Number of eyes implanted with different types of multifocal intraocular lenses throughout a 12-year period.
\r\n\t
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In 2011, Dr. Wu was recognized as a ‘Top 100 Outstanding Academic Leader for China’s Informatics’ by the China Informatics Society. He was awarded "Outstanding Contribution in Reviewing" by Q1 Journals such as Electronic Commerce Research and Applications (Elsevier).',coeditorOneBiosketch:null,coeditorTwoBiosketch:null,coeditorThreeBiosketch:null,coeditorFourBiosketch:null,coeditorFiveBiosketch:null,editors:[{id:"190913",title:"Dr.",name:"Robert M.X.",middleName:null,surname:"Wu",slug:"robert-m.x.-wu",fullName:"Robert M.X. Wu",profilePictureURL:"https://mts.intechopen.com/storage/users/190913/images/system/190913.jpg",biography:"Robert M.X. Wu has a diploma in Computer Science, a bachelor’s degree in Economics, and master’s and doctorate degrees in e-Commerce. He is currently lecturing e-commerce / Information Systems at Central Queensland University Australia (CQU). He has led more than ten industry-based research projects since 2012 and contributes to reviewing five A-level Australian Business Deans Council (ABDC) journals and Q1 journals.\r\nIn July 2011, Dr. Wu was recognized as a ‘Top 100 Outstanding Academic Leader for China’s Informatics’ by the China Informatics Society. In 2017 he was appointed Distinguished Professor at Shanxi Normal University, China. 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According to WHO data, it accounts for 48% of world blindness, and surgical removal of cataract is the only available treatment for a patient with developed cataract. The prevalence of cataract surgery increases with age, from 16% in the 65–69 age group up to 71% in more than 85 years age group [1]. Removal of cataract by phacoemulsification of the lens, followed by intraocular lens implantation, is in fact one of the most common surgical procedures. According to estimates, 20 million cataract surgeries are performed annually worldwide, but despite this impressive statistic, the number of patients visually handicapped by cataract still globally increases every year. Modern cataract surgery had tremendous development during the past 10–15 years. Improved surgical technique and modern materials have enlarged indication profile for cataract surgery. This also created higher postoperative expectations from patients. Although it is often expected that patient will not need spectacle correction after cataract surgery (at least for far vision), more than 50% of operated eyes need spectacles after surgery to achieve optimal vision. This is due to the fact that with the standard monofocal intraocular lenses (IOL), first of which had been implanted in 1950 by Sir Harold Ridley, only a spherical component of the refractive error can be corrected, without taking care of the astigmatism. In order to determine accurate IOL power for each patient’s eye, it is essential to determine keratometric values and axial length readings. Based on such readings, a calculation of the spherical power of the monofocal IOL is made with specially designed formulas adapted for each refractive error. Monofocal IOLs are readily available in different optical powers in every operating theater and thus can be implanted during a standard cataract case, correcting patient’s spherical error and providing good distance vision. However, full visual recovery in patients with corneal astigmatism and presbyopia will be limited by the fact that both corneal astigmatism and presbyopia were not corrected with the implantation of standard monofocal lens. Every patient with such IOL will lose its ability to focus near objects and will need spectacle correction of approximately +2.5 diopters for near vision. With the increasing patient’s expectations regarding their vision after the surgery, newer generations of intraocular lenses had to be provided.
First, IOLs successfully dealing with presbyopia, named multifocal lenses (MFIOLs) or “premium lenses,” were launched on the market in the early 1980s and were represented with diffractive and refractive design [2]. They were the first step toward full vision correction after cataract surgery. Bifocal diffractive IOL with +4.00D near addition is designed along the principles of diffractive optics and was available in a silicone or hydrophobic acrylic model. This lens consists of a three-piece or single-piece, square-edged 6.0 mm optic with a prolate anterior surface producing −0.27 spherical aberration. The posterior surface of the optic features a diffractive zone. The near addition is +4.00D translating to +3.00D at the spectacle plane. In the theory, the optical design redistributes incident light, 50% for near and 50% distance, independent of pupil size. Bifocal diffractive IOL with +3.00D near addition is aspheric one-piece hydrophobic IOL with central apodized diffractive structure and peripheral refractive zone. The near addition of +3.00D refers to +2.4D at spectacle plane. These lenses, due to their diffractive design, were able to provide patients with good near vision even without the use of spectacles, thus correcting presbyopia [3]. Refractive IOLs available at that time were multizonal IOLs with different areas for distant and near vision. They are a three-piece refractive acrylic lens with five concentric zones. Three zones, including the central one, are for far vision, and two zones are for near vision. An aspheric transition provides a balanced intermediate vision. The near add-power is +3.50D, translating to +2.50D at the spectacle plane. A unique edge design provides a 360° barrier aimed to offset the incidence of posterior capsular opacification (PCO) and minimizes edge glare. They gave good distant and intermediate visual acuity but poorer near vision with a significant problem with halos in night driving.
Disadvantages of MFIOLs caused by lens design were halo and glare (especially at night) in some patients, loss of contrast sensitivity, and the fact that patients needed some time for their brain to adapt to MFIOLs [4]. Moreover, the first multifocal IOLs were unable to correct vision at intermediate distance, which is mostly important for younger presbyopes who often use computers or other tasks at the distance of 60 cm to 1 m. Later on, newer, modern designs of MFIOLs were invented, trifocal, bifocal, and “low-add” lenses with different add-powers, extended range of vision, and quadrifocal IOLs, successfully correcting vision for all visual needs at distance, intermediate, and near [5, 6, 7]. Trifocal IOL is an aspheric, diffractive intraocular lens. The optical zone of trifocal lens had +3.33D near addition and a +1.66D intermediate addition (although different add-powers are also available). It has asymmetrical light distribution of 50, 20, and 30% for far, intermediate, and near foci, respectively. The IOL is fabricated from a hydrophilic acrylic material with a 25% water content and hydrophobic surface. This is a single-piece IOL with 6.0 mm optic diameter. Central 4.34 mm zone includes trifocal optic, and peripheral 1.66 mm zone has bifocal optic. It has a four-haptic design with an angulation of 0° and a 360° square edge to prevent posterior capsule opacification. Quadrifocal IOL is a non-apodized diffractive trifocal IOL with an intermediary 4.5 mm diffractive zone that distributes light to three focal points independent on pupil size. The IOL is a single-piece lens fabricated from a hydrophobic and ultraviolet- and blue light-filtering acrylate/methacrylate copolymer material. This novel diffractive structure has optimized light utilization, transmitting 88% of light at the simulated 3.0 mm pupil size to the retina. The light is split into two, with one half allocated to the distance focus and the other half split evenly between the near and intermediate focuses. The lens design is intended to improve the intermediate vision tasks and increase patient satisfaction, with a third focal point at an optimal intermediate distance of 60 cm, tending to provide more continuous vision. Bifocal diffractive “low-add” IOLs are provided with different add-powers (e.g., +2.75D, +3.25D, +4.00D add), and they have a full diffractive profile on the posterior surface of the optic. The relief height of the diffractive rings is equal in all three models; they have equal light distribution to distance and near regardless of pupil size or add-power. The focal point distance is controlled by the number and spacing of the diffractive rings, and patients have same contrast sensitivity and low-light visual acuity for all add-powers. Extended range of vision IOL delivers a continuous, full-range vision with reduced incidence of halos and glare. It merges two complementary technologies: echelette design which introduces a novel pattern of light diffraction that elongates the focus of the eye, resulting in an extended range of vision, and achromatic technology for the correction of longitudinal chromatic aberration which causes contrast enhancement. It is a diffractive, single-piece, aspheric IOL.
Although MFIOLs were able to fully correct vision in high percentage of patients, especially when modern lens designs are used, they were not applicable in eyes with the astigmatism, since such eyes have an individual need for correction of cylindrical power and axis which is different in each eye. In general population, 35% of eyes have the astigmatism of ≥1.25 diopter (D), 61% having with the rule astigmatism, 25% against the rule astigmatism, and 14% oblique astigmatism. Both the cataract itself and the astigmatism reduce patient’s vision and thus the quality of life. The anterior corneal surface shifts from with-the-rule to against-the-rule astigmatism with aging, whereas posterior corneal astigmatism remains as against the rule in most cases. Total corneal astigmatism is calculated from anterior and posterior corneal curvature measurements [8]. The quantity and axis of the astigmatic refractive error are different in each patient’s eye and can be corrected by spectacles with cylindrical power. If the eye scheduled for cataract surgery has a significant astigmatism, postoperative vision will be impaired by this refractive error, and patient will need spectacles to obtain adequate distance and near vision. For patients with significant astigmatism, solution was found with the invention of toric IOLs, which were designed for two functions: to restore visual acuity deteriorated by cataract and to correct corneal astigmatism [9, 10, 11, 12, 13]. Toric IOLs must be produced individually since each eye with the corneal astigmatism has a unique combination of spherical and astigmatic correction (regarding both the amount and the axis of astigmatism). Moreover, in a proper calculation of toric intraocular lens power, one should evaluate total corneal astigmatism as a better predictor than keratometric astigmatism [8, 14]. Since the prevalence of against-the-rule astigmatism significantly increases with age, such astigmatism should be treated more aggressively during cataract surgery [15]. The most recent advancement in IOL technology is a combination of multifocal and toric design, resulting in multifocal toric design of the lens which provides a complete visual recovery for patients with astigmatism and presbyopia [9, 16, 17].
Based on the positive visual outcome with the implantation of newer generation of lenses in a cataract surgery, modern IOLs have become treatment of choice for many patients with presbyopia and astigmatism even when their natural lens is still clear and has no cataract [18, 19, 20]. Namely, refractive errors such as hyperopia and myopia combined with presbyopia, and also plano-presbyopia, cannot be fully treated with refractive surgery on the cornea. Laser corneal ablation is highly effective in correction of refractive errors and may be the best option for younger population [21]. However, for patients aged 45 or more, only distance vision can be corrected by laser ablation, but the problem of presbyopia remains. With the surgery on the lens, called refractive lens exchange, and implantation of MFIOL full vision can be restored: distance, intermediate, and near vision. If MF toric IOL design is used, also the preexisting astigmatism can be fully corrected [9, 16, 17].
In this chapter, we have analyzed postoperative visual results in our patients operated for cataract and refractive lens exchange with implantation of different types of MFIOLs, used in our setting throughout the last 12 years.
A total of 4408 eyes were implanted with different presbyopia-correcting intraocular lenses in our hospital throughout a period of 12 years (2004–2016). Exclusion criteria for MFIOL implantation were corneal disease, retinal or optic nerve disease, or sever dry eye syndrome. Preoperative assessment included precise biometry and IOL calculation (IOL Master 500, Zeiss, Germany), corneal topography (Pentacam, Oculus, USA), aberrometry (Wavefront Aberrometer, USA), pupillometry, endothelial cell analysis (Noncontact Specular Microscope, Topcon, USA), optical coherence tomography (OCT, Zeiss, Germany), ultrasound, and careful examination of the retinal status. Patient’s selection and preoperative counseling were made by experienced cataract surgeons.
The first group of eyes included 2546 eyes implanted with bifocal diffractive MFIOLs (ReSTOR 4+,ReSTOR 3+, Tecnis, Acrylisa) and refractive design (ReZoom) MFIOLs, with a follow-up of 5 years. Most of the patients were implanted with same lens design in both eyes, while in 440 eyes, a technique so-called “mix and match” was used to enhance intermediate vision. In “mix and match” approach, a refractive IOL (ReZoom) was implanted in dominant eye and diffractive IOL (Tecnis or ReSTOR) in non-dominant eye. The second group of eyes included 1862 eyes implanted with MFIOLs of the following designs: (a) trifocal (Zeiss AT LISA tri), (b) quadrifocal (AcrySof IQ PanOptix), (c) combination of “low-add” bifocals with different add-powers (Tecnis ZKBOO +2.75D in dominant and Tecnis ZLBOO +3.25D add in non-dominant eye), and (d) extended range of vision (Symfony ZXR00) (see Table 1). Follow-up was at least 6 months (range 6–144 months). All eyes were operated under topical anesthesia, as a conventional phacoemulsification procedure on two phaco machines (Whitestar Signature, Abbott Medical Optics and Infinity Vision System, Alcon, USA). Special attention was made during the following surgical steps: small incision preferably on the steep axis, continuous curvilinear manual capsulorhexis with 5 mm diameter, careful polishing of the posterior and anterior capsule, and viscoelastic removal behind the IOL. Same MFIOL was implanted in both eyes simultaneously, except in case of “low-add” lenses where “low-add” with addition of +2.75 was implanted in dominant and “low-add” of +3.25 add in a non-dominant eye. Postoperative uncorrected visual acuity (UCVA) for far, intermediate, and near vision was evaluated for different types of MFIOL. For MF toric IOL implantation, the axis of astigmatism was marked on a patient’s eye during preoperative preparation, in a seated position on a slit lamp, and toric IOL was aligned with this mark during the surgery. The amount of corrected astigmatism was evaluated. Postoperative satisfaction rate, complication rate, and management of complications are presented for all MFIOLs.
Type of multifocal IOL | Number of eyes |
---|---|
Diffractive +4.00 bifocal | 1160 |
Diffractive +3.00 bifocal | 826 |
Refractive | 560 |
Trifocal | 649 |
Low-add | 550 |
Extended range of vision | 663 |
Quadrifocal | 30 |
Number of eyes implanted with different types of multifocal intraocular lenses throughout a 12-year period.
The number of eyes implanted with different types of multifocal intraocular lenses throughout a 12-year period in our hospital is represented in Table 1. In the first 5 years of MFIOL use, mainly lenses of diffractive bifocal and refractive design were implanted, while later on newer generations of MFIOL like trifocal, “low-add” combination, extended range of vision, and quadrifocal lenses were used.
Visual outcome after implantation of first-generation MFIOLs of diffractive and refractive design is represented in Figure 1. Close to 70% of eyes gained uncorrected distance visual acuity (UDVA) of 1.0, while <10% of eyes had UDVA of less than 0.8. Uncorrected near visual acuity (UNVA) was J1–J2 in 95% of eyes with diffractive IOLs and in 84% of eyes with refractive lens design. Overall, close to 90% of eyes was spectacle independent. “Mix and match” technique did not change visual outcome for distance vision and had slightly negative impact on near vision; however, it did increase percentage of spectacle-free time since it improved intermediate vision.
Percentage of eyes achieving (a) uncorrected distance visual acuity of >0.5, (b) uncorrected near visual acuity of >J5, and (c) a portion of time wearing glasses in eyes implanted with different types of multifocal intraocular lenses, in a 5-year follow-up.
With the first generation of lenses, the optical design could not provide good vision at intermediate distance. Therefore, we have started to implant the first lenses designed to improve intermediate vision—lenses of trifocal design and compared the outcome of these lenses with bifocal ones (Figure 2). With trifocal design very good UDVA and UNVA were preserved, and there was a significant improvement in uncorrected intermediate vision (UIVA), with mean visual acuity of 0.8 for intermediate tasks. With even newer design of trifocal lens—so-called quadrifocal IOL—more continuous vision at intermediate distance was obtained due to superior visual outcome at 60 cm (arm length). Novel technology of extended range of vision (EROV) lenses became available, and a combination of two different add-on powers in “low-add” bifocal lenses aimed to improve intermediate vision of our patients. Visual outcome of UDVA, UIVA, and UNVA in patients implanted with four modern lens designs compared to older lens designs are represented in Figure 3. As shown, modern MFIOL designs enabled a significant improvement of vision at distance of 60–100 cm (intermediate) as compared to diffractive and refractive MFIOLs, without compromising very good visual results at far and near. Satisfaction rate after MFIOL implantation according to preoperative refractive error is presented in Table 2. In patients with the astigmatism of >1D, multifocal toric lenses were implanted to correct the astigmatic part of the refractive error. The axis of toric MFIOL implantation was always marked in a sitting position, to avoid misplacement of the lens due to cyclotorsion while the patient is lying down. After toric MFIOL implantation, the mean preoperative astigmatism of 2.25 D was reduced to a mean of 0.32 D (Figure 4). The appearance of a bilaterally implanted trifocal toric IOLs, in a primary position (left) and with a dilated pupil (right), correcting patient’s vision in both eyes to 100% distance, intermediate, and near vision without any spectacles, is shown in Figure 5.
Comparison of mean uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA), and uncorrected near visual acuity (UNVA) between eyes implanted with trifocal and bifocal multifocal intraocular lenses (expressed in decimal values).
Comparison of uncorrected distance visual acuity (UDVA), uncorrected intermediate visual acuity (UIVA), and uncorrected near visual acuity (UNVA) between eyes implanted with diffractive (bifocal +4 and bifocal +3), refractive, trifocal, extended range of vision (EROV), “low-add,” and quadrifocal multifocal intraocular lenses.
Patient refraction | Satisfaction after surgery; average mark [1–10] |
---|---|
High hyperopia | 9.6 |
Low hyperopia | 9.1 |
Plano-presbyopia | 8.7 |
High myopia | 8.2 |
Low myopia | 8.1 |
Satisfaction rate after bilateral multifocal intraocular lens implantation, according to preoperative refractive error.
Change in the amount of astigmatism in eyes implanted with toric multifocal intraocular lens.
Patient aged 56, after bilaterally implanted trifocal toric IOLs, in a primary position (left) and with a dilated pupil (right). Visual acuity in both eyes is 100% for distance, intermediate (80 cm), and near, without any spectacles.
Complications related to MFIOL design like halo and glare were determined among our patients: 15% of patients with refractive lenses reported halos and glare during night driving. Due to severe halo and glare, we had to explant 12 out of 560 (2.1%) refractive IOLs and replace them with bifocal diffractive IOLs. In modern lens designs, the percentage of halo and glare ranged from 4 to 9%, being lowest in EROV IOL (Table 3). Postoperative residual refractive errors were solved with laser refractive surgery. Laser surgery was needed in 6.1% of patients with diffractive bifocal IOLs, while in another groups, enhancement rate was between 1 and 3% (Table 3). Almost one-third of patients reported symptoms of dry eye. Those patients were treated with artificial tears and punctal plugs when necessary. The need for spectacles was highest in refractive IOL group (25%), mostly for near reading. In bifocal diffractive group, 4–5% of patients had to wear glasses, mostly for computer or tasks at 60–100 cm. In EROV IOL group, 4.22% of patients needed glasses mainly for near vision. The best spectacle independence is achieved in patients with quadrifocal (although the number of implanted lenses is greatly smaller compared to other groups, so the data will most probably change with bigger numbers), trifocal, and bifocal diffractive IOL with “low-add” combination (Table 3). Posterior capsular opacification rate was very hard to compare because of a different follow-up (range 3–6%), but trifocal lens did have higher PCO rate compared to others, possibly due to hydrophilic material.
Lens design/complication rate (%) | Halo and glare | Laser enhancement for residual refractive error | Need for spectacle wear |
---|---|---|---|
Bifocal diffractive (Tecnis) | 7.7 | 6.1 | 5.5 |
Bifocal diffractive (ReSTOR) | 7.2 | 1.3 | 4 |
Refractive (ReZoom) | 15 | 2.6 | 25.2 |
Trifocal | 9 | 1.6 | 1.2 |
Extended range of vision | 4 | 1.76 | 4.42 |
“Low-add” bifocal | 8.6 | 2 | 1.3 |
Quadrifocal | 5 | 0 | 1 |
Complication rate after implantation of different types of multifocal intraocular lenses.
Nowadays, cataract surgery is becoming a more and more refractive surgery at the same time. Patient’s expectations are growing; but thanks to development of new technologies, surgery techniques, and intraocular lens designs, ophthalmologist can fulfill those demands. The aim of modern cataract surgery is to achieve good unaided vision at all distances together with high quality of vision in a safe manner and with a fast recovery. Presbyopia-correcting intraocular lenses are currently the most efficient and permanent treatment for presbyopia. First, IOLs successfully dealing with presbyopia, named multifocal intraocular lenses (MFIOLs), were launched on the market in the early 1980s. They were designed to have several foci in order to provide full vision correction after cataract surgery. These lenses, due to their design, were able to provide patients with good distance and near vision even without the use of spectacles [22]. However, due to their design, MFIOLs have also some disadvantages caused by the presence of several foci. Halo and glare (especially at night) are produced by defocused image and scattered light. Higher near additions at IOL optics increase halo and glare. Moreover, patients need some time for their brain to adapt to MFIOL (so-called neuroadaptation). Very often with neuroadaptation, symptoms of halo and glare tend to decrease. Another characteristic of MFIOL is loss of contrast sensitivity caused by separation of the light entering to the eye in two or three foci. Patients record this as slightly washed out or grayish image, especially in low-light conditions. MFIOLs are also very dependent on eventual residual refractive error, dryness of the eye, IOL centration, posterior capsule opacification, pupil size, and presence of vitreal opacities.
In eye hospital “Svjetlost,” MFIOLs are in use since 2004, and currently around one-third of all implanted lenses are MFIOLs. For the first 5 years, we have used MFIOLs available at that time: bifocal diffractive lenses with +4.00D addition (later on also with +3.00D addition) and refractive IOLs. Bifocal diffractive IOLs enabled very good uncorrected far vision and near vision at 30–40 cm, with very good satisfaction rate among patients who did not perform many tasks at intermediate distance (60–100 cm). Refractive IOLs performed somewhat better at intermediate distance range, but near vision was significantly worse as compared to diffractive design. Visual outcome after implantation of the first diffractive and refractive lenses recorded among our patients was similar to other published data [23, 24].However, lack of good intermediate vision was unacceptable for younger presbyopes performing many tasks at a distance of 60–100 cm. In an attempt to enhance intermediate vision, a technique called “mix and match” was invented aiming to ensure uncorrected vision at all distances. Refractive IOL was implanted in dominant eye (for far and intermediate) vision and diffractive IOL in non-dominant eye (for far and near). It worked well in majority of patients; however, in our hands around 25% of patients were complaining at different images in two eyes (because we used two different technologies) and/or photic phenomena. Some authors have reported very high satisfaction rate with “mix and match” approach, despite the fact that in a presented group of their patients also high percentage of halo and glare was reported [25]. These data show that despite some objective photic phenomena many patients still remain happy with the surgical outcome since they have gained spectacle independence. However, from physician’s point of view, we were not satisfied enough with the outcome of “mix and match” method, so we stopped using this technique and switched to newer generations of lens designs emerging on the market: trifocal, combination of “low-add” bifocals with different add-powers, and extended range of vision (EROV) technology [25, 26, 27].
In our hands, all types of new-generation or “premium” MFIOLs (trifocal, quadrifocal, “low-add” combination, and EROV) provided similar and very good UDVA. The main improvement of modern lens designs is the quality of uncorrected intermediate vision, which is very satisfying with all lenses. Trifocal lenses provided excellent far, intermediate, and near vision, which seems to be more “continuous” with quadrifocal design mainly for tasks at 60 cm distance. The EROV provided excellent distance and intermediate vision, performing slightly worse at near if emmetropia was aimed in both eyes. Thus, to improve near vision with EROV lens, we are now implanting many patients with a planned myopic shift of −0.5% in a non-dominant eye (“mini-monovision”), and in this manner, better near vision was achieved. The advantage of EROV IOL is that it maintains a very similar level of visual quality as monofocal IOL, less visual disturbances compared to bi- and trifocals, and we have successfully implanted this lens also in amblyopic patients and those with the previous refractive surgery on the cornea. To conclude, both EROV and trifocal IOLs are good options for patients with intermediate distance requirements, while in patients having numerous near-vision tasks, EROV IOL should be aimed slightly myopic in a non-dominant eye, or trifocal/quadrifocal technology may be used. Comparing to other lens designs, PCO occurrence was higher in trifocal lens, but subsequent YAG capsulotomy did not affect long-term visual outcome. Implantation of two “low-add” lenses with different near add-powers provided good near, intermediate, and distance vision, comparable to the outcome with EROV and trifocal/quadrifocal IOLs.
In our patients with the astigmatism >1D, multifocal toric IOLs were implanted. These lenses are capable of correcting both presbyopia and astigmatism. Invention of multifocal toric IOLs was based on very good results in astigmatic correction with monofocal toric IOLs, which showed to be safe and effective in correcting astigmatism and improving vision even in cataract patients with very high astigmatism such as topographically stable keratoconus, pellucid marginal degeneration, and post-penetrating keratoplasty astigmatism [28, 29, 30]. The systematic literature review shows that spectacle independence for patients treated with four brands of monofocal toric IOLs increased from 15 to 85% of those who never wore spectacles [1]. There are several specific requirements for the IOLs aimed to treat the astigmatism; the lens has to be easy to manipulate in the capsular bag in order to achieve good alignment and needs good long-term positional stability, as low as possible induction of capsular shrinkage and posterior capsule opacification. Namely, toric IOL which has to be produced for each individual case is marked on its surface for proper alignment in the capsular bag. Axis of astigmatism has to be determined and marked in a seating position due to cyclotorsional movements of the eye while the patient is lying down for the surgery. Proper alignment of toric IOL during surgery is crucial since misalignment of only 10o leads to a loss of one-third of the astigmatic correction. Moreover, even a small decentration of IOL of less than 1 mm will induce aberrations and poorer visual result [31]. Shrinkage of the capsular bag may also lead to decentration of the lens and thus have negative impact on its proper alignment. Misaligned toric intraocular lens has to be repositioned into its proper position by surgical revision. If surgical correction is needed, the intervention should be performed as soon as possible after the primary surgery to avoid manipulation in the capsular bag with abundant fibrosis. Although it is recommended to re-center the lens in the first months after primary surgery, it has been reported that lens can be safely repositioned even 15 months after its implantation [32]. According to our results, with properly calculated and implanted toric MFIOL, both spherical and cylindrical errors can be successfully corrected.
In recent years, special medical equipment and centering systems were invented to minimize potential sources of errors during each step of the surgery (e.g., Verion Image Guided System or Zeiss Callisto). Both systems may improve precision, and size of the incisions enables perfect shape and size of the capsulorhexis and more precise alignment of the toric IOL or multifocal IOL along the optical axis. Such a computer-assisted cataract surgery will make premium IOL surgery even more precise, but it will take some time till all the cataract surgery units embrace this technology. All the results presented in this chapter are obtained without the use of advanced computerized systems. Therefore, the outcome and performance of different MFIOL designs implanted in our hospital in the last 12 years are in fact more objective to compare, since the methodology of surgery did not change significantly throughout this period. Once we add sophisticated computer-controlled systems into standard equipment used during cataract surgery with MFIOL implantation, the results should improve further.
Finally, very important or maybe the most important issue when we discuss about MFIOL use is the issue which cannot be presented by pure scientific data—preoperative counseling. Spectrum of lens design available nowadays on the market is quite large, and only careful discussion over patient lifestyle, everyday activities, job, and expectations may provide to write answer on which lens design to use. Patients who are looking for guaranties, “perfect” vision, or 100% spectacle independence are not good candidates for MFIOLs. The first step toward good results is that the surgeon working with MFIOL understand that there is no perfect lens for every patient, and then to transfer in a proper way this information to a patient. Looking at the preoperative refractive errors, hyperopic patients are the best candidates for such surgery. It is very wise to under-promise how it is going to be with implanted MFIOLs and then hopefully over-deliver. With such a proper preoperative counseling, and subsequent choice of the MFIOL best suited to individual patient needs, all currently available MFIOLs will provide a high level of both spectacle independence and patient satisfaction.
Reorganization of the U.S healthcare system began in the early 1980s as hospital ownership and affiliation began to move toward health care network conglomerates. Prior to this, there were a large number of freestanding hospitals, both nonprofit and for-profit, which existed independently from other hospitals in the area. The system was such that each hospital functioned without any reliance on – or interactions with – neighboring hospitals. However, by the early 1990’s, many of these hospitals had entered into agreements to merge with each other. Additionally, many of these hospitals began to acquire autonomous physician groups to form a health care network conglomerate. This restructuring of the U.S. health care system continued throughout the begin of the 21st century. Much of this was driven by the introduction of new payment models in the Patient Protection and Affordable Care Act in 2010, which only served to further initiate mergers and acquisitions as a way to contend with ongoing payment reform.
These mergers were advantageous for a variety of reasons, but financially they were favorable based on the amount of market overlap between separate institutions. Based on previous research by Brooks and Jones [1], two major factors in increasing the likelihood of a merger were identified: the opportunity to increase efficiency and the opportunity to enhance market power.
The expected outcome of enhancing the market power was to increase profitability. By decreasing the amount of competing facilities, there was an opportunity for each healthcare network or set of hospitals to dictate certain prices for healthcare goods and services. The merger of hospitals tended to make the market power of the combination much greater than that of either hospital independently. This substantive alteration of power also served to change the market structure itself. Subsequently, this remodeling of the structure would then place pressures on other competing firms to engage in merger agreements as well.
Gains in efficiency would be made by incorporating the relative strengths of each independent hospital or physician group into a larger structure. Most often, one member of the merger benefits immediately from management expertise of the other merged affiliate. These increases in efficiency can only be seen when facilities combine their collective operations. The amount of market overlap is somewhat predictive of the amount of increase in efficiency seen with mergers. In those facilities with overlap between served markets, consolidating to decrease duplication of services will likely not only be easy, but also rewarding.
Hospital system mergers are well-established in the available literature. Of those that are reported, three significant mergers in major metropolitan cities are the most well-known and time tested [2]. In Philadelphia, in 1995, the University of Pennsylvania Health System acquired the Presbyterian Hospital, followed shortly thereafter by the Pennsylvania Hospital in 1997. This was part of an overarching goal to form an integrated city-wide academic healthcare system. In Boston, in 1994, Massachusetts General Hospital and the Brigham and Women’s Hospital merged to form a new healthcare system: Partners Healthcare. Both institutions were affiliated with Harvard University; the goal was to preserve each distinguished institute’s identity and renown while also forming a more inclusive healthcare system. Finally, in New York, in 1998, New York Hospital merged with Presbyterian Hospital to form New York-Presbyterian Hospital. Each institution was affiliated with a separate medical school (Cornell and Columbia, respectively); despite the merger, they have maintained a clinical independence from one another.
With an increasing number of hospital system mergers, a known sequela is the merging of the healthcare educational system. There is a considerable amount of literature reporting the trends in health care market concentration [3], in addition to the impact those trends have on healthcare costs and quality of care (arguably two of the most important factors in the health care system). However, there is a paucity of literature in regard to the outcomes of residency programs when their associated institutions have a merger or acquisition event.
The economics of residencies have been increasingly difficult during recent changes in the healthcare system. Historically, postgraduate medical education has been subsidized through a combination of public (Medicare and Medicaid) and private insurance payments. Teaching hospitals have, however, faced issues with decreasing reimbursements for a variety of reasons. A major difficulty that teaching hospitals encounter is the large amount of patients who are uninsured; some of their unpaid medical bills are financed by the hospital, while some is simply a debt that will never be repaid [4]. Another complex issue is the shifts in what type of reimbursement model is utilized by insurance companies. These issues overall result in a lower amount of total reimbursements, which trickles down to graduate medical education. These overall cost deficiencies put a tremendous amount of pressure on residency programs for collaboration to resolve these financial burdens.
With the ever-changing paradigm of healthcare delivery in the United States, the education of future physicians and surgeons remains a dynamic process. Residency mergers have become more common and will continue to occur more frequently. Establishing best practice to successfully merge residencies is important for seamlessness in training. In this chapter, we will review the available literature regarding reported residency mergers, with a focus on models and guidelines proposed to make an effective residency merger, including strategies to overcome the difficulties that present themselves during the process.
We began our literature review in August 2020 by conducting a search for “residency program merger” on PubMed and Google Scholar from all years available (1968–2020). There were a total of 33 results for this search query. We then narrowed down these results to those only describing mergers of graduate medical education. Additionally, we incorporated several papers that did not appear in our original search, but were listed as references in one or more publications that appeared in our search. Our aim was to include as many examples of residency mergers to develop a comprehensive view of graduate medical education mergers and the successes and challenges that have been identified.
The first reported residency merger was between two psychiatry residencies, one from The Institute of Living, and the other from the University of Connecticut [5]. In 1989, leaders from each program came together to discuss what the combined program would look like and how they would implement the changes; in July 1990, the combined program began. Both programs had their own set of strengths. The Institute of Living, which is located in downtown Hartford, Connecticut, is one of the oldest private psychiatric hospitals in the US; its reputation and location provide a diverse patient base and the opportunity for long term follow up. On the other hand, the University of Connecticut Health Center, which is located in a Hartford suburb, is an academic institution with a strong commitment to the education of both medical students and residents.
Based on these complementary characteristics, the respective institution leaders were hopeful that the merger would be successful. A task force to construct the new residency program was assembled and was comprised of both faculty and residents from both institutions. Salaries of the residents had differed between residency programs, so once merged, all salaries were standardized. Similarly, call requirements differed, so those too were standardized. Overall the merger was successful; both institutions used the merger to improve their educational experience as one cohesive unit.
There is limited literature available regarding residency mergers, but the most widely referenced specialties include pediatrics [6], psychiatry [5], family medicine [7], and surgery [8]. For the most part, the publications generally present the process behind the merged programs, the challenges they faced throughout the process, and the advice they offer for future mergers. Success of the merger is very subjective and is not typically measured objectively, with the exception of some literature which follow residents’ perspective of the process through surveys evaluating how positively or negatively they felt about the merger.
Unfortunately, the limited amount of information available about residency programs that have merged or are undergoing a merging process is compounded by the fact that there is no official record or list which is published by the Accreditation Council for Graduate Medical Education (ACGME). Not only does the ACGME not keep records of this, but previous personal communication with ACGME administrators have revealed that no data on residency mergers is maintained [9].
Although not specifically a merger, a well-publicized closure of a large academic institution made national news in the United States in 2019. Hahnemann University Hospital, a 500-bed teaching hospital in Philadelphia, Pennsylvania, announced its closure abruptly in June 2019, soon after it had recently welcomed 140 new residents to its varied residency programs. This chaotic sudden closure suddenly displaced more than 550 residents and fellows, who then had to quickly find residency positions elsewhere. Fortuitously, all trainees were able to find educational opportunities within 43 days [10]. This is a worst-case scenario result of financial pressures placed upon teaching hospitals. The goal of raising this discussion about residency mergers and collaboration is to avoid a similar unfortunate event.
Rider and Longmaid, both of Harvard Medical School, have had personal experience with mergers as well as conflict resolution and therefore published an article in 2003 detailing their advice for merging residency programs [9]. They identified 10 specific guidelines to keep in mind while going forward with the merging process, which we will discuss briefly.
The success of any merger is dictated by having a definitive plan that is effectively carried out. This can only be achieved with establishment of a leader who is capable of not only creating this plan but also putting it into action. Whether that is one of the previous residency program directors (PDs), a combination of individuals, or even another individual entirely, the leader should be clearly identified and communicated to all involved parties.
A plan should be established which addresses a few particular issues for the new program: goals of education and training, educational philosophy, governance of combined program, institutional cultures, and the impact of merger on faculty and trainees. The vision of the leader should be used to formulate a plan for these issues as well as a timetable for that plan to be fully operational. A more rapid timetable for the enactment of the plan is preferable, as the goal is of course to minimize the amount of disruptions during the process of combining programs.
The importance of a dynamic leader is not to be neglected, either. Although the leader may have his or her own vision, it should be combined with the input of faculty and residents from both institutions. Differing opinions will allow for the creation of an ideal program, to which all faculty will then be motivated to contribute. A suggestion based on previous successes in other health care mergers would be to create a committee of involved individuals who are dedicated to shaping the goals and vision for the future residency program. This would be a concrete way to incorporate the influence of all departments interested, as well as those of the residents. Flexibility is a necessary characteristic of a leader to establish a plan that not only fits the original vision but combines with the constructive input of others.
Communication is key! While the vision and plan are put into action by the leader, obstacles that challenge the success of that plan will always be encountered. Having clear channels of communication already established can be helpful when trying to address some of these obstacles. Frequent updates via multiple modes of communication will ensure that a communication link is available should any issues arise. Email would be the easiest, but not always the preferred method for everyone. An in-person meeting that is scheduled either weekly or bi-weekly could be helpful in making sure that all parties remain involved in planning and enacting change.
Generally, most people do not feel like change is a positive construct. Whenever change is initiated, it is sometimes felt as if it is a negative comment on how programs were already operating. This can be detrimental to staff and program morale, which can lead to a host of negative results including staff attrition/resignation or feelings of inadequacy/anxiety. Leadership for the merger should be responsible for helping faculty and residents cope with the change by “giving them time to react, validating and respecting their feelings, keeping them up to date and creating a safe environment in which they can talk about the change” [9].
While it initially may not seem like a good idea to allow involved parties to express their displeasure in the merging process, it does allow those individuals to feel as if they have been heard and their opinions matter. Even acknowledgement itself can sometimes satiate a person’s displeasure in the process. This can lead to acceptance, begrudging as it may be, rather than tension or conflict with many involved parties.
During a residency merger, it is not just the institutional structure of the overall program that has to and will change, but also the personal structure of how individuals carry out their daily activities and tasks. This may not necessarily be accepted, but rather “physicians may react to the changes brought about by a merger in a predictable pattern, usually reflecting a combination of denial, anger and frustration as their professional lives become progressively more disrupted by a process they may not support” [9].
Personal commitment to the success of the merger will be essential in overcoming the disruptions presented by the operational and structural changes, which is why it is so important to make sure that all individuals’ concerns are heard. The more the merger feels like it is a cooperative effort, the more individuals are willing to push through and own the discomforts of the process.
No institutional culture will be the same. Even if one larger program is enveloping a smaller program, it will be crucial to incorporate the cultures of both programs. The residents and faculty in each program chose their particular program for a unique set of reasons. Often, a major reason why a medical student would choose a program is that the culture fits with their particular value system and needs. Being able to assimilate the strengths of both programs, while abandoning the weaknesses, will allow for both sets of residents to succeed in the new environment. Without endorsement by each program’s residents and faculty, the program will flounder in the setting of resentment and tensions between the two separate groups. In a merger between Howard University Hospital (HUH) and Children’s National Medical Center (CNMC), the institutional leaders address a specific example of cultural differences experienced in the merger of their pediatric residencies that we will discuss in detail later in the chapter [11].
While this may seem like a simple concept, mutual respect is not always a given. Parties from either residency program may come into the merging process with pre-conceived notions and hostilities. One program may feel as if it is being “taken over” by the other, or one may feel as if it is being “invaded” by outsiders. When two groups merge, the natural instinct is for people to stay within their own group and be loyal to themselves, rather than incorporating with the second group. With time, this chasm between groups should begin to close, as they begin to interact with each other on a more frequent basis. Making sure that these interactions are positive is essential, and starts with making sure all residents and faculty have a mutual respect for one another.
The more an individual feels as if they are a part of the process to create a new and improved residency, the more dedicated they are to enduring the process. Regular meetings and an inclusive committee will be essential in making staff feel as if they are able to provide input and help shape the process. The goal is to reduce uncertainty and make individuals feel more comfortable with the changes throughout the merger.
Residents, not just faculty, are an important source of constructive input during this process. While a residency merger does impact faculty and other hospital staff, the most changes will be felt by the residents. Disruptions in everyday life and operations will be most noticeable to them. It is critical that they are able to give input just as much as the input provided by leaders in the department. They may, however, not be able to dedicate the same amount of time to the process, such as attending frequent meetings, given how much time they are dedicating to their education. There should be some type of forum or meeting specifically dedicated to residents, so they feel as if their input is received while also still protecting their time to focus on their professional training.
Each residency program will come with its own strengths and weaknesses. One may have a stronger academic program, while the other may have a stronger clinical program. Through the acceptance and assimilation of these separate resources, the combined program can be more successful than either program was individually. Identifying these strengths and weaknesses and discussing them among the leadership of the merger will be essential in deciding which components of each program to include in the combined program to create the most successful program possible.
Salaries, benefits, and stipends must be made equal for residents and faculty to allow for mutual respect between these groups. Without this, there will be resentment and hostilities among individuals, which will be a hindrance to the programs coming together as one. This idea of fairness and equality must also apply to call assignments and workloads for the same reason.
It will be helpful to identify individuals who are dedicated to improving the program merger process. This could be a pre-appointed committee, as originally discussed, which is comprised of individuals from both programs as well as those from a variety of departments including the resident groups themselves. Personal ownership and responsibility will then be felt by this team which is, together in cooperation, motivated to create the best residency program possible. This does have to occur in the background of all normal clinical activities, which means that the team or teams will need to be efficient and focused. Setting particular tasks and identifying sets of individuals to complete those tasks can be helpful in having them accomplished in reasonable time periods (Table 1).
Key Aspect | Suggested Actions |
---|---|
Establish program director(s) Equal representation from each program Create committee of involved faculty and residents | |
Outline objectives by each PGY level Design a comprehensive curriculum Protected time for all residents Systematic evaluations of faculty and residents | |
Develop combined vision for the future of the residency program | |
Acknowledge differences in institutional culture | |
Provide opportunities early on in the process for residents to work together Frequent social functions | |
Regularly scheduled meetings to provide updates Multiple modes of communication Acknowledge opinions (both negative and positive) | |
Equal call responsibilities Access to hospital-provided tablet or computer for clinical responsibilities | |
Provide equal salaries and benefits between residents of same PGY level Equity in resident book funds |
Key aspects and suggested actions for GME mergers.
In the small pool of literature available regarding residency mergers, one of the major difficulties described with the process is institutional cultural differences. Different facilities will have their own backgrounds and their own ways of doing things. Recognizing these cultural differences and finding a way to incorporate them together is crucial to setting a program merger up for success. This allows for the residents and faculty from each program to feel as if they are a part of the new residency program without feeling a sense of identity loss. We know that successful physicians are created in a variety of training environments; a merger that integrates the strengths of each culture to create shared values will be more successful in the long run, as it engages faculty and residents from both programs in a common goal. Cooperation is a major factor in determining program merge success.
A prime example of a residency merger which united programs with vastly different cultural backgrounds was the merger between two pediatrics programs at Howard University Hospital (HUH) and Children’s National Medical Center (CNMC) as described in a case study by Cora-Bramble et al. [11]. Howard University and its associated medical programs are historically black institutions, while Children’s National is predominantly white with relatively low representation of minorities. Respectively, the compositions of the two different residency programs differed in terms of the residents’ race and ethnicity in addition to inclusion or exclusion of international medical graduates (IMGs). Sizes of the residency programs also differed substantially, as the HUH program was comprised of 30 residents, while the CNMC program was comprised of 72 residents. Perhaps even most notably, the levels of care at each institution differed in that CNMC was a tertiary care center with a high level of specialization including PICU/NICU capabilities, while HUH was more of a community hospital without advanced capabilities or intensive care units.
The merger occurred in 2003 and was prompted by the closure of one of the largest hospitals associated with HUH, which was responsible for the majority of their pediatric patient volume. This triggered citations of the program by the ACGME based on the low volume and lack of available subspecialty exposure. HUH recognized its own weaknesses and began to seek out an opportunity to form a collaborative partnership with another institution. CNMC, which had originally been a rival rather than a partner, stepped in to fill this need. This partnership would serve both institutions as well as the community. Goals of this partnership were identified by the CNMC leadership as “1) to increase the size of the residency program without additional cost, 2) to increase the racial and ethnic diversity of residents, 3) to provide needed support to the historic HUH pediatric residency program, and 4) to establish a community health track.” [11].
Difficulties encountered during the merging process included clinical challenges, operational challenges, and interpersonal challenges. For the most part these impediments are the same that present themselves during any merger, as we have already discussed, but the most complex of these in this particular case was identified as the interpersonal. Apart from the typical difficulties such as unfamiliarity with the organizational structure of their new home hospital, the HUH residents also struggled against inherent biases. The CNMC residents were accustomed to the faster work pace that accompanied their more clinically advanced institution, while the HUH residents were particularly challenged by the higher demand. This lack of clinical acumen was concerning to both CNMC and nursing staff, and immediately put the HUH residents at a disadvantage. This disadvantage was further compounded by encounters of racism and elitism which they encountered during day-to-day operations.
A dramatic observation made in this study was the dichotomy between experiences of the two programs’ residents. Only 13% of CNMC residents felt like the merger was positive for the institution as a whole, as opposed to 63% of HUH residents. The disjunction between opinions was even more distinct when residents were asked if the merger was positive for the residency program in particular – 63% of HUH residents identified it as positive, versus 10% of CNMC residents. Although these striking differences were initially alarming, as time went by after the initial merging process, the dichotomy between the separate programs’ residents did begin to disappear. This was attributed to both the influx of new residents with each year, in addition to a gradual acceptance of the daily reality by pre-existing residents.
The authors of this study did identify some salient points from their merger which have implications to other residency programs undergoing mergers, particularly those with cross-cultural conflicts. Out of concern for the ethnic and racial biases expressed toward HUH residents, a zero-tolerance policy was adopted by the CNMC leadership. This did benefit the HUH residents and their interactions with other staff, but it also had the undesired effect of making the CNMC residents feel uncomfortable expressing any legitimate negative opinions, even those that were associated with patient safety issues. The suggestion made to combat this difficulty would be to engage in more frequent feedback with all residents (in this case the CNMC residents) to ensure that all residents are able to express concerns and have those addressed by faculty or other leadership.
Another recommendation in this study was to use social events in a constructive manner. Gatherings set up between the HUH and CNMC residents were not always successful due to the different cultural norms. It is important, then, when trying to merge two independent, culturally-divided groups, that a common social ground must be established. Allowing constructive interpersonal relationships between resident groups to blossom in the setting of a shared social ground would alleviate some of the conflicts felt by both factions.
The most critical lesson identified by the Howard University Hospital-Children’s National Medical Center merger was that of creating a “safe space” for the residents of both programs. This was presented as an opportunity for residents to discuss and resolve issues, especially those concerning racism, elitism, or other cultural challenges, in an atmosphere of open respect and tolerance. By creating this environment, many concerns were able to be addressed, with the goal to improve the merging process as it happened.
Developing a strong core of cultural competence is vital to a successful residency program merger. By instituting a positive set of attitudes, behaviors, and policies, a health care system can protect its residents as they undergo the difficult transition of a merger. This will not only benefit the residents themselves in terms of the level of satisfaction with their experience, but should also improve the quality of care that residents provide to their patients.
When merging a residency program, often times the medical students affiliated with the institution are not considered. However, their education and how they fare is just as important as the residents. Most residency programs are associated with a medical school, whether it be through an academic institution to which they both belong, or as a clinical site through which medical students regularly rotate. An essential task for the resident is being involved in the education of future physicians. In fact, residents typically spend much more time with students than do the faculty members and can provide complementary educational opportunities than that provided by faculty. In addition, many medical students will often choose a specialty based upon their experience with the residents.
Various studies have been completed and attribute approximately one-third of a medical students’ knowledge to resident teaching [12]. Educating medical students includes supervising, instructing, and evaluating medical students, which can take up a significant amount of time and effort on the part of the resident. This task, important as it may be, can then be occasionally lost in an extremely busy work week.
The merging process could lead to positive ramifications such as increased resources for medical students. By consolidating resident responsibilities, it is possible that residents may have more time available to engage with medical students. This would provide for a more satisfying experience for both the resident and the medical student, as a good rapport between resident and medical student can often be the deciding factor for whether or not the student enjoys the rotation and furthermore whether or not they decide to ultimately pursue that specialty.
Conversely, negative ramifications of the merger could include a diluted clinical experience. The same number of patients or procedures may have to be distributed among a greater number of residents, therefore decreasing the overall quality of education for each medical student. Similarly, any negative feelings or perceptions that the resident may harbor toward the merging process may impact the way that residents interact with faculty, co-residents, or medical students alike, even if only subconsciously.
There is a single study by Hines et al. in 1999 which discusses the impact of obstetrics and gynecology residency mergers on the medical student experience. Medical students from the Uniformed Services University for the Health Sciences were studied, as two new obstetrics and gynecology residency programs (one formed by two programs in San Antonio, Texas; the other formed by two programs in Washington, District of Columbia area) were clerkship sites. Medical students were given a questionnaire following the rotation. The questionnaire evaluated the students’ perceptions of the case load, instruction, and overall clinical experience. There were no statistically significant differences between experiences before the merger and after the merger.
Likewise, the National Board of Medical Examiners (NBME) subject examination in obstetrics and gynecology, which is given at the end of the rotation, was reported by the student. This served as an objective measure to evaluate the medical student experience. There was no statistically significant negative impact on NBME scores; in one program there was even a statistically significant positive impact on NBME scores. While this area could clearly use more investigation, this seemingly posits that the merger of residency programs has little to no significant deleterious impact on the education of medical students – either their satisfaction or their performance on standardized exams.
While the most obvious characters to consider during the residency merger process may be the residents, it is imperative that we too keep in mind the medical student. Doctor, after all, does have its origin in the Latin
As the authors of this chapter do originate from a surgical residency, we have a special interest in how a residency merger for a surgical residency should unfold. Additionally, surgical residencies have a factor to consider that is singular to surgery – the case log. In order to graduate from a surgical residency, trainees must meet a particular number of cases in each surgical category which is specifically set by the ACGME. This makes merging residency programs somewhat more comprehensive, as the case availability for trainees must be carefully evaluated before and after the merging process to ensure that the case mix requirements can be met for every resident, even if they are starting with vastly different numbers. This issue is one area that will need special consideration with surgical residencies.
A study published in 2015 evaluated the impact a merger between an academic surgical program (Yale New-Haven Hospital) and a community surgical program (Hospital of Saint Raphael) [13]. This publication is significant as it is one of the only studies that includes a Likert survey which was developed specifically to evaluate the perspective of the resident regarding the merging process. Categories included on the survey include relationships among residents, relationships with faculty, systems interactions, clinical training, surgical training, scholarship, and career plans. This survey, which was independently evaluated by 11 residency program directors for its generalizability, is a tool which may be valuable for future program merger evaluations.
The survey was completed at a single point in time after the merger, so the information provided by the survey responses is somewhat limited in its applicability. It was suggested by a commentary that to improve future studies a similar survey tool could be administered pre-merger and post-merger to eliminate some limitations [14]. However, responses that were received were generally positive. Community-trained residents felt as if their exposure to complex cases and scholarly or research activities had improved. Academic-trained residents, on the other hand, did not feel as if they had new deficits in their experience with the influx of new trainees; in fact, with the incorporation of community institutions, they felt as if they had an increased number of “bread and butter” surgical cases which improved their operative experience and made it easier to meet their case log numbers. Overall this study is hopeful; it identifies particular areas that should be considered in order to keep trainees satisfied with their training to make the experience as positive as possible for all involved.
Another piece of the available literature which focuses on issues unique to surgery is a survey-based study to evaluate the merging process between two general surgery programs in Grand Rapids, Michigan in 1999 [15]. A survey was administered to both faculty and residents after said merger. This survey assessed characteristics such as curriculum, administration, teaching, atmosphere, and career goals, such as graduation and preparation level for attending-ship versus fellowship.
Positives aspects of the process were identified as academic and educational opportunities. This may have been secondary to a very organized educational system, which benefited both sets of residents. Negative aspects of the process were identified as establishing a combined clinical rotation structure, defining resident coverage without significantly increasing clinical load, and reconciling program policies that were discrepant. These areas, particularly those that were identified as negative, can be a stepping stone for other surgical residencies, so that these challenges can be specifically addressed during similar program mergers.
Even surgical subspecialties are not immune to the pressures to merge or acquire one another. Two vascular surgery programs in Long Island, New York merged to form a collective program in 2001 in order to maximize their individual strengths [16]. Although there is no information on how successful their merging process was, the combined program was able to compose an educational schedule which they published with a goal of standardizing vascular surgery training as mergers and acquisitions continue to persist.
At this point, there is limited data regarding residency mergers. Additionally, those examining the impacts of hospital system mergers do raise some important issues which should be addressed with future studies regarding residency mergers. A recently published study in 2020 demonstrated a clinically significant decreased patient satisfaction score when examining multiple hospitals before and after their merger or acquisition [17]. While there have been several studies that examine the perspectives of the trainees, these have not incorporated the perspectives of other important members involved in the healthcare system – most notably the patient. Faculty are also a significant aspect of the training program; they have an essential perspective that needs to be considered.
Ideally, as residency mergers are likely to continue occurring, there should be a structure for future evaluation and studies of these mergers. A survey should be constructed to fully examine feelings of residents, faculty, and patients on the patient care experience and the academic experience (as applicable). The survey should then be administered pre-merger and post-merger in order to have a direct comparison and contrast to itself that is inherently reliable. This would not only give an assessment of the “success” of the merger, in addition to identifying areas that may be particular concerns to trainees, faculty, or patients throughout the merging process. This would allow those concerns to be addressed early so that all involved can feel as if the process is as positive as possible.
The health care industry continues to evolve. Economic pressures can have unpredictable results, including mergers in health care systems and therefore associated graduate medical education programs. While there is not a wide breadth of published information regarding previous merged programs, we can learn from the successes of those programs that have published data to set up future mergers for success. A comprehensive examination of the publications which have been reviewed in this chapter have identified some key points of importance in the process of graduate medical education program mergers: leadership, communication, and culture. Establishing an effective leader who can formulate a plan and then institute that plan is the first step to success. He or she must be a dynamic individual who is able to solicit and take advice and criticism from all those involved in the process, both residents and faculty alike. Productive communication with leadership will be key for ongoing success during the process of the merger. This will allow for the process to evolve as challenges arise, to ultimately create a program from which all will benefit. Institutional cultural differences must be acknowledged in order to create a cohesive merged program. Through establishing a positive set of attitudes, behaviors, and policies, cultural competence can be a characteristic of the newly formed program.
There is still much regarding residency mergers that is unknown. In order to have a more concrete evaluation of the success of graduate medical education mergers, a survey that is externally validated should be administered to residents and faculty. This would allow for an objective evaluation of the merging process, so that common issues could be identified and addressed in future mergers. Overall, residency mergers are not well described. The goal of this chapter is to provide a conglomerate of available information and to identify issues that may occur. As mergers continue to occur, we hope that this chapter may prove valuable to not only the leadership responsible for the merger, but also anyone involved in the process.
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\\n\\nThe application process is open after your submitted manuscript has been accepted for publication. To apply, please fill out a Waiver Request Form and send it to your Author Service Manager. If you have an official letter from your university or institution showing that funds for your OA publication are unavailable, please attach that as well. The Waiver Request will normally be addressed within one week from the application date. All chapters that receive waivers or partial waivers will be designated as such online.
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\n\nPlease consult our Open Access Funding page to explore some of these funding opportunities and learn more about how you could finance your IntechOpen publication. Keep in mind that this list is not definitive, and while we are constantly updating and informing our Authors of new funding opportunities, we recommend that you always check with your institution first.
\n\nFor Authors who are unable to obtain funding from their institution or research funding bodies and still need help in covering publication costs, IntechOpen offers the possibility of applying for a Waiver.
\n\nOur mission is to support Authors in publishing their research and making an impact within the scientific community. Currently, 14% of Authors receive full waivers and 6% receive partial waivers.
\n\nWhile providing support and advice to all our international Authors, waiver priority will be given to those Authors who reside in countries that are classified by the World Bank as low-income economies. In this way, we can help ensure that the scientific work being carried out can make an impact within the worldwide scientific community, no matter where an Author might live.
\n\nThe application process is open after your submitted manuscript has been accepted for publication. To apply, please fill out a Waiver Request Form and send it to your Author Service Manager. If you have an official letter from your university or institution showing that funds for your OA publication are unavailable, please attach that as well. The Waiver Request will normally be addressed within one week from the application date. All chapters that receive waivers or partial waivers will be designated as such online.
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He has both an MS and Ph.D. in Biomedical Engineering. He was previously a research scientist at the University of California Los Angeles (UCLA) and visiting professor and researcher at the University of North Dakota. He is currently working in artificial intelligence and its applications in medical signal processing. In addition, he is using digital signal processing in medical imaging and speech processing. Dr. Asadpour has developed brain-computer interfacing algorithms and has published books, book chapters, and several journal and conference papers in this field and other areas of intelligent signal processing. He has also designed medical devices, including a laser Doppler monitoring system.",institutionString:"Kaiser Permanente Southern California",institution:null},{id:"169608",title:"Prof.",name:"Marian",middleName:null,surname:"Găiceanu",slug:"marian-gaiceanu",fullName:"Marian Găiceanu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/169608/images/system/169608.png",biography:"Prof. Dr. Marian Gaiceanu graduated from the Naval and Electrical Engineering Faculty, Dunarea de Jos University of Galati, Romania, in 1997. He received a Ph.D. (Magna Cum Laude) in Electrical Engineering in 2002. Since 2017, Dr. Gaiceanu has been a Ph.D. supervisor for students in Electrical Engineering. He has been employed at Dunarea de Jos University of Galati since 1996, where he is currently a professor. Dr. Gaiceanu is a member of the National Council for Attesting Titles, Diplomas and Certificates, an expert of the Executive Agency for Higher Education, Research Funding, and a member of the Senate of the Dunarea de Jos University of Galati. He has been the head of the Integrated Energy Conversion Systems and Advanced Control of Complex Processes Research Center, Romania, since 2016. He has conducted several projects in power converter systems for electrical drives, power quality, PEM and SOFC fuel cell power converters for utilities, electric vehicles, and marine applications with the Department of Regulation and Control, SIEI S.pA. (2002–2004) and the Polytechnic University of Turin, Italy (2002–2004, 2006–2007). He is a member of the Institute of Electrical and Electronics Engineers (IEEE) and cofounder-member of the IEEE Power Electronics Romanian Chapter. He is a guest editor at Energies and an academic book editor for IntechOpen. He is also a member of the editorial boards of the Journal of Electrical Engineering, Electronics, Control and Computer Science and Sustainability. Dr. Gaiceanu has been General Chairman of the IEEE International Symposium on Electrical and Electronics Engineering in the last six editions.",institutionString:'"Dunarea de Jos" University of Galati',institution:{name:'"Dunarea de Jos" University of Galati',country:{name:"Romania"}}},{id:"4519",title:"Prof.",name:"Jaydip",middleName:null,surname:"Sen",slug:"jaydip-sen",fullName:"Jaydip Sen",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/4519/images/system/4519.jpeg",biography:"Jaydip Sen is associated with Praxis Business School, Kolkata, India, as a professor in the Department of Data Science. His research areas include security and privacy issues in computing and communication, intrusion detection systems, machine learning, deep learning, and artificial intelligence in the financial domain. He has more than 200 publications in reputed international journals, refereed conference proceedings, and 20 book chapters in books published by internationally renowned publishing houses, such as Springer, CRC press, IGI Global, etc. Currently, he is serving on the editorial board of the prestigious journal Frontiers in Communications and Networks and in the technical program committees of a number of high-ranked international conferences organized by the IEEE, USA, and the ACM, USA. He has been listed among the top 2% of scientists in the world for the last three consecutive years, 2019 to 2021 as per studies conducted by the Stanford University, USA.",institutionString:"Praxis Business School",institution:null},{id:"320071",title:"Dr.",name:"Sidra",middleName:null,surname:"Mehtab",slug:"sidra-mehtab",fullName:"Sidra Mehtab",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0033Y00002v6KHoQAM/Profile_Picture_1584512086360",biography:"Sidra Mehtab has completed her BS with honors in Physics from Calcutta University, India in 2018. She has done MS in Data Science and Analytics from Maulana Abul Kalam Azad University of Technology (MAKAUT), Kolkata, India in 2020. Her research areas include Econometrics, Time Series Analysis, Machine Learning, Deep Learning, Artificial Intelligence, and Computer and Network Security with a particular focus on Cyber Security Analytics. Ms. Mehtab has published seven papers in international conferences and one of her papers has been accepted for publication in a reputable international journal. She has won the best paper awards in two prestigious international conferences – BAICONF 2019, and ICADCML 2021, organized in the Indian Institute of Management, Bangalore, India in December 2019, and SOA University, Bhubaneswar, India in January 2021. Besides, Ms. Mehtab has also published two book chapters in two books. Seven of her book chapters will be published in a volume shortly in 2021 by Cambridge Scholars’ Press, UK. Currently, she is working as the joint editor of two edited volumes on Time Series Analysis and Forecasting to be published in the first half of 2021 by an international house. Currently, she is working as a Data Scientist with an MNC in Delhi, India.",institutionString:"NSHM College of Management and Technology",institution:null},{id:"226240",title:"Dr.",name:"Andri Irfan",middleName:null,surname:"Rifai",slug:"andri-irfan-rifai",fullName:"Andri Irfan Rifai",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/226240/images/7412_n.jpg",biography:"Andri IRFAN is a Senior Lecturer of Civil Engineering and Planning. He completed the PhD at the Universitas Indonesia & Universidade do Minho with Sandwich Program Scholarship from the Directorate General of Higher Education and LPDP scholarship. He has been teaching for more than 19 years and much active to applied his knowledge in the project construction in Indonesia. His research interest ranges from pavement management system to advanced data mining techniques for transportation engineering. He has published more than 50 papers in journals and 2 books.",institutionString:null,institution:{name:"Universitas Internasional Batam",country:{name:"Indonesia"}}},{id:"314576",title:"Dr.",name:"Ibai",middleName:null,surname:"Laña",slug:"ibai-lana",fullName:"Ibai Laña",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314576/images/system/314576.jpg",biography:"Dr. Ibai Laña works at TECNALIA as a data analyst. He received his Ph.D. in Artificial Intelligence from the University of the Basque Country (UPV/EHU), Spain, in 2018. He is currently a senior researcher at TECNALIA. His research interests fall within the intersection of intelligent transportation systems, machine learning, traffic data analysis, and data science. He has dealt with urban traffic forecasting problems, applying machine learning models and evolutionary algorithms. He has experience in origin-destination matrix estimation or point of interest and trajectory detection. Working with large volumes of data has given him a good command of big data processing tools and NoSQL databases. He has also been a visiting scholar at the Knowledge Engineering and Discovery Research Institute, Auckland University of Technology.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"314575",title:"Dr.",name:"Jesus",middleName:null,surname:"L. Lobo",slug:"jesus-l.-lobo",fullName:"Jesus L. Lobo",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/314575/images/system/314575.png",biography:"Dr. Jesús López is currently based in Bilbao (Spain) working at TECNALIA as Artificial Intelligence Research Scientist. In most cases, a project idea or a new research line needs to be investigated to see if it is good enough to take into production or to focus on it. That is exactly what he does, diving into Machine Learning algorithms and technologies to help TECNALIA to decide whether something is great in theory or will actually impact on the product or processes of its projects. So, he is expert at framing experiments, developing hypotheses, and proving whether they’re true or not, in order to investigate fundamental problems with a longer time horizon. He is also able to design and develop PoCs and system prototypes in simulation. He has participated in several national and internacional R&D projects.\n\nAs another relevant part of his everyday research work, he usually publishes his findings in reputed scientific refereed journals and international conferences, occasionally acting as reviewer and Programme Commitee member. Concretely, since 2018 he has published 9 JCR (8 Q1) journal papers, 9 conference papers (e.g. ECML PKDD 2021), and he has co-edited a book. He is also active in popular science writing data science stories for reputed blogs (KDNuggets, TowardsDataScience, Naukas). Besides, he has recently embarked on mentoring programmes as mentor, and has also worked as data science trainer.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"103779",title:"Prof.",name:"Yalcin",middleName:null,surname:"Isler",slug:"yalcin-isler",fullName:"Yalcin Isler",position:null,profilePictureURL:"https://s3.us-east-1.amazonaws.com/intech-files/0030O00002bRyQ8QAK/Profile_Picture_1628834958734",biography:"Yalcin Isler (1971 - Burdur / Turkey) received the B.Sc. degree in the Department of Electrical and Electronics Engineering from Anadolu University, Eskisehir, Turkey, in 1993, the M.Sc. degree from the Department of Electronics and Communication Engineering, Suleyman Demirel University, Isparta, Turkey, in 1996, the Ph.D. degree from the Department of Electrical and Electronics Engineering, Dokuz Eylul University, Izmir, Turkey, in 2009, and the Competence of Associate Professorship from the Turkish Interuniversity Council in 2019.\n\nHe was Lecturer at Burdur Vocational School in Suleyman Demirel University (1993-2000, Burdur / Turkey), Software Engineer (2000-2002, Izmir / Turkey), Research Assistant in Bulent Ecevit University (2002-2003, Zonguldak / Turkey), Research Assistant in Dokuz Eylul University (2003-2010, Izmir / Turkey), Assistant Professor at the Department of Electrical and Electronics Engineering in Bulent Ecevit University (2010-2012, Zonguldak / Turkey), Assistant Professor at the Department of Biomedical Engineering in Izmir Katip Celebi University (2012-2019, Izmir / Turkey). He is an Associate Professor at the Department of Biomedical Engineering at Izmir Katip Celebi University, Izmir / Turkey, since 2019. In addition to academics, he has also founded Islerya Medical and Information Technologies Company, Izmir / Turkey, since 2017.\n\nHis main research interests cover biomedical signal processing, pattern recognition, medical device design, programming, and embedded systems. He has many scientific papers and participated in several projects in these study fields. He was an IEEE Student Member (2009-2011) and IEEE Member (2011-2014) and has been IEEE Senior Member since 2014.",institutionString:null,institution:{name:"Izmir Kâtip Çelebi University",country:{name:"Turkey"}}},{id:"339677",title:"Dr.",name:"Mrinmoy",middleName:null,surname:"Roy",slug:"mrinmoy-roy",fullName:"Mrinmoy Roy",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/339677/images/16768_n.jpg",biography:"An accomplished Sales & Marketing professional with 12 years of cross-functional experience in well-known organisations such as CIPLA, LUPIN, GLENMARK, ASTRAZENECA across different segment of Sales & Marketing, International Business, Institutional Business, Product Management, Strategic Marketing of HIV, Oncology, Derma, Respiratory, Anti-Diabetic, Nutraceutical & Stomatological Product Portfolio and Generic as well as Chronic Critical Care Portfolio. A First Class MBA in International Business & Strategic Marketing, B.Pharm, D.Pharm, Google Certified Digital Marketing Professional. Qualified PhD Candidate in Operations and Management with special focus on Artificial Intelligence and Machine Learning adoption, analysis and use in Healthcare, Hospital & Pharma Domain. Seasoned with diverse therapy area of Pharmaceutical Sales & Marketing ranging from generating revenue through generating prescriptions, launching new products, and making them big brands with continuous strategy execution at the Physician and Patients level. Moved from Sales to Marketing and Business Development for 3.5 years in South East Asian Market operating from Manila, Philippines. Came back to India and handled and developed Brands such as Gluconorm, Lupisulin, Supracal, Absolut Woman, Hemozink, Fabiflu (For COVID 19), and many more. In my previous assignment I used to develop and execute strategies on Sales & Marketing, Commercialization & Business Development for Institution and Corporate Hospital Business portfolio of Oncology Therapy Area for AstraZeneca Pharma India Ltd. Being a Research Scholar and Student of ‘Operations Research & Management: Artificial Intelligence’ I published several pioneer research papers and book chapters on the same in Internationally reputed journals and Books indexed in Scopus, Springer and Ei Compendex, Google Scholar etc. Currently, I am launching PGDM Pharmaceutical Management Program in IIHMR Bangalore and spearheading the course curriculum and structure of the same. I am interested in Collaboration for Healthcare Innovation, Pharma AI Innovation, Future trend in Marketing and Management with incubation on Healthcare, Healthcare IT startups, AI-ML Modelling and Healthcare Algorithm based training module development. I am also an affiliated member of the Institute of Management Consultant of India, looking forward to Healthcare, Healthcare IT and Innovation, Pharma and Hospital Management Consulting works.",institutionString:null,institution:{name:"Lovely Professional University",country:{name:"India"}}},{id:"310576",title:"Prof.",name:"Erick Giovani",middleName:null,surname:"Sperandio Nascimento",slug:"erick-giovani-sperandio-nascimento",fullName:"Erick Giovani Sperandio Nascimento",position:null,profilePictureURL:"https://intech-files.s3.amazonaws.com/0033Y00002pDKxDQAW/ProfilePicture%202022-06-20%2019%3A57%3A24.788",biography:"Prof. Erick Sperandio is the Lead Researcher and professor of Artificial Intelligence (AI) at SENAI CIMATEC, Bahia, Brazil, also working with Computational Modeling (CM) and HPC. He holds a PhD in Environmental Engineering in the area of Atmospheric Computational Modeling, a Master in Informatics in the field of Computational Intelligence and Graduated in Computer Science from UFES. He currently coordinates, leads and participates in R&D projects in the areas of AI, computational modeling and supercomputing applied to different areas such as Oil and Gas, Health, Advanced Manufacturing, Renewable Energies and Atmospheric Sciences, advising undergraduate, master's and doctoral students. He is the Lead Researcher at SENAI CIMATEC's Reference Center on Artificial Intelligence. In addition, he is a Certified Instructor and University Ambassador of the NVIDIA Deep Learning Institute (DLI) in the areas of Deep Learning, Computer Vision, Natural Language Processing and Recommender Systems, and Principal Investigator of the NVIDIA/CIMATEC AI Joint Lab, the first in Latin America within the NVIDIA AI Technology Center (NVAITC) worldwide program. He also works as a researcher at the Supercomputing Center for Industrial Innovation (CS2i) and at the SENAI Institute of Innovation for Automation (ISI Automação), both from SENAI CIMATEC. He is a member and vice-coordinator of the Basic Board of Scientific-Technological Advice and Evaluation, in the area of Innovation, of the Foundation for Research Support of the State of Bahia (FAPESB). He serves as Technology Transfer Coordinator and one of the Principal Investigators at the National Applied Research Center in Artificial Intelligence (CPA-IA) of SENAI CIMATEC, focusing on Industry, being one of the six CPA-IA in Brazil approved by MCTI / FAPESP / CGI.br. He also participates as one of the representatives of Brazil in the BRICS Innovation Collaboration Working Group on HPC, ICT and AI. He is the coordinator of the Work Group of the Axis 5 - Workforce and Training - of the Brazilian Strategy for Artificial Intelligence (EBIA), and member of the MCTI/EMBRAPII AI Innovation Network Training Committee. He is the coordinator, by SENAI CIMATEC, of the Artificial Intelligence Reference Network of the State of Bahia (REDE BAH.IA). He leads the working group of experts representing Brazil in the Global Partnership on Artificial Intelligence (GPAI), on the theme \"AI and the Pandemic Response\".",institutionString:"Manufacturing and Technology Integrated Campus – SENAI CIMATEC",institution:null},{id:"1063",title:"Prof.",name:"Constantin",middleName:null,surname:"Volosencu",slug:"constantin-volosencu",fullName:"Constantin Volosencu",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/1063/images/system/1063.png",biography:"Prof. Dr. Constantin Voloşencu graduated as an engineer from\nPolitehnica University of Timișoara, Romania, where he also\nobtained a doctorate degree. He is currently a full professor in\nthe Department of Automation and Applied Informatics at the\nsame university. Dr. Voloşencu is the author of ten books, seven\nbook chapters, and more than 160 papers published in journals\nand conference proceedings. He has also edited twelve books and\nhas twenty-seven patents to his name. He is a manager of research grants, editor in\nchief and member of international journal editorial boards, a former plenary speaker, a member of scientific committees, and chair at international conferences. His\nresearch is in the fields of control systems, control of electric drives, fuzzy control\nsystems, neural network applications, fault detection and diagnosis, sensor network\napplications, monitoring of distributed parameter systems, and power ultrasound\napplications. He has developed automation equipment for machine tools, spooling\nmachines, high-power ultrasound processes, and more.",institutionString:"Polytechnic University of Timişoara",institution:{name:"Polytechnic University of Timişoara",country:{name:"Romania"}}},{id:"221364",title:"Dr.",name:"Eneko",middleName:null,surname:"Osaba",slug:"eneko-osaba",fullName:"Eneko Osaba",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/221364/images/system/221364.jpg",biography:"Dr. Eneko Osaba works at TECNALIA as a senior researcher. He obtained his Ph.D. in Artificial Intelligence in 2015. He has participated in more than twenty-five local and European research projects, and in the publication of more than 130 papers. He has performed several stays at universities in the United Kingdom, Italy, and Malta. Dr. Osaba has served as a program committee member in more than forty international conferences and participated in organizing activities in more than ten international conferences. He is a member of the editorial board of the International Journal of Artificial Intelligence, Data in Brief, and Journal of Advanced Transportation. He is also a guest editor for the Journal of Computational Science, Neurocomputing, Swarm, and Evolutionary Computation and IEEE ITS Magazine.",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"275829",title:"Dr.",name:"Esther",middleName:null,surname:"Villar-Rodriguez",slug:"esther-villar-rodriguez",fullName:"Esther Villar-Rodriguez",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/275829/images/system/275829.jpg",biography:"Dr. Esther Villar obtained a Ph.D. in Information and Communication Technologies from the University of Alcalá, Spain, in 2015. She obtained a degree in Computer Science from the University of Deusto, Spain, in 2010, and an MSc in Computer Languages and Systems from the National University of Distance Education, Spain, in 2012. Her areas of interest and knowledge include natural language processing (NLP), detection of impersonation in social networks, semantic web, and machine learning. Dr. Esther Villar made several contributions at conferences and publishing in various journals in those fields. Currently, she is working within the OPTIMA (Optimization Modeling & Analytics) business of TECNALIA’s ICT Division as a data scientist in projects related to the prediction and optimization of management and industrial processes (resource planning, energy efficiency, etc).",institutionString:"TECNALIA Research & Innovation",institution:{name:"Tecnalia",country:{name:"Spain"}}},{id:"49813",title:"Dr.",name:"Javier",middleName:null,surname:"Del Ser",slug:"javier-del-ser",fullName:"Javier Del Ser",position:null,profilePictureURL:"https://mts.intechopen.com/storage/users/49813/images/system/49813.png",biography:"Prof. Dr. Javier Del Ser received his first PhD in Telecommunication Engineering (Cum Laude) from the University of Navarra, Spain, in 2006, and a second PhD in Computational Intelligence (Summa Cum Laude) from the University of Alcala, Spain, in 2013. He is currently a principal researcher in data analytics and optimisation at TECNALIA (Spain), a visiting fellow at the Basque Center for Applied Mathematics (BCAM) and a part-time lecturer at the University of the Basque Country (UPV/EHU). His research interests gravitate on the use of descriptive, prescriptive and predictive algorithms for data mining and optimization in a diverse range of application fields such as Energy, Transport, Telecommunications, Health and Industry, among others. In these fields he has published more than 240 articles, co-supervised 8 Ph.D. theses, edited 6 books, coauthored 7 patents and participated/led more than 40 research projects. 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