Dissertations / Theses on the topic 'Health care delivery'

This dissertation investigates how patient-perceived integrated care and manager commitment influence the improvement and integration of health care delivery. Using survey instruments, across three studies I examine potential mechanisms for improving health care delivery: patient perceptions of integrated care, a physician organization care management program, and manager commitment to a quality improvement program. In Chapter Two, I examine how patient-perceived integrated care relates to utilization of health services. I assess relationships between provider performance on 11 domains of patient-reported integrated care and rates of emergency department (ED) visits, hospital admissions, and outpatient visits. I find better performance on two of the surveyed dimensions of integrated care are significantly associated with lower ED visit rates: information flow to other providers in doctor’s office and responsiveness independent of visits. Better performance on three dimensions of integrated care is associated with lower outpatient visit rates: information flow to specialist, post-visit information flow to the patient, and continuous familiarity with patient over time. No dimension of integration is associated with hospital admission rates. In Chapter Three, I use the same patient sample to evaluate the achievement of integrated care by a care management program (CMP) from the perspective of older patients with multiple chronic conditions. Survey results suggest that patient perceptions of integrated care vary substantially among survey items and domains. CMP enrollment is significantly associated with greater patient perceptions of care integration in two domains: connecting patients to home services and being responsive independent of visits, domains that were targeted for improvement by the CMP. Enrollment in the CMP is not significantly associated with other domains of integration. In Chapter Four, I assess whether and how senior and middle manager commitment to a falls reduction quality improvement (QI) program is associated with the successful implementation of the program. Survey results suggest managers’ affective commitment to the program is positively associated with program implementation success across all manager levels surveyed (senior managers, middle managers, and assistant middle managers). Stronger frontline worker support for the falls QI program partially mediates the relationship between manager affective commitment and falls program implementation success for middle managers and assistant middle managers, but not for senior managers. Manager affective commitment to the falls program mediates the relationship between organizational support for the falls program and program implementation success across all manager levels. Together, these studies advance our understanding of how patient-perceived integrated care, care management programs, and manager commitment to a quality improvement program influence the integration and improvement of health care delivery. Findings demonstrate how patient reports of integration can be useful guides to improving health systems. Dissertation results also provide empirical evidence of a relationship between manager commitment—at both the middle and senior manager levels—and successful QI program implementation. In addition, these studies provide practical implications for physicians and hospital managers seeking ways to improve the quality and integration of health care delivery.
Health Policy

Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Economics, 2013.
Cataloged from PDF version of thesis.
Includes bibliographical references (p. 167-172).
This thesis contains essays on health care delivery and financing. Chapter 1 studies the effect of organizational structure on physician behavior. I investigate this by studying emergency department (ED) physicians who work in two organizational systems that differ in the extent of physician autonomy to manage work: a "nurse-managed" system in which physicians are assigned patients by a triage nurse "manager," and a "self-managed" system in which physicians decide among themselves which patients to treat. I estimate that the self-managed system increases throughput productivity by 10-13%. Essentially all of this net effect can be accounted for by reducing a moral hazard I call "foot-dragging": Because of asymmetric information between physicians and the triage nurse, physicians delay discharging patients to appear busier and avoid getting new patients. Chapter 2 explores the development of physician practice styles during training. Although a large literature documents variation in medical spending across areas, relatively little is known about the sources of underlying provider-level variation. I study physicians in training ("housestaff") at a single institution and measure the dynamics of their spending practice styles. Practice-style variation at least doubles discontinuously as housestaff change informal roles at the end of the first year of training, from "interns" to "residents," suggesting that physician authority is important for the size of practice-style variation. Although practice styles are in general poorly explained by summary measures of training experiences, rotating to an affiliated community hospital decreases intern spending at the main hospital by more than half, reflecting an important and lasting effect of institutional norms. Chapter 3, joint with Jonathan Gruber, examines insurance enrollee choices in a "defined contribution exchange," in which low-income enrollees are responsible for paying for part of the price of insurance. Estimating the price-sensitivity of low-income enrollees for insurance represents a first step for understanding the implications of such a system that will soon become widespread under health care reform. Using data from Massachusetts Commonwealth Care, we find that low-income enrollees are highly sensitive to plan price differentials when initially choosing plans but then exhibit strong inertia once they are in a plan.
by David C. Chan.
Ph.D.

Chronic diseases impose heavy burdens on the United States health care system, particularly among some ethnic/racial groups such as American Indian and Alaska Natives who experience higher incidence of these diseases than non-Native population. In an effort to improve the health status of its patients, the Ukudigaunal Wellness Center (UWC) partnered with the Improving Patient Care (IPC) Collaborative to implement changes designed to improve chronic disease care for Native Alaskans through intensive monitoring of screening for chronic disease and selected chronic disease outcomes. For this program evaluation, the units of analysis were the changes in health service delivery and the resulting patient clinical outcomes. The data source was the Registration and Patient Management System (RPMS), repository for the data collected over the 14 months of the collaborative. The findings showed that the process measures that met IPC goals were due to improvements in service delivery by UWC. Goals for other services, such as diagnostic screenings, were not met because these clinical components had to be coordinated with facilities outside UWC. Outcome measures for BP and HgbA1c control were not met as these depended on the patients' abilities to self-manage the required procedures. The implications for social change included: (a) Positive outcome in managing chronic diseases is possible by combining chronic care models with Deming's model for improvement; (b) Increased patient awareness of chronic conditions and their long term consequences tended to support more responsible and successful patient self-management; (c) Use of external medical resources should be considered when patient privacy and confidentiality are concerns.

A dissertation submitted to the Faculty of Arts in fulfilment of the requirements for the Degree of Doctor of Philosophy (Community Psychology) in the Department of Psychology at the University Of Zululand, 2017
Health is a human need and considered to be a human right across all societies. Access to health care services is not a problem for those who can afford it, but, for those who cannot provide for themselves, legislation needs to protect their rights. Although there is legislation in place to protect these vulnerable populations, it is ultimately the health care practitioners’ job to protect and improve the health of their communities. It is these health care practitioners who were the inspiration for and focus of the present study. The present study emerged as a separate, but expanded version of the researcher’s limited 2011 study, which specifically focused on medical practitioners’ experiences of the current health care delivery system. Results from this 2011 study suggested that a broader spectrum of health care practitioners may be similarly affected by the current health care system and that their experiences may ultimately contribute towards a better understanding of the dynamics within which health care practitioners work and function. Therefore, the present phenomenologically-oriented study aimed to describe, explicate, interpret and analyse the experiences of a broad sample of health care practitioners through their lived, day-to-day realities in both the public and private health care sectors. Data were collected from a non-probability, purposive, convenience sample of 30 adult registered health care practitioners in public and private hospitals, clinics and private practices in the uThungulu District of Kwa-Zulu Natal, South Africa. There were 15 participants from the public and 15 from the private sector. An open-ended questionnaire was used to ascertain and understand their experiences, knowledge and exposure to the relatively new national health insurance (NHI) system, what they perceived as key objectives for effective transformation of the South African health care system, possible reasons for considering emigration in light of the current staff shortages and their views on the new NHI policy, in order to find solutions to problems. The overall data analysis consisted of three levels of subsidiary data analysis, descriptive, social constructionist and interpretive paradigms, each contributing to the whole, both “vertically and horizontally”, where participants’ experiences were described, explicated and interpreted. Research findings indicated persisting large divisions and fragmentation in and between the public and private health care sectors. Yet there was unity in responses concerning the poor and disadvantaged members of society and the challenges of their access to health care services. Sensitivity to human rights standards, past socio-political influences and awareness of health as a human right and need were evident in all participant responses. Valuable solutions to improve the health care delivery system were offered by health care practitioners as key stakeholders in the future of health care delivery in South Africa. Public health care practitioners’ experiences were dominated by overall expressions of unhappiness, anger and frustration related to poor service delivery, lack of resources, inadequate management structures, wages, inadequate consultation, fear for personal (and family) safety and the future of health care. Concern for the poor, vulnerable and the majority of citizens who use health care services, coupled with the burgeoning burden of disease, were perceived as a major stressor and source of anger towards the government and bureaucracy in general. Chronic stress and anxiety, suggestive of burnout and other negative psychological states, were also apparent. The inability to service long patient queues, inadequate communication structures/channels and lack of cohesive team practices, ethics and standards created a sense of emotional overburden and other negative affective states. These, and the uncertain future of health care under the new NHI, exerted extra stress on already overworked health care personnel. Education and effective consultation about the NHI were expressed as being inadequate and incomplete. Despite these factors, health care practitioners offered various valuable solutions and suggestions for the improvement of health care service delivery. Despite also being stressed, participants who work in the private sector were generally happier and they evinced less negative psychological states. Although a stressful environment with its own problems, within the private sector the NHI was considered to be a good concept in principle, although many participants doubted its feasibility and felt that regulatory changes often took place without adequate consultation. Given the nature and transparency of the present study, across multidisciplinary teams of health care practitioners, the researcher is of the opinion that the present study created a platform for discussion and debate around the context of a changing health care system within South Africa’s culturally diverse society. In conclusion, a critical review of the present study and recommendations for management structures, health care practitioners themselves and future research is provided.

Microcomputer support for health care delivery is a relatively new concept in developing countries, despite serious shortages of human expertise. In this light, the concept of microcomputer-based decision support for patient management at the rural health centre level in The Gambia is discussed and developed. Possible methodologies are devised and evaluated, taking into account constraints imposed both by feasibility of hardware for the rural African setting and by appropriate software techniques. Clinical data were collected for a pilot system, which was implemented using a Bayesian methodology, and assessed, with encouraging results. Further sources of data were then considered in order to generalise the pilot system into a prototype, which was implemented on a portable solar-powered microcomputer. The evaluation of this prototype system, and the difficulties involved in undertaking rigorous evaluations of this type of decision aid, are described and discussed. Whilst it is not proven that major health benefits would arise from the widespread introduction of such systems, the results of this preliminary study suggest that this type of approach merits further consideration and development.

This dissertation addresses resource allocation problems that occur in both public and private health care settings with the objective of characterizing the tradeoffs that occur when simultaneously incorporating multiple objectives and developing methods to address these tradeoffs. We examine three resource allocation problems (i) strategic allocation of financial resources and limited staffing capacity for the mobile delivery of health care within African countries, (ii) real-time allocation of hospital beds to internal patient requests, and (iii) development of patient redirection policies in response to limited bed availability in units within a system of hospitals. For each problem we define models, each with a different methodology, and utilize the models to develop allocation strategies that account for multiple competing objectives and examine the performance of the strategies with computational studies. In Chapter 2, we model African health care delivery systems utilizing a mixed-integer program (MIP) which accounts for financial and personnel constraints as well as infrastructure quality. We characterize tradeoffs in effectiveness, efficiency, and equity resulting from four allocation strategies with computational experiments representing the variety of spatial patterns that occur throughout the continent. The main contributions include (i) the development of a model that incorporates spatial and infrastructure characteristics and allows for a study of equity in the delivery of care, rather than access to care, and (ii) the characterization of tradeoffs in the three objectives under a variety of settings. In Chapter 3, we model the real-time assignment of bed requests to available beds as a queueing system and a Markov decision process (MDP). Through the development of bed assignment algorithms and simulation experiments, we illustrate the value of implementing strategic bed assignment practices which balance the bed management objectives of timeliness and appropriateness of assignments. The main contributions of this section include (i) the development of new bed assignment algorithms which use stochastic optimization techniques and outperform algorithms which mimic processes currently used in practice and (ii) the definition of a model and methods for the control of a large complex system that includes flexible units, multiple patient types, and type-dependent routing. In Chapter 4, we model the impact of a patient redirection policy in a hospital unit as a Markov chain. Assuming preferences for patient redirection are aligned with costs, we examine the impact of incremental changes to redirection policies on the probability of the unit being completely occupied, the long-run average utilization, and the long-run average cost of redirection. The main contributions of this chapter include (i) the introduction of a model of patient redirection with multiple patient thresholds and patient preference constraints and (ii) the definition of necessary conditions for an optimal patient redirection policy that minimizes the average cost of redirection.

Includes bibliographical references.
In this thesis, equality is considered as the absence of differences in utilization among individuals of different socioeconomic status while equity is taken to mean that individuals in equal need of health care should use the same amount of care, irrespective of their socioeconomic status. Using the above definitions, this thesis, examines equity/inequality in the utilization of public health care in Zambia. Concentration curves, concentration indices and horizontal equity indices were used for this purpose. This thesis focuses specifically on public health care that is subsidized by the Government. It is anticipated that the findings of this thesis will broaden the knowledge base on health care utilization inequities in Africa.

Decentralization of health services in Uganda, driven by the structural adjustment programme of the World Bank, was embraced by government as a means to change the health institutional structure and process delivery of health services in the country. Arising from the decentralization process, the transfer of power concerning functions from the top administrative hierachy in health service provision to lower levels, constitutes a major shift in management, philosophy, infrastructure development, communication as well as other functional roles by actors at various levels of health care. This study focused its investigation on ways and levels to which the process of decentralization of health service delivery has attained efficient and effective provision of health services. The study also examined the extent to which the shift of health service provision has influenced the role of local jurisdictions and communities. Challenges faced by local government leaders in planning and raising funds in response to decentralized health serdelivery were examined.

Family-centered care (FCC) focuses on considering the family in planning/implementing care and is associated with increased patient satisfaction. Little is known about factors that influence FCC. Using linear mixed modeling and Generalized Estimating Equations to analyze data from a cross-sectional survey of primary care practices in Ontario, this study sought to determine whether models of primary care service delivery differ in their provision of FCC and to identify characteristics of primary care practices associated with FCC. Patient-reported scores of FCC were high, but did not differ significantly among primary care models. After accounting for patient characteristics, practice characteristics were not significantly associated with patient-reported FCC. Provider-reported scores of FCC were significantly higher in Community Health Centres than in Family Health Networks. Higher numbers of nurse practitioners and clinical services on site were associated with higher FCC scores but scores decreased as the number of family physicians at a site increased.

BACKGROUND: Health Information Technology (HIT) enhances patient safety, which can also help to reduce health care costs. When it is used to replace the paper-based records, it will alter the workflow of front line workers and facilitate the management of care. The data captured can be shared in a seamless manner throughout the whole patient care journey. Since a significant upfront investment is required in the implementation and the use of the Electronic Health Record (EHR), it is still recognized as one of the major barriers. Despite these factors, governments and private health care provider organizations are all moving to implement a myriad of HITs. Therefore, meaningful use (MU) is an important criterion when assessing HIT utilization. This study focuses on the review and synthesis of evidence relating to the cost and effectiveness of health informatics adoption for health care delivery. Taking these findings into account may increase the likelihood of successful and cost-effective HIT implementation. METHODS: Literature searches of BMJ, Science Direct, and PubMed as well as a manual search for grey literature via Google scholar were performed. The inclusion criteria were any studies, both quantitative and qualitative, that describe the cost-effectiveness of informatics via any type of HIT used during the provision of health care services. English publications from 2003 to 2013 with any type of study setting were included. Through this search, nine articles were chosen for the final analysis. RESULTS: Among the nine selected studies, eight of them concluded that the adoption of HIT may-be-cost-effective to health care delivery. One study found the adoption of HIT not effective. The studies did not provide sufficient and concrete evidence to prove cost-effectiveness of HIT adoption. DISCUSSION: There is insufficient evidence to support the cost-effectiveness of HIT adoption. The cost data from these studies are not available. Data quality, system design, and physician behavior are other concern for MU of health informatics. Health care organization and governments should engage with the end-users (e.g. medical & paramedical personnel and patients) during system design (or selection), adaptation and implementation. CONCLUSION: Stakeholders should be aware of the tradeoffs throughout the implementation process. HIT scope, design, development, implementation, and performance monitoring should be well planned right from the start. In the foreseeable future, formal economics evaluation reports of Cost-Effectiveness Analysis (CEA) should be compulsory for stakeholders investing in Health Information Technologies.
published_or_final_version
Public Health
Master
Master of Public Health

This thesis is based on a comparative case study of two bustee neighbourhoods located in two separate wards of Calcutta, and of the factors which have affected the performance of public officials providing primary health care services to their inhabitants. It is argued that poor bureaucratic performance and a lack of accountability lie at the heart of problems with the health system in West Bengal. The thesis evaluates the effectiveness of 'governance' reforms, comprising decentralisation and the application of the principles of New Public Management (NPM), on the performance of public officials. NPM and decentralisation apply the core assumptions of neo-classical economics to the study of bureaucratic decision-making. The thesis argues that local officials in Calcutta may not always have chosen to behave in a way which maxmised their personal welfare, but that history, culture and politics may have affected the choices that they made. The thesis questions the view that decentralization necessarily leads to greater community participation challenges contemporary notions of what constitutes 'civil society' and suggests a more nuanced view of the relationship between civil society and good government. It questions NPM's claims to universality, which have resulted in its widespread application without due regard to local context, and argues that NPM inspired reforms have had a limited effect on health officials in Calcutta, in part, because of their failure to address the underlying causes of poor bureaucratic performance. The final chapter argues that the political influence of public sector workers has affected the willingness of the ruling Party to enforce the incentives to improve the performance of health care officials in West Bengal.

This thesis explores the quality of health care delivery in rural Ghana. In Ghana, the Ministry of Health has been concerned about the quality of health care for sometime, but improvements in quality have been slow to develop and become noticeable: there continue to be complaints about the quality of care given by health workers and received by clients. For their part, health workers have reported the challenges to delivering quality services, while patients describe difficulties of accessibility and technical competence of health workers. It was envisaged that an exploration of the quality of care at the district level would reveal the range of constraints to provision and receipt of quality care, providing an evidence-based analysis incorporating the views of the important stakeholder groups, that could help to contribute to quality improvement in rural Ghanaian health care, especially in primary health care delivery at the local level. The study reported here was carried out in rural Amansie West district in the Ashanti region of Ghana. Using the administrative district as a case study allowed for “multiple sources of evidence gathering”, thus ensuring that the findings are more likely to reflect reality if based on several different sources of information and types of data. The study design was qualitative and involved qualitative data collection methods, including: semi-structured interviews with 66 patients, 25 health workers from seven primary health care facilities and six core members of the district health management team; and focus groups that involved discussions with members from seven communities. These data collection methods explored study participants‟ ideas about the definition of quality of health care, perceptions about the quality of actual health care delivery and feelings about the quality improvement strategy adopted in the primary care facilities studied. Interviews were tape recorded with consent, and translated into English as they were transcribed. Data were analysed manually, using iteration and thematic analysis. Data collection and analysis were guided by a phenomenological approach intended to capture the essence of statements and their meaning to participants. Thematic qualitative analysis of the data suggested that the different provider, recipient and administrative level groups had similar views on what constituted quality of care. In their perceived definitions, all groups tended to emphasise the importance of interpersonal relations, accessibility, technical competence and effectiveness, but these dimensions variously „ranked‟ in importance by stakeholder groups. Perceptions of the quality of actual health care received and the quality improvement process being deployed in Amansie West revealed that many of the obstacles to high quality health care were described as residing within the structure of health care delivery. This study provides new knowledge about perceptions of quality, experience of quality and quality improvement in a rural area of a developing country. It has improved understanding of the differing views held by the different stakeholders. It shows the dimension of understanding about quality added when the views of patients and community members are considered in addition to providers and administrators. Findings suggest improvements could be made to structural aspects of health care provision that could improve quality: for example, appropriate equipment, trained health workers and sufficient numbers of trained workers.

Thesis (Ph.D.)--Boston University
Several new organizational health care delivery forms have developed in recent decades. For hospital services, the number of single specialty hospitals (SSHs) providing cardiac and orthopedic/surgical services has grown significantly. Physician-owners claim that these SSHs use limited-scope and economies of scale to provide higher quality of care and reduce costs. While SSH costs have been studied, a comprehensive assessment of SSH quality of care and an evaluation of factors affecting SSH location is useful. For primary care services, significant growth in the number of retail health clinics (RHCs) has employed nurse practitioners (NPs) to provide care for a limited set of low-acuity conditions. Whether state regulations limiting the ability of NPs to practice independently affect RHC location is not known. To assess whether SSHs provide higher quality of care than competing general hospitals, we compared process of care and outcome measures for SSHs and general hospitals in the same health care market for 2008 through 2011. Cardiac SSHs had better scores for some outcomes. All SSHs had some better and some worse process of care scores, although scores for all hospitals increased over time and differences between SSHs and general hospitals diminished. Any improvements in quality of care were not robust to other factors. To evaluate the economic factors affecting hospital service specialization, we used ordered logistic regression to model presence of an SSH or ambulatory surgery center (ASC) on supply, demand, and regulatory factors. A higher degree of hospital specialization is associated with higher population levels and growth, more specialists and operating rooms per capita, and the absence of certificate of need laws. To assess economic factors affecting RHC location and test whether regulations limiting NP practice autonomy affect RHC location, we used logistic regression to model presence of an RHC on relevant economic factors and state regulations limiting NP practice autonomy. RHC location is associated with higher private insurance levels and certain factors affecting primary care supply, but is unhindered by regulations limiting NP practice autonomy. Each new form of in health care delivery examined appears uniquely affected by geographic differences in supply, demand, and regulatory factors.

Unique barriers prevent parents in rural areas from seeking mental health services for their children. The implementation of innovative models of service delivery may reduce these barriers' impact on rural parents' treatment seeking. The purpose of this study was to determine: 1) parents' willingness to use innovative service delivery models; 2) barriers that parents perceive to seeking treatment in each of the 4 service delivery models, and; 3) the relationship between perceived barriers and willingness to seek help in the context of 4 service delivery models. Surveys were distributed to parents of children attending school in several counties in rural Appalachia. Results showed that parents perceived different barriers for different service models and that perceived barriers affected willingness differently depending on the model asked about. These results suggest that the use of innovative models (e.g., telehealth) may be acceptable in rural areas as alternatives to traditional mental health services.

There is emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and reduce costs. Unmet health-related social needs, such as food insecurity, inadequate or unstable housing, and lack of access to transportation may increase the risk of developing chronic conditions, reduce an individual's ability to manage these conditions, increase health care costs, and lead to avoidable health care utilization. In response, work on social needs is happening across large health systems in the United States, but the pace of progress is slow and accountability is diffuse. The goal of this applied research project is to examine Kaiser Permanente Northwest's patient navigator program as a case study for how health systems can transform into organizations that bridge clinical, social and behavioral health and redefine what it means to be a prevention-oriented delivery system. Kaiser Permanente Northwest (KPNW) provides high quality, patient-centered care to over 550,000 medical members and 240,000 dental members in Oregon and Southwest Washington. In conjunction with the Care Management Institute, KPNW created a patient navigator administered, social needs screening tool called "Your Current Life Situation" (YCLS). This thesis focuses on the data collected from this screening tool with an emphasis on operations management, workflows, and the technical tools that have been supported to do this work. The analysis also uses semi-structured qualitative interviews from patient navigators, physicians, social workers, community organizations and members to better understand the experience of social needs screening in clinical practice and its impact on members and community partners as they receive referrals for services outside the health care delivery system. Through using anthropological theory and methods, I seek to help health systems think and act differently by elevating the voice and experience of the community and translating vulnerable populations' needs into a language that can be integrated into multiple systems of care.

With advances in technology and science, life expectancy is increasing, but most of the elders must take care of themselves or live in assisted home. Between 2015 and 2060, the U.S. Census Bureau predicts that the population adult aged 65 to 84 will grow to 89%; meanwhile, the number of adult 85 and older are expected to more than triple and about 11 million people age sixty-five and older are predicted to live alone, which is almost a third of the American population. They may have problems to receive essential medications because they are unable to drive or do not have access to public transportations. The FlyMed Pharmacy will assist the elderly by providing home delivery services such as emergency or maintenance medications. Consultations and advice will be provided through a mobile app, DeliverMyMed.

The focus of health care reform is to contribute to better patient health and maintain an equitable access to the system while at the same time achieving a more effective and efficient use of increasingly scarce health care dollars. Due to budgetary and other restraints provincial governments are either spending less on health care or are looking to change the delivery and management of the health industry.
How the Canadian health care system responds to the challenges depends upon the interpretation of a number of factors. Three basic factors which are linked to any health care delivery system are financing, delivery and allocation of resources with the altering of one of these components affecting the others.
Has there developed a right to health care and if so, would this foreclose a curtailment of health care services? If there is no right to health care, can the courts or the Charter of Rights and Freedoms be used to protect the existing system? Is it possible for public interest groups, or others, to utilize judicial intervention to force a government, either at the provincial or federal level, to spend more on health care or change their health care policy? What if a patient is affected by decision affecting health care delivery, does this bring in civil liability?
This thesis will review these areas in an effort to understand, articulate and ascribe values to Canada's health care system and provide a legal and ethical analysis of alternative health care delivery systems.

The prevalence of untreated and undertreated mental health concerns and the comorbidity of chronic conditions and mental illness has led to greater calls for the integration of primary care and mental health. In 2012, the Oregon Health Authority authorized 16 Coordinated Care Organizations (CCO) to partner with their local communities to better coordinate physical, behavioral, and dental health care for Medicaid recipients. One part of this larger effort to increase coordination is the integration of primary care and mental health services in both primary care and community mental health settings. The underlying assumption of CCOs is that organizations have the capacity to fundamentally change how health care is organized, delivered, and financed in ways that lead to improved access, quality of care, and health outcomes. Using the Rainbow Model of Integrated Care (RMIC), this study examined the factors that impact organizational efforts to facilitate the integration of primary care and mental health through interviews with executive and senior staff from three CCOs. The RMIC focuses attention on the different levels at which integration processes may occur as well as acknowledges the role that both functional and normative enablers of integration can play in facilitating integration processes within as well as across levels. The following research question was explored: What key factors in Oregon's health care system impede or facilitate the ability of Coordinated Care Organizations to encourage the integration of primary care and mental health? Using a case study approach, this study drew upon qualitative methods to examine and identify the factors throughout the system, organizational, professional, and clinic levels that support CCO efforts to facilitate the integration of primary care and mental health. Fourteen primary interviews were conducted with executive and senior staff. In addition, eleven secondary interviews from a NIDA funded project as well as twenty-four key CCO documents from three CCOs were also included in this study. The RMIC was successful in differentiating extent of CCO integration of primary care and mental health. Findings demonstrate that normative and functional enablers of integration were most prevalent at the system and organization level for integrating mental health into primary care for these three CCOs. However, there was variation in CCO involvement in the development of functional and normative enablers of integration at the professional and clinic levels. Normative and functional enablers of integration were limited at all of the RMIC levels for integrating primary care into community mental health settings across all three CCOs. The Patient-Centered Primary Care Home model provided CCOs with an opportunity to develop functional and normative enablers of integration for integrating mental health in primary care settings. The lack of a fully developed model for integrating primary care services in community mental health settings serves as a barrier for reverse integration. An additional barrier is the instability of community mental health as compared to primary care; contributing factors include historically low wages and increased administrative burden. System wide conversations about where people are best served (i.e., primary care or community mental health) has yet to occur; yet these conversations may be critical for facilitating cross-collaboration and referral processes. Finally, work is needed to create and validate measures of integration for both primary care and community mental health settings. Overall findings confirm that integrating primary care and mental health is complex but that organizations can play an important role by ensuring the development of normative and functional enablers of integration at all levels of the system.

The private health care market in the United Kingdom is a multi-billion pound industry whose dynamics remain largely unexamined. This is so even though the boundaries between the public and private sectors are becoming increasingly blurred, particularly in England. Given the growing importance of this sector, the policy community needs to know more about the nature of private health care in the UK, how well the private market operates and how successful have been the various attempts within it to improve value for money and health care quality, given that private health care has traditionally been seen by many citizens as unaffordable. In particular this thesis traces recent efforts by the British United Provident Association (Bupa) to reshape the UK private healthcare market. The account provided draws on the author's experience as a senior Bupa manager involved in planning and implementing such changes. The thesis describes a series of Bupa initiatives designed to change provider behaviour in pursuit of improved quality and value-for-money, and the difficulties and obstacles encountered. The latter often centred on tensions or confrontation between the insurer and professional providers that are discussed in relation to the wider literature on the social and economic organisation of health care markets. An attempt has been made to draw some general conclusions via an empirical study of the role and limitations of market-based changes within the UK private sector. The broad conclusion is that the private market in the UK exemplifies those features of health care seen throughout the developed world that create imperfect market conditions. As such the market is highly resistant to insurer initiatives that would reverse the longstanding trend for premiums to rise above the rate of inflation. It is considered unlikely given the current market structure that any insurer, including Bupa, can escape these constraints in the short term. However, Bupa has implemented some successful initiatives that suggest that longer-term incremental change is possible.

The importance of health and quality health care in people’s daily lives is widely recognised. Physicians play a key role in delivering quality health care and improved patient outcomes. However, the evidence regarding physicians’ decision making and their perception of quality of health care delivery and its influencers is inconclusive. The overall aim of this thesis is to increase the understanding of quality in health care delivery and the factors that influence it from a physician’s perspective. This aim is fulfilled by conducting three interlinked research projects. The first research project comprises a systematic review of the literature that identifies the factors, contexts and theoretical underpinnings influencing physician decision making. The synthesis of 160 studies reveals two main categories of influencing factors. The first is ‘Contexts’, which refers to the set of circumstances or facts surrounding a particular event or situation. The second category is ‘Interventions’, which are the techniques, processes or actions introduced to create changes in how physicians make decisions while performing their clinical duties. Although extant literature provides ample evidence on factors influencing physician decision making the link to quality in health care is under researched. In the second research project, the author explores how physicians construct quality of health care delivery by means of investigating 162 clinical cases with 27 repertory gird interviews that yield eleven key constructs representing a classification of physicians’ conception of quality. The third research project examines physicians’ perceptions of enablers and barriers to quality in health care delivery, employing semi-structured interviews. Findings indicate that physician’s effort in delivering quality health care is largely influenced by factors affecting behavioural control (freedom to act). This research makes five contributions to knowledge. First, a novel classification of factors influencing physician decision making when prescribing is developed, providing new understanding of the link between these factors and quality of health care. Second, the systematic review shows an innovative application of factor analysis to structure the findings of a complex phenomenon. Third, the study presents a new conceptualisation of physicians’ construction of quality in health care. Fourth, the research provides a categorization of physicians’ perceived enablers and barriers to quality health care and the mechanisms by which they operate. Finally, this research develops a theoretically-grounded and empirically-informed conceptual model that incorporates three hitherto separate domains: agency, planned behaviour, and decision theories. This model provides a new integrated lens to better understand the complexities influencing quality in health care delivery. This study also makes two significant contributions to practice. First, the findings have helped initiate a transformation in the pharmaceutical industry’s business model, evolving from business-to-person to business-to-business. Second, the findings serve as a catalyst to drive organizational changes at Norway’s largest emergency hospital. As a result, a national debate was initiated, involving the Prime Minister and Minister of Health, on how hospital emergency care can best be provided at a national level.

This research was conducted to investigate how e-health technologies can contribute to the delivery of pharmaceutical care throughout the patient's journey and across traditional care boundaries. The hypothesis was that e-health technologies are enablers of efficient seamless delivery of pharmaceutical care. Qualitative and quantitative methods were used to examine how hospital clinical pharmacists work; to find out which toxicities were experienced by patients prescribed systemic anticancer therapy (SACT) and what their pharmaceutical care issues were; and to investigate the views of both cancer patients and community pharmacists relating to delivery of pharmaceutical care. The main findings were: access to mobile technology improved the efficiency of hospital clinical pharmacists; patients receiving SACT experienced a range of toxicity, some of which could be managed in primary care; patients would be happy to receive more from their community pharmacist; and community pharmacists should have access to electronic patient records (EPR) to safely deliver pharmaceutical care. Most patients who receive SACT experience toxicity in the community. Community pharmacists are ideally placed to support these patients but pharmacists require training and access to EPR to improve their confidence in managing SACT toxicity. Cancer care specialist pharmacists can contribute to the education and training of community pharmacists and initiatives to do so were implemented in NHS Greater Glasgow & Clyde (NHSGGC). Health and wellbeing Smartphone Apps can support patients and the Wellness Tracker, designed in this study, aimed to be an innovative technological aid for patients with cancer. Feedback from teenage patients was positive. XPost-study initiatives implemented in NHSGGC included electronic referral from hospital to GP-based pharmacists as step one. Two-way sharing of the electronic cancer pharmaceutical care plan; electronic referral to community pharmacists (step two) once access to EPR is granted; and clinical vignettes to support community pharmacists in providing advice to patients who have SACT toxicity will follow. Scottish cancer care pharmacists, in collaboration with the Scottish Directors of Pharmacy, have started development of nationally agreed pharmaceutical care bundles for community pharmacists to enable local delivery of pharmaceutical care to patients prescribed SACT.

Thesis (M. Eng. in Logistics)--Massachusetts Institute of Technology, Engineering Systems Division, June 2008.
Includes bibliographical references (leaves 68-72).
As the healthcare industry in United States continues to be constrained by increasing costs, new delivery channels are coming into practice. One such channel is home healthcare. Home healthcare presents challenges on the basis of acceptability by the medical community, insurers and patients, availability of care in fragmented locations and affordability of the product or service in comparison to other healthcare modes. This study analyzes these challenges in an attempt to suggest strategies to allow home healthcare to grow as an industry and the successful sustainability of that growth. Methods used to analyze home healthcare include the study of two home healthcare firms, one pharmaceutical manufacturer who used home healthcare to augment their product, and in-depth interviews with several stakeholders within the healthcare system.
by Katherine Szabo Fowler.
M.Eng.in Logistics

Thesis (Ph. D.)--Massachusetts Institute of Technology, Engineering Systems Division, 2013.
Cataloged from PDF version of thesis.
Includes bibliographical references (p. 163-178).
A health care delivery chain is a series of treatment steps through which patients flow. The Emergency Department (ED)/Inpatient Unit (IU) chain is an example chain, common to many hospitals. Recent literature has suggested that predictions of IU admission, when patients enter the ED, could be used to initiate IU bed preparations before the patient has completed emergency treatment and improve flow through the chain. This dissertation explores the merit and implications of this suggestion. Using retrospective data collected at the ED of the Veterans Health Administration Boston Health Care System (VHA BHS), three methods are selected for making admission predictions: expert opinion, naive Bayes conditional probability and linear regression with a logit link function (logit-linear regression). The logit-linear regression is found to perform best. Databases of historic data are collected from four hospitals including VHA BHS. Logit-linear regression prediction models generated for each individual hospital perform well based on multiple measures. The prediction model generated for the VHA BHS hospital continues to perform well when predictive data are collected and coded prospectively by nurses. For two weeks, predictions are made on each patient that enters the VHA BHS ED. This data is then summarized and displayed on the VHA BHS internet homepage. No change was observed in key ED flow measures; however, interviews with hospital staff exposed ways in which the prediction information was valuable: planning individual patient admissions, personal scheduling, resource scheduling, resource alignment, and hospital network coordination. A discrete event simulation of the system shows that if IU staff emphasizes discharge before noon, flow measures improve as compared to a baseline scenario where discharge priority begins at 1pm. Sharing ED crowding or prediction information leads to best patient flow performance when using specific schedules dictating IU response to the information. This dissertation targets the practical and theoretical implications of using prediction to improve flow through the ED/IU health care delivery chain. It is suggested that the results will have impact on many other levels of health care delivery that share the delivery chain structure.
by Jordan Shefer Peck.
Ph.D.

The development of new knowledge about patient care continues to progress at an ever-increasing rate but its transfer into clinical practice can be slow and unpredictable. This doctoral statement provides a critical overview of a substantial programme of work that has explored the utility of theoretical models of behaviour for promoting the uptake of research findings into routine care. Guided by the MRC Framework for the design and evaluation of complex interventions, the supporting publications describe the development and testing of an innovative and systematic approach to intervention design. As well as providing methods for identifying and applying behavioural theory, this work has also set standards for transparency in the intervention development processes. The work demonstrates that psychological theories of behaviour do have an important function for improving healthcare delivery by supporting clinical behaviour change, but important limitations remain. In my critical reflection of this body of work I discuss these challenges, considering in particular the omission of the patient perspective and the dynamic influence of the patient-professional interaction during the clinical encounter. I go on to propose an extended dual-perspective model supported by theory and evidence from other improvement literatures, epistemologies and disciplinary perspectives. The dual perspective model functions at the very core of healthcare delivery and illustrates the interdependency of professional and patient behaviour in determining healthcare decision making and patient outcomes. By formally including the patient perspective the revised model encompasses all three dimensions of the EBM paradigm. I argue for a focus on better understanding of the interactional and relational processes that are generated during the clinical encounter as an essential step forward for implementation and improvement science. The paradigm of patient-centred care is then revisited through the lens of capabilities thinking and is proposed as a vital mechanism for supporting the uptake of appropriate, evidence-based healthcare.

This thesis is concerned with the concept of undergraduate Interprofessional Education (IPE) as a possible model of practice for the education of health care professionals at the Faculty of Health Sciences, University of Malta. In 2010, the World Health Organisation published its Framework for Action on IPE and Collaborative Practice outlining a vision for a “collaborative practice-ready workforce” emphasising the importance of the health and educational systems as supporting pillars of IPE and collaborative practices (WHO, 2010, p.7). The concept of IPE had been mentioned in policy documents in Malta but no such model had ever been tried or tested at the University. This study aimed to explore stakeholders’ perspectives and perceptions of IPE and to encourage debate of adopting such an approach at the Faculty of Health Sciences. This thesis starts by tracing a history of IPE internationally, teasing out the diversity of policy drivers and motivating factors behind its inception and highlighting the lessons learnt for its development and sustainability into curricula; which, inter alia, include the importance of political drivers, national coherent policies, organisational support and earmarked central funding. This was crucial to underscore as it brought to the fore the paucity of such triggers for IPE within this research study. The study then adopts a qualitative case study approach underpinned by a social constructionist and interpretative stance designed to explore the possibility of IPE at the University of Malta. The purposive sample totalled sixty four participants and these included academics at the Faculty of Health Sciences, key informants from the education/health sectors and newly qualified health professionals. Data was gathered through a combination of focus group discussions and one-to-one interviews, and analysed using Ritchie and Spencer’s (1994) ‘Framework’ analysis supported by NVivo software. Findings yielded rich insights into participants’ perceptions of IPE; while they lauded the notion in principle, they identified a multiplicity of factors that would pose barriers to its enactment in practice. Some barriers might be described as symbolic while others were rooted in the practical domain of operational systems and structures. On a symbolic level, participants were particularly concerned that IPE would pose a threat to their professional identities and to the maintenance of boundaries that define the conceptual territories of the various professions. Participants also pointed to traits and behaviours they perceived as endemic in Maltese culture that would conflict with the enactment of IPE; these were especially relevant as the influence of macro cultural determinants has been largely overlooked in the interprofessional literature. These findings were interpreted through an interdisciplinary conceptual framework drawing on sociological discourses of professionalism and Bourdieu’s theories of societies and social practices. The framework also drew on concepts in anthropological discourses, focusing in particular on Hofstede’s theory of cultural dimensions as a means of theorising about the role that national culture can play in shaping perceptions and behaviours. The originality of this study lies in its a priori approach by exploring perceptions of an interprofessional model of practice when this philosophy had not yet been considered, and which in the process, identified contextual variables which could impact on the design and delivery of IPE. It is unique in employing various theoretical perspectives so as to transcend the factual findings and engage in higher order reconceptualisation. It is also the first study of IPE to be conducted in Malta; significant to consider for any potential interprofessional initiatives. This research contributes to the body of evidence underpinning IPE in two ways. It highlights again the existence of embedded hierarchies and power struggles across health systems and how these impact on IPE, and it uncovers the potential impact of national culture as a tangible determinant in the planning, development and delivery of IPE initiatives.

A thesis submitted in partial fulfilment of the requirements for the degree of Masters of Arts in Clinical Psychology at the University of Zululand, South Africa, 2011.
South Africa is at a critical point in the debate about the future of health-care in the occupation-specific dispensation (OSD). It also faces the exodus of valuable human resources that was perceived as greener pastures, as medical practitioners become increasingly dissatisfied with governmental policy, wage negotiations, work-place disillusionment, lack of service delivery, expressions of corruptions, and lack of resources. This research aimed to thematically analyse the experiences, opinions and feelings of medical practitioners in both the public and private health-care sectors as well as explored international trends with the intention of drawing comparisons, highlighting problem areas, and discussion of possible solutions. It was hoped that this research would contribute towards understanding the dynamics that marked the exodus of medical practitioners from South Africa, at a time when change in the health-care system was imminent. In order for the medical practitioners to remain in the current health-care system, a new dialogue would have been opened in which their concerns could be raised and evaluated.

This thesis considers the topic of economic evaluation in health care. Specifically we make a cost-effectiveness analysis of two different types of healthcare interventions. First, we evaluate the effects and cost-effectiveness of alternative methods of delivery associated with the introduction of epidural analgesia during labor. Then we analyse the costs and benefits of a colorectal cancer screening program. The first chapter introduces the study and provides a short review of the main economic evaluations techniques. The second chapter contains a survey of different measures of outcome and quality of life of health care interventions. Namely, we discuss which instruments (questionnaires) can be used to evaluate the effectiveness (in terms of clinical and psychological outcomes) of the delivery event and the colorectal cancer screening. The analysis is fundamental to the cost-effectiveness studies treated in chapter 4 and 5. The third and fourth chapters analyse the topic of alternative methods of delivery, with special attention to a recent phenomenon that has raised concerns worldwide, but especially in Italy: the increased use, at times not appropriate, of caesarean section practice. The third chapter provides a comparative analysis of the appropriateness of caesarean section practice, comparing Italy and United Kingdom. We analyse the differences in terms of the healthcare system and the socio-demographic framework in the two countries and we consider the potential factors that might explain the high frequencies and variability of caesarean section practice. The topic of the appropriateness of health care interventions plays a central role in the general debate surrounding public health care system sustainability. In recent years, in fact, an exponential growth in the frequency of caesarean sections has been registered in Europe. This phenomenon seems not to be completely justified suggesting inappropriate use, since caesarean section is practiced independently of clinical or epidemiologic reasons. We consider the effects that such a practice can have, not only in terms of healthcare expenditure, but also from a broader societal perspective, and we suggest possible health policies and clinical governance measures to manage this malpractice. Particularly, we examine the recent Italian proposal of introducing epidural analgesia among the Essential Levels of Assistance (LEA) with the aim that this will help to counteract the rise of caesarean sections. Despite the debates on this issue, few studies have paid attention to the real costs of alternative methods of delivery and the main literature refers to the American context, which is extremely different from the Italian one (Henderson J., 2001). For this reason, in the fourth chapter we analyse the costs and benefits involved in alternative methods of delivery (vaginal delivery, with and without epidural analgesia, and caesarean section) in the Italian framework. The empirical analysis has been conducted in an Italian university hospital, through direct collection of data, administration of questionnaires and direct interviews to patients and health staff. A logistic regression has been used to model the probability of the event “delivery with planned caesarean section” occurring as a function of a set of clinical and socio-economic characteristics of the women. A micro-costing analysis has been used to evaluate the direct health costs of each delivery method, following an activity-based costing approach. The analysis shows that caesarean section is, on average, more expensive if compared to vaginal delivery, but the difference is marginal if we take into account the opportunity-cost of time during labor. Since caesarean section is generally reimbursed more than vaginal delivery to cover the supposed higher costs of surgical intervention, differences between the real costs and the DRG tariffs may induce opportunistic behaviour in terms of clinical practice. The introduction of epidural analgesia among LEA would certainly have a huge impact in economic terms, but the final effect is not clear: it may reduce the frequency of inappropriate caesarean sections, but also it may increase the costs due to complications. From a societal perspective we consider also the indirect costs, the intangible costs (transport, medications, artificial feeding, time lost) and the benefits of each method. The cost-effectiveness analysis shows that, in general, vaginal delivery with analgesia provides better results both in terms of costs and benefits. Nevertheless, in many cases epidural analgesia can require emergency procedures, with worse results. The fifth chapter contains an economic evaluation of a colorectal cancer screening program. Colorectal cancer (CRC) is one of the most common forms of cancer in western countries. Evidence from several scientific studies suggests that screening for the early detection and removal of cancerous lesions can reduce the incidence of CRC, its resultant impact on mortality (Sonnenberg A., 2000, Lieberman DA., 1995) and improve patients’ quality of life (Taupin D., 2006; Miles A., 2006). The main literature on this topic refers to USA and few studies have been conducted in Italy. For this reason, the development of a specific study referred to a particular setting has been considered appropriate and relevant to increase the knowledge about the effectiveness and the costs of screening programs in the Italian framework. This work uses as case-study the experience of a CRC screening program in the Province of Ferrara and aims at determining the full cost of the screening program, at comparing the costs and effectiveness of the diagnostic techniques adopted (faecal occult blood and colonoscopy), and at the identification of the expected results in terms of cancer prevention. Also in this case, a micro-costing analysis has been used to identify and evaluate all of the costs involved in each phase of the screening program, following an activity-based costing approach to consider all the activities carried out in the assistance process. The effectiveness of the diagnostic instruments used, FOBT combined with colonoscopy, has been valued in terms of early detected lesions and years of life gained. The preliminary results show that, after the screening implementation, a huge number of new cases of hyperplasic polyps, dysplastic adenomas and carcinomas are detected. Moreover, early diagnosis allows the detection of colorectal cancer at the earliest Dukes’ stages. A MISCAN COLON model has been used to estimate the costs for year of life gained and the cost-effectiveness of the screening program.
Il presente lavoro considera il tema della valutazione economica in campo sanitario. Nello specifico vengono sviluppate due analisi di costo-efficacia con riferimento a due diversi tipi di programma sanitario. In primo luogo, si valutano gli effetti di diverse modalità di parto, esaminando in particolare la costo-efficacia dell’introduzione dell’analgesia epidurale in travaglio. In secondo luogo, si analizzano i costi e i benefici di un programma di screening per la prevenzione del tumore al colon-retto. Il primo capitolo ha un carattere introduttivo e offre una breve rassegna aggiornata delle principali tecniche di valutazione economica. Il secondo capitolo contiene una survey completa delle diverse misure di outcome e di qualità della vita degli interventi sanitari, considerando in particolare gli strumenti di indagine (questionari) utilizzati per valutare l’efficacia (impatti clinici e psicologici) dell’evento parto e dello screening del cancro al colon-retto. L’analisi è funzionale rispetto agli studi di costo-efficacia condotti poi nei capitoli 4 e 5. Il terzo e quarto capitolo analizzano il tema delle diverse metodiche di parto, puntando l’attenzione su un fenomeno che di recente ha destato non poche preoccupazioni a livello mondiale e in particolare in Italia: il ricorso crescente, e talora non appropriato, all’utilizzo della pratica del taglio cesareo. Il terzo capitolo effettua una analisi comparativa del livello di appropriatezza del ricorso alla pratica del taglio cesareo, confrontando l’Italia e il Regno Unito. Si analizzano le differenze di contesto sanitario e socio-demografico nei due Paesi e si considerano i fattori che potenzialmente potrebbero contribuire a spiegare una elevata frequenza e variabilità nell’utilizzo della pratica di taglio cesareo. Il tema dell’appropriatezza nel settore analizzato appare particolarmente rilevante nell’ambito del dibattito generale in tema di sostenibilità del sistema sanitario pubblico. Negli ultimi anni, infatti, è stato registrato un incremento esponenziale della frequenza di utilizzo del taglio cesareo in Europa. Tale fenomeno non sembra peraltro essere pienamente giustificato e sottende sovente un grado elevato di inappropriatezza, essendo il taglio cesareo spesso praticato indipendentemente da ragioni cliniche o epidemiologiche. Vengono considerati in particolare gli effetti che tale pratica può avere non solo in termini di spesa sanitaria pubblica, ma anche a livello sociale adottando una prospettiva più ampia, e si propongono misure di politica sanitaria e di governo clinico che possano consentire di controllare il fenomeno. Viene esaminata, in particolare, la misura recentemente prevista in Italia con la proposta di introdurre l’analgesia epidurale tra i Livelli Essenziali di Assistenza (LEA) allo scopo di contribuire a contrastare il tendenziale aumento dei parti cesarei. Nonostante gli accesi dibattiti sull’argomento, pochi studi hanno tuttavia posto l’attenzione sui costi reali delle diverse metodologie di parto e la letteratura esistente è riferita ad un contesto, quello americano, estremamente diverso da quello italiano (Henderson J., 2001). Per questa ragione, nel quarto capitolo si sono analizzati i costi e i benefici di diversi metodi di parto (parto vaginale, con e senza analgesia epidurale, e parto cesareo) avendo come riferimento il contesto italiano. L’analisi empirica è stata condotta considerando una azienda ospedaliera italiana, attraverso la raccolta diretta dei dati, la somministrazione di questionari e l’effettuazione di interviste alle pazienti. E’ stata effettuata una regressione logit per modellare la probabilità dell’evento “parto con taglio cesareo elettivo” come funzione di un insieme di caratteristiche cliniche e socio-economiche delle partorienti. I risultati ottenuti sembrano confermare l’ipotesi testata anche in altri studi secondo cui il taglio cesareo venga praticato per ragioni non-cliniche (Osborn J. and Signorelli C., 1995; Frost C., 2005). Attraverso una analisi micro-costing sono stati valutati i costi diretti di ciascuna metodologia di parto, seguendo un approccio activity-based costing. Dall’analisi svolta è emerso che il parto cesareo è mediamente più costoso rispetto al parto vaginale, ma la differenza è marginale se si considera il costo-opportunità del tempo di assistenza durante il travaglio. Inoltre, le differenze tra i costi effettivi e le tariffe DRG utilizzate per il rimborso delle prestazioni sanitarie, potrebbe indurre comportamenti opportunistici in termini di pratica clinica. I risultati dello studio dimostrano che l’introduzione dell’analgesia epidurale tra i LEA potrebbe avere certamente un impatto rilevante in termini economici, ma l’effetto complessivo finale non è chiaro: essa potrebbe contribuire a ridurre la frequenza di tagli cesarei inappropriati, ma nel contempo aumentare i costi legati a potenziali complicazioni. Adottando una prospettiva sociale, sono stati considerati anche i costi indiretti, i costi intangibili (trasporto, medicazioni, assistenza, allattamento, perdite di tempo) e i benefici di ciascuna tipologia di parto. L’analisi costo-efficacia mostra che in generale il parto vaginale con analgesia epidurale è preferito sia in termini di costi che benefici. Tuttavia, in molti casi l’analgesia epidurale può richiedere procedure d’emergenza, con risultati peggiori sia in termini di costi che di benefici. Nel quinto capitolo viene effettuata una valutazione economica di un programma di screening per la prevenzione del tumore al colon-retto. Il cancro del colon-retto (CRC) configura una delle forme di tumore più comuni nei paesi occidentali e rappresenta la seconda causa di morte per cancro in Europa (AIRT, 1998-2000). Numerose evidenze scientifiche suggeriscono che lo screening per la diagnosi precoce e la rimozione delle lesioni cancerose può ridurre l’incidenza del tumore del colon-retto e la connessa mortalità (Sonnenberg A., 2000, Lieberman DA., 1995) e aumentare la qualità di vita dei pazienti (Taupin D., 2006; Miles A., 2006). La maggior parte della letteratura su questo tema è riferita al contesto americano, estremamente diverso da quello italiano. E’ sembrato quindi opportuno e rilevante sviluppare uno studio specifico relativo ad una particolare realtà territoriale, per contribuire ad aumentare la conoscenza dell’efficacia e dei costi dei programmi di screening nella realtà italiana. L’analisi svolta utilizza come caso-studio l’esperienza di un programma di screening in Provincia di Ferrara, e ha l’obiettivo di determinare i costi effettivi del programma di screening, di confrontare i costi e l’efficacia delle tecniche adottate (test del sangue occulto e colonscopia), e di identificare i risultati attesi in termini di prevenzione del cancro. Anche in questo caso, ai fini della valorizzazione di tutti i costi relativi a ciascuna fase del programma di screening è stata utilizzata una analisi micro-costing, seguendo un approccio activity-based costing, che considerasse tutte le attività svolte nel processo di assistenza. L’efficacia dello strumento di diagnosi adottato, test del sangue occulto (FOBT) combinato con esame endoscopico, è stata valutata in termini di lesioni diagnosticate precocemente e di anni di vita guadagnati. I risultati preliminari ottenuti mostrano che, a seguito dell’adozione e dell’avvio del programma di screening, il numero di nuovi casi individuati di polipi iperplastici, adenomi displasici e carcinomi è aumentato notevolmente. Inoltre, la diagnosi precoce ha permesso una diagnosi dei nuovi casi di tumore negli stadi Dukes meno avanzati. Si descrive l'utilizzo del modello MISCAN COLON per stimare il numero di anni di vita guadagnati e la costo-efficacia del programma di screening.

Every mother and child has the right to survive childbirth which requires skilled birth attendants together with referral and available emergency obstetric care (EmOC). The objective of the study was to describe delivery care routines at different levels in the health care system in Quang Ninh province, Northern Vietnam. The design was cross sectional using a structured questionnaire. Two districts in Quang Ninh province with 40 Community Health Centres (CHC), three district hospitals and one region hospital was included in the study, in total 138 (CHC n=105 and hospitals n=33) health care providers participated. In our study 20% (CHC) of the health care providers assisting deliveries at CHC were midwives and health care provider’s in our study further report to have assisted at less then 10 deliveries/year (81% of respondents at CHC). Findings show that the health care provider’s routines and care for women during labour and delivery vary and that there is a need for re-training and that women in labour should be cared for by health care providers with adequate training like midwifery. In our study CHC had poor resources to provide basic or comprehensive EmOC. Our findings indicate that there is a need for re-training in delivery care among health care providers and since the number of deliveries at CHC is few they should be handled by someone who is a skilled birth attendant. Our findings also show a variation in care routines during labour and delivery among health care providers at CHC and hospital levels and this also show the need for re-training and support from proper authorities in order to improve maternal and newborn health.

This dissertation uses qualitative and quantitative case study data to appraise the application of economic demand models in pluralistic low income settings. Primary data from Cape Town, South Africa, are used to interrogate three elements of the neoclassical paradigm: the budget constraint, utility function and underlying preference-sets, and hyper-rationality and the assumption of full information. The neoclassical budget constraint may be affected by changes in price or income. This dissertation explains how perceptions of quality, community context and fear of social sanction may affect the perceived price of service access. Community context and support networks also affect an individual's available financial resources although conventional demand models do not capture the income effect of payments made directly to providers by non-household members. According to ordinal utility theory, consumers must be able to rank various bundles of commodities according to the satisfaction they yield. This dissertation considers how perceived quality, fear of community sanction, illness type, awareness of different providers and the mismatch of supply with perceived need can affect the composition and ranking of those bundles. Finally, New Institutional Economics (NIB) utilises satisficing and less than full information instead of strict optimisation. This dissertation attempts to formalise the NIB contributions by describing common strategies for satisficing and considering how the household and community context of care seeking may effect service use. A number of empirical and methodological techniques are used to estimate demand functions and move theory into practice. Longitudinal health diaries are used to collect data on health service use, expenditure and self-rated health. The data are analysed using panel data methods. The findings illustrate that, without a better understanding of demand-side barriers to effective diagnosis and treatment, curtailing the spread and impact of communicable diseases in pluralistic, low income settings will be difficult if not impossible.

When patients present with complaints of anxiety or depression, providers in the primary care setting often prescribe anxiolytics or antidepressants without conducting an early emotional trauma or adverse childhood experiences assessment. Several studies demonstrate the link between early emotional trauma (EET) or adverse childhood experiences (ACEs) and the increased risk of anxiety or depression as adults. This Clinical Scholarly Project (CSP) implemented the use of the Adverse Childhood Experience (ACE) Questionnaire with patients who had a diagnosis of anxiety or depression in the primary care setting to increase patient access to resources and align clinical practice with practice guidelines. Participants included eight primary care providers, 30 patients and 21 chart review patients. The CSP utilized a quasi-experimental design to determine if the use of the ACE Questionnaire by patients with anxiety or depression would result in patients receiving more community resources (to include counseling), strengthen the provider-patient relationship, increase provider comfort in discussing ACEs with their patients and result in patients receiving care that was evidence based. Patient sample participants received significantly more resources (M = 8.27, SD = 2.27) than the chart audit sample (M = 0.90, SD = 0.30). Patient sample members received an average of eight resources (M = 8.27) and utilized an average of five resources (M = 5.07). Use of the ACE Questionnaire resulted in more trust in provider-patient relationship by patients (80.0%) and the majority of the provider sample more comfortable discussing ACEs after the project (85.7%).

Master of Public Health - MPH
Background: HIV remains a global concern. Consequently, global institutions such as the World Health Organisation (WHO) and United Nations Programme on HIV and AIDS (UNAIDS) continue to work towards ending HIV/AIDS by facilitating innovative strategies to improve service delivery of antiretroviral therapy (ART). In 2016 WHO issued the ‘test and treat’ policy recommendation in line with the UNAIDS 2020, 90-90-90 target of reaching 90% people to know their HIV status, get 90% of these on ART treatment and to have 90% of those on treatment virally suppressed. Differentiated Care Models (DCMs) has been put in place for all stakeholders, from global, institutes, government departments and civil society to improve patient access to treatment and retention in care. While various evaluation studies have shown that DCMs improve the retention in care and adherence to medication behaviours of patients on ART, little is known about the patients’ experiences and preferences. The aim of the current study was to explore and compare the experiences of patients in three DCMs (Facility Adherence Clubs [FAC], Community Adherence Club [CAC] and Quick Pharmacy Pick-up [QPUP]) in a community health care facility in a township in Cape Town, South Africa. Methods: An exploratory qualitative study design was used. Data were collected through semi-structured interviews (12) and focus group discussions (6) with purposively selected participants from six DCMs. Thematic analysis was done using Atlas.ti version 8.0. Results: Patients found DCMs easily accessible and convenient and presented positive experiences in relation to the National Health Services (NHS) patients experience principles. FACs and CAC presented attributes of patient-centeredness as prescribed by the NHI. We found that the QPUP model fell short on attributes of patient-centeredness such as coordination and integration of care, information sharing, communication and education, and emotional/psychological support. Conclusions: The principles of DCMs acknowledge the diversity and preference of PLHIV in addressing the barriers they face in accessing ART while empowering these patients to self-manage their disease. Understanding the experiences of patients using DCMs could improve our understanding of how DCMs promote self-management among PLHIV (or not) and some of the challenges faced by the patients using these care models. This understanding could inform strategies to tailor ART delivery services that suit the patients’ needs and enhance their abilities to achieve optimal retention in care and viral suppression.

Background: More than 6.7 million people in Canada experience a mental illness during a one-year period. Mental illnesses are highly influenced by the determinants of health, which are the social, economic, and physical environments that contribute to an individual’s health status. Addressing mental illnesses requires a population health approach involving joint action across multiple sectors to focus on the determinants of health. This thesis examines the extent to which Primary Care (PC) and Public Health (PH) collaborations incorporated a population health approach to address mental illnesses. Methods: A secondary analysis of data collected through a multi-province (British Columbia, Ontario, Nova Scotia) study that examined factors related to strengthening primary health care through PC and PH collaboration was conducted. Focus group data from four cases of PC-PH collaborations that addressed mental health were used to examine whether mental health activities incorporated a population health approach, as well as to identify the enablers and barriers to carrying out the activities. A qualitative descriptive approach and thematic analysis were used. A coding framework and themes were developed deductively, based on the Public Health Agency of Canada’s population health framework, and through inductive analysis. Results: Twenty-nine themes and eighteen subthemes were identified that correspond to the Public Health Agency of Canada’s population health framework. Key enablers included working in a multidisciplinary team, addressing the determinants of health, and engaging the community. Key barriers were poor data systems, a lack of service integration, and a lack of action on demonstrating accountability for outcomes. Conclusions: Findings highlighted the relevance of a population health approach and demonstrate that certain aspects of the population health framework are more actionable than others in the area of mental health, thus identifying areas for the framework’s further development. The research also identifies enablers and barriers to conducting mental health activities, offering guidance on how to facilitate population health implementation. The results could help provide insight at the program and policy levels for PC and PH as well as other sectors related to collaborative strategies that could strengthen the delivery of mental health services by incorporating a population health approach.
Medicine, Faculty of
Graduate