Thesis (M.H.S.A.)--University of Michigan, 1981.

Thesis (M.P.H.)--University of Michigan, 1947.

Thesis (M.H.S.A.)--University of Michigan, 1977.

Thesis equivalent (M.P.H.)--University of Michigan, 1947.

The impact of the introduction of hospital medical day care programs on inpatient use was studied, to see if there was a reduction in average lengths of stay, cases or patient days, for those diagnostic categories in the programs. The provincial government funded these programs to create an alternative to hospitalization. Studies on the issue of whether or not day care is an alternative or substitutes for inpatient use were examined. Interest in ambulatory care is growing because of the increasing age of the population, increasing duration of chronic illness and increasing costs of hospital services. Three programs at Lions Gate Hospital in North Vancouver, B.C. were chosen: Chronic Obstructive Lung Disease (CO.L.D.) program, Diabetic Day Care,and the Neuro (Neurology) program. The population for study were divided into four groups: those from North and West Vancouver who used Lions Gate Hospital, patients from the rest of the Greater Vancouver Regional District (G.V.R.D.) who used other G.V.R.D. hospitals, arid to allow for 'spill-out' cases, those from North and West Vancouver who used other hospitals in the province and those from the rest of the G.V.R.D. who used Lions Gate Hospital. The methodology involved the use of a multiple time series design which would allow some comparison before and after the introduction of the CO.L.D. program, as well as comparison between the North Shore and the rest of the G.V.R.D. A regression analysis, using a dummy variable for the CO.L.D. program, on average length, of stay, cases and patient days showed no statistically significant results. The data collection period, 1970 to 1979/80, does not provide conclusive answers for Diabetic Day Care, introduced at Lions Gate Hospital in 1966 and in some of the hospitals of the rest of the G.V.R.D. in 1972, or for the Neuro program, introduced at Lions Gate Hospital in 1979. However, population and age adjusted cases and patient days for all three programs are consistently higher in the rest of the G.V.R.D. when compared with North and West Vancouver and deserve further investigation. The implications from this study, that there is no impact from medical day care, programs on rates of inpatient use, is consistent with similar studies on Diabetic Day Care and Day Care Surgery. The health care system does not seem to be able to respond to innovations of this type and they are additions to existing services. / Medicine, Faculty of / Population and Public Health (SPPH), School of / Graduate

Objectives: This retrospective analysis was conducted to derive national estimates of typical, atypical, and combination (typical-atypical) antipsychotic use and to examine factors associated with their use at adult (age ≫-18 years) ambulatory care visits by patients with mental health disorders in the United States. Methods: Data on adult visits with an International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis code for a mental health disorder were extracted from the office-based National Ambulatory Medical Care Survey and the outpatient facilitybased National Hospital Ambulatory Medical Care Survey from 1996 through 2003. The visits were categorized according to whether use of a typical, atypical, or combination antipsychotic was mentioned (either prescribed, supplied, administered, ordered, or continued at the visits). Total weighted visit estimates, weighted visit percentages, and 95% CIs were calculated across the 3 types of visit groups. Bivariate analysis was performed on the association between selected characteristics and the 3 visit groups. Multivariate logistic regression was performed on factors associated with atypical versus typical antipsychotic use. Results: During the 8-year period, there were an estimated 47.7 million adult ambulatory care visits involving a mental health disorder and mention of an antipsychotic (weighted percent: 0.83%; 95% CI, 0.73-0.93). From 1996/1997 to 2002/2003, visits involving atypical and combination antipsychotics increased by 195% and 149%, respectively, and visits involving typical antipsychotics decreased by 71%. Men, blacks, and those with public insurance made more visits in which combination antipsychotics rather than typical or atypical antipsychotics were mentioned. Relative to typical or combination antipsychotic visits, more atypical antipsychotic visits involved antide-pressants (weighted percent: 61.23% atypical, 37.29% typical, and 38.32% combination). Fewer atypical antipsychotic visits compared with typical or combination antipsychotic visits involved psychotic disorders (weighted percent: 32.94%, 51.23%, and 69.93%, respectively) and medications for extrapyramidal symptoms (weighted percent: 6.69%, 29.95%, and 36.64%). In multivariate analyses controlling for sex, race, diagnosis of schizophrenia, region, diagnosis of anxiety, and recent years, atypical versus typical antipsychotic use was significantly less likely at visits by those aged 41 to 64 years compared with those aged 18 to 40 years (adjusted odds ratio [OR] = 0.63; 95% CI, 0.47-0.84; P = 0.002); significantly less likely at visits by those with public compared with private insurance (Medicare OR = 0.59 [95% CI, 0.40-0.88], P = 0.010; Medicaid OR = 0.44 [95% CI, 0.28-0.69], P < 0.001); and significantly more likely at visits associated with depression compared with those not associated with depression (OR = 1.92; 95% CI, 1.26-2.93; P = 0.003) and those associated with bipolar disorder compared with those not associated with bipolar disorder (OR = 2.10; 95% CI, 1.32-3.36; P = 0.002). Conclusions: This retrospective analysis found more atypical than typical or combination antipsychotic use at US ambulatory care visits by adults with mental health disorders other than schizophrenia or psychoses in the period studied. Atypical versus typical antipsychotic use was significantly less likely at visits by adults aged 41 to 64 years and those with public insurance, but significantly more likely at visits by those with depression or bipolar disorder.

Diss. (sammanfattning) Linköping : Univ., 2004. / Härtill 4 uppsatser.

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.

Enhancing primary care is key to the Canadian health care reform. Considered as an indicator of primary care access and quality, hospitalisations for ambulatory care sensitive (ACS) conditions are commonly reported by Canadian organisations as sentinel events signaling problems with the delivery of primary care. However, the literature calls for further research to identify what lies behind ACS hospitalisation rates in regions with a predominantly urban population benefiting from universal access to health care. A theoretical model was built and, using an ecological design, multiple regressions were implemented to identify which neighbourhood characteristics explained the socio-economic gradient in ACS hospitalisation rates observed in Ottawa. Among these neighbourhoods, healthy behaviour and - to a certain extent - health status were significantly associated with ACS hospitalisation rates. Evidence of an association with primary care accessibility was also signaled for the more rural neighbourhoods. Smoking prevention and cessation campaigns may be the most relevant health care strategies to push forward by policy makers hoping to prevent ACS hospitalisations in Ottawa. From a health care equity perspective, targeting these campaigns to neighbourhoods of low socio-economic status may contribute to closing the gap in ACS hospitalisations described in this current study. Reducing the socio-economic inequalities of neighbourhoods would also contribute to health equity.

Introdução: No tocante à terapêutica antineoplásica, há três tipos de tratamentos que podem ser aplicados isoladamente, sequencialmente ou concomitantemente: cirurgia, radioterapia e quimioterapia. A complexidade do tratamento requer uma assistência segura e de qualidade que se torna, ainda mais desafiadora quando o maior volume dos atendimentos acontece em regime ambulatorial. Desse modo, torna-se fundamental, o adequado gerenciamento dos recursos humanos, o qual se inicia com a previsão de profissionais. Nesse sentido, o método Workload Indicators of Staffing Need (WISN) desenvolvido pela Organização Mundial de Saúde, fundamentado na avaliação da carga de trabalho despendida pelos profissionais, baseia-se em padrões de tempo das intervenções/atividades de saúde, utilizando os dados estatísticos disponíveis nas instituições .Objetivo: Avaliar a aplicação do método Workload Indicators of Staffing Need (WISN) para dimensionar a equipe de enfermagem para o cuidado a pacientes oncológicos em regime ambulatorial. Método: pesquisa de campo observacional e documental, com abordagem quantitativa e amostra intencional, realizada nos Ambulatórios de Clínicas Integradas, Quimioterapia, Radioterapia e Hospital Dia de um hospital público, de grande porte, especializado em Oncologia, localizado no município de São Paulo, com diversos selos de qualidade. Para aplicação do método realizou-se o conjunto de operações nas etapas preconizadas. Os dados estatísticos das ausências previstas e não previstas, bem como os relativos à produção da equipe de enfermagem foram obtidos junto á Diretoria Geral de Assistência. O instrumento de coleta de dados foi composto por 38 intervenções/atividades. Para a identificação do tempo despendido nas intervenções/atividades foi aplicada a técnica amostragem do trabalho, com observação direta de 51 enfermeiros e 50 técnicos de enfermagem, em intervalo de cinco minutos, por 47 dias. O cálculo do tempo das intervenções/atividades de enfermagem fundamentou-se no tempo total disponível dos profissionais e na categorização das intervenções/atividades propostas pelo método em questão. Resultados: Foram realizadas 16322 observações, sendo 12,6% a amostra de reteste, com 85% de concordância no teste de confiabilidade entre as observadoras de campo e a pesquisadora. O quadro de profissionais de enfermagem necessários para atender a carga de trabalho, na maior parte dos setores estudados não apresentou discrepância em relação ao existente. Os padrões de tempo utilizados nos cálculos expressaram a realidade dos setores e todos os componentes foram considerados adequados para as categorias profissionais envolvidas. A observação direta e o estudo de tempos foram as formas utilizadas para obtenção dos padrões das intervenções com maior precisão. Conclusão: O método WISN mostrou-se adequado para dimensionar os profissionais, fornecendo evidências sobre o quadro necessário para os setores. Entretanto, sua utilização pressupõe como condição a disponibilidade de dados estatísticos completos e organizados sistematicamente sobre a carga de trabalho dos profissionais e dos setores. Os resultados forneceram uma visão geral das intervenções/atividades de enfermagem realizadas nos setores ambulatoriais, bem como elas distribuíram-se dentro do tempo de trabalho, o que pode subsidiar a revisão de alguns processos da assistência de enfermagem para melhor atender os pacientes. Os padrões de tempo encontrados, neste estudo, poderão ser referências para o dimensionamento de enfermagem e a aplicação do método Workload Indicators of Staffing Need (WISN), propiciando discussões e reflexões sobre o atendimento com qualidade e segurança aos pacientes oncológicos em regime ambulatorial. / Introduction: regarding antineoplastic therapy, there are three types of treatments which can be applied separately, sequentially or simultaneously: surgery, radiotherapy and chemotherapy. The complexity of the treatment requires safe and high quality assistance which becomes even more challenging when most health care takes place in the outpatient setting. Thus, the appropriate management of human resources becomes fundamental, which begins with staffing requirements. Therefore, the Workload Indicators of Staffing Need method, developed by the World Health Organization, substantiated on workers workload evaluations, is based on time patterns of the health activities/interventions, using statistical data available in the institutions. Objective: To evaluate the application of the Workload Indicators of Staffing Need (WISN) method to calculate the nursing workforce for oncology patient care in the outpatient setting. Method: documentary and observational field research with intentional sample and quantitative approach, conducted in the output departments of Clínicas Integradas (Integrated Clinics), Chemotherapy, Radiotherapy and Day Hospital of an accredited public oncology hospital, situated in the city of São Paulo. In order to apply the method, the group of operations / protocols were performed following the steps suggested. The absence and productivity statistical datum were obtained at the general assistance board department. The data collection instrument was combined of 38 interventions/activities. The work sampling technique was used to identify the time spent on the interventions/activities, with direct observation of 51 nurses and 50 nurse assistants, having 5-minute intervals during 47 days. The time calculation of the nursing interventions / activities was based on the workers total available time and the interventions / activities categorization proposed by the WISN method. Results: 16322 field observations were conducted, 12,6% was sample retest, with 85% agreement among field observers and the researcher. The nursing staffing required to manage the workload, and most of the departments observed have not shown discrepancies regarding the current. The time standards used in the calculations conveyed the reality of the departments and all the components were considered appropriate for the professional categories involved. The direct observation and the time study were used in order to obtain more accurate pattern interventions. Conclusion: The WISN method proved to be suitable to determine staffing requirements, providing evidence on staffing in each department. However, in order to apply the WISN method it is necessary to have complete and systematically organized statistical data of the workers workloads and the setting. The results showed a general view of the nursing interventions/activities in outpatient departments, as well as the distribution during workload, which may suggest the review of some nursing protocols in order to improve the patients assistance. The time standards found in this study may be reference to measure the nursing staffing requirements and to apply the WISN method, promoting discussions and critical thinking on providing oncology patients with safe and high quality assistance in the outpatient facility.