Population-based Planning Research Articles

A Novel Black Widow Optimized Controller Approach for Automatic Generation Control in Modern Hybrid Power Systems

This research paper demonstrates an application of the Black Widow Optimization (BWO) approach to address the issue of load-frequency control (LFC) in networked power systems. BWO is an innovative metaheuristic method that quickly suggests technique is initially evaluated on a non-reheat thermal-thermal (NRTT) power system spanning two areas of interconnection, and then it is applied to two different actual power systems: (a) a two-area thermal-thermal considering Generation Rate Constraint (GRC); and (b) a two-area having thermal, hydro, wind, solar, and gas systems. The BWO method uses two fitness functions based on integral time multiplied absolute error (ITAE) and integral square error (ISE) to optimize controller gains. The suggested BWO algorithm's performance has been compared to that of existing meta-heuristic optimization methods, such as grey wolf optimization (GWO), comprehensive learning particle swarm optimization (CLPSO), and an ensemble of parameters in differential evolution (EPSDE). The simulation results show that BWO's tuning skills are better than other population-based planning methods like CLPSO, EPSDE, and GWO. The ITAE value is enhanced by 33.28% (GWO), 40.28% (EPSDE), and 43.27% (CLPSO) when the BWO algorithm is used in conjunction with the PID Controller for thermal system.

Empirical planning target volume modeling for high precision MRI guided intracranial radiotherapy

Magnetic resonance image-guided radiotherapy for intracranial indications is a promising advance; however, uncertainties remain for both target localization after translation-only MR setup and intrafraction motion. This investigation quantified these uncertainties and developed a population-based planning target volume (PTV) model to explore target and organ-at-risk (OAR) volumetric coverage tradeoffs. Sixty-six patients, 49 with a primary brain tumor and 17 with a post-surgical resection cavity, treated on a 1.5T-based MR-linac across 1329 fractions were included. At each fraction, patients were setup by translation-only fusion of the online T1 MRI to the planning image. Each fusion was independently repeated offline accounting for rotations. The six degree-of-freedom difference between fusions was applied to transform the planning CTV at each fraction (CTVfx). A PTV model parameterized by volumetric CTVfx coverage, proportion of fractions, and proportion of patients was developed. Intrafraction motion was quantified in a 412 fraction subset as the fusion difference between post- and pre-irradiation T1 MRIs. For the left-right/anterior-posterior/superior-inferior axes, mean±SD of the rotational fusion differences were 0.1±0.8/0.1±0.8/-0.2±0.9°. Covering 98% of the CTVfx in 95% of fractions in 95% of patients required a 3mm PTV margin. Margin reduction decreased PTV-OAR overlap; for example, the proportion of optic chiasm overlapped by the PTV was reduced up to 23.5% by margin reduction from 4mm to 3mm. An evidence-based PTV model was developed for brain cancer patients treated on the MR-linac. Informed by this model, we have clinically adopted a 3mm PTV margin for conventionally fractionated intracranial patients.

Co-Designing Together through Crisis: Development of a Virtual Care Guidance Document to Support Providers, Older Adults, and Caregivers.

COVID-19 has had a disproportionate and devastating impact on older adults. As health care resources suddenly shifted to emergency response planning, many health and community support services were cancelled, postponed, or shifted to virtual care. This rapid transformation of geriatric care resulted in an immediate need for practical guidance on decision making, planning and delivery of virtual care for older adults and caregivers. This article outlines the rapid co-design process that supported the development of a guidance document intended to support health and community support services providers. Data were collected through consultation sessions, surveys, and a rapid literature review, and analyzed using appropriate qualitative and quantitative methods. Although this work took place within the context of the COVID-19 pandemic, the resulting resources and lessons learned related to collective impact, co-design, population-based planning, and digital technologies can be applied more broadly.

Toward Improved Outcomes for Patients With Lung Cancer Globally: The Essential Role of Radiology and Nuclear Medicine.

PURPOSEKey to achieving better population-based outcomes for patients with lung cancer is the improvement of medical imaging and nuclear medicine infrastructure globally. This paper aims to outline why and spark relevant health systems strengthening.METHODSThe paper synthesizes the global lung cancer landscape, imaging referral guidelines (including resource-stratified ones), the reliance of TNM staging upon imaging, relevant multinational health technology assessments, and precisely how treatment selection and in turn patient outcomes hinge upon imaging findings. The final discussion presents data on current global gaps in both diagnostics (including imaging) and therapies and how, informed by such data, improved population-based outcomes are tangible through strategic planning.RESULTSImaging findings are central to appropriate lung cancer patient management and can variably lead to life-prolonging interventions and/or to life-enhancing palliative measures. Early-stage lung cancer can be treated with curative intent but, unfortunately, most patients with lung cancer still present at advanced stages and many patients lack access to both diagnostics and therapies. Furthermore, half of lung cancer cases occur in low- and middle-income countries. The role of medical imaging and nuclear medicine in lung cancer management, as outlined herein, may help inform strategic planning.CONCLUSIONLung cancer is the number one cancer killer worldwide. The essential role that medical imaging and nuclear medicine play in early diagnosis and disease staging cannot be overstated, pivotal in selecting the many patients for whom measurably improved outcomes are attainable. Prevention synergized with patient-centered, compassionate, high-quality lung cancer management provision mandate that strategic population-based planning, including universal health coverage strategies, should extend well beyond the scope of disease prevention to include both curative and noncurative treatment options for the millions afflicted with lung cancer.

Comparison of 3 image-guided adaptive strategies for bladder locoregional radiotherapy

The objective of this study was to compare the dosimetric differences of a population-based planning target volume (PTV) approach and 3 proposed adaptive strategies: plan of the day (POD), patient-specific PTV (PS-PTV), and daily reoptimization (ReOpt). Bladder patients (n = 10) were planned and treated to 46 Gy in 23 fractions with a full bladder in supine position by the standard strategy using a population-based PTV. For each patient, the adaptive strategy was executed retrospectively as follows: (1) POD—multiple distributions of various PTV sizes were generated, and the appropriate distribution based on the bladder of the day was selected for each fraction; (2) PS-PTV—population-based PTV was used for the first 5 fractions and a new PTV derived using information from these fractions was used to deliver the remaining 18 fractions; and (3) ReOpt—distribution was reoptimized for each fraction based on the bladder of the day. Daily dose was computed on all cone beam computed tomographies (CBCTs) and deformed back to the planning computed tomography (CT) for dose summation afterward. V95_Accu, the volume receiving an accumulated delivered dose of 43.7 Gy (95% prescription dose), was measured for comparison. Mean V95_Accu (cm3) values were 1410 (standard deviation [SD]: 227), 1212 (SD: 186), 1236 (SD: 199), and 1101 (SD: 180) for standard, POD, PS-PTV, and ReOpt, respectively. All adaptive strategies significantly reduced the irradiated volume, with ReOpt demonstrating the greatest reduction compared with the standard (− 25%), followed by PS-PTV (− 16%) and POD (− 12%). The difference in the magnitude of reduction between ReOpt and the other 2 strategies reached statistical significance (p = 0.0006). ReOpt is the best adaptive strategy at reducing the irradiated volume because of its frequent adaptation based on the daily geometry of the bladder. The need to adapt only once renders PS-PTV to be the best alternative adaptive strategy.

Automated population-based planning for whole brain radiation therapy.

Treatment planning for whole‐brain radiation treatment is technically a simple process, but in practice it takes valuable clinical time of repetitive and tedious tasks. This report presents a method that automatically segments the relevant target and normal tissues, and creates a treatment plan in only a few minutes after patient simulation. Segmentation of target and critical structures is performed automatically through morphological operations on the soft tissue and was validated by comparing with manual clinical segmentation using the Dice coefficient and Hausdorff distance. The treatment plan is generated by searching a database of previous cases for patients with similar anatomy. In this search, each database case is ranked in terms of similarity using a customized metric designed for sensitivity by including only geometrical changes that affect the dose distribution. The database case with the best match is automatically modified to replace relevant patient info and isocenter position while maintaining original beam and MLC settings. Fifteen patients with marginally acceptable treatment plans were used to validate the method. In each of these cases the anatomy was accurately segmented, but the beams and MLC settings led to a suboptimal treatment plan by either underdosing the brain or excessively irradiating critical normal tissues. For each case, the anatomy was automatically segmented with the proposed method, and the automated and manual segmentations were then compared. The mean Dice coefficient was 0.97, with a standard deviation of 0.008 for the brain, 0.85±0.009 for the eyes, and 0.67±0.11 for the lens. The mean Euclidian distance was 0.13±0.13 mm for the brain, 0.27±0.31 for the eye, and 2.34±7.23 for the lens. Each case was then subsequently matched against a database of 70 validated treatment plans and the best matching plan (termed autoplanned), was compared retrospectively with the clinical plans in terms of brain coverage and maximum doses to critical structures. Maximum doses were reduced by a maximum of 8.37 Gy for the left eye (mean 2.08), 11.67 for the right eye (1.90) and, respectively, 25.44 (5.59) for the left lens and 24.40 (4.85) for the right lens. Time to generate the autoplan, including the segmentation, was 3−4 min. Automated database‐ based matching is an alternative to classical treatment planning that improves quality while providing a cost‐effective solution to planning through modifying previous validated plans to match a current patient's anatomy.PACS number: 87.55.D, 87.55.tg, 87.57.nm

Working together to improve health and social care outcomes in Scotland

Earlier this year, the Scottish Parliament passed the Public Bodies (Joint Working) (Scotland) Act 2014, which establishes a framework to ensure health and social care services in Scotland are planned, resourced and delivered jointly by Health Boards and Local Authorities, working with nonstatutory partners to improve outcomes for people using services, their carers and families. The Act sets out a core set of principles and the legislative framework for integrating health and social care. Health Boards and Local Authorities will establish integrated partnership arrangements, called Integration Authorities, which will deliver national outcomes for health and wellbeing from a pooled budget for health and social care services. Integration Authorities will set up locality arrangements with local professional leadership of service planning. The Act places a heavy emphasis on the importance of effective strategic commissioning of services underpinned by a good, shared understanding of the population’s needs, and informed by professional and local community input. The new law applies to adult health and social care services – Health Boards and Local Authorities can also include children’s health and social care services, criminal justice social work, housing support etc. in their integrated arrangements if they agree to do so locally. The legislation includes a strong role for the third and independent sectors, clinicians, social workers, other professionals, and local communities. What will the reforms look like? Two models of integration are available for Health Boards and Local Authorities to choose from: delegation of functions and resources between Health Boards and Local Authorities. delegation of functions and resources by Health Boards and Local Authorities to a body corporate. An integrated budget will be established in each partnership to support delivery of integrated functions, which will cover at least adult social care, adult community health care, and aspects of adult hospital care that are most amenable to service redesign in support of prevention and better outcomes. Ministers will establish in Regulations which functions (and therefore budgets) must be included in the integrated arrangement. International Journal of Integrated Care – Volume 15, 27 May – URN:NBN:NL:UI:10-1-117032 – http://www.ijic.org/ 15th International Conference on Integrated Care, Edinburgh, UK, March 25-27, 2015 2 Each partnership will establish locality planning arrangements at sub-partnership level, which will provide a forum for local professional leadership of service planning. Each partnership will put in place a joint strategic commissioning plan for functions and budgets under its control – the joint strategic commissioning plan will be widely consulted upon with nonstatutory partners, patient and service user representatives, etc. Where the body corporate model is used, a chief officer must be appointed by the partnership to provide a single point of management for the integrated budget and integrated service delivery. In the delegation between partners model, this single point of management falls to the Chief Executive of the “lead” agency (i.e., the partner to whom functions and resources are delegated). The Act focuses on the importance of effective joint strategic planning and commissioning of services. This approach builds on the wealth of evidence for successful integration of health and social care from elsewhere in the UK and further afield, which demonstrates that, while no single organisational approach is required to deliver improvement, the following characteristics are consistently displayed by successful systems: Local planning systems focus on population need, rather than historic structures. Health and social care systems plan together for older people, for example – or for adults with chronic obstructive pulmonary disorder, or for children with complex needs, or for any other care group that is a local priority – rather than planning separately in terms of “health” provision and “social care” provision. Resources across health and social care are pooled to support delivery of the population-based plan. Resources reflect population need, and are managed to follow patient/service user need in order to deliver maximum benefit. This approach eliminates the risk of cost shunting, which can permit financial gain from poor performance on the part of one partner, at the cost of the other. Mechanisms are in place to ensure the opportunity for leadership by local clinicians and professionals from across health and social care, particularly GPs, in planning service provision. Clinical buy-in and leadership of integration is fundamental to improving outcomes. Strong, effective, consistent local leadership retains a relentless focus on outcomes for patients and service users.

Access to Care for Patients With Time-Sensitive Conditions in Pennsylvania

Collective knowledge and coordination of vital interventions for time-sensitive conditions (ST-segment elevation myocardial infarction [STEMI], stroke, cardiac arrest, and septic shock) could contribute to a comprehensive statewide emergency care system, but little is known about population access to the resources required. We seek to describe existing clinical management strategies for time-sensitive conditions in Pennsylvania hospitals. All Pennsylvania emergency departments (EDs) open in 2009 were surveyed about resource availability and practice patterns for time-sensitive conditions. The frequency with which EDs provided essential clinical bundles for each condition was assessed. Penalized maximum likelihood regressions were used to evaluate associations between ED characteristics and the presence of the 4 clinical bundles of care. We used geographic information science to calculate 60-minute ambulance access to the nearest facility with these clinical bundles. The percentage of EDs providing each of the 4 clinical bundles in 2009 ranged from 20% to 57% (stroke 20%, STEMI 32%, cardiac arrest 34%, sepsis 57%). For STEMI and stroke, presence of a board-certified/board-eligible emergency physician was significantly associated with presence of a clinical bundle. Only 8% of hospitals provided all 4 care bundles. However, 53% of the population was able to reach this minority of hospitals within 60 minutes. Reliably matching patient needs to ED resources in time-dependent illness is a critical component of a coordinated emergency care system. Population access to critical interventions for the time-dependent diseases discussed here is limited. A population-based planning approach and improved coordination of care could improve access to interventions for patients with time-sensitive conditions.

Deriving patient-specific planning target volume for partial bladder image guided radiation therapy

PurposeImage guided radiation therapy (IGRT) using bony anatomy for bladder cancer requires the use of large population-based planning target volume (PTV) margins to compensate for geometric uncertainties. This may result in a large volume of normal tissue being irradiated unnecessarily. Identification of the clinical target volume (CTV) is also a challenge during target delineation and treatment position verification. This study describes the use of lipiodol (Guerbet, US) and cone beam computed tomography (CBCT) in deriving patient-specific PTV (PS-PTV) for partial bladder IGRT. Methods and materialsTwelve patients underwent lipiodol injection into the bladder wall prior to radiation treatment. A PS-PTV was generated by the following: (1) Delineating partial bladder CTV (CTVpb) on 15 CBCTs; (2) registering the CBCTs with the planning CT image using lipiodol; (3) combining the 15 CTVpb to create an occupancy volume (OV); and (4) expanding the OV by 3 mm. Its efficacy in reducing irradiated volume and in providing coverage was assessed by comparing it with a 20-mm population-based PTV (popPTV) and using phase 2 CBCTs. ResultsThe median PS-PTV and popPTV (cm3) were 102 (range, 37-336) and 325 (range, 211-631), respectively. Median distance between the CTVpb and the PS-PTV edge (mm) were 6 superior, 6 right, 7 left, 7 anterior, 8 posterior, and 11 inferior. The absolute median reduction in the overlapping volume of rectum, small bowel, and large bowel were 0.3 cm3, 5.3 cm3, and 13.0 cm3, respectively. Despite large reductions in volume and margin compared with popPTV, PS-PTV achieved 100% target coverage. ConclusionsUsing lipiodol and CBCT to derive PS-PTV facilitated large reductions in the irradiated normal tissue volume without compromising target coverage.

Planning Framework for Weight Management in Primary Care

This initiative aimed to develop a flexible population-based planning framework for interprofessional primary care organizations to manage obesity. A scoping literature review (2003-2012) was completed to identify evidence of improved obesity management in primary care. In the second phase, focus groups were conducted with providers and patients; transcripts were thematically analyzed for ideas on new services. The final phase was review of the planning framework by 19 Family Health Teams in Ontario using a moderated consensus process and electronic meeting software. A national panel reviewed the draft, with help from the Canadian Obesity Network. The scoping review revealed that about 80% of intervention studies were directed to diabetes and/or cardiovascular diseases in adults. The most promising strategies included intensive skills training with patients, case management, provider education and additional provider tools (e.g. treatment algorithms and access to specialist expertise). For program planning purposes, providers identified 5 target groups: pregnancy to 2 yrs, 3-12 yrs, 13-18 yrs, 18+ yrs at risk or with health conditions, and 18+ with complex care needs. Desired outcomes for each target group were identified and activities were prioritized under categories: raising awareness, identification and initial management, follow-up management, expanded services, and practice initiatives. Evidence supports only some approaches that were important to providers. This novel planning tool clarifies key goals at different life stages and by health condition, and indicates where evidence and provider perspectives both converge and differ in developing program strategies to manage obesity. To date, the framework has facilitated priority setting in teams planning new services and implementation studies.

Do Indigenous Australians age prematurely? The implications of life expectancy and health conditions of older Indigenous people for health and aged care policy

To assess whether Indigenous Australians age prematurely compared with other Australians, as implied by Australian Government aged care policy, which uses age 50 years and over for population-based planning for Indigenous people compared with 70 years for non-indigenous people. Cross-sectional analysis of aged care assessment, hospital and health survey data comparing Indigenous and non-indigenous age-specific prevalence of health conditions. Analysis of life tables for Indigenous and non-indigenous populations comparing life expectancy at different ages. At age 63 for women and age 65 for men, Indigenous people had the same life expectancy as non-indigenous people at age 70. There is no consistent pattern of a 20-year lead in age-specific prevalence of age-associated conditions for Indigenous compared with other Australians. There is high prevalence from middle-age onwards of some conditions, particularly diabetes (type unspecified), but there is little or no lead for others. The idea that Indigenous people age prematurely is not well supported by this study of a series of discrete conditions. The current focus and type of services provided by the aged care sector may not be the best way to respond to the excessive burden of chronic disease and disability of middle-aged Indigenous people.

Geographic access to US Neurocritical Care Units registered with the Neurocritical Care Society.

Neurocritical care provides multidisciplinary, specialized care to critically ill neurological patients, yet an understanding of the proportion of the population able to rapidly access specialized Neurocritical Care Units (NCUs) in the United States is currently unknown. We sought to quantify geographic access to NCUs by state, division, region, and for the US as a whole. In addition, we examined how mode of transportation (ground or air ambulance), and prehospital transport times affected population access to NCUs. Data were obtained from the Neurocritical Care Society (NCS), US Census Bureau and the Atlas and Database of Air Medical Services. Empirically derived prehospital time intervals and validated models estimating prehospital ground and air travel times were used to calculate total prehospital times. A discrete total prehospital time interval was calculated for each small unit of geographic analysis (block group) and block group populations were summed to determine the proportion of Americans able to reach a NCU within discrete time intervals (45, 60, 75, and 90 min). Results are presented for different geographies and for different modes of prehospital transport (ground or air ambulance). There are 73 NCUs in the US using ground transportation alone, 12.8, 20.5, 27.4, and 32.6% of the US population are within 45, 60, 75, and 90 min of an NCU, respectively. Use of air ambulances increases access to 36.8, 50.4, 60, and 67.3 within 45, 60, 75, and 90 min, respectively. The Northeast has the highest access rates in the US using ground ambulances and for 45, 60, and 75 min transport times with the addition of air ambulances. At 90 min, the West has the highest access rate. The Southern region has the lowest ground and air access to NCUs access rates for all transport times. Using NCUs registered with the NCS, current geographic access to NCUs is limited in the US, and geographic disparities in access to care exist. While additional NCUs may exist beyond those identified by the NCS database, we identify geographies with limited access to NCUs and offer a population-based planning perspective on the further development of the US neurocritical care system.

Incorporating public health more closely into local governance of health care delivery: lessons from the Québec experience.

In 2004, the Quebec government undertook a major reorganization of its health care system by integrating public health more formally into local governance structures. In all, 95 new organizations - Health and Social Services Centres (CSSS)--were created and given a population-based responsibility. This mandate required that CSSSs broaden their range of services by adopting a population-based plan and integrating public health into their activities. To accomplish this, they needed to link public health and health care issues more formally within a single governance structure. The aim of this article is to identify and analyze various activities undertaken by CSSS managers to fulfill their population-based responsibility. We conducted a longitudinal case study of two CSSSs (2005-2008). Our analyses are based on real-time observations of 144 meetings of decision-makers/managers and professionals at the regional and local levels, 46 interviews with managers, as well as secondary data. CSSSs focused on five areas of population-based responsibility: primary health care, specialized services, vulnerable groups, health promotion and social services. Over time, the activities developed by CSSSs in relation to these five areas reflected an increasingly population-based perspective on the delivery of health care services. Service planning in the two cases under study is now based on a broader view of the health care continuum, and managers invest more time and resources in preventive interventions. Our study provides key information on the process of integrating a population-based perspective and preventive approaches in the planning and delivery of primary care services.

Incorporating Public Health More Closely Into Local Governance of Health Care Delivery: Lessons From the Québec Experience

Background and Objective: In 2004, the Quebec government undertook a major reorganization of its health care system by integrating public health more formally into local governance structures. In all, 95 new organizations – Health and Social Services Centres (CSSS) – were created and given a population-based responsibility. This mandate required that CSSSs broaden their range of services by adopting a population-based plan and integrating public health into their activities. To accomplish this, they needed to link public health and health care issues more formally within a single governance structure. The aim of this article is to identify and analyze various activities undertaken by CSSS managers to fulfill their population-based responsibility. Methods: We conducted a longitudinal case study of two CSSSs (2005-2008). Our analyses are based on real-time observations of 144 meetings of decision-makers/managers and professionals at the regional and local levels, 46 interviews with managers, as well as secondary data. Results: CSSSs focused on five areas of population-based responsibility: primary health care, specialized services, vulnerable groups, health promotion and social services. Over time, the activities developed by CSSSs in relation to these five areas reflected an increasingly population-based perspective on the delivery of health care services. Conclusion: Service planning in the two cases under study is now based on a broader view of the health care continuum, and managers invest more time and resources in preventive interventions. Our study provides key information on the process of integrating a population-based perspective and preventive approaches in the planning and delivery of primary care services. Key words: Population-based responsibility; public health; health care; Quebec

Integrating Public Health into Local Healthcare Governance in Quebec: Challenges in Combining Population and Organizational Perspectives

The quest for greater efficiency in health systems encourages governments to bring together two fields of practice that have largely developed in parallel in industrialized countries: public health and healthcare. Current healthcare reform in the province of Quebec formally integrates these two fields within a common governance structure. The objective of this paper is to discuss the issues arising from the integration of public health services into the planning and delivery of local healthcare services, and its potential effect on the overall performance of the healthcare system. The authors begin by describing the characteristics of these two sectors; then, they discuss current reforms in Quebec and the impact of various transitions (epidemiological, technological and organizational) that bring the sectors into greater convergence. The paper concludes with a discussion of obstacles and potential opportunities at two levels: (a) the development of population-based planning of services within healthcare organizations, and (b) the articulation of public health and healthcare services concerns at the local level. The ongoing reform in Quebec is a unique opportunity to maximize outcomes from the resources invested in the healthcare system, based on a collective vision for improving health. This paper was originally published in French, in the journal Pratiques et organisation des soins 39(2): 113-24.

Episodes of Care: To Include Primary Care is the Challenge

Population-based analysis and planning of health services should ideally cover all service utilization, with seamless care processes (across provider boundaries) as the observational units. The basic tool needed is an episode of care classification. Although hospital care has routinely been registered in computerized databases for decades, primary care has only recently been able to provide comparable patient data in an easily accessible form. We have designed a simple disease category system, which is easy to apply in routine registration in primary care, and which can be used in order to classify episodes of care. We have tested the feasibility of the approach by analysing one year of data in a data warehouse covering all health service utilization by citizens in the city of Helsinki, a total of over 4 million encounters. Results displayed, representing a small number of reports produced, include the treatment costs and volumes of the care episodes as classified in disease categories across health districts, and detailed analysis of `gross consumers' (patients with an annual treatment cost in excess of EUR 20,000), and patients treated in hospitals or long-term institutions.

Improving equity in the provision of primary health care: lessons from decentralized planning and management in Namibia.

This paper draws lessons from a review of primary health care services in Windhoek, the capital of Namibia, undertaken by a regional health management team. The review was carried out because of perceived increases in workload and inadequate staffing levels, arising from the rapid expansion of the city associated with inward migration. A survey of the utilization of government clinics was used to develop a more equitable allocation of primary health care services between localities. The survey revealed disparities between patterns of utilization of the services and the allocation of staff: the poorer localities were relatively underprovided. Decisions made centrally on resource allocation had reinforced the inequities. On the basis of the results of the review, the regional health management team redistributed nursing and medical staff and argued for a shift in the allocation of capital expenditure towards the poorer communities. The review demonstrates the potential for regional and provincial health management teams to make effective assessments of the needs of their populations and to promote the equitable delivery of primary health care services. In order to achieve this they need not only to become effective managers, but also to develop population-based planning skills and the confidence and authority to influence the allocation of resources between and within their regions and provinces.

Deaths Attributed to Pediatric Complex Chronic Conditions: National Trends and Implications for Supportive Care Services

Children with complex chronic conditions (CCCs) might benefit from pediatric supportive care services, such as home nursing, palliative care, or hospice, especially those children whose conditions are severe enough to cause death. We do not know, however, the extent of this population or how it is changing over time. To identify trends over the past 2 decades in the pattern of deaths attributable to pediatric CCCs, examining counts and rates of CCC-attributed deaths by cause and age (infancy: <1 year old, childhood: 1-9 years old, adolescence or young adulthood: 10-24 years old) at the time of death, and to determine the average number of children living within the last 6 months of their lives. We conducted a retrospective cohort study using national death certificate data and census estimates from the National Center for Health Statistics. Participants included all people 0 to 24 years old in the United States from 1979 to 1997. CCCs comprised a broad array of International Classification of Diseases, Ninth Revision codes for cardiac, malignancy, neuromuscular, respiratory, renal, gastrointestinal, immunodeficiency, metabolic, genetic, and other congenital anomalies. Trends of counts and rates were tested using negative binomial regression. Of the 1.75 million deaths that occurred in 0- to 24-year-olds from 1979 to 1997, 5% were attributed to cancer CCCs, 16% to noncancer CCCs, 43% to injuries, and 37% to all other causes of death. Overall, both counts and rates of CCC-attributed deaths have trended downward, with declines more pronounced and statistically significant for noncancer CCCs among infants and children, and for cancer CCCs among children, adolescents, and young adults. In 1997, deaths attributed to all CCCs accounted for 7242 infant deaths, 2835 childhood deaths, and 5109 adolescent deaths. Again, in 1997, the average numbers of children alive who would die because of a CCC within the ensuing 6-month period were 1097 infants, 1414 children, and 2548 adolescents or young adults. Population-based planning of pediatric supportive care services should use measures that best inform our need to provide care for time-limited events (perideath or bereavement care) versus care for ongoing needs (home nursing or hospice). Pediatric supportive care services will need to serve patients with a broad range of CCCs from infancy into adulthood.

Community care in South Thames (West) Region: is needs assessmentworking?

The objective of this study was to review the processes by which individuals' needs are being assessed andrelated to local eligibility criteria under the new arrangements for community care. An audit of the assessment process, definitions and measurement of need against Department of Health guidance was undertaken across the eight social services departments in South Thames (West) region. The results showed there is no standard approach to assessing needs: all social services have developed different assessment processes and different criteria for identifying needs. None use standardised measures of dependency such as the Barthel Index. Scales for measuring dependency have been developed locally so are not comparable between local authorities. Whilst local authorities have published eligibility criteria, in the main, these are purely descriptive accounts with considerable variation in practice in how local authorities are determining eligibility for services. In many authorities there remains ambiguity as to whether published eligibility criteria relate to eligibility for assessment or eligibility for services. Only one authority had attempted to quantify population needs and service provision in advance of setting its eligibility criteria. In conclusion, information collected on individuals cannot be aggregated for use in population-based planning, nor for monitoring purposes in any of the eight local authorities. National guidance is required on definitions of need and eligibility criteria. There is a need for a standardised core community data set, which embraces both health and social care.

Utilization of nursing home resources.

The total use and cost of nursing homes in Manitoba, for the fiscal year 1991/1992 were analyzed using a population-based health information system. The use of hospital beds by elderly patients for stays of 60 days or more was also analyzed to see if long hospital stays were substituting for nursing home beds. More than one in ten Manitobans 75 years of age and older and one in three who were 85 years and older resided in a nursing home for some time during the study period. The nursing home sector is characterized by none of the marked differences previously found in hospital use across the southern regions of the province, whose residents are similar in health and need characteristics. A single entry system, combined with a population-based planning approach, appears to provide equitable access to care across the province.