title: Redesigning clinical laboratory services: Securing efficient diagnoses for New Zealanders

authors: France, Necia

subjects: accounting

abstract: This monograph develops an evidence-based redesign plan for a key support service in the country’s health system. It is based on a doctoral thesis that evaluated the impact of market-style health resource control of New Zealand’s clinical laboratory services. The monograph summarises material detailed in the thesis, and extrapolates from it to make the following recommendations for improved cost-efficiency: 1) Competitive contracting as a means of price control for diagnostic laboratory services should be abandoned. 2) Laboratory remuneration should be cost-based and independent of specimen origin. 3) Costing methodology already developed and tested in Australia should be introduced here in order to define remuneration formulae. 4) A Laboratory Service Advisory Committee, representatives of clinical laboratories in both sectors, should provide service-related advice to the Ministry of Health. 5) Regionally representative laboratory committees should be charged with planning and co-ordinating district laboratory services, in the interests of cost-efficiency. 6) Interactive electronic expert systems should be developed in major regional laboratories as a counter to clinical laboratory misuse. 7) Technology retraining programmes aimed at achieving suitable medical laboratory technologist redeployment within the health system should be instated in main centres. Long-term, providers of workforce training should aim at developing greater flexibility in the health technology workforce.

text: Redesigning clinical laboratory services: Securing efficient diagnoses for New Zealanders This monograph develops an evidence-based redesign plan for a key support service in the country’s health system. It is based on a doctoral thesis that evaluated the impact of market-style health resource control of New Zealand’s clinical laboratory services. The monograph summarises material detailed in the thesis, and extrapolates from it to make the following recommendations for improved cost-efficiency: 1) Competitive contracting as a means of price control for diagnostic laboratory services should be abandoned. 2) Laboratory remuneration should be cost-based and independent of specimen origin. 3) Costing methodology already developed and tested in Australia should be introduced here in order to define remuneration formulae. 4) A Laboratory Service Advisory Committee, representatives of clinical laboratories in both sectors, should provide service-related advice to the Ministry of Health. 5) Regionally representative laboratory committees should be charged with planning and co-ordinating district laboratory services, in the interests of cost-efficiency. 6) Interactive electronic expert systems should be developed in major regional laboratories as a counter to clinical laboratory misuse. 7) Technology retraining programmes aimed at achieving suitable medical laboratory technologist redeployment within the health system should be instated in main centres. Long-term, providers of workforce training should aim at developing greater flexibility in the health technology workforce.

year: 2003-01

title: Toward a theory of the general-anesthetic-induced phase transition of the cerebral cortex. II. Numerical simulations, spectral entropy, and correlation times

authors: Steyn-Ross, D. Alistair

subjects: numerical simulations

abstract: In our two recent papers [M.L. Steyn-Ross et al., Phys. Rev. E 60, 7299 (1999); 64, 011917 (2001)] we presented clinical evidence for a general anesthetic-induced phase change in the cerebral cortex, and showed how the significant features of the cortical phase change (biphasic power surge, spectral energy redistribution, “heat capacity” divergence), could be explained using a stochastic single-macrocolumn model of the cortex. The model predictions were based on rather strong “adiabatic” assumptions which assert that the mean-field excitatory and inhibitory macrocolumn voltages are “slow” variables whose equilibration times are much longer than those of the input “currents” that drive the macrocolumn. In the present paper we test the adiabatic assumption by running numerical simulations of the stochastic differential equations. These simulations confirm the number and nature of the steady-state solutions, the growth of fluctuation power at transition, and the redistribution of spectral energy towards lower frequencies. We use spectral entropy to quantify these changes in the power spectral density, and to show that the spectral entropy should decrease markedly at the point of transition. This prediction agrees with recent clinical findings by Viertiö-Oja and colleagues [J. Clinical Monitoring Computing 16, 60 (2000)]. Our modeling work shows that there is an inverse relationship between spectral entropy H and correlation time T of the soma-voltage fluctuations: H∝- (ln T). In a theoretical analysis we prove that this proportionality becomes exact for an ideal Lorentzian process. These findings suggest that by monitoring the changes in EEG correlation time, it should be possible to track changes in the state of patient consciousness.

text: Toward a theory of the general-anesthetic-induced phase transition of the cerebral cortex. II. Numerical simulations, spectral entropy, and correlation times In our two recent papers [M.L. Steyn-Ross et al., Phys. Rev. E 60, 7299 (1999); 64, 011917 (2001)] we presented clinical evidence for a general anesthetic-induced phase change in the cerebral cortex, and showed how the significant features of the cortical phase change (biphasic power surge, spectral energy redistribution, “heat capacity” divergence), could be explained using a stochastic single-macrocolumn model of the cortex. The model predictions were based on rather strong “adiabatic” assumptions which assert that the mean-field excitatory and inhibitory macrocolumn voltages are “slow” variables whose equilibration times are much longer than those of the input “currents” that drive the macrocolumn. In the present paper we test the adiabatic assumption by running numerical simulations of the stochastic differential equations. These simulations confirm the number and nature of the steady-state solutions, the growth of fluctuation power at transition, and the redistribution of spectral energy towards lower frequencies. We use spectral entropy to quantify these changes in the power spectral density, and to show that the spectral entropy should decrease markedly at the point of transition. This prediction agrees with recent clinical findings by Viertiö-Oja and colleagues [J. Clinical Monitoring Computing 16, 60 (2000)]. Our modeling work shows that there is an inverse relationship between spectral entropy H and correlation time T of the soma-voltage fluctuations: H∝- (ln T). In a theoretical analysis we prove that this proportionality becomes exact for an ideal Lorentzian process. These findings suggest that by monitoring the changes in EEG correlation time, it should be possible to track changes in the state of patient consciousness.

year: 2001

title: Whanau Whakapakari: a Māori-centred approach to child rearing and Parent-training programmes

authors: Herbert, Averil May Lloyd

subjects: Whanau Whakapakari

abstract: The goal of this Whanau Whakapakari (Strengthening Families) research was to define critical aspects of Māori experiences and views on child-rearing practices, and to describe whanau (extended family) values and expectations for tamariki (children) and mokopuna (grandchildren).  Furthermore, these Māori views were included in culturally adapted parent-training programmes.  The overall aim was to devise an approach to emphasise client strengths and provide best outcomes for research participants.  Qualitative aspects included discussing the research processes in the Māori community by acknowledging the roles of whanau, hapu (sub-tribal), and iwi (tribal) structures.  I also identified the importance of pan-tribal and urban Māori groups in the current research.  As the project developed, an ongoing consultation and feedback protocol was established to ensure that Māori views on the research and the written outcomes were recognised.  In-depth interviews with kaumatua (elders), and focus groups with Māori service providers and Māori parents were analysed qualitatively to establish Māori values in child rearing and parenting, and the knowledge and skills that contribute to effective parenting and family functioning.  Values identified from these participants confirmed the central role of whanaungatanga (family connections), whakapapa (genealogy), and awhinatanga (support) for Māori. Two culturally adapted parent-training programmes, the Matuatanga (Parenting) Relationships Model and the Matuatanga Values Model programmes, were developed and compared with a Standard Parent Training programme.  The Matuatanga Relationships Model programme emphasised the importance of child, parent and whanau relationships and interactions.  The Matuatanga Values Model programme emphasised Māori values derived from the qualitative data - whanaungatanga, whakapapa and awhinatanga.  A range of pre- and post-training measures were undertaken to identify acceptable and appropriate measures for quantifying parent-training outcomes.  These included questions on support networks, parent expectations of children, parental self-efficacy, parental self-rating, critical-incident scenarios, and programme evaluation.  While 78 participants attended at least one of the research sessions 22 participants provided pre- and post-training measures for the Whanau Whakapakari programmes.  Results showed that there was a medium effect size improvement across all Standard Parent Training and Matuatanga Model programmes and a statistically significant improvement in the Standard Parent Training and Matuatanga Relationship Model programmes.  There were no statistically significant differences between the outcomes of the different programmes but qualitative differences from evaluation and feedback data were considered in identifying specific skills acquisition, general understanding and enjoyment components in the programmes.  Results from the different measures indicated that parent expectations and critical-incident scenario measures provided the most information on post-training changes.  Analysis of the outcome data with the attendance patterns confirmed the value of parent-training programmes per se and indicated that at least in the short term, parent effectiveness scores continued to improve for participants who continued to attend for more than one programme.  Programme follow-ups considered natural whanau supports in the Māori community and issues of social and cultural validity.  Integration of standard parent-training concepts and cultural concepts suggest a multi-dimensional approach which recognises parenting skills acquisition and cultural validation of whanau concepts relevant to parenting for Māori.

text: Whanau Whakapakari: a Māori-centred approach to child rearing and Parent-training programmes The goal of this Whanau Whakapakari (Strengthening Families) research was to define critical aspects of Māori experiences and views on child-rearing practices, and to describe whanau (extended family) values and expectations for tamariki (children) and mokopuna (grandchildren).  Furthermore, these Māori views were included in culturally adapted parent-training programmes.  The overall aim was to devise an approach to emphasise client strengths and provide best outcomes for research participants.  Qualitative aspects included discussing the research processes in the Māori community by acknowledging the roles of whanau, hapu (sub-tribal), and iwi (tribal) structures.  I also identified the importance of pan-tribal and urban Māori groups in the current research.  As the project developed, an ongoing consultation and feedback protocol was established to ensure that Māori views on the research and the written outcomes were recognised.  In-depth interviews with kaumatua (elders), and focus groups with Māori service providers and Māori parents were analysed qualitatively to establish Māori values in child rearing and parenting, and the knowledge and skills that contribute to effective parenting and family functioning.  Values identified from these participants confirmed the central role of whanaungatanga (family connections), whakapapa (genealogy), and awhinatanga (support) for Māori. Two culturally adapted parent-training programmes, the Matuatanga (Parenting) Relationships Model and the Matuatanga Values Model programmes, were developed and compared with a Standard Parent Training programme.  The Matuatanga Relationships Model programme emphasised the importance of child, parent and whanau relationships and interactions.  The Matuatanga Values Model programme emphasised Māori values derived from the qualitative data - whanaungatanga, whakapapa and awhinatanga.  A range of pre- and post-training measures were undertaken to identify acceptable and appropriate measures for quantifying parent-training outcomes.  These included questions on support networks, parent expectations of children, parental self-efficacy, parental self-rating, critical-incident scenarios, and programme evaluation.  While 78 participants attended at least one of the research sessions 22 participants provided pre- and post-training measures for the Whanau Whakapakari programmes.  Results showed that there was a medium effect size improvement across all Standard Parent Training and Matuatanga Model programmes and a statistically significant improvement in the Standard Parent Training and Matuatanga Relationship Model programmes.  There were no statistically significant differences between the outcomes of the different programmes but qualitative differences from evaluation and feedback data were considered in identifying specific skills acquisition, general understanding and enjoyment components in the programmes.  Results from the different measures indicated that parent expectations and critical-incident scenario measures provided the most information on post-training changes.  Analysis of the outcome data with the attendance patterns confirmed the value of parent-training programmes per se and indicated that at least in the short term, parent effectiveness scores continued to improve for participants who continued to attend for more than one programme.  Programme follow-ups considered natural whanau supports in the Māori community and issues of social and cultural validity.  Integration of standard parent-training concepts and cultural concepts suggest a multi-dimensional approach which recognises parenting skills acquisition and cultural validation of whanau concepts relevant to parenting for Māori.

year: 2001