Econometrics Essay Example | Topics and Well Written Essays - 3750 words

Econometrics - Essay Example Macintosh despite everything sells its PC straightforwardly to the clients utilizing an online store through different outlets in the worldwide space (Geweke, Horowitz and Pesaran, 2008). Simultaneously, Apple stores sell its items by means of other retail outlets, for example, the mass-showcase merchants. By examination, Apple and Gateway are practically equivalent in their size. They likewise react to their business challenges utilizing comparable market systems. The two firms are encountering different noteworthy challenges in the current market. The passing of Steve Jobs especially influences Apple’s stock return and makes it decrease in its whole economy and money related execution. This is particularly evident with the deals of PCs. The bookkeeping practices of Apple Inc. are firmly agreeable with the worldwide norm and give a declining execution in correlation with the Jobs time. The two organizations Apple and Gateway show an incomes decrease for the years somewhere in the range of 2011 and 2013. Apple declined by 16.7% while Gateway declined by 14.6% from 2012 to 2013. Throughout the fall in income for the two organizations, Apple figured out how to decrease its working use by 4%. In the occasion, Apple is working income decreased by 43 % (Angrist and Pischke, 2010). Apple likewise had positive outcomes from its speculations just as in the intrigue pay. Then again, Gateway experienced negative outcomes in similar angles. The aggregate effects of the various exhibitions were extremely poor for Gateway rather than Apple. Between the year 2011 and 2013 Apple declined in net gain by 54.7%. Apple had a groundbreaking operational return undoubtedly. Its fast proportion had multiplied. Benefit and Return on Equity expanded very nearly multiple times while its stock administration expanded in excess of multiple times quicker. These variables were the main impetus for the principal budgetary highlights and contrasts. The crucial factor for the negative advancements in Apple after the

Different Topics Writings

The accompanying sentence is a case of Engfish: â€Å"The Nixon years are maybe the most all around recollected and least overlooked according to the American individuals. † I picked this model since it was a sentence that I really composed for a history paper. In the wake of realizing what Engfish was, I was somewhat shocked to discover this sort of writing in my OWN papers! In addition to the fact that I stated that the Nixon years were the â€Å"most† very much recollected that, I proceeded to additionally explain the way that they were likewise the â€Å"least† forgotten.Of course, it's implied that if something is the most recalled that, it is additionally the least overlooked, yet without my own voice yet found, and not recognizing what my educator â€Å"wanted† or â€Å"was looking for†, I composed like this †to occupy space and sound more formal. Taking a gander at it now, it appears to be amusing. I could have just composed, â€Å"no one will ever overlook the Nixon years†. Let’s not overlook â€Å"in the eyes of the American people†.First of all, individuals don’t recall things in their eyes, and more than the American individuals will recollect the Nixon years. In the event that I needed to limit the subject, I could have composed, â€Å"America will always remember the Nixon years. † Fabulous Reality: The fenced-in school yard reverberated of ricocheting balls, hop rope drones, creaky swing chains and the crashing of enthusiastic kids pushing and pulling going back and forth. At the front of the one story building was an indication that said â€Å"Parent Teacher Conferences Oct. 27-29 and Fall Festival October 30†.On the west side of the boring block fabricating that confronted the stone and black-top play area, there were some split windows taped with conduit tape outwardly, while children’s craftsmanship and beautiful drapes adorned the inside. The blocks of t he medium estimated fabricating were enriched with dark scrawls from shower paint jars. Adolescents †former student of the structure †expressing that they had been there, whom they cherished, and what instructors they detested. In the midst of the scrawls emerged a huge yellow smiley face, totally round with oval eyes and a wide dark grin. There was a bleeding shot gap in its head.Metaphor/likeness 1: My life partner is superior to the best server at the best eatery. He regards my emotions as though they were the most significant porcelain dishes, with delicate gloves, and brisk and light consideration. He waits in my neck to get my fragrance as would a wine sweetheart with a jug of recently opened wine. He has an artist’s eye for my eyes, gazing at them and contemplating them to discover what lies underneath. I feel like a million bucks and he is the mogul, keeping close tabs on me, however allowing me to develop and work into something more as he the two parades a nd secures me.Metaphor/comparison 2: The child’s coos are better than the best melody at any point created or heard. Her eyes are more lovely than the reflection off of the dark blue water when it gets the sun on its most splendid days. Her grin is as earnest as her parent’s love for her. Her cries are just impressions of need, not misery. At the point when others are around her, her delight is spread as effectively as warm margarine on warm bread. Her excellence is as obvious similar to her reality. This small child young lady brings more warmth and delight than a Christmas day fire, yet she doesn't have any acquaintance with it.

A Psychological Perspective of The Turn of the Screw Essay -- Henry Ja

A Psychological Perspective of The Turn of the Screw  â â â Henry James was one of the popular scholars during the nineteenth and mid twentieth hundreds of years. He was known as an inventive and autonomous author. One of James' books, The Turn of the Screw (1898), has caused a great deal of contention among numerous pundits, and every one of them has had a specific translation. James' exploratory writing fabricated a nearby association between his novel and his perusers. The responses of the perusers toward The Turn of the Screw can be investigated mentally by breaking down how James built up his story utilizing sketchy occurrences, an inconsistent storyteller, unforeseen changes, an intriguing introduction, and compelling pictures and words. The impacts of James' composition on his perusers can be clarified unmistakably from a mental viewpoint. Perusers have their individual observations and encounters which are characterized as sense of self. Sigmund Freud called attention to that under the impacts of the outer world, the sense of self begins to respond in different structures, for example, putting away, adjusting, learning, or battling against outside occasions (2). The outer world incorporates all the things occurring outside human personalities, for example, exercises, in actuality, in films or in books. At the point when perusers respond to the practices of the Governess and different characters in The Turn of the Screw, it implies their self image reacts to the story that is the outer world for this situation. Since the recognition and encounters of every individual are not the same as the other, the responses to this novel are changed. Additionally, James' story was written in a modern way, which is probably going to prompt complex responses. Henry James capably has his perusers coordinated into his story. While the perusers are understanding T... ...Screw. Works Cited Auchincloss, Louis. Perusing Henry James. Minneapolis: University of Minnesota Press, 1975. Freud, Sigmund. An Outline of Psycho-Analysis. New York: W. W. Norton and Company, Inc., 1969. James, Henry. The Turn of the Screw. The Turn of the Screw and Other Short Novels. New York: New American Library, 1995. Luckacher, Ned. 'Hanging Fire': The Primal Scene of The Turn of the Screw. Henry James' Daisy Miller, The Turn of the Screw, and Other Tales:. Ed. Horold Bloom. New York: Chelsea House Publisher, 1987. 117-132. Nunning, Ansgar. Questionable Narrator. Encyclopedia of the Novel. Ed. Paul Schellinger. Chicago: Fitzroy Dearborn, 1998. 1386-1388. Wagenknecht, Edward. The Tales of Henry James. New York: Frederick Ungar Publishing Co., 1984. - . Seven Masters of Supernatural Fiction. New York: Greenwood Press, 1991.

The Future of Printed Books in the Digital Age Essay #2 - 550 Words

The Future of Printed Books in the Digital Age #2 (Essay Sample) Content: The Future of Printed Books in the Digital AgeStudents NameUniversity AffiliationThe Future of Printed Books in the Digital AgeBooks are cultural tools, which have undergone considerable changes since their inception. In the early times, books took the form of stones and clay tables, which, due to technology, evolved to the modernly printed book. Despite changes, the objective of books remained the same, which is, storing and preserving information. The storage and preservation of information have made it possible over the years to gain substantial knowledge. Therefore, the printed book will forever remain the most useful invention in learning (Bruccoli, 2007). On the other hand, professionals from libraries and publishing groups have commented that, the future usage of the printed books is on the decline taking into account the swiftly evolving technologies. The fear arises because digitalization has made it possible to provide printed books in electronic forms known as e-books, which has made it easier to access information. The threat is significant considering the wide usage e-books as the primary electronic contents in learning (Buzzeto-More, Nicole, Elaboid, 2007). The question on the future of printed books in the digital age has induced mixed reactions. While some scholars feel that printed books will survive the digital age, others have commented that digitalization will cause the death of printed books. Scholars in opposition to digitalization suggest that, digitalization of printed books reduces them to mere objects on the screen, which disqualifies them as books. E-books do not allow for sustained reading, which will result to poor reading techniques (Bruccoli, 2007). The supporters of digitalization have referenced the extensive usage of handheld devices, and the computer. The devices enhance portability of e-books and people can access e-books at their convenience. However, handheld devices battery life, readability, screen size a nd slow page turning are challenges that have continued to persist. Then again, it is undisputable that it is easier to trace words on a computer than when using the printed book. The availability of printed books online has resulted to copyright issues, which has seen many authors seek digital encryption, whereas others have denied access to their books (Buzzeto-More, Nicole, Elaboid 2007). In terms of profitability, some e-books are accessible free of charge, and authors are on the verge of losing money. Therefore, some authors are likely to follow a printed approach rather than the e-book approach to ensure they earn a living from the same. It is notable that the some societies are not in favor of printed books, but this does not make it conclusive that printed books will no longer feature in the society. In this context, the Digital Publishing Forum reported in the year 2006 that, despite the high numbers of hours spent by people on computers, people do not read at length on th e computers. Therefore, some will prefer printing when the reading material is three to four pages (Buzzeto-More, Nicole, Elaboid, 2007). Digitalization is dependent on the internet, ... The Future of Printed Books in the Digital Age Essay #2 - 550 Words The Future of Printed Books in the Digital Age #2 (Essay Sample) Content: The Future of Printed Books in the Digital AgeStudents NameUniversity AffiliationThe Future of Printed Books in the Digital AgeBooks are cultural tools, which have undergone considerable changes since their inception. In the early times, books took the form of stones and clay tables, which, due to technology, evolved to the modernly printed book. Despite changes, the objective of books remained the same, which is, storing and preserving information. The storage and preservation of information have made it possible over the years to gain substantial knowledge. Therefore, the printed book will forever remain the most useful invention in learning (Bruccoli, 2007). On the other hand, professionals from libraries and publishing groups have commented that, the future usage of the printed books is on the decline taking into account the swiftly evolving technologies. The fear arises because digitalization has made it possible to provide printed books in electronic forms known as e-books, which has made it easier to access information. The threat is significant considering the wide usage e-books as the primary electronic contents in learning (Buzzeto-More, Nicole, Elaboid, 2007). The question on the future of printed books in the digital age has induced mixed reactions. While some scholars feel that printed books will survive the digital age, others have commented that digitalization will cause the death of printed books. Scholars in opposition to digitalization suggest that, digitalization of printed books reduces them to mere objects on the screen, which disqualifies them as books. E-books do not allow for sustained reading, which will result to poor reading techniques (Bruccoli, 2007). The supporters of digitalization have referenced the extensive usage of handheld devices, and the computer. The devices enhance portability of e-books and people can access e-books at their convenience. However, handheld devices battery life, readability, screen size a nd slow page turning are challenges that have continued to persist. Then again, it is undisputable that it is easier to trace words on a computer than when using the printed book. The availability of printed books online has resulted to copyright issues, which has seen many authors seek digital encryption, whereas others have denied access to their books (Buzzeto-More, Nicole, Elaboid 2007). In terms of profitability, some e-books are accessible free of charge, and authors are on the verge of losing money. Therefore, some authors are likely to follow a printed approach rather than the e-book approach to ensure they earn a living from the same. It is notable that the some societies are not in favor of printed books, but this does not make it conclusive that printed books will no longer feature in the society. In this context, the Digital Publishing Forum reported in the year 2006 that, despite the high numbers of hours spent by people on computers, people do not read at length on th e computers. Therefore, some will prefer printing when the reading material is three to four pages (Buzzeto-More, Nicole, Elaboid, 2007). Digitalization is dependent on the internet, ...

Essay The Importance of Music Education - 1936 Words

Opening the invigorating article, â€Å"Why Music Education? 2007† having so many atrocities pulling the world apart, music is a great way for bringing people together (9). Diagnosed with a severe case of autism and blindness at birth, Derek Paravacini is viewed as a music savant. He has the extraordinary ability to play a music piece after just hearing it. Derek has been engrossed by the piano since the age of two and has been performing around the world since the age of nine. From studying various music genres, at age 32 he his able to transform an elegant classical piece into an upbeat jazz piece. His virtuosity has no limit as he continues to absorb every bit of knowledge pertaining to music. School boards that are cutting music†¦show more content†¦With a music education, some students who lack the money for an advancement in musical interests benefit in their educational career more than students in upper class communities. Catterall writes that students in low- income communities do better in schools with music programs (1).According to the article â€Å"Benefits of Musical Education†, in schools providing high- quality music educ ation programs, standardized tests score higher than the schools that offer deficient music education programs, despite the socioeconomic level of the community (1). With higher scores on tests, the school’s community will take more pride its school, in turn giving the school more support. Research proves that schools that provide a music education prosper far more efficiently in other qualities other than just rewarding grades. With challenging classes that students struggle with, art based programs offer a moment of relief in a student’s day. In the acclaimed article Students in music programs have better attendance records and prove to be more active in community affairs (â€Å"Benefts†¦Ã¢â‚¬  2).Having the ability to express one’s self through music will potentially keep that student from expressing themselves in hoodlum activities, helping the community obtain safety. In the acclaimed article â€Å"Why Music Education? 2007† the author explain s programs of music not only benefit kids in school, but the community as well (2). Music not only benefits a person inShow MoreRelatedThe Importance of Music in Education1426 Words   |  6 Pages2015 Final Paper The Importance of Music in Education Whether we choose to believe it or not, music is a very present thing in one’s day to day lifestyle. From turning on the radio in the morning, to listening to it while grocery shopping, putting in our headphones while we study, music is always there. Music is also extremely underrated, which is why so many public schools are constantly threatening to take away music programs all the time. But why is music education so vital in the growth ofRead MoreThe Importance Of Music Education790 Words   |  4 PagesTime Music education is a subject in school that should be essential for all students. If students continued to expand their music education, they would have higher test scores in subjects such as math and English. Having a school system where everyone is able to benefit from a school wide requirement of music education. Music education will help improve student test scores and improve students language development. Students who take music classes have higher test scores. Music education helpsRead MoreThe Importance Of Music Education2171 Words   |  9 PagesThe Importance of Music Education Perhaps the largest distinction between humans and all other animals on earth is the ability to both create and appreciate fine art. The musical art form has existed for thousands of years, and has allowed different cultures to express themselves and connect with one another. The most primitive sounds were simply drum hits and clapping, but over time music has grown in sophistication. Now, complicated symphonies can be heard in halls all across the world, with aRead MoreThe Importance of Music Education Essay951 Words   |  4 Pagestoday’s society? Some say that music education is a waste of valuable resources, takes time away from academic subjects, is noisy and distracting, when in reality this is false. Music is a valuable resource that every human being should enjoy. Although our economy has been failing lately, we should not let ourselves believe that the only way to be productive is in a field that makes us unhappy, like computers or science. In America’s recen t economic downfall, music education is commonly one of the firstRead MoreThe Importance of Music Education Essay885 Words   |  4 PagesImagine a world without music; it would be an extremely boring and quiet place to live. Music is found in every kind of culture and has been used for thousands of years as a means of expression. Music can deliver a message; it can be used as a vehicle for poetry; it can be appreciated for its aesthetic qualities, or it can serve as nothing more than entertainment. Recently, many studies have been conducted proving that music is vital to a childs education and development. However, many schoolRead MoreThe Importance and Effects of Music Education Essay examples1944 Words   |  8 Pages Music evaluated as a subjects that is many times overlooked. If a school seems to have financial trouble, then music and art programs are the first to get cut. Essentially, students do not need them to succeed and they are just hobbies. This is the mindset that many school boards have towards music education. I have had the pleasure of being involved in music from a young age. My schools did not offer music programs, but my parents saw an opportunity in music education so they decided to lookRead MoreEssay on The Importance of Music Education in the School Curriculum2336 Words   |  10 PagesMusic is all around us, yet many of us do not understand it. A simple man with an office job that you pick randomly off the street could most likely tell you the basic rules of American Football, and yet that same man could have never played football in his life before. If you asked that same guy the basics of the music he is listening to, I bet you would get a blank stare back. My argument relates directly to schools so many people can reason football is not technically taught in school, but whatRead MoreHigh School And The Neural And Scholastic Benefits Essay1626 Words   |  7 PagesGerald Ford said, â€Å"Music education opens doors that help children pass from school into the world around t hem a world of work, culture, intellectual activity, and human involvement. The future of our nation depends on providing our children with a complete education that includes music.† Music can do so much for the youth of the nation because it encourages group cooperation, independent study, and a way to relax. It has often been debated whether the benefits of music in school are significantRead MoreLiterature Review on Music Education Essay1000 Words   |  4 PagesLiterature Review This complex problem of music education has been studied for many years. Some disciplines go off of one another to conduct studies and analyze one’s results. Music educators tend to study how music education came to be. They are huge advocators for music education because of the benefits that come with the programs. Psychologists have studies done around the world to see what the affects of having knowledge in the subject of music are. With so many studies done, there are so manyRead MoreSchools Should Provide Better Funding For Such Programs1734 Words   |  7 Pagesschool years. Do you remember going to music classes? Learning how to pluck out simple songs on the piano, a xylophone, or a recorder; or learning how to sing out a catchy tune? Did you have as much fun as I remember having? This fun is about to come to an end for the coming generations. Public schools are beginning to cut music programs from their budgets altogether, so our children may never know the sweet sol ace of scratching out a simple song. Generally, music programs-- as well as fine arts as a

Working With College Students At California State University

I was drawn to working with college students when I moved into my residence hall as a first-year college student. When I moved into Jenkins Hall at California State University, Sacramento I found what would become my home for the next year. I became a part of the Residence Hall Association and a student leader in my community. I took on the position in order to help me as I transitioned into college, it helped with becoming accustomed to college and gave me a sense of belonging. Being the first in my family to go to college as well as a first-generation student I was given more opportunities than my families before me. There was nobody I could turn to with the questions I had about my college experience. For one of the few times in my†¦show more content†¦I believe that through the opportunity to research the different aspects of students’ lives I will learn different needs from both theory and practice. Throughout my life networking has been one of the areas that I have struggled with. The degree and the curriculum structure would allow me to grow both personally as well as professionally. The program will allow me to develop relationships through the structure of the cohort program. The cohort system will not only allow me to develop a network of systems within student affairs but will also give me the opportunity to become friends with like minded individuals. However, earning a graduate degree would be a stepping stone into beginning my career as a student affairs professional. The degree would allow me to begin by working in residence life which will contribute to my understanding of the importance of living on campus for overall student success. After obtaining the knowledge and skills necessary I will continue my education and obtain a doctorate which will allow me to conduct further research and take on more leadership roles within student affairs. The professional long-term goal is to become a Director for student retention and academic success at a university which will allow me to accomplish and bring together all of my three goals in one position. Personally, obtaining a master’s will allow me toShow MoreRelatedEssay For Executive Director954 Words   |  4 Pagesthe University of California Office of the President. I believe the University of California’s commitment to excellence, diversity, and access aligns with my vast experience, skills, values, and passion of working to ensure college access and opportunity for students. My extensive experience in the realms of K-12, Higher Ed, and UC Outreach make me an excellent candidate for this position. For more than twenty-seven years, I’ve worked to expand college preparation and access for students in CaliforniaRead MoreEveryone Will Benefit From Lower Tuition934 Words   |  4 Pageseducation. College costs have skyrocketed in the last decade. As Webley writes in her essay about student debt, â€Å"tuition is increasing at a rate double that of inflation† (Webley 131). Students are not only paying for tuition, which is an average of $8,244, they also are required to purchase books and mandatory meal plans, pay fees, and secure on-campus living (Clark). Students pay an average of $21,447 after all these costs (Clark). The cost of an education at a public university in California is wayRead MoreWhy Students Should Not Work934 Words   |  4 Pagesfor a college education is becoming increasingly inherent to upcoming students. Many students feel a need to work in order to pay for their education, but this can have mixed effects. Many fall off of their path of study a nd become entwined in a blue-collar life, they often cannot find their way out. A substantial amount of time and energy is required to flourish in college and a long shift at work can have a parasitic effect on a student’s academic potential. As a result working students find thatRead MoreA Proposal On A Modest Proposal1524 Words   |  7 PagesA Modest Proposal A college degree is becoming increasingly more valuable with many decent jobs requiring some sort of higher education. As more students prepare to enter college, many are faced with the escalating prices of not only tuition, but also other things such as textbooks and the cost of living. This problem has been especially prominent in California, particularly within the last month, due to the UC regent’s new and controversial plans for an in-state tuition increase of five percentRead MoreThe California State University System s Board Of Trustees1537 Words   |  7 Pages2017, the California State University system’s Board of Trustees voted yes to a tuition increase (Xia). Up until the morning before this decision arose, several California State University students were advocating for free tuition, or at least to stop this tuition increase, from Cal State Fullerton having postcards that can be signed to be sent to the Board of Trustees to students protesting in front of the Chancellor’s office in Long Beach (Xia). Although this battle was a lost for students, this isRead MoreOn March Twenty-Second, The California State University1386 Words   |  6 PagesOn March twenty-second, the California State University system’s Board of Trustees voted yes to a tuition increase (Xia). Up until the morning before this decision arose, several California State University students were advocating for free tuition, or at least to stop this tuition increase, from Cal State Fullerton having postcards that can be signed to be sent to the Board of Trustees to students protesting in front of the Chancellor’s office in Long Beach, students in this system statewide arguedRead MorePolitical Culture And Higher Education Regimes1738 Words   |  7 Pagesin order to ensure that all systems have a say in what policies are created to manage universities, with a Board of Regents directing over the state’s higher education. Both California and Louisiana’s systems operate differently, but have some similarities as well. California According to Kleiman and Gittell, political culture is â€Å"a combination of history and social factors,† and it has an impact on â€Å"state policies, including higher education† (in Brown et al., 2010, pp. 713). In California’sRead MoreCalifornia State University San Bernardino803 Words   |  4 PagesCalifornia State University San Bernardino California State University San Bernardino, located in the foothills of San Bernardino Mountains, serves over 20,000 students annually. The university has the most diverse student population of any university in the Inland Empire, and its listed among the best colleges and universities in the western United States ( The Princeton Review, 2015).The nationally accredited university has more than 70 traditional programs offered to students, which include baccalaureateRead MoreHow to Better a Community; Step One: College Students1711 Words   |  7 PagesJacob Schekman Julio Leal English 1A 6 July 2009 How to Better a Community; Step One: College Students â€Å"I went to a large state school – the University of Illinois – and during my time there, I became one of the best two or three foosball players in the Land of Lincoln. I learned to pass deftly between my rigid players, to play the corners, to strike the ball like a cobra would strike something a cobra would want to strike. I also mastered the dart game called Cricket, and the billiardsRead MoreThe Factors Influencing California Teacher Credentialing1130 Words   |  5 PagesTopic Proposal From the time California was admitted to the Union through today, the requirements for formal educators have continuously evolved. Multiple factors have influenced these changes. The economy, changes in immigrant communities, as well as scientific research on social emotional, physical and cognitive development of students. Changes in teaching style trends have also been influenced by the same factors. The success of the education system in California continues to be dependent on

Evaluation of Corporate Performance

Question: Discuss about the Term for Evaluation of Corporate Performance? Answer: Introduction Lockheed Martin Corp is a company manufacturing security and aerospace equipment. The company operates through five segments: Aeronautics This segment is concerned with research, design, development and manufacture of military aircraft. Aeronautics is chiefly involved in development of designs and prototype applications. The Advanced Development Program of the organization, known as the Skunk Works, has been focussing on unmanned aerial systems. Information Systems Global Solutions This segment is associated with applications and management of technology systems and information technology services for a wide range of applications. ISGS has been responsible for developing certain classified systems and services for Americas national security systems. The Hanford Mission Support system is one such program developed by the company for providing infrastructure and services related to site support to Americas Department of Energy, (Bakker Kloosterhof (ed.), 2010). Missiles Fire Control This segment provides defence systems, tactical missiles and precision strike weapons. MFC's primary programs include: The Patriot Advanced Capability3 (PAC3) and Terminal High Altitude Area Defence (THAAD) air and missile defence programs. The Special Operations Forces Contractor Logistics Support Services program is meant to provide logistic support services to special operation forces of U.S. military. The technical services business of MFC is meant to provide a wide network of technical and sustainment services for improving the missions of companys customers, catering to core markets in areas covering engineering servicesà Ã‚ ¾ Command, control, communications, computers, intelligence, surveillance and reconnaissance product supportà Ã‚ ¾ Global aviation solutionsà Ã‚ ¾ Counter threat services and education and sustainment services, (Bakker Kloosterhof (ed.), 2010). Mission Systems Training This segment is associated with combat systems. The primary programs of MST include: The Aegis Combat System, a fleet ballistic missile defence system which is also connected with sea based elements of the U.S. missile defence systemà Ã‚ ¾ The LCS, a surface combatant used by the U.S. Navy and designed to operate in shallow watersà Ã‚ ¾ MH-60 mission system and sensors, which includes the digital cockpit and weapons, used for the MH60 maritime helicopterà Ã‚ ¾ The TPQ53 Radar System, a sensor used by the US Army to locate and neutralize mortar and rocket threats. Space Systems This segment provides equipment for satellites, defence missile systems and space transportation systems. The Trident II D5 Fleet Ballistic Missile, a U.S. Navy program being used for launching of intercontinental ballistic missile by a submarine of the U.S. Navyà Ã‚ ¾ The Space Based Infrared System program, which is being used by the U.S. Air Force and is capable to detect and track the launch of missilesà Ã‚ ¾ An Advanced Extremely High Frequency system, which consists of communication satellites for the U.S. Air Forceà Ã‚ ¾ The Orion Multi-Purpose Crew Vehicle program, which is a spacecraft being developed for the National Aeronautics and Space Administration and is utilizing technology for human exploration missions beyond the low orbit of earthà Ã‚ ¾ Global Positioning System (GPS) III, a program which is being developed to modernize the GPS satellite system for the U.S. Air Force, (Bakker Kloosterhof (ed.), 2010). A Review of the Financial Statement Lockheed Martin Corp is a USA based multi-task, multi-purpose and multi-program organisation which is closely associated with the countrys military, space and national security programs. Incorporated in August 1994 in Bethesda, MD and having its Headquarters there since its inception, the organisation presently employs 126,000 people, who are looking after the companys five segments discussed above, (Ault, Arnold Gest, 2010). The companys current market capital outlay of $66,548 million, which is distributed through the companys 307,295,000 shares is held by the conglomerates 29,972 shareholders. The companys current share price is being quoted at $216.56 at NSY and the companys current PE Ratio stands at 18.897. With the current dividend declaration of $6.3, Lockheed Martin Corps present Earning Per Share (EPS) stands at $11.62, (Ault, Arnold Gest, 2010). Lockheed Martin Corp has been steadily increasing its Revenue Earnings since its inception in 1994 and has been consistently increasing its Gross Margin, which now stands at 11.27% and is among the highest in the segment, (Reynolds, Williams Savage, 2000). The robust structure and the management culture of the organisation is evident from the fact that the company has always shown a positive trend in its Operating Margin, which is currently at 11.78%. Another positive feature of the company, which again showcases the managements growth oriented policies, the consistency of services, the effective deployment of its manufacturing facilities and the range of products which it has been offering has helped the company show the financial accomplishments reflected in its financial statements, (Reynolds, Williams Savage, 2000). The management has also been efficiently managing and helping in the growth of companys Assets through proper planning and deployment of the assets for their growth and strength. This is reflected in the Asset Management policies and results which are showcased in the financial statements of the company. Asset Turnover is at 1.07, Inventory Turnover is reported at 10.44 and Receivables Turnover currently stands at 6.62. The efficiency of the management is also reflected in the 9.01 times turnover in the companys Property, Plant and Equipment, (Jorgenson Landon (ed.), 1993). When we look at the Financial Ratios of the company, we come across another bright spot in the managements acumen of managing people, finance and products. With a Quick Ratio of 0.65% and Current Ratio of 1.15%, the company has kept its lenders, investors and stakeholders satisfied and their loyalty has been reinforced in the managements policies by looking at the Net Current Assets to Total Assets Ratio at 4.36%. The Revenue to Assets ratio is also showing a healthy trend of the company at 0.94%. The management, as per (Richard (ed), 2014) not only kept the current assets under control, it was also instrumental in managing the debt situation of the company, by maintaining policies which were future oriented, provided growth of funds and kept the lenders loyal to the company. With a low ratio of 4.62 for Long Term Debt to Equity and maintaining Interest Coverage at 12.27 has been strengthening the companys future policies. The management also kept the Total Debt to Equity ratio at 4. 93, which is very close to the Long Term Debt to Equity ratio, (Richard (ed), 2014). Pro Forma Financial Statements Balance Sheet Income Statement Please Refer to Attached Excel Sheet. Ratio Analysis Liquidity Liquidity Ratio is the ratio between a companys liquid assets and its liabilities for a given period. For the current period ending 31 December 2015, this ratio for Lockheed Martin Corp stands at 0.65%. Financial Leverage The financial leverage ratio of Lockheed Martin Corp is the measure of the companys overall debt as compare with the assets of the company for a specific period. For the current period ending 31 December 2015, this ratio for Lockheed Martin Corp stands at 4.93%. Asset Management Asset Management Ratios measure the company management's success in managing its assets for generating revenues. These ratios are helpful in getting an insight into the success of the management's credit policy and inventory management. Under certain rules these ratios are also termed as Activity or Turnover Ratios. For the current period ending 31 December 2015, this ratio for Lockheed Martin Corp stands at 1.07. Profitability The companys Gross Margins and Operating Margin are the ratios which show the profitability of the company. For the current period ending 31 December 2015, these ratios for Lockheed Martin Corp stand at 11.27% and 11.78% respectively. Market Value The most common market value ratio is the Book value per share of a company. For the current period ending 31 December 2015, this ratio for Lockheed Martin Corp stands at 21.25%. Return On Equity For the current period ending 31 December 2015, this ratio for Lockheed Martin Corp stands at 110.97%. Economic Value Added For the current period ending 31 December 2015, this ratio for Lockheed Martin Corp stands at 38.93%. Synopsis Recommendations While analysing the financial data of Lockheed Martin Corp, it is evident that the company has been maintaining a robust financial, manpower and social governance culture, (Gibson Fraser, 2013). The loyalty of its lenders is evident from the fact that there are 1,400 institutions which have continuously reposed their faith in the abilities of Lockheed Martin Corp and its management. These institutions hold close to 82.83% of the companys share, numbering 286,310,309. In the current year, this faith of the institutions has shown a forward leap, when the shareholding pattern of the shares held by them surged to 90.58%. From the data released by NSY, this change has not resulted from the addition of new institutions, but has resulted because of an increased holding by the existing institutions, (Gibson Fraser, 2013). The robustness of the financial structure of the company is also shown by the surge in revenues for the period ending 31 December 2015 of three of the five segments of the company in comparison to revenues for period ending 31 December 2014, (Moens Jones (ed), 2013). These three segments are Aeronautics (from $14,920 million to $15,570); Mission Systems Training (from $7,147 million to $9,091); and Space Systems (from $8,065 million to $9,105). Only Information Systems Global Solutions (from $8,065 million to $9,105) and Missile Fire Control (from $8,065 million to $9,105) have shown a declining trend. Overall revenue receipts of the company have increased from $45,600 million to $46,132, (Moens Jones (ed), 2013). On the basis of these achievements which have become a kind of ritual for Lockheed Martin Corp, it is not out of context to recommend that this company can be treated as a role model not only for emerging entrepreneurs, management aspirants, share market investors and financial institutions but should also be considered as a worthy corporate citizen of the USA, a praiseworthy employer, a techno-giant of innovative ideas and a social corporation which has the welfare of society as its foremost goal. The advice of this author to investors, financial institutions and entrepreneurs is that they should look up to this company for emulating its ideas, ideologies and policies, (Schaffer, Agusti Dhooge, 2014). List of References Ault, H. J., Arnold, B. J. and Gest, G. (2010) Comparative income taxation: a structural analysis. (3rd ed.) Amsterdam: Kluwer Law International. Bakker, A. and Kloosterhof, S. (ed.). (2010) Tax risk management. Amsterdam: IBFD. Gibson, A. and Fraser, D. (2013) Business Law 2014. Frenchs Forest, NSW: Pearson Higher Education AU. Jorgenson, W. D. and Landon, R. (ed.). (1993) Tax reform and the cost of capital: an international comparison. Washington, DC: Brookings Institution Press. Moens, G. and Jones, R. (ed) (2013) International Trade and Business Law Review. Oxon: Routledge. Reynolds, W., Williams, A. J. and Savage, W. (2000) Your Own Business: A Practical Guide to Success. (3rd ed.) Sydney: Cengage Learning Australia. Richard, T.A. (ed) (2014) Professional Business Law Essays. New York: Richard TA. Schaffer, R., Agusti, F. and Dhooge, L. (2014) International Business Law and Its Environment. (9th ed.) Stamford, CT: Cengage Learning.

Willow Stores Target Market

Introduction Another name for target market is target audience. A target market is a particular group of consumers that a business targets. Businesses normally want to draw consumers closer and sell to them their goods and services. Factors that influence characteristics of a target market include economic class, age, location, gender, sexual orientation or ethnicity.Advertising We will write a custom report sample on Willow Stores Target Market specifically for you for only $16.05 $11/page Learn More Socio-economic classes enable business organizations to come up with a specific type of client who is likely to buy goods or services from the company. This means that businesses do not build goods and services randomly, without having specific target customers in mind. Target marketing enables businesses to locate their customers within a given population (Saunders 153). Identifying a market is an essential step for any form of business for its operation i n the long term. A business needs to identify its potential clients before taking steps of building the business in other areas. A business ought to define the most important traits of potential clients and identify the major ways in which the new business organization can fulfill the needs of the customer. This way it can easily spot a customer’s base (Maxwell 75). Background Information The study will take place between 15 February 2013 and 28 February 2013 with a view to establish a target market for â€Å"Willow† Creeks store. Willow Creeks store is a business that deals in home dà ©cor and furnishing at Yong and Egling areas both located in Toronto. Managers at Willow Creeks store postulate that the target market for Willow are women aged from 25 to 35 who are newly married, who need to furnish their home. This study aims to confirm, or nullify this hypothesis. Overall Purpose of the Research The main purpose of this research will be to determine the target marke t for Willow stores. That is, to find out who will buy the products that the company intends to sell in the stores as well as determine whether there is a large customer base for the proposed business. Research Objectives The main objective of this research will be to determine the target group of potential buyers. Postulated information indicates that most potential customers are women who range from 25 to 35 years, and this research aims at confirming or nullifying this postulation. The research will also aim at grouping the target customers according to their characteristics such as gender, income level, values, lifestyles, attitudes, hobbies, interests and marital status. Another objective will be identifying the location of its target market, particularly, whether they will be the newlyweds located in the urban area or those that live in the rural area.Advertising Looking for report on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More The last objective of this study will be to find out various techniques that competitors in the town use to sell their products, and the price at which competitors sell their products. Research Problems Businesses have to identify the right target customers for their products and services for them to prosper. However, distinguishing a particular segment from others is very technical and that is why most managers prefer to use surveys to ease the task. Research Questions What is the gender of the target market for new retro home accessory store â€Å"Willow† located on Yong Eglinton area? What is the age of the target market for new retro home accessory store â€Å"Willow† located on Yong Eglinton area? What is the income level of the target market for new retro home accessory store â€Å"Willow† located on Yong Eglinton area? What is the marital status of the target market for new retro home accessory store â€Å"Willow† located on Yong Eglinton area? How well do the products and services offered at new retro home accessory store â€Å"Willow† located on Yong Eglinton area meet the needs of customers? What are the personal values, interests and hobbies of the target market? What is the lifestyle and behavior of the target market? What is the location of the target market for new retro home accessory store â€Å"Willow† located on Yong Eglinton area? What is the location of Ethnic background of the target market for new retro home accessory store â€Å"Willow† located on Yong Eglinton area? What is the target market for our competitors? Research Methodology Research Design This research will obtain qualitative data using the questionnaires.. Qualitative method will be suitable for this study because the study aims at determining the target market for Willow stores. In other words, qualitative analysis is suitable for this study as it can offer a descriptive analysis of potential buyers, unlike quantitative analysis. Qualitative versus Quantitative Analysis Qualitative method collects data mainly in the form of open-ended questions, interviews and observations. Conversely, quantitative methods collect numerical data. The outcomes from quantitative research are easy to generalize. Nevertheless, the information formed by this method can be abstract and may not mirror a specific population, individual or circumstance. Qualitative method offers a better perception of the research problem through analyzing the first person experience, thus require only a smaller sample size to generate a more accurate result. Qualitative research is sufficient to describe complex events and offers case-by-case information that makes them suitable for cross case evaluation and analysis. To gain from advantages of each method this study will employ a mixed method. Instruments Instruments refer to tools used in data collection. In this research, Instruments will be participants, surveys, as well a s, open ended and multiple-choice questions. Questionnaire Procedure The researcher will give a questionnaire to each participant. The questionnaires will have pictures of the already set up Willow store and questions about the market that the store is likely to attract. Questions will be both open ended and multiple choice and they will aim at verifying whether most customers in the target group are newly, wed women aged between 25 and 35 years. The researcher will ask each participant to provide relevant answers to questions in the questionnaire.Advertising We will write a custom report sample on Willow Stores Target Market specifically for you for only $16.05 $11/page Learn More Data Analysis and Interpretation Data for analysis will come from responses in the questionnaires. The first stage in the analysis of data will be data reduction. Data reduction involves selecting and conceptualizing data that comes from fieldwork observations. The interviewe r will examine the questions and responses, in order to identify consistencies and differences among responses. After data examination, coding will occur for easier retrieval based on how each data set helps meet the research objectives. Coding shall involve demarcation of various segments in the data collected (Saunders 43). Last will be conclusion drawing. Conclusions and other interpretations will be in the form of tables and charts. Sampling Procedure The population for the research will be potential customers of new retro home accessory store â€Å"Willow† located on Yong Eglinton area. Due to the large size of the population, only a sample of 150 potential customers will take part, to ease collection of data. Selection of the sample will occur in the streets of Toronto, in the area of the store’s location and in suburb areas. Although most participants will be in the store’s area, Youge and Eglington, inclusion of a few participants from other parts will be necessary, for comparison purposes. Besides, this will be important, as not all newlyweds live in the city, but still choose to go to the city to shop for more styles than the basic ones offered in the suburbs. Selection of the 150 people to participate in the research will take place through ransom sampling. This sampling technique is preferable because any potential customer can give reliable information on the target market. Sample survey will occur at different days of the week and different times, in order to obtain impartial data. Data Sources Primary Research In this study, primary research will use in-person surveys around the 150 potential customers. The survey will focus on female shoppers. Questionnaire survey will contain multiple choice and open-ended questions in collecting data. Secondary Research In this study, secondary research will employ journal articles, newspapers, business articles and research papers. Examination and evaluation of these sources will take p lace accordingly. Data from secondary research will be essential, as it will help to analyze the results of primary research.Advertising Looking for report on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More Observation The researcher in this study will observe and take a note of current customer’s as well as potential customers buying behavior. Observations will have the same weight as data from primary and secondary sources when drawing conclusions. Works Cited Maxwell, Scott. The Missing Ingredients: Strategic Marketing to the â€Å"Money Guyz†. Business Insider, 15Aug. 2011.Web. Saunders, Elizabeth, G. If Your Target Market doesn’t Bite, Fish Somewhere Else. Business Insider, 22 Aug. 2010. Web. This report on Willow Stores Target Market was written and submitted by user Chance Kirby to help you with your own studies. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly. You can donate your paper here.

Globalization brought about rising number of students migrating to different countries for higher education The WritePass Journal

Globalization brought about rising number of students migrating to different countries for higher education 1.10   Reference Globalization brought about rising number of students migrating to different countries for higher education CHAPTER 1 INTRODUCTION 1.1   Background of study 1.2   The significance of the research1.3   Purpose Statement1.4   Problem Statement1.5 The conceptual framework1.6     Research Questions1.7    Ethical Consideration1.8    Research limitations1.9   Overview of the chapters1.10   ReferenceRelated CHAPTER 1 INTRODUCTION 1.1   Background of study Globalization brought about rising number of students migrating to different countries for higher education. As international educations’ landscape continue to change, students are seeking opportunities that are not only advantageous to their academic agenda, but also to their social and professional development within a global context (Marginso; Agawal, Said, Sehoole, Sorozi and De Wit; Daglish and Chan, cited in Fleischmann, Lawley and Raciti).   There are great challenges in higher education brought about by globalization. â€Å"These challenges are seen as threats as well as opportunities for higher education around the world† (Arambewela Hall, 2006 p142) Research has shown that there is a continuous rise in the number of international student in to the Netherlands.   Generally the transition of studying overseas either from a secondary school or from the work place in another country in always challenging and usually stressful. According to Pereda et al. international students are often less satisfied with their courses than other student. Most international student i.e. full-fee paying students may have similar issues with their fellow domestic students but additionally they face some distinguishing issues like inadequate financial resource, social adjustment, loneliness and cultural shock etc, these may affect the students’ experience and hence their overall satisfaction. Therefore the need to understand international students’ perception of the service quality is vital. For a business to achieve its financial objectives and survive, understanding what creates a great satisfying customer experience is crucial.   Research has shown that high service quality contributes significantly to profitability. Understanding the students’ perception of service quality and satisfaction at the university is vital to management and policy makers in the design, implementation and evaluation of services, as the key to sustainable competitive advantage is creating memorable customer experience. Competing in a highly competitive market requires the delivery of superior service because it affects corporate image. International students have a significant role to play on the country economy for the fact that the pay full tuition fees and they spend on the country’s home produced goods and services. 1.2   The significance of the research This research will be a source of knowledge about issues concerning international students to the researcher who is an international student. Not only will the research be beneficial to the researcher it would benefit other individuals or groups of individuals because of the following: This research focuses on the effect of adjustment issues on the overall services experience of the international student and student satisfaction which will add knowledge to the existing literature on higher education service quality. The importance of students from other countries to colleges and universities cannot be undermined as they bring with them different cultures which adds to the cultural richness of the institution. The outcome of the research will be valuable to different groups of individuals like university management team and lecturers, the students and their parents, and the country. To the university management it will provide insight about international students experience and their satisfaction which will help management in policy design and satisfying their customers the students and their parents. To the lecturers it would lead to a better understanding of the international students need and better delivery of the services hence increasing their satisfaction. Finally, the students will be better served by the university and their fellow students, their experience abroad will be enhanced. 1.3   Purpose Statement This study aims at evaluating the service quality of the Netherlands University. The overall objective is assessing international student’s perception of the service quality provided and adjustment issues, and its relative impact on students’ satisfaction and potential loyalty. Seek to:   Ã‚   Examine the dimensions of service quality and the determining factors of international student satisfaction at   the university   Ã‚   Analysing the effect of interaction of service quality and adjustment issue on international student satisfaction and potential student loyalty   Ã‚   gain an insight in international student perception of service quality in the Netherlands University    To provide a set of conclusions and recommendations to enhance the level of quality of service provided by universities. 1.4   Problem Statement As the international education continues to grow in size and international full-fee paying students expect to be treat as customers, they have several adjustment   issues which affects their overall experience and hence satisfaction. â€Å"How does the adjustment issues of international students affect the overall service experience and what are the effects of this experience on their satisfaction?† This research is conducted mainly to find answers to the question above. 1.5 The conceptual framework This research will be guide by the SERVQUAL survey developed by Parasurama et al. An adapted SERVQUAL model with some modification made to provide contextual relevance, will be used in this study as it will help the researcher measure the perceived service quality across the five SERVQUAL dimensions. The SERVQUAL is an instrument for assessing customer perception of service quality in service and retailing organization (Parasuraman et al, 1988) Based on extant literature adjustment issues affect affects international students experience at universities. These adjustment issues are Academic, socio-cultural and psychological factors. The main key to success in studying abroad is the degree to which the student adjusts to the above mentioned factors. Figure 1.1 Conceptual framework The conceptual model above illustrates the study of international students overall service experience and their relative satisfaction with the Stenden university in the Netherlands. The study with the aim of evaluating the service quality and adjustment issues of the international student on their overall service experience, will also evaluate the effect of the experience on their satisfaction and hence word-of-mouth and if they will chose same university for further education. The main dependent variable in this study is the student satisfaction with the university and the sub dependent variables are Positive word-of-mouth and same university for further study. The independent variables are service quality provided by the university and the student adjustment issues. These independent variables influence both influence the dependent variables. When there is an overall good experience this will lead to student satisfaction which in turn will lead to a positive word of mouth and may want to further study at same university. If quality of service offered by the school is good and students adjustment to academic, socio-culture and psychological is good this will also lead to student satisfaction. On the contrary if the service provided by the school is good but students have problems with adjusting this may have a negative effect on their overall experience and student satisfaction. 1.6     Research Questions   The central research focuses on the analysis of the international students’ perception of service quality and adjustment issues at Stenden university and the relative impact on student satisfaction and potential student loyalty. The research aims at answering the following research questions: Which   service quality factors are most important to international students What are the adjustment issues international students faces? What factors affect international students perception of service quality at the university What are the determinants of overall international students perceived service quality In what ways does the quality of service affect the satisfaction of international student? How does an adjustment issue affect student satisfaction? How can the overall experience of international students be enhanced. 1.7    Ethical Consideration All the information collected will be used strictly for the purpose/objectives of this research and the researcher will abide to the ethical principles of research. The researcher will strive to be objective in her judgment in scenarios that might come up by not taking side but by being critical. 1.8    Research limitations The period required to complete the research is short therefore time is a constraint. The results may not be generalizable as the research involves only a single organisation. 1.9   Overview of the chapters The study will consist of five chapters followed by reference and appendices Chapter 1 Introduction consists of: Background of study The significance of the research Purpose of the study Problem statement The conceptual framework Research questions Ethical considerations Research limitations Chapter 2 Literature review Higher Education    International full-fee paying student Service quality SERVQUAL Dimensions Adjustment issues of international student Student Experience Student Satisfaction    Positive word-of-mouth    Chose same university for further study Chapter 3 Methodology Research methodology    Quantitative research The research Process The population under study Research design Data collection Chapter 4 finding and analysis of Data Demographic profile of sampling Data analysis Chapter 5 Summary and Discussion   Conclusions Discussions Limitations recommendations 1.10   Reference Arambewela, R. and Hall, J. (2006). A Comparative Analysis of International Education Satisfaction Using SERVQUAL. Journal of Services Research 6 pg 141-146 Fleischman, D., Lawley, M., and Raciti, M. Community Engagement and the International Student Experience: Definition. From http://anzmac2010.org/proceedings/pdf/anzmac10Final00179.pdf Khawaja, N. and Dempsey, J. (2007). Psychological Distress in International University Students: An Australian Study. Australian Journal of Guidiance Counselling 6(1) pg 13-27 Mehdizadeh, N. and Scott, G. (2005). Adjustment problems of Iranian international students in Scotland. International Education Journal, 6(4), 484-493. Pereda, M., Airey, D., and Bennett, M. (2007). Service Quality in Higher Education : The Experience of Overseas Students. Journal of Hospitality, leisure, Sport Tourism Education 6(2) pg 55-67 Qiang, Z. (2003) Internationalizatin of Higher Education: towards a conceptual framework. Policy Futures in Education 1(2) pg 248-270 Rogers, C. and Smith, P. (1999). Identifying the needs of overseas students: a monitoring exercise at the University of Southampton, August 1992. Journal of International Education 3(3), 7-24 Sadrossadat, S. J. (1995). Psyco-Social and Cultural Adjustment Among International Students at the University of Wollongong, PhD Dissertation, University of Wollongong. Zeithaml, V.A. (1988). â€Å"Consumer Perceptions of Price, Quality, and Value: A Means –end Model and Synthesis of Evidence†, Journal of Marketing, 52 (2) Pg 2-22. Zeithaml, V.A, Bitner, M.J. Gremler, D.D.(2006). Services Marketing: integrated customer focus across the firm. International 4th Edition. Zeithaml, V. A., Parasuraman, A., Berry, L.L. (1990). Delivering Quality Service: Balancing Customer perceptions and Expectations. NewYork: The Free Press.

To what extent can improvements in productive flow and product quality Essay - 9

To what extent can improvements in productive flow and product quality lead to an increase in sales and profit - Essay Example Implementation of the new EHR systems requires the incorporation of older records into the patient’s electronic health record. One of the strategies involved in the incorporation of old records is scanning of older documents and including them in the system in the image format. However, studies by Ventres et al., (124–31) affirm that most physicians do not prefer inclusion of scanned images in the electronic systems. They prefer full electronic data-based systems because most scanned images are normally unclear; therefore difficult to read. The problem can be resolved through the development of EHR systems with image archival characteristics for converting the scanned documents into full electronic health records. The written records can also be converted into electronic formats through scanning the documents and then performing the Optical Data Recognition (OPR). Accurate recognition may not achieve the required clarity levels while illegible handwriting is poorly reco gnized by the optical character readers. This leads to the formation of the records that are difficult to read. The most successful strategy is making of the state’s database records available for transfer through downloading into individual health records. Privacy. Currently, health records are vulnerable for transmission and exchange over the internet. Rule for access, storage, auditing, authentications and transmission of medical records are contained in the Health Insurance Portability and Accountability Act (HIPAA) (Zaroukian 53-55). Although the restrictions are geared towards promoting the privacy of these records, concerns over the adequacy of the implementation of these standards exist. According to Zaroukian (56), implementation of the privacy regulations can only be achieved through enhancing cooperation between the public, health providers and service providers. The privacy concerns are the prominent challenge stalling the

Organizational Design & Behavior Essay Example | Topics and Well Written Essays - 500 words

Organizational Design & Behavior - Essay Example In situations wherein the crowding increases in the jails it may be difficult to oversee the system as a whole. As such it becomes necessary that a comprehensive review and overhaul of the complete organizational set up of the country’s criminal justice system is performed in order to correctly assess the situation and suggest changes that can offer more viable solutions. A closer look at the existing system will indicate that it is managed in relatively more complex manner as there are many layers of management. Multiple layers of management therefore create strong chances that the overall fixation of responsibilities and accountabilities remain a challenge. In order to overcome the situation and deal with the overcrowding problem, it is therefore necessary that the organizational restructuring is done. In order to overcome the situation, it is important that a comprehensive overhaul of the existing organizational set up is undertaken. The current system is multi-layered in nature it is therefore important that few layers are removed in order to make the system leaner and more flexible to adapt to the different challenges including that of over-crowding. It is important that the number of correctional institutions must be increased in order to successfully negotiate with the over-crowding problems. Increasing the number of institutions will therefore allow the country to develop a system which can accommodate the unexpected number of new entrants and as such can manage the overcrowding problem with relative ease and with minimum management burden. It is important that number of correctional programs shall be increased so that the recurring incidences do not take place. Proper and more adaptive correctional programs may help the jail inhabitants to become more responsible and mature citizens and do not engage themselves into kind of activities which can bring them back into the jails for minor or major crimes. The above

The Coach Essay Example for Free

The Coach Essay As a group coaches are often criticized for their overemphasis on winning and their overly serious attitude toward the league experience. Most studies, however, point out that in general Little League coaches get involved for the love of the game and for the love of their participating child. Coaches that angrily shout criticism from the sidelines are not appreciated or liked as are relaxed, supportive, and knowledgeable coaches who emphasize the improvement and learning of new skills. Coaches that develop close and personal relationships with the child and her/his parents are the most likely to contribute to a positive learning experience. Coaches are first and foremost role models and teachers. Good coaching is not about producing winning teams; its about asking every day before practice or a game: Is what were planning to do today in the best interest of the kids? The best lesson a coach can teach is that playing fairly makes everyone a winner, and that: Developing Coaching Philosophy A casual observer of any little league game site will notice the excessive seriousness and tension exhibited by coaches on the sidelines. Coaches and spectating parents get very involved with their childrens game. Some fail to realize the deleterious effects of their vocal protests regarding game referee decisions or disapproval of their childs performance. Several soccer leagues that I am familiar with have on record a very appropriate league philosophy statement. These statements emphasize learning, fair play, fun, equal opportunity, etc over winning. Ironically, the same leagues use trained referees and linesmen, for example, to officiate a game between two teams comprised of nine-year-old players. Players are often assigned to positions in which they are most productive or least destructive. And, coaches, parents and players exhibit excessive celebration when a goal is scored (even when the goal resulted from a clumsy goalie error) or when a game is won. Overly formal game control, early specialization, and excessive celebrations seem incompatible with a child-centered league philosophy. Should the league experience serve best only the most talented and promising individuals at the expense of the less skilled? A typical league reality of winning first, child second, seems to prevail over the same leagues beautifully crafted philosophy statement. The stress associated with coaching a losing team stems from the distorted view that winning equals good coaching and loosing equals poor coaching. The child that is allowed to play a variety of positions will learn and progress irrespectively of her or his teams winning or loosing record. In the soccer league that I joined as assistant coach during the Fall of 1999, the head coach knew which the two best teams on the league were several weeks before kickoff. Who gets the credit for coaching these kids? Four of the kids on our nine-year-old boys team never played the game. How are they going to learn and improve if we are not going to allow them to make mistakes? Sticking to a child-centered game plan can get very tricky and involve tough decisions. A Coaching Philosophy Some coaches get turned off by the word philosophy. They cannot see how any one philosophy can have an impact on their daily problems and work. Ones teaching or coaching philosophy, however, is actually a very practical matter. An analogy to ones philosophy may be equated to a pair of glasses that filter reality through ones personal experiences, opinions, values and beliefs. It has, therefore a direct influence on how we see and understand the world around us, what actions we take, and why we choose to behave in the ways we do. In fact, every coach, whether aware of it or not, is following certain principles or his philosophy while coaching. It may seem reasonable to assume that the philosophy that directs the coachs everyday life thinking and actions would be also applied by her/him to coaching. Yet, this often seems not to be the case. For example, most coaches would agree that a less skilled child with little or no self-confidence needs special attention and time investment. Yet, who are the kids that usually get the most attention, the most playing time, the most praise? Still, let’s assume, for example, that a businessman discovered that the firm he is negotiating with was dishonest. He decides to do his business with another group despite the fact that he may end up paying more for essentially the same product. This may not sound like good business, yet many a businessman I talked to expressed willingness to stick to their principles even if it meant higher expenses. How many coaches do you know that would stick to principles of sportsmanship or fair play rather than win a game? Obviously, we can readily see a gap between what a coach may think is the right thing to do in every day life situations, and the actions he/she ends up taking on the playing field. Developing an Alternative Coaching Philosophy Dr. Rainer Martens, a world renowned sport psychologist and publisher, explains that the development of a functional coaching philosophy involves two major tasks: †¢ become a student of your own feelings and who you are? †¢ prioritize and delineate your coaching objectives †¢ Developing Self-Awareness Children are great imitators. Therefore, you are more likely to shape them into your own image than into what you would actually like them to become. The coach is a very powerful role model. This is why it is important that the coach be honest as he/she evaluates her/himself and get in touch with here/his own feelings. The coach needs to discover whether he really likes who he/she is. A quick subjective self-awareness test would be to ask oneself When I was a child, would I have liked to have my current self as a parent? As a coach? If the answer is yes, explain to yourself why you think the way you do. What is it that makes you a good parent, teacher, coach? If you realize that you do not like everything about yourself, dont panic, nobodys perfect. The key factor is not for every coach to be a perfect individual. It is crucial, however, that the coach be honest with her/himself, and willing to take the appropriate steps to change for the better. Dr. Martens suggests that one such first step would be to form an open door policy and solicit feed back from the kids, assistant coaches and the parents. This, according to Dr. Martens means that the coach needs to learn to listento be attentive to both overt and covert communication patterns. Good listening skills ensure two way communications and thus decrease the filtering effect that often distorts the true message delivered by the other party. Prioritization and Delineation of Coaching Objectives It is an indisputable fact that children are their parents and nations most precious asset. It may seem natural to assume, therefore, that the majority of adults mean well for the kids. Yet, how often do we wish something for our child, and then step back and take the time to find out whether this is what the child really wants? More often than not, adults feel they know better, and thus, exclude children from the decision making process. Youth sport, unfortunately, is a prime example of this phenomenon. In 1987 the Athletic Footwear Association in America sponsored a study of 10,000 students ages 10-18 regarding their feelings about sport. The students reacted to questions such as why they participate, why they quit, and what changes they would make in order to get involved again in a sport they dropped. The most important finding of the study was that winning, which is the most publicized and pursued goal of sports never ranked higher than seventh even among the most competitive athletes. To have fun and to improve my skills were consistently the first two choices why the students chose to play sports. When asked why they dropped from sports three of the first five reasons were I was not having fun, coach was a poor teacher, and too much pressure. How many coaches you know would have predicted this outcome? (Rainer, 1987, 3-14) Dr. Martha E. Ewing and Dr. Vern Seefeld of the Youth Sports Institute of Michigan State University who conducted the study, and Dr. Steven J. Danish, chairman of the Department of Psychology at Virginia Commonwealth University who added psychological and developmental interpretations proposed the following truths about children and sport: Fun is pivotal; if its not fun, young people wont play a sport (Rainer, 1987, 3-14). Skill development is a crucial aspect of fun; it is more important than winning even among the best athletes. The most rewarding challenges of sports are those that lead to self-knowledge. Intrinsic rewards (self-knowledge that grows out of self-competition) are more important in creating lifetime athletes than are extrinsic rewards (victory or attention from others). The American Youth and Sports Participation study authors proposed the following tips for coaches and parents who are willing to develop an alternative coaching philosophy: For Coaches Become a communicator (a listener and a giver of feedback). Recognize the needs of your kids and balance your needs with theirs. Develop perspective: remember what you were like at their age and what you could do then; dont judge the kids by what you can do now. Remember the truths and plan activities with them in mind. Seek out workshops and educational programs that teach not only sports-related skills but also communication and interpersonal skills that will help you work with parents and get the most out of your kids. Try to work with parents and make them part of the team rather than viewing them as critics to be avoided. Coach Development Education, as pedagogical theory so perceptively points out, is a two-way process, which means that both sides of the process have an opportunity to influence each other. Therefore, the coach can expect to be shaped by his team members’ characters and styles in a way that is no less decisive than his or her influence upon them. Realizing it may prove a challenge to many authoritative coaches, yet this impact is undeniable and should not be underestimated. However, in case of a younger team, the coach’s influence is going to exceed that of the children as they, as mentioned before, are great imitators and need a role model to follow. For this reason among others, the coach has to develop certain moral and professional qualities that will form the basis for practical application of one’s coaching philosophy. The tenets of coaching philosophy determine which exactly qualities one needs in order to develop one’s team and bring them to a victory earned in the spirit of fair play sportsmanship. In the first place, a coach has to be a superb organizer. This is the coach’s primary function in the team: to unite a disparate set of players into a coherent whole. Unity in the contest has to stem from psychological unity of the team, the much talked about team spirit. A coach in one’s philosophy has to define how important a place the team occupies in his/her activities and endeavors and what ways of achieving this unity are legitimate and effective. In team sports specifically, the value of team relationships cannot be overrated, since a victory is only a product of collective efforts and rarely a gift of luck.

Burmese Days Essay -- essays research papers

George Orwell’s novel Burmese Days is set in 1920’s Burma under British colonialism. It focuses on the imperialism of the British and its effects on the relationships between the British, the British and Indians, and between the Indians themselves. The novel concentrates on the town of Kyauktada in Upper Burma.   Ã‚  Ã‚  Ã‚  Ã‚  Kyauktada is described as hot and sultry. It is a small town of about four thousand. The overwhelming majority of the inhabitants are Burmese, but there are also a hundred Indians, two Eurasians, sixty Chinese, and Seven Europeans. (Pg. 16) It is near the jungle and the Irrawaddy River. There are many trees and flowers, including honeysuckle. Though the English have jobs to perform much of their time is consumed with drinking whiskey in the Club, retreating from the “prickly'; heat, napping, and occasionally playing tennis or hunting. Though there is not much physical activity by the English, they do not complain about it. They do complain incessantly about the heat and about the possible acceptance of natives into their exclusively European Club.   Ã‚  Ã‚  Ã‚  Ã‚  In Burmese Days the overwhelming majority of British held themselves superior to the Burmese. They feel that it is their duty to rule over the less intelligent “niggers'; of Burma. Through the description of the characteristics of both the British and Burmese, Orwell helps us understand the value system through which the British have come to the conclusion that they must rule over the Burmese. An example of such a description is that of Maxwell, them acting Divisional Forest Officer. Maxwell is depicted as a “fresh-coloured blond youth of not more than twenty-five or six – very young for the post he held.'; (Pg. 22) This description lends value to the light skinned and fair-haired British, though some, like Flory, have black hair. Maxwell is also very young for his post, giving the impression that he is intelligent. Mr. Lackersteen, the manger of a timber firm, though forty and slightly bloated, it described a “fine-looking'; with an ingenu ous face. (Pg. 20- 21) This description leads us to believe British are good looking and honest. Orwell offers us numerous descriptions of favorable characteristics of the British, but he clearly distinguishes “bad'; British from &am... ...sire to become a member of the Club is seriously discussed. However, U Po Kyin succeeds in his quest for the membership to the Club by ruining Flory’s relationship with Elizabeth, which results in Flory killing Flo, his dog, and committing suicide. The prestige that Dr. Veraswami had possessed died with Flory. This ruined Flory, making a membership in the Club impossible. Instead U Po Kyin was elected into the Club, and became and agreeable, yet largely absent, member. Any possibility for understanding between Englishmen and Indians dies with Flory. This is because no other Englishmen could see beyond the stereotype of Indians as conniving, lazy, uncivilized “niggers.'; Though Mr. Macgregor did not dislike the Indians he only found them pleasing when they had no freedoms. None of these opinions held by the Englishmen are conducive to a reciprocal, understanding relationship between the British and the Burmese. Even if the English had overcome these barriers, the natives held stereotypes of the British as power-hungry, mean, degrading, and naà ¯ve. The feelings of the natives toward the British would also need to be overcome if an understanding were to be reached.

Why a Safe but Challenging Environment Is Important

Medical Decision Making http://mdm. sagepub. com/ Do Patient Decision Aids Meet Effectiveness Criteria of the International Patient Decision Aid Standards Collaboration? A Systematic Review and Meta-analysis Annette M. O'Connor, Carol Bennett, Dawn Stacey, Michael J. Barry, Nananda F. Col, Karen B. Eden, Vikki Entwistle, Valerie Fiset, Margaret Holmes-Rovner, Sara Khangura, Hilary Llewellyn-Thomas and David Rovner Med Decis Making published online 14 September 2007 DOI: 10. 1177/0272989X07307319.   A more recent version of this article was published on – Oct 5, 2007 Published by: http://www. sagepublications. com On behalf of: Society for Medical Decision Making Additional services and information for Medical Decision Making can be found at: Email Alerts: http://mdm. sagepub. com/cgi/alerts Subscriptions: http://mdm. sagepub. com/subscriptions Reprints: http://www. sagepub. com/journalsReprints. nav Permissions: http://www. sagepub. com/journalsPermissions. nav Version of Re cord – Oct 5, 2007 ;; OnlineFirst Version of Record – Sep 14, 2007 What is This? Downloaded from mdm. sagepub. com by guest on July 22, 2012 Med Decis Making OnlineFirst, published on September 14, 2007 as doi:10. 1177/0272989X07307319 Do Patient Decision Aids Meet Effectiveness Criteria of the International Patient Decision Aid Standards Collaboration? A Systematic Review and Meta-analysis Annette M. O’Connor, RN, PhD, Carol Bennett, MSc, Dawn Stacey, RN, PhD, Michael J. Barry, MD, Nananda F. Col, MD, MPH, MPP, Karen B. Eden, PhD, Vikki Entwistle, PhD, Valerie Fiset, MScN, Margaret Holmes-Rovner, PhD, Sara Khangura, Hilary Llewellyn-Thomas, PhD, David Rovner, MD Objective. Related article: Explain the Post 16 Options 2017 To describe the extent to which patient decision aids (PtDAs) meet effectiveness standards of the International Patient Decision Aids Collaboration (IPDAS). Data sources. Five electronic databases (to July 2006) and personal contacts (to December 2006). Results. Among 55 randomized controlled trials, 38 (69%) used at least 1 measure that mapped onto an IPDAS effectiveness criterion. Measures of decision quality were knowledge scores (27 trials), accurate risk perceptions (12 trials), and value congruence with the chosen option (3 trials). PtDAs improved knowledge scores relative to usual care (weighted mean difference [WMD] = 15. %, 95% confidence interval [CI] = 11. 7 to 18. 7); detailed PtDAs were somewhat more effective than simpler PtDAs (WMD = 4. 6%, 95% CI = 3. 0 to 6. 2). PtDAs with probabilities improved accurate risk perceptions relative to those without probabilities (relative risk = 1. 6, 95% CI = 1. 4 to 1. 9). Relative to simpler PtDAs, detailed PtDAs improved value cong ruence with the chosen option. Only 2 of 6 IPDAS decision process criteria were measured: feeling informed (15 trials) and feeling clear about values (13 trials). PtDAs improved these process measures relative to usual care (feeling uninformed WMD = –8. , 95% CI = –11. 9 to –4. 8; unclear values WMD = –6. 3, 95% CI = –10. 0 to –2. 7). There was no difference in process measures when detailed and simple PtDAs were compared. Conclusions. PtDAs improve decision quality and the decision process’s measures of feeling informed and clear about values; however, the size of the effect varies across studies. Several IPDAS decision process measures have not been used. Future trials need to use a minimum data set of IPDAS evaluation measures. The degree of detail PtDAs require for positive effects on IPDAS criteria should be explored. Key words: decision support techniques; patient education; patient participation; randomized controlled trials. (Med Decis Making 2007;XX:xx–xx) Received 23 July 2007 from the Ottawa Health Research Institute, Canada (AMO, SK, CB); University of Ottawa, Canada (AMO, DS); Massachusetts General Hospital, Boston (MJB); Maine Medical Center, Portland, Maine (NFC); Oregon Health and Science University, Portland (KBE); Social Dimensions of Health Institute, Dundee, UK (VE); Algonquin College, Ottawa, Canada (VF); Michigan State University, East Lansing (MH-R, DR); and Dartmouth Medical School, Hanover, New Hampshire (HL-T). Financial support for this study was provided by a group grant of the Canadian Institutes of Health Research. The funding agreement ensured the authors’ independence in designing the study, interpreting the data, and writing and publishing the report. Address correspondence to Annette M. O’Connor, RN, PhD, University of Ottawa, Ottawa Health Research Institute, 1053 Carling Avenue, ASB, Ottawa, Ontario, Canada K1Y 4E9; e-mail: [email  protected] ca. DOI: 10. 1177/0272989X07307319 P atient decision aids (PtDAs) are adjuncts to counseling that explain options, clarify personal values for the benefits versus harms, and guide patients in deliberation and communication. With the rapid proliferation of these tools, the International Patient Decision Aids Collaboration (IPDAS) has reached agreement on criteria for judging the quality of PtDAs. 1 IPDAS is a network of more than 100 researchers, practitioners, patients, and policy makers from 14 countries. These collaborators developed a checklist of criteria that payers, patients, practitioners, developers, and researchers can use to assess PtDAs they encounter. The criteria address 3 domains of quality: clinical content, the development process, and effectiveness. 554 †¢ MEDICAL DECISION MAKING/MON–MON 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Copyright 2007 by Society for Medical Decision Making.DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS†This article addresses the 3rd domain, the evaluation of PtDAs’ effectiveness in fostering a high-quality decision process and a high-quality choice. Over the past decade, there has been considerable debate about the definition of a good decision when there is no single best therapeutic action and choices depend on how patients value benefits versus harms. 2–6 To select criteria for decision quality, IPDAS participants were asked to identify â€Å"the things that you would nee d to observe in order to say that after using a patient decision aid, the way the decision was made was good and the choice that was made was good. IPDAS endorsed the following criteria for establishing that a decision aid is effective: †¢ Decision quality: The PtDA improves the match between the chosen option and the features that matter most to the informed patient. †¢ Decision processes leading to decision quality: The PtDA helps patients to recognize that a decision needs to be made, know options and their features, understand that values affect the decision, be clear about the option features that matter most, discuss values with their practitioner, and become involved in preferred ways. Our study objectives were 1) to describe the number and types of measures used in randomized controlled trials (RCTs) that correspond to IPDAS criteria for effectiveness and 2) to determine the extent to which RCTs of PtDAs meet these new IPDAS criteria for effectiveness. METHODS We have been updating the Cochrane Review of decision aids since the late 1990s. 7–9 This review differed from previous reviews by focusing on the new IPDAS criteria. Moreover, we used a new systematic review software, TrialStat SRS, to manage the search and data extraction; therefore, our search, screen, and data extraction were redone completely. Data sources included 1) electronic databases to July 2006 (MEDLINE, PsycINFO, CINAHL, and EMBASE), 2) Cochrane Controlled Trials Register (2006, issue 2), and 3) contact with known developers and evaluators to December 2006. The search strategy is described in the appendix. The search was not restricted on the basis of language. PtDAs were defined as interventions designed to help people make specific, deliberated choices among options (including the status quo) by providing information about the options and outcomes (e. . , benefits, DECISION AIDS: PAST, PRESENT, AND FUTURE harms) in sufficient detail that an individual could judge their value implicitly. Patient decision aids may also include information about the clinical condition, outcome probabilities tailored to personal risk factors, an explicit values clarification exercise (e. g. , a relevance chart, utility assessments of probable outcome states, a weigh scale), descriptions of others’ experiences, and guidance in the steps of decision making and communicating with others. This definition excludes interventions focused solely on lifestyle changes, hypothetical situations, clinical trial entry, or general advanced directives; education programs not geared to a specific decision; and interventions designed to promote adherence to a recommended option or to elicit passive informed consent. In the current review, we also excluded studies whose PtDAs were not available for inspection to catalogue their elements according to the new IPDAS domains. As a consequence, a few studies reported in the previous reviews were not included. We included published RCTs comparing 1) PtDAs to usual-care controls or 2) detailed PtDAs to simpler ones (which may not have the level of detail or may not contain all of the IPDAS elements). Participants were deciding about screening or treatment options for themselves, for a child, or for an incapacitated significant other. Two reviewers independently screened each study (CB, SK, DS, AMO, VF), extracted data (CB, SK), and assessed study quality (C. B. , S. K. ) using standardized forms, including the Jadad scale. 0 Inconsistencies were resolved by consensus. Trial results were described individually. Metaanalysis was used for decision quality and for decision process measures because these effects were expected to be independent of the type of decision. Meta-analysis was performed only on those outcomes with similar types of measures. Review Manager 4. 211 was used to estimate a weighted treatment effect (with 95% confidence intervals [CIs]), defined as weighted mean differences ( WMDs) for continuous measures and pooled relative risks (RRs) for dichotomous outcomes. The data used in each meta-analysis can be viewed in the online supplement available at http://mdm. sagepub. com/cgi/ content/full/Volume/Issue/Page#/DC1. All data were analyzed with a DerSimonian and Laird12 random effects model because of the diverse nature of the trials. Forest plots were used to assess and display potential heterogeneity, and funnel plots were used to explore publication bias. Because of statistically significant heterogeneity for most of the outcomes, we performed post hoc subanalyses to explore the potential causes of heterogeneity. Heterogeneity was explored according 555 Downloaded from mdm. sagepub. com by guest on July 22, 2012 O’CONNOR AND OTHERS to the following factors: type of decision (treatment versus screening), type of media of decision aid (video/ computer versus audio booklet/pamphlet), and a possible ceiling effect based on good usual-care scores (removal of studies with lower knowledge and realistic risk perception scores; removal of studies with higher decisional conflict scores for subscales feeling uninformed and unclear values). We analyzed the effects of removing the biggest outlier(s) defined by visual inspection of the forest plots. In addition, a post hoc analysis was performed to examine the effect of 1) excluding trials of low methodological quality and 2) excluding trials that were outliers and contributed to heterogeneity.RESULTSOf the 22,778 unique citations obtained in the review, we identified 1293 as relevant by title and then screened those abstracts (see Figure 1). Of these, 130 citations were retrieved for full-text review. Sixty-four studies were excluded for the following reasons: the study was not focused on making a choice (n = 33), the study was not an RCT (n = 14), the decision support intervention did not meet the definition of a PtDA (n = 8), the study involved a hypothetical situation (n = 6), and no outcome data were provided (n = 3). In all, 55 eligible trials (66 references) were found for duplicate data extraction and analysis. The 55 published RCTs evaluating individual PtDAs13–78 used 51 different PtDAs that focused on 23 different screening or treatment topics (see Table 1). Among the 51 different PtDAs, the elements most frequently included were information about the options and outcomes in sufficient detail to judge their value implicitly (100% by definition), information about the clinical condition (98%), outcome probabilities (84%), examples of others’ experiences (59%), explicit values clarification exercises (55%), and guidance in the steps of decision making (47%). Quality ratings in the trials ranged from 0/5 to 3/5. All studies lost 2 points because patients or practitioners could not be blinded to the intervention. As shown in Table 2, 38 of the 55 trials (69%) reported at least 1 outcome that could be mapped onto an IPDAS criterion for effectiveness; 33 (60%) measured some aspect of decision quality, and 15 (27%) measured a decision process leading to decision quality. Decision Quality As noted above, the definition of decision quality has 2 elements: the extent to which decisions are 556 †¢ MEDICAL DECISION MAKING/MON–MON 2007 informed and based on personal values. Trials used 3 measures corresponding to this definition: knowledge test results, accuracy of risk perceptions, and value congruence with chosen option. Knowledge. Twenty-seven of the 55 studies examined the effects of PtDAs on knowledge; 18 of these compared PtDAs to usual care, and 9 compared PtDAs with more or less detail. The studies’ knowledge tests were based on information contained in the PtDA, thereby establishing content validity. The proportion of accurate responses was transformed to a percentage scale ranging from 0% (no correct responses) to 100% (perfectly accurate responses). In the comparison of PtDAs to usual care15,16,18,26,28,29, 31,36,39,41,43,48,50,64,65,69,73,78 (Figure 2), PtDAs had higher average knowledge scores (WMD = 15. 2%, 95% CI = 11. 7, 18. 7). The 9 studies comparing detailed with simpler PtDAs22,24,30,35,54,60,61,63,66 (Figure 3) showed a smaller effect (WMD = 4. 6%, 95% CI = 3. 0, 6. 2). Accurate risk perceptions. Eleven of 55 studies examined the effects of including probabilities of PtDAs on the accuracy of patients’ perceived probabilities of outcomes. 4,28,41,43–45,54,63,73,74,77 Eight studies measured perceived probabilities as percentages,24,28,43–45,54,73,74 and 3 gauged probabilities in words. 41,63. 77 Perceived outcome probabilities were classified as accurate according to the percentage of individuals whose judgments corresponded to the scientific evidence about the chances of an outcome for similar people. In 4 of 5 studies that elicited perceived probabilities for multiple outcomes,24,44,54,60 the propo rtion of realistic expectations was averaged; in the remaining study,43 the most conservative result was chosen for meta-analysis. People who received a detailed PtDA with descriptions of outcomes and probabilities were more likely to have accurate risk perceptions than those who did not receive this information; the pooled RR of having accurate risk perceptions was 1. 6 (95% CI = 1. 4, 1. 9; Figure 4). The pooled relative risk for probabilities described in words was 1. 3 (95% CI = 1. 1, 1. 5). The pooled relative risk for probabilities described as numbers was 1. 8 (95% CI = 1. 4, 2. 3). Value congruence with chosen option. Four of 55 studies measured value congruence with the chosen option; however, Lerman and others41 did not calculate differences between interventions. The 3 trials comparing interventions were similar in that they 1) focused on the decision to take menopausal hormone replacement therapy (HRT) and 2) compared 2 active interventions. However, these trials used different measures of value (text continued on p 565) Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† 2,778 unique citations identified for initial screening (screening based on review of the title) 1,293 potentially relevant citations identified and screened (based on review of the abastract) for retrieval 130 citations retrieved for full-text review 64 excluded: study not focused on making a choice (n = 33); study was not RCT (n = 14); decision support intervention did not meet the definition of a PtDA (n = 8); study involved a hypothetical situatio n (n = 6); no outcome data provided (n = 2); protocol only (n = 1) 5 eligible trials (66 references) for duplicate data extraction Data entry & RCT meta- analysis Figure 1 Flowchart of the procedural steps in the systematic review. RCT = randomized controlled trial; PtDA = patient decision aid. DECISION AIDS: PAST, PRESENT, AND FUTURE Downloaded from mdm. sagepub. com by guest on July 22, 2012 557 Table 1 Elements in DAs Characteristics of 55 Trials Included in the Systematic Review of Patient Decision Aids 558 Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Others’ Experiences Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Guidance in Steps of DM Source, Year, Location Auvinen and others13,14 2004, Finland 3/5 1/5 2/5 3/5 2/5 2/5 — X — X X X — — X X X — — X — X X — — X X — — X — X — — — X — — X X X — X — — — X — — — — — X — — — X — — — X — — — — — — — — X — — Barry and others15 1997, United States Bekker and others,16,17 2004, United Kingdom Bernstein and others18 1998, United States Pamphlet PtDA Standard care by clinical guideline Interactive videodisc PtDA Usual care Decision analysis plus consultation Usual care Video PtDA Usual care Clancy and others19 1988, United States 30 + 30 men: prostate cancer treatment 67 + 61 women: HRT 1/5 — X X X X X X X X X — X X X X X 103 + 100 men: prostate cancer treatment 104 + 123 men: benign prostate hypertrophy treatment 59 + 58 women: prenatal diagnostic screening for Down syndrome 65 + 53 patients: ischemic heart disease treatment 753 + 263 physicians: hepatitis B vaccine Davison and Degner20 1997, Canada Deschamps and others21 2004, Canada 3/5 — X X X — X — X — X — — — X — X — X — X — X — — — X — — — X — X Downloaded from mdm. sagepub. com by guest on July 22, 2012 Deyo and others22 2000; Phelan and others23 2001, United States 2/5 Dodin and others24 2001, Canada 50 + 47 adults: colon cancer screening 3/5 2/5 3/5 143 + 144 parents: infant polio vaccine schedules 112 + 114 men: PSA testing 190 + 203 patients: herniated disc or spinal stenosis treatment 52 + 49 women: HRT Pamphlet + decision analysis PtDA Usual care Written materials, PtDA, and audiotape of consultation Usual care Audiotape and booklet Pharmacist consultation Interactive videodisc PtDA Simple PtDA pamphlet Audiotape booklet PtDA Simple PtDA pamphlet Dolan and Frisina25 2002, United States Dunn and others26 1998, United States Frosch and others27 2003, United States — X — X X X X X X X — X — X X — — — — — — X — X X — — — — — Computer: analytic hierarchy process and pamphlet PtDA Usual care Video and pamphlet PtDA Usual care Video PtDA Internet presentation mirroring content of video continued) Gattellari and Ward28 2003, Australia 3/5 3/5 3/5 X X — X — X — X X — X X — X — X X — — X — — — — — X X — — — X — — X — — — X — X â⠂¬â€ X — X — X X X X X X — X — X — X — — — — — X — — — — — X — X — X — X — X — X — — — — — 140 + 140 men: PSA testing 86 + 50 women: breast cancer surgery 1/5 126 + 122 men: PSA testing Gattellari and Ward29 2005, Australia Goel and others30 2001, Canada Green and others31 2001, United States 3/5 CD-ROM PtDA plus counseling Genetic counseling Pamphlet PtDA Usual care Pamphlet PtDA General information leaflet Pamphlet PtDA General information leaflet Audiotape and booklet PtDA Simple PtDA pamphlet CD-ROM PtDA plus counseling Usual care Green and others32,33 2004, United States 0/5 2/5 Herrera and others34 1983, United States Hunter and others35 2005, Canada 3/5 3/5 2/5 3/5 Audiotape and booklet PtDA Usual care Audiotape and booklet Individual genetic counseling Decision board PtDA Usual care Video plus booklet PtDA Usual care Booklet PtDA Personal risk profile X — X — X — X — X X X — 2/5 X X X — X — X X X — X X X — X X 9 + 14 higher risk women: breast cancer genetic testing 106 + 105 higher risk women: breast cancer genetic testing 56 + 47 parent(s): circumcision of male newborns 116 + 126 women: prenatal diagnostic testing X — X — X X X — X X X — X X — — X — X — X — X — X — — — Downloaded from m dm. sagepub. com by guest on July 22, 2012 Johnson and others36 2006, United States Kennedy and others37 2002, United Kingdom Lalonde and others38 2006, Canada — — X — X — X — X — X — — — — — X — X — X — X — X — X — (continued) Laupacis and others39 2006, Canada 2/5 Legare and others40 2003, Canada 122 + 164 women: breast cancer genetic testing 100 + 101 women: prenatal diagnostic testing 1/5 32 + 35 patients: dental surgery 300 + 298 women: menorrhagia treatment 13 + 13 patients: cardiovascular health treatment 60 + 60 patients: preoperative autologous blood donation 97 + 87 women: HRT erman and others41 1997, United States Leung and others42 2004, China Audiotape booklet PtDA Simple pamphlet PtDA Discussion PtDA and counseling Usual care wait list control Interactive multimedia PtDA Video and pamphlet 559 Table 1 Elements in DAs continued) 560 Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Others’ Experiences Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Guidance in Steps of DM Source, Year, Location Man-Son-Hing and others43 1999, Canada — X X X X — — — 3/5 1/5 2/5 X X X X X X — X — X — X — X — X — X — X — X — X — X — — — X — X 3/5 Audiotape and booklet PtDA Usual care X X X X X — X — X — — — — — — X — X — X — — — — — — McAlister and others44 2005, Canada McBride and others45,46 2002, United States Miller and others47 2005, United States 139 + 148 aspirin users in atrial fibrillation trial: move to warfarin 219 + 215 patients: antithrombotic therapy 289 + 292 women: HRT 279 women: BRCA1 BRCA2 gene testing Montgomery and others48,49 2003, United Kingdom 52 + 55 + 51 + 59 adults: hypertension treatment 3/5 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Morgan and others50 2000, Canada 3/5 3/5 — X — X — X — X X — X — X — X — X X — X — X — X — — — — — — — — — — X — — X — X — X — — — — — — — — — — X — Murray and others51 2001, United Kingdom 3/5 2/5 Murray and others52 2001, United Kingdom Myers and others53 2005, United States 121 + 121 men: PSA testing 120 + 120 patients: ischemic heart disease treatment 57 + 55 men: benign prostate hypertrophy treatment 102 + 102 women: HRT Audiotape and booklet PtDA Usual care Pamphlet PtDA Usual care Discussion PtDA and general information pamphlets General information pamphlets Decision analysis PtDA Video and booklet PtDA Decision analysis, video and booklet PtDA Standard care Interactive videodisc PtDA Usual care Interactive videodisc PtDA Usual care O’Connor and others54 1998, Canada 81 + 84 women: HRT 1/5 X X X X X — X — X — X — Interactive videodisc PtDA Usual care Discussion PtDA and general information pamphlet General information pamphlet Audiotape and booklet PtDA Simple PtDA pamphlet O’Connor and others55 1999, Canada 3/5 X X X X X X 1/5 3/5 0/5 — X — X — X — X — X — — — — — — — X — — X X X X X X — X X X X X — — — X 16 + 17 women: osteoporosis treatment 384 + 384 men: PSA testing 37 + 37 patients: dental orthognathic surgery 3/5 3/5 X X X — X — X — X — — — — — — — — X — X 101 +100 women: HRT Oakley and Walley56 2006, United Kingdom Partin and others57 2004, Canada Phillips and others58 1995, United States Pignone and others59 2000, United States Audiotape and booklet PtDA DA without explicit values clarification Audiotape and booklet PtDA Usual care Video PtDA Usual care Video imaging of facial reconstruction PtDA Usual care Video PtDA Usual care — — — X Rostom and others60 2002, Canada X X X X X X — X X X X X X X X X — X — — — 125 + 124 adults: colon cancer screening 25 + 26 women: HRT X X X X — — — — — — — — — — X X — — — — — 83 + 89 women: HRT 1/5 Computer PtDA with testing + feedback regarding knowledge Audiotape with booklet Lecture with personal decision exercise PtDA Simple PtDA pamphlet Booklet PtDA Simple PtDA pamphlet Booklet PtDA Usual care Rothert and others61 1997; Holmes-Rovner and others62 1999, United States Schapira63 2000, United States 1/5 2/5 Downloaded from mdm. sagepub. com by guest on July 22, 2012 Schwartz and others64 2001, United States 2/5 Booklet PtDA Usual care Shorten and others65 2005, Australia X — X — X — X — — — X — Street and others66 1995, United States 1/5 22 + 135 men: prostate cancer screening 191 + 190 Ashkenazi Jewish women: breast cancer genetic testing 85 + 84 pregnant women: birthing options after previous cesarean delivery 30 + 30 women: breast cancer surgery Interactive multimedia PtDA Simple PtDA X X X X — — — — X — X — (continued) 561 562 Table 1 Elements in DAs (continued) Source, Year, Locat ion Number of Enrollees in Intervention + Comparison: Options Considered Quality Rating (Jadad) Comparison of Most and Least Intensive Intervention Options and Clinical Outcomes Problem Explicit Outcome Values Probability Clarification Others’ Experiences Guidance in Steps of DM VanRoosmalen and others67,68 2004, the Netherlands X X — X — X — X — X — X — X — X X — — X — X — X — — X — — X — X — X — X — X — X — X X X X — — — — — — — — — — — — — X — 44 + 44 women with BRCA1/2 mutation: prophylactic surgery 3/5 X X X X — — X — — — — — — — X — — — — — X X — — — — — — — — — — — — — — Volk and others69,70 1999, United States 3/5 3/5 3/5 80 + 80 men: prostate cancer screening Vuorma and others71,72 2003, Finland Video and brochure PtDA with decision analysis Same video and brochure PtDA pamphlet Video with pam phlet PtDA Usual care Booklet PtDA Usual care Whelan and others73 2003, Canada 3/5 2/5 184 + 179 women: menorrhagia treatment 82 + 93 women: breast cancer chemotherapy Downloaded from mdm. sagepub. com by guest on July 22, 2012 Whelan and others74 2004, Canada Wolf and others75,76 1996, United States 1/5 2/5 Script PtDA Usual care Pamphlet PtDA Usual care 94 + 107 women: breast cancer surgery 103 + 102 men: prostate cancer screening Decision board PtDA and booklet Usual care with booklet Decision board PtDA Usual care Script PtDA Usual care Wolf and Schorling77 2000, United States Wong and others78 2006, United States 266 + 133 seniors: colon cancer screening 162 + 164 women: pregnancy termination Note: DM = decision making; PtDA = patient decision aid; HRT = hormone replacement therapy; PSA = prostate-specific antigen. Table 2 Cumulative Studies Still in 2007 Review Reporting Outcome in Each Cochrane Review Update Year % n/N Lead Author 15 50 18 Trials Measuring Outcomes That Map onto the International Patient Decision Aid Standards (IPDAS) Criteria Outcome Decision quality 2007 1999 2003 15 27 2/13 8/30 49 27/55 Knowledge scores 999 2003 54 57 7/13 17/30 Realistic expectations, accurate risk perceptions Barry, Morgan, Bernstein, Lerman,41 Rothert,61 O’Connor,54 Street66 As above plus Schwartz,64 Man-Son-Hing,43 Volk,69 Dunn,26 Green,31 Goel,30 Shapira,63 Rostom,60 Phelan,23 Dodin24 As above plus Bekker,16 Gattellari,28 Johnson,36 Whelan,73 Shorten,65 Montgomery,48 Gattellari,29 Laupacis,39 Wong,78 Hunter35 OConnor,54 Lerman41 As above plus Wolf,77 McB ride,45 Man-Son-Hing,43 Rostom,60 Shapira,63 Dodin24 As above plus Whelan,74 Whelan,73 McAlister,44 Gattellari28 Value congruence with chosen option Decisional Conflict Scale (DCS) 2007 1999 2003 2007 1999 2003 2007 80 2007 1999 2003 2007 1999 2003 57 15 30 27 15 33 24 15/55 2/13 10/30 13/55 2/13 9/30 17/30 Downloaded from mdm. sagepub. com by guest on July 22, 2012 22 0 10 5 15 30 12/55 0/13 3/30 3/55 2/13 9/30 Decision process leading to decision quality Feeling informed, subscale of the DCS Feeling clear about values, subscale of DCS O’Connor,55 Holmes-Rovner,62 Dodin24 As above OConnor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Shorten,65 Laupacis,39 Whelan,74 McAlister,44 Lalonde,38 Legare,40 Hunter35 O’Connor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Laupacis,39 McAlister,44 Wong,78 Bekker,16 Lalonde38 O’Connor,54 Morgan50 As above plus Murray,51 Murray,52 Dolan,25 Man-Son-Hing,43 Dodin,24 Goel,30 OConnor55 As above plus Montgomery,48 Laupacis,39 McAlister,44 Lalonde38 Note: Trials included in 1999 and 2003 but not in 2007 are Davison and others (measuring feeling informed, clear values); Maisels and others,81 Michie and others82 (measuring knowledge scores), and Thornton and others. 83 These authors were eliminated because we were unable to verify what was in their decision aid to meet the IPDAS definition of a decision aid. 563 O’CONNOR AND OTHERS Study or subcategory y Bekker 2004 Gattellari 2003 Johnson 2006 Whelan 2003 Schwartz 2001 Man-Son-Hing 1999 Morgan 2000 Shorten 2005 Montgomery 2003 Gattellari 2005 Laupacis 2006 Volk 1999 Lerman 1997 Barry 1997 Wong 2006 Bernstein 1998 Dunn 1998 Green 2001 N Decision Aid Mean (SD) 74. 00(14. 50) 50. 00(18. 40) 92. 60(11. 00) 80. 20(14. 40) 65. 71(14. 29) 75. 91(15. 72) 76. 00(32. 04) 75. 33(15. 00) 75. 00(17. 00) 57. 20(21. 30) 83. 00(19. 50) 48. 00(22. 40) 68. 90(19. 00) 75. 00(45. 00) 85. 00(26. 70) 83. 00(16. 00) 83. 67(23. 13) 95. 00(7. 00) N Usual Care Mean (SD) 71. 50(16. 00) 45. 00(15. 90) 85. 20(15. 60) 71. 70(13. 30) 57. 14(15. 71) 66. 46(16. 07) 62. 00(32. 04) 60. 53(17. 07) 60. 00(18. 00) 42. 20(16. 70) 67. 40(17. 00) 31. 00(18. 30) 49. 00(21. 70) 54. 00(45. 00) 60. 00(21. 70) 58. 00(16. 00) 55. 53(22. 80) 65. 00(21. 00) W MD (random) 95% CI W eight % 5. 68 6. 3 5. 49 6. 16 6. 41 6. 24 4. 61 6. 04 5. 43 6. 03 5. 32 5. 50 6. 00 3. 84 5. 81 5. 61 5. 83 3. 97 100. 00 W MD (random) 95% CI 2. 50 [-3. 31, 8. 31] 5. 00 [0. 39, 9. 61] 7. 40 [0. 98, 13. 82] 8. 50 [4. 37, 12. 63] 8. 57 [5. 55, 11. 59] 9. 45 [5. 68, 13. 22] 14. 00 [4. 81, 23. 19] 14. 80 [10. 23, 19. 37] 15. 00 [8. 39, 21. 61] 15. 00 [10. 40, 19. 60] 15. 60 [8. 64, 22. 56 ] 17. 00 [10. 61, 23. 39] 19. 90 [15. 17, 24. 63] 21. 00 [9. 25, 32. 75] 25. 00 [19. 60, 30. 40] 25. 00 [18. 95, 31. 05] 28. 14 [22. 83, 33. 45] 30. 00 [18. 71, 41. 29] 15. 22 [11. 71, 18. 73] 50 106 32 82 191 137 90 99 50 131 53 78 122 104 154 61 143 29 6 108 35 93 190 136 97 92 58 136 53 80 164 123 159 48 144 14 Total (95% CI) 1712 1786 Test for heterogeneity: ? 2 = 130. 32, df = 17 (P ; 0 . 00001), I? = 87. 0% Test for overall effect: Z = 8. 50 (P ; 0. 00001) -50 Favors Usual Care 0 50 Favors Decision Aid Figure 2 Effect of patient decision aids on patients’ mean scores on knowledge tests: decision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study N Goel 2001 Rothert / H-Rovner O'Connor 1998-RCT Hunter 2005 Schapira 2000 Street 1995 Rostom 2002 Deyo / Phelan Dodin 2001 Total 77 83 81 116 122 30 25 41 52 627 Detailed DA Mean (SD) 81. 67(11. 1) 86. 79(11. 34) 75. 00(20. 00) 64. 53(19. 61) 83. 33(12. 78) 82. 60(11. 60) 93. 80(9. 00) 71. 76 (17. 06) 71. 04(15. 45) N Simple DA Mean (SD) 80. 00(12. 22) 83. 75(11. 54) 71. 00(21. 00) 60. 13(19. 00) 78. 33(15. 00) 76. 40(13. 80) 87. 10(11. 80) 62. 35(23. 53) 61. 20(17. 90) WMD (random) 95% CI Weight % 14. 31 21. 90 6. 62 10. 92 22. 45 6. 23 7. 85 3. 67 6. 06 100. 00 WMD (random) 95% CI 1. 67 [-2. 59, 5. 93] 3. 04 [-0. 40, 6. 48] 4. 00 [-2. 26, 10. 26] 4. 40 [-0. 47, 9. 27] 5. 00 [1. 60, 8. 40] 6. 20 [-0. 25, 12. 65] 6. 70 [0. 95, 12. 45] 9. 41 [1. 00, 17. 82] 9. 84 [3. 30, 16. 38] 4. 63 [3. 02, 6. 24] 48 87 84 126 135 30 26 49 49 634 Test for heterogeneity: ? 2 = 7. 18, df = 8 (P = 0. 52 ), I? = 0% Test for overall effect: Z = 5. 63 (P < 0. 00001) -50 Favours Simple 0 50 Favours Detailed Figure 3 Effect of patient decision aids (DAs) on patients’ mean scores on knowledge tests: detailed versus simple decision aids. WMD = weighted mean difference; CI = confidence interval. 564 †¢ MEDICAL DECISION MAKING/SEP–OCT 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† Study or subcategory y Decision Aid n/N 90/122 189/266 73/94 109/265 82/122 33/52 58/81 47/82 70/187 88/139 57/106 1516 Usual Care n/N 108/164 72/133 62/107 82/274 62/135 21/49 39/84 34/92 27/165 40/148 11/108 1459 RR (random) 95% CI W eight % 11. 11 10. 83 10. 55 10. 01 10. 16 7. 66 9. 45 8. 54 7. 54 9. 04 5. 12 100. 00 RR (random) 95% CI 1. 12 [0. 96, 1. 31] 1. 31 [1. 10, 1. 56] 1. 34 [1. 10, 1. 63] 1. 37 [1. 09, 1. 73] 1. 46 [1. 17, 1. 83] 1. 48 [1. 01, 2. 17] 1. 54 [1. 18, 2. 02] 1. 55 [1. 12, 2. 15] 2. 29 [1. 55, 3. 38] 2. 34 [1. 75, 3. 14] 5. 28 [2. 93, 9. 50] 1. 61 [1. 35, 1. 92] Lerman 1997 Wolf 2000 Whelan 2004 McBride 2002 Schapira 2000 Dodin 2001 O'Connor 1998-RCT Whelan 2003 McAlister 2005 Man-Son-Hing 1999 Gattellari 2003 Total (95% CI) Total events: 896 (Decision Aid), 558 (Usual Care) Test for heterogeneity: ? 2 = 52. 06, df = 10 (P ; 0. 00001), I? = 80. 8% Test for overall effect: Z = 5. 34 (P ; 0. 00001) 0. 1 0. 2 0. 5 1 Favours Usual Care 2 5 10 Favours Decision Aid Figure 4 Effect of patient decision aids on the proportion of patients classified as having accurate risk perceptions. RR = relative risk; CI = confidence interval. congruence. Holmes-Rovner and others62 measured the correlation between the subjective expected value of hormones and women’s likelihood of taking HRT, converted here to the percentage of variance in likelihood explained by alues. Dodin and others24 measured the percentage of variance in decisions explained by values. O’Connor and others55 used logistic regression to estimate the percentage agreement between values and choice. PtDAs improved value congruence with the chosen option in 2 of 3 studies. In the trial by Dodin and others,24 24% of the variance in HRT decisions wa s explained by personal values when a detailed PtDA with explicit values clarification was used; in contrast, 14% of the variance in decisions was explained when a simpler PtDA was used (P = 0. 003). In the study by Holmes-Rovner and others,62 the percentage of variance in the likelihood of choosing HRT that was explained by women’s expected values was greater when a more detailed PtDA was used (13%–14%) than when a simpler PtDA was used (0. 09%–2%). O’Connor and others55 found that the addition of an explicit values clarification exercise in a PtDA did not improve agreement between values and the chosen option. However, in the subgroup of women who chose HRT, women who used the PtDA with explicit values clarification DECISION AIDS: PAST, PRESENT, AND FUTURE ad a trend toward better agreement (40%) than did those who used an identical PtDA without explicit values clarification (0%, P = 0. 06). Decision Processes Leading to Decision Quality There were no trials evaluating the extent to which PtDAs helped patients to recognize that a decision needs to be made, understand that values affect the decision, and discuss values with their practitioner. Althoug h 8 trials evaluated effects on patient participation, none focused on helping patients become involved in preferred ways. Some studies measured patients’ self-reports about feeling informed and clear about personal values. The measures used to evaluate these 2 criteria were 2 subscales of the Decisional Conflict Scale (DCS). The DCS is reliable, discriminates between those who make or delay decisions, is sensitive to change, and discriminates between different decision support interventions. 54,79 The scores are standardized to range from 0 (no decisional conflict) to 100 points (extreme decisional conflict). Scores of 25 or lower are associated with follow through with decisions, whereas scores that exceed 38 are associated with delay in decision making. 54 When PtDAs are compared with usual care, 565 Downloaded from mdm. agepub. com by guest on July 22, 2012 O’CONNOR AND OTHERS Study or subcategory y Decision Aid N Mean (SD) 22. 17(9. 47) 27. 56(10. 51) 16. 25(13. 75) 29. 93(17. 26) 15. 75(13. 00) 20. 00(21. 50) 15. 75(13. 25) 15. 00(12. 50) 21. 67(15. 83) 32. 50(15. 00) Usual Care N Mean (SD) 58 45 54 93 37 94 148 215 159 56 959 49. 14(25. 40) 38. 88(20. 02) 27. 25(15. 00) 38. 89(22. 53) 24. 50(21. 25) 27. 50(21. 50) 21. 00(14. 75) 20. 00(15. 00) 25. 83(19. 17) 31. 67(14. 17) WMD (random) 95% CI Weight % 8. 64 9. 09 10. 03 9. 73 7. 93 9. 28 11. 82 12. 25 11. 33 9. 90 100. 00 WMD (random) 95% CI -26. 97 [-34. 1, -19. 93] -11. 32 [-17. 83, -4. 81] -11. 00 [-16. 43, -5. 57] -8. 96 [-14. 73, -3. 19] -8. 75 [-16. 67, -0. 83] -7. 50 [-13. 79, -1. 21] -5. 25 [-8. 49, -2. 01] -5. 00 [-7. 60, -2. 40] -4. 16 [-8. 05, -0. 27] 0. 83 [-4. 74, 6. 40] -8. 35 [-11. 89, -4. 80] 02 Uninformed Subscale Montgomery 2003 50 Murray BPH 2001 52 Laupacis 2006 54 Murray HRT 2001 93 Dolan 2002 41 Morgan 2000 86 Man-Son-Hing 1999 139 McAlister 2005 219 Wong 2006 154 Bekker 2004 50 Subtotal (95% CI) 938 Test for heterogeneity: 48. 12, df = 9 (P ; 0. 00001), I? = 81. 3% Test for overall effect: Z = 4. 61 (P ; 0. 0001) -50 0 Favours Decision Aid 50 Favours Usual Care ?2 = Figure 5 Effect of patient decision aids on patients’ scores on the Uninformed subscale of the Decisional Conflict Scale: d ecision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study or subcategory y Detailed DA N Mean (SD) 22. 50(17. 50) 17. 50(12. 50) 20. 75(10. 75) 22. 50(17. 50) 38. 25(12. 00) Simple DA N Mean (SD) 84 49 45 100 12 27. 50(20. 00) 22. 25(14. 75) 24. 00(16. 00) 20. 00(17. 50) 31. 25(10. 75) W MD (random) 95% CI W eight % 20. 52 21. 72 22. 00 23. 42 12. 34 100. 00 W MD (random) 95% CI -5. 0 [-10. 73, 0. 73] -4. 75 [-10. 10, 0. 60] -3. 25 [-8. 51, 2. 01] 2. 50 [-2. 34, 7. 34] 7. 00 [-2. 12, 16. 12] -1. 32 [-5. 27, 2. 62] 02 Uninformed Subscale O'Connor 1998-RCT 81 Dodin 2001 52 Goel 2001 76 O'Connor Wells 1999 101 Lalonde 2006 12 Subtotal (95% CI) 322 290 Test for heterogeneity: ? 2 = 9. 24, df = 4 (P = 0. 06), I? = 56. 7% Test for overall effect: Z = 0. 66 (P = 0. 51) -50 0 Favours Detailed DA 50 Favours Simple DA Figure 6 Effect of patient decision aids on patients’ scores on the Uninformed subscale of the Decisional Conflict Scale: detailed ve rsus simple decision aid (DA). WMD = weighted mean difference; CI = confidence interval. a negative score indicates a reduction in decisional conflict, which is in favor of the PtDA. In our review, 15 trials used the DCS subscale for feeling informed and 13 trials used the DCS subscale for feeling clear about values. Because this DCS subscale measures self-reported comfort with knowledge and not actual knowledge, we elected to consider it a process measure and to reserve the gold standard of objective knowledge tests in assessing decision quality. The WMD in feeling uninformed about options, benefits, and harms was –8. (95% CI = –11. 9 to –4. 8) in the 10 trials16,25,39,43,44,48,50–52,78 that compared the PtDAs to usual care (Figure 5). The 5 trials that compared detailed with simpler PtDAs24,30,38,54,55 had a WMD in feeling uninformed of –1. 3 (95% CI = –5. 3 to 2. 6; Figure 6). Eight trials comparing PtDA to usual care25,39,43,44,48,50–52 had a WMD of –6. 3 (95% CI = –10. 0, –2. 7) for feeling clear about values (Figure 7). Five trials compared detailed to simpler PtDAs. 24,30,38,54,55 For these trials, the WMD in feeling clear about values was –1. 1 (95% CI = –4. 8 to 2. ; Figure 8). 566 †¢ MEDICAL DECISION MAKING/MON–MON 2007 Downloaded from mdm. sagepub. com by guest on July 22, 2012 DECISION AIDS â€Å"EFFECTIVENESS CRITERIA OF DECISION AIDS† Study or sub-category Decision Aid N Mean (SD) 50 54 41 82 53 139 219 86 724 28. 50(12. 50) 18. 75(16. 50) 19. 75(15. 75) 37. 50(15. 00) 35. 38(12. 33) 16. 25(12. 50) 15. 00(12. 50) 30. 00(3. 25) Usual Care N Mean (SD) 58 55 37 84 45 148 215 94 736 51. 29(25. 73) 30. 00(17. 00) 29. 25(24. 00) 42. 85(16. 57) 40. 56(16. 44) 19. 00(14. 75) 17. 50(15. 00) 30. 00(3. 25) WMD (random) 95% CI Weight % 9. 8 11. 11 8. 15 12. 88 11. 64 14. 75 15. 30 16. 40 100. 00 WMD (random) 95% CI -22. 79 [-30. 26, -15. 32] -11. 25 [-17. 54, -4. 96] -9. 50 [-18. 61, -0. 39] -5. 35 [-10. 16, -0. 54] -5. 18 [-11. 02, 0. 66] -2. 75 [-5. 91, 0. 41] -2. 50 [-5. 10, 0. 10] 0. 00 [-0. 95, 0. 95] -6. 33 [-9. 98, -2. 69] 03 Unclear Values Subscale Montgomery 2003 Laupacis 2006 Dolan 2002 Murray HRT 2001 Murray BPH 2001 Man-Son-Hing 1999 McAlister 2005 Morgan 2000 Subtotal (95% CI) Test for heterogeneity: 57. 71, df = 7 (P ; 0. 0 0001), I? = 87. 9% Test for overall effect: Z = 3. 40 (P = 0. 007) -50 Favours Decision Aid 0 50 Favours Usual Care ?2 = Figure 7 Effect of patient decision aids on patients’ scores on the Unclear Values subscale of the Decisional Conflict Scale: decision aid versus usual care. WMD = weighted mean difference; CI = confidence interval. Study or sub-category y Detailed DA N Mean (SD) 81 77 52 12 97 25. 00(17. 50) 24. 00(12. 50) 25. 00(13. 75) 39. 50(10. 75) 22. 50(15. 00) N 84 45 49 12 100 Simple DA Mean (SD) 32. 50(17. 50) 25. 75(15. 75) 24. 75(13. 50) 37. 50(13. 00) 20. 00(15. 00) W MD (random) 95% CI W eight % 21. 23 21. 09 21. 32 10. 94 25. 42 100. 0 W MD (random) 95% CI -7. 50 [-12. 84, -2. 16] -1. 75 [-7. 13, 3. 63] 0. 25 [-5. 07, 5. 57] 2. 00 [-7. 54, 11. 54] 2. 50 [-1. 69, 6. 69] -1. 05 [-4. 81, 2. 70] O'Connor 1998-RCT Goel 2001 Dodin 2001 Lalonde 2006 O'Connor Wells 1999 Subtotal (95% CI) 319 290 Test for heterogeneity: ? 2 = 9. 02, df = 4 (P = 0. 06 ), I? = 55. 7% Test for overall effect: Z = 0. 55 (P = 0. 58) -50 0 Favours Detailed DA 50 Favours Simple DA Figure 8 Effect of patient decision aids on patients’ scores on the Unclear Values subscale of the Decisional Conflict Scale: detailed versus simple decision aid (DA). WMD = weighted mean difference; CI = confidence interval. Post hoc Analysis Effects of study quality. To examine the effect of possible bias from including trials of low methodological quality, the 13 trials15,21,31,34. 41,45,54,56,58,61,63,66,77 with Jadad scores of 0 or 1 were excluded from the analysis. Overall, the results remained the same. There was a significant improvement in knowledge scores for the comparison of PtDAs to usual-care controls (WMD = 14. 0%, 95% CI = 2. 4, 8. 6) and for the comparison of detailed to simpler PtDAs (WMD = 5. 5%, 95% CI = 2. 4, 8. 6). The proportion of patients having accurate risk perceptions was greater for patients receiving PtDAs with information on outcome probabilities (RR = 2. 0, 95% CI = 1. 4, 2. 8). Publication bias. There were too few studies to explore potential publication bias for all of the outcomes, with the exception of knowledge for the comparison of PtDAs to usual care. The funnel plot for this outcome (Figure 9) points to the absence of smaller negative studies. DECISION AIDS: PAST, PRESENT, AND FUTURE Downloaded from mdm. sagepub. com by guest on July 22, 2012 567 O’CONNOR AND OTHERS Comparison: 01 Decision Aids versus Usual Care Outcome: 0 07 Knowledge: Decision Aids vs Usual Care SE(WMD) 2 4 6 8 -100 -50 0 50 100 WMD (fixed) Figure 9 Funnel plot of all 18 randomized controlled trials comparing patient decision aids to usual care (knowledge). WMD = weighted mean difference. Heterogeneity. There was statistically significant heterogeneity when PtDAs were compared with usual care for 4 outcomes: knowledge test scores, realistic risk perceptions, feeling uninformed, and feeling unclear regarding personal values (Table 3). It should be noted that the heterogeneity of the effect was not in the direction but in the size. When we explored the potential factors contributing to heterogeneity (Table 3), we found that none of the factors eliminated heterogeneity for the outcomes of knowledge scores. When grouped into treatment and screening decisions, the WMD for knowledge scores was slightly higher for the treatment group (16. 6% v. 13. 1%), but there was still statistically significant heterogeneity. For the outcomes of accurate risk perceptions, heterogeneity was not significant when we removed 3 studies with lower accurate risk perception scores in the usual-care control group (P = 0. ). 28,43,44 For the outcome of feeling uninformed, heterogeneity was no longer significant with 1) removal of 3 studies with higher uninformed scores in the usual-care control group (P = 0. 11), 2) inclusion of only audio booklet/ pamphlet decision aids (P = 0. 06), and 3) removal of an outlier48 (P = 0. 06). None of the factors eliminated heterogeneity for the outcomes of unclear values scores. DISCUSSION The majority o f trials report on at least 1 IPDAS effectiveness measure, predominately knowledge test scores. Of those reporting IPDAS measures, we found that PtDAs were superior to usual practices in 568 †¢ MEDICAL DECISION MAKING/SEP–OCT 2007 meeting the new IPDAS standards 1) for decision quality and 2) for 2 process measures (feeling informed and feeling clear about personal values). Detailed PtDAs had superior effects over simpler PtDAs on value congruence with the chosen option and on accurate risk perceptions but not on knowledge test scores or on self-reports about feeling informed and feeling clear about values. We also identified the gaps in the use of measures of effectiveness endorsed by IPDAS, notably, value congruence with the chosen option and most of the decision process measures. There are some study limitations. Study quality ratings of all trials included in the review were low because they all lost 2 points for lack of blinding. Although not an a priori exclusion criterion for this review, in the future, we may consider using study quality ratings for the selection of included trials. The conclusions of this review are limited by 1) inadequate power to detect important differences in effectiveness in subgroups and 2) the wide variability in the decision contexts, the elements within the PtDAs, the type of comparison interventions, the targeted outcomes, and the evaluation procedures. This article focuses solely on measures of effectiveness, not harms. The small number of studies for most outcomes did not allow for analysis of publication bias because of the failure to publish negative studies. Moreover, there may have been publication bias because of failure to report all negative findings in a published study. Lastly, several of the outcomes demonstrated statistically significant heterogeneity. It reflects differences across clinically diverse studies; therefore, the pooled effect size and CI should be interpreted as a range across conditions, which may not be applicable to a specific condition. There are several implications for future research. Studies are needed to evaluate the effects of PtDAs on congruence between values and chosen options. Moreover, the methods for quantifying value congruence should be explored. The IPDAS decision processes criteria leading to decision quality should also be measured. It would be helpful to develop a standardized approach to measurement. With the addition of more trials to the database, it may be possible to tease out the reason for heterogeneity of results, including variability in 1) study quality, 2) comparison intervention, 3) elements within PtDAs, 4) decision type, and 5) format of decision aid (e. g. , video, Internet, booklet). The degree of detail in PtDAs that is required for positive effects on IPDAS criteria should also be explored. Downloaded from mdm. sagepub. com by guest on July 22, 2012 Table 3 Exploration of Potential Factors Affecting Heterogeneity Outcome Overall Effect Treatment Decision Screening Decision Video/Computer Decision Aid Audio/Pamphlet Decision Aid Baseline Risk in Usual-Care Groupa Removal of Outliers Knowledge 1. 6 (1. 4, 1. 9) –3. 5 (–12. 9, 5. 8) 1. 6 (1. 1, 2. 3) No data 15. 2 (11. 7, 18. 7) 16. 6 (12. 0, 21. 2) 13. 1 ( 7. 7, 18. 5) 21. 4 (16. 5, 26. 2) 11. 9 (8. 3, 15. 6) 1. 6 (1. 4, 1. 9) 15. 6 (11. 3, 19. 9) 1. 3 (1. 2,1. 5)* 1. 6 (1. 4, 1. 9) 17. 316,28,36 (13. 7, 20. 9) 1. 528 (1. 3, 1. 7) –8. 4 (–11. 9, –4. 8) –9. 4 (–13. 3 –5. 5) 12. 6 (–19. 5, –5. 8) –4. 9 (–7. 6, –2. 3)*** –5. 4 (–7. 7, –3. 2)** –6. 248 (–8. 4, –4. 1)*** –8. 0 (–15. 1, –1. 0) –4. 5 (–8. 4, –0. 6) –3. 6 (–6. 8, –0. 5) –4. 0 r48 (–6. 7, –1. 3) Downloaded from mdm. s agepub. com by guest on July 22, 2012 Accurate risk perceptions Uninformed Subscale of the Decisional Conflict Scale Unclear values subscale of the Decisional Conflict Scale –6. 0 (–9. 8, –2. 3) Insufficient data –6. 3 (–10. 0, –2. 7) Note: Values are presented as the weighted mean treatment effect (95% confidence interval). Chi-square heterogeneity test P value