In emergency medical transport, “time to definite care” is very important. Emergency medical services and transport medicine agencies have several possible vehicle options for interfacility transfers. Use of a land vehicle, helicopter, or fixed wing aircraft will be dependent on patient condition, distance between sending and receiving hospitals, crew configuration and capabilities, and other factors such as weather and road conditions. This thesis lays out the complex process of patient transfers and highlights the challenges in decision making under time pressure; it then describes the behaviour of human operators in estimating time to definite care. To support the operators in choosing a transportation mode, a decision support tool was built, which provides relevant time estimates for interfacility transfers based on historical dispatch and call data. The goal is to enable operators to make evidence-based decisions on vehicle allocation. A prototype interface was generated and was evaluated through a usability study.

Introduction : Les statines ont prouvé leur efficacité dans le traitement des dyslipidémies. Cependant, ces molécules sont associées à des effets secondaires d’ordre musculaire. Puisque ces effets peuvent avoir des conséquences graves sur la vie des patients en plus d’être possiblement à l’origine de la non-observance d’une proportion importante des patients recevant une statine, un outil pharmacogénomique qui permettrait d’identifier a priori les patients susceptibles de développer des effets secondaires musculaires induits par une statine (ESMIS) serait très utile. L’objectif de la présente étude était donc de déterminer la valeur monétaire d’un tel type d’outil étant donné que cet aspect représenterait une composante importante pour sa commercialisation et son implantation dans la pratique médicale courante. Méthode : Une première simulation fut effectuée à l’aide de la méthode de Markov, mais celle-ci ne permettait pas de tenir compte de tous les éléments désirés. C’est pourquoi la méthode de simulation d'évènements discrets fut utilisée pour étudier une population de 100 000 patients hypothétiques nouvellement initiés sur une statine. Cette population virtuelle a été dupliquée pour obtenir deux cohortes de patients identiques. Une cohorte recevait le test et un traitement approprié alors que l'autre cohorte recevait le traitement standard actuel—i.e., une statine. Le modèle de simulation a permis de faire évoluer les deux cohortes sur une période de 15 ans en tenant compte du risque de maladies cardio-vasculaires (MCV) fatal ou non-fatal, d'ESMIS et de mortalité provenant d’une autre cause que d’une MCV. Les conséquences encourues (MCV, ESMIS, mortalité) par ces deux populations et les coûts associés furent ensuite comparés. Finalement, l’expérience fut répétée à 25 reprises pour évaluer la stabilité des résultats et diverses analyses de sensibilité ont été effectuées. Résultats : La différence moyenne des coûts en traitement des MCV et des ESMIS, en perte de capital humain et en médicament était de 28,89 $ entre les deux cohortes pour la durée totale de l’expérimentation (15 ans). Les coûts étant plus élevés chez celle qui n’était pas soumise au test. Toutefois, l’écart-type à la moyenne était considérable (416,22 $) remettant en question la validité de l’estimation monétaire du test pharmacogénomique. De plus, cette valeur était fortement influencée par la proportion de patients prédisposés aux ESMIS, par l’efficacité et le coût des agents hypolipidémiants alternatifs ainsi que par les coûts des traitements des ESMIS et de la valeur attribuée à un mois de vie supplémentaire. Conclusion : Ces résultats suggèrent qu’un test de prédisposition génétique aux ESMIS aurait une valeur d’environ 30 $ chez des patients s’apprêtant à commencer un traitement à base de statine. Toutefois, l’incertitude entourant la valeur obtenue est très importante et plusieurs variables dont les données réelles ne sont pas disponibles dans la littérature ont une influence importante sur la valeur. La valeur réelle de cet outil génétique ne pourra donc être déterminée seulement lorsque le modèle sera mis à jour avec des données plus précises sur la prévalence des ESMIS et leur impact sur l’observance au traitement puis analysé avec un plus grand nombre de patients. / Introduction: Statins have proven their efficacy in the treatment of dyslipidemias. However, these molecules are associated with muscular side effects. Since these side effects may have adverse consequences on patients’ daily life and have an important role in the discontinuation of statin therapy in a large proportion of patients, it would be useful to develop a pharmacogenomic test that identifies a priori the individuals who are likely to develop statin-related muscular side effects (SRMSE). The objective of the present study was to determine of the monetary value of such a type of test considering that this aspect would represent an important component of its marketing and implementation into medical practice. Method: The first simulation was carried out using the method of Markov, but this one did not allow consider all the desired elements. This is why the discrete events simulation method have been used to study a population of 100 000 hypothetical patients newly initiated on a statin. This virtual population was duplicated to have two identical cohorts of patients. The first one was administered the test and a suitable treatment while the second received the current standard treatment—that is, a statin. The model allowed the two cohorts to evolve over a period of 15 years taking into account the risks of fatal and non fatal cardiovascular diseases (CVD), SRMSE and mortality from other causes than CVD. The consequences (CVD, SRMSE, death) incurred in these two populations and the associated costs were then compared. Finally, the process was repeated 25 times to assess the stability of the results and various sensitivity analyses were carried out. Results: The mean difference of CVD and SRMSE treatments, lost of human capital and drugs costs between the two cohorts was of 28.89 $, these costs being higher in the cohort who was not administered the test. However, the standard deviation with the average was considerable (416.22 $) calling in question the validity of the monetary estimate of the test pharmacogenomic.This difference varied a lot as a function of the proportion of patients being predisposed to SRMSE, the efficacy and the costs of the alternative treatments, the SRMSE cost, and the value assigned to one additional month of life. Conclusion: The results suggest that a test of genetic predisposition to SRMSE would have a value around 30 $ in patients who start a statin treatment. However, uncertainty surrounding the value obtained is very important and several variables for which the real data are not available in the literature have an important influence on the value. The real value of this genetic tool could thus be given only when the model is updated with more precise data on the prevalence of the ESMIS and their impact on the observance at the treatment and then analyzed with a higher number of patients.

While some individuals can successfully age at home, others with similar levels of need may require facility based long-term care (LTC). The question addressed in this thesis is: “What factors determine whether or not older persons age at home?” I argue that in addition to the characteristics and care needs of individuals (the demand side); access to home and community care (H&CC) at the local level (the supply side) determines whether or not older people receive care at home relative to other settings. In emphasizing the role of the supply side, I draw on Neoinstitutional Theory and the Theory of Human Ecology to examine how institutions of the state (policies, norms, values, and organizational structures) facilitate or constrain opportunities to age at home across urban and rural areas. In conducting my analysis I draw on the Balance of Care (BoC) framework to analyze the characteristics of individuals waiting for LTC placement in Thunder Bay (urban community) and the surrounding Region (rural communities) of Northwestern Ontario. The BoC framework provides the means to estimate the extent to which their needs could potentially be met in the community if home and community care (H&CC) services were available. The results show that individuals waiting for LTC placement in Thunder Bay experienced higher levels of impairment than those in the Region. However in both areas, most individuals required assistance with instrumental activities of daily living (e.g. housekeeping, meal preparation, etc). In both areas there was limited access to informal caregivers. If a H&CC package were to be made available, 8% of those waiting for facility based LTC in Thunder Bay could potentially be supported safely and cost-effectively at home compared to 50% in the surrounding Region. The results confirm that the supply side matters. When H&CC cannot be accessed, LTC may become the default option, particularly in rural and remote areas. If given access to H&CC, a significant proportion of individuals can potentially age at home.

While some individuals can successfully age at home, others with similar levels of need may require facility based long-term care (LTC). The question addressed in this thesis is: “What factors determine whether or not older persons age at home?” I argue that in addition to the characteristics and care needs of individuals (the demand side); access to home and community care (H&CC) at the local level (the supply side) determines whether or not older people receive care at home relative to other settings. In emphasizing the role of the supply side, I draw on Neoinstitutional Theory and the Theory of Human Ecology to examine how institutions of the state (policies, norms, values, and organizational structures) facilitate or constrain opportunities to age at home across urban and rural areas. In conducting my analysis I draw on the Balance of Care (BoC) framework to analyze the characteristics of individuals waiting for LTC placement in Thunder Bay (urban community) and the surrounding Region (rural communities) of Northwestern Ontario. The BoC framework provides the means to estimate the extent to which their needs could potentially be met in the community if home and community care (H&CC) services were available. The results show that individuals waiting for LTC placement in Thunder Bay experienced higher levels of impairment than those in the Region. However in both areas, most individuals required assistance with instrumental activities of daily living (e.g. housekeeping, meal preparation, etc). In both areas there was limited access to informal caregivers. If a H&CC package were to be made available, 8% of those waiting for facility based LTC in Thunder Bay could potentially be supported safely and cost-effectively at home compared to 50% in the surrounding Region. The results confirm that the supply side matters. When H&CC cannot be accessed, LTC may become the default option, particularly in rural and remote areas. If given access to H&CC, a significant proportion of individuals can potentially age at home.

The intent of this project was to integrate an existing mobile phone-based telemonitoring system into a home care nursing environment. Analyses were conducted to examine nursing workflows and home care constraints. User-centric design, development, and testing were used to modify the current telemonitoring system for a home care pilot study with heart failure clients. Interim results show technology acceptance by home care nurses and improved self-awareness in clients; the telehomecare system offers its greatest value as an opportunity for client education following clinical alerts. The pilot study will continue with a focus on increased client recruitment and selectivity towards those most in need of chronic disease management. It is expected that the system will result in an improvement in health outcomes and more efficient delivery of home care visits. The results from this study will provide insight into the impact of a new service delivery model for home care nurses.

Proliferation of ethics programs in healthcare organizations has occurred without rigorous evaluation. This qualitative study explored what makes an ethics program effective from the perspective of 15 practising ethicists across Canada. Objectives were to: describe how practising ethicists define ethics program effectiveness, identify evaluation strategies, and identify critical success factors. Ethicists defined effectiveness as: 1) meeting standards; 2) making a difference; and 3) delivering value for investment. To evaluate, ethicists assessed: ethics program activity data, qualitative feedback, relevant accreditation results, peer review, and pre- and post- results. Ethicist competencies and attributes, organizational understanding of, and support for, the ethics program, and a community of practice were critical success factors. Effectiveness emerged as a multi-dimensional concept. Findings provide a preliminary outline of what an ethics program evaluation framework might include and inform practice standard development, ethicist training programs, and organizational oversight for ethics programs.

Proliferation of ethics programs in healthcare organizations has occurred without rigorous evaluation. This qualitative study explored what makes an ethics program effective from the perspective of 15 practising ethicists across Canada. Objectives were to: describe how practising ethicists define ethics program effectiveness, identify evaluation strategies, and identify critical success factors. Ethicists defined effectiveness as: 1) meeting standards; 2) making a difference; and 3) delivering value for investment. To evaluate, ethicists assessed: ethics program activity data, qualitative feedback, relevant accreditation results, peer review, and pre- and post- results. Ethicist competencies and attributes, organizational understanding of, and support for, the ethics program, and a community of practice were critical success factors. Effectiveness emerged as a multi-dimensional concept. Findings provide a preliminary outline of what an ethics program evaluation framework might include and inform practice standard development, ethicist training programs, and organizational oversight for ethics programs.

The intent of this project was to integrate an existing mobile phone-based telemonitoring system into a home care nursing environment. Analyses were conducted to examine nursing workflows and home care constraints. User-centric design, development, and testing were used to modify the current telemonitoring system for a home care pilot study with heart failure clients. Interim results show technology acceptance by home care nurses and improved self-awareness in clients; the telehomecare system offers its greatest value as an opportunity for client education following clinical alerts. The pilot study will continue with a focus on increased client recruitment and selectivity towards those most in need of chronic disease management. It is expected that the system will result in an improvement in health outcomes and more efficient delivery of home care visits. The results from this study will provide insight into the impact of a new service delivery model for home care nurses.

Purpose: Patients’ perspectives of informed consent for chiropractic care have not been investigated. This study explored how patients of chiropractors perceived the exchange of risk information during informed consent. Methods: Interviews were conducted with 26 participants, recruited from chiropractic clinics. Interview transcripts were analyzed using a constant comparative method of analysis. Findings: Participants experienced informed consent as an on-going process where risk perceptions were shaped throughout four distinct stages. In the first stage information acquired prior to arriving at the clinic for treatment shaped perceptions of risk. In the second stage participants assessed the perceived competence of the practitioners. Participants then signed the consent form and discussed the risks with t heir practitioner. Finally, they communicated with their practitioners during treatment to ensure their pain threshold was not crossed. Conclusion: These findings suggest that patients perceive informed consent as a social process involving on-going communication with their practitioners.

This study investigates the use of five broad accountability mechanisms by gathering the perceptions of charities involved in the Canadian effort to reduce under-5 mortality abroad. While annual deaths in children under the age of 5 declined from an estimate of over 24.0 million in 1960 to under 8.0 million in 2010, mortality reduction goals have been established and missed for decades. As worldwide economies worsen, the amount of funds available for development assistance can be expected to decrease. This study seeks to determine if having accountability mechanisms is perceived to improve organizational behaviour, results and/or reduce costs. It uses a mixed methods approach including: a literature review to gain an understanding of accountability, effectiveness, development and under-5 mortality; key informant interviews to gain an understanding of funders, charities and development; a survey to gather the information required to answer the research questions; and a multiple-case study to gain a better appreciation of how accountability is used and to gather evidence of survey responses. The study investigates: which accountability mechanisms charities have, why they have them and the associated accountability holders; standards body memberships; the relationship between accountability mechanisms and various organizational characteristics; and the perceived effects of accountability mechanisms on organizational behaviour, results and costs. The survey finds that: charities say that they adopt accountability mechanisms because it is a good management practice that is perceived to improve organizational behaviour and results while not incurring costs in excess of the benefits; charities are more likely to adopt accountability mechanisms due to internal pressures than external pressures; the use of accountability mechanisms increases with organization size; and there is a greater difference in use of accountability mechanisms between small and large charities than there is between medium and large charities. The multiple-case study confirms the survey results. This study fills a gap in the literature by providing a Canadian perspective on the use of accountability mechanisms and the relationships amongst them and their perceived effects on organizational behaviour, results and costs. As economic burdens increase, increased accountability may lead to improved results even with fewer dollars.