<p> Background: Health Care Transition (HCT) describes the purposeful, planned movement of adolescents from child to adult-orientated care. The purpose of this phenomenological study is to uncover the meaning of transition to adult centered care as experienced by Young Adults with Cerebral Palsy (YA-CP) through the research question: What are the lived experiences of young adults with cerebral palsy transitioning from pediatric to adult healthcare? Method: 6 females and 3 males, aged 19 -25 years of age, who identified as carrying the diagnosis of cerebral palsy without cognitive impairment were interviewed. Giorgi's (1985) method for analysis of phenomenology was the framework for the study and guided the phenomenological reduction. Results: The lived experiences of YA-CPs transition to adult health care, expressed from the data is expert novices with evidence and experience based expectations, negotiating new systems (effective/ineffective) interdependently (parents and provider support) accepting less than was expected. Conclusions: More information and support is needed for the YA-CP during transition to ensure a well-organized move to appropriate adult-oriented health care that is considerate of the lifelong impact of the disorder. Nursing's role as advocate, mentor and guide can optimize the individual's response to the transition process.</p>

<p> The Accountable Care Organization (ACO) has been introduced in the US as a health system reform initiative with potential to achieve the immediate and long-term goals of improving population health, improving quality and producing greater value for the healthcare dollars spent. Over the past half-century, a number of health system reforms have been designed and implemented with these goals as the intended outcomes. These efforts have produced, at best, incremental learning, variable improvements in performance outcomes, and modest cost-savings. Early evaluations of the health, quality and cost outcomes from ACO sites suggest that the long-term effectiveness of the ACO care model faces obstacles similar to those that have impeded the long-term success of past health system reform efforts. The fundamental question of how to transform the existing construct of care delivery towards one of open collaboration, team-based care and active management of health and patient populations remains elusive (Institute of Medicine, 2012).</p><p> It is under these conditions that three independent but thematically linked investigations were conducted. The first investigation, a comparative policy analysis of US-based health system reform efforts found that transforming the construct of care delivery&mdash;how care is organized and how care is delivered are fundamentally social and relational processes that impact the outcomes of reform. These processes have been underexplored alongside other change levers in the health services research and practice communities to the detriment of healthcare organizations confronted by the need to transform the construct of care delivery as the healthcare environment transitions towards accountable care. </p><p> The second and third investigations were focused at the level of the healthcare organization and its members. The instrumental case of a large integrated delivery system transforming its disease management program for diabetes towards an ACO model was used to further examine the social and relational dynamics of health system reform. The second investigation, a qualitative analysis of the social-psychological dimensions of the change process, found that ACO characterization, Uncertainty, conceptual perceptions of the notion of accountability, and Electronic Health Record implementation influenced how the network of providers made sense of transformation towards accountable care and their perception of system readiness to engage in change and be successful. </p><p> The third investigation, an applied example, demonstrated how relational coordination and social network analysis can be used as complementary tools to inform the design and implementation of interventions intended to transform the construct of care delivery in support of the goals of health system reform. Measurement of the quality of team performance found weak relational coordination ties across each network and among the roles treating and managing diabetes in a network. Social Network Analysis (SNA) of relational coordination found differential pathways for leveraging roles structures within a network in support of change efforts. </p><p> Collectively, these investigations suggest that if ACOs are to achieve the short- and long-term goals of health system reform, the social and relational dynamics of change are important to incorporate and consider alongside of other health system reform change levers.</p>

Introduction : Les statines ont prouvé leur efficacité dans le traitement des dyslipidémies. Cependant, ces molécules sont associées à des effets secondaires d’ordre musculaire. Puisque ces effets peuvent avoir des conséquences graves sur la vie des patients en plus d’être possiblement à l’origine de la non-observance d’une proportion importante des patients recevant une statine, un outil pharmacogénomique qui permettrait d’identifier a priori les patients susceptibles de développer des effets secondaires musculaires induits par une statine (ESMIS) serait très utile. L’objectif de la présente étude était donc de déterminer la valeur monétaire d’un tel type d’outil étant donné que cet aspect représenterait une composante importante pour sa commercialisation et son implantation dans la pratique médicale courante. Méthode : Une première simulation fut effectuée à l’aide de la méthode de Markov, mais celle-ci ne permettait pas de tenir compte de tous les éléments désirés. C’est pourquoi la méthode de simulation d'évènements discrets fut utilisée pour étudier une population de 100 000 patients hypothétiques nouvellement initiés sur une statine. Cette population virtuelle a été dupliquée pour obtenir deux cohortes de patients identiques. Une cohorte recevait le test et un traitement approprié alors que l'autre cohorte recevait le traitement standard actuel—i.e., une statine. Le modèle de simulation a permis de faire évoluer les deux cohortes sur une période de 15 ans en tenant compte du risque de maladies cardio-vasculaires (MCV) fatal ou non-fatal, d'ESMIS et de mortalité provenant d’une autre cause que d’une MCV. Les conséquences encourues (MCV, ESMIS, mortalité) par ces deux populations et les coûts associés furent ensuite comparés. Finalement, l’expérience fut répétée à 25 reprises pour évaluer la stabilité des résultats et diverses analyses de sensibilité ont été effectuées. Résultats : La différence moyenne des coûts en traitement des MCV et des ESMIS, en perte de capital humain et en médicament était de 28,89 $ entre les deux cohortes pour la durée totale de l’expérimentation (15 ans). Les coûts étant plus élevés chez celle qui n’était pas soumise au test. Toutefois, l’écart-type à la moyenne était considérable (416,22 $) remettant en question la validité de l’estimation monétaire du test pharmacogénomique. De plus, cette valeur était fortement influencée par la proportion de patients prédisposés aux ESMIS, par l’efficacité et le coût des agents hypolipidémiants alternatifs ainsi que par les coûts des traitements des ESMIS et de la valeur attribuée à un mois de vie supplémentaire. Conclusion : Ces résultats suggèrent qu’un test de prédisposition génétique aux ESMIS aurait une valeur d’environ 30 $ chez des patients s’apprêtant à commencer un traitement à base de statine. Toutefois, l’incertitude entourant la valeur obtenue est très importante et plusieurs variables dont les données réelles ne sont pas disponibles dans la littérature ont une influence importante sur la valeur. La valeur réelle de cet outil génétique ne pourra donc être déterminée seulement lorsque le modèle sera mis à jour avec des données plus précises sur la prévalence des ESMIS et leur impact sur l’observance au traitement puis analysé avec un plus grand nombre de patients. / Introduction: Statins have proven their efficacy in the treatment of dyslipidemias. However, these molecules are associated with muscular side effects. Since these side effects may have adverse consequences on patients’ daily life and have an important role in the discontinuation of statin therapy in a large proportion of patients, it would be useful to develop a pharmacogenomic test that identifies a priori the individuals who are likely to develop statin-related muscular side effects (SRMSE). The objective of the present study was to determine of the monetary value of such a type of test considering that this aspect would represent an important component of its marketing and implementation into medical practice. Method: The first simulation was carried out using the method of Markov, but this one did not allow consider all the desired elements. This is why the discrete events simulation method have been used to study a population of 100 000 hypothetical patients newly initiated on a statin. This virtual population was duplicated to have two identical cohorts of patients. The first one was administered the test and a suitable treatment while the second received the current standard treatment—that is, a statin. The model allowed the two cohorts to evolve over a period of 15 years taking into account the risks of fatal and non fatal cardiovascular diseases (CVD), SRMSE and mortality from other causes than CVD. The consequences (CVD, SRMSE, death) incurred in these two populations and the associated costs were then compared. Finally, the process was repeated 25 times to assess the stability of the results and various sensitivity analyses were carried out. Results: The mean difference of CVD and SRMSE treatments, lost of human capital and drugs costs between the two cohorts was of 28.89 $, these costs being higher in the cohort who was not administered the test. However, the standard deviation with the average was considerable (416.22 $) calling in question the validity of the monetary estimate of the test pharmacogenomic.This difference varied a lot as a function of the proportion of patients being predisposed to SRMSE, the efficacy and the costs of the alternative treatments, the SRMSE cost, and the value assigned to one additional month of life. Conclusion: The results suggest that a test of genetic predisposition to SRMSE would have a value around 30 $ in patients who start a statin treatment. However, uncertainty surrounding the value obtained is very important and several variables for which the real data are not available in the literature have an important influence on the value. The real value of this genetic tool could thus be given only when the model is updated with more precise data on the prevalence of the ESMIS and their impact on the observance at the treatment and then analyzed with a higher number of patients.

<p> The purpose of this study is to analyze the effect of email communication between providers and patients. The research also tests for the frequency of email usage in different provider settings. The following study performs a secondary data analysis on the Electronic Medical Records data retrieved from the (2009) National Ambulatory Medical Survey (NAMCS) to test for the following five hypotheses: (a) Use of email consults with patients will decrease in-patient visits, (b) Use of email consults will decrease telephone consults, (c) Hospital systems use higher email consults compared to that in solo practices and group practices, (d) Medical practices with an implemented electronic medical records system use higher email consults, and (e) Practices with greater private insurance reimbursements use higher email consults. A chi-squared analysis is performed to test for the association between the use of email consultations and its effects on other factors. The results showed that there is a reasonable association between use of email consults and hospital visits, email consults and telephone consults, email consults and implementation of electronic medical records (EMR), and email consults and the type of payers. On the contrary, there was no significant association between email consults and the type of medical practice. Although electronic communication can improve efficiency, accessibility and quality of healthcare, not every medical practice has integrated it into their care delivery.</p>

<p> Diabetes is a chronic disease that is revealed through the form of abnormal serum glucose levels. Serum glucose levels that are not maintained at acceptable clinical diagnostic standards contribute to additional physical complications that impact the individual&rsquo;s ability to carry out effectively the activities of daily living. The chronic nature of the disease requires long-term monitoring and management by the healthcare team and the individual diagnosed with the condition. </p><p> Diabetes is a major health issue that impacts millions of individuals globally. Diabetes has been identified as one of the most challenging health problems of the 21st Century (International Diabetes Federation, 2011a). Many states such as North Carolina are experiencing significant increases in the diabetes prevalence rate among racial and ethnic groups. Unfortunately, diabetes prevalence rates are higher among minority populations. North Carolina has experienced a significant increase in the number of diverse populations living in rural and urban areas throughout the state. Therefore, delivery of healthcare services may need to be targeted towards populations at higher risk of developing chronic diseases such as diabetes. </p><p> Although the outlook of inhibiting the development of diabetes is daunting, much can be done to delay and manage the disease process more effectively. It has been well established that lifestyle changes related to nutrition, physical activity, blood glucose monitoring, medication therapy if applicable, and self-management education will improve the quality of life. Therefore, the health behavioral practices used to manage lifestyle activities are crucial to the state and outcome of the individual&rsquo;s condition. Consequently, diabetes is a chronic disease that is heavily dependent on the actions of the individual and their frequency in carrying out critical diabetes self-care practices. The purpose of this research study was to examine the differences in diabetes self-care practices among diverse populations living in the rural southeastern portion of North Carolina. Understanding the differences in diabetes self-care practices is critically important to the management of diabetes. Self-care practices are the cornerstones to achieving a healthier outcome in the management of diabetes. Healthy diets and exercise practices are a few of the many diabetes self-care activities that can minimize the disease. This will help prevent the development of diabetes associated with complications such as blindness, hypertension, kidney and heart disease. Identifying differences in self-care practices among diverse populations should be taken into consideration when planning diabetes educational training. Increasing the span of knowledge regarding the differences or similarities of self-care practices may assist healthcare providers in selecting thoughtful planned initiatives that will move the culture of patient accountability in daily self-care practices to a new level of healthier outcomes.</p>

<p> This study utilized a multi-case, bounded case, single-site case study research design to examine how well instructional designers perceive themselves able to practice ID in health care industries. Questions central to this study focused on how instructional designers perceive their preparation to practice, usefulness of professional development organizations or affiliations in which they participated while practicing ID, both academic and non-academic curricula, and utilization of ID practices when designing and developing ID projects in health care environments. </p><p> The site selected for this study was a teaching hospital in Southeast Metropolitan Detroit, Michigan. Sampling size was limited to five instructional designers who had been working in the health care environment. Using a case study approach, convenient sampling was utilized to obtain detailed information about the experiences of instructional designers in the health care sector. Upon completion of interviews, participants had the opportunity to show completed work projects and were provided an opportunity to reflect on ID practice via journal entries over a two week time period. The constant comparative method was utilized for data analysis whereby a within-case analysis was conducted followed by a cross case analysis. Findings of this research showed that participants felt well prepared to practice ID in their respective health care environment and offered a variety of ways in which an instructional designer can explore the field of health care, how academic program administrators can collaborate with health care organizations to provide ID opportunities for students, and ways in which health care administrators can explore additional learning opportunities for their ID employees.</p>

<p> Access to primary medical care and prevention services in Nigeria is limited, especially in rural areas, despite national and international efforts to improve health service delivery. Using a conceptual framework developed by Penchansky and Thomas, this case study explored the perceptions of community residents and healthcare providers regarding residents' access to primary healthcare services in the rural area of Isu. Using a community-based research approach, semistructured interviews and focus groups were conducted with 27 participants, including government healthcare administrators, nurses and midwives, traditional healers, and residents. Data were analyzed using Colaizzi's 7-step method for qualitative data analysis. Key findings included that (a) healthcare is focused on children and pregnant women; (b) healthcare is largely ineffective because of insufficient funding, misguided leadership, poor system infrastructure, and facility neglect; (c) residents lack knowledge of and confidence in available primary healthcare services; (d) residents regularly use traditional healers even though these healers are not recognized by local government administrators; and (e) residents can be valuable participants in community-based research. The potential for positive social change includes improved communication between local government, residents, and traditional healers, and improved access to healthcare for residents.</p>

<p>Using Action Research, Implementation Science, and Institutional Ethnography, this practice-focused research explored inhibiting and promoting factors related to implementing buprenorphine treatment within HIV primary care while simultaneously developing, installing and initially implementing an interdisciplinary buprenorphine treatment/practice. Data was collected and analyzed using constructivist grounded theory method strategies. Data collection/generation included documentary analysis, key informant interviews, field data from collaborative interdisciplinary team processes, researcher reflective practice, a patient focus group, and an interdisciplinary buprenorphine treatment/practice manual. </p><p> The research had several achievements. It identified three key implementation inhibiting categories, (1) significant and persistent bias, (2) plaguing and difficult questions, and (3) buprenorphine expectionalism. It also developed countering implementation promoting categories, (1) be an educated advocate and dispel myths, (2) identify core components of interdisciplinary buprenorphine treatment and uniformity of care, and (3) dementionalizing interdisciplinary treatment/practice. It exposed scope of practice issues and mapped out the specifics of the types of services each discipline would provide, the detail of those practices, their coordination, as well as the areas of practice where there was joint responsibility and overlap. It increased the capacity and competences of the research organization and the 18 interdisciplinary buprenorphine team members. It also explicated the many forms of power operating in the study and the importance of power sharing, adapting treatment, leadership support, structural components and resources on the development and implementation process. </p><p> This study shed light on the reality that prescribing buprenorphine and taking up the practice of treating opioid dependence/addiction means that clinicians must be prepared and skilled to provide care where issues of life and death, emotional distress, and significant uncertainties are part of the landscape. The study findings also highlight that balancing safety (both patient and staff) with control and authority is an important aspect of buprenorphine treatment. An interdisciplinary focus expanded the concept of treatment and addressed many important aspects of caring for people with opioid dependence/addiction that often go unaccounted for and/or unnoticed. Without an interdisciplinary frame, patients are at risk for receiving substandard care. This study demonstrated that the interdisciplinary practices needed to provide quality care and improve health outcomes are interdependent. </p>

<p> The federal government provides an uncapped reimbursement of state Medicaid spending. In theory, states can use the federal Medicaid funds as a replacement for state funds or the federal funds, which take the form of a matching grant that reduces the relative price of Medicaid, can increase (or stimulate) spending on Medicaid with state-raised tax revenue. In the first dissertation paper, <i> Subsidizing Medicaid Growth: The Impact of the Federal Reimbursement on State Medicaid Programs,</i> I use a state panel data set from 1992 to 2006 to assess the impact of the federal reimbursement on the size of state Medicaid programs. I find that a one point increase in a state's Medicaid reimbursement percentage increases state per capita Medicaid spending between $5 and $16 and increases the percentage of the state's population receiving Medicaid benefits by 0.04 percent to 0.29 percent. </p><p> The first paper also utilizes a case study that shows significant growth in Alaska's Medicaid program after its effective federal Medicaid reimbursement increased 50 percent between 1998 and 1999. The large growth in Alaska's Medicaid program after this increase provides evidence that states respond to large increases in the federal Medicaid subsidy in a stimulative manner by increasing spending with state-raised revenue. Overall, the results in the first paper are consistent with the hypothesis that decentralization in the form of intergovernmental matching grants increases the size of government. I also find that states with wealthier and more liberal populations tend to have larger Medicaid programs and that states with Democratic legislatures tend to have more Medicaid beneficiaries than states with Republican legislatures all else equal. </p><p> Since 2008, states have experienced significant budgetary pressure; in large part, because of rising Medicaid enrollment due to the recession and weak recovery. Between 2009 and 2011, many states enacted health care provider taxes as a way to bring in additional revenue through the federal Medicaid reimbursement. Provider taxes are generally supported by health care providers since states often give providers an implicit or explicit guarantee of a return of at least as much funding through higher payment rates or supplemental payments. In the second dissertation paper, <i>Impact of Hospital and Nursing Home Taxes on State Medicaid Spending,</i> I assess the impact of the two largest provider taxes, the hospital tax and the nursing home tax, on state Medicaid expenditures using a panel dataset of 42 states from between 2007 and 2011. I find significantly larger Medicaid spending growth for hospitals in states that added hospital taxes and significantly larger Medicaid spending growth for nursing homes in states that added nursing home taxes within the first two years of the enactment of the tax. I also find some evidence that states with hospital taxes were able to increase their total Medicaid spending more than states without hospital taxes during the economic downturn and initial recovery period. This paper also contains evidence that nursing home taxes diverted Medicaid spending from home and community based services to nursing homes. </p><p> In the third dissertation paper, <i>Statewide Health Impact of Tennessee's Medicaid Expansion,</i> I utilize a quasi-experimental approach to assess the impact of a large statewide public health insurance expansion on access to health care services, health care utilization, and health outcomes. In 1994, Tennessee expanded its state Medicaid program, called TennCare, by about ten percent of the state's population. Along with a major Medicaid expansion, Tennessee increased government subsidies for individuals to purchase health insurance coverage and emphasized managed care. Using a difference-in-difference methodology with Tennessee's neighboring states as controls, I found that TennCare's impact on utilization was mixed as blood pressure and cholesterol checks increased but regular physician check-ups decreased relative to the surrounding region. Surprisingly, both self-reported health and mortality rates were less favorable in Tennessee relative to the control states after TennCare. Ultimately, the evidence in this paper suggests that health reform built around a significant public insurance expansion is likely to result in minimal, if any, overall health gains measured in the entire population, at least in the short run. </p><p> The final dissertation section summarizes the findings from the three dissertation papers, discusses the economic efficiency of the uncapped federal Medicaid reimbursement and state provider taxes, and makes several predictions related to the Medicaid expansion in the Patient Protection and Affordable Care Act.</p>

<p> This dissertation provides an analysis and evaluation of factors influencing states to enact inpatient health care transparency laws between 1971 and 2006 inclusive, using event history analysis. The primary research question investigates "What factors influence a state legislature to enact a health care transparency law?" To narrow the scope of study, I focus on factors influencing states to enact health care transparency laws to collect and publicly report inpatient data. </p><p> The Unified Model of State Policy Innovation, developed by F.S. Berry and W.D. Berry (1990, 1999), provides the framework for the study hypotheses and the analysis of inpatient health care transparency law enactments by states. The Unified Model of State Policy Innovation posits a unified explanation for state policy adoptions. The model unifies the internal determinants and regional diffusion approaches of analysis for state policy adoption. </p><p> This study tests eight hypotheses using event history analysis (EHA). EHA is an analytical technique that allows for the testing of a state government innovation theory that incorporates internal determinants and regional influences on state policy adoption. Although there are numerous methods to conduct event history analysis, this study uses the Cox proportional hazards model (also known as Cox regression). Cox regression is a popular method for studying time-to-event data for policy adoption and diffusion studies. This study's quantitative analysis provides support for legislative ideology and unified party control of state government acting as factors influencing inpatient health care transparency law enactments by states. Additionally, the health care crisis and neighbors variables were statistically significant, but in an opposite direction than predicted. </p><p> The findings of this research suggest that state adopters of an inpatient health care transparency law are more likely to enact an inpatient health care transparency law when the state government is increasing in liberalism and when unified political party control of the governor and the governorship of both houses of the state legislature is increasing. </p><p> To generate new insights into the enactment of inpatient health care transparency laws, I conduct a case study of a national health care data professional association using several techniques, including telephone interviews. The qualitative analysis provides support for professional associations and policy champions as diffusion agents for inpatient health care transparency law enactments by states. </p><p> This dissertation supports variables traditionally used in policy adoption research including legislative ideology and unified political party control in state government. However, it will be interesting to see whether internal determinants such as professional associations gain traction over the traditional regional diffusion influences such as states sharing borders as factors influencing state policy adoption. Meanwhile, as evidenced in this study, there continues to be support for a model incorporating both internal and regional influences to explain policy adoption by states. The theory of policy innovation and diffusion to predict the factors influencing the spread of policies and the use of Berry &amp; Berry's (1990, 1999) Unified Model of State Policy Innovation prosper as their applicability to numerous public policy areas, including health care, are continually demonstrated. Similarly, event history analysis and specifically the Cox regression method continue to gain support as their value as analytical methods and appropriateness for use in public policy studies is repeatedly demonstrated. </p><p> The outlook for the future of the health care transparency movement looks promising. The health care transparency movement promotes improved access to information, patient empowerment, improved patient safety and quality of care, improved provider accountability, and lower health care costs. This movement is not a fad, but rather a permanent change being implemented in all health care settings across the United States. Improved health through reliable, accessible data and data-supported decisions is increasingly becoming the norm and less an idealistic scenario to be realized in the distant future. </p>