Relevant bibliographies by topics / Donabedian’s Model of Health Care Quality

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Academic literature on the topic 'Donabedian’s Model of Health Care Quality'

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Published: 4 June 2021
Last updated: 1 February 2022

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Journal articles on the topic "Donabedian’s Model of Health Care Quality"

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Lachance, Joanie, Frédéric Douville, Clémence Dallaire, Katia Grillo Padilha, and Maria Cecilia Gallani. "The use of the Nursing Activities Score in clinical settings: an integrative review." Revista da Escola de Enfermagem da USP 49, spe (December 2015): 147–56. http://dx.doi.org/10.1590/s0080-623420150000700021.

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ABSTRACT Objective analyze how studies have approached the results obtained from the application of the Nursing Activities Score (NAS) based on Donabedian’s model of healthcare organization and delivery. Method CINAHL and PubMed databases were searched for papers published between 2003 and March 2015. Results 36 articles that met the inclusion criteria were reviewed and double-coded by three independent coders and analyzed based on the three elements of Donabedian’s health care quality framework: structure, process and outcome. The most frequently addressed, but not always tested, variables were those that fell into the structure category. Conclusion variables that fell into the process category were used less frequently. Beside NAS, the most frequently used variables in the outcome category were mortality and length of stay. However, no study used a quality framework for healthcare or NAS to evaluate costs, and it is recommended that further research should explore this approach.
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Gebrekidan, Gezahegn, Gezahegn Tesfaye, Mitiku Teshome Hambisa, and Negussie Deyessa. "Quality of Tuberculosis Care in Private Health Facilities of Addis Ababa, Ethiopia." Tuberculosis Research and Treatment 2014 (2014): 1–9. http://dx.doi.org/10.1155/2014/720432.

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Ensuring provision of good quality tuberculosis (TB) care, especially in private for profit health facilities, is an important component of TB control strategy to reduce poor medical practice which results in multidrug resistant TB (MDR-TB). The aim of this study was to investigate quality of TB care in private health facilities of Addis Ababa. A facility based cross-sectional study was conducted based on Donabedian’s structure-process-outcome model of health care quality. Quality of care was determined by adherence to National TB Program guidelines, treatment success rate, and client satisfaction. Exit interview was conducted on 292 patients on the intensive phase of treatment and 384 patient records were reviewed in eight private health facilities. Initial diagnostic AFB test was done for 95.4% of pulmonary TB patients. Most important components of TB care recommended by national guidelines were delivered for a significant proportion of patients. Majority (75%) of the clients were found to be satisfied with each component of TB care. The treatment success rate was 90.9%. The quality of TB care was fairly good. However, only 77.7% of the patients were counseled for HIV testing. Strengthening HIV counseling and testing, tackling shortage of streptomycin and laboratory reagent at private TB clinic is crucial.
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Amati, Rebecca, Amer A. Kaissi, and Annegret F. Hannawa. "Determinants of good and poor quality as perceived by US health care managers." Journal of Health Organization and Management 32, no. 5 (August 20, 2018): 708–25. http://dx.doi.org/10.1108/jhom-03-2018-0075.

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Purpose The scientific literature evidences that the quality of care must be improved. However, little research has focused on investigating how health care managers – who are responsible for the implementation of quality interventions – define good and poor quality. The purpose of this paper is to develop an empirically informed taxonomy of quality care as perceived by US managers – named the Integrative Quality Care Assessment Tool (INQUAT) – that is grounded in Donabedian’s structure, process and outcome model. Design/methodology/approach A revised version of the critical incident technique was used to collect 135 written narratives of good and poor quality care from 74 health care managers in the USA. The episodes were thematically analyzed. Findings In total, 804 units were coded under the 135 written narratives of care. They were grouped under structure (9 percent, n=69), including organizational, staff and facility resources; process (52 percent, n=419), entailing communication, professional diligence, timeliness, errors, and continuity of care; outcomes (32 percent, n=257), embedding process- and short-term outcomes; and context (7 percent, n=59), involving clinical and patient factors. Process-related categories tended to be described in relation to good quality (65 percent), while structure-related categories tended to be associated with poor quality (67 percent). Furthermore, the data suggested that managers did not consider their actions as important factors influencing quality, but rather tended to attribute the responsibility for quality care to front-line practitioners. Originality/value The INQUAT provides a theoretically grounded, evidence-based framework to guide health care managers in the assessment of all the components involved with the quality of care within their institutions.
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Owen, J. B., and J. F. Wilson. "Improving quality of care: Challenges to implementing quality indicators." Journal of Clinical Oncology 24, no. 18_suppl (June 20, 2006): 16030. http://dx.doi.org/10.1200/jco.2006.24.18_suppl.16030.

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16030 Background: To assess the overall quality of cancer care, efforts seek consensus quality indicators that crosscut health services. Although pilot programs have collected and analyzed relevant clinical data, they have been unable to collect radiation oncology (RO) data detailed enough to assess the quality of services or to inform key decision makers. Quality Research in Radiation Oncology (QRRO) conducted retrospective surveys of national practice since 1973 with major positive impact on the quality of practice through recursive processes. Methods: From Donabedian’s model of quality assessment, QRRO analyzes crucial quality components by conducting Facilities, Process, and Outcomes Surveys. Survey design allows calculation of national averages for patients treated with RO and comparisons by key factors. Evolving data collection methods allow assessment of modern technologies. Methods start with definition and measurement of evidence-based quality indicators but allow greater detail and specification than most other quality measurement efforts. Results: QRRO showed that radiation dose affected outcomes for prostate cancer patients. Higher radiation doses were associated with improved local tumor control rates and treatment techniques affected toxicity rates. These results, presented widely in numerous venues, stimulated dose escalation clinical trials. Trials conducted in the USA all used QRRO results as critical data, providing the major impetus to test new directions in dose escalation and new methods to target delivery more precisely. National practice shifted to higher doses and use of conformal techniques. The dataset is unique in providing cross-sectional information on practice patterns with a wide variety of treatment approaches from many institutions and sufficient details of treatment delivery to allow examination of questions about quality and effects of techniques. Conclusions: Mounting societal demands for improvement in the quality of care, ever increasing complexity of radiation therapy, and escalating use of multi-modality treatment make continuing to measure, report, and improve quality of care in RO crucial to patients and the profession. Methods must keep pace with new technologies and techniques in radiation therapy. [Supported by NCI grant CA 65435]. No significant financial relationships to disclose.
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Breyer, Juliana Zeni, Juliana Giacomazzi, Regina Kuhmmer, Karine Margarites Lima, Luciano Serpa Hammes, Rodrigo Antonini Ribeiro, Natália Luiza Kops, Maicon Falavigna, and Eliana Marcia Wendland. "Hospital quality indicators: a systematic review." International Journal of Health Care Quality Assurance 32, no. 2 (March 11, 2019): 474–87. http://dx.doi.org/10.1108/ijhcqa-04-2018-0091.

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PurposeThe purpose of this paper is to identify and describe hospital quality indicators, classifying them according to Donabedian’s structure, process and outcome model and in specific domains (quality, safety, infection and mortality) in two care divisions: inpatient and emergency services.Design/methodology/approachA systematic review identified hospital clinical indicators. Two independent investigators evaluated 70 articles/documents located in electronic databases and nine documents from the grey literature, 35 were included in the systematic review.FindingsIn total, 248 hospital-based indicators were classified as infection, safety, quality and mortality domains. Only 10.2 percent were identified in more than one article/document and 47 percent showed how they were calculated/obtained. Although there are scientific papers on developing, validating and hospital indicator assessment, most indicators were obtained from technical reports, government publications or health professional associations.Research limitations/implicationsThis review identified several hospital structure, process and outcome quality indicators, which are used by different national and international groups in both research and clinical practice. Comparing performance between healthcare organizations was difficult. Common clinical care standard indicators used by different networks, programs and institutions are essential to hospital quality benchmarking.Originality/valueTo the authors’ knowledge, this is the first systematic review to identify and describe hospital quality indicators after a comprehensive search in MEDLINE/PubMed, etc., and the grey literature, aiming to identify as many indicators as possible. Few studies evaluate the indicators, and most are found only in the grey literature, and have been published mostly by government agencies. Documents published in scientific journals usually refer to a specific indicator or to constructing an indicator. However, indicators most commonly found are not supported by reliability or validity studies.
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Oostendorp, Rob AB, JW Hans Elvers, Emiel van Trijffel, Geert M. Rutten, Gwendolyne GM Scholten–Peeters, Marcel Heijmans, Erik Hendriks, et al. "Relationships Between Context, Process, and Outcome Indicators to Assess Quality of Physiotherapy Care in Patients with Whiplash-Associated Disorders: Applying Donabedian’s Model of Care." Patient Preference and Adherence Volume 14 (March 2020): 425–42. http://dx.doi.org/10.2147/ppa.s234800.

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Romeyke, Tobias, Elisabeth Noehammer, and Harald Stummer. "Ensuring Quality in Interdisciplinary Inpatient Chronic Care." SAGE Open 10, no. 2 (April 2020): 215824402091465. http://dx.doi.org/10.1177/2158244020914654.

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Pay for Quality (P4Q) concepts are discussed as solution for ensuring quality in health care in the context of budgetary concerns. However, little is known regarding the application to and effectiveness for complex chronic treatments. This article describes the incentivization approach taken in Germany, where complex codes requiring specific quality criteria were implemented into the Diagnosis Related Groups (DRGs) system. Using two examples (early complex geriatric rehabilitation, multimodal rheumatological complex treatment), we analyze the quality indicators according to the Donabedian Model and contrast the effects regarding compensation to traditional treatments. In total, the approach allows taking into account treatment and financial requirements.
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Sibthorpe, Beverly, and Karen Gardner. "A Conceptual Framework for Performance Assessment in Primary Health Care." Australian Journal of Primary Health 13, no. 2 (2007): 96. http://dx.doi.org/10.1071/py07027.

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As health systems strive to achieve improvements in quality, equity and efficiency, systems of performance assessment are increasingly being introduced. To function effectively as tools for internal quality improvement, they need to be aligned with staff and organisational objectives, foster insight into practice and provide a focus for learning leading to improvement. Adopting such a "coalface" perspective, we developed a conceptual framework to underpin the potential development of a quality system for a large primary health care program. The Framework for Performance Assessment in Primary Health Care (FPA_PHC) is grounded in evaluation theory and explicitly identifies the processes of primary health care articulated by the World Health Organization (WHO). It is based on Donabedian's (1998) now classic "structure", "process", "outcome" model for assessment of quality of care. The FPA_PHC specifies the development of objectives that are focused on patients/families/communities and has four indicator levels relating to stewardship, organisational structures and processes, processes of care and intermediate outcomes. Equity can be assessed by asking of processes of care and intermediate outcomes: "is it the same for everyone?" The indicators can be mapped to higher order system performance frameworks such as the National Health Performance Framework. The FPA_PHC has been adopted for the National Quality and Performance System for Divisions of General Practice and its application in this and a second setting are described.
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Hakwia Kooma, Emmanuel, and David Zinyengere. "IMPLEMENTING QUALITY A MISSING PIECE WITH A NEED FOR PROCESS OF BEHAVIOR CHANGE: A CASE FOR IMPLEMENTING QUALITY CB-IRS DELIVERY MODEL IN ZAMBIA." International Journal of Advanced Research 8, no. 11 (November 30, 2020): 351–73. http://dx.doi.org/10.21474/ijar01/12017.

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Background: In the wake of increasing malaria cases in Zambia, IRS has been coming under increasing accountable pressurefromthe publicfor quality IRS performance and its decentralized approach. In response, anew IRS approach Community-BasedIndoor Residual Spraying (IRS)Delivery model has been introduced in the country and institutionalized in the community health care system.The objective of this study was to introduce quality assurance approach methods to the model in terms of structure, process and outcomes for quality performance. Materials and Methods: We reviewed both published and unpublished documents, articles, papers on quality service delivery and explored field experiences and the understanding of IRS service delivery. The Donabedian model has been found to lead to improvements of quality that in turn could improve the health outcome of the community. Equally, dimensions of quality were analyzed under effectiveness, efficacy, acceptability, equity and relevance to IRS delivery of services and best approaches. Results: Quality assurance becomes strong and successful when its well organized with features of a health atmosphere that motivates IRS teams, Spray operators (SOPs), and the house hold owners, thus becoming a common goal as a result of good level management. The District IRS Operational Committee, typically must possess quality assurance superior technical skills and expertise. However, it is not only quality assurance guidelines that strengthen team building but also established rules, processes, tracking ofprogress, IRS quality assurance learningenvironment, improvements and leadership support initiatives. These could be supplemented by enabling tools and a nurturing qualityfriendly atmosphere within the IRS teams and SOPs as front liners. Donabedian model for improvement of quality has been widely adopted in the hospital care set up, but hasnot yet been fully recognized, utilized and validated in the vector control system. Conclusion: The study suggests that the Donabedian`s structure-process-outcome isa valid modelfor implementingquality CB-IRS Delivery model in the IRS program campaign. The interventions that perform well in terms of structure tend to perform better forquality service delivery processes, that in turn have favorable influence on the community health status outcome.
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Shah, Mairaj, and Shagufta Perveen. "STATE OF HEALTHCARE QUALITY AND PATIENT SAFETY IN PAKISTAN." Pakistan Journal of Public Health 6, no. 4 (December 1, 2016): 1–4. http://dx.doi.org/10.32413/pjph.v6i4.3.

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Many low and middle income countries have developed their own national accreditation standards and accreditation systems for regulating and improving the quality of healthcare services. Healthcare quality is defined as the degree to which health services to individuals and populations increases the likelihood of desired health outcomes and are consistent with current professional knowledge. This paper attempts to assess the state of Pakistan's healthcare quality and patient safety in a structured way using Donabedian's model. Some of the key specific challenges identified for Pakistan's healthcare quality initiatives are lack of national healthcare accreditation system and integrated national guidelines, policies and procedures on healthcare quality and patient safety. Lack of national quality care indicators. Absence of an organizational culture that holds people accountable and lack of pre-service and in-service training for health staff in quality care management and leadership with little contextual research on quality care initiatives. Possible ways to improve the state of health care quality in Pakistan may include (i) up gradation and implementation of policies and procedures that regulate quality and patient safety issues in healthcare settings across the country (ii) introduction of a national healthcare accreditation programme across the nation (iii) development of networks and consortia between public and private sectors in Pakistan (iv) capacity building of health care professionals in quality and patient safety (v) Formulation of quality improvement teams at national and provincial level (vi) development of a culture of accountability and ownership (vii) learning from experiences of other countries and implementation quality care tools and locally validated indicators.
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Dissertations / Theses on the topic "Donabedian’s Model of Health Care Quality"

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Williams, Cynthia. "Home Care Quality Effects of Remote Monitoring." Doctoral diss., University of Central Florida, 2014. http://digital.library.ucf.edu/cdm/ref/collection/ETD/id/6383.

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Despite concerted efforts to decrease costs and increase public health, the embattled U.S. health care system continues to struggle to alleviate these widespread issues. Because the problem of hospital utilizations among patients with heart failure is posited to increase as the population ages, innovative methodologies need to be explored to mitigate adverse events. Remote monitoring harnesses the strength of advanced information and communication technology to affect positive changes in health care quality and cost. By reaching across geographical boundaries, remote monitoring may support increased access to less costly services and improve the quality of home health care. The purpose of the study was to examine the home care quality effects of remote monitoring technology in patients with heart failure and to provide an economic justification for its adoption and diffusion. It compared remote monitoring as a potential intervention strategy to a standard no-intervention group (without remote monitoring). Specifically, it analyzed remote monitoring as a viable strategy to decrease hospital readmissions and emergency department visits. It also compared the cost of remote monitoring against the current standard-of-care. The theoretical framework of Donabedian's Quality Model was used in the evaluation of remote monitoring. A retrospective posttest only, case control study design was used to test the degree which remote monitoring was effective in promoting health care quality (hospital readmissions and decreased emergency department visits). Retrospective chart reviews were performed using electronic medical records (EMR). Analysis of Variance, Path Analysis, Automatic Interaction Detector Analysis (Dtreg), and Cost Outcomes Ratio were used to test the hypotheses and validate the proposed theoretical model. No significant difference was noted in remote monitoring and usual care groups. Results suggested that remote monitoring does not statistically lead to a decrease in heart failure-related hospital readmissions and all-cause emergency department visits. Results of the cost ratio analysis suggested that there was no statistically significant difference in the net income between usual care and remote monitoring; however, data suggest that there were significant increases in cost and intensity of nursing utilization for the remote monitoring intervention. The Automatic Interaction Detector Analysis showed that the unfavorable results in hospital readmissions were due to a decrease in collaborative care and patient education prior to the recommendation for hospitalization. The role of nursing care, whether in hospital or community-based care, in heart failure management is critical to quality outcomes. As the field continues to consider the use of technology in health care, decision makers should think through the process of patient care such that preventable hospital readmissions are decreased and patients received quality care.
Ph.D.
Doctorate
Health and Public Affairs
Public Affairs; Health Services Management and Research Track
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Yildiz, Ozkan. "A Comprehensive Model For Measuring Health Care Process Quality: Health Care Process Quality Measurement Model (hpqmm)." Phd thesis, METU, 2012. http://etd.lib.metu.edu.tr/upload/12614318/index.pdf.

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Similar to the manufacturing sector, process improvement gains much attention in health care sector. Measuring process quality is one of the most important components of process improvement and numerous healthcare quality indicator models are developed to achieve this aim. Existing quality models focus on some specific diseases, clinics or clinical areas. Although they contain structure, process, or output type measures, there is no model which measures the quality of health care processes comprehensively. As a result, hospitals cannot compare quality of processes internally and externally. To bring a solution to the above problems, we developed Health Care Process Quality Measurement Model (HPQMM), and it is applied in three public hospital&rsquo
s laboratory and assessment processes. We observed that, the developed model determines weak and strong aspects of the processes, gives a detailed picture for the process quality, extends the quality aspects of existing models, and provides quantifiable information to hospitals to compare their processes with multiple organizations.
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Waterstraat, Frank Riegle Rodney P. "Adapting the quality function deployment model to health plan design." Normal, Ill. Illinois State University, 2001. http://wwwlib.umi.com/cr/ilstu/fullcit?p3064505.

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Thesis (Ph. D.)--Illinois State University, 2001.
Title from title page screen, viewed March 10, 2006. Dissertation Committee: Rodney P. Riegle (chair), J. Christopher Eisele, George Padavil, John H. Bantham, Thomas J. Bierma. Includes bibliographical references (leaves 124-128) and abstract. Also available in print.
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Plauché, Leneé Michele. "Eliminating waste in US health care: evaluating accountable care organizations as a model for quality sustainable care." Thesis, Boston University, 2013. https://hdl.handle.net/2144/12191.

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Thesis (M.A.)--Boston University
In 2011, the United States spent $2.7 trillion in health care expenditures, accounting for 17.9 percent of the Gross Domestic Product (GDP). Health care spending increased by 3.9 percent in 2011 and is expected to surpass 20 percent of GDP by 2020. An investigation of national trends in health spending conducted by the Institute of Medicine (IOM) estimates that approximately 30 percent of US health expenditures—that is, about $750 billion—is wasteful spending. Analysis of spending trends suggests waste in health care falls into one of six categories: (1) failures in care delivery; (2) failures in care coordination; (3) overtreatment; (4) administrative complexity; (5) pricing failures; (6) and fraud and abuse. A sustainable level of health spending would be one that grows at the same rate as the GDP; this would require cutting health care expenditures by an estimated $2.2 trillion by 2020. Distributing these cuts across the spectrum of wasteful spending by specifically targeting cost-containment efforts toward those areas of waste, it is possible—albeit challenging—to create a more solvent health care system. The Patient Protection and Affordable Care Act of 2010 (ACA), landmark legislation of the Obama administration, introduced extensive policy changes and addressed the unsustainable trajectory of Medicare with the debut of the Accountable Care Organization (ACO). The novel ACO design aims to bring hospitals and physician groups into partnerships with the common goal of providing quality, affordable care to a defined population of patients with the introduction of a Shared Savings Program and a triple aim of: (1) improving population health; (2) providing higher quality-care experiences; and (3) moderating per-capita health care cost increases. The ACO has the potential to address each of the six areas of waste specified by the Institute of Medicine, bringing health care expenditures down to sustainable levels, while also increasing the quality of care and the efficiency of US health care overall. The ACO model is promising, but poses its own challenges as a largely untested health system structure, and will require extensive efforts to refine and perfect the model in order to be a feasible answer to the US health care crisis.
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Hopson, Christopher Paul. "Alternative Models of Nursing Home Care: A Study of the Impact of the Teaching Nursing Home Model on Staff Quality and the Quality of Resident Care." Diss., Temple University Libraries, 2009. http://cdm16002.contentdm.oclc.org/cdm/ref/collection/p245801coll10/id/47128.

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Business Administration
Ph.D.
As the percentage of elderly adults within the U.S. continues to grow, long-term care options will increase. Facing increased competition from other forms of long-term care, many nursing homes are seeking innovative models to enhance management and clinical care practices. The Teaching Nursing Home model, first established in the 1970s, is one in which academic institutions partner with nursing homes to create information exchanges between the nursing home and the school. Currently, nursing schools throughout the country work with nursing homes to create clinical training sites for nursing students. The partnership is also used to encourage research among school faculty and to assist nursing homes in their management of best practices. This study examined the impact of these relationships on nursing home quality. Twenty teaching nursing homes were matched with twenty nursing homes that are not engaged in this practice. Using nursing home quality scores published by the Centers for Medicare and Medicaid Services, mean outcomes for the matched pairs were compared using T-tests. Regression analyses were also performed to test whether quality improves over time within a teaching nursing home. The results from the T-tests performed did not show overall quality differences between the matched pairs. However, when analyzed regionally, some significance was observed for teaching nursing homes in the Upstate NY region (p<0.1). The study discusses some of the differences in design of the teaching nursing homes within that region and the impact that may have on results. Time as a teaching nursing home did not appear to affect quality for nursing homes in this study. Possible explanations for these insignificant results are discussed in the Summary, Discussion and Limitations section of the study. Overall, the findings from this study suggest that the Teaching Nursing Home model can add value to nursing homes by offering them research and professional training opportunities with academic institutions. Within the study, recommendations are made to further explore the impact of these partnerships on nursing home quality and to encourage the development and use of the model through policy changes.
Temple University--Theses
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Salazar, Ligia de. "Assessment of health students performance by the community using perceived quality of care model." Thesis, McGill University, 1996. http://digitool.Library.McGill.CA:80/R/?func=dbin-jump-full&object_id=40337.

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The trend in medical education and in general, among health professionals, is based, on the current changes of health systems aimed to improve relevance equity, and cost effectiveness of health care. With respect to human health resources, there is lack of agreement among the competence level, performance and the needs of both the system using them and the target population. Therefore, it is important and necessary to consider both the community and health services as partners in the task of defining these changes and in the provision of health services to meet the above mentioned criteria.
The main purpose of this partnership is to encourage efforts to promote, oversee, and apply the actions in each one of the instances in order to improve training of human resource, strengthen local health systems, and empower the communities. Human resource competence and performance, the capacity to provide services, and the degree of community participation and commitement to health, are key elements in improving service quality.
The philosophy of current curricula reform at the Valle University stresses the partnership relationship between academic institutions, services centers, and the community, in the training of health professionals. The proposed investigation focuses on the community-based training aspect of student performance assessment and its relation to the health care system and academia. Specifically, the study will focus on designing valid and reliable instruments for community assessment of student performance, using both qualitative and quantitative aspects of data collection and analysis to assess "patient satisfaction" as an indicator of quality of care.
The results of this study demonstrate that the proposed assessment activity will allow the educational and health services institutions to have relevant and dynamic information as feedback for planning and adjustment of their programs. At the same time, it will allow the community to participate in an effective way in aspects related to their health care. The results of this study will be used as a basis for producing guidelines for involving communities (users) in the health care students evaluation process.
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Obioma, Chidiadi. "Improving the Quality of Nursing Documentation in Home Health Care Setting." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/3500.

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Poor nursing documentation of patient care was identified in daily nurse visit notes in a health care setting. This problem affects effective communication of patient status with other clinicians, thereby jeopardizing clinical decision-making. The purpose of this evidence-based project was to determine the impact of a retraining program on the quality of documentation of patient care in nurses' notes in a home health agency in central Texas. A retrospective audit of quality of nursing documentation using the Nurse and Midwifery Content Audit Tool (NMCAT) was done. A pre- and posttest design was used. A convenience sample of de-identified nurses' notes (80 pre- and 80 post) was selected from active patient records in the agency (n = 160). Descriptive and inferential statistics from the project showed that there was improved quality for the 15 criteria representing quality nursing documentation. After the educational intervention, documentation of patient's status if changed or unchanged improved to 80%, and patient's response to treatment improved (57% to 85%), entries were written as incidents occurred improved (53% to 64%). The nurse refers to the patient by name improved (0% to 66%). These findings were an indication of practice change, validating the need for periodic audits of nurses' notes in the agency in order to demonstrate compliance with quality standards. Based on the project findings, a retraining program is recommended to improve structured nursing documentation in a home health agency. This project is likely to contribute to social change as it enhanced the information communicated to other health care providers, coordination of care, and patient outcomes.
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Pruksapong, Matana. "Development of a model for assessing the quality of an oral health program in long-term care facilities." Thesis, University of British Columbia, 2008. http://hdl.handle.net/2429/1529.

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Background: There is little information on how the quality of oral health services in long-term care (LTC) facilities is conceptualized or assessed. Objectives: This study aims to develop a model for assessing the quality of oral healthcare services in LTC facilities. Methods: This study is divided into four main steps. Firstly, I examined literature for existing concepts relating to program evaluation and quality assessment in healthcare to build a theoretical framework appropriate to dental geriatrics. Secondly, I explored as an ethnographic case study a comprehensive oral healthcare program within a single administrative group of 5 LTC facilities in a large metropolis by interviewing 33 participants, including residents and their families, nursing staff, administrators and dental personnel. I also examined policy documents and made site visits to identify other attributes influencing the quality of the program. Thirdly, I drafted the assessment model combining a theoretical framework with empirical information from the case study. And lastly, I tested the feasibility and usability of the model in another dental geriatric program in northern British Columbia. I applied the assessment model by conducting 15 interviews with participants in the program, made site-visits to the 5 facilities, and reviewed documents on the development and operation of the program. Results: A combination of theory-based evaluation and quality assurance provided six sequential and iterative steps for quality assessment of oral health services in LTC. The empirical information supported the theoretical framework that a program of oral healthcare in a LTC context should be assessed for quality from multiple perspectives; it should be comprehensive; and it should include the three main attributes of quality - capacity, performance, and outcomes. Participants revealed 20 quality indicators along with suggested program objectives which encompass eight quality dimensions such as effectiveness, efficiency, and patient-centered. Conclusion: The model provides a unique system for assessing the quality of dental services in LTC facilities that seems to meet the needs of dental and non-dental personnel in LTC.
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Berg, Gina M. "Predicting global satisfaction ratings of quality health care among trauma patients: Testing a structural equation model." Diss., Wichita State University, 2009. http://hdl.handle.net/10057/2372.

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Background: Patient satisfaction has been debated as an indicator of quality hospital care. It is debated in the literature as to whether or not patients can accurately judge technical quality of healthcare services. Purpose of the Study: The purpose of the study was to determine if patients’ perceptions of interpersonal care are related to or influence patients’ perceptions of technical care.
Thesis (Ph.D.)--Wichita State University, College of Liberal Arts and Sciences, Dept. of Psychology
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Holmes, Elizabeth Ann. "An evaluation of the Midwifery Development Unit service specifications, through the quality assurance model for midwifery." Thesis, University of Glasgow, 1995. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.295331.

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Books on the topic "Donabedian’s Model of Health Care Quality"

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Longo, Daniel R. Integrated quality assessment: A model for concurrent review. Chicago, Ill: American Hospital Pub., 1989.

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Oddo, Francine. Putting the "T" in health care TQM: A model for integrated TQM. Methuen, Mass: Goal/QPC, 1992.

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Lerer, Leonard B. Quality and complexity in the health care sector: Towards an inclusive model. Fontainebleau: INSEAD, 1999.

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Service, United States Indian Health. Evaluation of a quality assurance model for public health nursing: Appendices. [Rockville, Md.?]: The Service, 1990.

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South East Thames Regional Health Authority. Working Group on Quality in Primary Health Care. Primary health carein a general practice setting: A model of good practice : report from a Working Group on Quality in Primary Health Care. Bexhill-on-Sea: SETRHA, 1994.

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California. Bureau of State Audits. Department of Health Services: Despite shortcomings in the Department's monitoring efforts, limited data suggest its two-plan model does not adversely affect quality of and access to health care. Sacramento, Calif. (555 Capitol Mall, Suite 300, Sacramento, 95814): Bureau of State Audits, 1999.

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Goldberg, Alvin M., and Carl C. Pegels. Quality Circles in Health Care Facilities: A Model for Excellence. Aspen Pub, 1985.

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Excellence Model in the Health Sector, The: Sharing Good Practice. Kingsham Press Ltd, 2005.

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Wooldridge, Nancy H. Quality Assurance Criteria for Pediatric Nutrition Conditions: A Model. Amer Dietetic Assn, 1988.

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(Editor), Peter Ramsaroop, Marion J. Ball (Editor), David Beaulieu (Editor), and Judith V. Douglas (Editor), eds. Advancing Federal Sector Health Care: A Model for Technology Transfer (Health Informatics). Springer, 2001.

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Book chapters on the topic "Donabedian’s Model of Health Care Quality"

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Shroyer, A. Laurie W., Brendan M. Carr, and Frederick L. Grover. "Health Services Information: Application of Donabedian’s Framework to Improve the Quality of Clinical Care." In Health Services Evaluation, 109–39. New York, NY: Springer US, 2019. http://dx.doi.org/10.1007/978-1-4939-8715-3_7.

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Shroyer, A. Laurie W., Brendan M. Carr, and Frederick L. Grover. "Health Services Information: Application of Donabedian’s Framework to Improve the Quality of Clinical Care." In Data and Measures in Health Services Research, 1–31. Boston, MA: Springer US, 2015. http://dx.doi.org/10.1007/978-1-4899-7673-4_7-1.

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McCauley, Mary, and Nynke van den Broek. "A Sustainable Model of Assessing Maternal Health Needs and Improving Quality of Care During and After Pregnancy." In Global Maternal and Child Health, 187–96. Cham: Springer International Publishing, 2021. http://dx.doi.org/10.1007/978-3-030-54775-2_13.

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Moksnes, Unni Karin. "Sense of Coherence." In Health Promotion in Health Care – Vital Theories and Research, 35–46. Cham: Springer International Publishing, 2021. http://dx.doi.org/10.1007/978-3-030-63135-2_4.

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AbstractThis chapter introduces the concept of sense of coherence which is a core concept in the salutogenic model defined by Aron Antonovsky. The salutogenic model posits that sense of coherence is a global orientation, where life is understood as more or less comprehensible, meaningful, and manageable. A strong sense of coherence helps the individual to mobilize resources to cope with stressors and manage tension successfully with the help of identification and use of generalized and specific resistance resources. Through this mechanism, the sense of coherence helps determine one’s movement on the health ease/dis-ease continuum. Antonovsky developed an instrument named Orientation to Life Questionnaire to measure the sense of coherence which exists in two original versions: a 29-item and a 13-item version. This chapter presents the measurement of the sense of coherence and the validity and reliability of the 13-item scale. It gives a brief overview of empirical research of the role of sense of coherence in association with mental health and quality of life and also on sense of coherence in different patient groups including nursing home residents, patients with coronary heart disease, diabetes, cancer, and mental health problems. It also briefly discusses the implications of using salutogenesis in health care services and the importance of implementing this perspective in meeting with different patient groups. The salutogenic approach may promote a healthy orientation toward helping the patient to cope with everyday stressors and integrate the effort regarding how to help the patient manage to live with disease and illness and promote quality of life.
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Körükcü, Öznur, and Kamile Kabukcuoğlu. "Health Promotion Among Home-Dwelling Elderly Individuals in Turkey." In Health Promotion in Health Care – Vital Theories and Research, 313–27. Cham: Springer International Publishing, 2021. http://dx.doi.org/10.1007/978-3-030-63135-2_22.

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AbstractAlthough the social structure of Turkish society has changed from a broad family order to a nuclear family, family relations still hold an important place, where traditional elements dominate. Still, elderly people are cared for by their family in their home environment. Thus, the role of family members is crucial in taking care of elderly individuals. In Turkey, the responsibility of care is largely on women; the elderly’s wife, daughter, or daughter-in-law most often provides the care. Family members who provide care need support so that they can maintain their physical, psychological and mental health. At this point, Antonovsky’s salutogenic health model represents a positive and holistic approach to support individual’s health and coping. The salutogenic understanding of health emphasizes both physical, psychological, social, spiritual and cultural resources which can be utilized not only to avoid illness, but to promote health.With the rapidly increasing ageing population globally, health expenditures and the need for care are increasing accordingly. This increase reveals the importance of health-promoting practices in elderly care, which are important for the well-being and quality of life of older individuals and their families, as well as cost effectiveness. In Turkey, the emphasis on health-promoting practices is mostly focused in home-care services including examination, treatment, nursing care, medical care, medical equipment and device services, psychological support, physiotherapy, follow-up, rehabilitation services, housework (laundry, shopping, cleaning, food), personal care (dressing, bathroom, and personal hygiene help), 24-h emergency service, transportation, financial advice and training services within the scope of the social state policy for the elderly 65 years and older, whereas medical management of diseases serves elderly over the age of 85. In the Turkish health care system, salutogenesis can be used in principle for two aims: to guide health-promotion interventions in health care practice, and to (re)orient health care practice and research. The salutogenic orientation encompasses all elderly people independently of their position on the ease-/dis-ease continuum. This chapter presents health-promotion practices in the care of elderly home-dwelling people living in Turkey.
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Nascimento, Vânia, César Fonseca, Maria Céu Marques, and Abílio Costa. "Sensitive Indicators to Rehabilitation Nursing Care in a Rehabilitation Program for People in the Surgical Process, Based on the Health Quality Model." In Gerontechnology, 283–94. Cham: Springer International Publishing, 2019. http://dx.doi.org/10.1007/978-3-030-16028-9_25.

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Renzi, Pietro, and Alberto Franci. "Frameworks and inequalities in healthcare: some applications." In Proceedings e report, 115–20. Florence: Firenze University Press, 2021. http://dx.doi.org/10.36253/978-88-5518-304-8.23.

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Background Social determinants of health (SDOH) have increasingly entered health policy conversations as a growing body of researches, reveal the direct relationship between social determinants and health outcome. In fact, the recent literature is moving from the traditional model that focus on how health affects economic status, to a new view that economic status affects health. Objectives To investigate the principal conceptual frameworks for action on social determinants of health. Another aim is to contribute on the ongoing discourse on feasible measures which could be used to alert regions to inequalities in the distribution of health. Methodology, Italian data are used as a demonstration. Quadrant charts illustrate associations between how much regions spend on health and how effectively health system functions. The relevant inequality measures are used to rank health inequalities. Main results Frameworks have been presented to help communities, health professionals and others begin to better understand and address a variety of factors that affects health. Quadrant analysis technique shows the extent to which spending more on health, translates into better health outcomes, higher quality of care and improve access to care across the Italian regions, whilst also recognition the importance of major risk factors. Conclusions The social inequalities in health and what this means for how we understand and reduce them, as not to date been compressively examined empirically. There is an urgent need to expand our knowledge with comparable data on health determinants and more refined health outcomes. Furthermore, there is a need for feasible inequality measures in the health information systems. The measures used in this study, provide a step to inform and guide the uptake of equity-sensitive policies.
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Gilmartin, Mattia J., and David Melzer. "Process Innovation in Health Care: A New Model for the New Knowledge Economy." In Quality in Health Care, 17–26. Routledge, 2019. http://dx.doi.org/10.4324/9781315192611-2.

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Gaudino, Mario, Vipin Zamvar, and Richard L. Prager. "Quality metrics in coronary artery bypass grafting." In State of the Art Surgical Coronary Revascularization, edited by Stephen E. Fremes and Michael E. Halkos, 135–38. Oxford University Press, 2021. http://dx.doi.org/10.1093/med/9780198758785.003.0026.

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Quality may be defined differently by different individuals and the objective measurement of quality is often challenging. In the United States Institute of Medicine’s 1990 report, Medicare: A Strategy for Quality Assurance, the definition of quality included ‘the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge’. The foundational definition of quality in medicine, and certainly in surgery, comes from Avedis Donabedian’s 1966 article utilizing the triad of structure, process, and outcome. Structure refers to the inherent characteristics of the setting where care is provided, process to the particulars and procedural details of the care, and outcome to the end results of the care.
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Azam, Mohammad, Mohamed Rafik Noor Mohamed Qureshi, and Faisal Talib. "Quality Evaluation of Health Care Establishment Utilizing Fuzzy AHP." In Hospital Management and Emergency Medicine, 498–535. IGI Global, 2020. http://dx.doi.org/10.4018/978-1-7998-2451-0.ch025.

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Quality evaluation of healthcare establishment (HCE) is a difficult process as it involves multiple components of quality criteria with various factors and sub-factors therein. Further, the quality criteria are not universally standardized. The subjective evaluation in itself is not reliable as a tool so that available HCEs may be investigated for selecting the best among them. Thus, to avoid vagueness and imprecision due to process of human cognition the need to evolve a useful method for evaluation of quality of HCE was essentially required. To achieve such an objective three well established HCEs from northern cities of India have been studied. An Integrated Quality Model designed for HCE (Azam et al., 2012a, 2012b) and specifically tested previously with the AHP study by the authors (Azam et al., 2015) with its components, parameters and factors sub-factors has been utilized to evaluate the quality aspects of HCEs forming subjects of the current study. Further, the standard formula of Fuzzy AHP methodology with the application of fuzzy set theory was applied to the multiple components of the quality criteria with various factors and sub-factors therein pertaining to various HCEs forming the subject of the study. Quality of the HCEs thus could be evaluated empirically avoiding vagueness due to human cognition factors. Utilizing this methodology respective rankings of HCEs could also be assigned among them with practical utility to maintain the required quality of their services. Quality evaluation of Health Care Establishment utilizing Fuzzy AHP along with fuzzy set theory is a unique method which will benefit the client patients to select the best HCE among the available alternatives of HCEs. It also helps the managers to improve the business by allocating scarce resources wherever critically required to improve various quality components criteria factors and sub-factors of their HCEs.
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Conference papers on the topic "Donabedian’s Model of Health Care Quality"

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Wahyuni, Ni Putu Sri, and Ede Surya Darmawan. "Patient Centered Care Model to Improve the Quality and Safety of Patient Care in Hospital: A Systematic Review." In The 6th International Conference on Public Health 2019. Masters Program in Public Health, Graduate School, Universitas Sebelas Maret, 2019. http://dx.doi.org/10.26911/the6thicph.04.53.

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Wahyuni, Ni Putu Sri, and Ede Surya Darmawan. "Patient Centered Care Model to Improve the Quality and Safety of Patient Care in Hospital: A Systematic Review." In The 6th International Conference on Public Health 2019. Masters Program in Public Health, Graduate School, Universitas Sebelas Maret, 2019. http://dx.doi.org/10.26911/the6thicph-fp.04.27.

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Hoerbst, Alexander, and Elske Ammenwerth. "A structural model for quality requirements regarding Electronic Health Records - State of the art and first concepts." In 2009 ICSE Workshop on Software Engineering in Health Care. IEEE, 2009. http://dx.doi.org/10.1109/sehc.2009.5069604.

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Jonny and Teuku Yuri M. Zagloed. "The development of an integrated Indonesian health care model using Kano’s model, quality function deployment and balanced scorecard." In 3RD INTERNATIONAL MATERIALS, INDUSTRIAL AND MANUFACTURING ENGINEERING CONFERENCE (MIMEC2017). Author(s), 2017. http://dx.doi.org/10.1063/1.5010648.

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"DEVELOPMENT OF A FRAMEWORK MATURITY MODEL FOR THE CONTINUED QUALITY IMPROVEMENT OF A LOCALLY CUSTOMISED CLINICAL INFORMATION SYSTEM USED IN CRITICAL CARE MEDICINE." In International Conference on Health Informatics. SciTePress - Science and and Technology Publications, 2011. http://dx.doi.org/10.5220/0003163902860294.

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Aliza, Ana Dyah, and Farida Kartini. "Student Perception of the Preceptorship Model in Midwifery Care: A Scoping Review." In The 7th International Conference on Public Health 2020. Masters Program in Public Health, Universitas Sebelas Maret, 2020. http://dx.doi.org/10.26911/the7thicph.03.43.

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ABSTRACT Background: Preceptorship is a time-limited, education-focused model for teaching and learning within a clinical environment that uses a clinical staff as role models. Its primary goal is to assist new staff and students in adapting to their roles, develop clinical skills and socialize the novice to a department or institution. This difference has caused various opinions from related parties. This study aimed to determine the implementation of a tutorial system from different levels of student education to the entire midwifery health care system. Subjects and Method: A scoping review method was conducted in eight stages including (1) Identification of study problems; (2) Determining priority problem and study question; (3) Determining framework; (4) Literature searching; (5) Article selection; (6) Critical appraisal; (7) Data extraction; and (8) Mapping. The search included PubMed, Wiley, Google Scholar, dan Sciendirect. The inclusion criteria were English-language and full-text articles published between 2000 and 2019. The data were selected by the PRISMA flow chart. Results: Ten articles from total of 803 articles found. It was divided into two categories: Elements in the preceptorship model and application of preceptorship. Preceptorship can help preceptors to improve teaching effectiveness and create an effective learning environment so that preceptors can perform clinical skills to improve the quality of education. The problem that arises in preceptorship in many student reports is the difficulty students experience in finding their clinical practice area. Professional organizations provide several solutions to the issues that occur in a preceptorship, one of which is paying attention to student attendance and facilitating students to give input and ideas. Conclusion: The application of the principles in the practice of midwifery clinics varies because the guideline instruments are not standardized. Keywords: Perspectives, Preceporship, Students, Midwifery Correspondence: Ana Dyah Aliza, Universitas ‘Aisyiyah Yogyakarta. Jalan Ringroad Barat No.63, Mlangi, Nogotirto, Gamping Sleman, Yogyakarta, Email: anadyahaliza@gmail.com Mobile: 085600072744. DOI: https://doi.org/10.26911/the7thicph.03.43
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Avcil, Seniha. "International Accreditation in Health and Quality Standards in Health in Turkey." In International Conference on Eurasian Economies. Eurasian Economists Association, 2020. http://dx.doi.org/10.36880/c12.02372.

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Accreditation studies in health started in the USA in the beginning of the 20th century, and in the beginning of the 21st century, the World Health Organization (WHO) announced that it is necessary to determine the health care standards of member countries and to give importance to accreditation studies. Turkey in 2003, "Health Transformation Program" began apps. Within the scope of this program, “Quality Standards in Health " were determined in 2005. Refurbished versions of the standards set continue today, and the evaluation process according to the determined standards started in 2017 to cover all public and private health institutions. Health tourists; the diversity of health care, quality and prefer to receive health services from Turkey due to different advantages. The international accreditation of the health institution is a remarkable variable that influences the preference of health tourists. In this study; It is aimed to determine the opinions of the health institutions that have international accreditation and international health tourism authorization certificate regarding the comparison of the Quality Standards in Health (SKS) and evaluation process and the international accreditation evaluation process. It was designed in the research screening model and it was found appropriate to use qualitative methods. The research group consists of employees of health institutions that have international health tourism authorization certificate and international accreditation, among the organizations whose Quality Standards in Health (SKS) were evaluated in Istanbul in February 2020. The data were collected face to face by the researcher and recorded in the semi-structured interview form.
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Japarova, Damira. "Formation of a Market Model in the Financing of Health Care in the Kyrgyz Republic." In International Conference on Eurasian Economies. Eurasian Economists Association, 2019. http://dx.doi.org/10.36880/c11.02235.

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Due to the collapse of the Union, there was a reduction in funding for health care costs, as well as deterioration in the infrastructure and quality of medical services. The transitional economy in the Kyrgyz Republic has identified additional features in the health system. The main ones are the low level of funding, the presence of the shadow market of medical services, inefficient structure and the prevalence of high-cost hospital treatment. The market mechanism is developing, however, without state regulation. The Kyrgyz Republic continues to reform its health-care system. The task was to improve the methods of their financing. New mechanisms for financing medical services have been introduced. Despite the reduction in the number of hospitals, the number of patients treated in hospitals has increased.
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Lee, Cevadne, Ellen Ahn, Mary Anne Foo, Sherry Huang, Becky Nguyen, Tricia Nguyen, Jacqueline Tran, Robert Bristow, and Sora Park Tanjasiri. "Abstract PO-021: A hub and spoke model to improve cancer care quality: Advancing Cancer Care Together (ACCT) for Asian American Medicaid beneficiaries in Orange County, California." In Abstracts: AACR Virtual Conference: Thirteenth AACR Conference on the Science of Cancer Health Disparities in Racial/Ethnic Minorities and the Medically Underserved; October 2-4, 2020. American Association for Cancer Research, 2020. http://dx.doi.org/10.1158/1538-7755.disp20-po-021.

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Wolfe, I., C. Lemer, M. Heys, A. Ingrassia, J. Newham, J. Forman, R. Satherley, and R. Lingam. "G346 Cyphp evelina london new care model to improve health, healthcare quality, and patterns of service use among children and young people." In Royal College of Paediatrics and Child Health, Abstracts of the RCPCH Conference and exhibition, 13–15 May 2019, ICC, Birmingham, Paediatrics: pathways to a brighter future. BMJ Publishing Group Ltd and Royal College of Paediatrics and Child Health, 2019. http://dx.doi.org/10.1136/archdischild-2019-rcpch.334.

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Reports on the topic "Donabedian’s Model of Health Care Quality"

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Bolivia and Mexico: System-wide planning is needed for decentralized postabortion care. Population Council, 2005. http://dx.doi.org/10.31899/rh16.1000.

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Governments in developing countries recognize the need for appropriate technology for the treatment of emergencies from incomplete abortion or miscarriage. Numerous studies have investigated the appropriateness of an integrated model of postabortion care (PAC) that includes three essential elements: emergency treatment for spontaneous or induced abortion; counseling and family planning services; and links to other reproductive health services. Many integrated PAC services include replacement of the conventional clinical treatment, sharp curettage (SC), with manual vacuum aspiration (MVA). In 1997 and 1999 the Population Council supported intervention studies in Mexico and Bolivia, respectively, to assess PAC programs in terms of safety, effectiveness, quality of care, cost, and subsequent contraceptive use by clients. Both interventions introduced integrated PAC services and compared the outcomes of MVA and SC use in large public hospitals. To assess changes in service quality and costs, researchers analyzed clinical records and interviewed clients and providers before and after the interventions. As noted in this summary, SC and MVA are equally safe and effective and can be provided on an outpatient basis. Integrating clinical treatment with family planning counseling and services increased clients’ knowledge and contraceptive use.
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Perceptions of community pharmacists, patent and proprietary medicine vendors, and their clients regarding quality of family planning services: The IntegratE Project. Population Council, 2021. http://dx.doi.org/10.31899/rh17.1016.

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The IntegratE Project is a four-year initiative (2017–21) implemented by the Population Council and partners that seeks to increase access to contraceptive methods by involving the private sector (community pharmacists [CPs] and patent and proprietary medicine vendors [PPMVs]) in family planning (FP) service delivery in Lagos and Kaduna States, Nigeria. The project aims to establish a regulatory system with the Pharmacists Council of Nigeria to ensure that CPs and PPMVs provide quality FP services, comply with FP regulations, and report service statistics to the Health Information Management System (HMIS). To achieve this, the project is implementing: a pilot three-tiered accreditation system for PPMVs; a supervisory model to ensure standard drug-stocking practices; building the capacity of CPs and PPMVs to provide a wider range of FP services and data report to the HMIS. This brief focuses on quality of care received by women voluntarily seeking FP services from CPs and PPMVs. CPs and PPMVs and their clients appear to be satisfied with the FP services offered by CPs and PPMVs; on-going learning opportunities, and a supportive supervision system that is properly coordinated should be sufficient to maintain the quality of services offered by CPs and PPMVs.
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Voices of vulnerable and underserved adolescents in Guatemala: A summary of the qualitative study 'Understanding the lives of indigenous young people in Guatemala'. Population Council, 2005. http://dx.doi.org/10.31899/pgy19.1011.

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Governments in developing countries recognize the need for appropriate technology for the treatment of emergencies from incomplete abortion or miscarriage. Numerous studies have investigated the appropriateness of an integrated model of postabortion care (PAC) that includes three essential elements: emergency treatment for spontaneous or induced abortion; counseling and family planning services; and links to other reproductive health services. Many integrated PAC services include replacement of the conventional clinical treatment, sharp curettage (SC), with manual vacuum aspiration (MVA). In 1997 and 1999 the Population Council supported intervention studies in Mexico and Bolivia, respectively, to assess PAC programs in terms of safety, effectiveness, quality of care, cost, and subsequent contraceptive use by clients. Both interventions introduced integrated PAC services and compared the outcomes of MVA and SC use in large public hospitals. To assess changes in service quality and costs, researchers analyzed clinical records and interviewed clients and providers before and after the interventions. As noted in this summary, SC and MVA are equally safe and effective and can be provided on an outpatient basis. Integrating clinical treatment with family planning counseling and services increased clients’ knowledge and contraceptive use.
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