Thesis (Ph. D.)--University of Washington, 1997. / Vita. Includes bibliographical references (leaves [170]-199).

Thesis (doctoral)--Lund University, 1998. / Added t.p. with thesis statement inserted.

Thesis (doctoral)--Lund University, 1998. / Added t.p. with thesis statement inserted.

Developing strategies to cope with increase in the ageing population and age-related chronic diseases is one of the societies biggest challenges. The characteristics of the ageing process shows significant inter-individual variation. Building genomic signatures that could account for variation in health outcomes with age may facilitate early prognosis of individual age-correlated diseases (e.g. cancer, coronary artery diseases and dementia) and help in developing better targeted treatments provided years in advance of acquiring disabling symptoms for these diseases. The aim of this thesis was to explore methods for diagnosing molecular features of human ageing. In particular, we utilise multi-platform transcriptomics, independent clinical data and classification methods to evaluate which human tissues demonstrate a reproducible molecular signature for age and which clinical phenotypes correlated with these new RNA biomarkers.

Background: Advance care planning (ACP) was originally designed to promote autonomy and is commonly conceptualised as informing treatment and decisions in the event of a person’s loss of capacity. In the UK, healthcare policy has emphasised the potential for ACP to significantly contribute to improvements in experiences of death and dying for patients and their significant others. Older people with progressive frailty are at high risk of mortality, loss of capacity and increasing dependency on carers and care services, yet uptake of ACP in this group is poor. Little is known about whether frail older people regard advance care planning as relevant or what perspectives they have on decision making for the future. Aim: To explore the expectations, experiences and understandings of frail older people and their significant others of planning for future care and to examine the implications of this for the practice of ACP. Methods: The study adopted an exploratory case study design using serial qualitative interviews and the responsive interview technique. Frail older people and their nominated carers were recruited from hospital wards in a large University Hospital NHS Trust prior to discharge. They took part in up to two interviews either in hospital or in their homes. Within and cross-case qualitative analysis was undertaken. Findings: Sixteen frail older people and eight significant others were recruited (Seventeen female, seven male, age range 70-96). The study found that frail older people experience profound uncertainty, associated with rapid changes to their physical and/or mental state and complex challenges in everyday life. Consequently, their attention is focused on day-to-day maintenance of quality of life, rather than on future care or advance decision making. Many had difficulty imagining a future; as dependency grew, so did reliance on care services to support their needs. What once would have been deemed an unacceptable way of living became routine. For many, the care system offers a lifeline without which they would not be able to exist at home. However, it also appeared to offer little individual flexibility, meaning that frail older people struggled to assert the control over day-to-day decisions and choices that others take for granted. This increasing dependency and reliance on care and care services has the potential to undermine the decision-making capacity of frail older people. For many, autonomous choice and decision making gave way to relationships, partnerships and negotiations that are commensurate with a more relational model of autonomy. Conclusion: The end-of-life orientation of current ACP policy and practice is at odds with the dynamic nature of frailty and does not correspond to individuals’ needs to maximise their current quality of life. The liberal ideal of autonomy as self-determination and self-interest presented by the legalistic and ideologically driven policy of ACP is out of step with the lived worlds of frail older people. For those facing increasing dependency on care and care services, frameworks that acknowledge a more relational approach when planning future care will be needed in order to engage this group of frail older people in ACP.

Heart failure is a common and serious chronic condition, which can be as ‘malignant’ as most forms of cancer (Stewart, MacIntyre, Hole, Capewell, & McMurray, 2001). Recent estimates are that around 40,000 men and 45,000 women are living with heart failure in Scotland (Stewart, MacIntyre, Capewell, & McMurray, 2003). Heart failure is significantly influenced by socioeconomic factors, with people on lower incomes being more likely to develop, and die faster from, heart failure (McAlister et al, 2004). There is a growing body of research on the experience of living with heart failure, however, none provides serious consideration of the role of socioeconomic factors in impacting the experience of heart failure, and some qualitative research may actually obscure such factors. There were two main aims in this thesis. One was to explore how qualitative research methods can better consider the relationship between experience and broader context, such as the influence of socio-economic factors on health. The other aim was to examine the experiences of people as they live with and die from heart failure in ways that situate their accounts in the broader context of their lives. An initial research study, on which I was the main researcher, focused on the experiences of 30 people living with advanced heart failure. These people, their carers and key health professionals were interviewed, where possible, three times over a six months period. This thesis re-examines that study, focusing on 20 of those participants, for which a total of 122 interviews were conducted. I used a dialogical approach to see whether the socioeconomic context of heart failure for these respondents, could be captured through exploring experiences, performance, relationships, discourses and institutional practices, the social processes that mediate the relationship between socioeconomic disadvantage and chronic diseases were explored. This offers important learning in relation to the experience of living with heart failure, along with the experience of providing care. The findings highlight the need to broaden our view of chronic illness beyond biomedical approaches, and grow our methodological approaches along with that, in order to develop knowledge and practice that has relevance for people who live with and die from heart failure.

No description available.

Thesis (M.D.) -- University of Texas Southwestern Medical Center at Dallas, 2007. / Vita. Bibliography: pp. 40-41.

This study was a cross-sectional epidemiologic evaluation of the clinical, sociodemographic, lifestyle and hospital utilisation characteristics of patients with diabetes, chronic obstructive pulmonary disease and chronic heart failure. Patients were enrolled in chronic disease management services of the Northern Alliance Hospital Admission Risk Program-Chronic Disease Management (Northern Alliance HARP-CDM Program). The program was established in accordance with the Department of Human Services’ (Victoria, Australia) initiative to intervene against increasing acute hospital demand by patients with chronic disease and complex needs. Amongst others, the Northern Alliance HARP-CDM Program provides services for patients with diabetes, chronic heart failure and chronic obstructive pulmonary disease. Patient cohorts with these three chronic diseases were the focus of this study. The Northern Alliance HARP-CDM Program catchment comprises of a culturally and linguistically diverse (CALD) population in the northern part of metropolitan Melbourne. Patients in this region mainly access acute hospital services at the Northern Hospital. The study sought to explore whether the CDM services enrolled patients whom based on their characteristics, fit the risk profile of the intended HARP-CDM target patient population. / The study cohorts demonstrated a CALD make up of above Victorian state averages. The majority (60%) were born overseas, preferred a language other English and were over 60 years old. In contrast to previously published studies, CALD did not demonstrate a significant contribution to disease control, quality of life or level of hospital utilisation. Place of residence for these patients showed clusters within some Local Government Areas. This has implications for service location, access and disease surveillance. Also, it presents opportunities for area targeted health promotion and prevention and overall service location. The majority (77%) of those with chronic heart failure had an abnormal left ventricular ejection fraction. The diabetes cohort was characterised by higher HbA1c (9%) than the target of less than 8%. Similarly the patients had greater than recommended waist circumferences (Males 106cm vs. 94cm; Females 106 vs. 80cm) places them at an increased risk of cardiovascular disease. For those with COPD, 42% had severe pulmonary impairment (FEV%predicted ≤ 40%) while 36% were moderate in the moderate category. / There was increased hospital utilisation with increasing age for those with COPD. With the exception of the diabetes cohort, there was no significant evidence as to the role of ethno-cultural factors in the study cohorts’ health, quality of life or level of hospital utilisation. However, ethno-cultural factors may contribute to the complexity of patient management processes and warrants further investigation. / Prior to enrolment in the Northern Alliance HARP-CDM Program, patients who could be considered high users of emergency department services made up 20% of those in the diabetes service, 43% in the COPD service and 50% amongst those in the CHF service. Similar figures for hospital admissions ranged from 20% for the diabetes services to 56% for the CHF service cohorts respectively. Although the diabetes service was the biggest of the three the majority of patients in the service had no previous history of acute hospital utilisation. Members of the diabetes service cohort were characterised by hospital utilisation rates lower than the Northern Hospital’s (ED: 34 vs. 72 per 100 patients, Admissions: 33 vs. 68 per 100 patients in the Pre HARP-CDM Period). Patients in the COPD service (ED: 115 Pre and 158 during HARP-CDM) and CHF service (160 Pre and 159 during HARP-CDM) had ED presentation rates per 100patients that were higher than the hospital’s (72 and 69). / The rates suggest the first 14 months of the Northern Alliance HARP-CDM Program were associated with increased hospital utilisation by patients enrolled the Northern Alliance HARP-CDM Program. The increments were greater than increases for the Northern Hospital for the same periods. Contrary to the intended goal of reducing acute hospital utilisation, the majority of the clientele did not fit the primary HARP-CDM Program criteria of high acute hospital users. But patients who were enrolled following previous hospital utilisation were well-targeted. However there are several patients who are likely HARP-CDM Program candidates who fall though the gaps between the acute hospital services and the program. / It is recommended the program and services increase enrolments and access for the target patient populations. There is a need for early intervention chronic disease management and health promotion. This service would cater for clients who by virtue of having a chronic disease are at risk but are currently not high acute hospital users. Such a service would free up vacancies in the Northern Alliance HARP-CDM Program, thus enabling increased intake and equitable access for the target patient population, especially those who fall though the gaps as referred to earlier. Funding for such a service is available through DHS. In light of strong evidence for exercise rehabilitation and its ability to positively impact patient outcomes, quality of life, survival and hospital utilisation, consideration needs to be given to this as part of the Northern Alliance HARP-CDM Program chronic disease management care model.

Self-rated health (SRH) is a commonly used measure in surveys. The associations of SRH in Canadian First Nations populations have not previously been fully studied. Univariate, bivariate, and multivariate analyses were conducted to determine how participants rated their health and what factors associated with SRH in a Manitoba First Nation. Respondents rated their health substantially worse than the general Canadian population. Men rated their health worse than women, and older adults rated their health worse than younger adults. In multivariate analyses, sex, hypertension, arthritis, the metabolic syndrome, number of chronic conditions, vision and mobility difficulties, perceived stress, perceived control over health and life, and community conditions were independently associated with SRH. These results suggest that asymptomatic conditions may be incorporated into the SRH of community members and suggest a complex interaction of health-related factors, stressors, and psychosocial factors that contribute to community members’ SRH.