Allogeneic Hematopoietic Stem Cell Transplantation is applied in the management of cancer. It involves myeloablative chemoradiotherapy followed by infusion of donor stem cells. The characteristics of the donor stern cells influences transplant outcomes which itself, is dependent on the donor characteristics. The purpose of this thesis was to explore preferences over donor characteristics. A systematic review was performed to identify all donor characteristics associated with outcome. Eight traditional and 5 non-traditional characteristics were identified. The results of the review were used to inform a survey of the Canadian Bone Marrow Transplant Group which primarily includes transplant physicians. An online survey and conjoint analysis of Canadian Bone Marrow Transplant Group members was performed to define relative importance of donor characteristics. Canadian Bone Marrow Transplant Group members, including transplant physicians caring for adults strongly indicate preference for donors related to recipients (HR 2.97) over the donor's age, gender and cytomegalovirus compatibility.

This thesis aims to establish the principles that should govern the conception of health websites in Aboriginal context. For Aboriginal Canadians in remote communities, it is essential to gain accurate, reliable and relevant access to health information. Health websites customized to the preferences of users and to the cultural particularities of Aboriginal culture are a possible means to vehicle this information to them. A user-centered approach is used to gather data on the preferences of presentation types and content on health websites for Aboriginal people. Remote focus group sessions were conducted using videoconferencing. Different Web presentation types, mainly videos and text-based Web pages, from Diabetes and COPD websites, are presented to the users during the focus group sessions. A qualitative data analysis is done to examine user preferences and what factors have an influence on those preferences. Key findings include: (1) the type of disease being presented on the websites has an influence on the preferences of users; (2) the preferences of users vary based on the different disease aspects presented; (3) the different factors related to the living location, such as the limited access to healthcare and the Internet, the inaccessibility of certain foods and the diversity of cultures of the different remote communities also affect the preferences of users; (4) users prefer websites to contain elements related to their culture. The findings of this research have allowed for the development of the principles for the conception of health websites. Health website owners should apply these principles to use the appropriate presentation types, add content that is more meaningful to its target audience, and reorganize the content so that the most relevant information is more easily accessible to the users. As a consequence of conducting qualitative research, the main limitation of this research is the small sample size. Future research should be conducted with a larger sample size that is more representative of the general population and of the heterogeneity of Aboriginal culture to confirm the results of this study.

<p> Global explosion of mobile technology has engendered a new instrument to address the challenges in public health and to revolutionize the paradigm of healthcare access and delivery system. Today mobile phone coverage has increased to a significant 90% of the world&rsquo;s population. The rising ubiquity and infiltration of mobile phones has kindled the beginning of a new era in healthcare, mobile health (mHealth). mHealth is the amalgamation of mobile telecommunication and multimedia into an on the go mobile health care delivery system. </p><p> Pediatric Pal is a mHealth application targeted to care for children and help build a healthier tomorrow for them. Pediatric Pal is designed to be the &ldquo;Drive Thru&rdquo; for the pediatric healthcare system. The mhealth app focuses on giving patients access to a highly sophisticated medical diagnosis tool. By using latest searching technologies, the system can take a pattern of symptoms in everyday language and instantly compute from our vast database. The app design and development will be outsourced to a web design Hyperlink solutions agency. Database for the app will be maintained in house and test runs will be run within the house. </p><p> The main source of revenue for the app will be from user subscription and upfront cash payment. Premium downloads will bring in the extra revenue as well. </p><p> Pediatric Pal puts world&rsquo;s medical knowledge at the patients fingertips and enables them to make sense of your symptoms. It will change the way patients speak to their doctor forever.</p><p>

<p> Bullying has long been associated with school children. In recent years, however, more attention has been paid to the bullying that has reached beyond the playground and into the workforce. One population facing this problem is staff nurses. To date, no one has found an effective way to address workplace bullying in the healthcare field, nor have effective methods been found for retaining trained nurses affected by this problem. The focus of this dissertation was on understanding nurses&rsquo; lived experiences and how nurses decided to remain in their current working position despite these problems. Taking a phenomenological approach and using the conceptual framework of resilience, the study included telephone interviews of 2 pilot study participants and 12 main study participants. Recorded and transcribed participant responses to interview questions were coded thematically and analyzed. Three main themes emerged: stories of working with workplace bullying, challenges of the lived experiences of being bullied, and special techniques of nurses being bullied. Three subthemes also emerged: despair, love of being a nurse, and resilience. This study gave a voice to nurses affected by this problem, revealing special challenges they encounter and coping strategies they employ. Hospital administrators can use the findings of this study to create social change within nurses&rsquo; working environment by implementing policies that will keep their nurses safe and happily employed. Future research should focus on workplace bullying in the nursing field and how it affects patient safety.</p><p>

<p> The demand for psychiatry is driven by the amount of patients that require mental health services. In the United States, there is a growing need for mental health services. One in every 5 adults in America suffers from some type of mental illness; 1 in every 20 has a serious mental illness. In 2014, 60% of adults living with a mental illness did not receive treatment for it. The amendment of the Mental Health Parity and Addiction Equity Act by the Patient Protection and Affordable Care Act has expanded access to mental health services. However, although the accessibility to psychiatric services has increased, a shortage of psychiatrists has resulted in long wait times, creating challenges to meet the demand. Pacific Psychiatric Group is a direct pay, outpatient practice that offers mental health services at competitive, fixed cash rates. Insurance will not be accepted. The burden of overhead dealing with the bureaucracy and administration of insurance will be eliminated, which helps to keep costs low and allows providers to focus on the patient. Pacific Psychiatric Group&rsquo;s mission is to alleviate accessibility challenges and provide timely, high quality, personalized, patient-focused mental health services. This proposed business plan will demonstrate how Pacific Psychiatric Group plans to improve accessibility, transparency, and quality of psychiatric services in an effort to reduce the number of untreated individuals.</p><p>

<p> With the era of the baby boomers getting to an age where health care issues will be at an all-time high, the shortage of nurses is a problem many health care organizations are already facing. There is a huge opportunity for many nurses to get hired given the state of California requires facilities to maintain a nurse-to-patient ratio. These ratios vary depending on the severity level of the patient&rsquo;s illness or condition the unit admits. </p><p> The goal of the company is to be able to help hospitals, convalescent home, retirement centers and other skilled nursing facilities meet their patient satisfaction expectations by providing the nurses needed to maintain quality of care. Nurses that will be provided are Licensed Vocational Nurses, Registered Nurses and Nurse Practitioners. </p><p> The company will have a unique approach to market itself out of Long Beach to be accessible to both Los Angeles and Orange County population and facilities. This business plan will go over four different chapters of the Gomez Nurse Staffing Agency in topics such as Marketing, Feasibility, Laws and Regulations and Financial Statements.</p><p>

<p> This qualitative research study addressed the problem that the healthcare industry has no clear evidence of the academic competencies that influence the attainment of organizational success. The study was based on one case study at a Commission on Accreditation of Healthcare Management Education (CAHME) accredited Masters of Health Administration (MHA) program at an Illinois University Case Site. The case study explored the various perspectives related to the value of academically prepared leaders along with the emerging competencies required to prepare the future healthcare leadership pipeline. The research followed a hermeneutic approach of 22 semi-structured interviews with four sub-groups of faculty and alumni from the university case site along with healthcare administrators and human resource executives using a criterion-based snowball strategy. The open systems theoretical lens and criterion based snowball strategy implicated leadership&rsquo;s impact and influence to sustain change within teams. These interviews were designed to uncover the practical nature of healthcare competencies as key predictors for successful professional development programs, as well as barriers for professionalization. The participants indicated that interpersonal skills, conceptual skills, and technical skills were vital for healthcare administration competencies and professionalization. Traditional knowledge-based programs, tactical training, and a balanced blend conceptual and interpersonal skills emerged as a compulsory enhancement to the fundamental deliverables of core curriculum. Future research should include defining the specific core competencies and factors that influence the success or failure of formal education initiatives that provide the requirements necessary for organizations to build strong leadership, developing solid succession strategies, and creating educational accountabilities to deliver safe and high quality outcomes for key stakeholders. Additional recommendations for future research should focus on quantitative initiatives that measure the value of core leadership competency and the incorporation of those skill into the healthcare delivery system. Several analogous barriers were uncovered among each sub-group for consideration in the standardization of competencies for the professionalization of leadership positions in healthcare administration. Future research should explore enhanced objectivity in the execution of succession planning programs. Additionally, further research will be needed to uncover which licensure tools provides the best assurance that core competencies are being met.</p><p>

<p> Ambulatory care comprises a major and increasingly important part of the U.S. and other countries&rsquo; health care sectors. Every year in the U.S., about 80% of the population seeks care at a doctor&rsquo;s office, amounting to one billion visits. These visits divide almost equally between primary care and specialty clinic organizations. Diagnostic work is part of most ambulatory care, and central to over 40% of patient visits that originate due to a new problem or a flare-up of an ongoing chronic problem. Yet, the risks associated with diagnostic failures have not garnered much attention from health care leaders and policy makers until a recent National Academy of Medicine (NAM 2015) report synthesized research data with the statement that &ldquo;most people will experience at least one diagnostic error in their lifetime, sometimes with devastating consequences.&rdquo; This dissertation first reviews organizational theories and measurement challenges relevant to diagnostic safety and quality in the context of ambulatory care, and then presents three papers analyzing specific organizational factors hypothesized to enable or thwart an accurate and timely diagnosis. The first paper targets delayed diagnosis from missed evidence-based monitoring in high-risk conditions (e.g., cancer) within five specialty clinics in an urban publicly funded health system. The second paper analyzes staff-reported office problems that could lead to diagnostic error (e.g., not having test results when needed) in over 900 primary and specialty clinics across the nation. The third paper examines the associations between two types of time pressure (i.e., encounter-level and practice-level), organizational factors, and patient effects including perceptions of missed diagnostic opportunities. The three primary conclusions from this work are 1) organizational vulnerabilities for missed monitoring common to the different clinics included challenges with data systems, communications handoffs, population-level tracking, and patient activities, leading to the development of &lsquo;design seeds&rsquo; for context-flexible solutions to improve diagnostic quality; 2) two organizational factors&mdash;stage of health information technology (HIT) deployment and patient safety culture are associated with diagnostic-related office problems, and 3) encounter and practice-level time stressors in primary care clinics are associated with perceptions of greater adverse effects on diagnosis and treatment, and worse patients&rsquo; experiences of chronic care from the clinic team, respectively, as well as associated with several organizational factors including HIT, patient-centered culture, relational coordination for interdependent teamwork, and leadership facilitation of changes to address frontline practice challenges. Taken together, the dissertation papers also demonstrate the applicability of the NAM Improving Diagnosis Conceptual Framework for research on ambulatory care organizations. </p><p>

This dissertation investigates whether differences in organizational innovation amongst health care providers can explain the huge variation in costs and outcomes. I specifically consider two facets of organizational innovation: the deployment of information technology and the relationships between hospitals and physicians. In the first chapter, I investigate IT adoption in a service setting by considering the impact of electronic medical records (EMRs) on the length of stay and clinical outcomes of patients in US hospitals. To uncover the distinct impacts of EMRs on operational efficiency and care coordination, I present evidence of heterogeneous effects by patient complexity. I find that EMRs have the largest impact for relatively less complex patients. Admission to a hospital with an EMR is associated with a 2\% reduction in length of stay and a 9\% reduction in thirty-day mortality for such patients. In contrast, there is no statistically significant benefit for more complex patients. However, I present three additional results for complex cases. First, patients returning to the same hospital benefit relative to those who previously went to a different hospital, which could be due to easier access to past electronic records. Second, computerized order entry is associated with higher billed charges. Finally, hospitals that have a high share of publicly insured patients, and hence a bigger incentive to curb resource use, achieve a greater reduction in length of stay for complex patients after EMR adoption. In the second chapter, co-authored with Robert Huckman, I investigate the role of process specialists in guiding customers through such complex service transactions by considering the management of patients admitted to U.S hospitals. Traditionally, a patient's primary care physician has been in charge of his or her hospital admission. Over the past decade, however, there has been a steady rise in the use of hospitalists - physicians who spend all their professional time at the hospital - in managing inpatient care. Using data from the American Hospital Association and the Agency for Healthcare Research and Quality's Nationwide Inpatient Sample (NIS) database, we find that hospitals with hospitalist programs achieve reductions in the risk-adjusted length of stay of inpatients over the time period 2003 to 2010. The effect is strongest for complex patients who have a higher number of comorbidities. Our findings support the view that process specialists such as hospitalists are particularly beneficial for complex transactions that entail a greater degree of coordination. In the final chapter, I document the positive relationship between consolidation in the health care industry and technology adoption. I propose several mechanisms that could explain the association between the adoption of electronic medical records and greater hospital-physician integration. I show that the positive correlation between technology adoption and hospital consolidation has been increasing over time. I show that hospitals located in concentrated markets are more likely to adopt electronic medical records and to use hospitalists. Moreover, for a limited set of hospitals, the quality of management is positively associated with the adoption of electronic medical records and the use of hospitalists. / Business Economics

In this dissertation, we propose methodology to account for missing data as well as a strategy to account for outcome heterogeneity. Missing data occurs frequently in empirical studies in health and social sciences, often compromising our ability to make accurate inferences. An outcome is said to be missing not at random (MNAR) if, conditional on the observed variables, the missing data mechanism still depends on the unobserved outcome. In such settings, identification is generally not possible without imposing additional assumptions. Identification is sometimes possible, however, if an exogeneous instrumental variable (IV) is observed for all subjects such that it satisfies the exclusion restriction that the IV affects the missingness process without directly influencing the outcome. In chapter 1, we provide necessary and sufficient conditions for nonparametric identification of the full data distribution under MNAR with the aid of an IV. In addition, we give sufficient identification conditions that are more straightforward to verify in practice. For inference, we focus on estimation of a population outcome mean, for which we develop a suite of semiparametric estimators that extend methods previously developed for data missing at random. Specifically, we propose inverse probability weighted estimation, outcome regression based estimation and doubly robust estimation of the mean of an outcome subject to MNAR. For illustration, the methods are used to account for selection bias induced by HIV testing refusal in the evaluation of HIV seroprevalence in Mochudi, Botswana, using interviewer characteristics such as gender, age and years of experience as IVs. The development of coherent missing data models to account for nonmonotone missing at random (MAR) data by inverse probability weighting (IPW) remains to date largely unresolved. As a consequence, IPW has essentially been restricted for use only in monotone MAR settings. In chapter 2, we propose a class of models for nonmonotone missing data mechanisms that spans the MAR model, while allowing the underlying full data law to remain unrestricted. For parametric specifications within the proposed class, we introduce an unconstrained maximum likelihood estimator for estimating the missing data probabilities which is easily implemented using existing software. To circumvent potential convergence issues with this procedure, we also introduce a constrained Bayesian approach to estimate the missing data process which is guaranteed to yield inferences that respect all model restrictions. The efficiency of standard IPW estimation is improved by incorporating information from incomplete cases through an augmented estimating equation which is optimal within a large class of estimating equations. We investigate the finite-sample properties of the proposed estimators in extensive simulations and illustrate the new methodology in an application evaluating key correlates of preterm delivery for infants born to HIV infected mothers in Botswana, Africa. When a risk factor affects certain categories of a multinomial outcome but not others, outcome heterogeneity is said to be present. A standard epidemiologic approach for modeling risk factors of a categorical outcome typically entails fitting a polytomous logistic regression via maximum likelihood estimation. In chapter 3, we show that standard polytomous regression is ill-equipped to detect outcome heterogeneity, and will generally understate the degree to which such heterogeneity may be present. Specifically, nonsaturated polytomous regression will often a priori rule out the possibility of outcome heterogeneity from its parameter space. As a remedy, we propose to model each category of the outcome as a separate binary regression. For full efficiency, we propose to estimate the collection of regression parameters jointly by a constrained Bayesian approach which ensures that one remains within the multinomial model. The approach is straightforward to implement in standard software for Bayesian estimation. / Biostatistics