Background and Rationale: The increasing prevalence of type 2 diabetes, particularly in rural communities, is a major problem facing our nation. Many patients are in poor compliance with ADA guidelines for diabetes management. In addition, patients with diabetes in rural communities often face challenges that can impede management initiatives by health care providers (Utz, 2008). Quality care must be achieved to reduce the likelihood of costly, life-altering, and potentially fatal complications (American Diabetes Association, 2008). To manage chronic diseases effectively and prevent secondary complications, an organized quality review process within the practice setting should be in place to address quality indicators in an ordered and timely manner. Purpose and Aims: The purpose of this project was to develop a quality improvement initiative (electronic diabetes education flow sheet - DEFS) associated with managing type 2 diabetes in a rural, nurse practitioner-managed clinic. The specific objectives were 1) to evaluate the extent to which select type 2 diabetes quality indicators are met; 2) to develop, implement, and evaluate a diabetes education process for a rural, nurse practitioner-managed clinic; and 3) to implement a QI framework clinic personnel can use for future QI initiatives. Methods: The Plan-Do-Study-Act (PDSA) cycle was the framework used to implement the QI initiative. Process and outcome measures were collected for baseline data and the DEFS was developed. Routine evaluation by the QI committee ensured appropriate utilization of the DEFS. Patients receiving initial diabetes education were interviewed to understand their perspective of the education experience. For eight weeks, process data was reviewed to ensure improvements in diabetes education. Results: Data analysis of process measures showed inconsistent documentation of selected quality indicators. Outcome measures were controlled 62% to 70% of the time. Clinical staff successfully integrated the DEFS into patient education and expanded its use to ensure compliance. Limited numbers of patient volunteers prohibited analyzing patient feedback on the education process. Significance: This project demonstrated how QI initiatives can bring about positive changes in patient management. Based on this demonstration of how the PDSA cycle can be used to address clinical concerns, other rural nurse-managed clinics might use a similar method to implement QI initiatives to ensure quality healthcare.

Approved for public release; distribution is unlimited / The National Naval Medical Center (NNMC), Bethesda, Maryland, set as a strategic goal the improvement of internal efficiency among its many clinical activities. Clinical services lacked the ability to improve their statistical process, which relied on workload and expense data. Since the data systems had removed provider identifiers, it was impossible to produce data on provider productivity and efficiency. Numerous efforts to improve the clinical staff's efficiency were unsuccessful because of data integration limitations. Clinical service managers could not review their clinical service staff roster nor maintain the correct coding of personnel because they did not have access to the Standard Personnel Manpower System (SPMS). The step-wise approach business plan described in this thesis outlines the steps taken to generate productivity and efficiency feedback reports. These reports provided the clinical managers the necessary performance metrics to determine on a monthly basis how effectively their clinical services were operating. / Lieutenant, United States Naval Reserve

Class of 2006 Abstract / Objectives: To evaluate the group clinic patients’ visit satisfaction and self-efficacy assessments at baseline and six months after the implementation of the heart failure group clinic. Additional outcomes of interest included health service utilization and medication management. Methods: This study utilized a pre-experimental design to compare patients’ clinic visit satisfaction and self-efficacy assessments at baseline and six months. Demographic variables, diagnoses, vitals, health service utilization and medication management data were obtained retrospectively from the computerized patient record system (CPRS). Results: Eleven patients met the inclusion criteria, agreed to participate and completed the informed consent. Mean age was 64.1 years (± 11.28); 100% were male; 45.5% were white, not of Hispanic origin. Health service utilization could not be compared using the planned analysis because of the limited data available for this outcome. Medication management trends included titrating angiotensin-converting enzyme inhibitors (n=1), titrating beta-blockers (n=6), and converting from non-preferred HF medications to ACC/AHA guideline recommended agents (n=3). The mean self-efficacy score increased at follow-up when compared to baseline data (7.4 ± 1.7 versus 6.4 ± 2.7, respectively) with no statistical significance shown between the two groups (p=0.12). Additionally, the mean patient satisfaction score increased at follow-up when compared to the baseline scores (74.5 ± 12.3 versus 71.0 ± 15.1 respectively); however, data analysis revealed no statistical significance (p=0.50). Conclusions: Our study demonstrated trends suggesting improved patient satisfaction and improved self-efficacy with a group clinic model in veteran patients with heart failure. Group clinic settings have the potential to optimize HF medication management in the setting of enormous demand for VA healthcare services and limited financial resources.

Class of 2006 Abstract / Objectives: To determine the effectiveness of etanercept therapy on C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), height, weight and body mass index (BMI) of patients with juvenile rheumatoid arthritis in an ambulatory pediatric clinic. Methods: This project used a pretest-posttest design that assessed patients before treatment with etanercept and then 6 months after the treatment was begun. Pre-treatment and post-treatment data were obtained through a retrospective chart review. A chart review was performed to collect each patient’s ESR, CRP, height, weight, BMI, and demographic data using a standardized data collection instrument. A paired t-test was performed to compare the pre-treatment and post-treatment data for the ESR, CRP, height, weight and BMI measurements. Results: Nine patients were identified that met the study inclusion. The mean age (SD) of the patients was 13.1 (4.4) years. Increases in weight and height parameters were seen after 6 months of etanercept treatment (p= 0.05, 0.002, respectively). There were no differences found in BMI, CRP and ESR parameters (p= 0.133, 0.753, 0.188, respectively) between the pre and post measurements. Conclusions: This pre-post analysis of 9 patients with juvenile rheumatoid arthritis found that etanercept therapy was associated with a significant gain in weight and height. However, this study found no differences in CRP or ESR after etanercept treatment. Additional research in larger populations is needed to more fully describe the changes in monitoring parameters following etanercept therapy.

Philosophiae Doctor - PhD / Introduction: The overall aim of this study was to develop a programme to facilitate quality client-centred care in Primary Health Care clinics of the rural West Coast District. Research design and -method: Both quantitative and qualitative methods were applied for this study . Phase 1, a situational analysis collected and analysed quantitative data from the perspective of clients and clinical nurse practitioners via structured questionnaires. The population included all clients 18 years and older (N=137 991) of the fixed clinics (N=25) in the five subdistricts of the West Coast District. According to the Cochran formula a sample of (n=383) should be adequate to represent the population. Non-proportional sampling was applied to estimate the number of participants per clinic. An all-inclusive sample of (n=64) clinical nurse practitioners participated in the study. Phase 2, the qualitative part of the situational analysis, applied five focus group discussions to explore and describe the managers and allied health professionals’ perceptions about quality client-centred care. A semi-structured interview schedule was compiled to guide the focus group discussions. An all-inclusive sample was utilised to include all the managers and allied health professionals of the five subdistricts (N=43). Phase 3 included the development of the programme based on the study findings and literature. Quantitative results: The analysis revealed the following quality client-centred care challenges, namely: Patient Rights (Domain 1) were not always respected and adhered to as these were characterised by: language (statistical p<0.001 and practical significant with a large effect size d=0.74); Satisfaction and Safety (statistical p<0.001 and practical significant with a medium effect size d=0.55); Referral Procedures (statistical significant p<0.001); Waiting Times (statistical p<0.001 and practical significant with a medium effect size d=0.47) and Confidentiality difficulties (statistical p<0.001 and practical significant with a medium effect size d=0.68). The Domain 2, Clinical Governance, Care and Safety showed shortcomings as highlighted by the Client and his/her Family (statistical p<0.001 and practical significant with a large effect size d=0.77). Clinical Support Services, Domain 3, revealed inadequacies regarding the continuous availability of medication (statistical significant p<0.008) and the reporting of side-effects (statistical significant p<0.001). Furthermore, Public Health Domain 4, showed that clients identified community health promotion and disease prevention events (statistical p<0.01 and practical significant with a large effect size d=0.79), and home visits by the community healthcare workers (statistical p<0.001 and practical significant with a large effect size d=1.09) as both a “problem” and a “gap”. Leadership and Corporate Governance, Domain 5 was characterised by the lack of: visible organograms (clients mean 2.40), community communication (clients mean 2.12 & clinical nurse practitioners mean 2.36), visibility of goals, values and future plans of the Western Cape Department of Health (statistical p<0.001 and practical significant with a medium effect size d=0.59) and role and function of the clinic committees (statistical significant p<0.008). Moreover, Domain 6, Operational Management was challenged by inadequate staffing levels (statistical significant p<0.003). Lastly, Domain 7: Infrastructure was characterised by the lack of drinking water in the waiting areas (clients mean 2.08 & clinical nurse practitioners mean 2.02), inadequate clinic space (clients mean 2.10 & clinical nurse practitioners 2.23); maintenance not up-to-date (statistical significant p<0.002); physical appearance of the clinic (statistically significant p<0.001) did not have a positive effect on staff morale and evacuation plans (statistical p<0.001 and practical significant with a medium effect size d=0.54) were not visible. In addition, correlations between the domains showed that the domains are not in silos, but are interdependent on another. Qualitative results The qualitative, thematic data analysis revealed various inadequacies regarding quality client-centred care. Theme One about the Patient Rights revealed that patients were not always treated with the necessary respect and dignity. Theme Two concerning Patient Care, revealed that focus group participants were well-informed on what the concept client-centred care entailed. However, patients and or clients did not always experience their care as client-centred. Theme Three about the Clinical Support Services, indicated shortages of medication and medical equipment; long waiting time for specialists and rehabilitation referral appointments. Theme Four, referring to the Public Health confirmed that health promotion and prevention activities are limited, due to various organizational factors and community healthcare workers’ activities which are limited to home-based care activities. Theme Five, Corporate Governance and Leadership matters were characterised by too many processes or “red tape” resulting in inefficient procurement processes, inadequate staffing and inactive health committees. Theme Six, Operational Management highlighted the severe pressure under which the operational managers have to work, resulting from their twofold role of being the clinic manager and at the same time operate as a clinical nurse practitioner. Theme Seven refers to Infrastructure and Facilities and is characterised by inadequate maintenance and lack of space according to the number of clients and package of care. To summarise: The situational analysis revealed 81 problems. These problems form the evidence base for the development of the programme to facilitate quality client-centred care in primary helth care clinics of the rural West Coast District.

The challenges facing the health system in South Africa are likely to impact on life-long adherence for patients in the context of the rollout of ART. Smaller ART programs have been able to demonstrate good adherence rates, but the question remains if this can be achieved by large public sector ART programs. Most adherence researchers share the basic understanding that patients are adherent when they take their medications as prescribed by the health provider. An approach to adherence that combines both clinical and social knowledge—a biosocial approach— is likely to move us to a better understanding of adherence and how to improve adherence to ART. This study on social support and ART adherence aims to gather and document information that could be used to improve services and program strategies for strengthening and maintaining adherence at ART rollout sites in Gauteng. The two study sites Carletonville Hospital and Zola Clinic were chosen randomly from all second-generation rollout sites in the Province. Data were collected from a total of 359 respondents, 164 in Carletonville and 195 in Zola. The response rate was 98.3%. The results showed that the majority of the respondents were female (72.1%) and about 44.9% were within the age group 30-39 years. In terms of educational attainment, most respondents (70.1%) had received secondary education and 2.5% had not attended school. Based on assets quintiles scores of 1-5, with 5 being the highest score, about one-third of the respondents scored 1, and only 7% scored 5. Compared with Carletonville, respondents from Zola were more educated and better resourced. At the facilities, treatment preparation and support and adherence assessment procedures are routine features of the ART program and entail pre and post test counseling, group education and adherence counseling and serve as mechanisms for adherence support. This is enhanced by routine follow-up appointments where ART patients are provided information on side effects of ARVs, effectiveness of treatment, CD4 cell and viral load counts and referral to services not provided at the facility. Additionally, support groups accessed by patients undertake a range of educational activities on staying healthy, viral load and CD4 cell counts and ARVs. Although respondents were largely positive about their interactions with health providers and the support they provided, some expressed concern about health workers being too busy to address their problems, not treating patients with enough respect and sometimes patients leaving without receiving treatment because staff were either absent or late or queues were too long. The HIV disclosure rate was high (95.5%). However, respondents were more likely to disclosure to a family member, but less likely to a friend, neighbor or religious leader. Selfreported adherence and viral load adherence rates were high (97.6% and 76.6% respectively) but CD4 adherence was lower at 51.0%. The study did not document a convincing association between social support and ART adherence. Only two variables (receiving food supplements and age groups) were significantly associated with CD4 and viral load adherence. Given the limitations of the study, a longitudinal study is needed in these sites to better understand the predictors of short and long-term adherence and to explore ways to better measure the relevance, content and quality of the social support services being utilized by ART patients at facility and community levels. Interventions and policies are needed to respond to the concerns identified from the study regarding inadequate attention and respect by health providers, absence or lateness of doctors and pharmacists and challenges pertaining to access to food, income and disability grants.

MSc (Med) Epidemiology and Biostatistics, Faculty of Health Sciences, University of the Witwatersrand, 2009 / Abstract not included on cd

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