The process of patient care relies on clinical data spread across specialized hospital departments. Powerful software is being designed to assimilate this disconnected patient data before treatment can be decided. However, these data are often presented to clinicians on interfaces that do not fit clinical workflows, leading to poor operational efficiency and increased patient safety risks. This project relies on ethnographic design methods to create evidence of clinician preferences pertaining to the presentation and collection of information on user interfaces in patient rooms. Using data gathered in clinical observation, a prototype interface was designed to enable doctors to conduct clinical tasks through a usable patient room interface. The prototype evaluation with doctors identified clinical tasks that are relevant in the patient room and provided insight into the perceived usability of such an interface. The evaluation sessions also elucidated on issues of patient-centeredness in technology design, effortless authentication and interface customizability.

Chronic disease is rising globally, but LMICs may require novel approaches to management suited to a low-resource setting. Private health care providers in LMICs have experimented and developed new models for organizing, financing, and delivering care. This thesis examines some of the innovations that have emerged in LMICs to manage chronic disease. Using a common performance measurement framework and drawing from a database of over 1200 innovative health programs, I identify and evaluate 46 programs addressing chronic disease in LMICs. I then go on to identify, innovative practices used by the subset of 19 diabetes focussed programs and catalogue them according to the Chronic Care Model (CCM). Delivery system design is the most commonly used domain of the CCM, which even earlier has shown to have great potential to impact health outcomes. Few of the identified innovations may also have the potential for ‘Reverse innovation’ in high income countries.

Background: Intensity Modulated Radiation Therapy (IMRT) is a method of delivering high-dose radiation to tumours while sparing surrounding healthy tissues. Despite its wide availability IMRT utilization varies across Ontario. The study’s objective was to examine key steps in the implementation process and identify factors that facilitate or impede IMRT implementation. Research Methods: An embedded multiple case study design, utilizing document analysis and key-informant interviews, was employed. Four cancer centres were selected and key-informant interviews were conducted with radiation oncologists, physicists, radiation therapists, and administrators. Results: Eighteen of 21 invited key-informants participated (86% participation rate) providing a range of insights on the factors influencing IMRT implementation. Overall, three cases made progress in the implementation of IMRT, while one case had limited implementation over the same time period. Conclusion: These findings help explain the observed variation in IMRT implementation across Ontario, which is multifaceted and reflects ongoing processes of change and reinvention.

Objective: To complete a cost-minimization analysis (CMA) of the cost of sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) in the management of early-stage breast cancer (ESBC) in a hypothetical Ontario hospital setting. Methods: Decision-analysis modeling, with a decision-tree and Markov states, was used to estimate hospital costs for the two treatment options. The model was populated with data from the literature and costs from the Ontario Case Costing Initiative, a publicly accessible, government-sponsored, costing database. Model variability and parameter uncertainty were quantified by probabilistic sensitivity analysis (PSA). Results: The SLNB treatment algorithm was cost-minimizing compared to the ALND-only treatment option. The costs of treating postoperative complications did not contribute to the incremental average cost. Conclusion: A treatment algorithm that involves SLNB as the initial axillary-staging procedure in the setting of ESBC offers a cost-savings over the ALND-only option. This result is generalizable to all Ontario hospitals.

In April 2008, the Ontario government announced its top two healthcare priorities for the next 4 years, one of which is reducing wait time in emergency rooms. To study the wait time in emergency rooms or any other departments in a hospital, one must investigate resource planning, scheduling, and utilization within the hospital. This thesis provides hospitals with a set of simulation and optimization tools to help identify areas of improvement, particularly when there are a number of alternatives under consideration. A simulation tool (a Monte Carlo simulation model) estimates patient demand for beds in a hospital during a typical week. Two optimization tools (an integer programming mathematical model and a heuristics model) demonstrate opportunities for smoothing the patient demand for beds by adjusting the operating room schedule.

Aims: To investigate the natural history of CHC, estimate the disease burden of CHC, and assess the cost-effectiveness of screening for CHC among immigrants living in Canada. Methods: A retrospective cohort study compared the prognosis of CHC between immigrant patients and native-born patients who had advanced fibrosis. A cross-sectional study assessed the association between obesity and hepatitis C viremia. The disease burden of CHC among immigrants was estimated through Markov cohort model. The cost-effectiveness of screening for CHC was assessed among immigrants. Results: The retrospective cohort study including 318 patients demonstrated that immigrant patients had significantly higher risk of hepatocellular carcinoma than Canadian-born patients (p=0.005). The hazard ratio associated with ‘immigrant’ for hepatocellular carcinoma in multivariate Cox proportional-hazards analyses reduced to the least and non-significant (p=0.318) after adjusting age and type 2 diabetes. The prevalence of obesity in 1118 individuals tested positive for hepatitis C antibody was 28.8%. Multiple regression analyses and propensity score methods suggested a significant association between obesity and hepatitis C viremia. The disease burden study estimated that immigrants with CHC had much shorter average life years (26.9 years vs. 39.1 years) and quality adjusted life years (20.6 years vs. 32.4 years) than the age matched immigrants without CHC. The cost-effectiveness study indicated that screening for CHC among immigrants from 183 countries (72.1% of immigrant population in Canada) had an incremental cost-effectiveness ratio less than $50,000 per quality adjusted life year gained. Conclusion: Immigrant patients with CHC could have a higher risk of HCC than native-born patients. The significant association between obesity and hepatitis C viremia could explain the observed high prevalence of type 2 diabetes in patients with CHC. CHC reduces the average life expectancy of immigrants with CHC more than 10 years. Screening for CHC is cost-effective among over 70% of immigrants living in Canada.

Background: Intensity Modulated Radiation Therapy (IMRT) is a method of delivering high-dose radiation to tumours while sparing surrounding healthy tissues. Despite its wide availability IMRT utilization varies across Ontario. The study’s objective was to examine key steps in the implementation process and identify factors that facilitate or impede IMRT implementation. Research Methods: An embedded multiple case study design, utilizing document analysis and key-informant interviews, was employed. Four cancer centres were selected and key-informant interviews were conducted with radiation oncologists, physicists, radiation therapists, and administrators. Results: Eighteen of 21 invited key-informants participated (86% participation rate) providing a range of insights on the factors influencing IMRT implementation. Overall, three cases made progress in the implementation of IMRT, while one case had limited implementation over the same time period. Conclusion: These findings help explain the observed variation in IMRT implementation across Ontario, which is multifaceted and reflects ongoing processes of change and reinvention.

Objective: To complete a cost-minimization analysis (CMA) of the cost of sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) in the management of early-stage breast cancer (ESBC) in a hypothetical Ontario hospital setting. Methods: Decision-analysis modeling, with a decision-tree and Markov states, was used to estimate hospital costs for the two treatment options. The model was populated with data from the literature and costs from the Ontario Case Costing Initiative, a publicly accessible, government-sponsored, costing database. Model variability and parameter uncertainty were quantified by probabilistic sensitivity analysis (PSA). Results: The SLNB treatment algorithm was cost-minimizing compared to the ALND-only treatment option. The costs of treating postoperative complications did not contribute to the incremental average cost. Conclusion: A treatment algorithm that involves SLNB as the initial axillary-staging procedure in the setting of ESBC offers a cost-savings over the ALND-only option. This result is generalizable to all Ontario hospitals.

In April 2008, the Ontario government announced its top two healthcare priorities for the next 4 years, one of which is reducing wait time in emergency rooms. To study the wait time in emergency rooms or any other departments in a hospital, one must investigate resource planning, scheduling, and utilization within the hospital. This thesis provides hospitals with a set of simulation and optimization tools to help identify areas of improvement, particularly when there are a number of alternatives under consideration. A simulation tool (a Monte Carlo simulation model) estimates patient demand for beds in a hospital during a typical week. Two optimization tools (an integer programming mathematical model and a heuristics model) demonstrate opportunities for smoothing the patient demand for beds by adjusting the operating room schedule.

Objective: determine whether accreditation through Accreditation Canada is associated with more favorable resident safety in Ontario LTC homes and which facility characteristics are predictive of accreditation. Methods: logistic regression was used to determine predictors of accreditation. To examine the association between accreditation and safety, safety was operationalized as five MDS-RAI quality indicators: prevalence of falls, restraints, catheters, pressure ulcers, and infections. Separate multivariable models were developed for each indicator. Results: the odds of accreditation were approximately six times smaller for municipal (p < 0.001) and non-profit facilities (p < 0.001) relative to for-profits; three times greater for chains relative to non-chains (p < 0.001); and twice as large for urban relative to rural facilities (p = 0.04). Of the five quality indicators examined, only one (falls) was associated with accreditation. After adjusting for confounders, accredited homes were estimated to have 8% lower fall rates than non-accredited homes (p = 0.01).