Information technology [IT] that enables electronic access to patient health records has been widely recognized as a promising means to improve the quality of care for patients with chronic diseases, and reduce health care costs through better health information delivery and encouragement of self-management. IT applied to assist chronic disease management is inadequately studied in Canadian health care settings. This thesis describes the development and modest pilot implementation of an electronic tool, the Diabetes Complication Surveillance System [DCSS]. The DCSS was conceived as a self-monitoring tool that facilitates regular checks on conditions of diabetes patients, including acute and long-term complications. The DCSS is relatively unusual, as it facilitates glycemic control and also allows patients to address the long-term complications of diabetes. The development of the DCSS involved literature reviews and consultations with clinician experts. Questionnaire results from the pilot provided positive feedback.

Objectives: The concept of clinical champions has been widely promoted, yet empirically underdeveloped in health services literature. The objectives of this study are to investigate the role of the clinical champion and how it contributes to effective patient safety change. Methods: Case study design was used to examine the role of champions in the implementation of rapid response teams in two hospitals. Central themes were derived through qualitative analysis of semi-structured interviews with key informants. Results: Analysis revealed a typology of champions: clinical, managerial, and executive. Champions engaged in five core activities: disseminating knowledge, advocating, building relationships, navigating boundaries, and facilitating consensus. Individuals became champions by informal emergence or by formal appointment combined with informal emergence. Conclusions: This study furthered understanding of patient safety champions by revealing types, activities, and modes of emergence. Findings will allow health care professionals to use an evidence-based approach to identifying and supporting champions.

This study explored the current state of eHealth policy in Latin American and the Caribbean (LAC). It is based on a novel methodological approach to the conduct of systematic reviews of documents that are not always published in peer-reviewed journals. 33 countries were included in the study and 19 ICT and 7 eHealth policies were identified. A hybrid inductive and deductive content analysis approach was used to provide an in- depth analysis and comparison of existing national eHealth policies in LAC. The study found that there has been considerable progress in the establishment of ICT policies in the LAC region, but less so for eHealth policy specifically. The findings suggest that the establishment of a strategic framework that may guide and support decisions and choices in the development of national eHealth policies, could prove to be an essential tool in the successful implementation of eHealth in LAC.

Objective: To identify principles and rules used by stakeholders in making limit-setting decisions for publicly funded dental care. Methods: A purposive sample, including administrators, academics, funders, clinicians and community representatives was surveyed using a 28-item questionnaire, in the first round of a proposed three-round modified Delphi study. Using open and closed-ended questions participants made and explained decisions on prioritizing populations and services. Open-ended text was analyzed with a thematic qualitative approach using open and axial coding. Results: Consensus emerged on two rationing principles; achieving equity and providing essential care. Rules for eligibility were defined as the inability to pay and/or assume full personal responsibility for securing dental care. Inclusion/exclusion of treatment categories rested on relieving pain/infection, preventing disease and maintaining/restoring function. Conclusions: Stakeholders presented principles and rules that suggest extending the distribution of publicly funded dental care to include, at a minimum, essential services for those unable to afford care.

The purpose of this thesis was to analyze factors related to labour market survival and withdrawal behaviour in the profession of Occupational Therapy in Ontario from 1997 to 2006. To provide a portrait of the OT labour market in Ontario overall, and in relation to sector and age, three types of analysis were used: descriptive statistics (including “stay, switch, and leave” analysis), “Stickiness” and “Inflow” analysis, and survival analysis. The largest proportion of OTs worked in the Hospital sector, which had a great ability to retain OTs according to the “Stickiness” analysis. However, when controlling for other variables using survival analysis, none of the sector variables had a significant effect on survival. The youngest and oldest age groups had the highest propensity of leave, due to mobility, family commitments, and retiring (oldest group only). Overall, the profession in Ontario had a strong ability to retain OTs working in the profession during the study period.

Master of Arts / Department of Economics / Dong Li / Comprehensive worksite wellness programs were first introduced in the United States in the late 1970s and early 1980s, with the goals of improving health, reducing health care expenditures, and demonstrating senior management’s commitment to the health and well-being of workers (Ozminkowski et al, 2002). As the annual cost of employer-sponsored family health coverage increased four percent between 2012 and 2013 (Kaiser Family Foundation, 2013), many companies are turning to worksite wellness programs. Wellness programs have shown not only to reduce health care costs, but also decrease absenteeism and increase employee satisfaction. The studies on the benefits of wellness programs are not conclusive; there seems to be a general lack of good data collection and analysis. This report discusses what determines an employer’s likelihood of offering a wellness program, what determines an employee’s participation in a wellness program, and a benefits analysis of wellness programs.

Master of Science / Industrial & Manufacturing Systems Engineering / David H. Ben-Arieh / Telemental health systems, a form of telemedicine, use electronic communication media to provide patients in remote locations access to psychological and psychiatric specialists. The structure of telemental health systems has a major impact on their performance. Discrete-event simulations offer useful results concerning capacities and utilization of specific resources. Simulation, however, cannot provide theoretical properties of analyzed systems. Petri net representations of systems can overcome this shortfall, offering a wide range of easily-analyzed and useful properties. Their ability to model resource conflict, parallel activities, and failure modes fits nicely with the reality of telemental health systems. Analysis of behavioral properties of Petri nets can provide meaningful information for system analysts. The most useful properties include net boundedness, liveness, and non-reachability of certain undesirable states. The thesis discusses methods to find all these properties. Specifically, it provides property-preserving net reductions to facilitate analysis of boundedness and liveness and describes an integer programming model to solve reachability and coverability problems. Moreover, this thesis outlines a simulation analysis of synchronous and asynchronous telemental health systems. The paper then describes a Petri net model of a generic telemental health delivery system. The paper subjects the model to an integer programming model and net reduction. The integer programming model indicated that the number of resources in the system remains static, full utilization of resources at a given time is possible, conflict over resources is possible, and improper work prioritization is possible within the model. Net reduction and analysis with open-source software showed that the model is bounded and live. These results can aid telemedicine system architects in diagnosing potential process issues. Additionally, the methods described in the paper provide an excellent tool for further, more granular analysis of telemedicine systems.

Proponents of Canadian health reform in the 1990s argued for regional structures, which enables budget silos to be broken down and integrated budgets to be formed. Although regionalization has been justified on the basis of its potential to increase home care resources, political science draws upon the scope of conflict theory, which instead suggests marginalized actors, such as home care, may be at risk of being cannibalized in order to safeguard the interests of more powerful actors, such as hospitals. Prince Edward Island, Nova Scotia, and New Brunswick, constitute a natural policy experiment. Each has made different decisions about the regionalization model implemented to restructure health care delivery. The policy question underpinning this research is: What are the implications of the different regional models chosen on the allocation of resources to home care? Provincial governments are at liberty to fund home care within the limits of their fiscal capacity and there are no federal terms and conditions which must be complied with. This policy analysis used a case comparison research design with mixed methods to collect quantitative and qualitative data. Two financial outcomes were measured: 1) per capita provincial government home care expenditures and 2) the home care share of provincial government health expenditures. Hospital data was used as a comparator. Qualitative data collected from face-to-face, semi-structured interviews with regional elite key informants supplemented the expenditure data. The findings align with the scope of conflict theory. The trade-off between central control and local autonomy has implications for these findings: 1) home care in Prince Edward Island increased it share from 1.6% to 2.2% of provincial government health spending; 2) maintaining central control over home care in Nova Scotia resulted in an increase in its share from 1.4% to 5.4%, and 3) in New Brunswick, home care share grew from 4.1% to 7.6%. Inertia and entrenchment of spending patterns was strong. Health regions did not appear to undertake resource reallocation to any great extent in either Prince Edward Island or New Brunswick. Resource reallocation did occur in Nova Scotia where the hospital share of government spending went down and was reallocated to home care and nursing homes. But, Nova Scotia is the only province of the three in which home care was not regionalized. Regional interests in maintaining existing levels of in-patient hospital beds was clearly a source of tension between the overarching policy goals formulated for health reform by the provincial governments and the local health regions.

This dissertation involved linking a clinical cystic fibrosis (CF) data registry with administrative databases to evaluate clinical, demographic, and geographical predictors of hospitalization in CF patients living in Ontario over a 10 year period. In addition, this work assessed the ability of administrative data to identify individuals with CF using the clinical registry as the reference standard. Sex was an independent predictor of hospitalization rates for individuals with CF. Females had a significantly higher hospitalization rate compared to males even after adjusting for important clinical factors suggesting that this finding is not simply due to worse CF disease. In those between 7 and 19 years of age, the adjusted hospitalization rate was 38% higher in females (rate ratio[RR] 1.38, 95% confidence interval [CI] 1.11-1.73). Similarly in those over the age of 19, females had a 30% higher hospitalization rate compared to males (RR 1.30, 95% CI 1.06-1.59). Other significant predictors associated with higher hospitalization rates in both age groups were lower lung function, worse nutritional status, pancreatic insufficiency, and the presence of CF-related diabetes. The presence of Burkholderia cepacia complex in the sputum was a significant predictor in those over the age of 19 years (RR 1.54, 95% CI 1.26-1.89). Distance to CF centre, community size and socioeconomic status were not significant predictors of hospitalization rates in either age group. There was no significant trend in hospitalization rates over time once rates were adjusted for markers of disease severity (p=0.08). Comparing administrative data with the CF registry data, administrative data captured hospitalizations more comprehensively. Despite CF being a specific diagnosis, health administrative databases alone were insufficient to reliably and accurately identify individuals with CF unless they had been hospitalized. The reason for the gender disparity seen within this dissertation is likely multifactorial. There may be differences in outpatient management between the sexes, hormonal influences may modulate disease severity causing higher hospitalization rates, and patient and provider-level influences may affect the decision to hospitalize a patient. Further research is needed in this area to elucidate the factors contributing to this gender gap.

Coordination is a vital component in health care provision and teamwork. The need for better coordination is particularly prominent in outpatient setting where patients assume the primary responsibility to follow-up on their own health care, especially when treatment is complex and lengthy in duration. Relational coordination represents a type of informal coordination process reinforced by communication and supportive relationships. This concept has been associated with enhanced interprofessional team performance, including patient care outcomes. This study aimed to examine the theoretical underpinnings of relational coordination in the outpatient setting using social capital theory. It was hypothesized that social capital, resources embedded within network of relationships, would predict relational coordination. Additionally, social capital was hypothesized to be predicted by team tenure; and relational coordination was hypothesized to be predicted by formal coordination mechanisms. A non-experimental, cross-sectional survey design was used to examine the relationship between social capital and relational coordination. Participants (N=342) were physicians and nurses recruited from outpatient clinics in two University affiliated hospitals. Study surveys were sent to 501 nurses and 187 physicians with follow-up reminders sent at three, five and seven weeks after the initial distribution of surveys. The overall response rate was 49.71%. Study variables were measured using previously validated instruments with acceptable levels of reliability and validity. Structural equation modeling (SEM) was used for hypothesis testing. Final analysis revealed good fit of data to the hypothesized model (Chi-square=383.38, df=177, p<0.001; CFI=0.966; RMSEA=0.060; SRMR=0.0316). SEM revealed that social capital predicted both factors of relational coordination [communication (β=0.70, p<0.001); supportive relationship (β=0.81, p<0.001)], and team tenure predicted social capital (β=0.13, p<0.05). In addition, the association between team tenure and relational coordination (β=0.09, p<0.05) was found to be partially mediated by social capital. Findings of this study suggested that characteristics within relational ties are predictive of informal coordination. Administrators may facilitate teamwork through team building initiatives that foster these relational qualities, such as trust and shared language. Future research can further investigate the association between social capital and relational coordination in other health care settings, as well, in larger teams involving health care professionals in addition to physicians and nurses.