I Sverige har vårdköerna varit hett debatterade under större delen av 2000-talet. Detta berorpå att vårdköerna har blivit långa, vilket har lett till att politikerna stiftat lagar som stipulerarhur lång tid en patient ska få vänta på vård. Detta är den så kallade Vårdgarantin, som innebärbland annat att patienten inte ska behöva vänta längre än 90 dagar på kirurgisk vård efterfastställd diagnos. Trots Vårdgarantin har vårdköerna inte minskat, utan snarare ökat. Utifrån denna problematik är syftet att undersöka alternativkostnaden för samhället av att inteprioritera vårdkön. Vi gör detta genom att analysera operationer som har längre väntetid änvad Vårdgarantin föreskriver, och undersöker hur kostnadseffektiva operationerna är för attberäkna hur många år i full hälsa som går förlorade på grund av väntetiderna. Slutligendiskuterar vi vad regionens kostnader blir av att inte prioritera vårdköerna. För att svara på frågeställningarna gör vi en litteratursökning likt en tidigare studie nyligengenomförd i Irland för att undersöka kostnadseffektiviteten av kirurgiska behandlingar, ochdärefter jämföra kostnadseffektiviteten mot ett tröskelvärde för kostnadseffektivitet på 300000 SEK. Resultatet visar att en större investering i den svenska vårdkön vore mycketkostnadseffektivt, då operationernas kostnadseffektivitet är betydligt lägre än tröskelvärdet på300 000 SEK. I studien visar vi exempelvis att ingen av de sex interventionerna somundersöks kostar mer än 50 000 SEK per år i full hälsa, medan svenska beslutsfattare inomvårdsektorn är villiga att acceptera en kostnad uppemot 2 miljoner SEK under vissaförutsättningar. Det ska dock tilläggas att patienterna som står i vårdkö får vård till slut, ävenom det kan dröja flera år tills de får det. Vår slutsats är att patienter som väntar på vård är en nedprioriterad grupp i sjukvården, ochatt de representerar en alternativkostnad som beslutsfattare bör ta i beaktande vid andrainvesteringsmöjligheter gällande hälsa- och sjukvård. Vidare forskning bör bland annatutreda möjligheterna att förkorta väntetiderna. / The waiting lists for healthcare have been heavily debated in Sweden during the 21st century.It has been so because patients have been waiting for healthcare much longer than expected,which has led politicians to change the healthcare laws, promising to decrease the queuingtime for patients. This is the so-called Vårdgarantin (Healthcare Warranty), which, amongother things, says that a patient should not have to wait longer than 90 days for surgery, afterreferral. Despite Vårdgarantin, the waiting lists have not decreased, but rather increased. Based on this problem we have chosen to examine the opportunity cost for society of notprioritizing the healthcare waiting lists by analyzing which surgeries have longer waiting liststhan the Vårdgaranti prescribes. We will also examine how cost effective each surgery is andcalculate how many years at full health is lost in the population when society does notprioritize addressing the queues. Furthermore, we will discuss the Swedish regions’ (which isthe administrative unit in Sweden that is responsible for providing health care to its citizens)opportunity costs by not prioritizing the waiting list. To answer these issues, have we done a literature study, in the same fashion as researchers inIreland recently, to examine the cost effectiveness of surgeries and compare it to a 300 000SEK cost-effectiveness threshold. Our results show that it would be cost effective forSwedish regions to invest in reducing their waiting lists, due to relatively low costs per yearwith full health of surgeries with long waiting lists. In our study, all of the six includedinterventions cost less than 50 000 SEK per year in full health. This can be compared to theSwedish decision makers who sometimes are willing to pay up to 2 million SEK per year atfull health for the very ill under extraordinary circumstances. It should be noted that thepatients who are in the healthcare queue receive care in the end, even if it can take severalyears until the patients receive it. Conclusively, patients waiting for care is a deprioritized group in the healthcare sector andcan be seen as an opportunity cost when considering new investment opportunities. Furtherresearch should investigate the possibilities of how waiting times can be reduced.

Healthcare resources in Sweden are limited, and not everyone that wants care can receive it. Restrictions on access to care are therefore necessary. The restrictions can be implemented in various ways, but in Sweden, waiting lists are used. Waiting lists are often considered a more equitable way to distribute healthcare compared to using prices. Research has however shown that these waiting lists sometimes lead to inequalities, where, for example, higher income is associated with shorter waiting times. We study the relationship between socioeconomic status and waiting times for elective care in Region Östergötland during the period 2018-2023. Linear regression analysis is used to study this link. The overall delivery of care appears equal, but the specialty of Ophthalmology shows disparities in waiting times related to socioeconomic factors. A more detailed analysis also shows that the relationship varies depending on the length of the waiting time within Ophthalmology / Hälso- och sjukvårdens resurser i Sverige är knappa och alla som vill ha vård kan inte få det. Begränsningar i tillgången till vård är således ett måste. Det kan ske på flera olika sätt men i Sverige används vårdköer för detta. Köer anses ofta vara ett mer jämlikt sätt att fördela vård än att använda priser. Det finns dock studier som visar att dessa vårdköer ibland leder till ojämlikheter, där exempelvis högre inkomst är kopplat till kortare väntetider. Vi studerar sambandet mellan socioekonomisk status och väntetid till elektiv kirurgi i Region Östergötland under 2018-2023. Linjär regressionsanalys används för att analysera sambandet. Resultaten visar att vården i stor utsträckning levereras på ett jämlikt sätt. Det existerar dock ojämlikheter inom specialistområdet Ögonsjukvård kopplat till socioekonomisk status. En mer detaljerad analys visar även att sambandet varierar beroende på väntetidens längd inom Ögonsjukvård.

[ES] La buena gestión de la atención primaria como puerta de entrada al sistema sanitario condiciona el funcionamiento de la atención especializada y la hospitalización, lo cual repercute directamente sobre la salud de la población. La sostenibilidad del sistema de salud público implica que los servicios de atención primaria sean eficientes. Objetivo Desarrollar un modelo para evaluar la eficiencia en cuanto a actividad realizada y resultados de salud de las unidades funcionales (UF) de atención primaria del Departamento de Salud Valencia Clínico - La Malvarrosa en los años 2015 a 2019. Metodología Se han integrado las bases de datos de la Conselleria de Sanitat Universal i Salut Pública y el Departamento de Salud Valencia Clínico - La Malvarrosa para obtener para cada UF: características de la población asignada, actividad asistencial y recursos humanos de los centros y consultorios de atención primaria. El análisis factorial pone de manifiesto las principales diferencias y similitudes encontradas entre las UF y permite reducir el número de variables utilizadas para elaborar los modelos de evaluación de la eficiencia, de manera que no se pierda poder explicativo, y facilite la interpretación de los resultados. Se ha utilizado el Análisis Envolvente de Datos (DEA) con orientación input y output y rendimientos variables a escala para la evaluación de la eficiencia. Los inputs incluidos han sido las tasas por 10.000 habitantes de: personal facultativo y personal de enfermería (inputs no discrecionales) y coste farmacéutico; como outputs se han incluido las tasas por 10.000 habitantes de: urgencias hospitalarias, consultas externas, derivaciones, hospitalizaciones evitables, mortalidad evitable y el indicador de eficiencia en la prescripción. Urgencias, hospitalizaciones evitables y mortalidad evitables se consideran outputs no deseables. Y como variables exógenas se han incluido el porcentaje de población mayor de 65 y 80 años y un indicador de morbilidad (case-mix). Se han analizado las puntuaciones de eficiencia de cada UF según tres modelos. Todos los modelos incorporan los mismos inputs y diferentes combinaciones de outputs relacionados con: Actividad asistencial (primer modelo), outcomes o resultados de salud (segundo modelo) y actividad asistencial + outcomes (tercer modelo, en el que se incluyen todos los outputs). Cada modelo se analiza con y sin variables exógenas. Resultados Se han evaluado los tres modelos con sus diferentes especificaciones para identificar las diferencias entre ellos y ver cuál de ellos permite diferenciar más claramente la eficiencia de las UF, teniendo en cuenta variables de calidad, y las características de la población. Se ha obtenido la puntuación de eficiencia de cada UF y se han identificado las UF que forman parte de la frontera eficiente del grupo estudiado. Los resultados han mostrado que existen diferencias en las puntuaciones de eficiencia estimadas en función de las variables introducidas como outputs. Determinadas UF se encuentran siempre en la frontera eficiente o muy cerca, mientras que otras UF son siempre ineficientes. Por otra parte, cuando se consideran outputs de actividad asistencial, las puntuaciones de eficiencia de todas las UF mejoran y aumenta el número de UF eficientes. Se detecta que la puntuación de eficiencia de las UF desciende, en general, a lo largo del periodo evaluado. Esta disminución es más pronunciada cuando se incluyen sólo los outputs de actividad. Conclusiones Se han obtenido diferentes resultados en función del modelo utilizado. El DEA permite analizar las ineficiencias de los centros de atención primaria, aunque es necesario identificar los objetivos esperados de las UF, ya que la perspectiva de los análisis influye en los resultados. / [CA] La bona gestió de l'atenció primària com a porta d'entrada al sistema sanitari condiciona el funcionament de l'atenció especialitzada i l'hospitalització, la qual cosa repercuteix directament sobre la salut de la població. La sostenibilitat del sistema de salut públic implica que els serveis d'atenció primària siguen eficients. Objectiu Desenvolupar un model per a avaluar l'eficiència quant a activitat realitzada i resultats de salut de les unitats funcionals (UF) d'atenció primària del Departament de Salut València Clínic - La Malva-rosa en els anys 2015 a 2019. Metodologia S'han integrat les bases de dades de la Conselleria de Sanitat Universal i Salut Pública i el Departament de Salut València Clínic - La Malva-rosa per a obtindre per a cada UF: característiques de la població assignada, activitat assistencial i recursos humans dels centres i consultoris d'atenció primària. L'anàlisi factorial posa de manifest les principals diferències i similituds trobades entre les UF i permet reduir el nombre de variables utilitzades per a elaborar els models d'avaluació de l'eficiència, de manera que no es perda poder explicatiu, i facilite la interpretació dels resultats. S'ha utilitzat l'Anàlisi Envolupant de Dades (DEA) amb orientació input i output i rendiments variables a escala per a l'avaluació de l'eficiència. Els inputs inclosos han sigut les taxes per 10.000 habitants de personal facultatiu i personal d'infermeria (inputs no discrecionals) i cost farmacèutic; com a outputs s'han inclòs les taxes per 10.000 habitants de consultes, urgències hospitalàries, derivacions, hospitalitzacions evitables, mortalitat evitable i l'indicador d'eficiència en la prescripció. Urgències, hospitalitzacions evitables i mortalitat evitables es consideren outputs no desitjables. I com a variables exògenes s'han inclòs el percentatge de població major de 65 i 80 anys i un indicador de morbiditat (case-mix). S'han analitzat les puntuacions d'eficiència de cada UF segons tres models. Tots els models incorporen els mateixos inputs i diferents combinacions d'outputs relacionats amb activitat assistencial (primer model), outcomes o resultats de salut (segon model) i activitat assistencial + outcomes (tercer model, en el qual s'inclouen tots els outputs). Cada model s'analitza amb i sense variables exògenes. Resultats S'han avaluat els tres models amb les seues diferents especificacions per a identificar les diferències entre ells i veure quin d'ells permet diferenciar més clarament l'eficiència de les UF, tenint en compte variables de qualitat, i les característiques de la població. S'ha obtingut la puntuació d'eficiència de cada UF i s'han identificat les UF que formen part de la frontera eficient del grup estudiat. Els resultats han mostrat que existeixen diferències en les puntuacions d'eficiència estimades en funció de les variables introduïdes com a outputs. Determinades UF es troben sempre en la frontera eficient o molt a prop, mentre que unes altres UF són sempre ineficients. D'altra banda, quan es consideren outputs d'activitat assistencial, les puntuacions d'eficiència de totes les UF milloren i augmenta el número d'UF eficients. Es detecta que la puntuació d'eficiència de les UF descendeix, en general, al llarg del període avaluat. Aquesta disminució és més pronunciada quan s'inclouen només els outputs d'activitat. Conclusions S'han obtingut diferents resultats en funció del model utilitzat. El DEA permet analitzar les ineficiències dels centres d'atenció primària, encara que és necessari identificar els objectius esperats de les UF, ja que la perspectiva de les anàlisis influeix en els resultats. / [EN] The proper management of primary healthcare as the gateway to the health system determines the performance of specialised healthcare and hospitalisation, which has a direct impact on the health of the population. The sustainability of the public health system requires the efficiency of primary healthcare services. Objectives To develop a model to evaluate the efficiency in terms of activity and health outcomes of the functional units (FU) of primary healthcare of the Valencia Clínico - La Malvarrosa Health District in the years 2015 to 2019. Methodology The databases of the Conselleria de Sanitat Universal i Salut Pública and the Valencia Clínico - La Malvarrosa Health District have been integrated to obtain for each FU: characteristics of the covered population, healthcare activity and human resources of the primary healthcare centres. The factorial analysis reveals the main differences and similarities found between the FUs and makes it possible to reduce the number of variables used to develop the efficiency evaluation models, so as not to lose explanatory power and to facilitate the interpretation of the results. Data Envelopment Analysis (DEA) with input and output orientation and variable returns to scale has been used to assess the efficiency. The inputs included were the rates per 10,000 inhabitants of: professional and nursing staff (non-discretionary inputs) and pharmaceutical cost; outputs included the rates per 10,000 inhabitants of: consultations, hospital emergencies, referrals, avoidable hospitalisations, avoidable mortality and the prescription efficiency indicator. Emergencies, avoidable hospitalisations and avoidable mortality are considered undesirable outputs. As exogenous variables we have included the percentage of the population over 65 and 80 years old and a morbidity indicator (case-mix). The efficiency scores of each FU have been analysed according to three models. All models incorporate the same inputs and different combinations of outputs related to: healthcare activity (first model), outcomes (second model) and healthcare activity + outcomes (third model, in which all outputs are included). Each model is analysed with and without exogenous variables. Results The three models have been evaluated with their different specifications to identify the differences between them and to see which of them allows the efficiency of the FU to be differentiated more clearly, considering quality variables and the characteristics of the population. The efficiency score of each FU has been obtained and the FUs that form part of the efficient frontier of the group studied have been identified. The results show that there are differences in the estimated efficiency scores depending on the variables introduced as outputs. Certain FUs are always on the efficient frontier or very close to it, while other FUs are always inefficient. On the other hand, when healthcare activity outputs are considered, the efficiency scores of all FUs improve and the number of efficient FUs increases. It is found that the efficiency score of the FU generally decreases over the period under evaluation. This decline is more pronounced when only activity outputs are included. Conclusions Different results have been obtained depending on the model used. The DEA makes it possible to analyse the inefficiencies of primary healthcare centres, although it is necessary to identify the expected objectives of the FU, as the perspective of the analysis influences the results. / González De Julián, S. (2023). Medida de la eficiencia en atención primaria: fronteras eficientes y modelos no paramétricos condicionados [Tesis doctoral]. Universitat Politècnica de València. https://doi.org/10.4995/Thesis/10251/196735

No / Using data for every elective procedure in 2007 in the English National Health Service, we found evidence of socioeconomic inequality in the probability of having a procedure cancelled after admission while controlling for a range of patient and provider characteristics. Whether this disparity is inequitable is inconclusive.; Using data for every elective procedure in 2007 in the English National Health Service, we found evidence of socioeconomic inequality in the probability of having a procedure cancelled after admission while controlling for a range of patient and provider characteristics. Whether this disparity is inequitable is inconclusive. Copyright A[c] 2012 John Wiley & Sons, Ltd.; � Using data for every elective procedure in 2007 in the English National Health Service, we found evidence of socioeconomic inequality in the probability of having a procedure cancelled after admission while controlling for a range of patient and provider characteristics. Whether this disparity is inequitable is inconclusive.

L'objectif principal de ce travail est d’étudier en profondeur certaines techniques biostatistiques avancées en recherche évaluative en chirurgie cardiaque adulte. Les études ont été conçues pour intégrer les concepts d'analyse de survie, analyse de régression avec “propensity score”, et analyse de coûts. Le premier manuscrit évalue la survie après la réparation chirurgicale de la dissection aigüe de l’aorte ascendante. Les analyses statistiques utilisées comprennent : analyses de survie avec régression paramétrique des phases de risque et d'autres méthodes paramétriques (exponentielle, Weibull), semi-paramétriques (Cox) ou non-paramétriques (Kaplan-Meier) ; survie comparée à une cohorte appariée pour l’âge, le sexe et la race utilisant des tables de statistiques de survie gouvernementales ; modèles de régression avec “bootstrapping” et “multinomial logit model”. L'étude a démontrée que la survie s'est améliorée sur 25 ans en lien avec des changements dans les techniques chirurgicales et d’imagerie diagnostique. Le second manuscrit est axé sur les résultats des pontages coronariens isolés chez des patients ayant des antécédents d'intervention coronarienne percutanée. Les analyses statistiques utilisées comprennent : modèles de régression avec “propensity score” ; algorithme complexe d'appariement (1:3) ; analyses statistiques appropriées pour les groupes appariés (différences standardisées, “generalized estimating equations”, modèle de Cox stratifié). L'étude a démontrée que l’intervention coronarienne percutanée subie 14 jours ou plus avant la chirurgie de pontages coronariens n'est pas associée à des résultats négatifs à court ou long terme. Le troisième manuscrit évalue les conséquences financières et les changements démographiques survenant pour un centre hospitalier universitaire suite à la mise en place d'un programme de chirurgie cardiaque satellite. Les analyses statistiques utilisées comprennent : modèles de régression multivariée “two-way” ANOVA (logistique, linéaire ou ordinale) ; “propensity score” ; analyses de coûts avec modèles paramétriques Log-Normal. Des modèles d’analyse de « survie » ont également été explorés, utilisant les «coûts» au lieu du « temps » comme variable dépendante, et ont menés à des conclusions similaires. L'étude a démontrée que, après la mise en place du programme satellite, moins de patients de faible complexité étaient référés de la région du programme satellite au centre hospitalier universitaire, avec une augmentation de la charge de travail infirmier et des coûts. / The main objective of this work is to study in depth advanced biostatistical techniques in adult cardiac surgery outcome research. The studies were designed to incorporate the concepts of survival analysis, regression analysis with propensity score, and cost analysis. The first manuscript assessed survival, and cardiovascular specific mortality, following surgical repair of acute ascending aortic dissection. The statistical analyses included survival analyses with multiphase parametric hazard regression and other parametric (exponential, Weibull), semi-parametric (Cox) or non-parametric models (Kaplan Meier), comparison with the survival of a matched cohort for age, gender and race using State lifetables, and modelization with bootstrapping and multinomial logit models. The study showed that the early and late survival following surgical repair has improved progressively over 25 years in association with noticeable changes in surgical techniques and preoperative diagnostic testing. The second manuscript focused on outcomes following isolated coronary artery bypass grafting in patients with a history of percutaneous coronary intervention. The statistical analyses included multivariable regression models with propensity score, complex matching algorithm (1:3) and appropriate statistical analyses for matched groups (standardized differences, generalized estimating equations, and survival analyses with stratified proportional hazards models). The study showed that remote prior percutaneous coronary intervention more than 14 days before coronary artery bypass grafting surgery was not associated with adverse outcomes at short or long-term follow-up. The third manuscript evaluated the financial consequences and the changes in case mix that occurred at an academic medical center subsequent to the implementation of a satellite cardiac surgery program. The statistical analyses included two-way ANOVA multivariable regression models (logistic, linear or ordinal), propensity score, and cost analyses using Log-Normal parametric models. “Survival” analyses models were also explored, using “cost” instead of “time” as the outcome of interest, and led to similar conclusions. The study showed that, after implementation of the satellite cardiac surgery program, fewer patients of lower complexity came to the academic medical center from the satellite program area, with a significant increase in nursing workload and costs.

Este trabalho teve o objetivo de analisar o registro dos prontuários hospitalares como subsídio para a gestão em saúde. Foram analisados 430 prontuários de egressos de 2 hospitais públicos municipais de São Paulo internados em abril de 2010. Os resultados mostraram que os registros dos hospitais foram diferentes na maioria das variáveis estudadas, motivo pelo qual foram tratados separadamente. Observou-se que as variáveis sexo, idade, número de diagnósticos, motivo da saída, tempo de permanência e número de cuidados foram totalmente registradas. Enquanto que as variáveis pressão arterial, freqüência cardíaca, freqüência respiratória, temperatura, dor, alimentação, banho e locomoção foram parcialmente registradas. Analisando as variáveis totalmente registradas verificou-se que no Hospital A e B, respectivamente, adultos de 30 a 59 anos (35.9%, 42.3%), idosos com 60 anos ou mais (22.8%, 16.3%) e crianças menores de 4 anos (20.1%, 17.2%) foram os que mais demandaram internações. Da mesma forma, crianças (4 a 5 dias, 4 a 6 dias) e idosos (2 a 6 dias, 4 a 6 dias) necessitaram de maior tempo de permanência. No Hospital A, as doenças do aparelho respiratório (20.5%) foram as principais responsáveis pelas internações, seguidas pelos transtornos mentais e comportamentais (14.4%). Enquanto que, no Hospital B, as doenças do aparelho respiratório (15.4%) foram as principais responsáveis pelas internações, seguidas pelas doenças do aparelho circulatório (13.5%). No Hospital A e B, respectivamente, os cuidados básicos foram mais freqüentemente registrados na saída (n=278, n=315) em comparação à admissão (n=271, n=234), enquanto que os cuidados invasivos foram mais freqüentemente registrados na admissão (n=505, n=618), em comparação à saída (n=201, n=208). Analisando a presença do registro parcial das variáveis, houve ocorrência no Hospital A na admissão e saída, respectivamente, em: pressão arterial (73.5%, 73.5%), freqüência cardíaca (72.1%, 71.6%), freqüência respiratória (39.1%, 29.3%), temperatura (89.3%, 80.5%), dor (12.6%, 11.2%), alimentação (92.6%, 95.3%), banho (91.6%, 94.4%) e locomoção (94.9%, 95.8%). Enquanto que, no Hospital B, houve presença de registro parcial na admissão e saída, respectivamente, em: pressão arterial (80%, 73.5%), freqüência cardíaca (80.5%, 73%), freqüência respiratória (21.4%, 12.1%), temperatura (96.7%, 89.8%), dor (1.4%, 0.5%), alimentação (100%, 99.5%), banho (99.1%, 99.1%) e locomoção (99.5%, 99.1%). A associação entre as variáveis indicativas: tempo de permanência e número de cuidados na admissão e na saída com as demais variáveis, mostrou que, quanto maior o tempo de permanência e o número de cuidados na admissão e saída, maior a idade, o número de diagnósticos e o comprometimento clínico e funcional. / This work aims to set the basis for a health management by analyzing the key informations of 430 medical records, which were taken from two public hospitals in the city of São Paulo, in April 2010.The research showed that the records were different in both hospitals in most of the variables studied. Consequently, they had to be analysed distinctively. It was observed that, while the variables: gender, age, diagnosis, hospital discharge reasons, lengh of stay and medical cares were entirely recorded, variables like blood pressure, cardiac and breathing frequency, body temperature, pain, food, bath and locomotion were partially recorded. Considering the variables entirely recorded, it was verified that in the hospitals A and B, respectively, the most medical admission requirements were for adults between 30-59 years of age (35.9%, 42.3%), elderly aged 60 or older (22.8%, 16.3%) and children under 4 years old (20.1%, 17.2%). On the same way, children (4 a 5 days, 4 a 6 days) and elderly (2 a 6 days, 4 a 6 days) had longer lenght of stay. In hospital A respiratory system diseases (20.5%) were the leading cause of medical admissions followed by mental and behavioral disorders (14.4%), compared to hospital B, respiratory system diseases (15.4%) followed by circulatory system illnesses(13.5%). In both cases A and B, respectively, the basic care were more frequent on the hospital discharge (n=278, n=315) if compaired to admissions (n=271, n=234), while invasive care were more frequent in the admissions (n=505, n=618) if compaired to hospital discharge (n=201, n=208). Upong analyzing the presence of the variables partial record, it has occurred in hospital A at the time of admissions and medical discharges, respectively,: blood pressure (73.5%, 73.5%), cardiac frequency (72.1%, 71.6%), breathing frequency(39.1%, 29.3%), body temperature (89.3%, 80.5%), pain (12.6%, 11.2%), food (92.6%, 95.3%), bath (91.6%, 94.4%) and locomotion (94.9%, 95.8%), while in the the hospital B, it has occurred respectively;: blood pressure (80%, 73.5%), cardiac frequency (80.5%, 73%), breathing frequency (21.4%, 12.1%), body temperature (96.7%, 89.8%), pain (1.4%, 0.5%), food (100%, 99.5%), bath (99.1%, 99.1%) and locomotion (99.5%, 99.1%). The association between the variables: lenght of stay and number of cares at the time of hospital admissions and discharges with the other parameters, showed that the longer the length of stay and the greater the number of cares in admissions and discharges, the older are the inpatients and the greater are the number of diagnosis and the clinical and functional impairements.

The thesis provides a comprehensive overview of key issues affecting practice, policy and patients, in current efforts for colorectal cancer (CRC) disease control. The global burden of CRC is expected to increase by 60% to more than 2.2 million new cases and 1.1 million deaths by 2030. CRC incidence and mortality rates vary up to 10-fold worldwide, which is thought to reflect variation in lifestyles, especially diet. Better primary prevention, and more effective early detection, in screening and surveillance, are needed to reduce the number of patients with CRC in future1. The risk factors for CRC development include genetic, behavioural, environmental and socio-economic factors. Changes to surveillance, which offer non-invasive testing and provide primary prevention interventions represent promising opportunities to improve outcomes and personalise care in those at risk of CRC. By systematic review of the literature, I highlight the gaps in comparative effectiveness analyses of post-polypectomy surveillance. Using micro-simulation methods I assess the role of non-invasive, faecal immunochemical testing in surveillance programmes, to optimise post-polypectomy surveillance programmes, and in an accompanying sub-study, I explore the value of adding an adjunct diet and lifestyle intervention. The acceptability of such revisions is exposed to patient preference evaluation by discrete choice experiment methods. These preferences are accompanied by evidence generated from the prospective evaluation of the health literacy, numeracy, sedentary behaviour levels, body mass index (BMI) and information provision about cancer risk factors, to highlight the potential opportunities for personalisation and optimisation of surveillance. Additional analysis examines the optimisation of a screening programme facing colonoscopy constraints, highlighting the attendant potential to reduce costs and save lives within current capacity.

Although arsenic is naturally present in the environment, 99% of human exposure to arsenic is through ingestion. Throughout history, arsenic is known as “the king of poisons”; it is mutagenic, carcinogenic, and teratogenic. Even in smaller concentrations, it accumulates in the body and takes decades before any physical symptoms of arsenic poisoning shows. According to the World Health Organization (WHO), the safe concentration of arsenic in drinking water is 10 µg/L. However, this limit is often times ignored until it is decades too late and people begin showing symptoms of having been poisoned. This is the current situation for Vietnam, whose legal arsenic concentration limit is 50 µg/L, five times higher than the WHO guidelines. Groundwater in Vietnam was already naturally high in arsenic due to arsenic-rich soils releasing arsenic into groundwater. Then, in the past half century, with the use of arsenic-laden herbicides dispersed during the Vietnam War and subsequent industrial developments, the levels of bio-available arsenicals has dangerously spiked. With the proliferation of government-subsidized shallow tube-wells in the past two decades, shallow groundwater has become the primary source for drinking and irrigation water in Vietnam. This is a frightening trend, because this groundwater has arsenic concentrations up to 3050 µg/L, primarily in the +3 and +5 oxidation states, the most readily available oxidation states for bioaccumulation. This thesis argues that measures must be taken immediately to remedy the high concentration of arsenic in groundwater, which in Vietnam is the primary and, in some cases, the sole source of water for domestic consumption and agricultural production. Although there are numerous technologies available for treating arsenic in groundwater, not all of them are suited for Vietnam. By analyzing the historical, cultural, economic, and political parameters of Vietnam, several optimal treatments of groundwater for drinking water emerged as most recommended, a classification that is based on their local suitability, social acceptability, financial feasibility, and governmental support. Further research on irrigation water treatment is proposed due to the need for sustainable crop production, the safe ingestion of rice and vegetables, and the continued growth of Vietnam’s economy, which is heavily dependent on agriculture.

L'objectif principal de ce travail est d’étudier en profondeur certaines techniques biostatistiques avancées en recherche évaluative en chirurgie cardiaque adulte. Les études ont été conçues pour intégrer les concepts d'analyse de survie, analyse de régression avec “propensity score”, et analyse de coûts. Le premier manuscrit évalue la survie après la réparation chirurgicale de la dissection aigüe de l’aorte ascendante. Les analyses statistiques utilisées comprennent : analyses de survie avec régression paramétrique des phases de risque et d'autres méthodes paramétriques (exponentielle, Weibull), semi-paramétriques (Cox) ou non-paramétriques (Kaplan-Meier) ; survie comparée à une cohorte appariée pour l’âge, le sexe et la race utilisant des tables de statistiques de survie gouvernementales ; modèles de régression avec “bootstrapping” et “multinomial logit model”. L'étude a démontrée que la survie s'est améliorée sur 25 ans en lien avec des changements dans les techniques chirurgicales et d’imagerie diagnostique. Le second manuscrit est axé sur les résultats des pontages coronariens isolés chez des patients ayant des antécédents d'intervention coronarienne percutanée. Les analyses statistiques utilisées comprennent : modèles de régression avec “propensity score” ; algorithme complexe d'appariement (1:3) ; analyses statistiques appropriées pour les groupes appariés (différences standardisées, “generalized estimating equations”, modèle de Cox stratifié). L'étude a démontrée que l’intervention coronarienne percutanée subie 14 jours ou plus avant la chirurgie de pontages coronariens n'est pas associée à des résultats négatifs à court ou long terme. Le troisième manuscrit évalue les conséquences financières et les changements démographiques survenant pour un centre hospitalier universitaire suite à la mise en place d'un programme de chirurgie cardiaque satellite. Les analyses statistiques utilisées comprennent : modèles de régression multivariée “two-way” ANOVA (logistique, linéaire ou ordinale) ; “propensity score” ; analyses de coûts avec modèles paramétriques Log-Normal. Des modèles d’analyse de « survie » ont également été explorés, utilisant les «coûts» au lieu du « temps » comme variable dépendante, et ont menés à des conclusions similaires. L'étude a démontrée que, après la mise en place du programme satellite, moins de patients de faible complexité étaient référés de la région du programme satellite au centre hospitalier universitaire, avec une augmentation de la charge de travail infirmier et des coûts. / The main objective of this work is to study in depth advanced biostatistical techniques in adult cardiac surgery outcome research. The studies were designed to incorporate the concepts of survival analysis, regression analysis with propensity score, and cost analysis. The first manuscript assessed survival, and cardiovascular specific mortality, following surgical repair of acute ascending aortic dissection. The statistical analyses included survival analyses with multiphase parametric hazard regression and other parametric (exponential, Weibull), semi-parametric (Cox) or non-parametric models (Kaplan Meier), comparison with the survival of a matched cohort for age, gender and race using State lifetables, and modelization with bootstrapping and multinomial logit models. The study showed that the early and late survival following surgical repair has improved progressively over 25 years in association with noticeable changes in surgical techniques and preoperative diagnostic testing. The second manuscript focused on outcomes following isolated coronary artery bypass grafting in patients with a history of percutaneous coronary intervention. The statistical analyses included multivariable regression models with propensity score, complex matching algorithm (1:3) and appropriate statistical analyses for matched groups (standardized differences, generalized estimating equations, and survival analyses with stratified proportional hazards models). The study showed that remote prior percutaneous coronary intervention more than 14 days before coronary artery bypass grafting surgery was not associated with adverse outcomes at short or long-term follow-up. The third manuscript evaluated the financial consequences and the changes in case mix that occurred at an academic medical center subsequent to the implementation of a satellite cardiac surgery program. The statistical analyses included two-way ANOVA multivariable regression models (logistic, linear or ordinal), propensity score, and cost analyses using Log-Normal parametric models. “Survival” analyses models were also explored, using “cost” instead of “time” as the outcome of interest, and led to similar conclusions. The study showed that, after implementation of the satellite cardiac surgery program, fewer patients of lower complexity came to the academic medical center from the satellite program area, with a significant increase in nursing workload and costs.

Este trabalho teve o objetivo de analisar o registro dos prontuários hospitalares como subsídio para a gestão em saúde. Foram analisados 430 prontuários de egressos de 2 hospitais públicos municipais de São Paulo internados em abril de 2010. Os resultados mostraram que os registros dos hospitais foram diferentes na maioria das variáveis estudadas, motivo pelo qual foram tratados separadamente. Observou-se que as variáveis sexo, idade, número de diagnósticos, motivo da saída, tempo de permanência e número de cuidados foram totalmente registradas. Enquanto que as variáveis pressão arterial, freqüência cardíaca, freqüência respiratória, temperatura, dor, alimentação, banho e locomoção foram parcialmente registradas. Analisando as variáveis totalmente registradas verificou-se que no Hospital A e B, respectivamente, adultos de 30 a 59 anos (35.9%, 42.3%), idosos com 60 anos ou mais (22.8%, 16.3%) e crianças menores de 4 anos (20.1%, 17.2%) foram os que mais demandaram internações. Da mesma forma, crianças (4 a 5 dias, 4 a 6 dias) e idosos (2 a 6 dias, 4 a 6 dias) necessitaram de maior tempo de permanência. No Hospital A, as doenças do aparelho respiratório (20.5%) foram as principais responsáveis pelas internações, seguidas pelos transtornos mentais e comportamentais (14.4%). Enquanto que, no Hospital B, as doenças do aparelho respiratório (15.4%) foram as principais responsáveis pelas internações, seguidas pelas doenças do aparelho circulatório (13.5%). No Hospital A e B, respectivamente, os cuidados básicos foram mais freqüentemente registrados na saída (n=278, n=315) em comparação à admissão (n=271, n=234), enquanto que os cuidados invasivos foram mais freqüentemente registrados na admissão (n=505, n=618), em comparação à saída (n=201, n=208). Analisando a presença do registro parcial das variáveis, houve ocorrência no Hospital A na admissão e saída, respectivamente, em: pressão arterial (73.5%, 73.5%), freqüência cardíaca (72.1%, 71.6%), freqüência respiratória (39.1%, 29.3%), temperatura (89.3%, 80.5%), dor (12.6%, 11.2%), alimentação (92.6%, 95.3%), banho (91.6%, 94.4%) e locomoção (94.9%, 95.8%). Enquanto que, no Hospital B, houve presença de registro parcial na admissão e saída, respectivamente, em: pressão arterial (80%, 73.5%), freqüência cardíaca (80.5%, 73%), freqüência respiratória (21.4%, 12.1%), temperatura (96.7%, 89.8%), dor (1.4%, 0.5%), alimentação (100%, 99.5%), banho (99.1%, 99.1%) e locomoção (99.5%, 99.1%). A associação entre as variáveis indicativas: tempo de permanência e número de cuidados na admissão e na saída com as demais variáveis, mostrou que, quanto maior o tempo de permanência e o número de cuidados na admissão e saída, maior a idade, o número de diagnósticos e o comprometimento clínico e funcional. / This work aims to set the basis for a health management by analyzing the key informations of 430 medical records, which were taken from two public hospitals in the city of São Paulo, in April 2010.The research showed that the records were different in both hospitals in most of the variables studied. Consequently, they had to be analysed distinctively. It was observed that, while the variables: gender, age, diagnosis, hospital discharge reasons, lengh of stay and medical cares were entirely recorded, variables like blood pressure, cardiac and breathing frequency, body temperature, pain, food, bath and locomotion were partially recorded. Considering the variables entirely recorded, it was verified that in the hospitals A and B, respectively, the most medical admission requirements were for adults between 30-59 years of age (35.9%, 42.3%), elderly aged 60 or older (22.8%, 16.3%) and children under 4 years old (20.1%, 17.2%). On the same way, children (4 a 5 days, 4 a 6 days) and elderly (2 a 6 days, 4 a 6 days) had longer lenght of stay. In hospital A respiratory system diseases (20.5%) were the leading cause of medical admissions followed by mental and behavioral disorders (14.4%), compared to hospital B, respiratory system diseases (15.4%) followed by circulatory system illnesses(13.5%). In both cases A and B, respectively, the basic care were more frequent on the hospital discharge (n=278, n=315) if compaired to admissions (n=271, n=234), while invasive care were more frequent in the admissions (n=505, n=618) if compaired to hospital discharge (n=201, n=208). Upong analyzing the presence of the variables partial record, it has occurred in hospital A at the time of admissions and medical discharges, respectively,: blood pressure (73.5%, 73.5%), cardiac frequency (72.1%, 71.6%), breathing frequency(39.1%, 29.3%), body temperature (89.3%, 80.5%), pain (12.6%, 11.2%), food (92.6%, 95.3%), bath (91.6%, 94.4%) and locomotion (94.9%, 95.8%), while in the the hospital B, it has occurred respectively;: blood pressure (80%, 73.5%), cardiac frequency (80.5%, 73%), breathing frequency (21.4%, 12.1%), body temperature (96.7%, 89.8%), pain (1.4%, 0.5%), food (100%, 99.5%), bath (99.1%, 99.1%) and locomotion (99.5%, 99.1%). The association between the variables: lenght of stay and number of cares at the time of hospital admissions and discharges with the other parameters, showed that the longer the length of stay and the greater the number of cares in admissions and discharges, the older are the inpatients and the greater are the number of diagnosis and the clinical and functional impairements.