Proefschrift Rijksuniversiteit Groningen. / Met lit.opg. - Met samenvatting in het Nederlands.

L’aumento dei costi in sanità, l’aumentata prevalenza delle patologie croniche, le disuguaglianze attuali, evidenziano la domanda crescente di una popolazione fragile che richiede una risposta globale ai bisogni della persona nel suo insieme, attraverso la costruzione di un sistema sanitario integrato che ne garantisca una presa in carico efficace. Riuscire a gestire le patologie croniche in modo appropriato è la sfida a cui sono chiamati i professionisti socio-sanitari; ma quali sono gli elementi per riuscirci? Le evidenze scientifiche dimostrano che è fondamentale l’integrazione tra i professionisti e lo sviluppo dei Percorsi Diagnostici Terapeutici Assistenziali (PDTA). In quest’ottica, in Italia e in particolare in Emilia-Romagna e nell’Azienda USL di Bologna si sono succeduti, e ancora si stanno evolvendo, diversi modelli di organizzazione per migliorare la gestione appropriata delle patologie croniche e l’aderenza alle linee guida e/o ai PDTA. Il ruolo del medico di medicina generale (MMG) è ancora fondamentale e il suo contributo integrato a quello degli gli altri professionisti coinvolti sono imprescindibili per una buona gestione e presa in carico del paziente cronico. Per questo motivo, l’Azienda USL di Bologna ha sviluppato e implementato una politica strategica aziendale volta a disegnare i PDTA e incoraggiato la medicina generale a lavorare sempre di più in gruppo, rispetto al modello del singolo medico. Lo studio ha individuato nelle malattie cardiovascolari, che rimangono la causa principale di morte e morbilità, il suo focus prendendo in esame, in particolare,lo scompenso cardiaco e il post-IMA. L’obiettivo è verificare se e quanto il modello organizzativo, le caratteristiche del medico e del paziente influiscono sul buon management delle patologie croniche in esame valutando la buona adesione alla terapia farmacologica raccomandata dalle linee guida e/o PDTA dello scompenso cardiaco e post-IMA. / The rising health care costs, the increasing prevalence of chronic conditions, the existing inequalities in access to care highlight the growing demand for a response to the needs of a fragile population, through the construction of an integrated health system that could ensure an effective provision of care. Managing chronic diseases appropriately is a challenge for health care professionals, but which are the key elements to achieve it? Scientific evidence indicates that the integration between professionals and the development of Integrated Care Pathways are fundamental. In Italy and especially in Emilia Romagna and in Local Health Authority of Bologna, different models of organization have been implemented and are still evolving to improve the management of chronic diseases, the appropriateness and adherence to guidelines and/or pathways. The role of the general practitioner is still vital and his/her contribution together with that of other health care professionals are essential for the appropriate treatment of chronic diseases. . For this reason, the Local Health Authority of Bologna has pursued a policy aimed at developing integrated care pathways and encouraged general practitioners to work together rather than running individual practices. The study has chosen cardiovascular diseases, and specifically heart failure and acute myocardial infarction, as its focus because these diseases are the leading cause of death and morbidity. The goal is to determine if and how the organizational models, the characteristics of the physician and of the patient are associated with the good management of chronic cardiovascular diseases and whether the different collaborative organizational models of general practitioners are also associated with adherence to the pharmacological treatments recommended by the guidelines and/or the integrated care pathways for heart failure and acute myocardial infarction.

Proefschrift Universiteit Maastricht. / Samenvatting in het Nederlands. Ten dele eerder verschenen en nog te verschijnen art. Met lit. opg. - Met een samenvatting in het Nederlands.

Formål:Formålet med undersøgelsen har været at undersøge hvilke oplevelser, erfaringer ogforståelse kommunalt ansatte sagsbehandlere med bevilligendekompetence ansat i Region Hovedstaden har i sager der vedrører voksne med spiseforstyrrelser. Hvorfor henvender de sig, hvilke ydelser bevilliges/ afslås og hvilket formål har indsatsen set i et folkesundhedsperspektiv. Metode: Semistrukturerede kvalitative interviews blev udførtmed ti sagsbehandlere fra ni kommuner i region hovedstaden. Data blev analyseret ved hermeneutisk filosofi og analyse. Resultater:Resultaterne gavfem temaer og 20 undertemaer. Defem temaervar; ansvarsforholdetimellem regioner og kommuner; henvendelser fra borgere med spiseforstyrrelser til sagsbehandlere; sagsbehandling; den primære sektor; sagsbehandlernes faglige viden og inddragelse af teori. Resultaterne viser at sektoransvarlighedsprincippet og økonomiske budgetter medvirker til at borgere lander imellem to sektorer i sagsbehandlingen.Sagsbehandlerne ser en til to sager om året og oftest drejer det sig om unge piger som lider af enten AN, BN eller BED. Der sesCo-morbide lidelser og sociale problemer, sagerne er langvarige og der forekommer tvangsindlæggelse. Oftest anvendes § 85, §100, §107, §108 fra loven om Social Serviceog den bedste sagsbehandling sker i samarbejde med eksperter fra den behandlende sektor. Der ses ikke behov for etablering af indsatser rettet imod spiseforstyrrelser i kommunalt regi. Sagsbehandlerne arbejder på et generaliseret niveau og inddrager erfaringer oginstrukser isagsbehandlingen. Fagteori inddrages i begrænset omfang for eksempel recovery, sundhedsfremme, motiverende samtale, balance skema og anerkendende tilgang. Konklusion: Hvis sagsbehandlerne i kommunerne skal medvirke til at opdage, påbegynde behandling, henvise, tvangsindlægge, efterbehandle og opdage recidiv på baggrund af deres fags empiri må de have klare rammer og retningslinjer for hvor de kan opsøge informationer om samarbejdspartnere, behandlingssteder og henvisnings metoder. Det er vigtigt at eliminere de barrierer der er for at tilbyde ydelser som indeholder terapi hvis intentionen om den primære sektors indsats skal blive praksis / Aim:Thisstudy aimedto examine grant-competent social workers’experiences and understanding of adults with eating disordersin Denmark’s Capital Region. In particular, we aimed to identify social needs, benefits grantedor denied and for what purposes, and the public health perspective. Method: We used semi-structured qualitative interviews with ten social workers from nine municipalities in the Capital Region. All data was analyzed using Hermeneutic philosophy. Results: Our dataidentifiedfive major themes: (i) responsibilities between regions and municipalities; (ii) contact between individuals with eating disorders and social workers; (iii) case management; (iv) the primary sector; and (iv) social workers’ knowledge and use of theory. We determined that sector responsibility and financial budgets contribute to public landing between the community sector and the regional sector. Each year, social workerssee one or two individuals with eating disorders, often young girls suffering from anorexianervosa, bulimia nervosa,or binge eating disorder. When clients exhibit co-morbidityand social problems, cases are lengthy and sometimes requirein voluntary hospitalization, most often facilitated by §85, §100, §107, and §108 of the Law on Social Services.Cases with the best outcomeare characterized by cooperation with medical experts. Specialist theory is involved to a limited extent (e.g.,examples, recovery, health promotion, motivational interviewing, balance sheet,and the appreciative approach. Conclusion: Social workers operateon a generalized level,professional experience and instructions to treat clients. They see no need for the establishment of efforts directed towards specialized eating disorders units in the primary sector.If social workers in local authorities are granted to detect disease, initiate treatment, initiate referrals, involuntarily institutionalize clients and record their progress,and detect recurrence on the basis of subjective empiricism,they need clear guidance and direction for locating information about professional partnerships, health care facilities, and referral methods. Importantly, eliminating barriers to services that include therapy will enhance the primary sector's ability to meet legal requirements / <p>ISBN 978-91-86739-78-2</p>

Despite the effectiveness of brief lifestyle interventions delivered in primary health care (PHC), implementation in routine practice remains suboptimal. Previous research suggests that there are many barriers to PHC clinicians addressing lifestyle risk factors, however few studies have identified the importance of various factors and how they shape practices. This thesis aimed to develop and describe a theoretical model to explain the lifestyle risk factor management practices of PHC clinicians and to identify critical leverage points for intervention. The study analysed data collected as part of a larger feasibility project of risk factor management in three community health teams in NSW, Australia, involving 48 PHC providers working outside of general practice. Grounded theory principles were used to inductively develop a model, involving three main stages of analysis: 1) an initial model was developed based on quantitative analysis of clinician survey and audit data, and qualitative analysis of a purposeful sample of participant interviews (n=18) and journal notes; 2) the model was then refined through additional qualitative analysis of participant interviews (n=30) and journal notes; and 3) the usefulness of the model was examined through a mixed methods and case study analysis. The model suggests that implementation of lifestyle risk factor management reflects clinicians??? beliefs about commitment and capacity. Commitment represents the priority placed on risk factor management and reflects beliefs about role congruence, client receptiveness and the likely impact of intervening. Capacity beliefs reflect clinician views about self efficacy, role support and the fit between risk factor management and ways of working. The model suggests that clinicians formulate different intervention expectations based on these beliefs and their philosophical views about appropriate ways to intervene. These expectations then provide a cognitive framework guiding their risk factor management practices. Finally, clinicians??? appraisal of the overall benefits and costs of addressing lifestyle issues acts to positively reinforce or to diminish their commitment to implementing these practices. The model extends previous research by outlining a process by which clinicians??? perceptions shape implementation of lifestyle risk factor management in routine practice. This provides new insights to inform the development of effective strategies to improve such practices.

Text in English with summaries in English, Afrikaans and Zulu / Bibliography: leaves 102-115 / The study investigated the management of medical records in the Primary Health Care services (PHCs) of Diepsloot. The study investigated the regulatory framework, records infrastructure, records security, records management staff skills and the filing system. A qualitative design guided by the interpretive paradigm was used to guide the case study. Interviews, focus groups, and observations generated data from 50 participants. The study revealed that the regulatory instruments used to manage records lack implementation and compliance. There was a lack of security measures, a shortage of records management infrastructure and inconsistency in the filing system. There is a low level of skill in the records management staff. The study recommended the implementation of a regulatory policy that will guide and ensure effective governance of records in PHCs. Records should be secure from misuse by unscrupulous individuals. PHC records need to be managed by experienced professionals. The filing system should be easily accessible. / Die studie het ondersoek ingestel na die bestuur van mediese rekords in die Primêre Gesondheidsorgdienste (PHC's) van Diepsloot. Die studie het ondersoek ingestel na die regulatoriese raamwerk, rekord van infrastruktuur, rekord sekuriteit, vaardighede vir rekordbestuur en die liasseerstelsel. 'n Kwalitatiewe ontwerp gelei deur die interpretatiewe paradigma is gebruik om die gevallestudie te lei. Onderhoude, fokusgroepe en waarnemings het gegewens van 50 deelnemers gegenereer. Die regulatoriese instrumente wat gebruik word om rekords te bestuur, het geen implementering en nakoming nie. Die studie het aan die lig gebring dat daar 'n gebrek aan veiligheidsmaatreëls was, 'n tekort aan infrastruktuur vir rekordbestuur en teenstrydigheid in die liasseringstelsel. Die personeel in rekordbestuur het 'n lae vlak van vaardigheid. Die studie het die implementering van 'n regulatoriese beleid aanbeveel wat die doeltreffende bestuur van rekords in PHC's sal lei en verseker. Rekords moet beskerm word teen misbruik deur gewetenlose individue. PHC-rekords moet deur ervare professionele persone uitgevoer word. Die liasseerstelsel moet maklik toeganklik wees. / Lolu cwaningo luphenywe ngokuphathwa kwamarekhodi ezokwelashwa emnyangweni Wezokunakekelwa kwempilo okuyisisekelo (i-PHCs) eDiepsloot. Ucwaningo luphenywe ngohlaka lokulawula, ingqalasizinda yamarekhodi, ukuphepha kwamarekhodi, amakhono okuphathwa kwamarekhodi nohlelo lokufayila. Umklamo olungaqanjwa uqondiswa yi-paradigm yokutolika wasetshenziselwa ukuqondisa ucwaningo lwesigameko. Izingxoxo, amaqembu okugxila kanye nokubukwa kukhiqize idatha evela kubahlanganyeli abangu 50. Izinsizakusebenza zokulawula ezisetshenziselwa ukuphatha amarekhodi zingenakho ukusebenza nokuhambisana. Ucwaningo luveze ukuthi bekukhona ukuntuleka kwezindlela zokuphepha, ukushoda kwengqalasizinda yokuphathwa kwamarekhodi kanye nokungahambelani ohlelweni lokugcwalisa. Kunezinga eliphansi lekhono kubasebenzi bokuphathwa kwamarekhodi. Ucwaningo lincome ukusetshenziswa kwenqubomgomo yokulawula ezohola futhi iqinisekise ukuphathwa kwamarekhodi kuma-PHCs ngendlela efanele. Amarekhodi kufanele avikeleke ekusetshenzisweni kabi ngabantu abangathembekile. Amarekhodi we-PHC adinga ukuqhutshwa ngochwepheshe abanolwazi. Uhlelo lokufayila kufanele lutholakale kalula. / Information Science / M. Inf.

Abstract Surgery for ear, nose and throat (ENT) diseases most often aims to improve quality of life (QoL). The extent of having QoL as an outcome in papers included in evidence-based medicine databases is not known. In primary sinonasal surgery, the QoL outcomes and predictors and usability of various QoL instruments need more clarification. The aim was to: 1. Find out with a systematic literature review how the Cochrane database currently includes the QoL dimension. 2. Investigate the effect of primary sinonasal surgery on QoL, to identify predictors of QoL outcomes and to compare QoL instruments. In total 160 adults undergoing primary septoplasty (SP) or endoscopic sinus surgery (ESS) were recruited in 2010–2014 with 206 controls for a prospective matched cohort study. QoL was measured with a disease-specific Sino-Nasal Outcome Test–22 (SNOT–22) and generic RAND–36 before surgery and 12 months after surgery. Retrospective Glasgow Benefit Inventory (GBI) was also used. QoL was an outcome measure in 10% (3 out of 30) of trials included in Cochrane databases on most common ENT surgeries. The use of QoL since the year 2000 has increased. The total SNOT–22 score improved in both patient groups after surgery, almost to the level of the controls, In the SP group (N=64) from 34.9 to 19.1 and in ESS (N=70), from 35.1 to 19.3. The control cohort’s SNOT–22 was 17.7 at entry and after follow-up, 15.3 (N=165). RAND–36 and GBI also improved after surgery. The best predictor for a good QoL outcome in multivariate analysis after surgery was a high preoperative (≥20) SNOT–22 score in the SP and ESS groups (adjusted odds ratio 10; 95% confidence interval 1.6–64 and 12; 2.5–55, respectively). In receiver operating characteristic curve analysis, the highest preoperative SNOT–22 total score of 30 was the most sensitive (74%) and specific (70%). GBI seemed to be the most sensitive instrument to detect a change, but the three instruments in this study agreed in only about 10% of the patients who had the worst impact before surgery or best outcome. The results suggest that papers on the Cochrane databases on ENT surgeries have rarely addressed the QoL outcome. Septal deviation and recurrent acute or chronic rhinosinusitis lowered QoL. Primary surgery on these conditions improved QoL almost to the level of the control population, which was not symptom-free either. A high preoperative SNOT–22 total score was the best predictor of a beneficial outcome. The QoL instruments identified different patients experiencing the best improvement after surgery. / Tiivistelmä Korva-, nenä- ja kurkkutautien (KNK) kirurgia tähtää useimmiten elämänlaadun (EL) parantamiseen. EL:n huomioinnin yleisyys näyttöön perustuvien tietokantojen sisältämissä tutkimuksissa ei ole tiedossa. Primaareissa nenäleikkauksissa EL:n tulokset, ennustekijät ja eri mittareiden käytettävyys kaipaavat lisätietoja. Tarkoituksena oli 1: Tutkia systemaattisella kirjallisuuskatsauksella miten nykyiset Cochrane-suositukset huomioivat EL:n. 2: Tutkia primaarin nenäkirurgian vaikutus EL:uun, tunnistaa EL:n ennustekijöitä ja vertailla eri mittareita. Yhteensä 160 primaariin nenän väliseinäleikkaukseen (VL) tai sivuonteloiden tähystysleikkaukseen (ESS) tulevaa aikuista ja 206 ikä- ja sukupuolivakioitua verrokkia osallistui etenevään kaltaistettuun kohorttitutkimukseen vv. 2010-2014. EL mitattiin tautispesifillä Sino-Nasal Outcome Test -22:lla (SNOT–22) ja yleisellä RAND–36:lla ennen leikkausta ja 12 kk leikkauksen jälkeen. Kolmantena mittarina käytettiin taannehtivaa Glasgow Benefit Inventoryä (GBI). Cochrane-tietokannan yleisimpien KNK-leikkausten tutkimuksista 10 %:ssa (3 30:stä) sisälsi EL-tuloksia. Vuoden 2000 jälkeen EL:n käyttö on lisääntynyt. SNOT–22 kokonaispistemäärä parani VL- ja ESS-ryhmissä lähes kontrollien tasolle, VL-ryhmässä (N=64) 34.9:stä 19.1:een ja ESS-ryhmässä (N=70) 35.1:stä 19.3:een. Kontrollien SNOT–22 oli alussa 17.7 ja seurannan jälkeen 15.3. Myös RAND–36 ja GBI paranivat leikkauksen jälkeen. Monimuuttuja-analyysissä hyvän EL-tuloksen paras ennustetekijä oli korkea leikkausta edeltävä SNOT–22 sekä VL- että ESS-ryhmissä (vakioitu vetokertoimien suhde 10; 95 % luottamusväli 1.6–64 ja 12; 2.5–55, ryhmittäin). ROC (receiver operating characteristic) -käyräanalyysissä leikkausta edeltävä arvo 30 antoi parhaan herkkyyden (74 %) ja tarkkuuden (70 %). GBI vaikutti herkimmältä aistimaan muutoksen, mutta mittarit olivat samaa mieltä vain noin 10%:ssa niistä potilaista, joilla oli huonoin EL ennen leikkausta tai paras tulos leikkauksen jälkeen. Tulosten mukaan Cochrane-tietokannassa olevat KNK-tautien kirurgian tutkimukset ovat ottaneet harvoin elämänlaadun huomioon. Nenän väliseinän vinous ja toistuva äkillinen tai krooninen sivuontelotulehdus laskivat EL:ua. Näiden tautien primaarikirurgia paransi EL:n lähes samalle tasolle kuin kontrolliryhmällä. Korkea leikkausta edeltävä SNOT–22 –kokonaispistemäärä ennusti parhaiten hyvää tulosta. Eri EL-mittarit tunnistivat eri potilaat, jotka hyötyivät parhaiten leikkauksista.

Abstract Type 2 diabetes is one of the fastest increasing lifestyle diseases globally. Its cure is not yet possible, but there is firm evidence from scientific studies that it can effectively be prevented by lifestyle changes. There is limited evidence-based information on the prevention of diabetes in practice. This dissertation offers new desirable information on the issue. The aim of this dissertation study was to describe the prevalence of risk factors for type 2 diabetes and hidden glucose disorders predicting the development of diabetes in the Finnish adult population, and to analyse whether the risk for developing diabetes could be reduced by simple lifestyle counselling. Furthermore, the ability of the Finnish Diabetes Risk Score (FINDRISC) to detect glucose disorders leading to diabetes and undiagnosed diabetes was analysed. In the dissertation data from large Finnish population surveys (the FINRISK 2002 glucose tolerance survey and the FIN-D2D 2004−2005 survey) were analysed. In addition, a prospective design and large-scale intervention were included. We found that obesity and glucose disorders are very common in the Finnish middle-aged population. Prevalence of obesity was 24% for men and 28% for women, that of abnormal glucose metabolism 42% for men and 33% for women, and that of undiagnosed diabetes 9% for men and 7% for men. One quarter of individuals aged 45−64 years were at high risk for diabetes. Lifestyle interventions were offered to more than 10,000 high-risk individuals, 3,379 men and 6,770 women. Of the men, 43% were also at high risk for cardiovascular morbidity and 42% at high risk for cardiovascular mortality estimated through the FRAMINGHAM and SCORE risk engines, respectively. The FINDRISC, originally developed for predicting the risk of development of type 2 diabetes, also predicted the prevalence of diabetes in the population. The effect of lifestyle interventions on weight and its association with glucose tolerance was evaluated in individuals at high risk for diabetes in a one-year follow-up. In total 17.5% of them lost ≥&#160;5% weight. Their relative risk for diabetes decreased 69% compared with the group that maintained their weight. This study shows that FINDRISC predicts prevalent type 2 diabetes. A significant proportion of middle-aged Finnish population has a glucose disorder including undiagnosed type 2 diabetes. Lifestyle interventions in primary health care may promote weight loss, which decreases the risk of diabetes. / Tiivistelmä Diabetes on yksi nopeimmin lisääntyvistä elintapasairauksista maailmassa. Sitä ei vielä voida parantaa, mutta tieteellisissä tutkimuksissa on kiistattomasti osoitettu, että sitä voidaan tehokkaasti ehkäistä elintapamuutoksilla. Diabeteksen ehkäisystä käytännössä on hyvin niukasti tutkimustietoa. Tämä väitöskirja tuo kaivattua lisätietoa aiheesta. Väitöstutkimuksen päätavoitteena oli selvittää diabeteksen riskitekijöiden ja piilevien diabetesta ennakoivien sokerihäiriöiden yleisyyttä suomalaisessa aikuisväestössä. Tämän ohella tavoitteena oli selvittää voidaanko yksinkertaisella elintapaneuvonnalla vähentää sellaisten henkilöiden sairastumisvaaraa, joilla oli suuri riski sairastua diabetekseen. Lisäksi arvioitiin diabetesriskitestin kykyä tunnistaa ennakoivat sokerihäiriöt ja aiemmin tunnistamaton diabetes. Tutkimuksessa käytettiin laajoja suomalaisia väestötutkimusaineistoja: FINRISKI-2002 -tutkimusta, sen alaotosta ja D2D-väestötutkimusta 2004–2005. Mukana oli myös pitkittäisasetelma ja laajamittainen interventio. Tutkimuksen perusteella huomasimme, että lihavuus ja sokerihäiriöt ovat hyvin yleisiä keski-ikäisillä suomalaisilla. Merkittävästi lihavia (BMI&#160;≥&#160;30 kg/m2) oli 24&#160;% miehistä ja 28&#160;% naisista ja poikkeava sokeriaineenvaihdunta oli 42&#160;%:lla miehistä ja 33&#160;%:lla naisista. Tunnistamaton diabetes oli 9&#160;%:lla miehistä ja 7&#160;%:lla naisista. Suuressa diabetekseen sairastumisvaarassa oli neljäsosa 45−64-vuotiaista. Interventioon otettiin yli 10&#160;000 suuressa diabeteksen sairastumisriskissä olevaa henkilöä, 3&#160;379 miestä ja 6&#160;770 naista. Miehistä 43&#160;% oli suuressa sairastumisvaarassa myös sydän- ja verisuonisairauteen ja 42&#160;% suuressa kuolemanvaarassa Framingham- ja SCORE-riskilaskureilla arvioituna. Tyypin 2 diabeteksen sairastumisriskin arviointiin kehitetty Riskitesti ennusti hyvin myös diabeteksen esiintymistä väestössä. Elintapainterventioiden vaikutusta painoon ja sokeriaineenvaihduntaan analysoitiin vuoden seurannassa sellaisilla henkilöillä, joilla oli suuri diabetesriski. Paino laski 5&#160;% tai enemmän 17,5&#160;%:lla, jolloin sairastumisriski diabetekseen väheni 69&#160;% verrattuna ryhmään, jonka paino ei muuttunut. Tutkimuksen perusteella lihavuus, sokerihäiriöt ja tunnistamaton diabetes ovat yleisiä keski-ikäisessä väestössä. Riskitesti on hyvä työkalu myös diabeteksen seulonnassa. Perusterveydenhuollossa tarjottavalla elintapaneuvonnalla voidaan saada aikaan laihtuminen, joka vähentää sairastumisvaaraa diabetekseen.

Η παρούσα διατριβή έχει στόχο τη διερεύνηση της επίδρασης της νέας ιατρικής τεχνολογίας στην αποτελεσματικότητα παραγωγής των Μονάδων Εντατικής Θεραπείας (ΜΕΘ) στην Ελλάδα, καθώς και τον εντοπισμό των στοιχείων που επηρεάζουν τη διαδικασία λήψης αποφάσεων στο πλαίσιο του Εθνικού Συστήματος Υγείας (ΕΣΥ) για την υιοθέτηση ιατρικής τεχνολογίας. Για την εκτίμηση της αποτελεσματικότητας κάθε μονάδας, εφαρμόζεται η τεχνική bootstrapped DEA των Simar και Wilson (2007), ενώ για την διερεύνηση των στοιχείων που οδηγούν στην απόφαση υιοθέτησης γίνεται χρήση υποδειγμάτων probit. Κατόπιν, με τη χρήση υποδειγμάτων επιβίωσης εντοπίζονται οι παράγοντες που κατηγοριοποιούν τις Νοσοκομειακές μονάδες αναφορικά με το χρόνο υιοθέτησης. Ο αξονικός τομογράφος στα δημόσια νοσοκομεία χρησιμοποιείται σαν μελέτη περίπτωσης. Η μελέτη κατέδειξε ελλείμματα τόσο στην τεχνική αποτελεσματικότητα όσο και στην αποτελεσματικότητα κλίμακας στις περισσότερες μονάδες που εξετάστηκαν, κυρίως λόγω έλλειψης νοσηλευτικού προσωπικού. Τα αποτελέσματα δείχνουν ότι αν και η τεχνική αποτελεσματικότητα επωφελείται από την ενσωμάτωση των νέων ιατρικών τεχνολογιών, η αποτελεσματικότητα κλίμακας παραμένει ανεπηρέαστη. Αναφορικά με το την πιθανότητα και το χρόνο υιοθέτησης, διαπιστώθηκε ότι το μέγεθος του νοσοκομείου και η πληρότητα επιδρούν θετικά. Τέλος, τα συμπεράσματα επεξηγούν το βαθμό στον οποίο η υιοθέτηση νέας τεχνολογίας επηρεάζει τόσο την αποτελεσματικότητα των Νοσοκομειακών μονάδων γενικότερα, όσο και τη διαδικασία λήψης σχετικών αποφάσεων. Η παρούσα Διατριβή συμβάλλει στην γενικότερη ανάπτυξη της αποτελεσματικότητας του Συστήματος Υγείας και στην προώθηση του διαλόγου μεταξύ των εμπλεκόμενων στα θέματα διοίκησης και διαχείρισης του Συστήματος Υγείας. / This thesis aims to investigate the effect of new medical technology on the production efficiency of Intensive Care Units (ICUs) in Greece and unravel the elements which influence the decision making process concerning the adoption of new medical technologies in the context of the Greek Health System. In order to evaluate the efficiency of each Unit, the bootstrapped DEA of Simar and Wilson (2007) is applied, while a probit model is used for exploring the elements that lead to the adoption decision. Then, the factors that categorize hospitals regarding the timing of adoption are identified through the use of survival models. Computerized tomography in the Greek public sector is used as a case study. The study demonstrated deficits in both technical and scale efficiency in most Units, mainly due to lack of nursing staff. The results show that while technical efficiency has benefited from new medical technology integration, the scale efficiency remains unaffected. With respect to the likelihood and the time of adoption, it was found that the hospital’s size and plenitude have positive impact. Finally, the findings explain the extent to which health technology adoption affects both the hospital’s efficiency and the decision-making process. The present thesis contributes to the overall increase of the Health System efficiency as well as in promoting the dialogue between health administrators.

La formazione, in ambito sanitario, è considerata una grande leva di orientamento dei comportamenti, ma la metodologia tradizionale di formazione frontale non è la più efficace, in particolare nella formazione continua o “long-life education”. L’obiettivo primario della tesi è verificare se l’utilizzo della metodologia dello “studio di caso”, di norma utilizzata nella ricerca empirica, può favorire, nel personale sanitario, l’apprendimento di metodi e strumenti di tipo organizzativo-gestionale, partendo dalla descrizione di processi, decisioni, risultati conseguiti in contesti reali. Sono stati progettati e realizzati 4 studi di caso con metodologia descrittiva, tre nell’Azienda USL di Piacenza e uno nell’Azienda USL di Bologna, con oggetti di studio differenti: la continuità di cura in una coorte di pazienti con stroke e l’utilizzo di strumenti di monitoraggio delle condizioni di autonomia; l’adozione di un approccio “patient-centred” nella presa in carico domiciliare di una persona con BPCO e il suo caregiver; la percezione che caregiver e Medici di Medicina Generale o altri professionisti hanno della rete aziendale Demenze e Alzheimer; la ricaduta della formazione di Pediatri di Libera Scelta sull’attività clinica. I casi di studio sono stati corredati da note di indirizzo per i docenti e sono stati sottoposti a quattro referee per la valutazione dei contenuti e della metodologia. Il secondo caso è stato somministrato a 130 professionisti sanitari all’interno di percorso di valutazione delle competenze e dei potenziali realizzato nell’AUSL di Bologna. I referee hanno commentato i casi e gli strumenti di lettura organizzativa, sottolineando la fruibilità, approvando la metodologia utilizzata, la coniugazione tra ambiti clinico-assistenziali e organizzativi, e le teaching note. Alla fine di ogni caso è presente la valutazione di ogni referee. / Education, in health care, is a great lever to orient behaviors. The usual training methods are not the most effective, especially in continuing or “long-life” education. The primary objective is to determine if the “case study” methodology, normally used in empirical research, can help health professionals to learn methods and tools about organizational and managerial domain, starting from description of processes, decisions, results in real contexts. The case studies were designed and built, with descriptive methodology, in two Local Health Authorities, the first-one in Piacenza and the second-one in Bologna. The cases have different study objects: the continuity of care in a cohort of patients with stroke and use of tools for monitoring the conditions of their autonomy; the adoption of “patient-centred” approach in a patient with COPD at home and caregiver engagement into self-care and self-monitoring; the perception that caregivers, General Practitioners and other professionals have about Dementia and Alzheimer’s network; the fallout of the training 2013 of pediatricians in their clinical activity. The case studies are accompanied by “teaching note” for teachers and have been subjected to 4 referees for the evaluation of methodology used and contents. The second case has been submitted to 130 professionals in the path of “skills and potentials assessment” realized in Bologna’s Local Authority. The referees have commented on the contents of each case, the method of presentation and reading tools of the organization, emphasizing usability, approving the methodology used, the conjugation between different areas of clinical care and organizational areas, and teaching notes. They provided helpful suggestions for administration in education. At the end of each case there is the evaluation of each of the referees.