Process-related Measures Research Articles

Protocol update for a randomised controlled feasibility trial of exercise rehabilitation for people with postural tachycardia syndrome: the PULSE study

BackgroundThe PULSE (PostUraL tachycardia Syndrome Exercise) study is a randomised controlled trial assessing the feasibility of conducting a multicentre RCT testing supervised exercise rehabilitation with behavioural and motivational support, compared to best-practice usual care, for people with Postural Tachycardia Syndrome (PoTS). The original trial protocol was published in BMC Pilot & Feasibility Studies (accessible at https://doi.org/10.1186/s40814-020-00702-1). The PULSE intervention consists of (1) individual assessment; (2) 12-week, twice-weekly, supervised exercise training; (3) behavioural and motivational support; and (4) guided lifestyle physical activity. The control intervention is best-practice usual care with a single 30-min, one-to-one practitioner appointment, and general advice on safe and effective physical activity.Sixty-two people (aged 18–60 years) with a confirmed diagnosis of PoTS will be invited to enrol on a feasibility RCT with an embedded qualitative study. The primary outcome will be feasibility; process-related measures will include eligibility, recruitment, randomisation and withdrawal rates, along with indicators of exercise programme adherence and acceptability. Secondary physiological, clinical and health-related outcomes will be assessed. In response to the COVID-19 pandemic, here we describe amendments to the trial protocol.MethodsRestrictions imposed by the COVID-19 pandemic meant it was necessary to change the delivery of the PULSE and control interventions. These changes reflected the need to limit the risk of COVID-19 transmission in a clinical population, some of whom were at increased risk of contracting the virus and suffering serious illness. The major change was that the originally intended centre-based PULSE and control interventions would now be delivered remotely on-line. Subsequently, there were minor changes to the participant eligibility criteria. These decisions followed an on-line co-creation session with people affected by PoTS, and relevant public and professional stakeholders.ConclusionsWe present an update of the original trial protocol in response to the COVID-19 pandemic. No participants were recruited to the original protocol; thus, results will reflect the on-line delivery of the intervention. PULSE will be the first randomised trial to assess the feasibility of conducting a definitive multi-centre RCT testing supervised on-line exercise rehabilitation with behavioural and motivational support, compared to best-practice usual care, for people with PoTS.Trial registrationISRCTN45323485 registered on 7 April 2020.

Protocol for a randomised controlled feasibility trial of exercise rehabilitation for people with postural tachycardia syndrome: the PULSE study

BackgroundPostural orthostatic tachycardia syndrome (POTS) is an autonomic nervous system disorder causing an abnormal cardiovascular response to upright posture. It affects around 0.2% of the population, most commonly women aged 13 to 50 years. POTS can be debilitating; prolonged episodes of pre-syncope and fatigue can severely affect activities of daily living and health-related quality of life (HRQoL). Medical treatment is limited and not supported by randomised controlled trial (RCT) evidence. Lifestyle interventions are first-line treatment, including increased fluid and salt intake, compression tights and isometric counter-pressure manoeuvres to prevent fainting. Observational studies and small RCTs suggest exercise training may improve symptoms and HRQoL in POTS, but evidence quality is low.MethodsSixty-two people (aged 18–40 years) with a confirmed diagnosis of POTS will be invited to enrol on a feasibility RCT with embedded qualitative study. The primary outcome will be feasibility; process-related measures will include the number of people eligible, recruited, randomised and withdrawn, along with indicators of exercise programme adherence and acceptability. Secondary physiological, clinical and health-related outcomes including sub-maximal recumbent bike exercise test, active stand test and HRQoL will be measured at 4 and 7 months post-randomisation by researchers blinded to treatment allocation. The PostUraL tachycardia Syndrome Exercise (PULSE) intervention consists of (1) individual assessment; (2) 12-week, once to twice-weekly, supervised out-patient exercise training; (3) behavioural and motivational support; and (4) guided lifestyle physical activity. The control intervention will be best-practice usual care with a single 30-min, one-to-one practitioner appointment, and general advice on safe and effective physical activity. For the embedded qualitative study, participants (n = 10 intervention, n = 10 control) will be interviewed at baseline and 4 months post-randomisation to assess acceptability and the feasibility of progressing to a definitive trial.DiscussionThere is very little high-quality research investigating exercise rehabilitation for people with POTS. The PULSE study will be the first randomised trial to assess the feasibility of conducting a definitive multicentre RCT testing supervised exercise rehabilitation with behavioural and motivational support, compared to best-practice usual care, for people with POTS.Trial registrationISRCTN45323485 registered on 7 April 2020.

Evaluating compliance with process-related quality metrics and survival in oral cavity squamous cell carcinoma: Multi-institutional oral cavity collaboration study.

Process-related measures have been proposed as quality metrics in head and neck cancer care. A recent single-institution study identified four key metrics associated with increased survival. This study sought to validate the association of these quality metrics with survival in a multi-institutional cohort. Multicenter retrospective study of patients with oral cavity squamous cell (1/2005-1/2015). Baseline patient and disease characteristics and compliance with quality metrics was evaluated. Association between compliance with quality metrics with overall survival (OS), disease-free survival (DFS), and disease-specific survival (DSS) was evaluated using Cox proportional hazards models. Failure to comply with two or more of the quality metrics was associated with worse OS, DFS, and DSS. Adherence to all or all but one of the quality metrics was found to be associated with improved survival. Process-related quality metrics are associated with increased survival in patients with oral cavity squamous cell carcinoma in a multi-institutional cohort.

Energy efficient machine tools

The growing global energy demand from industry results in significant ecological and economical costs. Aiming to decrease the impact of machining operations, an increasing number of research activities and publications regarding energy efficient machine tools and machining processes can be found in the literature. This keynote paper provides an overview of current machine- and process-related measures to improve the energy efficiency of metal cutting machine tools. Based on an analysis of the energy requirements of machine tool components, design measures to reduce the energy demand of main and support units are introduced. Next, methods for an energy efficient operation of machine tools are reviewed. Furthermore, latest developments and already available energy efficiency options in the machine tool industry are discussed. The paper concludes with recommendations and future research questions for more energy efficient machine tools.

A detailed review on current status of energy efficiency improvement in the Swiss industry sector

While quantitative methods for tracking the evolution of energy efficiency (EE) in industry do exist, these cannot always be directly applied, mainly due to lack of data on physical activity levels, as encountered in Switzerland. Therefore, a bottom-up method is developed and tested for estimating the sectoral physical activity levels in Switzerland. On this basis, sector-specific EE indices are determined. The results show that during the period 2009–2016, EE improved most in the paper sector (3.3% p.a.), followed by minerals (2.3% p.a.) and food (1.6% p.a.) sectors while the levels have remained approximately unchanged in chemical and metal sectors. Furthermore, the annual change in final energy demand was decomposed into changes of physical production, price levels and EE. The analysis concluded that only the food sector performed well according to all performance indicators. The detailed analysis of the Swiss target agreements’ data has revealed major final energy savings in chemical and food sectors during the period 2000–2016. Among the different categories of EE measures, process related measures have proven to yield the highest energy savings across all sectors. The results indicate the successful implementation of EE measures in Swiss industry, favored by the relatively strict Swiss regulatory framework and its target agreement mechanism.

Routine incorporation of longer-term patient-reported outcomes into a Dutch trauma registry

PurposeRoutine collection of post-discharge patient-reported outcomes within trauma registries can be used to benchmark quality of trauma care. This process is dependent on geographic and cultural context, but results are lacking regarding the European experience. We aimed to investigate the feasibility of routine inclusion of longer-term patient-reported health-related quality of life (HRQoL) in a Dutch National Trauma Database (DNTD) and to characterize these outcomes in a prospective cohort study.MethodsAll adult patients (≥ 18 years) who presented for traumatic injury in 2015–2016 and met the inclusion criteria of the DNTD were included. Inclusion criteria of the DNTD are presence of traumatic injury, hospital presentation within 48 h from trauma and hospital admission for treatment of traumatic injury or immediate mortality from traumatic injury after presentation. Exclusion criteria were death, mental impairment, insufficient command of Dutch language and residency outside the Netherlands. Primary outcomes were process-related measures of feasibility (response rate, response methods and reasons for non-response). Secondary outcomes were HRQoL measures [EuroQOL 5-Dimensions 3-Level (EQ-5D-3L) with added cognitive dimension and Visual Analogue Scale (EQ-VAS)].Results2025 unique patients met the initial inclusion criteria, with 1753 patients eligible for follow-up. Of these, 1315 patients participated (response rate 75%). The majority of questionnaires, 990 (75%), were completed on paper, with an additional 325 (25%) through telephone interviews. Primary reason for non-response was lack of contact information (245/438 non-responders; 56%). Median EQ-5D score was 0.81 (IQR 0.68–1.00) (mean 0.74; SD 0.31) and median EQ-VAS score was 78 (IQR 65–90). Compared to a Dutch reference population (mean EQ-5D = 0.87), EQ-5D scores were significantly lower (p < 0.001).ConclusionsRoutine collection of HRQoL is feasible within European health systems, like in the Netherlands. Further integration of these measures into trauma registries may aid worldwide benchmarking of trauma care quality.

An innovative implementation strategy to improve the use of Dutch guidelines on hypertensive disorders in pregnancy: A randomized controlled trial.

To evaluate the effectiveness of an innovative strategy to improve implementation of evidence-based guidelines on the management of hypertension in pregnancy compared to a common strategy of professional audit and feedback. Cluster randomized controlled trial (c-RCT). Sixteen Dutch hospitals. All patients with a hypertensive disorder during pregnancy who were admitted to one of the participating hospitals between April 1st 2010 and May 1st 2011, were suitable for inclusion; the only exclusion criterion was the presence of lethal fetal abnormalities. Hospitals were randomly assigned to either an innovative implementation strategy including a computerized decision support system (DSS) and professional audit and feedback or a minimal implementation strategy of audit and feedback only. Primary outcome measure was a combined rate of major maternal complications. Secondary outcome measures included process-related measures on guideline adherence, and patient-related outcomes. A process evaluation was performed alongside. No statistically significant difference was found in both the occurrence of major complications and most secondary outcome measures between the two groups. Process evaluation showed limited use of the computerized DSS, with a large variation between hospitals (0-49,5% of the eligible patients), but positive experiences of actual users. Using a computerized DSS for implementation of the clinical guidelines for the management of hypertension in pregnancy did not result in fewer major maternal and fetal complications. Limited use of the DSS in the innovative strategy group could be an explanation for the lack of effect.

Intergenerational Continuity in Adverse Childhood Experiences and Rural Community Environments.

To understand the role of the community environment on intergenerational continuity in adverse childhood experiences (ACEs) among a rural White sample. Parents in 12 counties in rural Iowa reported retrospectively on their own ACEs in 1989. We measured their child's ACEs retrospectively and prospectively across adolescence (n = 451 families). We measured structural and social process-related measures of community environment (i.e., community socioeconomic status, parents' perception of community services, perceived community social cohesion, and neighborhood alcohol vendor density) on multiple occasions during the child's adolescence. The 4 measures of community environment were all correlated with the child's ACEs, but only alcohol vendor density predicted ACEs after inclusion of covariates. Intergenerational continuity in ACEs was moderated by both social cohesion (b = -0.11; SE = 0.04) and alcohol vendor density (b = -0.11; SE = 0.05). Efforts to increase community social cohesion and manage alcohol vendor density may assist families in breaking the cycle of maltreatment across generations.

The effects of safety checklists in medicine: a systematic review

Safety checklists have become an established safety tool in medicine. Despite studies showing decreased mortality and complications, the effects and feasibility of checklists have been questioned. This systematic review summarises the medical literature aiming to show the effects of safety checklists with a number of outcomes. The Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement was used. All studies in which safety checklists were used as an additional tool designed to assure that an operation or task was performed as planned were included. The initial search extracted 7408 hits. Twenty-nine articles met the inclusion criteria. Five additional studies were identified by a cross-referencing search. Four groups were made according to outcome measures. One group (n = 7) had 'hard' outcome measures, such as mortality and morbidity. The remaining studies, reporting 'softer' process-related measures, were divided into three categories: adherence to guidelines (n = 6), human factors (n = 16), and reduction of adverse events (n = 5). The main findings were improved communication, reduced adverse events, better adherence to standard operating procedures, and reduced morbidity and mortality. None of the included studies reported decreased patient safety or quality after introducing safety checklists. Safety checklists appear to be effective tools for improving patient safety in various clinical settings by strengthening compliance with guidelines, improving human factors, reducing the incidence of adverse events, and decreasing mortality and morbidity. None of the included studies reported negative effects on safety.

Vlot schrijven - Een multidimensioneel perspectief op ‘writing fluency’

This article presents a brief review of commonly used fluency measures in writing research. These ‘traditional’ measures are complemented with fluency indicators derived from keystroke logging. The data were collected from an experiment with 80 students writing two descriptive texts, one in their mother tongue and one in their second language. This study provided information on new measures to describe fluency, taking also more process related measures into account. Next, on the basis of a principal component analysis, a new multidimensional model is presented to better address the complexity of fluency in writing. The model consists of four dimensions: (a) production, (b) process variation, (c) revision, and (d) pause behavior. Finally, in an additional case study - focusing on the use of digital sources during writing - we explored a fifth component, viz. (e) source fragmentation. These five components create a multi-dimensional and differentiated perspective on writing fluency that can be further explored in follow-up studies.

Communicative diagnosis of cost-saving options for reducing nitrogen emission from pig finishing

Reducing nitrogen emission from livestock production is usually perceived as costly. Nevertheless, production process related measures addressing the transformation of input(s) into output(s) may result in a cost-saving reduction of nitrogen emission. This paper explores the separate and combined use of traditional key performance indicators and an environmentally adjusted Data Envelopment Analysis (DEA) to reveal firm-specific cost-saving mechanisms for pig-finishing farms. Traditional key performance indicators are easy to communicate but have shortcomings when assessing benchmarks for comparative farm analysis. The environmentally adjusted DEA decomposes both cost and environmental efficiencies into technical and allocative efficiency components, separating the physical production analysis from price and nutrient content information. DEA makes efficiency benchmarks and improvement paths explicit, but the practical value of such efficiency scores is low. This paper proposes to take advantage of both methods: concrete benchmarks and eligible improvement paths are assessed using frontier methods, while the decision variables that steer farmers towards changes are described in terms of traditional key performance indicators. This leads to an improved diagnosis that is easy to communicate to farmers and may therefore facilitate decision support. Our pig-finishing case study shows that farms can achieve economic-environmental win–win situations through improving technical, cost allocative and cost efficiencies, which are mainly driven by feed conversion. Less technical efficient farms are found to require a lower delivery weight in order to minimize costs, which shows the farm-specificity of economic-environmental improvement advice.

Identifying Error-Prone Software—An Empirical Study

A major portion of the effort expended in developing commercial software today is associated with program testing. Schedule and/ or resource constraints frequently require that testing be conducted so as to uncover the greatest number of errors possible in the time allowed. In this paper we describe a study undertaken to assess the potential usefulness of various product-and process-related measures in identifying error-prone software. Our goal was to establish an empirical basis for the efficient utilization of limited testing resources using objective, measurable criteria. Through a detailed analysis of three software products and their error discovery histories, we have found simple metrics related to the amount of data and the structural complexity of programs to be of value for this purpose.