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The results can be quantified in terms of increases in customer volume discount 30 mg remeron with mastercard illness and treatment, amount of sales buy generic remeron 15 mg medications just like thorazine, and profits. While the benefits of marketing can be measured in such con- crete terms for some health services, the results are often much fuzzier in healthcare. Indeed, it is often difficult to separate profitable from unprof- itable services in healthcare. Furthermore, a public hospital may measure the success of its promotions in terms of how many patients it prevents from using its emergency room. An academic medical center may measure the success of its marketing initiatives in terms of the volume of research grants it receives, innovative techniques it develops, or number of subjects it can attract for clinical trials. Quantifying the differences that exist between healthcare providers in any meaningful way is difficult, particularly with hospitals and physician groups. It is often not possible to compare the level of technology, quality of the medical staff, or even price differentials for such organizations. Information that would allow quantitative comparisons between organizations may not be available; even when it is available (e. As the healthcare system has become more complex, it has increasingly become the case that virtually all hospitals are characterized by some minimal level of services, personnel, and equipment; the same is likely to be true of large specialty practices. If all organizations have com- parable attributes, making a case for a comparative advantage of one over another is difficult. Healthcare marketing, to a great extent, shares a problem with cer- tain other industries—the challenge of marketing services rather than goods. Relative to 42 arketing Health Services goods, services are intangible and much more difficult to conceptualize. The purchase of goods tends to be a one-shot process, whereas services may be ongoing. It is more difficult to quantify services, and consumers evaluate them differently from more tangible products. Because services are often more personal (especially in the case of healthcare), they are likely to be assessed in subjective rather than objective terms. Services are distinguished from goods in that they are generally pro- duced as they are consumed, and they cannot be stored or taken away. Services are further characterized by (1) intangibility, (2) variability, (3) inseparability, (4) perishability, and (5) ownership considerations. They are variable in that they cannot be subjected to the quality controls placed on goods but rather reflect the variations that characterize the human beings who pro- vide the services. Thus, we find substantial differences in the effectiveness of various surgical procedures from hospital to hospital. Services are insep- arable from the producer in that they are dispensed on the spot, without any separation from the provider. Services are perishable in that they can- not be stored; once provided, they have no residual value. Finally, services defy ownership rules in that, unlike goods, they do not involve transfer of tangible property from the seller to the buyer. The marketing of services is further complicated by the multidi- mensional nature of the service. Unlike a good, a service can be thought of as having three components: (1) the people who dispense it, (2) the physical conditions under which it is dispensed, and (3) the processes involved in its provision. Market researchers evaluating the level of patient satisfaction for a provider invariably find that customers rate the experi- ence in terms of their treatment by the staff, the physical circumstances (e. While marketers of packaged goods must consider a number of aspects of the process, they generally are able to focus on the product. They do not have to be concerned with the characteristics of those dispensing the product, nor with the processes involved in the customer obtaining the product. For this reason marketers of health services must consider a wider range of issues. Developments Encouraging Healthcare Marketing Despite the barriers to the incorporation of marketing into healthcare noted above, significant progress was made during the last decades of the twen- tieth century in establishing marketing as an integral function of health- The Challenge of Healthcare M arketing 43 care organizations.

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The use of RPE in estimation or production mode should be dependent on where the patient is within the rehabilitation process buy generic remeron 30 mg on line treatment yellow tongue. Are your patients psychologically and physiologically skilled with their exercise and perceptions of effort to use production mode? For unconfident or inexperienced anxious patients purchase 15 mg remeron visa fungal nail treatment, this could be at a low rating because of the fear associated with causing an exertion-related cardiac event. In the early stages of rehabilitation this provides patients with some input and gives them some control over their exercise intensity. It has been demonstrated that individuals who have not been active feel more positive about their exer- cise when working at a moderate compared to a higher intensity (Parfitt and Eston, 1995; Parfitt, et al. Once it is recognised that the patient has gained confidence, the exercise leader can encourage them to work to higher levels of effort. This fits with the physiological progressions discussed earlier in the section on monitoring HR. When patients are happy working at the appropriate RPE in estimation mode, they can be moved towards using RPE in production mode. The use of RPE in this way ties in well with the important aspect of helping patients attain a sense of mastery, which is bene- ficial to their mental well-being (Soenstroem, 1984; Stephens, 1988; Buckley, 2003). RPE, psychological status and social milieu Psychosocial factors can influence up to 30% of the variability in an RPE score (Dishman and Landy, 1988; Williams and Eston, 1989). Such influences may help to explain the wider variability of RPE, for a given %HRRmax, reported by Whaley, et al. The patients’ psychological status has two aspects, which can influence RPE: their state of mental well being and the state of motivation to exercise. The social milieu in which the exercise takes place plays a key role in influencing patients’ well-being and motivation to exercise (Dishman, 1994). It is known that fol- lowing a cardiac event, there can be a concomitant psychological morbidity (Todd, et al. Individuals with heightened anxiety and depression tend to inflate estimation mode RPE scores compared to those without psycho- logical morbidity (Rejeski, 1981). Furthermore, Kohl and Shea (1988) sug- gested, though the evidence is equivocal, that individuals with an external locus of control compared to those with an internal locus of control give higher RPEs for a given work rate. The inhibiting social situ- ation can include an exercise test, individuals feeling inferior to other patients’ abilities in ability, consciousness of body image or physical inferiority, and competitiveness during the exercise session. The effect of psychological status and the presence of disease in modulating RPE scores are not new areas of investigation (Borg and Linderholm, 1970; Morgan, 1973; Morgan, 1994). Borg and Linderholm (1970) found that cardiac patients gave higher RPE values for a given HR compared to age-matched control participants. This greater RPE in the patient group was correlated with the severity of disease. Therefore, not only is RPE used as an aid to monitor exercise intensity, but the RPE values that individuals give may provide cues to the practitioner to consider the patient’s psychological state. Considering all of these issues, changes in RPE over a course of rehabilita- tion may partially be a function of changes in psychological well being. Never- theless, for patients to perceive their exercise as getting easier over time, independent of the amount of physiological change, provides positive feed- back and motivation towards continued participation through a sense of achievement (Dishman, 1994). Continued participation will secure the longer- term physiological benefits that patients can derive from regular exercise. RPE and the ambient environment The ambient environment includes the temperature and humidity of the exer- cise environment, the effects of water during swimming pool exercise and any audio-visual stimulants. The strongest association of temperature and humid- ity to RPE is found with skin temperature (Pivarnik and Senay, 1986). When skin temperature is raised, either as result of increased room temperature, humidity or core temperature not being dissipated due to higher humidity, RPE increases for a given work rate. Music has been demonstrated to dampen perceptions of exertion more than visual distractions like video displays or televisions (Karagheorghis and Terry, 1997; Nethery, 2002). This is important for cardiac patients, where background music could potentially influence patients to over-exert themselves. Water-based activity has also been shown to be a damper of perceived exer- tion in light of the following evidence. Movement in water is used therapeu- tically because it greatly reduces both the gravitational and traction load on skeletal joints, while at the same time providing external resistance (Prins and Cutner, 1999). It is believed to have a soothing interface with the skin and dampens the potential for jerky limb movements (Sukenik, et al.

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As you will see from the notes below order 15mg remeron amex treatment walking pneumonia, you do not need to be able to perform the F test yourself to com e up with com m ents like this purchase remeron 15 mg symptoms high blood sugar, but you do need to understand what its tails m ean. The sum m ary checklist in Appendix 1, explained in detail in the sections below, constitutes m y own m ethod for assessing the adequacy of a statistical analysis, which som e readers will find too sim plistic. If you do, please skip this section and turn either to a m ore com prehensive presentation for the non-statistician, the "Basic statistics for clinicians" series in the Canadian Medical Association Journal,1–4 or to a m ore m ainstream statistical textbook. If you do, you m ight get stuck with non-param etric tests, which aren’t as m uch fun (see section 5. But if outliers are helping your case, even if they appear to be spurious results, leave them in (see section 5. Better still, m ention them briefly in the text but don’t draw them in on the graph and ignore them when drawing your conclusions (see section 5. Alternatively if at six m onths the results are "nearly significant", extend the trial for another three weeks (see section 5. You m ight find that your intervention worked after all in Chinese fem ales aged 52 to 61 (see section 5. N one of the points presupposes a detailed knowledge of the actual calculations involved. The first question to ask, by the way, is "H ave the authors used any statistical tests at all? If they are presenting num bers and 77 H OW TO READ A PAPER claim ing that these num bers m ean som ething, without using statistical m ethods to prove it, they are alm ost certainly skating on thin ice. Have they determined whether their groups are comparable and, if necessary, adjusted for baseline differences? M ost com parative clinical trials include either a table or a paragraph in the text showing the baseline characteristics of the groups being studied. Such a table should dem onstrate that both the intervention and control groups are sim ilar in term s of age and sex distribution and key prognostic variables (such as the average size of a cancerous lum p). If there are im portant differences in these baseline characteristics, even though these m ay be due to chance, it can pose a challenge to your interpretation of results. In this situation, you can carry out certain adjustm ents to try to allow for these differences and hence strengthen your argum ent. To find out how to m ake such adjustm ents, see the section on this topic in D ouglas Altm an’s book Practical statistics for medical research. W e can, for exam ple, calculate the average weight and height of a group of people by averaging the m easurem ents. But consider a different exam ple, in which we use num bers to label the property "city of origin", where 1 = London, 2 = M anchester, 3 = Birm ingham , and so on. W e could still calculate the average of these num bers for a particular sam ple of cases but we would be com pletely unable to interpret the result. The sam e would apply if we labelled the property "liking for x", with 1 = not at all, 2 = a bit, and 3 = a lot. Again, we could calculate the "average liking" but the num erical result would be uninterpretable unless we knew that the difference between "not at all" and "a bit" was exactly the sam e as the difference between "a bit" and "a lot". In general, param etric tests are m ore powerful than non-param etric ones and so should be used if at all possible. N on-param etric tests look at the rank order of the values (which one is the sm allest, which one com es next, and so on), and ignore the absolute differences between them. As you m ight im agine, statistical significance is m ore difficult to dem onstrate with non- param etric tests and this tem pts researchers to use statistics such as the r value (see section 5. N ot only is the r value (param etric) easier to calculate than an equivalent non-param etric statistic such as Spearm an’s , but it is also m uch m ore likely to give (apparently) significant results. U nfortunately it will also give an entirely spurious and m isleading estim ate of the significance of the result, unless the data are appropriate to the test being used. M ore exam ples of param etric tests and their non-param etric equivalents (if present) are given in Table 5.

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