Background: In response to high cost and inadequate quality, the healthcare system is in the midst of a transition from paying for volume to paying for value. Billions of dollars could be saved through more effective medication use, and evidence supports the role of the community pharmacist in lowering healthcare cost and improving healthcare quality through medication optimization. Despite this, value-based payment models for community pharmacies are rare, and those that do exist have not been critically evaluated and implementation in a commercially insured population is rare. Objective: The first objective was to design and test a conceptual model of pharmacy value. The second objective was to evaluate variation in the value community pharmacies provide a commercial insurer by assessing the relationship between attributed patients’ healthcare quality and cost. Methods: This study used prescription and medical claims data for 2012 and 2013 from a large commercial insurer in Iowa and South Dakota. Patients were attributed to the pharmacy filling the majority of their prescriptions. Pharmacies’ weekly prescription volume and Sunday prescription filling behavior were used as structural measures of healthcare quality. Percent of days covered (PDC) metrics for beta-blockers, statins, renin-angiotensin system antagonists and non-insulin diabetes agents were used as process metrics. Pharmacies were excluded if the denominator for any PDC metric was less than 15. Outcome metrics consisted of a non-trauma, non-cancer, unplanned hospitalization rate and a non-trauma ED visit rate. Cost impact was categorized into pharmaceutical, medical, and total cost of care. High quality pharmacies with typical or low associated costs or low cost pharmacies with typical to high quality were identified as high value and vice versa for low value. All metrics were risk-adjusted using mixed effect models with a random pharmacy intercept. The ratio between observed and expected quality scores was used for quality scoring. Quality outliers were identified by comparing the 95% CI around pharmacies’ risk-adjusted scores to the all-pharmacy risk-adjusted score mean. A t-test was used to assess variation in pharmacy value. Results: There were 171 pharmacies and 74,581 patients eligible for scoring on all quality metrics. Mixed effects models observed a small but significant impact of pharmacy on process and outcome healthcare quality. No relationship between structures and processes, processes and outcomes was detected. Ten pharmacies were scored as high quality and nine as low quality. Similar numbers were identified for cost outliers, and significant variation in value was detected. Implications/conclusions: Results support the hypothesis that high and low value pharmacies exist. A well-designed value-based payment model could be used to create incentives for pharmacists to enhance care for commercially insured patients, but validation is needed to ensure that incentives are aligned appropriately.

Despite concerted efforts to decrease costs and increase public health, the embattled U.S. health care system continues to struggle to alleviate these widespread issues. Because the problem of hospital utilizations among patients with heart failure is posited to increase as the population ages, innovative methodologies need to be explored to mitigate adverse events. Remote monitoring harnesses the strength of advanced information and communication technology to affect positive changes in health care quality and cost. By reaching across geographical boundaries, remote monitoring may support increased access to less costly services and improve the quality of home health care. The purpose of the study was to examine the home care quality effects of remote monitoring technology in patients with heart failure and to provide an economic justification for its adoption and diffusion. It compared remote monitoring as a potential intervention strategy to a standard no-intervention group (without remote monitoring). Specifically, it analyzed remote monitoring as a viable strategy to decrease hospital readmissions and emergency department visits. It also compared the cost of remote monitoring against the current standard-of-care. The theoretical framework of Donabedian's Quality Model was used in the evaluation of remote monitoring. A retrospective posttest only, case control study design was used to test the degree which remote monitoring was effective in promoting health care quality (hospital readmissions and decreased emergency department visits). Retrospective chart reviews were performed using electronic medical records (EMR). Analysis of Variance, Path Analysis, Automatic Interaction Detector Analysis (Dtreg), and Cost Outcomes Ratio were used to test the hypotheses and validate the proposed theoretical model. No significant difference was noted in remote monitoring and usual care groups. Results suggested that remote monitoring does not statistically lead to a decrease in heart failure-related hospital readmissions and all-cause emergency department visits. Results of the cost ratio analysis suggested that there was no statistically significant difference in the net income between usual care and remote monitoring; however, data suggest that there were significant increases in cost and intensity of nursing utilization for the remote monitoring intervention. The Automatic Interaction Detector Analysis showed that the unfavorable results in hospital readmissions were due to a decrease in collaborative care and patient education prior to the recommendation for hospitalization. The role of nursing care, whether in hospital or community-based care, in heart failure management is critical to quality outcomes. As the field continues to consider the use of technology in health care, decision makers should think through the process of patient care such that preventable hospital readmissions are decreased and patients received quality care.

The rising cost of health care in the Philippines is a concern for the Department of Defense and TRICARE beneficiaries. The purpose of this quantitative cross-sectional research study was to determine the efficacy and acceptability of a different method to deliver health care to increase access to health care and decrease out-of-pocket costs while maintaining quality of care for TOP Standard beneficiaries who receive health care under the Philippine Demonstration. Secondary data was used to determine the acceptability of an alternative reimbursement methodology to decrease cost but maintain access to quality care. The Andersen's behavioral health care model and the Donabedian quality health care model were used to interpret the study results. A data set of 180 participants was evaluated using a cross-sectional quantitative methodology. Two Spearman correlations were used to examine the relationship between financial burden and satisfaction (r = .41, p < .001) and financial burden and confidence (r = .44, p < .001). Linear and binary regressions assessed the effects of age and gender on satisfaction with health care finder functionality when requesting a waiver (F (2,26) = 1.22, p = .313, R2 = .09). A computation of one-sample t-tests to determine the impact of a closed network, beneficiary out-of-pocket cost, and quality health care in Demonstration areas found the beneficiaries were satisfied with the demonstration. An analysis of the claims data pre and post demonstration showed a difference in the patients' out-of-pocket expenses and the acceptability and preference for a closed network. Social change was demonstrated by a decrease in the cost for TRICARE standard beneficiaries in the Philippines.

Barn- och ungdomspsykiatrin (BUP) och Barn- och ungdomshabiliteringen (HAB) är två specialistvårdsenheter i Sverige som båda ger vård till barn med autismspektrumtillstånd (AST). De nämnda vårdenheterna har skilda målgrupper och uppdrag vilket skulle kunna leda till varierande vårdkvalitet för barn med AST utifrån vårdenhet. Syftet med studien var att undersöka hur föräldrar till barn med AST definierar och upplever vårdkvaliteten inom vårdenheterna BUP och HAB samt att synliggöra eventuella likheter och skillnader mellan enheterna. Totalt 12 kvalitativa intervjuer genomfördes och analyserades med hjälp av kvalitativ innehållsanalys. Som teoretiskt ramverk användes Donabedians modell för att mäta vårdkvalitet utifrån struktur, process och utfall. Föräldrarna i studien beskrev vårdens kvalitet utifrån Donabedians tre kvalitetsmått.  Studien identifierade tre viktiga processfaktorer av vikt för vårdkvalitet: Kontinuitet, bemötande och tillgänglighet. Föräldrarna beskrev stora brister inom de tre processkategorierna, som de upplevde bero på strukturella faktorer inom hälso- och sjukvårdsorganisationen. Föräldrars egna förmågor upplevdes vara av stor vikt för den givna vårdens kvalitet. Skillnader i vårdkvalitet mellan BUP och HAB beskrevs gällande bemötande och tillgänglighet till insatser. Studiens resultat kan användas i förbättringsarbeten inom vården för barn med AST.

Barn- och ungdomspsykiatrin (BUP) och Barn- och ungdomshabiliteringen (HAB) är två specialistvårdsenheter i Sverige som båda ger vård till barn med autismspektrumtillstånd (AST). De nämnda vårdenheterna har skilda målgrupper och uppdrag vilket skulle kunna leda till varierande vårdkvalitet för barn med AST utifrån vårdenhet. Syftet med studien var att undersöka hur föräldrar till barn med AST definierar och upplever vårdkvaliteten inom vårdenheterna BUP och HAB samt att synliggöra eventuella likheter och skillnader mellan enheterna. Totalt 12 kvalitativa intervjuer genomfördes och analyserades med hjälp av kvalitativ innehållsanalys. Som teoretiskt ramverk användes Donabedians modell för att mäta vårdkvalitet utifrån struktur, process och utfall. Föräldrarna i studien beskrev vårdens kvalitet utifrån Donabedians tre kvalitetsmått. Studien identifierade tre viktiga processfaktorer av vikt för vårdkvalitet: Kontinuitet, bemötande och tillgänglighet. Föräldrarna beskrev stora brister inom de tre processkategorierna, som de upplevde bero på strukturella faktorer inom hälso- och sjukvårdsorganisationen. Föräldrars egna förmågor upplevdes vara av stor vikt för den givna vårdens kvalitet. Skillnader i vårdkvalitet mellan BUP och HAB beskrevs gällande bemötande och tillgänglighet till insatser. Studiens resultat kan användas i förbättringsarbeten inom vården för barn med AST.

Submitted in fulfillment of the requirements for the Degree in Masters of Technology in Nursing, Durban University of Technology, Durban, South Africa, 2015. / Background The current health care system in South Africa and its diverse settings of health care delivery system require a nurse who can make decisions, think critically, solve problems and work effectively in a team. Traditional nursing education teaching strategies have over the years relied on didactic and often passive approaches to learning. In pursuit of quality, academics and students must be continually engaged in a process of finding opportunities for improving the teaching and learning process. Purpose of the study The purpose of this study was to evaluate the structure and the process in case based learning at the University of Technology. Methodology This study is qualitative in nature, governed by an interpretive paradigm. This is a case study, which enabled the researcher to merge student interview data with records in order to gain insight into the activities and details of case based learning as practised at the University of Technology under study. Most importantly, the case study method was deemed appropriate for the current study, since case-based learning as a pedagogical approach (and a case) cannot be abstracted from its context for the purposes of study. Case based learning is evaluated in its context namely, the undergraduate nursing programme, using the Donabedian framework of structure, process and product. Results The study recorded that students were positive towards case based learning though some identified dynamics of working in groups as demerits of case based learning. The structures that are in place in the programme and the CBL processes are adequate and support CBL. There are however areas that need attention such as the qualification of the programme coordinator, the size of the class-rooms and the service of the computer laboratory. Conclusion The study found that apart from a few minor discrepancies, case based learning is sufficiently implemented, and experienced as invaluable by students, at the University of Technology under study.