acase@tulane.edu

acase@tulane.edu

acase@tulane.edu

acase@tulane.edu

acase@tulane.edu

acase@tulane.edu

As healthcare and health systems become increasingly complex, expectations of what constitutes high quality care continue to evolve. Stakeholders now require contemporary and meaningful measures of system performance. As such, valid healthcare quality metrics are rapidly becoming essential for those providing and receiving healthcare to assess performance and motivate change. This thesis investigates the utility of quality indicators in trauma care. Multiple in-hospital indicators have been promulgated by various bodies for assessing quality of trauma care. The properties of ideal indicators have been widely documented however few published data have reported these properties for many trauma measures. The emphasis on trauma process measures (eg. time to interventions) highlights the need for indicators with known links to patient outcomes. This process-outcome link may be viewed as a measure of an indicator’s construct validity. As this property is unknown for many trauma indicators, this thesis focuses on the construct validity of a number of routinely utilised trauma indicators. In this thesis, the available in-hospital indicators proposed by The American College of Surgeons Committee on Trauma and additional indicators used in the Victorian State Trauma System were investigated for their relationships with patient outcomes. A small number of indicators were found to have statistically significant relationships with patient outcomes, however many indicators demonstrated counter-intuitive relationships, whereby high quality care was linked with poorer patient outcomes. These results suggested that links between indicators and outcomes may not be best measured using individual indicators for individual patients. Rather, a strategy for measuring patient outcomes at the hospital level may be needed. To combine multiple indicators into a single measure of hospital level performance, a number of composite methods were explored using two trauma registries. Three composite weighting schemes were employed. As composite measures are often used for provider ranking or benchmarking, the stability of hospital ranks between providers and over time was investigated. The composites were found to have moderate to strong correlations (0.76-0.99) however variability in composite hospital rankings existed, particularly for middle ranking facilities. The construct validity of each available indicator and composite score was investigated through the relationship with hospital level risk-adjusted mortality using Poisson regression models, risk adjusting for expected deaths using the TRISS formulation. Each composite measure demonstrated a significant association with mortality, with the mortality decrease across the middle 50% of each composite score ranging from 12.06% – 16.13%. These findings suggest that complex measures such as trauma composite indices may be better able to measure the interactions between processes within complex systems that influence quality of care. This thesis adds valuable insight into the use of indicators for assessing quality of care in trauma systems. The combination of individual indicators into composite forms appears to strengthen the construct validity of these measures. By demonstrating the process-outcome link for trauma composite indices, this thesis has identified a means of utilising process measures to assess hospital level performance that may become important for future public reporting and hospital funding schemes.

Background: Health systems internationally face a common set of challenges: ageing populations, increasing numbers of patients suffering from multiple long-term conditions (multimorbidity) and severe pressure on health and care budgets. ‘Integrated care’ is pitched as the solution to current health system challenges. But, in the literature, what integrated care actually involves is complex and contested. Aims: 1. What does ‘integrated care’ currently look like in practice in the NHS? 2. What is the effectiveness of current models of ‘integrated care’? 3. To what extent are there differential effects of ‘integrated care’ for different types of multimorbidity? Methods: The thesis utilises routinely collected data, systematic review and meta-analysis, combined with quasi-experimental methods (difference-in-differences, and subgroup analysis, difference-in-difference-in-differences). Results: The current implementation of the concept of integrated care is predominantly carried out through multidisciplinary team (MDT) case management of ‘at risk’ (usually of secondary-care admissions) patients in primary care. This approach, however, has not proven capable of meeting health outcome and utilisation/cost aims. Patient satisfaction, though, is consistently improved by the approach. There might also be positive spill-over effects of increased team-working through MDTs for the wider practice population. There does not appear to be a multimorbidity subgroup which benefits significantly more than others in terms of secondary-care utilisation or cost. However, patients at the end of life and/or those with only primary-care sensitive conditions might benefit slightly more than others. Conclusions: Integrated care, in its current manifestation, is not a silver bullet that will enable health systems to simultaneously accomplish better health outcomes for those with long-term conditions and multimorbidity while increasing their satisfaction with services and reducing costs. The current financial climate might mean that other means of achieving prioritised aims are required in the short-term, with comprehensive primary care and population health strategies employed to better prevent/compress the negative effects of lifestyle-associated conditions in the longer-term.

Orientador: Gastão Wagner de Sousa Campos / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-22T14:11:19Z (GMT). No. of bitstreams: 1 Monte-Cardoso_Felipe_M.pdf: 1128961 bytes, checksum: 79bf3c446afd7b22c866befd436b70ff (MD5) Previous issue date: 2013 / Resumo: Dentre os impasses vividos pelo Sistema Único de Saúde (SUS), discutem-se atualmente questões relativas à privatização da gestão e da assistência, ao subfinanciamento, à separação entre ações de saúde curativa e de saúde preventiva e às profundas assimetrias sociais no acesso aos bens de saúde. Este estudo busca colocá-las em perspectiva histórica, ao analisar a formação do modo de produção de saúde durante a ditadura civil-militar de 1964 a 1985. Para tanto, se buscará compreender o problema da saúde nos marcos da questão social dentro do processo de formação histórica da sociedade brasileira a partir de revisão bibliográfica. O debate sobre a formação compreende o Brasil como uma sociedade capitalista dependente, caracterizada por uma dupla articulação que combina subordinação externa e segregação social, e advoga a necessidade histórica da superação deste padrão. Durante a ditadura, a lógica dos negócios como estruturante da política de saúde e a modernização dos padrões de consumo no setor foram aspectos estimulados pelo regime, reproduzindo o caráter segregador da saúde no Brasil. Com relação ao primeiro aspecto, a unificação do aparelho previdenciário favoreceu o aprofundamento do modelo de privatização, através do estímulo ao setor privado contratado, bem como aos convênios firmados com empresas, e incentivo estatal para construir e equipar hospitais privados para servir ao sistema previdenciário. O caráter dispendioso do modelo, o uso do fundo previdenciário para outros fins (grandes projetos de infraestrutura) e o acúmulo de casos de corrupção contribuiu para agravar a crise financeira da Previdência Social de fins da década de 1970. Os serviços de saúde previdenciários passaram por um processo de integração aos demais serviços do sistema público como forma de superar a crise, sem, no entanto, transformar o caráter segmentado, lucrativo, privatista e heterogêneo do sistema de saúde. Com relação ao segundo aspecto, a chegada das empresas transnacionais farmacêuticas e de equipamentos e insumos ao Brasil, potencializada pelo regime ditatorial, transformaram as práticas de saúde, aprofundando em escala inédita o trabalho centrado no médico e em procedimentos com alto grau de incorporação tecnológica e dissociados da realidade sanitária brasileira. Estas transformações, afinadas com a expansão do modelo previdenciário privatista, baseadas no mimetismo cultural dos países centrais, terminaram por agravar a dependência brasileira dos produtos das transnacionais, bem como as distorções geradas por este modelo. A crise dos anos 70 e 80 explicitou estas contradições e acelerou a maturação dos movimentos de contestação ao regime e ao modelo de saúde brasileiro, que se aglutinaram em torno da necessidade de uma Reforma Sanitária. Estes movimentos questionaram as bases das práticas sanitárias vigentes e propôs uma estratégia de mudança do setor centrada em reformas do aparelho de Estado apoiadas pela pressão popular. No entanto, a transição pelo alto que caracterizou o fim da ditadura representou a manutenção do monopólio de poder político nas mãos da burguesia dependente, sob a tutela dos organismos financeiros internacionais e em vigência de mais um ciclo de privatização da assistência à saúde, comprometendo o caráter profundamente transformador e democrático das proposições reformistas / Abstract: Among the dilemmas experienced by the Brazilian Unified Health System (SUS), current issues are related to the privatization of management and assistance, the underfunding, the separation between health actions curative and preventive health and the profound social inequalities in access to health goods. This study tries to put them in historical perspective, to analyze the formation of the health production mode during the civil-military dictatorship (1964 to 1985). To do so, it will be tried to understand the health problem in the framework of social issues within the historical process of the Brazilian society formation from a literature review. The debate over the formation comprises Brazil as a dependent capitalist society, characterized by a double articulation that combines external subordination and social segregation, and advocates the necessity of overcoming this historical pattern. During the dictatorship, the business logic structuring of health policy and modernization of consumption patterns in the sector aspects were encouraged by the regime, reproducing the segregated character of healthcare in Brazil. Regarding the first aspect, the unification of the social security favored deepening of the privatization model, by encouraging the private sector contractor, as well as agreements with companies and state incentives to build and equip hospitals to serve the social security health system. The expensive nature of the model, the use of social security fund for other purposes (such as large infrastructure projects) and the accumulation of corruption gates contributed to aggravating the late 1970s' financial crisis of Social Security. Health services went through a process of integration with other services in the public system as a way to overcome the crisis, without, however, transforming the segregated, profitable, privatized and heterogeneous character of the health system. Regarding the second aspect, the arrival of transnational corporations (pharmaceutical and medical equipment and supplies) to Brazil, boosted by the dictatorial regime, transformed health practices, deepening in an unprecedented scale work focused on medical procedures and with a high degree of technological incorporation disassociated from reality of Brazilian health needs. These transformations, in tune with the expansion of privatizing social security model, based on cultural mimicry of central countries, ended up aggravating the dependency of Brazilian products of transnational as well as the distortions generated by this model. The crisis of the 70's and 80 made these contradictions explicit and accelerated maturation of movements against the regime and Brazilian health model, which coalesced around the need for health reform. This movement questioned the basis of the existing sanitary practices and proposed a strategy for change in the sector based on reforms of the state apparatus supported by popular pressure. However, the "transition from above" that characterized the end of the dictatorship represented maintaining the monopoly of political power in the hands of the dependent bourgeoisie, under the tutelage of international financial organizations and in the presence of another cycle of health care privatization, compromising the profoundly transformative and democratic character of the reformists' propositions / Mestrado / Política, Planejamento e Gestão em Saúde / Mestre em Saude Coletiva

archives@tulane.edu / Public health finance is still a relatively young field and, as such, many questions have yet to be asked—and answered. To date, few have examine how specific revenue streams—alone or in combination—shape local health departments’ (LHD) resources and capacity to accomplish their public health missions. Given ongoing policy conversations about financing for public health, it’s important for researchers to rigorously examine the and the potential costs and benefits associated with different revenue sources. Introduction Chapter: The central thesis for the body of work encapsulated by this dissertation is simple: where money comes from matters. This chapter critically examines published evidence and theory linking public health financing mechanisms and their interactions to LHD operations, outputs, and even outcomes. The chapter also introduces situates the specific research questions addressed in this dissertation within a broader conceptual framework. Paper 1: The first paper examines the relationship between revenue diversification and revenue volatility among Washington State LHDs. Using fixed effects linear regression models and revenue data reported during 1998-2014 by all LHDs operating in Washington State, the paper finds little evidence to suggest revenue diversification is significantly associated with revenue volatility. Paper 2: The second paper evaluates whether available revenue sources differentially effected the scope of programs provided by Washington State LHDs between 2000 and 2011. Using two measures of program scope and both linear and non-linear fixed effects panel regression models, the paper finds that only funding received from federal Medicaid was consistently and significantly associated with both measures of program scope. Paper 3: The third paper examines changes in total LHD expenditures in Washington State between 2006 and 2013 following introduction of a new state funding program to support core public health services and infrastructure. Using a pre-post design regression model to evaluate changes in LHD expenditures, the paper finds overall spending among LHDs significantly increased with receipt of the new state funds in the first years of the program. However, those increases were not sustained over the longer term Conclusion Chapter: The final chapter reviews findings from the three papers and discusses their implications for public health policy, practice, finance, and research. / 1 / Abigail Hope Viall