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1
Weijer, Charles. "Selecting subjects for participation in clinical research : an empirical inquiry and ethical analysis." Thesis, National Library of Canada = Bibliothèque nationale du Canada, 1997. http://www.collectionscanada.ca/obj/s4/f2/dsk2/ftp02/NQ30414.pdf.
2
Duro, Charles. "Effects of Lifestyle Changes on the Health of African Americans With Type 2 Diabetes." ScholarWorks, 2017. https://scholarworks.waldenu.edu/dissertations/4362.
Abstract:
African Americans are adversely affected by Type 2 diabetes at a greater rate than their European American counterparts; however, research on the effects of Type 2 diabetes on African Americans is limited. Lifestyle modifications that include the incorporation of physical activity and dietary changes can help patients with Type 2 diabetes better manage their disease and improve their overall quality of health. The purpose of this phenomenological study was to explore the experiences of African Americans with Type 2 diabetes who incorporated these self-management behaviors, discerning if they had improved health and quality of life. The self-efficacy framework was applied to understand the research problem and interpret study results. An in-depth interview protocol was used to explore participants' perspectives and lived experiences in disease management. Interview transcripts and participant data were analyzed using a thematic-content-analysis approach. According to study findings, participants experienced physical activity and dietary changes, and their self-efficacy directly correlated with their experience of positive changes in their health status. Providing programs that support the adoption of healthy lifestyles for this population will help mitigate the later effects of diabetic complications. Implications for social change include the provision of strategies that will help in formulating programs and policies that will reduce diabetic complications and deaths due to complications.
3
Tiwari, Vikram. "Information sharing and coordinated capacity management in service delivery networks." [Bloomington, Ind.] : Indiana University, 2008. http://gateway.proquest.com/openurl?url_ver=Z39.88-2004&rft_val_fmt=info:ofi/fmt:kev:mtx:dissertation&res_dat=xri:pqdiss&rft_dat=xri:pqdiss:3331249.
Abstract:
Thesis (Ph.D.)--Indiana University, Kelley School of Business, 2008.Title from PDF t.p. (viewed on Jul 23, 2009). Source: Dissertation Abstracts International, Volume: 69-11, Section: A, page: 4414. Advisers: Kurt M. Bretthauer; Munirpallam A. Venkataramanan.
4
Lampman, Michelle Ann. "Assessment of the relationship between rural location and performance of Patient-Centered Medical Home processes among veterans health administration primary care clinics: an explanatory sequential mixed methods study." Diss., University of Iowa, 2016. https://ir.uiowa.edu/etd/3125.
Abstract:
The Patient-Centered Medical Home (PCMH) is a new model for primary care delivery intended to improve the care experience for both patients and providers, improve the health of populations, and reduce health care costs. Adopting the PCMH model into practice requires considerable investment of time and resources which often act as barriers for many small primary care practices; especially in rural areas. Few studies have examined performance of the PCMH model in rural clinics that have successfully implemented the model. It is important to obtain a comprehensive understanding of how context from the surrounding environment relates to implementation and performance of the model and whether there are differences between rural and urban primary care clinics.
This study used a sequential explanatory mixed methods approach to assess differences in performance of the Patient Aligned Care Team (PACT) model between rural and urban primary care clinics within the Veterans Health Administration (VHA). Generalized Estimating Equations with repeated measures were used to estimate associations between rurality and five process-oriented endpoints among a national sample of 891 VHA primary care clinics. Results indicate that, after adjusting for patient characteristics and clinic structural capacity, clinics located in large rural or small/isolated rural areas demonstrated difficulty with enhancing access through use of non-traditional encounters (i.e. telephone visits, group visits, or secured messaging) and facilitating care coordination through post-discharge follow-up compared to urban clinics. Findings also suggest that rural clinics were more likely to struggle to meet system-wide performance standards for these same two PACT-related processes than their urban counterparts.
A multiple-case study of five VHA primary care clinics was conducted to obtain a contextual understanding of the relationships between rurality and performance of PACT processes from the perspective of primary care staff engaged in PACT implementation. A comparison of the experiences of staff across the five cases revealed cross-cutting themes that are important to understanding the implementation and performance of PACT-related processes within these clinics. These themes included: both rural and urban clinics experience distance-related barriers; patient preferences and behavior impact performance of PACT-related processes; and primary care clinics experience frequent change. Findings from this qualitative assessment highlight the importance of understanding the unique context and circumstances experienced by each clinic and how they relate to performance and implementation of the PACT model. Insights gained through the qualitative assessment revealed that performance of PACT is influenced by complex relationships with both internal and external context. Combination of both quantitative and qualitative methods provided a more comprehensive understanding of these relationships beyond what could have been learned from a solitary assessment of standardized metrics by gaining additional context directly from the voices of those engaged in PACT care delivery.
Identifying differences in PACT performance between rural and urban clinics calls attention to the possibility of unique advantages and challenges for PACTs delivering care to rural patients which need further exploration. Findings from this study contribute to the current understanding of PCMH implementation in rural settings by moving beyond the barriers related to structural capacity to performance of processes aligned with PCMH principles. More widespread implementation of PCMH will require additional attention to the complex relationships between the PCMH and surrounding context in order for primary care practices to successfully implement the model.
5
Castora-Binkley, Melissa. "The Impact of the Veterans Health Administration's Home Based Primary Care on Health Services Use, Expenditures, and Mortality." Scholar Commons, 2015. https://scholarcommons.usf.edu/etd/5457.
Abstract:
Background: Among patients with multiple chronic conditions, care coordination and integration remains one of the major challenges facing the U.S. health care system. A home-based, patient-centered primary care program has been offered through the Veterans Health Administration (VHA) since the 1970s for frail veterans who have difficulty accessing VHA clinics. The VHA Home Based Primary Care (VHA HBPC) aims to integrate primary care, rehabilitation, disease management, palliative care, and coordination of care for frail individuals with complex, chronic diseases within their homes. Early research suggested that VHA HBPC was associated with positive outcomes (e.g., reduced resource use and patient satisfaction). However, evidence regarding the effect of the VHA HBPC program on health services use (especially hospital and nursing home use), expenditures, and other patient outcomes remains limited. The present study is designed to fill this gap as the rise in the number of veterans with complex health care needs will likely increase in the coming decades.
Objectives: The current study aimed to examine the impact of VHA HBPC on health services use, expenditures, and mortality among a cohort of new VHA HBPC enrollees identified in the national VHA data system. The specific aims of this study were: 1) to examine the effect of VHA HBPC on major health service use (hospital, nursing home, and outpatient care) paid for by the Veterans Administration; 2) to examine the effect of VHA HBPC on total health services expenditures; and 3) to examine whether VHA HBPC enrollees experienced similar mortality and survival as compared to a matched concurrent cohort.
Methods: This study used a retrospective cohort design. A new VHA HBPC enrollee cohort (the treatment group) and a propensity matched comparison cohort (the comparison group) were identified from VHA claims in fiscal years (FY) 2009 and 2010 and were followed through FY 2012. Data on health service use, expenditures, and mortality/survival data were obtained via the VHA administrative datasets (i.e., Decision Support System, Purchased Care, and Vital Status Files). Propensity scores of being enrolled in the VHA HBPC were generated by a logistic regression model controlling for potential confounders. After 41,244 matched pairs were determined adequate through several diagnostic methods, means tests, relative risk analyses, and generalized linear models were used to estimate the effect of VHA HBPC on outcomes. Additionally, a Cox proportional hazards regression model was used to estimate the effect of VHA HBPC on survival. Subgroup analyses were conducted stratifying by age (85 and older), comorbidities (2 or more), and the receipt of palliative care. Based on the results of the original analyses, a series of sensitivity analyses were conducted that modified the described sample selection criteria and matching algorithm.
Results: Analyses of the original cohort revealed that VHA HBPC patients had significantly higher risks of being admitted into a hospital (RR 1.53, 95% CI 1.51-1.56) or nursing home (RR 1.65, CI 1.50 - 1.81). The average total expenditures during the study period were significantly higher for the VHA HBPC group as compared to the control group ($85,808 vs. $44,833, respectively; p < .001). In terms of mortality and survival, VHA HBPC enrollees had higher mortality (RR 1.45, CI 1.43 - 1.47), and shorter survival (HR 1.89, CI 1.86 - 1.93) as compared to those in the comparison group. Subgroup analyses found that these relationships generally remained when stratified by age 85 or older or having two or more comorbidities. However, for those who received palliative care, VHA HBPC participants had significantly lower risk of VHA hospitalization overall (RR 0.84, CI 0.81 - 0.87) and immediately prior to death. Finally, exploratory post-hoc analysis suggested that VHA HBPC recipients were at higher risk of VHA hospitalization at 30 (RR 1.11, CI 1.06 - 1.16), 60 (RR 1.16, CI 1.11 - 1.20), and 90 days (RR 1.16, 1.12 - 1.21) prior to death relative to the comparison group. After selecting only those that had a baseline hospitalization and refining the matching algorithm to account for time to death and additional comorbidities, VHA HBPC participants who had been enrolled in the program for at least six months had lower risks for hospital (RR 0.89, CI 0.88 - 0.90) and nursing home admissions (RR 0.74, CI 0.67 - 0.81). However, total expenditures remained significantly higher among those in VHA HBPC relative to the comparison group ($89,761 vs. $85,371, respectively; p < .001).
Discussion: This study found that without accounting for important covariates such as initial hospitalization, time to death, and a range of comorbidities, VHA HBPC was associated with higher health service use, higher expenditures, higher mortality, and shorter survival as compared to a similar group of patients not receiving VHA HBPC. After accounting for these factors, VHA HBPC was associated with a lower risk of nursing home use, and after six months, VHA HBPC was associated with lower risk of both nursing home and hospital use. These findings suggest that while VHA HBPC may improve quality of life and patient satisfaction through patient-centered integrated primary care, it may not generate cost savings for the healthcare system. Future research is needed to understand variation in program implementation and how this affects the impact of VHA HBPC on service use and cost.
6
KRZYWKOWSKI-MOHN, SARA M. EdD. "Diabetic Control and Patient Perception of the Scheduled In Group Medical Appointment at the Cincinnati Veterans Administration Medical Center." University of Cincinnati / OhioLINK, 2008. http://rave.ohiolink.edu/etdc/view?acc_num=ucin1210103113.
7
Weigel, Paula Anne Michel. "The comparative effectiveness of chiropractic on function, health, depressive symptoms, and satisfaction with care among medicare beneficiaries." Diss., University of Iowa, 2014. https://ir.uiowa.edu/etd/4791.
Abstract:
Musculoskeletal complaints are one of the most common reasons for visits to medical and chiropractic professionals in the United States, and spine-related symptoms in particular comprise the largest share of these complaints. Spine-related conditions increase as people age, having implications for rising disability and consequent spending by Medicare and Medicaid on increased health services use and long-term services and support. Chiropractic is one type of treatment used by older adults with these types of health problems. Covered by Medicare since 1972, chiropractic spinal manipulation is allowed for the express purpose to arrest the progression of functional decline or restore and possibly improve patient function. No studies, however, have examined whether chiropractic use by Medicare beneficiaries has indeed arrested functional decline, delayed disability, or restored health. The purpose of this dissertation research is to examine the comparative effectiveness of chiropractic use relative to no treatment and alternative medical care on the health and functional trajectories of community-dwelling older adults. I also examine the comparative effect of chiropractic on satisfaction with care. This is accomplished through the use of two longitudinal surveys with representative Medicare populations linked to Medicare provider claims. The first analysis examines the long-term comparative effect of chiropractic relative to no use and alternative care on functional decline, self-rated health decline, and the onset of additional depressive symptoms in a cohort of older Medicare beneficiaries, both with and without back conditions. The second study examines the effect of chiropractic compared to medical only episodes of care on health and functional decline in an older adult population with uncomplicated back conditions over a two-year period. The third and final study examines the comparative effect of chiropractic relative to medical care only on one-year changes in function, self-rated health, and satisfaction with care in a nationally representative age-eligible Medicare population with spine-related musculoskeletal conditions.
Study results suggest that chiropractic has a consistently protective effect when compared to routine alternative medical care against decline in function among older adults with spine-related conditions, both over the long-term and the short-term. Chiropractic also has a comparative protective effect against decline in self-rated health in the short-term, but has no differential effect on the onset of depressive symptoms either in the short-term or long-term . Medicare beneficiaries using chiropractic for spine-related health conditions are relatively more satisfied than those using medical care only with the information provided to them about their condition, and with follow-up care provided after the initial visit.
This research is the first of its kind to examine the comparative effectiveness of chiropractic relative to other usual sources of care for Medicare beneficiaries, in general and specifically among those with spine-related conditions, finding that chiropractic use has a comparatively beneficial effect on function, health, and satisfaction with care. The results have important policy implications for clinicians, patients, and Medicare because of the potential to shift clinical practice away from technologically intense and expensive treatments toward therapies like chiropractic spinal manipulation that demonstrate a comparative advantage in preserving health and function among older adults.
8
DePuccio, Matthew J. "Examining How Primary Care Team Structures are Used and Their Effect on Cross-Disciplinary Relationships: A Qualitative Study." VCU Scholars Compass, 2019. https://scholarscompass.vcu.edu/etd/6071.
Abstract:
Team-based primary care is an innovative care delivery model that has the potential to improve access to comprehensive, coordinated, and high-quality patient care. It is understood that in order for primary care teams to work effectively, health care providers must work across disciplinary boundaries and develop strong relationships that enable them to coordinate their roles and expertise. This research investigated how health care providers make use of different team structures (i.e., tools) to manage their interdependent work, enabling them to deliver team-based primary care. This research also examined how team structures influence the intra-team relationships important for coordinating care. By exploring the different ways primary care teams enact team structures, this research identifies ways primary care teams use team structures differently to address the needs of patients and coordinate team-based care.
In-person interviews were conducted at 7 primary care clinics participating in a population health management program in a southeastern city in the United States. Research participants from various health care disciplines (e.g., medicine, nursing, social work) were asked to describe their experiences delivering team-based primary care. Interviews were recorded, transcribed, and analyzed. Data were analyzed using a constant comparative approach in order to investigate how different team structures were used to address the needs of patients and the challenges of delivering team-based primary care.
The data suggested that primary care teams enact structures in different ways. In some teams, huddles were used to anticipate the specific needs of patients and coordinating care, referrals occurred via warm handoffs with co-located providers, and protocols were used to facilitate collaborative problem-solving. In other clinics, huddles were focused on clinic operations, referrals were performed using traditional methods (e.g., phone calls), and protocols were used to guide task delegation. Participants in some clinics described how team huddles were used to leverage high-quality relationships by fostering respectful interactions between team members. More research is needed to determine whether the use of patient-focused huddles, warm handoffs, and protocols that initiate problem-solving is associated with better patient outcomes, particularly for patient populations with complex medical and non-medical needs.
9
Leon, de la Barra Sophia. "Building research capacity for indigenous health : a case study of the National Health and Medical Research Council : the evolution and impact of policy and capacity building strategies for indigenous health research over a decade from 1996 to 2006." University of Sydney, 2007. http://hdl.handle.net/2123/3538.
Abstract:
Master of PhilosophyAs Australia’s leading agency for funding health research (expending over $400 million in 2006), the National Health and Medical Research Council (NHMRC) has a major responsibility to improve the evidence base for health policy and practice. There is an urgent need for better evidence to guide policy and programs that improve the health of Indigenous peoples. In 2002, NHMRC endorsed a series of landmark policy changes to acknowledge its ongoing role and responsibilities in Indigenous health research—adopting a strategic Road Map for research, improving Indigenous representation across NHMRC Council and Principal Committees, and committing 5% of its annual budget to Indigenous health research. This thesis examines how these policies evolved, the extent to which they have been implemented, and their impact on agency expenditure in relation to People Support. Additionally, this thesis describes the impact of NHMRC policies in reshaping research practices among Indigenous populations.
10
Leung, Yat (Gary) Hung. "Behavioral Health Disorders and the Quality of Diabetes Care: A Dissertation." eScholarship@UMMS, 2010. https://escholarship.umassmed.edu/gsbs_diss/456.
Abstract:
Both diabetes and behavioral health disorders (mental and substance use disorders) are significant health issues in the United States. While previous studies have shown worse health outcomes in people with diabetes and co-occurring behavioral health disorders (BHDs) than those with diabetes alone, it is unclear whether the quality of diabetes care was poorer in the presence of co-occurring BHDs. Although previous research has observed a trend of positive outcomes in people with comprehensive diabetes care, there is a lack of evidence about whether that mode of care delivery can improve outcomes in people with co-occurring BHDs. Therefore, further studies are necessary.
Using a combined dataset from Medicare and Medicaid claims for Massachusetts residents, this study compared the quality of diabetes care (e.g., having at least 1 hemoglobin A1c test) and diabetes outcomes (e.g., eye complications) among Medicare and Medicaid beneficiaries with diabetes and co-occurring BHDs to those with diabetes alone in Massachusetts in 2005. The results showed a mixed picture on the relationships between BHDs and diabetes outcomes. While substance use disorders had adverse impact on adherence to quality measures (e.g., 20% less likely to attain full adherence, p0.05).
Findings from this dissertation research suggest that disparities exist in the quality of diabetes care and health outcomes between people with substance use disorders and those without. The mode of care delivery needs to be further examined so that interventions can be designed to improve the outcomes of people with diabetes.
11
Campbell, William W. III. "A COMPARISON OF QUALITY INDICATORS BETWEEN MEDICARE ACCOUNTABLE CARE ORGANIZATIONS AND HEALTH MAINTENANCE ORGANIZATIONS USING PUBLICLY AVAILABLE DATA." VCU Scholars Compass, 2018. https://scholarscompass.vcu.edu/etd/5284.
Abstract:
The purpose of this study is to explore differences in quality between Medicare Accountable Care Organizations (ACO) and Health Maintenance Organizations (HMO). Three outcomes measures reported by these plans use different methodologies but possess enough alignment to permit comparison: percent of diabetic patients with last HbA1c > 9.0%, colon cancer screening rate and ER visits per 1,000. These outcomes are the dependent variables (DV). A secondary purpose is to explore differences in quality based on the size of the beneficiary population served, using the same measures.
As the Medicare program faces threats to its solvency in coming decades, with 10,000 baby boomers becoming eligible every day, and the ongoing national conversation about healthcare more generally, approaches to Value-Based Purchasing (VBP) are becoming more common. Organizations seeking to identify the types of VBP arrangements in which they should enter have precious little information on the comparative performance of VBP approaches relative to outcomes measures. Different structures create different incentives through the plan design and risk/reward. The convergence or dissipation of the plan incentives at the level of the provider, particularly in primary care, may be a source of variance.
This study is retrospective, non-experimental, and uses publicly available data on the performance of Medicare ACO and HMO plans in calendar year 2015, for the identified measures. Using the Donabedian Structure-Process-Outcome framework, this study explores the impact of structure by type of plan and size of population served, relative to the outcomes. Race, average Hierarchical Condition Category (HCC) risk score and duration of operations are control variables. The analysis uses multiple hierarchical regression to better understand the relationship between the independent variables (IV) and DVs, after the impact of the control variables (CV).
After controls, the IVs did offer some explanation of variation in outcomes. The ACO plans fared better on HbA1c control, while HMO plans had fewer ER visits per 1,000. No discernable difference existed between the HMO and ACO plans with regard to colon cancer screening rate. Serving larger populations led to better performance on all three measures. In general performance was worse on each measure in both models when the percent of not-White patients or average HCC risk score increased. A longer duration of operations also associated to better performance on the outcome measures.
12
Kerr, Karolyn. "The institutionalisation of data quality in the New Zealand health sector." Thesis, University of Auckland, 2006. http://hdl.handle.net/2292/1899.
Abstract:
This research began a journey towards improved maturity around data quality management in New Zealand health care, where total data quality management is 'business as usual" institutionalised into the daily practices of all those who work in health care. The increasingly information intensive nature of health care demands a proactive and strategic approach to data quality to ensure the right information is available to the right person at the right time in the right format, all in consideration of the rights of the patient to have his/her health data protected and used in an ethical way. The work extends and tests principles to establish good practice and overcome practical barriers. This thesis explores the issues that define and control data quality in the national health data collections and the mechanisms and frameworks that can be developed to achieve and sustain good data quality. The research is interpretive, studying meaning within a social setting. The research provides the structure for learning and potential change through the utilisation of action research. Grounded theory provides the structure for the analysis of qualitative data through inductive coding and constant comparison in the analysis phase of the action research iterative cycle. Participatory observation provided considerable rich data as the researcher was a member of staff within the organisation. Data were also collected at workshops, focus groups, structured meetings and interviews. The development of a Data Quality Evaluation Framework and a national Data quality Improvement Strategy provides clear direction for a holistic and 'whole of health sector' way of viewing data quality, with the ability for organisations to develop and implement local innovations through locally developed strategies and data quality improvement programmes. The researcher utilised the theory of appreciative enquiry (Fry, 2002) to positively encourage change, and to encourage the utilisation of existing organisational knowledge. Simple rules, such as the TDQM process and the data quality dimensions guided the change, leaving room for innovation. The theory of 'complex systems of adjustment' (Champagne, 2002; Stacey, 1993) can be instilled in the organisation to encourage change through the constant interaction of people throughout the organisation.
13
Lord, Tanya. "Early Detection and Treatment of Acute Clinical Decline in Hospitalized Patients: An Observational Study of ICU Transfers and an Assessment of the Effectiveness of a Rapid Response Program: A Dissertation." eScholarship@UMMS, 2011. https://escholarship.umassmed.edu/gsbs_diss/561.
Abstract:
The Institute for Healthcare Improvement (IHI) has promoted implementing a RRS to provide safer care for hospitalized patients. Additionally, the Joint Commission made implementing a RRS a 2008 National Patient Safety Goal. Although mandated, the evidence to support the effectiveness of a RRS to reduce cardiac arrests on hospital medical or surgical floors and un-anticipated ICU transfers remains inconclusive, partly because of weak study designs and partly due to a failure of published studies to report all critical aspects of their intervention. This study attempted to evaluate the effectiveness and the implementation of a RRS on the two campuses of the UMass Memorial Medical Center (UMMMC).
The first study presented was an attempt to identify the preventability and timeliness of floor to ICU transfers. This was done using 3 chief residents who reviewed 100 randomly selected medical records. Using Cohen’s kappa to assess the inter-rater reliability it was determined that 13% of the cases could have possibly been preventable with earlier intervention.
The second study was an evaluation of the effectiveness of the Rapid Response System. Outcomes were cardiac arrests, code calls and floor to ICU admissions. There were two study periods 24 months before the intervention and 24 months after. A Spline regression model was used to compare the two time periods. Though there was a consistent downward trend over all 4 years there were no statistically significant changes in the cardiac arrests and ICU transfers when comparing the before and after periods. There was a significant reduction in code calls to the floors on the University campus.
The third study was a modified process evaluation of the Rapid Response intervention that will assess fidelity of RRS implementation, the proportion of the intended patient population that is reached by the RRS, the overall number of RRS calls implemented (dose delivered) and the perceptions of the hospital staff affected by the RRS with respect to acceptability and satisfaction with the RRS and barriers to utilization. The process evaluation showed that that the Rapid Response System was for the most part being used as it was designed, though the nurses were not using the specific triggers as a deciding factor in making the call. Staff satisfaction with the intervention was very high.
Overall these studies demonstrated the difficulty in clearly defining outcomes and data collection in a large hospital system. Additionally the importance of different study designs and analysis methods are discussed.
14
Baughman, Margaret C. "Consumer Participation in Identifying Barriers to Ohio's Adolescent Alcohol and Drug Treatment Services." University of Akron / OhioLINK, 2009. http://rave.ohiolink.edu/etdc/view?acc_num=akron1259624734.
15
Lines, Lisa M. "Outpatient Emergency Department Utilization: Measurement and Prediction: A Dissertation." eScholarship@UMMS, 2014. https://escholarship.umassmed.edu/gsbs_diss/710.
Abstract:
Approximately half of all emergency department (ED) visits are primary-care sensitive (PCS) – meaning that they could potentially be avoided with timely, effective primary care. Reducing undesirable types of healthcare utilization (including PCS ED use) requires the ability to define, measure, and predict such use in a population.
In this retrospective, observational study, we quantified ED use in 2 privately insured populations and developed ED risk prediction models. One dataset, obtained from a Massachusetts managed-care network (MCN), included data from 2009-11. The second was the MarketScan database, with data from 2007-08. The MCN study included 64,623 individuals enrolled for at least 1 base-year month and 1 prediction-year month in Massachusetts whose primary care provider (PCP) participated in the MCN. The MarketScan study included 15,136,261 individuals enrolled for at least 1 base-year month and 1 prediction-year month in the 50 US states plus DC, Puerto Rico, and the US Virgin Islands.
We used medical claims to identify principal diagnosis codes for ED visits, and scored each according to the New York University Emergency Department algorithm. We defined primary-care sensitive (PCS) ED visits as those in 3 subcategories: nonemergent, emergent but primary-care treatable, and emergent but preventable/avoidable.
We then: 1) defined and described the distributions of 3 ED outcomes: any ED use; number of ED visits; and a new outcome, based on the NYU algorithm, that we call PCS ED use; 2) built and validated predictive models for these outcomes using administrative claims data; 3) compared the performance of models predicting any ED use, number of ED visits, and PCS ED use; 4) enhanced these models by adding enrollee characteristics from electronic medical records, neighborhood characteristics, and payor/provider characteristics, and explored differences in performance between the original and enhanced models.
In the MarketScan sample, 10.6% of enrollees had at least 1 ED visit, with about half of utilization scored as PCS. For the top risk group (those in the 99.5th percentile), the model’s sensitivity was 3.1%, specificity was 99.7%, and positive predictive value (PPV) was 49.7%. The model predicting PCS visits yielded sensitivity of 3.8%, specificity of 99.7%, and PPV of 40.5% for the top risk group.
In the MCN sample, 14.6% (±0.1%) had at least 1 ED visit during the prediction period, with an overall rate of 18.8 (±0.2) visits per 100 persons and 7.6 (±0.1) PCS ED visits per 100 persons. Measuring PCS ED use with a threshold-based approach resulted in many fewer visits counted as PCS, discarding information unnecessarily. Out of 45 practices, 5 to 11 (11-24%) had observed values that were statistically significantly different from their expected values. Models predicting ED utilization using age, sex, race, morbidity, and prior use only (claims-based models) had lower R2 (ranging from 2.9% to 3.7%) and poorer predictive ability than the enhanced models that also included payor, PCP type and quality, problem list conditions, and covariates from the EMR, Census tract, and MCN provider data (enhanced model R2 ranged from 4.17% to 5.14%). In adjusted analyses, age, claims-based morbidity score, any ED visit in the base year, asthma, congestive heart failure, depression, tobacco use, and neighborhood poverty were strongly associated with increased risk for all 3 measures (all P<.001).
16
Lines, Lisa M. "Outpatient Emergency Department Utilization: Measurement and Prediction: A Dissertation." eScholarship@UMMS, 2004. http://escholarship.umassmed.edu/gsbs_diss/710.
Abstract:
Approximately half of all emergency department (ED) visits are primary-care sensitive (PCS) – meaning that they could potentially be avoided with timely, effective primary care. Reducing undesirable types of healthcare utilization (including PCS ED use) requires the ability to define, measure, and predict such use in a population.
In this retrospective, observational study, we quantified ED use in 2 privately insured populations and developed ED risk prediction models. One dataset, obtained from a Massachusetts managed-care network (MCN), included data from 2009-11. The second was the MarketScan database, with data from 2007-08. The MCN study included 64,623 individuals enrolled for at least 1 base-year month and 1 prediction-year month in Massachusetts whose primary care provider (PCP) participated in the MCN. The MarketScan study included 15,136,261 individuals enrolled for at least 1 base-year month and 1 prediction-year month in the 50 US states plus DC, Puerto Rico, and the US Virgin Islands.
We used medical claims to identify principal diagnosis codes for ED visits, and scored each according to the New York University Emergency Department algorithm. We defined primary-care sensitive (PCS) ED visits as those in 3 subcategories: nonemergent, emergent but primary-care treatable, and emergent but preventable/avoidable.
We then: 1) defined and described the distributions of 3 ED outcomes: any ED use; number of ED visits; and a new outcome, based on the NYU algorithm, that we call PCS ED use; 2) built and validated predictive models for these outcomes using administrative claims data; 3) compared the performance of models predicting any ED use, number of ED visits, and PCS ED use; 4) enhanced these models by adding enrollee characteristics from electronic medical records, neighborhood characteristics, and payor/provider characteristics, and explored differences in performance between the original and enhanced models.
In the MarketScan sample, 10.6% of enrollees had at least 1 ED visit, with about half of utilization scored as PCS. For the top risk group (those in the 99.5th percentile), the model’s sensitivity was 3.1%, specificity was 99.7%, and positive predictive value (PPV) was 49.7%. The model predicting PCS visits yielded sensitivity of 3.8%, specificity of 99.7%, and PPV of 40.5% for the top risk group.
In the MCN sample, 14.6% (±0.1%) had at least 1 ED visit during the prediction period, with an overall rate of 18.8 (±0.2) visits per 100 persons and 7.6 (±0.1) PCS ED visits per 100 persons. Measuring PCS ED use with a threshold-based approach resulted in many fewer visits counted as PCS, discarding information unnecessarily. Out of 45 practices, 5 to 11 (11-24%) had observed values that were statistically significantly different from their expected values. Models predicting ED utilization using age, sex, race, morbidity, and prior use only (claims-based models) had lower R2 (ranging from 2.9% to 3.7%) and poorer predictive ability than the enhanced models that also included payor, PCP type and quality, problem list conditions, and covariates from the EMR, Census tract, and MCN provider data (enhanced model R2 ranged from 4.17% to 5.14%). In adjusted analyses, age, claims-based morbidity score, any ED visit in the base year, asthma, congestive heart failure, depression, tobacco use, and neighborhood poverty were strongly associated with increased risk for all 3 measures (all P<.001).
17
Rickard, Megan L. "Public school superintendents' perceptions of schools assisting students in obtaining health insurance." Toledo, Ohio : University of Toledo, 2010. http://rave.ohiolink.edu/etdc/view?acc%5Fnum=toledo1262895549.
Abstract:
Dissertation (Ph.D.)--University of Toledo, 2010.Typescript. "Submitted to the Graduate Faculty as partial fulfillment of the requirements for the Doctor of Philosophy Degree in Health Education." "A dissertation entitled"--at head of title. Title from title page of PDF document. Bibliography: p. 160-181.
18
Tolliver, Robert M. "Using the Theory of Planned Behavior to Predict Executives’ Intentions to Hire Psychologists in Federally Qualified Health Centers." Digital Commons @ East Tennessee State University, 2016. https://dc.etsu.edu/etd/3123.
Abstract:
Health psychologists with training in integrated care are ideal candidates to work in Federally Qualified Health Centers (FQHCs). However, despite the large documented need for more behavioral health providers in FQHCs, psychologists are underrepresented in this setting compared to other behavioral health professions. The purpose of this study was to: 1) examine the specific beliefs that are most relevant to executives’ intentions to hire psychologists, 2) determine how executives’ perceived control over hiring psychologists varies by several demographic variables, and 3) examine how well the Theory of Planned Behavior (TPB) predicts executives’ intentions to hire psychologists. Method: Executives (N = 222) from every US Census defined division of the country completed an online TBP survey assessing demographics and beliefs about hiring psychologists. Path analysis was used to examine the relationships between TPB variables. Results: Executives ranked psychologists as highly proficient in integrated care and general clinical skills but less proficient in research and leadership skills. Compared to other skills, executives ranked research skills as lower in importance for clinical staff to possess. Longer executive job tenures (but not FQHC budget or rural status) predicted more perceived control over hiring practices. The standard TPB was a poor fit with the data, but a modified version explained 78% of the variance in executives’ intent to hire psychologists. In this model, executives’ normative beliefs were most predictive of their intent to hire. Implications: Results point to the importance of internal champions within FQHCs who advocate for psychologists as well as the need for early interprofessional education. Opportunities exist for health service psychologists to promote the value of research to executives and to differentiate themselves by emphasizing their skills in research and implementation science.
19
Ellison, Jeffrey. "Collaborative Models of Care in the Appalachian Region of Tennessee: Examining Relationships Between Level of Collaboration, Clinic Characteristics, and Barriers to Collaboration." Digital Commons @ East Tennessee State University, 2014. https://dc.etsu.edu/etd/2435.
Abstract:
Decades of research have shown that there are significant advantages to maintaining close communicative and collaborative relationships between primary care and behavioral health providers. Fiscal, structural, and systemic barriers, however, often restrict the degree to which such interprofessional collaboration can occur. In the present study the authors examined relationships between primary care clinics in the Appalachian region’s characteristics (i.e., clinic type, rurality, and clinic size), barriers (i.e., fiscal, structural, and systemic) reported to using increased collaboration, and the level of collaboration used at a particular clinic.
For the present study 136 surveys were completed by providers working in primary care practices across the Appalachian region of Tennessee. The results showed that only about one fifth of the primary care clinics in Appalachian Tennessee reported engaging in moderate to high levels of primary care behavioral health (PCBH) collaboration (e.g., colocated or integrated models of care). Among community health clinics, however, nearly half reported moderate or high levels of collaboration.
The findings of this study underscore the importance policy change (e.g., changes in reimbursement patterns, increases in incentives, introduction of PCBH models in training programs) in facilitating the uptake of high levels of PCBH collaboration in Appalachian Tennessee (especially in regards to nonpublicly funded clinics). Further, the methodology used in this study could provide policymakers and researchers in other regions of the U.S. with a means for obtaining baseline data regarding local trends in PCBH collaboration and could serve as first step in developing a standardized methodology for comparing the overall uptake of PCBH collaboration models across regions.
20
Dobrzykowski, David D. "Linking Antecedents and Consequences of Value Density in the Healthcare Delivery Supply Chain." University of Toledo / OhioLINK, 2010. http://rave.ohiolink.edu/etdc/view?acc_num=toledo1289833170.
21
Jankowski-Wilkinson, Andrea Faye. "The Effects of Caffeine Gum Administration on Reaction Time and Lower Body Pain During Cycling to Exhaustion." University of Akron / OhioLINK, 2008. http://rave.ohiolink.edu/etdc/view?acc_num=akron1216942978.
22
Lucas, D. Pulane. "Disruptive Transformations in Health Care: Technological Innovation and the Acute Care General Hospital." VCU Scholars Compass, 2013. http://scholarscompass.vcu.edu/etd/2996.
Abstract:
Advances in medical technology have altered the need for certain types of surgery to be performed in traditional inpatient hospital settings. Less invasive surgical procedures allow a growing number of medical treatments to take place on an outpatient basis. Hospitals face growing competition from ambulatory surgery centers (ASCs). The competitive threats posed by ASCs are important, given that inpatient surgery has been the cornerstone of hospital services for over a century. Additional research is needed to understand how surgical volume shifts between and within acute care general hospitals (ACGHs) and ASCs. This study investigates how medical technology within the hospital industry is changing medical services delivery. The main purposes of this study are to (1) test Clayton M. Christensen’s theory of disruptive innovation in health care, and (2) examine the effects of disruptive innovation on appendectomy, cholecystectomy, and bariatric surgery (ACBS) utilization. Disruptive innovation theory contends that advanced technology combined with innovative business models—located outside of traditional product markets or delivery systems—will produce simplified, quality products and services at lower costs with broader accessibility. Consequently, new markets will emerge, and conventional industry leaders will experience a loss of market share to “non-traditional” new entrants into the marketplace. The underlying assumption of this work is that ASCs (innovative business models) have adopted laparoscopy (innovative technology) and their unification has initiated disruptive innovation within the hospital industry. The disruptive effects have spawned shifts in surgical volumes from open to laparoscopic procedures, from inpatient to ambulatory settings, and from hospitals to ASCs. The research hypothesizes that: (1) there will be larger increases in the percentage of laparoscopic ACBS performed than open ACBS procedures; (2) ambulatory ACBS will experience larger percent increases than inpatient ACBS procedures; and (3) ASCs will experience larger percent increases than ACGHs. The study tracks the utilization of open, laparoscopic, inpatient and ambulatory ACBS. The research questions that guide the inquiry are: 1. How has ACBS utilization changed over this time? 2. Do ACGHs and ASCs differ in the utilization of ACBS? 3. How do states differ in the utilization of ACBS? 4. Do study findings support disruptive innovation theory in the hospital industry? The quantitative study employs a panel design using hospital discharge data from 2004 and 2009. The unit of analysis is the facility. The sampling frame is comprised of ACGHs and ASCs in Florida and Wisconsin. The study employs exploratory and confirmatory data analysis. This work finds that disruptive innovation theory is an effective model for assessing the hospital industry. The model provides a useful framework for analyzing the interplay between ACGHs and ASCs. While study findings did not support the stated hypotheses, the impact of government interventions into the competitive marketplace supports the claims of disruptive innovation theory. Regulations that intervened in the hospital industry facilitated interactions between ASCs and ACGHs, reducing the number of ASCs performing ACBS and altering the trajectory of ACBS volume by shifting surgeries from ASCs to ACGHs.
23
Pham, Tan Phu. "Differences in Access to Care and Healthcare Utilization Among Sexual Minorities: A Master's Thesis." eScholarship@UMMS, 2014. https://escholarship.umassmed.edu/gsbs_diss/719.
Abstract:
BACKGROUND: The barriers in accessing healthcare for gay, lesbian and bisexuals individuals are not well explored. These challenges as well as a lack of knowledge concerning this understudied group has prompted the Institute of Medicine to create a research agenda to build a foundational understanding of gay, lesbian and bisexual health and the barriers they encounter.1 the primary aim of this study will be to compare the differences in health care access and utilization between gay/lesbian, bisexual and heterosexual individuals using a large, nationally representative dataset of the U.S. population.
METHODS: Data from 2001 to 2012 from the National Health and Nutrition Examination Survey was pooled. Using logistic regression, we calculated the unadjusted and adjusted odds ratios of having health insurance, having a routine place and seeing a provider at least one in the past year.
RESULTS: We found that gay men were more likely to have health insurance coverage (ORadj:2.13 95%CI: 1.15,3.92), while bisexual men were at a small disadvantage in having health insurance coverage (ORadj:0.82 95%CI: 0.46,1.46). Bisexual men were more likely to have received health care in the past 12 months (ORadj:3.11 95%CI: 1.74,5.55). Lesbian women were less likely to have health insurance coverage (ORadj-lesbian:0.58 95%CI: 0.34,0.97).
CONCLUSION: This study contributed to the limited knowledge on understanding the health care access and utilization among gay, lesbian and bisexual individuals, which was classified as a high priority by the Institute of Medicine. Expanding health insurance coverage through the Affordable Care Act and Universal Partnership Coverage may reduce the disparities among gay, lesbian and bisexual individuals.
24
Pham, Tan Phu. "Differences in Access to Care and Healthcare Utilization Among Sexual Minorities: A Master's Thesis." eScholarship@UMMS, 2006. http://escholarship.umassmed.edu/gsbs_diss/719.
Abstract:
BACKGROUND: The barriers in accessing healthcare for gay, lesbian and bisexuals individuals are not well explored. These challenges as well as a lack of knowledge concerning this understudied group has prompted the Institute of Medicine to create a research agenda to build a foundational understanding of gay, lesbian and bisexual health and the barriers they encounter.1 the primary aim of this study will be to compare the differences in health care access and utilization between gay/lesbian, bisexual and heterosexual individuals using a large, nationally representative dataset of the U.S. population.
METHODS: Data from 2001 to 2012 from the National Health and Nutrition Examination Survey was pooled. Using logistic regression, we calculated the unadjusted and adjusted odds ratios of having health insurance, having a routine place and seeing a provider at least one in the past year.
RESULTS: We found that gay men were more likely to have health insurance coverage (ORadj:2.13 95%CI: 1.15,3.92), while bisexual men were at a small disadvantage in having health insurance coverage (ORadj:0.82 95%CI: 0.46,1.46). Bisexual men were more likely to have received health care in the past 12 months (ORadj:3.11 95%CI: 1.74,5.55). Lesbian women were less likely to have health insurance coverage (ORadj-lesbian:0.58 95%CI: 0.34,0.97).
CONCLUSION: This study contributed to the limited knowledge on understanding the health care access and utilization among gay, lesbian and bisexual individuals, which was classified as a high priority by the Institute of Medicine. Expanding health insurance coverage through the Affordable Care Act and Universal Partnership Coverage may reduce the disparities among gay, lesbian and bisexual individuals.
25
Modayil, Maria I. "Global Health Experiences in the Development of Healthcare Professionals." Ohio University / OhioLINK, 2020. http://rave.ohiolink.edu/etdc/view?acc_num=ohiou1597416179932742.
26
Walker, Lauryn. "Patient-Centered Medical Homes and Hospital Value-Based Purchasing: Investigating Provider Responses to Incentives." VCU Scholars Compass, 2019. https://scholarscompass.vcu.edu/etd/5796.
Abstract:
Provider incentives are a commonly used policy tool to mold provider behaviors.1 However, while we frequently measure the change in patient outcomes, failure to consistently produce changes in outcomes does not mean that providers are not changing their behavior. This paper focuses on two programs with null or inconsistent quality outcomes to try to identify why such inconsistency occurs. The two programs, both ratified in the Affordable Care Act, are 1) patient-centered medical homes (PCMHs), and 2) the Medicare Hospital Value-Based Purchasing (HVBP) program.
Chapter 1: Using data from the Medical Expenditure Panel survey (MEPS), I match provider characteristic surveys to member experience with care in order to evaluate characteristics key to patient-centered medical homes. I find that patient-perceived patient-centeredness of a practice is not related to the number of PCMH attributes a practice reports. However, some characteristics do play specific and significant roles in patient perception and outcomes. For instance, case management is not only associated with increased patient perception of after-hours access to care, but overall costs were reduced. Interestingly, having after hours clinic hours was more common with practices highly consistent with PCMH criteria, but these hours did not result in decreased emergency department use or cost of care.
Chapter 2: The second provider incentive studied is the Medicare Hospital Value-Based Purchasing Program (HVBP). This program assigns payment adjustments based on performance on a series of rotating quality metrics. To date, changes in patient outcomes cannot be attributed to the program; however, it should not be concluded that hospitals are not responding at all. I identify changes in staffing by provider type as an early indicator of hospital response to payment incentives. Data come from the Virginia Health Information (VHI) Hospital Cost Report, 2010-2017. Using a generalized linear model, I find that when receiving a penalty, hospitals reduce staffing among the most and least expensive personnel (physicians and nursing aides). Hospitals increase nursing and administrative staff following a bonus. These findings are consistent with hospitals responding to incentives both by aiming to improve efficient use of resources and maintain or improve quality of care.
Chapter 3: Finally, I assess potential unintended consequences of the HVBP program, specifically the provision of charity care. Using the VHI cost reports for year 2013 to 2017 with a regression discontinuity model, I find that hospitals receiving a bonus decrease their charity care among the lowest income patients (under 100% federal poverty level (FPL)). Hospitals receiving a penalty tend to reduce charity care among higher income patients (100%-200% FPL). These findings are consistent with two separate responses to the incentives. Hospitals receiving bonuses appear to be cream-skimming healthier, wealthier individuals while hospitals receiving penalties appear to be shifting the focus of their charity care to the most needy, likely in an effort to reduce cost of care levels overall while maintaining their community benefit programs, potentially as a result of goal gradient cognitive bias.
27
Marshall, Carol. "Modelling the shift in the balance of care in the NHS." Thesis, University of Stirling, 2013. http://hdl.handle.net/1893/20350.
Abstract:
The concept of Shifting the Balance of Care was first introduced to NHS Scotland in 2005 through the Kerr Report. The key messages from the report were to: ensure sustainable and safe local services, which are supported by the right skills, change the emphasis of care into the community, provide preventative reactive care, and fully integrate the system to tackle the changes, use technology more effectively, and involve the public in finding solutions to change. Following the report, a framework was developed which highlighted and prioritised eight areas of improvement. These areas for improvement are the focus by which this research examines if Operational Research (OR), specifically OR models, can have a positive impact in Shifting the Balance of Care. The research utilises underlying OR methodologies and methods and provides evidence from the literature of the ability of nine selected models to facilitate the Shift in the Balance of Care. A contributing factor to the research is the barriers to implementation of OR models into the NHS. With reference to the literature, the common barriers to implementation of OR models are categorised and used to provide direction to modellers where implementation barriers are more prevalent in some models than in others. The research also provides empirical evidence of three selected models’ (the Lean Methodology, Process Mapping and Simulation, developed over two Case Studies) ability to address and influence the prioritised Improvement Areas, with the addition of a newly developed model: SoApt. The development of SoApt follows the Principles of Model Development derived as a guide to modellers who wish to develop a new model. SoApt is also empirically explored in a Case Study and provides some evidence of the models ability to aid Decision-makers, faced with limited budgets, to choose between options which will Shift the Balance of Care. OR methods and methodologies are examined to ascertain the Roles of Models for each model explored in the Case Studies. Examination of the Roles of Models against the Improvement Areas provided evidence of a models’ ability to address more than one of the priority areas and that models can be used together or sequentially. In addition, with reference to OR methods and methodologies, a theoretical Evaluation Framework is proposed which suggests the User and User Satisfaction is key to the evaluation of a model’s success; positive experiences of the User and Use of the model may help to eliminate some of the barriers to implementation.
28
Levison-Johnson, Jody. "The Experience of Children's Mental Health Leaders During Times of Constraint: A Narrative Study." Antioch University / OhioLINK, 2020. http://rave.ohiolink.edu/etdc/view?acc_num=antioch1604218872367868.
29
Strömberg, Helén. "Sjukvårdens industrialisering : mellan curing och caring - sjuksköterskearbetets omvandling." Umeå: Univ, 2004. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-257.
30
Gopalakrishna-Remani, Venugopal. "Information Supply Chain System for Managing Rare Infectious Diseases." Kent State University / OhioLINK, 2012. http://rave.ohiolink.edu/etdc/view?acc_num=kent1341245050.
31
Theiss, Diana L. "Promoting Educational Well-Being for Foster Care Youth in Lucas County, Ohio: Exploring the Impact of Race, Age, and Service Provision on the Development of Human Capital." The Ohio State University, 2010. http://rave.ohiolink.edu/etdc/view?acc_num=osu1268077502.
32
Chen, Han-Yang. "Hospital Treatment Practices, 30-Day Hospital Readmissions, and Long-Term Prognosis in Patients Hospitalized with Acute Myocardial Infarction: A Dissertation." eScholarship@UMMS, 2015. http://escholarship.umassmed.edu/gsbs_diss/771.
Abstract:
Background: Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in the U.S. Acute myocardial infarction (AMI), with or without ST-segment elevation, is a common presentation of coronary heart disease and affected more than 800,000 American adults in 2010. The overall goal of this dissertation was to examine decade-long trends in the extent of delay in the receipt of a primary percutaneous coronary intervention (PCI) among patients hospitalized with ST-segment elevation myocardial infarction (STEMI), 30-day hospital readmission rates in patients having survived an AMI, and multiple decade long trends in 1-year post-hospital all-cause mortality, as well as factors associated with these outcomes, among patients hospitalized with AMI.
Methods: Data from the Worcester Heart Attack Study, a population-based chronic disease surveillance project that has been carried out among adult residents of the Worcester, MA, metropolitan area, hospitalized with AMI on a biennial basis from 1975 through 2009 at all medical centers in central MA, were used for this dissertation.
Results: Between 1999 and 2009, among patients hospitalized with STEMI, the likelihood of receiving a primary PCI within 90 minutes after emergency department arrival increased dramatically from 1999/2001 (11.6%) to 2007/2009 (70.5%). Between 1999 and 2009, among hospital survivors of an AMI, the 30-day all-cause rehospitalization rates decreased from 1999/2001 (20.3%) to 2007/2009 (16.7%). The overall cause-specific 30-day rehospitalization rates due to CVD, non-CVD, and AMI were 10.1%, 7.1%, and 1.8%, respectively, during the years under study. Between 1975 and 2009, among hospital survivors for a first AMI, the 1-year post-discharge mortality rates remained relatively stable from 1975-1984 (12.9%) to 1986-1997 (12.5%), but increased during 1999-2009 (15.8%). We identified several demographic, clinical and in-hospital treatment factors associated with an increased risk of failing to receive a primary PCI within 90 minutes after emergency department arrival, 30-day readmissions, and 1-year post-discharge mortality.
Conclusions: Our findings can hopefully lead to the enhanced development of innovative, patient-centered, intervention strategies which can further improve the treatment and transitions of care, as well as short and long-term prognosis, of men and women hospitalized with AMI.
33
Wilks, Chrisanne. "Factors Associated with Client Satisfaction at Community-based Mental Health Agencies in Ohio." The Ohio State University, 2015. http://rave.ohiolink.edu/etdc/view?acc_num=osu1448966548.
34
Fischer, Shira H. "Factors Associated with Ordering and Completion of Laboratory Monitoring Tests for High-Risk Medications in the Ambulatory Setting: A Dissertation." eScholarship@UMMS, 2011. https://escholarship.umassmed.edu/gsbs_diss/543.
Abstract:
Since the Institute of Medicine highlighted the devastating impact of medical errors in their seminal report, “To Err is Human” (2000), efforts have been underway to improve patient safety. A portion of medical errors are due to medication errors, and a large portion of these can be attributed to inadequate laboratory monitoring.
In this thesis, I attempt to address this small but important corner of this patient safety endeavor. Why are patients not getting their laboratory monitoring tests? Do they fail to complete them or do doctors not order the tests in the first place? Which prescribers and which patients are least likely to do what is needed for testing to happen and what interventions would be most promising?
To address these questions, I conducted a systematic review of existing interventions. I then proceeded with three aims: 1) To identify reasons that patients give for missing monitoring tests; 2) To identify patient and provider factors associated with monitoring test ordering; and 3) To identify patient and provider factors associated with completion of ordered testing.
To achieve these aims, I worked with patients and data at the Fallon Clinic. For aim 1, I conducted a qualitative analysis of their reasons for missing tests as well as reporting completion and ordering rates. For aims 2 and 3, I used electronic medical record data and conducted a regression with patient and provider characteristics as covariates to identify factors contributing to test ordering and completion.
Interviews revealed that patients had few barriers to completion, with forgetting being the most common reason for missing a test. The quantitative studies showed that: older patients with more interactions with the health care system were more likely to have tests ordered and were more likely to complete them; providers who more frequently prescribe a drug were more likely to order testing for it; and drug-test combinations that were particularly dangerous, indicated by a black box warning, were more likely to have appropriate ordering, though for these combinations, primary care providers were less likely to order tests appropriately, and patients were less likely to complete tests.
Taken together, my work can inform future interventions in laboratory monitoring and patient safety.
35
Lämås, Kristina. "Magmassage vid förstoppning upplevelser, effekter och kostnadseffektivitet /." Umeå : Umeå universitet, 2009. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-27014.
36
Quinn, Joann Farrell. "The Impact Of Social Competencies And Role Factors On The Relational Construction Of Identity And Participation Of Physician Leaders." Case Western Reserve University School of Graduate Studies / OhioLINK, 2013. http://rave.ohiolink.edu/etdc/view?acc_num=case1364575883.
37
Khubchandani, Jagdish. "Adolescent Dating Violence: School Nurses’ Perceptions and Practices." University of Toledo / OhioLINK, 2010. http://rave.ohiolink.edu/etdc/view?acc_num=toledo1288059136.
38
Oliveira, Roberto Santos de. "Mapeamento dos serviços de saúde da rede assistencial do município de Nova Iguaçu - análise situacional." Universidade Federal Fluminense, 2010. https://app.uff.br/riuff/handle/1/1226.
Abstract:
Submitted by Fabiana Gonçalves Pinto (benf@ndc.uff.br) on 2015-12-21T13:35:56Z
No. of bitstreams: 1
Roberto Santos de Oliveira.pdf: 6262428 bytes, checksum: 39f1c09619185c6bb47ea3a4e0128673 (MD5)Made available in DSpace on 2015-12-21T13:35:56Z (GMT). No. of bitstreams: 1 Roberto Santos de Oliveira.pdf: 6262428 bytes, checksum: 39f1c09619185c6bb47ea3a4e0128673 (MD5) Previous issue date: 2010
EELVI Ltda
Mestrado Profissional em Enfermagem Assistencial
Estudo descritivo de abordagem qualitativa que realiza o diagnostico situacional da rede assistencial própria do Sistema Único de Saúde no município de Nova Iguaçu. Realiza o mapeamento das unidades de saúde, através de uma ferramenta conhecida como geo-referenciamento. O marco teórico se apoia nas concepções de Cecílio, Merhy, Bodstein, Hartz, Mendes, Buss entre outros; encontra suporte metodologico em Minayo e analisa os resultados a partir das concepções de Levefre sobre o discurso do sujeito coletivo. Como resultados, foram mapeadas 72 Unidades de Saúde: sendo 01 Hospital Geral, 01 Centro de Referencia Materno Infantil, 03 Unidades Mistas, 03 Centros de Atenção Psico-Social, 02 Policlínicas, 01 Centro de Saúde, 01 Posto de Saúde, 24 Unidades Básicas de Saúde, 33 Equipes de Saúde da Família e 03 Unidades da Família. A organização segue os principios estabelecidos pelo Sistema de Saúde, Nova Iguaçu operacionaliza suas ações de saúde principalmente na atenção básica, através da estratégia de saúde da família. Quando confrontamos os resultados encontrados com os parâmetros legais de cobertura assistencial, constatamos que a realidade ainda está aquém do ideal; apesar deste fato, ao situar o município dentro do Estado do Rio de Janeiro, lançando mão de estratégias de avaliação como o Indice de Desenvolvimento Humano, encontramos um crescimento, modesto mas equilibrado entre Estado e União, destacando Nova Iguaçu, através do indicador: Expectativa de vida, que recebe reflexos da assistência prestada à saúde. Conclui identificando o espaçamento geográfico da rede própria, e um esboço da área de cobertura das unidades; percebe-se que são necessárias estratégias de adequação, treinamentos e hierarquização da rede, para utilização da dinâmica de referências e contra-referências, atividades próprias do planejamento em saúde, que vem sendo desenvolvida também pela enfermeira, quando ocupa a posição de gestor. Como contribuição traz as informações coletadas na modalidade de um manual de localização para encaminhamentos entre as Unidades de saúde
A descriptive study of qualitative approach that performs the status diagnosis of the self care network of the Unified Health System in Nova Iguacu. Performs the mapping of health facilities through a tool known as geo-referencing. The theoretical framework is based on the conceptions of Cecilio, Merhy, Bodstein, Hartz, Mendes, Buss and others; finds methodological support in Minayo and analyzes the results starting from concepts of the Levefre on the collective subject discourse. The results were 72 mapped Health Units: 01 the General Hospital, 01 Center Reference Maternal and Child, 03 Mixed Units, 03 Centers for Psycho-Social Care, 02 Polyclinics, 01 Health Center, 01 Health Post, 24 Basic Units Health, 33 Family Health Teams and 03 Units of the Family. The organization follows the principles established by the Health System, Nova Iguaçu operationalized its health activities mainly in primary care through the strategy of family health. When we confront the results with the legal parameters of coverage, we find that the reality is still far from ideal, despite this fact, to be located within Rio de Janeiro county, making use of assessment strategies such as Development human Index, we found a modest growth well balanced between State and Union, highlighting Nova Iguaçu, by indicator: life expectancy, which receives reflections of health care provided. It concludes by identifying the geographic spacing of the health network itself, and an outline of the coverage area of the units, one realizes that strategies are needed to adapt, training and hierarchy of the network, to use the momentum of references and cross-references, activities characteristic of planning health, and that also is being developed by the nurse, when she occupies the position of manager. As a contribution, brings the information collected in the reference guide for tracking referrals between the health units
39
Bazile, Emmanuel Patrick. "Electronic Medical Records (EMR): An Empirical Testing of Factors Contributing to Healthcare Professionals’ Resistance to Use EMR Systems." NSUWorks, 2016. http://nsuworks.nova.edu/gscis_etd/964.
Abstract:
The benefits of using electronic medical records (EMRs) have been well documented; however, despite numerous financial benefits and cost reductions being offered by the federal government, some healthcare professionals have been reluctant to implement EMR systems. In fact, prior research provides evidence of failed EMR implementations due to resistance on the part of physicians, nurses, and clinical administrators. In 2010, only 25% of office-based physicians have basic EMR systems and only 10% have fully functional systems. One of the hindrances believed to be responsible for the slow implementation rates of EMR systems is resistance from healthcare professionals not truly convinced that the system could be of substantive use to them.
This study used quantitative methods to measure the relationships between six constructs, namely computer self-efficacy (CSE), perceived complexity (PC), attitude toward EMR (ATE), peer pressure (PP), anxiety (AXY), and resistance to use of technology (RES), are predominantly found in the literature with mixed results. Moreover, they may play a significant role in exposing the source of resistance that exists amongst American healthcare professionals when using Electronic Medical Records (EMR) Systems. This study also measured four covariates: age, role in healthcare, years in healthcare, gender, and years of computer use. This study used Structural Equation Modeling (SEM) and an analysis of covariance (ANCOVA) to address the research hypotheses proposed. The survey instrument was based on existing construct measures that have been previously validated in literature, however, not in a single model. Thus, construct validity and reliability was done with the help of subject matter experts (SMEs) using the Delphi method. Moreover, a pilot study of 20 participants was conducted before the full data collection was done, where some minor adjustments to the instrument were made. The analysis consisted of SEM using the R software and programming language.
A Web-based survey instrument consisting of 45 items was used to assess the six constructs and demographics data. The data was collected from healthcare professionals across the United States. After data cleaning, 258 responses were found to be viable for further analysis. Resistance to EMR Systems amongst healthcare professionals was examined through the utilization of a quantitative methodology and a cross-sectional research measuring the self-report survey responses of medical professionals. The analysis found that the overall R2 after the SEM was performed, the model had an overall R2 of 0.78, which indicated that 78% variability in RES could be accounted by CSE, PC, ATE, PP, and AXY. The SEM analysis of AXY and RES illustrated a path that was highly significant (β= 0.87, p < .001), while the other constructs impact on RES were not significant. No covariates, besides years of computer use, were found to show any significance differences.
This research study has numerous implications for practice and research. The identification of significant predictors of resistance can assist healthcare administrators and EMR system vendors to develop ways to improve the design of the system. This study results also help identify other aspects of EMR system implementation and use that will reduce resistance by healthcare professionals. From a research perspective, the identification of specific attitudinal, demographic, professional, or knowledge-related predictors of reference through the SEM and ANCOVA could provide future researchers with an indication of where to focus additional research attention in order to obtain more precise knowledge about the roots of physician resistance to using EMR systems.
40
Gammon, Hannah Lee. "The Student Perspective: An Exploration of the Experiences and Needs of University Students with Mental Illness." Wright State University Professional Psychology Program / OhioLINK, 2014. http://rave.ohiolink.edu/etdc/view?acc_num=wsupsych1374611249.
41
Mykhalovskiy, Eric. "Knowing health care / governing health care exploring health services research as social practice /." Thesis, National Library of Canada = Bibliothèque nationale du Canada, 1999. http://www.collectionscanada.ca/obj/s4/f2/dsk1/tape10/PQDD_0018/NQ56249.pdf.
42
Ott, Kenneth Brad. "The Closure of New Orleans' Charity Hospital After Hurricane Katrina: A Case of Disaster Capitalism." ScholarWorks@UNO, 2012. http://scholarworks.uno.edu/td/1472.
Abstract:
Abstract
Amidst the worst disaster to impact a major U.S. city in one hundred years, New Orleans’ main trauma and safety net medical center, the Reverend Avery C. Alexander Charity Hospital, was permanently closed. Charity’s administrative operator, Louisiana State University (LSU), ordered an end to its attempted reopening by its workers and U.S. military personnel in the weeks following the August 29, 2005 storm. Drawing upon rigorous review of literature and an exhaustive analysis of primary and secondary data, this case study found that Charity Hospital was closed as a result of disaster capitalism. LSU, backed by Louisiana state officials, took advantage of the mass internal displacement of New Orleans’ populace in the aftermath of Hurricane Katrina in an attempt to abandon Charity Hospital’s iconic but neglected facility and to supplant its original safety net mission serving the poor and uninsured for its neoliberal transformation to favor LSU’s academic medical enterprise.
43
Yoon, Eunju. "Food defense management plan implementation intention : an application of protection motivation theory." Diss., Manhattan, Kan. : Kansas State University, 2007. http://hdl.handle.net/2097/439.
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Donato, Francis A. "Reforming health care through managed care." Instructions for remote access. Click here to access this electronic resource. Access available to Kutztown University faculty, staff, and students only, 1995. http://www.kutztown.edu/library/services/remote_access.asp.
Abstract:
Thesis (M.P.A.)--Kutztown University of Pennsylvania, 1995.Source: Masters Abstracts International, Volume: 45-06, page: 2939. Abstract precedes thesis as [1] preliminary leaf. Typescript. Includes bibliographical references (leaves 91-92).
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Holmberg, Leif. "Health-care processes a study of medical problem-solving in the Swedish health-care organization /." Lund : Lund University Press, 1997. http://books.google.com/books?id=1jNrAAAAMAAJ.
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Garris, Bill R., and Amy J. Weber. "Relationships Influence Health: Family Theory in Health-Care Research." Digital Commons @ East Tennessee State University, 2018. https://doi.org/10.1111/jftr.12294.
Abstract:
This article reviews the presence of family theory in health-care research. First, we demonstrate some disconnect between models of the patient, which tend to focus on the individual, and a large body of research that finds that relationships influence health. We summarize the contributions of family science and medical family therapy and conclude that family science models and measures are generally underutilized. As a result, practitioners do not have access to the rich tool kit of lenses and interventions offered by systems thinking. We propose several possible ways that family scientists can contribute to health-care research, such as using the family as the unit of analysis, exploring theories of the family as they relate to health, and suggesting greater involvement of family scientists in health research.
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Catena, Rodolfo. "Essays on health care operations management." Thesis, University of Oxford, 2015. http://ora.ox.ac.uk/objects/uuid:3c2035a6-b5d0-43b7-9b12-4883e5db4526.
Abstract:
The aim of operations management in health care is to enhance the provision of services to patients and to decrease costs. Overall worldwide health care expenditures represent around 10.5% of the global GDP and are projected to increase at an annual rate of 5.3% from 2015 to 2017 [74]. In order to investigate how to curb health care costs, I study the English NHS, a health care system that provided universal care to around 54 million people in 2014 [243]. The NHS has launched many initiatives to improve the performance of hospital operations such as the "QIPP" program, which has the objective to save £20 billion of costs by 2015 [98]. Given this framework, this research aims to contribute to the theory that is guiding these operational changes, using data on all admissions to hospitals and focussing on the inguinal hernia, one of the most common surgical procedures [86]. In the next chapters, this research describes inguinal hernia care delivery in the English NHS, examines the impact of spillovers and complementarities on costs, and investigates the effects of length of stay reduction on risk of re-admission and risk of death. The findings of this thesis indicate that one of the possible problems in the delivery of inguinal hernia care in the NHS is the decrease in the number of elective operations performed and the increase in readmission rates. They also clarify how decisions on allocation of resources can affect hospital expenditures by showing that loss in focus can increase health care costs and by pointing out that there is little evidence to support the theory of spillovers and complementarities in the surgical context. Finally, the results of this research can be used to suggest the logic of a policy to decrease length of stay that can inform hospital decisions and can decrease hospital costs.
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Robinson, Rachel Elizabeth. "Living knowledge : embodied health care research practice /." Thesis, Connect to this title online; UW restricted, 2007. http://hdl.handle.net/1773/11187.
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Phelps, John Clayton. "Health Care Leaders' Strategies to Reduce Nursing Turnover." ScholarWorks, 2019. https://scholarworks.waldenu.edu/dissertations/7326.
Abstract:
Health care leaders who lack effective nurse turnover strategies can negatively affect patient quality of care, productivity, and profitability. The purpose of this single case study was to explore strategies health care leaders used to reduce nursing turnover in a health care organization. The conceptual framework for this study was Herzberg's 2-factor theory. Data were collected from semistructured interviews with 4 health care leaders in the West Texas region who had a history of reducing nurse turnover for a minimum of 5 years from the date of hire, and from review of organizational documents related to the strategies to reduce nurse turnover, including policy handbooks and annual reports. Data were analyzed using word frequency and coding to distinguish patterns. Three key themes emerged: leadership support, job satisfaction, and compensation. The results of this study might contribute to social change through an increased understanding of nurse turnover strategies that would improve productivity and the overall quality of patient care to yield organizational success, decreased mortality rates, and improved community health.
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Marti-Morales, Madeline. "Care coordination, family-centered care and functional ability in children with special health care needs in the United States." ScholarWorks, 2011. https://scholarworks.waldenu.edu/dissertations/870.
Abstract:
Children with special health care needs (CSHCN) generally have physical, mental, or emotional conditions that require a broader range and greater quantity of health and related services compared to typical children. Care coordination (CC) and family-centered care (FCC) are necessary in the quality of health care for CSHCN. A gap exists in the literature regarding the impact of CC and FCC on children's functional ability (FA). Previous researchers have focused on met and unmet health care needs, but not on health outcomes or functionality. The purpose of this study was to determine if there was an association between CC, FCC, and FA in CSHCN. The design of this study was a secondary analysis of data from the 2005--2006 National Survey of CSHCN. The study was guided by an adapted socioecological multilevel conceptual framework. Statistical methods included univariate, bivariate, and multiple logistic regression analysis. Results indicated that CC was associated with FA in CSHCN. CSHCN that did not receive CC had a 53% increased risk (OR =1.53, 95%CI 1.21--1.94, p < 0.001) for a limitation in FA compared to CSHCN that received CC, controlling for age, gender, number of conditions, household poverty level, parental educational level, and health insurance. FCC was not associated with a limitation in FA in CSHCN ( p = 0.61). Findings from this study were consistent with the socioecological multilevel framework and the literature on care coordination. This study contributed to positive social change by providing information that can be used by public health officials, health care providers and policy makers in developing policies to assure that care coordination is provided to CSHCN and their families in order to improve their health outcomes and functionality.