Thesis (Ph. D.)--University of Missouri-Columbia, 2006. / The entire dissertation/thesis text is included in the research.pdf file; the official abstract appears in the short.pdf file (which also appears in the research.pdf); a non-technical general description, or public abstract, appears in the public.pdf file. Title from title screen of research.pdf file viewed on (March 2, 2006) Vita. Includes bibliographical references.

The U.S. pharmaceutical industry has been remarkably successful in developing new treatments for many of the leading causes of morbidity and mortality. These new treatments and their high prices lead government and private parties to increase spending and raise the issue of access. Price and cost increases have stimulated insurance costs, raising questions about the value of new technologies. A key way to address the increase in pharmaceutical prices is to investigate the impact of newer therapies on overall health expenditure. There is a conflict among researchers about the benefits and costs of newer and better drugs. Some researchers argue that newer and better drugs keep people out of hospitals and provide significant cost savings. Another group of researchers argue in their work that newer drugs do not really provide significant cost savings. This dissertation investigates the impacts of break-through drug classes on overall health care expenditures. Empirical evidence presented in this dissertation shows that drugs belonging to new drug classes provide significant advances in treatment of conditions compared to other drugs. The results indicate that all new drug classes except Fluoroquinolones provide substantial cost savings on overall health care expenditures. This dissertation also explores the relations between FDA Therapeutic Drug Classification and total health care expenditures. It offers a better methodology by incorporating both the quality and the age of the drugs to capture their effects on total health care expenditures. It studies the impacts of the quality and the age of the drugs on the diseases of following therapeutic classes: musculoskeletal system and connective tissue, skin and subcutaneous tissue, neoplasm, mental disorders, nervous system and sense organs, circulatory system, respiratory system, digestive system, genitourinary system. The nature of therapeutic conditions coupled with their duration lead us to conclude that for some therapeutic categories newer priority drugs are preferable, for others newer standard drugs are better. The results suggest that there is no general rule to state that newer priority drugs decrease health care expenditures.

The cerebral damage after cardiac arrest is thought to arise both from the ischemia during the cardiac arrest but also during reperfusion. It is the degree of cerebral damage which determines the outcome in patients. This thesis focuses on the cerebral damage after cardiac arrest. In two animal studies, positron emission tomography (PET) was used to measure cerebral blood flow, oxygen metabolism and oxygen extraction in the brain. After restoration of spontaneous circulation (ROSC) from five or ten minutes of cardiac arrest there was an immediate hyperperfusion, followed by a hypoperfusion which was most evident in the cortex. The oxygen metabolism decreased after ROSC with the lowest values in the cortex. The oxygen extraction was high at 60 minutes after ROSC, indicating an ischemic situation. After ten minutes of cardiac arrest, there was a hyperperfusion in the cerebellum. In 31 patients resuscitated after cardiac arrest and treated with hypothermia for 24 hours, blood samples were collected from admission until 108 hours after ROSC. The samples were analyzed for different biomarkers in order to test the predictive value of the biomarkers. The patients were assessed regarding their neurological outcome at discharge from the intensive care unit and after six months. Brain derived neurotrophic factor (BDNF) and glial fibrillary acidic protein (GFAP) was not associated with outcome. Neuron specific enolase (NSE) concentrations were higher among those with a poor outcome with a sensitivity of 57% and a specificity of 93% when sampled 96 hours after ROSC. S-100B was very accurate in predicting outcome; after 24 hours after ROSC it predicted a poor outcome with a sensitivity of 87% and a specificity of 100%. Tau protein predicted a poor outcome after 96 hours after ROSC with a sensitivity of 71% and a specificity of 93%.

Patients are living longer with many types of cancer; however, often they face sudden possibilities of dying, not only due to their advancing illness but due to complications of their treatment. Consequently, they can express substantial existential distress. Nurses’ close proximity to patients puts them in an ideal place to assess and engage with patients’ existential distress; yet this kind of research has been scarce. The purpose of this doctoral thesis was to explore nurses’ experiences of being with patients facing the threat of mortality. Yalom describes this threat as the fear of death, isolation, anxiety and responsibility about freedom, and meaninglessness. The study took place in a cancer setting where care is highly technological and goals of cure dominate, specifically, two bone marrow transplant units of one institution in Canada. Benner’s methodology of interpretive phenomenology guided data collection and analysis of focused observations and interviews with 19 registered nurses. The experience of fighting cancer while preparing for the possibility of letting go was the main theme. Letting go did not reflect nurses’ intents to abandon life but to release patients (if only briefly) from perceived norms of the curative culture. More specifically, the main theme was characterized by: 1) working within the culture of cure and the possibilities of patients dying, 2) concern about “bursting the bubble of hope,” 3) whether to and how to respond to patients’ distress and dying, and 4) coping with patient involvement. In the context of responsive relationships (patients and their families, and healthcare colleagues), nurses reported engaging in communication about the threat of patients’ mortality, and responding with letting be and supporting families to let go, the management of technology and prevention of technological intrusions, and striving for patients to have “easier” deaths. Results indicate a potential to enhance nurses’ supportive care constituted by their perceived responsibility to engage and respond to patients’ existential distress. Moreover, this study suggests that more attention is warranted not only to policy, education, and research that focuses on patients’ existential well-being, but to the well-being of nurses working within tensions of curing and comforting.

In healthy adult relationships both participants serve as attachment figures and caregivers, with each partner seeking and providing care for the other as needed (Hazan & Shaver, 1987). However, chronic illness may result in one individual requiring disproportionately more care without being able to fully reciprocate. The purpose of this research was to investigate the relevance of attachment as a predictor of care receiving, relationship, and health related variables, in a sample of adults experiencing a chronic illness. This investigation employed survey methodology, and 68 individuals with Multiple Sclerosis (MS) participated. Hierarchical multiple regression analyses supported theoretically derived hypotheses. Attachment, conceptualized in terms of the orthogonal constructs of attachment anxiety and attachment avoidance, was found to be a relevant construct in predicting self-reported reaction to care receiving, relationship functioning and quality of life in a sample of individuals with MS. Analyses revealed that elevated attachment anxiety is associated with feelings such as anger, embarrassment, and indebtedness in response to receiving help, while elevated attachment avoidance predicted care receiver perceptions that they were being discouraged from continued independence. In terms of relationship functioning, care receivers with elevated attachment anxiety and care receivers with elevated attachment avoidance reported less trust, acceptance, and intimacy in their relationships, and were less committed to their relationships and their relationship partners. Additionally, elevated attachment avoidance was predictive of lower overall relationship satisfaction. Finally, elevated attachment anxiety predicted poorer mental health and overall quality of life, while elevated attachment avoidance predicted poorer physical health. Interactions between attachment constructs and type of caregiver (spouse/partner vs. other) were observed in several analyses suggesting that attachment anxiety exerts its strongest influence within committed relationships, whereas the power of attachment avoidance appears to be generally more pervasive. The results of this investigation can be understood within the context of the biopsychosocial model of coping with chronic illness. Knowledge of attachment style may be clinically useful as it provides insight into individuals behaviour and emotional experiences in relationships. Attachment- informed interventions may lead to improvement in relationships and subsequent improvement in psychological functioning and physical heath.

In an attempt to improve patient care and compensate for growing demands, new tools and strategies are under constant review and development for improvements and analyses. Advances in technology, analyses of the use of public funding, acquiring additional capital, and adapting practical tools and resources from other industries are commonly considered to improve the situation. This work provides a series of recommendations and analyses of solutions for emergency healthcare developed with Oakville Trafalgar Memorial Hospital (OTMH) in mind that can be scaled and adapted for all hospitals and emergency departments. Solutions applied were analyzed for their effect on patient care and health care providers. Recommendations for future improvements and work have been made and numerous concepts were drawn from previous studies and applications in other industries, and adapted for OTMH. It is concluded that the solutions had a positive effect on both the staff experience as well as patient throughput.

In an attempt to improve patient care and compensate for growing demands, new tools and strategies are under constant review and development for improvements and analyses. Advances in technology, analyses of the use of public funding, acquiring additional capital, and adapting practical tools and resources from other industries are commonly considered to improve the situation. This work provides a series of recommendations and analyses of solutions for emergency healthcare developed with Oakville Trafalgar Memorial Hospital (OTMH) in mind that can be scaled and adapted for all hospitals and emergency departments. Solutions applied were analyzed for their effect on patient care and health care providers. Recommendations for future improvements and work have been made and numerous concepts were drawn from previous studies and applications in other industries, and adapted for OTMH. It is concluded that the solutions had a positive effect on both the staff experience as well as patient throughput.

Patients are living longer with many types of cancer; however, often they face sudden possibilities of dying, not only due to their advancing illness but due to complications of their treatment. Consequently, they can express substantial existential distress. Nurses’ close proximity to patients puts them in an ideal place to assess and engage with patients’ existential distress; yet this kind of research has been scarce. The purpose of this doctoral thesis was to explore nurses’ experiences of being with patients facing the threat of mortality. Yalom describes this threat as the fear of death, isolation, anxiety and responsibility about freedom, and meaninglessness. The study took place in a cancer setting where care is highly technological and goals of cure dominate, specifically, two bone marrow transplant units of one institution in Canada. Benner’s methodology of interpretive phenomenology guided data collection and analysis of focused observations and interviews with 19 registered nurses. The experience of fighting cancer while preparing for the possibility of letting go was the main theme. Letting go did not reflect nurses’ intents to abandon life but to release patients (if only briefly) from perceived norms of the curative culture. More specifically, the main theme was characterized by: 1) working within the culture of cure and the possibilities of patients dying, 2) concern about “bursting the bubble of hope,” 3) whether to and how to respond to patients’ distress and dying, and 4) coping with patient involvement. In the context of responsive relationships (patients and their families, and healthcare colleagues), nurses reported engaging in communication about the threat of patients’ mortality, and responding with letting be and supporting families to let go, the management of technology and prevention of technological intrusions, and striving for patients to have “easier” deaths. Results indicate a potential to enhance nurses’ supportive care constituted by their perceived responsibility to engage and respond to patients’ existential distress. Moreover, this study suggests that more attention is warranted not only to policy, education, and research that focuses on patients’ existential well-being, but to the well-being of nurses working within tensions of curing and comforting.

The purpose of this study was to understand what the care recipients considering as care quality in their long-term eldercare. Our intention has been to contribute a bit to the development of the care work. Previous studies show that user surveys are carried out regularly but there is very few studies that are based on care recipients own opinions and experiences. The main questions in the study have been to examine what is considered as good elder care from a user perspective. Even to understand the characteristics of a good meeting with the care staff and also examine how the elder care in Nybro municipality can improve. This study was based on a qualitative method in the form of seven interviews with recipient of elder care. The interviews were based on five themes which were; background, care, interaction, "special housing and social interaction" and also changes. The collected material is analyzed from a symbolic interactionism perspective. We view the symbolic interactionism as a useful perspective to gain an understanding of the interaction between care recipients and staff, and how it can develop care work The result revealed that the elder care in Nybro Municipality is generally of good quality and that it works well with home care. The care recipients appreciate when the care staffs are cheerful and friendly during visits, and they use the term "helpfulness" to describe what characterize a good treatment. What emerges as a negative aspect of the elder care is that the care staffs are extremely busy and always in a rush at each visit, which may partly affect the care a bit negative. The study shows a desire for change to improve care staff working environment. All respondents have different perceptions of the elderly and what is considered quality of care. Although there are common views on certain things, it is because of their differing views at who they interact with and in what context, the overall situation.

In healthy adult relationships both participants serve as attachment figures and caregivers, with each partner seeking and providing care for the other as needed (Hazan & Shaver, 1987). However, chronic illness may result in one individual requiring disproportionately more care without being able to fully reciprocate. The purpose of this research was to investigate the relevance of attachment as a predictor of care receiving, relationship, and health related variables, in a sample of adults experiencing a chronic illness. This investigation employed survey methodology, and 68 individuals with Multiple Sclerosis (MS) participated. Hierarchical multiple regression analyses supported theoretically derived hypotheses. Attachment, conceptualized in terms of the orthogonal constructs of attachment anxiety and attachment avoidance, was found to be a relevant construct in predicting self-reported reaction to care receiving, relationship functioning and quality of life in a sample of individuals with MS. Analyses revealed that elevated attachment anxiety is associated with feelings such as anger, embarrassment, and indebtedness in response to receiving help, while elevated attachment avoidance predicted care receiver perceptions that they were being discouraged from continued independence. In terms of relationship functioning, care receivers with elevated attachment anxiety and care receivers with elevated attachment avoidance reported less trust, acceptance, and intimacy in their relationships, and were less committed to their relationships and their relationship partners. Additionally, elevated attachment avoidance was predictive of lower overall relationship satisfaction. Finally, elevated attachment anxiety predicted poorer mental health and overall quality of life, while elevated attachment avoidance predicted poorer physical health. Interactions between attachment constructs and type of caregiver (spouse/partner vs. other) were observed in several analyses suggesting that attachment anxiety exerts its strongest influence within committed relationships, whereas the power of attachment avoidance appears to be generally more pervasive. The results of this investigation can be understood within the context of the biopsychosocial model of coping with chronic illness. Knowledge of attachment style may be clinically useful as it provides insight into individuals behaviour and emotional experiences in relationships. Attachment- informed interventions may lead to improvement in relationships and subsequent improvement in psychological functioning and physical heath.