majority was intervention studies on the effects of mindfulness-training programs on nursing stress. Higher mindfulness is correlated with lower nursing stress. Mindfulness-based training programs were found to have significant positive effects on nursing stress and psychological well-being. The studies were found to have non-standardized intervention methods, inadequate research designs, small sample size, and lack of systematic follow-up on the sustainability of treatment effects, limiting the generalizability of the results. There is also a lack of research investigation into the underlying mechanism of action of mindfulness on nursing stress. Future research that addresses these limitations is indicated.&lt;/em&gt;&lt;/p&gt;

Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia.

Pelvic floor muscle physical therapy is recommended in clinical guidelines for women with provoked vestibulodynia (PVD). Including isolated or combined treatment modalities, physical therapy is viewed as an effective first-line intervention, yet no systematic review concerning the effectiveness of physical therapy has been conducted. To systematically appraise the current literature on the effectiveness of physical therapy modalities for decreasing pain during intercourse and improving sexual function in women with PVD. A systematic literature search using PubMed, Scopus, CINHAL, and PEDro was conducted until October 2016. Moreover, a manual search from reference lists of included articles was performed. Ongoing trials also were reviewed using clinicaltrial.gov and ISRCTNregistry. Randomized controlled trials, prospective and retrospective cohorts, and case reports evaluating the effect of isolated or combined physical therapy modalities in women with PVD were included in the review. Main outcome measures were pain during intercourse, sexual function, and patient's perceived improvement. The literature search resulted in 43 eligible studies including 7 randomized controlled trials, 20 prospective studies, 5 retrospective studies, 6 case reports, and 6 study protocols. Most studies had a high risk of bias mainly associated with the lack of a comparison group. Another common bias was related to insufficient sample size, non-validated outcomes, non-standardized intervention, and use of other ongoing treatment. The vast majority of studies showed that physical therapy modalities such as biofeedback, dilators, electrical stimulation, education, multimodal physical therapy, and multidisciplinary approaches were effective for decreasing pain during intercourse and improving sexual function. The positive findings for the effectiveness of physical therapy modalities in women with PVD should be investigated further in robust and well-designed randomized controlled trials. Morin M, Carroll M-S, Bergeron S. Systematic Review of the Effectiveness of Physical Therapy Modalities in Women With Provoked Vestibulodynia. Sex Med Rev 2017;5:295-322.

The Animator’s Body in Expanded Cinema

Building on phenomenological studies of the body and feminist structural materialist film theory and practice, this article proposes that performed methods of direct-on-film animation shape novel choreographies and produce original filmic patterns and rhythms. The author draws a parallel between Foucault’s disobedient ‘non-normative’ body and non-standardized interventions with film technology. The article analyses the innovative choreographies that arise from rotoscoping techniques, direct-on-film practices and expanded cinema performances. Focusing specifically on Free Radicals (Len Lye, 1958) and Reel Time (Annabel Nicolson, 1973), the author uses these analyses to shed light on her own performance of making films by moving in unusual ways, in time with technologies, and marking directly onto the film surface with the animated body. While engaging with structural materialist questions of film form, process and materials, this article departs from such modernist concerns to propose that the performance of filmmaking offers opportunities to explore the tenacity and vulnerability of particular bodies. The author suggests that performed filmmaking is equally about the traces of actions made on film and the unusual choreography that brings these marks into being.

Hacia la validez de constructo en contextos no estandarizados de evaluación.

Program evaluation is usually applied to non-standardized intervention contexts. This implies, among others, deficiencies of: a) validated theoretical models; b) non-standard measurement instruments; c) reliable measures. In this work, we show that Factor Analysis with polychoric correlations and Multilevel Analysis could be an adequate procedure to gain construct validity evidence in non-standard evaluative contexts, where the measures are not quantitative and usually are nested. The empirical study is carried out on a sample of 2754 workers of the University of Seville. They have completed a satisfaction questionnaire about training courses aimed to prepare them for the correct performance of their jobs. We highlight the complementarities between both analytical techniques to study the differential variability provided by explained variables nested in different hierarchical level to predict the perceived satisfaction.

Deep Brain Stimulation in Major Depression: Plastic Changes of 5-Hydroxytryptamine Neurons

Major depressive disorder (MDD) is a severe psychiatric syndrome with a very high socioeconomic impact. The high cost of MDD is attributable to its large incidence in the general population (lifetime prevalence is close to 20%); the long duration of depressive episodes; and emergence of depressive episodes during active periods of adult life, which results in very large labor costs. The large and increasing impact of MDD is not paralleled by marked improvements in its treatment. The antidepressant market is dominated by drugs targeting the monoamine systems, such as selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors, which are pharmacologic refinements of tricyclic antidepressant drugs, which were discovered serendipitously in the 1950s. Selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors have increased treatment compliance because of the absence of severe side effects. However, their speed and efficacy are suboptimal, leaving a large percentage of patients with partial or incomplete responses after several months of treatment. Many patients are refractory to numerous pharmacologic treatments and require nonstandard interventions to improve their quality of life and reduce suicide risk. Antidepressant-like Effects of Cortical Deep Brain Stimulation Coincide With Pro-neuroplastic Adaptations of Serotonin SystemsBiological PsychiatryVol. 76Issue 3PreviewCortical deep brain stimulation (DBS) is a promising therapeutic option for treatment-refractory depression, but its mode of action remains enigmatic. Serotonin (5-HT) systems are engaged indirectly by ventromedial prefrontal cortex (vmPFC) DBS. Resulting neuroplastic changes in 5-HT systems could thus coincide with the long-term therapeutic activity of vmPFC DBS. Full-Text PDF ErratumBiological PsychiatryVol. 76Issue 5PreviewErratum to: “Deep Brain Stimulation in Major Depression: Plastic Changes of 5-Hydroxytryptamine Neurons” by Artigas which appeared in Biological Psychiatry (2014;76:174-175). On page 175, column 1, 8th line from the bottom, the findings were inadvertently misstated as a decrease rather than an increase. The full corrected sentence is: “Using this procedure, the authors found that CSDS induced a robust and significant increase of the density of 5-HT nerve endings in various forebrain areas, including the vmPFC, the basolateral amygdala, and the dentate gyrus of the hippocampal formation, which was normalized after long-term DBS treatment.” Full-Text PDF

Behavioral Economics and Psychology of Incentives

Monetary incentives can backfire while nonstandard interventions, such as framing, can be effective in influencing behavior. I review the empirical evidence on these two sets of anomalies. Paying for inherently interesting tasks, paying for prosocial behavior, paying too much, paying too little, and providing too many options can all be counterproductive. At the same time, proper design of the decision-making environment can be a potent way to induce certain behaviors. After presenting the empirical evidence, I discuss the relative role of beliefs, preferences, and technology in the anomalous impacts of incentives. I argue that inference, signaling, loss aversion, dynamic inconsistency, and choking are the primary factors that explain the data.

Beyond Standard Adjuvant Therapy for Colon Cancer: Role of Nonstandard Interventions

Epidemiologic and scientific research indicates that diet and other lifestyle factors have a significant influence on the risk of developing colorectal cancer. Obesity, consumption of red meat, a Western pattern diet, alcohol, and smoking influence one's risk of developing colorectal cancer while physical activity, vitamin D, postmenopausal estrogen use, aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs) decrease one's risk. Until recently, it was largely unknown if any of these modifiable factors influence the outcomes of patients already diagnosed with colorectal cancer. However, data are emerging of factors that may influence disease recurrences and mortality for colorectal cancer survivors. Prospective observational studies have shown that increased exercise after diagnosis and avoidance of a Western pattern diet are associated with reduced risk of cancer recurrence and improved overall survival in early-stage colorectal cancer after standard therapy. Patients with class II and III obesity (body mass index [BMI] ≥35 kg/m(2)) have a modestly increased risk of recurrence. Regular use of aspirin or cyclooxygenase (COX)-2 inhibitors decrease recurrence rates and increase serum vitamin D levels. In contrast, change of weight after diagnosis or smoking status (never, past, or current) are not associated with outcomes after diagnosis. The data supporting these observations will be reviewed, potential mechanisms of actions will be discussed, and the next steps forward will be proposed.

Introduction to the Special Issue: Changing Conceptions of Special Education

After a long history of exclusion, litigation and legislation now ensure access to a free, appropriate education for students with disabilities. The legal safeguards and processes that have been used to identify and place students in special education were designed to provide access, but they do not guarantee excellence of educational services and outcomes for students with disabilities. As a result, the alignment of the Individuals With Disabilities Education Improvement Act (IDEA) and the No Child Left Behind Act of 2001 (NCLB) now mandates the inclusion of students with disabilities in high-stakes assessments of academic achievement and meaningful participation in the general education curriculum. These changes in policy, which were meant to address persistent problems of educational equity, have profound practical implications for the delivery of educational services to all students. Meanwhile, scholarly inquiry into the education of students with disabilities continues to raise exciting possibilities as well as practical challenges for both general and special educators. The University of Delaware's (UD) School of Education invited nationally prominent scholars-six speakers and five policy experts--to present and discuss their perspectives on changing conceptions of special education. The 2-day symposium attracted over 100 practitioners, scholars, and policy makers. Speakers presented papers that explored the theoretical, policy, and/or practice perspectives that shape the experience and structure of education for students with disabilities; lines of inquiry that inform current thinking about special education; challenging areas for future inquiry into the education of students with disabilities; and the future relationship between general and special education. These papers are featured in this special issue. McLaughlin considers views of equity that have emerged in K-12 education practice as a result of intersecting interpretations of civil rights statutes, social science research, and education accountability policies. She traces important shifts in how educational equity is defined, from notions of equal access to equal opportunity to equal outcomes, noting the tension that has resulted from competing concerns for group versus individual equity. She raises the question of whether students with unique needs can ever be treated justly when held to universal standards. She concludes with a proposal that embraces accountability for both group and individual equity. Artiles, Kozleski, Trent, Osher, and Ortiz analyze traditional explanations for the disproportional representation of historically underserved groups in special education. These explanations fail to consider the complicated historical and cultural influences on policies and practices that result in disproportionality. Further, traditional explanations may have the unintended effect of reinforcing the assumption that achievement deficits are a defining feature of underserved students. The authors argue for a view of culture that recognizes its regulative, interpretative, and instrumental properties. They recommend critically analyzing the theoretical foundations of research and embracing a multidimensional conception of culture that recognizes the centrality of practice to teachers' professional development. Fuchs, Fuchs, and Stecker describe contrasting perspectives about the response-to-intervention (RTI) initiative, which has engendered considerable interest among policy makers and practitioners. The authors argue that these perspectives, which they associate with IDEA and NCLB, differ in significant ways despite agreement about the importance of early intervention, early identification, and strengthening general education. Among these differences include the role of special education in a multitiered system of service delivery and the use of validated instructional protocols. The authors are especially concerned that the implementation of the NCLB perspective will blur the difference between special and general education, and promote the use of nonstandard and ineffective interventions. …

PELVIC FLOOR ELECTRICAL STIMULATION, BIOFEEDBACK, AND BEHAVIORAL THERAPY FOR PERSISTENT POST-PROSTATECTOMY INCONTINENCE

Hypertonicity of the pelvic floor (PFH) is a disabling condition with urological, gynecological and gastrointestinal symptoms, sexual problems and chronic pelvic pain, impacting quality of life. Pelvic floor physical therapy (PFPT) is a first-line intervention, yet no systematic review on the efficacy of PFPT for the treatment of PFH has been conducted.To systematically appraise the current literature on efficacy of PFPT modalities related to PFH.PubMed, Embase, Emcare, Web of Science, and Cochrane databases were searched from inception until February 2020. A manual search from reference lists of included articles was performed. Ongoing trials were reviewed using clinicaltrial.gov. Randomized controlled trials (RCTs), prospective - and retrospective cohorts and case-study analyses were included.Outcome measures were pelvic floor muscle tone and function, pain reports, sexual function, pelvic floor symptom scores, quality of life and patients’ perceived effect.The literature search resulted in 10 eligible studies including 4 RCTs, 5 prospective studies, and 1 case study published between 2000 and 2019. Most studies had a high risk of bias associated with the lack of a comparison group, insufficient sample sizes and non-standardized interventions. Six studies were of low and 4 of medium quality. All studies were narratively reviewed. Three of 4 RCTs found positive effects of PFPT compared to controls on five out of 6 outcome measures. The prospective studies found significant improvements in all outcome measures that were assessed. PFPT seems to be efficacious in patients with chronic prostatitis, chronic pelvic pain syndrome, vulvodynia, and dyspareunia. Smallest effects were seen in patients with interstitial cystitis and painful bladder syndrome.The findings of this systematic review suggest that PFPT can be beneficial in patients with PFH. Further high-quality RCTs should be performed to confirm the effectiveness of PFPT in the treatment of PFH.van Reijn-Baggen DA, Han-Geurts IJM, Voorham-van der Zalm PJ, et al. Pelvic Floor Physical Therapy for Pelvic Floor Hypertonicity: A Systematic Review of Treatment Efficacy. Sex Med Rev 2022;10:209–230.

Worksite health promotion research: challenges, current state and future directions

Background: Worksite health promotion (WHP) addresses diverse individual and work-related health determinants. Thus, multiple, non-standardized interventions as well as company outcomes other than health have to be considered in WHP research. Methods: The article builds primarily on published research reviews in WHP and related fields. It discusses key practical and research challenges of the workplace setting. The evidence available on the effectiveness of WHP is summarised and conclusions are drawn for future WHP practice and research. Results: WHP research on health-oriented, behavioural interventions shows that the level of evidence ranges from suggestive to acceptable for key prevention areas such as physical activity, nutrition, fitness, smoking, alcohol and stress. Such interventions are effective if key conditions are met. Future research is needed on long-term effects, on multi-component programs and on programs, which address environmental determinants of health behaviour as well. Research on work-related determinants of health shows the economic and public health relevance of WHP interventions. Reviews of work-oriented, organisational interventions show that they produce a range of individual and organisational outcomes. However, due to the complexity of the organisational context, the generalisability and predictability of such outcomes remain limited. Conclusions: WHP research shows success factors of WHP and provides evidence of its effectiveness. In future, the evidence base should be expanded by developing adaptive, company-driven intervention approaches which allow for continuous optimisation of companies from a health perspective. Also, approaches for active dissemination of such a systemic-salutogenic occupational health management approach should be developed to increase the public health impact of WHP.

Worksite health promotion research: challenges, current state and future directions

Background : Worksite health promotion (WHP) addresses diverse individual and work-related health determinants. Thus, multiple, non-standardized interventions as well as company outcomes other than health have to be considered in WHP research. Methods : The article builds primarily on published research reviews in WHP and related fields. It discusses key practical and research challenges of the workplace setting. The evidence available on the effectiveness of WHP is summarised and conclusions are drawn for future WHP practice and research. Results : WHP research on health-oriented, behavioural interventions shows that the level of evidence ranges from suggestive to acceptable for key prevention areas such as physical activity, nutrition, fitness, smoking, alcohol and stress. Such interventions are effective if key conditions are met. Future research is needed on long-term effects, on multi-component programs and on programs, which address environmental determinants of health behaviour as well. Research on work-related determinants of health shows the economic and public health relevance of WHP interventions. Reviews of work-oriented, organisational interventions show that they produce a range of individual and organisational outcomes. However, due to the complexity of the organisational context, the generalisability and predictability of such outcomes remain limited. Conclusions : WHP research shows success factors of WHP and provides evidence of its effectiveness. In future, the evidence base should be expanded by developing adaptive, company-driven intervention approaches which allow for continuous optimisation of companies from a health perspective. Also, approaches for active dissemination of such a systemic-salutogenic occupational health management approach should be developed to increase the public health impact of WHP.

What's happening in quality improvement at the local hospital: a state-wide study from the Cooperative Cardiovascular Project.

The objective of this study was to investigate what happened to improve the quality of care for acute myocardial infarction (AMI) at all 32 nonfederal hospitals in Connecticut and to assess the impact of the Cooperative Cardiovascular Project (CCP) on quality improvement (QI) activities for AMI. We performed a questionnaire study with secondary analyses using the CCP database. On-site interviews were conducted with QI directors at all 32 Connecticut nonfederal hospitals that participated in the Health Care Financing Administration's Cooperative Cardiovascular Project (CCP) in 1992-93 and 1995. The interviews sought information about the makeup of QI departments, specific approaches used to improve the care of patients with AMI, and the perceived value of the CCP to each individual hospital. Results showed that the number of full-time equivalents (FTEs) and FTEs per beds employed in QI departments ranged from 1 to 30 and from 0.4 to 7.9, respectively, with a registered nurse most often serving as the department head (27/32). Over half of the departments (17/32) had additional responsibilities. The majority (25/32) used some combination of physician champions, multidisciplinary QI teams, standing orders, or critical pathways to effect change in AMI care. Finally, 26 of the 32 hospitals believed the CCP was valuable because it provided credible benchmark data, a catalyst for change, or a specific focus on processes of care needing improvement in AMI. Despite great variability in institutional resources, all 32 hospitals used a similar combination of QI approaches to effect change in AMI care. However, there is variable scientific evidence supporting these approaches. Externally sponsored projects such as the CCP appear to play a useful role for individual hospitals. Defining the optimal methods of QI is difficult given that hospitals are using complex combinations of nonstandardized improvement interventions.