Canada is challenged with a perceived nursing shortage. Better understanding of the factors that influence satisfaction and turnover may help to formulate improved strategies for retention of the nursing workforce. Our analysis revealed that satisfaction levels in both the job and the nursing profession are high in the Canadian nursing workforce corresponding to relatively high retention rates in the workforce. We found that dissatisfaction with the job and nursing are distinct concepts that are intrinsically associated. Dissatisfaction in the job significantly increased the likelihood of dissatisfaction with being a nurse and vice versa for RNs. Also, nurses were more likely to express intentions to switch jobs than intentions to leave nursing. Job dissatisfaction was the strongest predictor for both the intentions to leave nursing and switch jobs. The findings suggest that targeting both the job structures and the profession’s role would help to maintain and improve retention rates for nurses.

Methods to improve self-care and clinical management of heart failure are required, especially in light of the anticipated increase in heart failure prevalence and associated high costs. Remote patient monitoring (RPM) has been shown to improve heart failure outcomes, but the feasibility and efficacy of mobile phone-based RPM systems are still unknown. The main objectives of this research were to investigate the optimal design of a mobile phone-based RPM system, and to determine the effects of the system on self-care, clinical management, and health outcomes. A mobile phone-based RPM system was first developed using a user-centric design process. It was then evaluated with a six-month randomized controlled trial consisting of 100 patients attending a heart function clinic. The quality of life improved only for the intervention group, but both intervention and control groups improved with respect to self-care, heart function, and heart failure prognosis. The clinic was determined to be a confounder. Patients who were enrolled into the clinic for less than six months showed significantly greater improvements (six months is required for patients to stabilize from medication optimization). Therefore, a subgroup analysis using data from the 63 patients who were enrolled into the clinic for over six months at time of recruitment was performed. The results from the subgroup analysis indicated that the RPM system improved self-care, heart function, and heart failure prognosis at statistically significant and clinically meaningful levels. These improvements were found to be a result of enhanced self-care knowledge and practices, as well as enhanced clinical management enabled by the system. No differences in mortality or hospital admissions were found between groups, but the trial was underpowered to detect changes in these outcome measures. In summary, mobile phone-based RPM was found to be a feasible and effective tool to help improve heart failure management and outcomes.

Violence and traumatic brain injury (TBI) are two major public health concerns. This thesis is comprised of three different research topics; the epidemiology of intentional TBI in Ontario, discharge against medical advice (DAMA) as an undesirable outcome of acute stage, and functional changes after receiving rehabilitation care. To study these areas, three different datasets from the Canadian Institute for Health Information (CIHI) were used. The first epidemiological study on intentional TBI identified 1,409 (8.0%) intentional TBIs and 16,211 (92.0%) unintentional TBIs. Of the intentional TBIs, 389 (27.6%) were self-inflicted TBI (Si-TBI) and 1,020 (72.4%) were other-inflicted TBI (Oi-TBI). The most common causes of Si-TBI were “jumping from high places” and “firearms”. Major causes of Oi-TBI were ‘fight and brawl” and “struck by objects”. Si-TBI was associated with younger age, female gender, and having a history of alcohol/drug abuse. Oi-TBI was also associated with younger age and having an alcohol/drug abuse history and also with male gender. The second study on discharge against medical advice found that 446 (2.84%) TBI patients left hospitals without medical advice. DAMA was significantly associated with intentional injuries in those with self-inflicted TBI and other-inflicted TBI. DAMA was also associated with younger age and a history of alcohol/drug abuse. Using univariate analyses, the third study found that people with intentional TBI had significantly lower FIM gains in the motor area and significantly lower relative function gains (as measured by Montebello Rehabilitation Factor Score) in the cognitive area. Multivariate analyses of the same data showed that intentional TBI was also associated with lower cognitive relative gains, while controlling for age, gender, alcohol/abuse history, and other demographic and clinical variables. Persons with intentional TBI were found to be less likely to be discharged home, controlling for other relevant confounders. In conclusion, a person who has been injured due to assault or suicidal attempt may need more individualized care as they may be at greater risk for adverse rehabilitation outcomes. These findings regarding people with intentional TBI provide a basis for enhancing efforts on prevention of violence-related TBI and DAMA, and also for improving rehabilitation programs and discharge plans for this vulnerable population.

No systematic research has been undertaken in Canada on the relationship between hospital performance, organizational monitoring capacity and board governance. This three-part dissertation aims to fill that gap. The conceptual framework elaborated in a theoretical paper and tested in two exploratory empirical studies proposes that boards reflect their institutions, with high performers exhibiting greater capacity to harmonize accountability needs and align governance decision-making and monitoring systems with external performance measurement and reporting requirements. Top team (board and management) characteristics, and governance practices, both proposed elements of “governance capacity,” are hypothesized to reflect and reinforce “organizational monitoring and alignment capacity” thereby contributing directly and indirectly to key aspects of hospital performance including quality of care, financial health and patient satisfaction. Using hierarchical regression analyses, six hypotheses were tested on a sample of 101 acute hospital corporations that participated in the 2005, 2006 and 2007 Ontario Hospital Report Research Collaborative. After controlling for hospital size, evidence of a statistically significant relationship was detected between organizational monitoring and alignment capacity and quality performance, and between one element of governance capacity, governance practices, and financial performance. A relationship was also detected between governance practices and top team characteristics, including diversity, education and turnover. These findings suggest that the relationship between hospital governance and performance is tenuous and that some aspects of performance may be more amenable to governance influence than others. In highly-regulated environments governance space is circumscribed and myriad stakeholders have a stronger pulse on singular aspects of organizational performance than the board. This study argues that the role of boards in environments of distributed governance is to mine the ‘accountability web’ for timely, multivariate intelligence on performance and use it to drive alignment, integration and performance improvement. The contribution of this research, its limitations, and implications for researchers, policymakers and hospital leaders are discussed.

Concerns, Desires and Expectations Of Surgery For Adolescent Idiopathic Scoliosis: A Comparison Of Patients’, Parents’ & Surgeons’ Perspectives. Master of Science, 2008 Unni G. Narayanan Department of Health Policy, Management & Evaluation University of Toronto ABSTRACT This study explored the concerns, desires (goals) and expectations of adolescents undergoing surgery for idiopathic scoliosis, and contrasted their priorities with those of their parents and surgeons. Parents were more concerned than their children about the consequences of scoliosis and of surgery. With the exception of improving physical appearance, surgeons' goals of surgery were different from those of either the patients or parents. There was little agreement among surgeons about the natural history of scoliosis, other goals of surgery and the likelihood of specific outcomes. Parents wanted and expected more from surgery than their children. Parents and patients had greater expectations of surgery than surgeons. Although adolescents had different priorities from their parents, parents were aware of these differences and reliably predicted their children’s priorities. These findings have important implications on shared decision-making and informed consent, and might contribute to better understanding and measurement of outcomes that matter to patients.

Antipsychotic use is an important issue in long-term care (LTC) homes due to their widespread use, the potential for serious adverse events and limited evidence about their efficacy in treating behavioural and psychological symptoms of dementia. Rates of antipsychotic use vary across LTC homes, but little is known about the contribution of physicians to this variation. This study documented the characteristics of physicians who regularly treated residents in Ontario LTC homes and examined variation in antipsychotic prescribing across physicians. In a population-based retrospective cohort of LTC residents, 637 (52.8%) of 1,207 LTC physicians cared for 46,365 (90.4%) of all residents. Overall, 27.3% of residents received antipsychotic therapy, but extremely high prescribers prescribed antipsychotics to 42.8% of their patients. Variation in physician antipsychotic prescribing persisted after controlling for clinical and behavioural resident characteristics. This variation was reduced by 47.1% when LTC homes were accounted for in multilevel cross-classification logistic regression models.

Methods to improve self-care and clinical management of heart failure are required, especially in light of the anticipated increase in heart failure prevalence and associated high costs. Remote patient monitoring (RPM) has been shown to improve heart failure outcomes, but the feasibility and efficacy of mobile phone-based RPM systems are still unknown. The main objectives of this research were to investigate the optimal design of a mobile phone-based RPM system, and to determine the effects of the system on self-care, clinical management, and health outcomes. A mobile phone-based RPM system was first developed using a user-centric design process. It was then evaluated with a six-month randomized controlled trial consisting of 100 patients attending a heart function clinic. The quality of life improved only for the intervention group, but both intervention and control groups improved with respect to self-care, heart function, and heart failure prognosis. The clinic was determined to be a confounder. Patients who were enrolled into the clinic for less than six months showed significantly greater improvements (six months is required for patients to stabilize from medication optimization). Therefore, a subgroup analysis using data from the 63 patients who were enrolled into the clinic for over six months at time of recruitment was performed. The results from the subgroup analysis indicated that the RPM system improved self-care, heart function, and heart failure prognosis at statistically significant and clinically meaningful levels. These improvements were found to be a result of enhanced self-care knowledge and practices, as well as enhanced clinical management enabled by the system. No differences in mortality or hospital admissions were found between groups, but the trial was underpowered to detect changes in these outcome measures. In summary, mobile phone-based RPM was found to be a feasible and effective tool to help improve heart failure management and outcomes.

Violence and traumatic brain injury (TBI) are two major public health concerns. This thesis is comprised of three different research topics; the epidemiology of intentional TBI in Ontario, discharge against medical advice (DAMA) as an undesirable outcome of acute stage, and functional changes after receiving rehabilitation care. To study these areas, three different datasets from the Canadian Institute for Health Information (CIHI) were used. The first epidemiological study on intentional TBI identified 1,409 (8.0%) intentional TBIs and 16,211 (92.0%) unintentional TBIs. Of the intentional TBIs, 389 (27.6%) were self-inflicted TBI (Si-TBI) and 1,020 (72.4%) were other-inflicted TBI (Oi-TBI). The most common causes of Si-TBI were “jumping from high places” and “firearms”. Major causes of Oi-TBI were ‘fight and brawl” and “struck by objects”. Si-TBI was associated with younger age, female gender, and having a history of alcohol/drug abuse. Oi-TBI was also associated with younger age and having an alcohol/drug abuse history and also with male gender. The second study on discharge against medical advice found that 446 (2.84%) TBI patients left hospitals without medical advice. DAMA was significantly associated with intentional injuries in those with self-inflicted TBI and other-inflicted TBI. DAMA was also associated with younger age and a history of alcohol/drug abuse. Using univariate analyses, the third study found that people with intentional TBI had significantly lower FIM gains in the motor area and significantly lower relative function gains (as measured by Montebello Rehabilitation Factor Score) in the cognitive area. Multivariate analyses of the same data showed that intentional TBI was also associated with lower cognitive relative gains, while controlling for age, gender, alcohol/abuse history, and other demographic and clinical variables. Persons with intentional TBI were found to be less likely to be discharged home, controlling for other relevant confounders. In conclusion, a person who has been injured due to assault or suicidal attempt may need more individualized care as they may be at greater risk for adverse rehabilitation outcomes. These findings regarding people with intentional TBI provide a basis for enhancing efforts on prevention of violence-related TBI and DAMA, and also for improving rehabilitation programs and discharge plans for this vulnerable population.

Previous research has established a consensus that in-hospital adverse events are ubiquitous, cause significant harm to patients, and have important financial consequences. However, information on the extent, consequences and costs of adverse events in Canada is limited. For example, there is, as yet, no published study that has investigated the costs of adverse events in a Canadian context. This dissertation aims to redress this situation by providing Ontario-based estimates of the impact of eleven nursing sensitive adverse events on cost, death, readmission, and ambulatory care use within 90 days after hospitalization. This dissertation also aims to contribute more broadly to the patient safety literature by quantifying the impact of diagnostic coding error in administrative data on estimates of the excess costs attributable to adverse events. Given the increasing importance of these estimates in Canada and elsewhere for hospital payment policy and for assessments of the business case for patient safety, this is an important gap in the literature. Each of the adverse events was associated with positive excess costs, ranging from $29,501 (metabolic derangement) to $66,412 (pressure ulcers). Extrapolation from the study hospitals yielded a provincial estimate of $481 million in annual excess costs attributable to the adverse events, which represents 2.8 percent of Ontario’s total hospital expenditures. Several of the adverse events were also associated with significant excess rates of death, readmission, and ambulatory care use. These results suggest that there are economic as well as ethical reasons to improve patient safety in Ontario hospitals. Estimates of adverse event costs were highly sensitive to coding error. The excess cost of adverse events is likely to be significantly underestimated if the error is ignored. This finding, coupled with the observation that the likelihood of error is ignored in most studies, suggests that previous assessments of the business case for patient safety may have been biased against the cost effectiveness of patient safety improvements. Furthermore, the observed extent of institutional level variation in adverse event coding indicates that administrative data are an inadequate basis for adverse event payment policies or for public reporting of adverse event rates.

BACKGROUND: Teratology Information Services (TIS) educate the public and health professionals via telephone regarding the safety of drugs and other exposures during pregnancy and lactation. Currently TIS consultations are free, but funding is eroding. A cost-benefit analysis may inform resource allocation. It was hypothesized that an individual TIS consultation regarding anti-depressant use during pregnancy provides a positive net benefit compared to a family doctor (FD) consultation. METHODS: A survey of international TIS was conducted to gauge TIS costs. A discrete choice experiment (DCE) was designed to assess preferences and willingness-to-pay (WTP, an estimate of benefit) for teratology counseling. DCE respondents (local community volunteers) chose between potential counseling services following an anti-depressant exposure during pregnancy. Services were described by five service attributes and one cost attribute, which were generated in focus groups. Preferences and WTP were estimated using logit regression. Incremental benefits and costs of counseling by TIS and FD were compared in a probabilistic sensitivity analysis to obtain the incremental net benefit from both a societal (productivity costs included) and health system perspective. The FD consultation was costed through OHIP billing codes. The TIS consultation was micro-costed. RESULTS: Eighteen TIS in North America and 16 international TIS completed the survey. Most TIS are small (median two employees, median budget US$69,000). The DCE had 175 respondents. The most important attribute of counseling was receiving very helpful information; information delivery methods were less important. WTP for the TIS scenario was CDN$124 (SD $12); WTP for the FD scenario was CDN$79 (SD $8). Service costs were similar for TIS and FD (approximately $32/consultation); FD had higher productivity costs. Incremental TIS benefits were likely to outweigh costs under both the societal and health system perspectives (probability 99% and 97% respectively). CONCLUSIONS: An economic evaluation of a program that delivers pregnancy health information via telephone required a novel approach. While there are some methodological challenges to valuing benefits through willingness-to-pay, it may be appropriate for valuing counseling. TIS should emphasize their ability to provide high quality information. The benefits of an individual TIS consultation on anti-depressant use during pregnancy are likely greater than the costs.