Thesis (M.S.)--Virginia Polytechnic Institute and State University, 1994. / Vita. Abstract. Includes bibliographical references (leaves 112-117). Also available via the Internet.

Thesis (Ph. D.)--University of Queensland, 1998. / Includes bibliographical references. Also issued online.

The Military Health Services System (MHSS) is one of the largest health care systems in the United States comprising over 115 hospitals, 471 clinics and an annual operating budget in excess of 15 billion dollars. In 1993, Congress directed the Secretary of Defense to implement a model of health care reform emphasizing the principles of managed care and regional contracting as cost containment tools, while improving the uniformity of aocess and benefit structure. The TRICARE program was proposed by the Department of Defense (DOD) and approved by Congress in 1994. TRICARE presents a triple option of a health maintenance organization, preferred provider organization, or a fee for service indemnity plan. The health maintenance organization option presents the greatest potential for cost savings to DOD through utilization management and large-scale, regional contracting to augment variability in the MRSS access and benefit structure. A twenty-four month population-based time series design presented significant changes in the utilization of ambulatory health services when subjects enrolled in a program grounded in managed competition within a budget. Improved access to an integrated health care system, including shifts to more cost-effective portals was found among the broader population as well as high-risk chronic subjects. The findings validate the theoretical constructs of managed competition under global budgets, previously untested in the literature. The data also refute concerns for high-risk populations to be undeserved and undercared for in managed care models of delivery. The DOD program with its variant of the Health Alliance or Health Insurance Purchasing Cooperative demonstrates that access to a national uniform benefit package, movement toward universal coverage, community rating, and cost-conscious decision making among consumers is a feasible mechanism for achieving the objectives of health care reform. The initial findings from DOD health care reform offer the first empirical and applied outcome evidence from one of the most important theoretical developments in health care policy and economics in the twentieth century.

The objectives of this study were to assess the construct validity and predictive validity of a previously published comorbidity classification scheme designed for use with administrative data. The scheme groups non-primary discharge diagnoses into a set of thirty comorbidity indicators, which may be used to describe and compare populations with respect to burden of comorbid illness. The scheme was developed on a large population of hospitalized patients in California in 1992 (training population) and the predictive effect of the indicators estimated with respect to the outcomes length of stay, hospital charges, and in-hospital death. The current study drew data from the Massachusetts Hospital Case Mix Data Base of 1992 (testing population). The effect of the comorbidity indicators on each outcome was estimated by fitting ordinary least squares regression (OLSR) models of length of stay and hospital charges, as well as logistic regression models of in-hospital mortality, to the testing population. The estimated effect of the comorbidity indicators on each outcome, adjusted for demographics and characteristics of index hospitalization, was compared between the training and testing populations. The characteristics of the testing population were largely similar to those of the training population. The relationship between burden of comorbid illness (as measured by the number of comorbidity indicators per patient) and the outcomes was comparable in the two populations. The estimated adjusted effect of the comorbidity indicators and the predictive ability of the OLSR models were comparable in the training and testing population with respect to the outcomes length of stay and charges. The estimated adjusted effect of the comorbidity indicators on in-hospital death was not comparable in the two populations. The results support construct validity and predictive validity of the comorbidity classification in Massachusetts discharge data in 1992. Other aspects of baseline risk must be accounted for separately. The estimated adjusted effect of the indicators in the training population on the outcomes length of stay and charges, but not in-hospital death, is generalizable to Massachusetts' discharge data and may be further generalizable. Practical application of the comorbidity indicators for comorbidity adjustment in epidemiological research should be further explored.

Thesis (M. Sc.)--University of Hong Kong, 1990. / Xerox of typescript.

Thesis (Ph.D.)--George Mason University, 2008. / Vita: p. 208. Thesis director: Roger Stough. Submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy in Public Policy. Title from PDF t.p. (viewed July 3, 2008). Includes bibliographical references (p. 196-207). Also issued in print.

Thesis (M.S.)--West Virginia University, 2000. / Title from document title page. Document formatted into pages; contains vi, 57 p. Vita. Includes abstract. Includes bibliographical references (p. 38-42).

Thesis (Ph. D.)--University of Wisconsin--Madison, 1974. / Typescript. Vita. eContent provider-neutral record in process. Description based on print version record. Includes bibliography.

Objective measures of clinical performance are needed before economics or Benchmarking can successfully maximize the efficiency of the health care system. In the Intensive care unit (ICU), mortality is one of the most important clinical outcomes and different tools have been developed to estimate its probability of occurrence (Acute Physiology and Chronic health Evaluation (APACHE), the Simplified Acute Physiology Score (SAPS), and the Mortality Probability Model (MPM)). By assigning probabilities of hospital mortality to each patient, these systems classify patients by severity and are useful for the control of confounding by severity, the discussion of prognosis with patients and their families and in the evaluation of performance. However, if poor fit exists in one particular ICU, this is consistent with differences in both, either performance or patient-mix between this ICU and those used to develop the model. Case mix is one of the most important biases in health care economical evaluations and severity models are still inappropriate to fully adjust for case mix. The objectives of this research were to describe how differences in diagnostic covariate pattern mix affect model fit and to explore adjustment methods for case mix when the ratio of observed to expected deaths is used to compare the performance of a study ICU with the overall performance of other ICUs. The maximum likelihood adjustment of rate ratios and the dummy variable method of adjustment for case mix are useful tools to adjust for changes in patient mix and could be applied to compare ICU quality performance. The proportional sampling method of adjustment for patient mix is not applicable in real life situations because it fails to adjust for patient mix, especially when an ICU has a lower overall mortality ratio (attributable to a particular patient mix), than the developmental data set.

This thesis is about UK healthcare decision-makers’ responses to guidance that a new interventional procedure is safe and efficacious, and whether additional information would be helpful.  The aims were to conceptualise how evidence could be used to best inform decision-making; investigate the ways in which decision-makers currently respond to such guidance; identify types of additional useful information, and assess the feasibility and value of providing these. The study was based on the UK Interventional Procedures Programme (IPP).  A multidimensional framework for categorising evidence (explanatory vs. pragmatic) was developed and tested using IPP-evaluated procedures.  A qualitative study explored how local NHS decision-makers respond to IPP guidance and whether additional information might be useful to them.  A range of approaches – from simple descriptive data, through evidence syntheses, to economic models of cost-effectiveness – were explored in a case study of radiofrequency ablation (RFA) for snoring. NHS decision-makers’ responses to IPP guidance varied and they indicated additional information would be helpful.  Available evidence on the effects of procedures went beyond ‘efficacy’.  The case study showed it was possible, within limitations, to provide useful additional information but at increasing costs as complexity increased. Decision-makers vary in their responses to IPP guidance.  Additional information (such as prevalence, incidence, costs and likely cost-effectiveness), which they indicated would be useful, is potentially available but the feasibility of providing this varies depending on the nature of the evidence available and the related costs.  The thesis indicates that the quality of decision-making would be improved if guidance that a new procedure is safe and efficacious were to be contextualised through specific extra information.