South Africa is one of the countries with the highest burden of Mycobacterium tuberculosis (TB) in the world. The fact that adult patients diagnosed with TB frequently do not attend their primary healthcare clinics after discharge from hospital for continued treatment remains a challenge for public health in South Africa. This qualitative study employed semi-structured interviews, focus group discussions and observations explored the experiences of patients, their families, healthcare workers and policy makers, with continuity of TB care following diagnosis in hospital. The key research question was what factors were shaping patients’ attendance at primary healthcare clinics following TB diagnosis and start of treatment in tertiary and district hospitals. Sub questions were: how did patients diagnosed with TB interpret and act upon their diagnosis and treatment at the tertiary/district hospital? What roles did patients play in the discharge process? What were their home circumstances and experiences at the clinics they were referred to, regarding their registration and follow-up plan? What were the perceptions of patients, healthcare workers and policy makers on what influences patients’ attendance/non-attendance at clinics? The objective of this study was to contribute to our understanding of patients’ experiences and perceptions of treatment of TB and how services to patients could be improved to enhance better continuity of care. I drew on a three-fold theoretical framework: patient-centred care, Foucault’s concept of the 'medical gaze’ and social determinants of health. My study built upon previous and ongoing research on the topic of continuity of care for TB in Cape Town. I argued that problems in the provision of TB services to hospital patients could be understood as failures of the services at the hospital to achieve some of the core components of patient-centered care. Furthermore, I argued that better systems for following-up patients from the hospitals to their homes and clinics would provide more understanding of the challenges patients faced when they have been referred from a tertiary or district hospital to continue with their treatment. Insights gained from qualitatively following patients from diagnosis to discharge and their home circumstances helped to better understand the problem South Africa faced with continuity of care for TB treatment.

Continuity of care (COC) refers to the delivery of seamless services, continuous caring relationships, and information sharing across care providers. A disruption in COC—that is, care fragmentation (CF)—is an important cause of inefficiency in the Canadian healthcare system; such disruption leads to increased healthcare costs and reduced quality of care. Addressing this issue is particularly challenging among older adults, who often have medically complex needs; such patients can require many care transitions across multiple care settings. An effective strategy for COC improvements is to optimize discharge planning among older adults. However, this is hampered by the imperfect understanding of older patients’ needs, which are associated with their health complexity. Therefore, making early predictions about the patients’ health complexity and incorporating this information into discharge planning decisions can potentially improve COC. In this thesis, I develop data-driven predictive–prescriptive analytics frameworks that leverage machine learning (ML) approaches and a rich, massive set of longitudinal data collected over a decade. The first essay in this dissertation studies the early prediction of older patients’ complexity in hospital pathways using ML. It also examines whether we can conduct accurate prognostics with current information on patient complexity. The second study examines how two common measures of patient complexity—multimorbidity and frailty—concurrently affect post-discharge readmission and mortality among older patients. It also investigates the dependency of the outcomes on other essential socio-demographic factors. Finally, the third study examines the feasibility of predicting patients at risk of fragmented readmission—that is, readmission to a different hospital than the initial one. It uses this predictive information to derive optimal policies for preventing CF while addressing disparities in the decision-making process. The findings highlight the feasibility, utility, and performance of predicting patient complexity and important adverse outcomes, potentially undermining COC. This thesis shows that advanced knowledge and explicit utilization of this information could support decision-making and resource planning toward a targeted allocation at the system level; moreover, it informs actions that affect patient-centered care transition at the service level to optimize patient outcomes and facilitate upstream discharge processes, thereby improving COC. / Thesis / Doctor of Philosophy (PhD) / The aging population in Canada is growing significantly relative to the population as a whole, and several challenges are involved in providing aging people with proper healthcare services. One of these challenges is disruptions in continuity of care. Older adults are often medically complex or frail; they may have multiple diseases and require many care transitions across healthcare settings. Poor continuity of care among these patients leads to health deterioration during care trajectories, resulting in reduced quality of care and increased healthcare costs and inefficiencies. This thesis includes three essays that provide practical insights and solutions regarding the issue of continuity of care disruptions, spanning from predicting the issue to strategies to prevent it in a data-driven manner.

Background: Improving adherence to medication is a persistent challenge within the health system. Adherence is influenced by many factors at the patient, provider, treatment and health system levels. Adherence may also be affected by continuity of care; defined as the consistent professional relationship between a health provider or source of care and a patient. Objective: To estimate the strength of association between continuity of community pharmacy care and adherence to statin medication among persons initiating statin therapy in Nova Scotia between 1998 and 2008.  Methods: This was a retrospective cohort study using administrative data from the Nova Scotia Seniors’ Pharmacare program. Subjects were included if they were dispensed at least one prescription for a statin medication between 1998 and 2008. Continuity of care was calculated via two methods: the Usual Provider of Care (UPC) index and the Continuity of Care Index (COCI), which measure the density and dispersion of relational continuity of care, respectively. Adherence was calculated using the medication possession ratio. The strength of association between continuity of care and adherence was analyzed using hierarchical regression. Results: During the study period, 31 592 individual subjects received a first statin dispensation. Adjusted hierarchical regression showed that for each 0.10 increase in continuity of care, the odds of adherence increase by 3% (95% CI: 1.01-1.05). Continuity of care measured by the UPC is highly correlated with continuity of care measured by the COCI (r=0.98). Conclusions: Continuity of community pharmacy care is positively associated with adherence to statins among Nova Scotian seniors who initiated statin therapy between 1998 and 2008.

This study examined pre- and post-implementation of a same-day post-detoxification residential admission policy within a Veteran Health Administration (VHA) facility to determine improved outcomes consistent with the larger literature. A single facility sample of participants who received detoxification from alcohol pre- and post-policy change was identified utilizing administrative and health record data. Chi-square testing and independent samples T-testing evaluated changes between a 2018 pre-policy cohort and a 2019 post-policy cohort. Policy implementation of same-day admissions to residential treatment after detoxification resulted in statistically significant change in instances of waiting, wait times for participants who waited, no-show, and readmissions during the six months following inpatient discharge. Mortality, cancellation rates, and discharge type did not differ significantly. These findings further support previous research that outlines the relationship between efficient post-detoxification continuity of care and increased positive outcomes.

Background: Individuals who make multiple visits to EDs for mental health complaints are a highly visible and challenging group. Recent healthcare priorities aimed at reducing inappropriate or unnecessary service use call for improved continuity of care. Implementing effective continuity interventions is contingent on sound foundational knowledge including population profiling and conceptual understanding. A deficit in these key elements is apparent in existing literature. These gaps in knowledge must be addressed to ensure quality continuity research targeting frequent presenters. Furthermore, there is a paucity of research available that implements evidence-informed methods and theory-driven measurement strategies. Objective: To strengthen the knowledge base on frequent mental health-related ED use and continuity in mental healthcare by addressing existing gaps in foundational knowledge and examining the phenomena at a regional tertiary healthcare centre. Method: This was a three-phase emergent study design using mixed methods. Phase 1 was an integrative study to synthesize research on frequent presenters to the ED for mental health complaints. Phase 2 was a theory analysis to explore the conceptual understanding of continuity in mental healthcare. Phase 3 was an observational case-control study of an exemplar population at a regional tertiary healthcare centre using the evidence-informed methods emerging from the first two phases. Results: From this enquiry, I proposed an evidence-informed profile for frequent presenters to the ED for mental health complaints, summarized parameters used to identify the frequent presenter population, highlighted existing areas of theoretical consensus not yet recognized in continuity research, and provided a global understanding of continuity in mental healthcare and an approach for selecting measurement strategies for continuity research. The observational study strengthened the emerging frequent presenter profile and explored CoC using a comprehensive tool. Conclusion: This doctoral thesis addresses important gaps in foundational knowledge by providing an evidence-informed frequent presenter population profile and global theoretical summary of continuity in mental healthcare. The observational study appears to be the first to use a theory-driven measurement tool and results differ from previous studies in which simple measurement approaches are used. Given this, new hypotheses/questions about the focus and role of CoC with frequent ED use need to be explored. / Thesis (Ph.D, Nursing) -- Queen's University, 2013-04-26 10:47:19.626

Diabetes is emerging as a major threat to health, with global economic and social implications. Recent research has shown that the morbidity and mortality associated with diabetes can be reduced by timely and effective treatment. However, unless people with diabetes have access to this treatment, the impact of diabetes will continue to rise. This thesis therefore explores the current standards of care which people with diabetes receive. It also looks at factors likely to impact on delivery of diabetes care. Studies were conducted at two levels. In the studies described in Chapters 2 and 3, general data applicable to all or nearly all patients with diabetes were collected. This approach substantially eliminates selection bias but precludes the ability to examine clinical outcomes. In the other studies, detailed in Chapters 4, 5 and 6, specific aspects of diabetes care pertaining to more select groups of diabetic subjects were examined. This approach allows clinical parameters to be examined in more detail but is more subject to selection bias. It is hoped that the combination of these two approaches provides a more balanced view of the topic under examination. In Australia, the Medicare Program, a single government controlled universal health insurance fund, provides access to medical services for all residents. Medicare occasions of service data therefore represent the most comprehensive source of information regarding health service utilisation in Australia. The data does not account for people receiving diabetes care through public hospital based services. However, a survey of public hospitals within NSW (n=198), described in Chapter 2, showed that the number of individuals in this category is relatively small and represents only 5.2% of the diabetic population. Using Medicare item codes, and with the permission and assistance of the Commonwealth Department of Health and Aged Care, data were extracted on attendance to medical practitioners and utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997. All data were stratified by the presence of diabetes, gender and age group. Individuals were deemed to have diabetes if an HbA1c, which can only be ordered for a person with known diabetes, had been performed over the 5-year period and the sample size adjusted for the incidence of diabetes. Once adjusted, the number of people with diabetes in NSW for the individual years 1993 to 1997 were 143,920, 156,234, 168,216, 177,280 and 185,780. Comparison with 1996 census data confirmed a 91.7% capture of the total NSW population (5,495,900/5,995,545 individuals). The data were retrieved for NSW as a whole and for individual postcodes. Postcodes were then classified by population density as either major urban, urban or rural. On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. As seen in Chapter 2, a large proportion of people with diabetes were also under the care of specialists and consultant physicians, up to 51.2% and 41.8% respectively, a 3 to 4 fold increase when compared with their non-diabetic counterparts. In regard to geographical location, once adjusted for age and gender, the odds ratio of attending a specialist was only slightly higher for people with diabetes living in areas of high population density when compared to people with diabetes living in rural areas. This ratio reached as high as 1.85 in regard to attendance to consultant physicians (Chapter 3). The odds ratio for the non-diabetic population was similar indicating that the difference in access to consultant physicians was not disease specific. Analysis of results showed that despite the increase in service utilisation, large proportions of people with diabetes were not routinely monitored in regard to diabetes and its complications across the State. By 1997, HbA1c was still not performed in over 40% of people with diabetes each year and only 11.6% of the diabetic population had undergone microalbuminuria estimation. Interestingly, the differences in levels of monitoring between rural and urban areas were surprisingly small. Monitoring of diabetes and its complications did improve in all parts of the State over the study period. However, the greatest improvement was seen in rural areas, despite rural patients having fewer attendances to general practitioners and fewer patients attending specialist care. In the face of finite resources and the rising prevalence of diabetes, an increasing number of patients will need to rely on general practitioners to provide diabetes care regardless of where they live. A 'shared care' approach which encourages and supports general practitioners to manage patients with diabetes, while giving them access to specialist services for those patients that require them, is increasingly being advocated as a way of maximising efficacy while minimising costs. Yet if health care professionals leave undone what they think is done by others, shared care can become neglected care. Chapter 4 reports a detailed audit of 200 randomly selected shared care patients who were assessed on two or more occasions. This study showed that the majority of specialist treatment recommendations are implemented by general practitioners. Doctors formally registered with the Diabetes Shared Care Programme and those who write longer referral letters were more likely to implement recommendations than their counterparts. Moreover, the average HbA1c and the complication profile of these patients were similar to those found in various studies around the world. This suggests that diabetes can be well managed by a shared care approach that is adequately integrated. To overcome the problem that data is lacking on those patients that did not return for specialist review, a further 200 shared care patients who were lost to follow up from the shared care system were traced. Information regarding whether treatment recommendations had been implemented was sought from both the referring doctor and the patient. Overall, information on 182 of the 200 patients could be obtained. As discussed in Chapter 5, comparison of the returned and non returned patients' demographic and clinical profiles at time of their initial specialist review showed that general practitioners differentiated between the 'more complicated' patients, choosing to re-refer those with macrovascular disease, while maintaining the care of 'less complicated' patients. Re-referral for specialist review was also dependent on the patient remaining under the care of their original doctor. Encouragingly, general practitioners seemed to take a more active role in the non-returned group. They included more details regarding type and duration of diabetes in the referral letters of patients who were not re-referred for specialist review. They also implemented more treatment recommendations in the non-returned group, with the difference in implementation rate for metabolic recommendations reaching statistical significance. This study also showed that movement of patients between doctors raises concern regarding continuity of care. The multi-factorial nature of diabetes means that best practice is not easily accommodated within a single appointment. Thus continuity of care becomes an important issue. To assess the current status, 479 consecutive patients referred to the Royal Prince Alfred Hospital Diabetes Centre in a 6-month period were recruited and underwent a detailed clinical assessment. They were also questioned regarding the number of general practitioners they attended and the length of time they had been under the care of the referring doctor. The results outlined in Chapter 6 showed that the majority of people with diabetes (87.7%) attended only one general practitioner and had been under the care of that doctor medium to long term. Younger patients, who were relatively healthy apart from the presence of diabetes, were more likely to attend several general practitioners or have changed their general practitioner within the last year. This lack of continuity had little difference on acute outcomes such as glycaemic and blood pressure control. Appropriately, continuity of care increased with increasing age and the increasing prevalence of diabetes complications, mainly macrovascular disease. These studies indicate that further efforts are required to improve the overall standard of diabetes care within Australia. At present there is a heavy dependency on specialist services. As the population ages and the number of people with diabetes increases, much of this burden will fall on general practitioners, as is already evident in rural areas. When provided with appropriate support and infrastructure, general practitioners are able to maintain standards of care through referral of patients with more complex medical problems and by maintaining the degree of continuity appropriate to the patient's needs. However, the collection of relevant information to monitor future trends in diabetes services provision is important. As shown in this thesis, Medicare data represents an easy and cost effective method with which to do so.

This study examined the potential impact on processes of care and patient outcomes upon exposure of supportive and concurrent care provided by primary care providers (PCPs) to their hospitalized patients. A secondary objective was to describe the PCPs who conduct these services, and the patients who receive them. There was a marked, observable trend that PCP visits to their hospitalized patients is on the decline (dropped 10% between 2003 and 2009). The patients who received in-hospital visits from their PCPs had more disease burden and were hospitalized longer than the control group. Patients who received and in-hospital visit from their PCP were more likely to receive home care services and PCP visits post-discharge [adjusted OR 1.20 (95% CI 1.12-1.28)]. They were also less likely to experience the composite outcome of death, hospital readmission, or emergency department visit [aOR 0.95 (95% CI 0.91-0.98)].

This study examined the potential impact on processes of care and patient outcomes upon exposure of supportive and concurrent care provided by primary care providers (PCPs) to their hospitalized patients. A secondary objective was to describe the PCPs who conduct these services, and the patients who receive them. There was a marked, observable trend that PCP visits to their hospitalized patients is on the decline (dropped 10% between 2003 and 2009). The patients who received in-hospital visits from their PCPs had more disease burden and were hospitalized longer than the control group. Patients who received and in-hospital visit from their PCP were more likely to receive home care services and PCP visits post-discharge [adjusted OR 1.20 (95% CI 1.12-1.28)]. They were also less likely to experience the composite outcome of death, hospital readmission, or emergency department visit [aOR 0.95 (95% CI 0.91-0.98)].

Diabetes is emerging as a major threat to health, with global economic and social implications. Recent research has shown that the morbidity and mortality associated with diabetes can be reduced by timely and effective treatment. However, unless people with diabetes have access to this treatment, the impact of diabetes will continue to rise. This thesis therefore explores the current standards of care which people with diabetes receive. It also looks at factors likely to impact on delivery of diabetes care. Studies were conducted at two levels. In the studies described in Chapters 2 and 3, general data applicable to all or nearly all patients with diabetes were collected. This approach substantially eliminates selection bias but precludes the ability to examine clinical outcomes. In the other studies, detailed in Chapters 4, 5 and 6, specific aspects of diabetes care pertaining to more select groups of diabetic subjects were examined. This approach allows clinical parameters to be examined in more detail but is more subject to selection bias. It is hoped that the combination of these two approaches provides a more balanced view of the topic under examination. In Australia, the Medicare Program, a single government controlled universal health insurance fund, provides access to medical services for all residents. Medicare occasions of service data therefore represent the most comprehensive source of information regarding health service utilisation in Australia. The data does not account for people receiving diabetes care through public hospital based services. However, a survey of public hospitals within NSW (n=198), described in Chapter 2, showed that the number of individuals in this category is relatively small and represents only 5.2% of the diabetic population. Using Medicare item codes, and with the permission and assistance of the Commonwealth Department of Health and Aged Care, data were extracted on attendance to medical practitioners and utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997. All data were stratified by the presence of diabetes, gender and age group. Individuals were deemed to have diabetes if an HbA1c, which can only be ordered for a person with known diabetes, had been performed over the 5-year period and the sample size adjusted for the incidence of diabetes. Once adjusted, the number of people with diabetes in NSW for the individual years 1993 to 1997 were 143,920, 156,234, 168,216, 177,280 and 185,780. Comparison with 1996 census data confirmed a 91.7% capture of the total NSW population (5,495,900/5,995,545 individuals). The data were retrieved for NSW as a whole and for individual postcodes. Postcodes were then classified by population density as either major urban, urban or rural. On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. As seen in Chapter 2, a large proportion of people with diabetes were also under the care of specialists and consultant physicians, up to 51.2% and 41.8% respectively, a 3 to 4 fold increase when compared with their non-diabetic counterparts. In regard to geographical location, once adjusted for age and gender, the odds ratio of attending a specialist was only slightly higher for people with diabetes living in areas of high population density when compared to people with diabetes living in rural areas. This ratio reached as high as 1.85 in regard to attendance to consultant physicians (Chapter 3). The odds ratio for the non-diabetic population was similar indicating that the difference in access to consultant physicians was not disease specific. Analysis of results showed that despite the increase in service utilisation, large proportions of people with diabetes were not routinely monitored in regard to diabetes and its complications across the State. By 1997, HbA1c was still not performed in over 40% of people with diabetes each year and only 11.6% of the diabetic population had undergone microalbuminuria estimation. Interestingly, the differences in levels of monitoring between rural and urban areas were surprisingly small. Monitoring of diabetes and its complications did improve in all parts of the State over the study period. However, the greatest improvement was seen in rural areas, despite rural patients having fewer attendances to general practitioners and fewer patients attending specialist care. In the face of finite resources and the rising prevalence of diabetes, an increasing number of patients will need to rely on general practitioners to provide diabetes care regardless of where they live. A 'shared care' approach which encourages and supports general practitioners to manage patients with diabetes, while giving them access to specialist services for those patients that require them, is increasingly being advocated as a way of maximising efficacy while minimising costs. Yet if health care professionals leave undone what they think is done by others, shared care can become neglected care. Chapter 4 reports a detailed audit of 200 randomly selected shared care patients who were assessed on two or more occasions. This study showed that the majority of specialist treatment recommendations are implemented by general practitioners. Doctors formally registered with the Diabetes Shared Care Programme and those who write longer referral letters were more likely to implement recommendations than their counterparts. Moreover, the average HbA1c and the complication profile of these patients were similar to those found in various studies around the world. This suggests that diabetes can be well managed by a shared care approach that is adequately integrated. To overcome the problem that data is lacking on those patients that did not return for specialist review, a further 200 shared care patients who were lost to follow up from the shared care system were traced. Information regarding whether treatment recommendations had been implemented was sought from both the referring doctor and the patient. Overall, information on 182 of the 200 patients could be obtained. As discussed in Chapter 5, comparison of the returned and non returned patients' demographic and clinical profiles at time of their initial specialist review showed that general practitioners differentiated between the 'more complicated' patients, choosing to re-refer those with macrovascular disease, while maintaining the care of 'less complicated' patients. Re-referral for specialist review was also dependent on the patient remaining under the care of their original doctor. Encouragingly, general practitioners seemed to take a more active role in the non-returned group. They included more details regarding type and duration of diabetes in the referral letters of patients who were not re-referred for specialist review. They also implemented more treatment recommendations in the non-returned group, with the difference in implementation rate for metabolic recommendations reaching statistical significance. This study also showed that movement of patients between doctors raises concern regarding continuity of care. The multi-factorial nature of diabetes means that best practice is not easily accommodated within a single appointment. Thus continuity of care becomes an important issue. To assess the current status, 479 consecutive patients referred to the Royal Prince Alfred Hospital Diabetes Centre in a 6-month period were recruited and underwent a detailed clinical assessment. They were also questioned regarding the number of general practitioners they attended and the length of time they had been under the care of the referring doctor. The results outlined in Chapter 6 showed that the majority of people with diabetes (87.7%) attended only one general practitioner and had been under the care of that doctor medium to long term. Younger patients, who were relatively healthy apart from the presence of diabetes, were more likely to attend several general practitioners or have changed their general practitioner within the last year. This lack of continuity had little difference on acute outcomes such as glycaemic and blood pressure control. Appropriately, continuity of care increased with increasing age and the increasing prevalence of diabetes complications, mainly macrovascular disease. These studies indicate that further efforts are required to improve the overall standard of diabetes care within Australia. At present there is a heavy dependency on specialist services. As the population ages and the number of people with diabetes increases, much of this burden will fall on general practitioners, as is already evident in rural areas. When provided with appropriate support and infrastructure, general practitioners are able to maintain standards of care through referral of patients with more complex medical problems and by maintaining the degree of continuity appropriate to the patient's needs. However, the collection of relevant information to monitor future trends in diabetes services provision is important. As shown in this thesis, Medicare data represents an easy and cost effective method with which to do so.

No description available.