Description of general practitioners role in a complex view of Health system - communication between doctors and hospital facilities and definition of the related essential duties and operations, characteristics of private practice focusing on selected general practitioner practice.

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This study evaluated the relationship of varying body mass index and average annual health care costs and absenteeism in a group of 524 municipal employees. The 269 employees with health care claims and the 487 employees with attendance records were categorized into five different BMI categories based on self-reported weight and height. Findings from the study suggest that as BMI increases, average annual health care costs and average annual absenteeism increase. However, BMI was only significantly related to absenteeism. The study also found significant relationships between education and health care costs and absenteeism. No significant differences for health care costs or absenteeism were found based on race, age, gender, wellness center membership, or smoking status.

La douleur chronique dont la prévalence est en augmentation en particulier chez les sujets âgés est considérée comme l’un des problèmes de santé les plus graves, non seulement en termes de souffrance humaine et de conséquences physiques et psychiques associées mais aussi en terme économique pour le système de santé et la société. Sa prise en charge reste toujours complexe surtout chez les sujets âgés d’une part pour des raisons liées aux mécanismes physiopathologiques variées de la douleur et à la pharmacopée insatisfaisante et d’autre part, pour des raisons de changements liés à l'âge, de modifications pharmacocinétiques et pharmacodynamiques. Dans ce contexte, ce travail de thèse issu principalement de la sous-cohorte S.AGE douleur chronique, nous donne l’opportunité (1) de décrire l’état actuel de la prise en charge médicamenteuse de la douleur chronique chez les sujets âgés non institutionnalisés par des médecins généralistes en fonction du genre des médecins; (2) d’identifier les facteurs prédictifs de chute chez les sujets âgés souffrant de douleur chronique et; (3) d’estimer le coût de consommation de soins dans cette population ainsi que d’identifier les facteurs associés aux coûts et leur évolution au cours de temps.Les principaux résultats sont:(1) Aucune différence n’a été mise en évidence entre les médecins hommes et femmes dans la prescription d’antalgiques de palier 1, 2 ou 3 (selon la classification d’OMS). Cependant, comparés aux médecins femmes, les médecins hommes ont prescrit plus de médicaments pour la douleur neuropathique et moins de médicaments Anti-Arthrosiques Symptomatiques d’Action Lente (AASAL) même après l’ajustement sur plusieurs facteurs de confusion;(2) Les facteurs prédictifs de chute identifiés chez les personnes âgées souffrant de douleur chronique sont: les antécédents préalables de chute, la dépendance dans les activités quotidiennes mesurée par l’échelle ADL, l'âge ≥75 et le fait de vivre seul à domicile. Ces facteurs non spécifiques à la douleur chronique se sont avérés pertinents dans les sous-cohortes S.AGE fibrillation atriale (FA) et diabète de type 2 (DT2).(3) Le coût moyen total de consommation de soins au premier semestre du suivi à été estimé à 2548€ ± 8885€/patient. Les facteurs indépendants associés aux coûts étaient: les comorbidités associées, la dépendance dans les activités quotidiennes, la dépression clinique probable, la nature permanente de la douleur, la douleur de type neuropathique, le fait de vivre seul à domicile, la lombalgie chronique et les fractures vertébrales/ tassement vertébraux. Dans les 18 mois suivants, les coûts de soins de santé ont augmenté de 48% (p <0,0001) (78%, 26%, 14% et 7% pour les hospitalisations, les prescriptions médicamenteuses, les visites médicales et paramédicales, respectivement).En conclusion, ce travail de thèse apporte des résultats sur plusieurs aspects de la douleur chronique chez les sujets âgés, leurs conséquences et leur prise en charge. Les résultats suggèrent une différence liée au genre de médecin dans la prescription des médicaments contre la douleur neuropathique et AASAL. Les résultats ont identifié également différents facteurs associés aux chutes et aux dépenses de santé sur lesquels des actions préventives de santé pourraient contribuer à une meilleure prise en charge des sujets âgés dans le futur. / Chronic pain whose prevalence is increasing particularly in the elderly is considered as one of the most serious health problems not only in terms of human suffering and associated physical and psychological consequences but also in terms of huge economic consequences for the health care system and society. Its management remains complex in the elderly on one hand for reasons related to the various pathophysiological mechanisms of pain and unsatisfactory pharmacopoeia. On the other hand, for reasons of changes related to age, pharmacokinetic and pharmacodynamic changes. In this context, this thesis derived mainly from the sub-cohort S.AGE chronic pain gives us the opportunity (1) to describe the current state of medical management of elderly suffering from chronic pain by general practitioners (GPs) according to the gender of the practitioner; (2) to identify predictors of falls in elderly patients with chronic pain; (3) to estimate health care consumption costs in this population as well as to identify factors associated to cost.The main results are: (1) no differences were found between male and female GPs in prescribing analgesics step1, 2 or 3 (according to World Health Organization classification). However, compared to women GPs, male GPs have prescribed more drugs for neuropathic pain and less Symptomatic Slow Acting Drugs for Osteoarthritis (SySADOA), even after adjustment for several confounding factors; (2) predictors of falls in the elderly with chronic pain are: fall history, dependence in daily activities measured by the ADL scale, ≥75 age and living alone at home. These factors have proven to be relevant in the sub cohort S.AGE atrial fibrillation and type 2 diabetes mellitus;(3) The average total cost of care consumption in the first semester was estimated to € 2.548 ± € 8.885. Independent factors associated with the costs were comorbidities, dependence in daily activities, the probable clinical depression, permanent pain, neuropathic pain, living alone at home, chronic low back pain and vertebral fractures/ vertebral compression. Health care costs increased significantly by 48% (p <0.0001) (78%, 26%, 14% and 7% for hospitalizations, medications, medical and paramedical visits, respectively) during the follow-up period.In conclusion, this thesis brings results on several aspects of chronic pain in the elderly, their consequences and management. The results suggest a difference by physician gender in prescription of drugs against neuropathic pain and SySADOA. The results also identified different predictors of falls and cost, which could contribute to a better prevention and care for elderly in the future.

The implementation of Electronic Health Records (EHR) has improved medical documentation in terms of accuracy, team communication, and ease of ordering tests and prescriptions; however, charting in an EHR strains the provider/patient relationship and contributes to physician burnout. Medical scribes are a promising potential solution to these problems. Our study aims to demonstrate that implementation of scribes into a medical residency program positively affects provider/patient satisfaction and improves quality and efficiency of EHR documentation. Our study evaluated the effectiveness and utility of scribes in a residency training program utilizing the established implementation framework “RE-AIM,” or Reach, Effectiveness, Adoption, Implementation (quality), and Maintenance. During the study’s initial “Training Phase,” 11 first and second-year Family Medicine residents conducted scribe-facilitated patient visits. Patient and provider satisfaction ratings were collected, note quality was evaluated, and time to note closure was measured. During the subsequent “Choice Phase,” residents were given the option of whether to utilize scribes, and the same data measures were collected. Resident satisfaction ratings during the Training Phase showed an average score of 6.03 (on a 1-7 scale where “7” = “strongly agree” with positive statements), and a pilot sample of 9 patients showed an average patient satisfaction rating of 4.77 (on a 1-5 scale where “5” = “strongly agree” with positive statements). Scribe-facilitated notes coded for quality had an average score of 3.375 (on a 1-5 scale where 5 is “extremely” high quality). Finally, residents’ average time to note closure was decreased by more than 8 hours in scribe-facilitated visits. During the Choice Phase, all 11 participating residents requested scribe-facilitated visits, again with very high patient satisfaction scores (4.67 on a 1-5 scale) as well as high clinician satisfaction scores (6.06 on a 1-7 scale). Choice Phase note quality and note-closure time are currently being assessed. These results demonstrate that scribes improve clinician and patient satisfaction, as well as quality and efficiency of EHR documentation. Limitations include a small sample size of clinicians and patients. Further research is needed with larger sample sizes to determine whether scribes in a medical residency program represent a sustainable and effective intervention.

Since the mid-1970s, top managers, politicians, and officials in both public and private institutions have promoted contracting-out services (privatization) as a means of increasing efficiency, flexibility, and quality. The privatization trend has occurred in many public sector organizations particularly in city services and prisons. Public health services are not immune to this trend. Today many county health departments have contracted the provision of public health services like womens health, primary care, and laboratory services. However, very few studies have analyzed the impact of these privatizations on cost, access, and health outcomes. Proponents favoring the private provision of these services argue that private providers are more efficient and can deliver these services at a lower cost. Also, because of better innovation, private providers can even improve quality. However, among opponents there is concern that a for-profit private provider might cut costs that adversely affects the quality of these services. The purpose of this dissertation is to analyze the effects of the privatization of primary care services on cost, access, and health outcomes in nine large counties in the state of Florida. In a survey of county health departments conducted in 1999, 61 out of 67 counties had outsourced at least one service. Primary care was the second most frequently privatized program. Womens health was the program most often privatized by counties. Using mixed models and logistic regression, a comparison was made between large counties that outsourced primary care services and counties that did not. Multiple years of data were obtained from federal and state sources for analysis.

Submitted by Diego Gomes (diego.gomes@gmail.com) on 2016-04-26T18:23:39Z No. of bitstreams: 1 Thesis_Diego Braz Pereira Gomes.pdf: 1441990 bytes, checksum: eaa77253b29a0fe0108cafc8657d9327 (MD5) / Approved for entry into archive by Maria Almeida (maria.socorro@fgv.br) on 2016-05-09T12:55:02Z (GMT) No. of bitstreams: 1 Thesis_Diego Braz Pereira Gomes.pdf: 1441990 bytes, checksum: eaa77253b29a0fe0108cafc8657d9327 (MD5) / Approved for entry into archive by Maria Almeida (maria.socorro@fgv.br) on 2016-05-09T12:55:18Z (GMT) No. of bitstreams: 1 Thesis_Diego Braz Pereira Gomes.pdf: 1441990 bytes, checksum: eaa77253b29a0fe0108cafc8657d9327 (MD5) / Made available in DSpace on 2016-05-09T12:56:21Z (GMT). No. of bitstreams: 1 Thesis_Diego Braz Pereira Gomes.pdf: 1441990 bytes, checksum: eaa77253b29a0fe0108cafc8657d9327 (MD5) Previous issue date: 2013-01-13 / This thesis contains three chapters. The first chapter uses a general equilibrium framework to simulate and compare the long run effects of the Patient Protection and Affordable Care Act (PPACA) and of health care costs reduction policies on macroeconomic variables, government budget, and welfare of individuals. We found that all policies were able to reduce uninsured population, with the PPACA being more effective than cost reductions. The PPACA increased public deficit mainly due to the Medicaid expansion, forcing tax hikes. On the other hand, cost reductions alleviated the fiscal burden of public insurance, reducing public deficit and taxes. Regarding welfare effects, the PPACA as a whole and cost reductions are welfare improving. High welfare gains would be achieved if the U.S. medical costs followed the same trend of OECD countries. Besides, feasible cost reductions are more welfare improving than most of the PPACA components, proving to be a good alternative. The second chapter documents that life cycle general equilibrium models with heterogeneous agents have a very hard time reproducing the American wealth distribution. A common assumption made in this literature is that all young adults enter the economy with no initial assets. In this chapter, we relax this assumption – not supported by the data – and evaluate the ability of an otherwise standard life cycle model to account for the U.S. wealth inequality. The new feature of the model is that agents enter the economy with assets drawn from an initial distribution of assets. We found that heterogeneity with respect to initial wealth is key for this class of models to replicate the data. According to our results, American inequality can be explained almost entirely by the fact that some individuals are lucky enough to be born into wealth, while others are born with few or no assets. The third chapter documents that a common assumption adopted in life cycle general equilibrium models is that the population is stable at steady state, that is, its relative age distribution becomes constant over time. An open question is whether the demographic assumptions commonly adopted in these models in fact imply that the population becomes stable. In this chapter we prove the existence of a stable population in a demographic environment where both the age-specific mortality rates and the population growth rate are constant over time, the setup commonly adopted in life cycle general equilibrium models. Hence, the stability of the population do not need to be taken as assumption in these models. / Esta tese contém três capítulos. O primeiro capítulo usa um modelo de equilíbrio geral para simular e comparar os efeitos de longo prazo do Patient Protection and Affordable Care Act (PPACA) e de reduções de custos de saúde sobre variáveis macroeconômicas, orçamento do governo e bem-estar dos indivíduos. Nós encontramos que todas as políticas foram capazes de reduzir a população sem seguro, com o PPACA sendo mais eficaz do que reduções de custos. O PPACA aumentou o déficit público, principalmente devido à expansão do Medicaid, forçando aumento de impostos. Por outro lado, as reduções de custos aliviaram os encargos fiscais com seguro público, reduzindo o déficit público e impostos. Com relação aos efeitos de bem-estar, o PPACA como um todo e as reduções de custos melhoram o bem-estar dos indivíduos. Elevados ganhos de bem-estar seriam alcançados se os custos médicos norte-americanos seguissem a mesma tendência dos países da OCDE. Além disso, reduções de custos melhoram mais o bem-estar do que a maioria dos componentes do PPACA, provando ser uma boa alternativa. O segundo capítulo documenta que modelos de equilíbrio geral com ciclo de vida e agentes heterogêneos possuem muita dificuldade em reproduzir a distribuição de riqueza Americana. Uma hipótese comum feita nesta literatura é que todos os jovens adultos entram na economia sem ativos iniciais. Neste capítulo, nós relaxamos essa hipótese – não suportada pelos dados – e avaliamos a capacidade de um modelo de ciclo de vida padrão em explicar a desigualdade de riqueza dos EUA. A nova característica do modelo é que os agentes entram na economia com ativos sorteados de uma distribuição inicial de ativos. Nós encontramos que a heterogeneidade em relação à riqueza inicial é chave para esta classe de modelos replicar os dados. De acordo com nossos resultados, a desigualdade Americana pode ser explicada quase que inteiramente pelo fato de que alguns indivíduos têm sorte de nascer com riqueza, enquanto outros nascem com pouco ou nenhum ativo. O terceiro capítulo documenta que uma hipótese comum adotada em modelos de equilíbrio geral com ciclo de vida é de que a população é estável no estado estacionário, ou seja, sua distribuição relativa de idades se torna constante ao longo do tempo. Uma questão em aberto é se as hipóteses demográficas comumente adotadas nesses modelos de fato implicam que a população se torna estável. Neste capítulo nós provamos a existência de uma população estável em um ambiente demográfico onde tanto as taxas de mortalidade por idade e a taxa de crescimento da população são constantes ao longo do tempo, a configuração comumente adotada em modelos de equilíbrio geral com ciclo de vida. Portanto, a estabilidade da população não precisa ser tomada como hipótese nestes modelos.

Adverse Childhood Experiences (ACEs) include childhood exposure to abuse or violence, a parents' divorce, mental illness, substance use disorder, and are identified as risk factors for negative life outcomes. While ACEs screenings are commonly used in mental health and pediatric settings, screening for ACEs in primary care settings is less prevalent. The purpose of this project is to integrate screening for ACEs into a primary care setting and make appropriate referrals for follow-up, thus reducing potential negative life outcomes. The process was designed for a primary care practice located in Winston-Salem, North Carolina. Part one assessed level of awareness and screening history which determined training focus. Each provider and staff member received 30-45 minutes of training on ACEs screening algorithm, a detailed approach to guide treatment. The training was followed by question-and-answer sessions to address concerns. Part two, involved screening using the Center for Youth Wellness, Adverse Childhood Experiences Questionnaire for Children (CYW ACE-Q Child) which was initiated by the front office employee. Front office employee identified patients present for an annual well visit, briefly explained the screening tool, and handed it to the patient on a clipboard. The patient returned the completed form to the Certified Medical Assistant (CMA) when called in from the waiting room. The provider reviewed the ACEs screening and made referrals as appropriate. Part three involved data collection and analysis. Responses were collected weekly for nine weeks. The responses collected will be analyzed using quantitative statistics. The expected outcome is to note progressive increase in screening activities and when appropriate, followed by referrals to community agencies and organizations. The project educated clinicians about ACEs and created awareness among clinicians in a primary care setting to mitigate potential negative life outcomes. Barriers to integrating ACEs screening included employees' absence of training, lack of confidence in the subject matter, limited time frame to complete the screening, and fear of damaging patient-provider relationships. Barriers were mitigated through employee training, repetitive implementation of ACEs screening, and therapeutic communication with patients. The CYW ACE-Q was reserved for those arriving early or on time for their annual wellness visit to allow adequate time for completion. Recommendations include incorporating the CYW ACE-Q into all primary care visits to further intervene with referrals thereby enhancing patients' overall quality of life.

This diploma thesis deals with the preparation of the implementation of multifunctional buildings in Bratislava. These are three detached multi-storey apartment buildings connected by a joint basement. The diploma thesis includes a technical report to the construction technological project, a study of the implementation of main technological phases, solving of broader relations of transport routes with the design of supply routes, a time schedule and a financial plan of the object, a detailed time plan for the rough substructure and rough superstructure, a building site equipment project, a machine assembly design and its assessment, a technological regulation for monolithic structures, a control plan and test plan for monolithic structures, a specification of the time period of the removal of the formwork of monolithic structures, an occupational safety and health plan and selected points of the LEED certification. The thesis also includes a plan for securing resources for the rough structure with added schedules of workers, machines and building materials, a cost estimation budget of selected technological processes, a noise study, and a financial analysis of the expected investment profit.