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Advanced Queueing

To take advantage of the Advanced Queuing option of Oracle8 you can make use of the TOracleQueue component. The TOracleQueue component encapsulates the basic functionality of the DBMS_AQ package. It provides a convenient way to enqueue messages into a queue or to dequeue messages from a queue. Messages can be dequeued in a background thread of your application, and the events that are generated in threaded mode can occur synchronously or asynchronously with the main thread of your applicatio.

Session Pooling

In server applications that frequently need to create sessions to process requests from client applications, it may be useful to use connection pooling. Without a pooling concept, each request could lead to an actual database logon and logoff. By using the TOracleSessionPool component, you can maintain a pool of database sessions that can be used and reused for different requests. You can define the minimum an maximum number of sessions in the pool, define the TimeOut behavior for idle sessions in the pool, and preset the username, password and database.

Support for Oracle specific features

Direct Oracle Access supports many Oracle specific features. Besides the features mentioned above, it supports Oracle8 and Oracle8i features like LOB Locators, Objects & References, XMLTYPE, Timestamps, Scrollable Queries, Password Expiration, External Procedure development, and the Oracle Services for MTS.

System requirements

Direct Oracle Access requires a Windows 95, 98, ME, NT4, 2000, XP, Vista, Windows 7, Windows 8 or Windows 10 client, with Oracle SQL*Net, Net 8, Net 9, Net 10, Net 11, Net 12, Net 18 or Net 19 installed. The supported Oracle Server versions are 7.x, 8.x, 8i, 9i, 10g, 11g, 12c, 18c and 19c on any platform. Direct Oracle Access is available for all recent versions of Delphi and C++Builder.

Trial versions

You can download a fully functional trial version to try out Direct Oracle Access yourself. Visit our ordering page for ordering details and price information. We have a customer list available if you want to get an impression of what organizations are using Direct Oracle Access.

Pricing & Licensing

Standard or Object version
The Direct Oracle Access components are available in two versions, the Standard version and the Object version. The Object version allows you to use Oracle8’s Object extension through the TOracleObject and TOracleReference objects.

Oracle Monitor Pro option
The Oracle Monitor allows you to monitor the database activities that your Direct Oracle Access applications generate. The Lite version is available for free, and the Pro version can be purchased as an option for a Direct Oracle Access license. The Pro version includes additional features like database and network statistics, and query plan analysis.

Service Contract option
If you order an Annual Service Contract for a Direct Oracle Access license, you are entitled to technical support by e-mail and free product upgrades for the period of 1 year. Without this contract, you will receive only patch releases of the Direct Oracle Access version you purchased.
You can order the service contract directly with Direct Oracle Access or at a later time. The service contract can be renewed when it expires after 1 year.

Sourcecode option
You can additionally order the Sourcecode option, which is not related to the number of Direct Oracle Access licenses. Direct Oracle Access is programmed in Delphi, but the sourcecode can be compiled in C++Builder as well.

License terms
For every developer you need to purchase a Direct Oracle Access license and Monitor Pro license. You can additionally order the sourcecode, which may be used by all licensed developers.
You are allowed to build and sell any executable using the Direct Oracle Access components, no royalties are required. You are not allowed to distribute the registered (original or altered) components.

Collection of outcomes for use in evaluation of health care, quality improvement, clinical decision-making or effectiveness research continues to be promoted and encouraged. Routine collection of health related outcomes can occur in more formal contexts, for example in developing patient or disease registries, or less formal where findings are documented in individual patient charts. Collection of health related outcomes can be used at a system level or for individual patient management. In either case, the dilemma remains as to which health related outcomes to select that accurately captures the intended purposes for collection. There are a large number of criteria that could be considered to select outcomes which makes the process challenging.

Several attempts to establish a minimum or core set of criteria used to evaluate or select outcomes have been reported [1,2,3,4,5,6]. However, there are important limitations in these previous recommendations. Some focus predominately on patient reported [1] or psychological/ behavioural outcomes [2, 3]; there are many other types of measures used to assess the impact of care. Another attempt was developed in the context of comparing clinical trials and using an agreed upon set of common outcomes [4]. Similarly another is to be considered broadly at a systems level and not readily operationalized with consistency [5, 6]. Although helpful, these previous criteria recommended to select outcomes may not be applicable for all types of outcomes or in other contexts in which they were developed.

This paper will detail a protocol to establish criteria for selecting health related outcome measures (HROM) in the context of primary health care (PHC). PHC is characterized by patients with multifactorial health problems and accordingly the interventions are multilayered and complex. We propose a Delphi consensus study that includes experts in HROM development and clinical research. We provide background information around definitions and use of HROM, previous attempts to establish criteria to select measures, hypothesized benefits and use of HROM in clinical settings, the relevance to the PHC context and evaluation of complex interventions generally. The proposed research protocol details are specified and previous gaps in the literature are addressed. The overall goal of this research is to contribute to the development of a transparent and reproducible process to select HROM that will be used across different sites that are implementing and adapting complex PHC interventions.

Purpose and definition of outcomes and health related outcome measures

Apart from the practical and logistical aspects of routine collection of health related outcomes for evaluation purposes, there are some challenges conceptually in defining what is and is not an outcome. This is related to the variation in definitions of an outcome generally, as well as, definitions of an outcome measure and an outcome assessment [7,8,9,10,11,12,13,14,15,16,17,18,19,20,21,22,23]. The term outcome is often used in a global sense to connect the expected impact of an intervention. It is also used frequently to refer to instruments or scales used to assess or evaluate interventions or patient status at any point in the health care trajectory. The term outcome may be confused with the term endpoint (which sometimes is defined as a group of outcomes used to establish the benefit or harm of an intervention).

For the purposes of this paper we have adopted the definition of an outcome as one that captures a “measureable characteristic that is influenced or affected by an individuals’ baseline state or an intervention as in a clinical trial or other exposure” [8, 19]. An outcome could reflect both the benefit or harm to a patient who receives an intervention and exposure [10]. This definition is in keeping with the Donabedian framework for quality improvement which defines outcome as the “effects of care on the health status of patients and populations” [11]. Outcome assessment is considered to be the most important of three categories of assessment of quality of care (including structure (context where care is delivered and including buildings, equipment, staffing, etc.) and process (interactions between patients, providers, system) [11, 24, 25]. In this quality improvement framework, the focus of outcomes is on the impact of care on the person receiving it. Ideally the assessment of outcome of care should always reflect what patients actually experience and consider important [26]. Thus HROM are measures or scales or instruments that are designed to capture outcomes (domains and constructs) in a health care context.

What is key in this definition of outcomes and HROM is that it is not the specific type of measure or instrument or test that is used in the assessment but rather the intended purpose of the outcome measurement and the timing of the collection during care receiving. For example, consider hemoglobin A1c in the care of patients with diabetes. Capture of the frequency of measurement of hemoglobin A1c can be used to assess health service processes; estimation of the mean level (or mean change) can be used to assess the impact of the health services outcome (on the recipient). The influential Food and Drug Administration (FDA) in the United States considers a clinical outcome assessment as one that may use any of four primary types of “outcome measures” that would reflect domains important to relevant stakeholders and these include: patient reported outcome measures (PROM) or (PRO), observer reported outcomes (ObsRO), clinician reported outcomes (ClinRO), and performance outcomes (PerfO). In the FDA regulatory process, laboratory tests, biomarkers, and even mortality/survival are also important types of outcomes that can be used to assess the effectiveness of interventions (in their regulatory capacity, this refers to drugs, devices and biomarkers) for which approval is sought. This broad understanding of HROM and their potential classification are useful in understanding outcome assessment generally.

Use of HROM as an intervention

Promoting the capture of HROM in daily practice has long been a goal for assessing the effectiveness of care provided to patients [27]. However, it is only recently that there is increasing recognition that the routine collection and interpretation of HROM in practice can be shown to influence ongoing care, such that it becomes an intervention in and of itself. Greenhalgh [28, 29] hypothesized pathways of influence and impact of using PROM in clinical settings. Within this hypothesized model, the use of PROM (a type of HROM) will prompt clinicians to discuss health related quality of life concerns, it will enable clinicians to detect unrecognised problems, and will likely change the way in which a clinician will respond (as the findings from the PROM may show a change in the health related quality of life . The act of reviewing or using PROM serves to monitor treatment potentially resulting in changes to the patient’s behaviour and improvement in the patient’s overall health status or satisfaction with care. Thus, outcome assessment by collecting HROM not only evaluates the impact of an intervention at the resolution or end of a particular episode of care, but it can be considered an added “intervention” that serves to direct or modify care. For example, the rate of screening for depression is one outcome that could be used to demonstrate the impact of a routine visit to a family doctor. However, if the screening result is positive, then the physician will now direct care to address this previously undetected health problem. In the context of PHC, like other areas of health care provision, a wide spectrum of HROM are used to assess both simple and complex interventions and single and comorbid health conditions. Added to this complexity is that most visits to PHC are for symptoms or complaints rather than diseases so the range of available HROM related to single diseases are less appropriate [30].

It is not clear which of types of HROM should be selected to provide useful information to assess the impact of care or to allow clinicians and decision-makers to direct or modify care. What is an ideal HROM in one context may not be so in another context and in part reflects the intended purpose of the outcome assessment. The challenge for clinicians, researchers and decision-makers is to select the most appropriate HROM in light of the fact that likely several well established HROM currently exist and are candidates for selection. Although there have been some attempts to set some general guidelines for selecting HROM for outcome assessment, these criteria have several key limitations that have been noted and none provide recommendations for dealing with equally valid but competing measures.

Hypothesized benefits of using HROM in clinical settings

Donabedian was one of the first to propose that structure, process and outcomes are seminal to evaluating quality of care [24, 25]. Since the late 1960s there has been great emphasis on the selection and use of HROM in quality assessment but also in effectiveness research and even directing clinical decision-making for individual patients. As noted previously, Greenhalgh [28, 29] hypothesized pathways of influence and impact of using PROM in clinical settings. Within this model, PROM can be considered as having multiple purposes that include “clinical tests”, “interventions” and “outcomes”. Table 1 details how the model specifies the clinical goal when using PROM and the potential impact of using these in clinical settings. Note that this model may be applied to HROM, as the definition of HROM includes PROM (as well as, ObsRO, ClinRO, PerfO).

When considering the clinical goals (i.e., assess change, monitor, detect, etc.) for using an HROM, it is not clear if the criteria used to select measures will vary as a function of the specific purpose. It is likely that the criteria may vary not only as a function of the clinical purpose for using the HROM, but also the health domain being assessed by the tool and for other administrative concerns. Soliciting expert opinions on this issue would add to the knowledge of how to apply HROM for clinical, administrative, or research purposes.

Primary health care context and complex interventions

In the context of PHC, there is increasing recognition that most interventions are complex. The Medical Research Council (United Kingdom) has been instrumental in conceptualizing the issues related to developing, evaluating, and reporting on complex interventions [31]. Complex interventions are characterized by having a number of interactions between components and requiring a number of different behaviours by those delivering or receiving the intervention [31]. Adding to this definition is that a number of groups and organizational levels are affected by the intervention. Although some would make the distinction between the complexity of the intervention versus the complexity of the health system [32] the two components interact. Flexibility and adaptation characterize complex interventions [31]. Practically this means that changes in implementation of an intervention are to be expected. More importantly, it follows that a number of outcomes may be required, as well as variability in outcomes assessing the same attribute of interest [31]. This would suggest that adaptations of interventions in one component of a health system may result in the need to select different or modify existing HROM relative to that context. The benefit of this is that it reflects the varying and flexible aspects of PHC interventions and therefore reflects strengths of the interventions in different settings.

The development of this Delphi consensus study is considered in the context of such a complex intervention. Health TAPESTRY is a novel intervention currently being implemented in Canadian PHC settings and undergoing evaluation in a randomized trial. The intervention components involve patients, volunteers, health care teams, and researchers, as well as, the use of an electronic patient health record accessed by all relevant stakeholders [33]. There are several affiliates of Health TAPESTRY across different sites in Canada that vary in their patient populations and focus in PHC services. As expected, each Health TAPESTRY site currently uses different HROM (or will need to select new HROM), and this may present challenges for evaluating benefits and quality of this complex intervention. One overriding goal of Health TAPESTRY is to integrate new and old functionality within and across each of these centres. As the Health TAPESTRY intervention is being adapted and implemented it did not seem feasible to enforce standardization of HROM. However, stakeholders acknowledge that there is a need to guide selection of key HROM to be used in evaluating the impact of the Health TAPESTRY intervention across implementation sites. Health TAPESTRY serves as a quintessential example of PHC issues and the complexity of evaluation. Recognizing the potential for differences across Health TAPESTRY sites, a valid and trustworthy process to review and accept suggestions for HROM is needed to allow for evaluation of effectiveness and impact across sites. To our knowledge there is no guideline or consensus on criteria to select HROM within a PHC setting.