1.1 Background: Since Diagnosis Related Groups (DRGs) systems were firstly introduced in USA in 1983, they have begun to be implemented in more developed countries and some developing countries among the world during two decades. As one of the prospective payment systems, it focuses on enhancing the efficiency through reduction in the length of stays in hospitals, and improves the health care services by decreasing and controlling the unnecessary treatments. This paper reviewed the impacts of DRGs both in the countries with long period’s implementation and in China, including the above beneficial outcomes and negative influences in health care delivery. Furthermore, considering the current concerns of health care delivery in Mainland China, this paper discussed the difficulties and challenges in widely implementation over the whole country. 1.2 Methods: This study focused on the published papers in English through Pubmed, Google scholar, Google and in Chinese through CNKI. The articles in Chinese were searched from 1994. A literature search of all articles was conducted using keywords such as DRGs, impacts, efficiency, and quality both in English and in Chinese, so that relevant studies had been chosen according to the aims of the review. 1.3 Result: This review revealed the beneficial outcomes within health care delivery after the implementation of DRGs, which focused on the decrease in average length of hospital stay and the medical expenses per case. In addition, the relevant adverse outcomes had been reflected simultaneously through the studies, which were mainly indicated through the increase in emergency visits and mortality rates. The findings included both the benefits DRGs brings and negative outcomes, and the current effects of DRGs in Mainland China. 1.4 Conclusion: Diagnosis Related Groups (DRGs) system plays the different roles in different kinds of health care systems. It controls the medical expenses through less hospital activities, which can be indicated by the decreases in both the lengths of hospital stay and medical expenditures per case through the literatures. However, this system may produce the adverse outcomes within health care delivery due to insufficient, intentional, and cost-saving services. Furthermore, China has introduced this payment system since 1994, and needs to overcome the challenges through the gradual implementation process. / published_or_final_version / Public Health / Master / Master of Public Health

Cervical cancer is the ninth leading cause of female cancer deaths in Hong Kong. In 2011, 391 new cases of cervical cancer were diagnosed and the age-standardized incidence rate was 7.2 per 100,000 standard populations. In 2012, 133 women died from this cancer, accounting for 2.5% of female cancer deaths. The age-standardized death rate of cervical cancer was 2.1 per 100,000 standard populations. Human papillomavirus (HPV) infection is an established cause of cervical cancer. HPV vaccines offer more than 70% protection for women against HPV types 16 and 18 infections and their related cervical precancerous lesions and cervical cancer. As there are usually no symptoms in high-risk HPV infection, it is often diagnosed at a late stage. Regular cervical smears can offer early detection of pathological changes and pre-cancerous stage for a timely medical treatment to prevent progression to cervical cancer. The Cervical Screening Programme (CSP) of Department of Health (DH) was launched on 8 March 2004. It is a voluntary program with the objectives to increase the population coverage of cervical screening among women and to reduce the incidence and mortality of cervical cancer in Hong Kong. Women participating in the programme are encouraged to have cervical smears in the medical centres of their own choices and to provide their cervical smear information through their health care providers to the central registry of the CSP - The Cervical Screening Information System (CSIS). As at 31 December 2013, 491,674 women have registered with CSP. When DH implemented CSP in March 2004, a report was published in the same year showing evidence that an organized screening compared with the opportunistic screening could substantially increase benefits and reduce costs. Another local study conducted early this year supported by the Health Services Research Fund also highlighted the importance and urgency in enhancing the current screening protocol. It is of public health interests to study and compare the programme outcomes with countries like Finland, Australia, UK and Japan where different policy was adopted for the prevention of cervical cancer. Information gathered from research papers on epidemiological studies has been collected and analyzed on population benefit (outcome, access, disparities), cost (cost benefit, efficiency, cost containment), equity, feasibility and constituency perspectives in formulation of the policy alternatives. In conclusion, strengthening what is already in place with better allocative efficiency could protect the female population against cervical cancer. From the education perspective, emphasis on the risk of HPV infection in the sex education curriculum would raise the awareness on the precaution of HPV infections amongst young females. Additionally, vaccination at the age of 12 can provide protection against most types of HPV. It is strongly recommended that a cervical screening and HPV co-testing strategy at a triennial interval could provide the best cost and benefit effectiveness. Together they can enhance protection coverage of women at 12 through immunization and from 25 - 64 through active population screening. The ultimate objectives to reduce incidence, mortality and increase coverage could be achieved. / published_or_final_version / Public Health / Master / Master of Public Health

Assisted reproduction technology is increasingly used for treatment of couples with subfertility. These women are usually of more advanced maternal age and carry a higher risk of fetal Down syndrome. Results from early publications showed that biochemical markers for screening of fetal Down syndrome in the second trimester were different between pregnancies from in vitro fertilization (IVF) and natural conception. This could potentially increase the false positive rate and result in unnecessary invasive diagnostic procedures. Questions were raised as to whether the alterations were related to ovarian stimulation. This laid the fundamentals of a series of studies presented in this thesis with an aim to address the variations in the concentrations of markers of fetal Down syndrome and the fetal growth profile of pregnancies conceived following different assisted reproduction treatments. Studies were conducted on maternal serum and amniotic fluid alpha fetoprotein (AFP) and human chorionic gonadotrophin (hCG) in the second trimester in pregnancies conceived by assisted reproduction. A reduced level of AFP in maternal serum in pregnancies with fresh embryos together with an elevated level of hCG in both maternal serum and amniotic fluid in pregnancies with frozen thawed embryos were found. This pioneer piece of data showing the raised hCG in frozen thawed embryo pregnancies with unstimulated treatment cycles spoke against the ovarian driven hypothesis, but suggested placental dysfunction be a possible underlying pathophysiology. For markers adopted in the first trimester, the level of pregnancy associated protein A (PAPP-A) was significantly reduced in pregnancies from assisted reproduction. The data on free βhCG was heterogeneous. Apart from biochemical markers, the nuchal translucency was also increased in these singleton pregnancies but not in dichorionic twins. As the direction of deviations of these markers in unaffected pregnancies from assisted reproduction resembled those observed in pregnancies affected by Down syndrome, appropriate adjustment was necessary to reduce the false positive rate for these women. Altered biochemical markers, notably a low PAPP-A level, were also associated with adverse obstetric outcomes. The changes observed in pregnancies from assisted reproduction might be a manifestation of an intrinsic placental insufficiency or fetal developmental delay. A longitudinal study was performed to examine the intrauterine fetal growth profile in these pregnancies. The rate of increment in the mean sac size, which could represent an adaptive compensatory mechanism, was significantly greater in pregnancies from assisted reproduction compared to natural conception. We concluded that pregnancies conceived after assisted reproduction technology were different from pregnancies from natural conception in terms of the concentrations of biochemical and ultrasound markers of Down syndrome. Due to the wide variation in treatment protocols and patients’ background demographics, the exact underlying pathophysiology might be difficult to be explored. Couples undergoing assisted reproduction treatment should be counseled on the increased risk of adverse pregnancy course and perinatal outcome. / published_or_final_version / Medicine / Master / Doctor of Medicine

Among complications associated with non-syndromic cleft lip and/or palate (NSCL/P) in school age children, conductive hearing loss has been thoroughly investigated because the symptoms are noticeable and the treatment is often easy to access. Research on central auditory processing disorder [(C)APD] has been rarely explored in this clinical population. However, children with NSCL/P have been reported to have delayed speech and language development, as well as poor academic performance in general compared to craniofacially normal peers, despite their peripheral hearing problems typically resolving with age. In order to investigate suspected (C)APD in children with NSCL/P, the present research program was initiated. The study aimed to utilize a comprehensive test battery to assess auditory status in children with NSCL/P, and to investigate whether they have a greater frequency of (C)APD compared to craniofacially normal children. 147 children with NSCL/P and 60 normal children were recruited. They were Mandarin speakers and attending regular schools. The children with NSCL/P did not have peripheral hearing problems at time of assessment. There were three types of assessment tools used in the present research program. Firstly, hearing health tests were conducted to evaluate peripheral hearing function. Case history and auditory questionnaire reports were completed by caregivers to obtain basic medical and developmental information (Chapter 3). Secondly, auditory behavioral tests of (C)APD functioning were administered, including a gap detection test and a speech in noise recognition test (Chapter 4). Thirdly, an auditory evoked potential (AEP) assessment was conducted as an objective evaluation of the central auditory nervous system (Chapter 5). Based on the results of this research program, it was concluded that, firstly, children with NSCL/P showed behaviors typically found in children with (C)APD when questionnaire results were considered. Children with cleft palate (CP) showed the most negative outcomes, and cleft lip (CL) group children showed results equivalent to craniofacially normal children. Secondly, behavioral assessment results showed that compared to control group children, maturation for temporal resolution abilities was delayed in children with NSCL/P. Also, the ability to use interaural timing and intensity cues for speech recognition in a noisy environment was poorer in children with CP and CLP. Finally, abnormal AEP findings in children with cleft suggested longer neural transmission times and delayed development of the auditory nervous system may occur in this population. In summary, the research program found that children with NSCL/P are at higher risk of auditory processing difficulties compared to craniofacially normal children. In addition, a comprehensive test battery is more appropriate for making an accurate diagnosis of (C)APD in this population than a single assessment protocol. The present research program has contributed to an enhanced awareness of potential (C)APD in children with NSCL/P, which had not been investigated using a comprehensive test battery for a large sample of children with cleft disorders in any previous studies. Since Chinese language specific assessment tools are limited, further studies to develop an appropriate, comprehensive test battery for the diagnosis of auditory processing disorder in Chinese children with oral cleft and to explore effective management of this disorder are required. / published_or_final_version / Speech and Hearing Sciences / Doctoral / Doctor of Philosophy

The management of low back pain (LBP) has long been a challenge as it is a highly prevalent disease worldwide due to the lack of an apparent etiology and a conclusive therapeutic treatment. Heterogeneous groups of LBP patients with diverse medical backgrounds also complicate the problem. A clinical threshold is demanded to match the patients and treatments appropriately in order to maximize the treatment success rate. Besides, the assessments of disability and pain perception due to LBP made by self-evaluated questionnaires in current clinical setting are highly susceptible to subjective feeling and the memory of patients. LBP and spasm are closely related but little is known for the underlying physiology, especially the musculature of LBP patients with spasm. These problems exacerbate the difficulty in LBP rehabilitation further. Surface electromyography (sEMG) topography is a cutting- edge technology to assess the lumbar muscle in vivo non-invasively by illustrating the distribution of global muscle activity visually. sEMG topography has the potential application as an objective assessment tool for LBP rehabilitation. In present study, sEMG topography was used to address 1) the prognostic value of sEMG topography on LBP rehabilitation, 2) the establishment and validation of a clinical classification threshold for identification of LBP patients who are responsive to exercise therapy and 3) the investigation of sEMG topography in accordance with the physiological outcomes (functional disability, pain perception and spasm). Forty-five healthy subjects and fifty patients with chronic non-specific LBP were enrolled to the study. sEMG test was conducted to every subject under the motions of lumbar flexion and extension in order to gather the myoelectric signals by a 16-channel sEMG. Various sEMG topographic parameters (sEMG parameters) were developed for quantitative analysis of sEMG topography. They were Root-Mean-Square-Difference of Relative Area (RMSD RA), Relative Width (RMSD RW) and Relative Height (RMSD RH) at flexion and extension. Results showed that sEMG parameters were of significant prognostic value for LBP patients towards exercise therapy. A clinical threshold of 0.21 was proposed and validated based on the geometric calculation of RMSD RA and RMSD RW at flexion and extension. The threshold was substantiated to increase the success rate of exercise therapy from 46% to 86% when the value measured by sEMG topography was below 0.21. sEMG parameters were found significantly associated with disability and pain perception in a positive manner. Severer disability and pain perception were represented by larger values of sEMG parameters. sEMG topography demonstrated symmetric patterns for patients with or without spasms on bilateral sides of lumbar muscles. The symmetry in sEMG topography evinced the consistency of the musculature of bilateral lumbar muscles while the lost of symmetry might indicate malfunction of lumbar muscles unilaterally. To conclude, this study corroborated versatile roles of sEMG topography in LBP rehabilitation as a prognosis, clinical threshold, and objective measurement. The findings of this study have paved the way of sEMG topography for future application in clinical setting. A study of larger scale would be recommended to complement the present findings. / published_or_final_version / Orthopaedics and Traumatology / Master / Master of Philosophy

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This dissertation explores a diagnostic image analysis framework using multispectral digital colposcopy for real-time in vivo detection of cervical cancer. In the first part of the dissertation, the clinical feasibility of a previously developed multispectral digital colposcope (MDC) is demonstrated using a hamster cheek pouch model of carcinogenesis. Various studies on MDC applications to cervical cancer detection in human subjects are then presented. First, an automated diagnostic image analysis algorithm for cervical cancer using white light reflectance images is presented. The algorithm can identify pre-neoplastic tissue areas from an entire cervix based on intensity changes feature in the reflectance images induced by acetic acid treatment. Then, the information about tissue type is incorporated into the diagnostic image analysis framework. For this purpose, a Markov Random Field (MRF) model is adopted and the results are discussed. One of the practical difficulties of utilizing a MRF model in unpolarized white light reflectance imaging is the specular reflection problem since the effect of specular reflection extends into surrounding tissue areas. Through the use of cross polarized imaging, the effects of specular reflection reduced and the ability to segment images based on tissue types is enhanced, leading to better diagnostic performance. The diagnostic performance of polarized imaging is compared to that of unpolarized imaging. In order to assess the performance of the proposed approach, a gold standard for the entire cervical image is constructed using histopathology results from a whole cervix specimen. The results presented in this dissertation indicate that an automated diagnostic image analysis framework for early detection of cervical cancer has the potential to be clinically applied as a low cost alternative screening technique in developing countries. Advances in imaging technology as well as in image analysis algorithms will continue to reduce the cost of diagnostic imaging systems and improve the imaging and diagnostic capability, leading to an inexpensive, real-time, minimally-invasive alternative to conventional screening techniques for early detection of cervical cancer in developing countries. / text

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / abstract / toc / Clinical Psychology / Master / Master of Social Sciences

published_or_final_version / abstract / toc / Educational Psychology / Master / Master of Social Sciences