Background: Major depressive disorder (MDD) is commonly treated with antidepressants, but many patients undergo trial-and-error to find the medication best suited for them. Pharmacogenomic (PGx) testing was developed to provide prescribing guidance for a variety of medications including antidepressants. PGx testing is not yet part of standard depression care in Canada, but clinical implementation efforts are ongoing. Patient perspectives, as well as the views of people with professional expertise about this technology, are critical to health technology assessment (HTA) and policy decisions, and can inform implementation. Methods: This dissertation produces actionable patient and key informant (i.e., clinician, scientists, policy actor, industry member) perspectives evidence for future HTA and policy- making through three independent studies: a systematic review and qualitative meta-synthesis of patient experiences of treatment-resistant depression (TRD), and two qualitative description studies about patient and key informant perspectives on PGx testing to guide antidepressant prescribing. Results: Trial-and-error of medications often leaves patients feeling hopeless but desperate to get better. Patients and key informants both felt the main benefit of PGx testing is its potential to reduce the time between diagnosis and successful treatment. The main findings of this research were concrete suggestions for how PGx testing may be integrated in the health system. Participants preferred this technology be deployed in primary care, with patients with TRD identified as a possible priority population. The ideal PGx test would incorporate genetic variants common in non-white populations to ensure equity of health outcomes, and mechanisms to facilitate equity of access (eg., public funding) were considered important. Conclusions: Patients and key informants both described benefits of PGx testing to guide antidepressant prescribing. Patients typically raised more concerns than key informants. Future research is needed around some of the ethical and social issues related to PGx testing, as well as to address feasibility questions. / Dissertation / Doctor of Philosophy (PhD) / Pharmacogenomic (PGx) testing may facilitate targeted prescribing of antidepressants by identifying genetic factors that play a role in how a person responds to these drugs. However, this technology is not yet widely or systematically used in clinical care. This dissertation focuses on how PGx testing might be implemented in primary care in Ontario, Canada. It examines which patients this type of genetic testing may be most appropriate for, and collects and analyzes the views of patients with depression and experts on PGx testing about this technology. The main benefit of PGx testing was its potential to help people get better faster, and primary care was uniformly considered an appropriate care setting for the use of this technology. There were some concerns that people may not fully understand the limitations of PGx testing. Future research is needed to understand how this technology might fit into clinician workflows across the healthcare system.

Mobile apps are the primary means by which consumers access digital health and wellness software, with delivery dominated by the ‘Apple App Store’ and the ‘Google Play Store’. Through these virtual storefronts Apple and Google act as the distributor (and sometimes, importer) of many thousands of health and wellness apps into the EU, some of which have a medical purpose. As a result of changes to EU law which came into effect in May 2021, they must now ensure that apps are compliant with medical devices regulation and to inform authorities of serious incidents arising from their use. The extent to which these new rules are being complied with in practice is uneven, and in some areas unclear. In light of EU legislation related to competition, which came into effect in November 2022, it is also unclear how conflicts of interest can be managed between Apple and Google’s roles as gateway duopoly importers and distributors whilst also developers of their own competitive health products. Finally, with the proposed European health data space regulation, wellness apps will be voluntarily registered and labelled in a fashion more like medical devices than consumer software. We explore the implications of these new regulations and propose future models that could resolve the apparent conflicts. All stakeholders would benefit from improved app store models to sustainably evolve safer, better, and fairer provision of digital health applications in the EU. As EU legislation comes into force it could serve as a template for other regions globally.

Thesis (M.S.H.P.) / BACKGROUND: Emergency department (ED) visits for psychiatric issues have grown at a disproportionately higher rate than other visits. This has been attributed to factors including severe cuts in mental health (MH) services and identified as a culprit in ED overcrowding. Little is known, however, about how mental health reason-for-visit (MHRFV) interacts with patient and hospital characteristics to affect wait times to see an ED provider. OBJECTIVE: To determine if wait time (WT) to see a provider at the ED differs for those presenting with MHRFV and how various patient and hospital-level characteristics interact to affect it. METHODS: Data were obtained from the National Hospital Ambulatory Medical Care Survey (NHAMCS) for visits to EDs throughout the United States. We examined data for patients ≥ 18 years of age who visited an ED in years 2009 and 2010. Patient weights were used to generate national estimates. Patients’ primary reasons-for-visit were used to identify the MH group for analysis and comparison to all other RFVs. Predictors of WT were chosen based on the Andersen Behavioral and ED overcrowding models. WTs were log-transformed for initial bivariate and final multivariate regression models to assure a more normal distribution. RESULTS: Mean WT was 56.5 and 55.8 minutes for MHRFV and all others respectively with a shared median of 31 minutes. As expected with our large sample (n = 47,831), all variables of interest were significantly associated with WT. Adjusting for patient and hospital level characteristics, a multivariate regression revealed that MHRFV prolonged WT by about 50%. After adjustment for independent variables, interactions with MHRFV were tested as the main outcomes of interest. Blacks with MHRFV had WTs 62% longer, patients age 41-64 31% longer, payer status of Medicare/Medicaid or no coverage had WTs about 24% and 14% longer than private insurance. Conversely, patients at government owned hospitals had WTs 145%, and non-profits 42%, lower than private hospitals. CONCLUSIONS: This is the first time that ED WT has been examined in this depth with a sample of patients presenting with MH issues. The results indicate that disparities are more pronounced in this subgroup of ED patients. / 2999-01-01

Recent public health scholarship finds that health outcomes are explained by the social and individual determinants of health rather than the individual-level determinants alone. The individualistic perspective has dominated the 20th century institutionalization of public health in the United States where the public health system has tended to focus largely, if not exclusively, on individual factors. This persistent orientation lies in contrast to another set of perspectives that have also persisted, focused on social causes, which are currently dominant in contemporary public health academic literature and in major, international health organizations. Whether the orientation within the United States is due to a prevailing paradigm among public health officials or is the result of new ideas about health causation being dampened under organizational weight is unknown. Despite public health being central to decreasing morbidity and mortality in the 20th century, significant gaps remain in researchers' understanding of what influences practice in the American public health system. My dissertation research investigates the broad outlines of the determinants of health as understood by state public health administrators. I study how the understanding of the determinants of health affects the practice of public health through analyzing how the ideas of state public health administrators interact with the organizational dynamics of the public health organizations they lead. This mixed-methods dissertation uses survey research and in-depth interviews and quantitative and qualitative analysis. I find that state public health officials' professionalization, length of tenure, level of education, and gender affect the perspective of health causation to which they adhere. I also find that the state public health officials with a social health frame more commonly report they are situated in organizations that are learning environments. Both organizational and ideational factors influence public health practice. The interview data expand this finding to paint a complex picture of organizational and ideational factors influencing one another as well as resulting practices. This research reveals that state public health officials often have strong health frames that are only able to shape the edges of their practice due to the political and organizational dynamics interacting with state public health departments. / Ph. D.

Swedish healthcare faces several significant challenges, including increased waiting times and a shortage of healthcare staff. These challenges necessitate efficient resource utilization to optimize operations. One strategy to address these challenges is through improvement work, which involves identifying and remedying shortcomings in the healthcare system. Despite prior research that has developed multiple improvement models, this study observed a lack of specific guidelines for improvement work in healthcare. Moreover, although a substantial amount of data is collected within healthcare, it was found that this data is not always fully utilized as a basis for decision-making. Therefore, this study aims to investigate how data-driven improvement work can be facilitated within healthcare. To achieve this objective, information about existing improvement methods, data management, and strategies was gathered. This information was used as the basis for identifying methods that can facilitate improvement work in healthcare. Additionally, a case study was conducted at an Ear, Nose, and Throat-clinic within Region Östergötland to provide concrete insight into how improvement work can be initiated. The study also resulted in the development of a productivity measure to analyze how new outcome variables can be developed based on existing data in healthcare. The case study also laid the groundwork for future improvement efforts at the clinic. Interviews were also conducted with various healthcare professionals about their experiences with improvement work, strategies, and data usage. The analysis of the case study and interviews emphasized the need for clearer structures for improvement work, where decisions are based on data and patients’ needs are considered. The study led to the development of the BOTA model, which aims to facilitate improvement work within healthcare. The model serves as a tool to guide healthcare organizations through structured improvement processes. BOTA is designed to be easy to implement, fulfilling the study’s aim of creating a method to facilitate improvement work within healthcare. / Svensk hälso- och sjukvård står inför flera betydande utmaningar, inklusive ökade väntetider för vård och brist på vårdpersonal. Dessa utmaningar kräver en effektiv resursanvändning för att optimera verksamheten. En strategi för att möta dessa utmaningar är genom förbättringsarbete, vilket innebär att identifiera och åtgärda brister i verksamheten. Trots tidigare forskning som har utvecklat flera modeller för förbättringsarbete, har denna studie observerat en brist på specifika riktlinjer för förbättringsarbete inom hälso- och sjukvården som är enkla att tillämpa i praktiken. Vidare samlas en betydande mängd data in inom sjukvården, men det observerades att denna data inte alltid utnyttjas fullt ut som grund för beslutsfattande. Denna studie syftar därför till att undersöka hur datadrivet förbättringsarbete kan underlättas inom sjukvården. För att uppnå detta syfte samlades information om befintliga metoder inom förbättringsarbete, datahantering och strategier. Denna information användes som grund för att identifiera metoder som kan underlätta förbättringsarbete inom sjukvården. Dessutom utfördes en fallstudie på en Öron-, näs- och halsklinik inom Region Östergötland för att ge konkret insikt i hur förbättringsarbete kan initieras. Studien resulterade även i framtagningen av ett produktivitetsmått för att analysera hur nya resultatvariabler kan utvecklas baserat på befintlig data inom sjukvården. Fallstudien bidrog också till att lägga grunden för framtida förbättringsarbete på kliniken. Intervjuer genomfördes även med olika yrkesgrupper inom sjukvården om deras erfarenheter av förbättringsarbete samt strategi- och dataanvändning. Analysen av fallstudien och intervjuerna betonade behovet av tydligare strukturer för förbättringsarbete där beslut grundas på data och där patienternas behov beaktas. Resultatet av studien ledde till utvecklingen av modellen BOTA, som syftar till att underlätta förbättringsarbete inom vården. Modellen fungerar som ett verktyg för att leda sjukvårdsverksamheter genom förbättringsarbete på ett strukturerat sätt. BOTA är utformad för att vara enkel att implementera, vilket uppfyller studiens syfte att skapa en metod för att underlätta förbättringsarbete inom sjukvården.

Background: The Dental and Pharmaceutical Benefits Agency (TLV) decides what prescription drugs should be included in the Swedish high-cost protection. For drugs to be included, TLV requires that they achieve a reasonable balance between health effects and costs. This requirement is operationalized as Cost-Effectiveness Thresholds(CETs) that vary with disease severity and represent the maximum tolerated cost per unit of health. Objectives: To investigate how close to the CETs pharmaceutical producers set their prices, and if they act on opportunities to raise them when permitted by higher disease severity. Methods: I reviewed 335 of TLV’s publicly available reimbursement decisions between 2017 and 2024 and extracted Incremental Cost-Effectiveness Ratios (ICERs) where available (n = 91) along with TLV’s severity classifications. These were analyzed descriptively and with an Ordinary Least Squares (OLS) model explaining ICERs with severity classifications. In extended OLS models, I added a dummy variable indicating whether a drug had previously been approved for subsidy, and another to control for systematic differences in ICERs between drugs approved for restricted and general subsidy. Results: Pharmaceutical producers do not price to the CETs, but ICERs increase significantly with severity. Previous subsidy approval was negatively associated with ICERs whereas being approved for restricted subsidy was associated with a higher ICER, but both dummies were statistically insignificant. Additionally, a majority of ICERs were higher than previous estimates of the healthcare system’s marginal cost for producing a unit of health. Key Implications: Reimbursement authorities like TLV should expect pharmaceutical producers to act on opportunities to raise prices when weighing additional benefits and cost-savings into their reimbursement decisions. However, researchers should be careful to assume that producers will price to CETs when developing theoretical frameworks. Furthermore, TLV should consider revising their CETs to reflect the opportunity cost of healthcare to avoid incurring net health losses to society

In the context of health care delivery for senior citizens, this research utilizes three studies that examine the development and implementation of health policy and the factors that can directly or indirectly impact the effective delivery of health services to senior citizens. It utilizes three essays employing mixed methods (qualitative and quantitative) methods including semi structured interviews, multiple regression and partial least squares structural equation modelling to examine the extent to which the implementation of health services delivered attributes of primary and integrated care to seniors. The two essays identified methods, approaches and strategies of integrated care relevant to the development of policy that can be successfully implemented when the contextual issues that older people consider to be important in maintaining their functional capabilities and their motivation to improve health as perceived by them are addressed. Consequent upon the results from these studies, the third essay examines the methodological issues on integrated geriatric care implementation when guidelines for effective policy development identified were not followed. By highlighting the relationship between effective policy and patient satisfaction, these three essays' recommended approach enhances the theory of health design that confirms that theoretical models of primary care must incorporate the system, process and service delivery levels of care to optimize seniors health.

2025 / This dissertation examines the role of the 340B Drug Pricing Program in the US health care safety-net and its implications for access, affordability, and health equity. The 340B Program allows certain hospitals and public health clinics that serve a disproportionate share of low-income patients to purchase outpatient drugs from manufacturers at steep (estimated 25–75%) discounts; however, the 340B statute does not specify whether discounts are to be passed along to patients nor how profits generated from full price drug sales of discount-acquired drugs (i.e., “spread pricing”) is to be spent. This has led to calls for reform. At the same time, the 340B Program is well-situated to play an important role in the delivery of care for syndemic conditions (i.e., HIV, substance use disorder (SUD), mental health disorders), which disproportionately affect marginalized patient populations.Revenues generated from the 340B program present a key opportunity for hospitals to invest in low-profit services that may especially benefit socially and economically marginalized patient populations, such as HIV and SUD services (i.e., “mission motivated” behavior). However, providers face competing financial incentives to reinvest 340B revenue into high-profit services or services with high-cost drugs to maximize spread pricing (i.e., “margin motivated” behavior). The impact of the 340B program on low-profit or syndemic service provision is unclear. The overarching goal of this dissertation is to assess the relevance of the 340B Program to hospital finances, safety-net spending, and provision of low-profit services. This dissertation has three aims. First, I synthesize what is known about the 340B Program in the peer-reviewed, empirical literature via a systematic scoping review, categorizing outcomes indicating margin- versus mission-motivated behavior by 340B providers. Second, I assess the financial wellbeing and service provision decisions of nonprofit hospitals in the years following enrollment into the 340B Program using a staggered difference-in-differences design, based on 20 years (2000–2019) of Medicare Cost Reports and American Hospital Association survey data. Third, I estimate the impact of a 340B Medicare reimbursement cut on nonprofit hospital finances and safety-net spending outcomes, using a triple differences approach, based on cost reports and hospital tax filings. / 2027-01-16T00:00:00Z

Thesis (MSc (Interdisciplinary Health Sciences. Speech-Language and Hearing Therapy. Centre for Rehabilitation Studies))--Stellenbosch University, 2008. / Purpose To date no health policy analysis tool has been developed to analyse access and equity for people with disabilities. Further, there is very little information available on health and disability policy implementation. The intention of this research is to develop a health policy framework to analyse access and equity, focussing on people with disabilities, that can be used by policy makers. This research analyses four health policies and focuses on the facilitators and the implementation barriers. The findings of this research will impact on new policies developed in the future. Method The study included both a desk - top review and a descriptive study. The desk - top review entailed the formulation of a disability - focussed framework for health policy. This was then used to analyse health policies in terms of their disability inclusiveness. Qualitative data was gathered from interviews and questionnaires and focussed on policy processes and implementation. This was incorporated into the analysis. An ideal seven - step policy process model was developed. This was used to compare the reported policy process with the four policies followed. The four health policies used in the research are: the Primary Health Care Policy, the National Rehabilitation Policy, the Provision of Assistive Devices Guidelines and the Free Health Care Policy. Four key informants with extensive experience and knowledge were interviewed on policy processes and implementation. Questionnaires were also sent to Provincial Rehabilitation Managers to obtain their viewpoints on barriers and facilitators to policy implementation. Results Analysis of the four health policies showed varying levels of access and equity features. In terms of policy processes: all four policies had different stakeholders who initiated the policy development process. Two of the policies viz. the National Rehabilitation Policy and the Provision of Assistive Devices Guidelines, had people with disabilities as part of the stakeholder group involved in the policy formulation. The National Rehabilitation Policy had a comprehensive monitoring and evaluation section whereas this was absent in the other three policies. From the information gained from interviews and questionnaires, it appeared that the barriers to policy implementation included: attitudes, environmental access, human and financial resources. Facilitators to policy implementation include: policy process and design, availability of human and financial resources, support systems, management support, organisational structures and finally positive attitudes that all impacted favourably on policy implementation. Conclusions The developed health policy analysis framework served its purpose. Most policies did not have monitoring and evaluation guidelines that make implementation difficult to assess. Recommendations are made to improve policy design and content, specifically related to access and equity. Intersectoral collaboration and disability coordination needs to be improved. People with disabilities also need to engage with government departments, to monitor implemented policies and to advocate for change from outside the health system.

The dissertation is a compilation of three essays on Turkey's poverty alleviation programs. The first paper focuses on the welfare impact of the global financial Crisis on Turkish households. The second paper considers the protective impact of the Green Card non-contributory health insurance program in Turkey during the Crisis in 2008-2009. The third paper uses experimental data from the field in eastern Turkey, to look at patterns of agricultural technology diffusion in a rural development program implemented in a post-conflict setting.