The Military Health Services System (MHSS) is one of the largest health care systems in the United States comprising over 115 hospitals, 471 clinics and an annual operating budget in excess of 15 billion dollars. In 1993, Congress directed the Secretary of Defense to implement a model of health care reform emphasizing the principles of managed care and regional contracting as cost containment tools, while improving the uniformity of aocess and benefit structure. The TRICARE program was proposed by the Department of Defense (DOD) and approved by Congress in 1994. TRICARE presents a triple option of a health maintenance organization, preferred provider organization, or a fee for service indemnity plan. The health maintenance organization option presents the greatest potential for cost savings to DOD through utilization management and large-scale, regional contracting to augment variability in the MRSS access and benefit structure. A twenty-four month population-based time series design presented significant changes in the utilization of ambulatory health services when subjects enrolled in a program grounded in managed competition within a budget. Improved access to an integrated health care system, including shifts to more cost-effective portals was found among the broader population as well as high-risk chronic subjects. The findings validate the theoretical constructs of managed competition under global budgets, previously untested in the literature. The data also refute concerns for high-risk populations to be undeserved and undercared for in managed care models of delivery. The DOD program with its variant of the Health Alliance or Health Insurance Purchasing Cooperative demonstrates that access to a national uniform benefit package, movement toward universal coverage, community rating, and cost-conscious decision making among consumers is a feasible mechanism for achieving the objectives of health care reform. The initial findings from DOD health care reform offer the first empirical and applied outcome evidence from one of the most important theoretical developments in health care policy and economics in the twentieth century.

The objectives of this study were to assess the construct validity and predictive validity of a previously published comorbidity classification scheme designed for use with administrative data. The scheme groups non-primary discharge diagnoses into a set of thirty comorbidity indicators, which may be used to describe and compare populations with respect to burden of comorbid illness. The scheme was developed on a large population of hospitalized patients in California in 1992 (training population) and the predictive effect of the indicators estimated with respect to the outcomes length of stay, hospital charges, and in-hospital death. The current study drew data from the Massachusetts Hospital Case Mix Data Base of 1992 (testing population). The effect of the comorbidity indicators on each outcome was estimated by fitting ordinary least squares regression (OLSR) models of length of stay and hospital charges, as well as logistic regression models of in-hospital mortality, to the testing population. The estimated effect of the comorbidity indicators on each outcome, adjusted for demographics and characteristics of index hospitalization, was compared between the training and testing populations. The characteristics of the testing population were largely similar to those of the training population. The relationship between burden of comorbid illness (as measured by the number of comorbidity indicators per patient) and the outcomes was comparable in the two populations. The estimated adjusted effect of the comorbidity indicators and the predictive ability of the OLSR models were comparable in the training and testing population with respect to the outcomes length of stay and charges. The estimated adjusted effect of the comorbidity indicators on in-hospital death was not comparable in the two populations. The results support construct validity and predictive validity of the comorbidity classification in Massachusetts discharge data in 1992. Other aspects of baseline risk must be accounted for separately. The estimated adjusted effect of the indicators in the training population on the outcomes length of stay and charges, but not in-hospital death, is generalizable to Massachusetts' discharge data and may be further generalizable. Practical application of the comorbidity indicators for comorbidity adjustment in epidemiological research should be further explored.

Objective measures of clinical performance are needed before economics or Benchmarking can successfully maximize the efficiency of the health care system. In the Intensive care unit (ICU), mortality is one of the most important clinical outcomes and different tools have been developed to estimate its probability of occurrence (Acute Physiology and Chronic health Evaluation (APACHE), the Simplified Acute Physiology Score (SAPS), and the Mortality Probability Model (MPM)). By assigning probabilities of hospital mortality to each patient, these systems classify patients by severity and are useful for the control of confounding by severity, the discussion of prognosis with patients and their families and in the evaluation of performance. However, if poor fit exists in one particular ICU, this is consistent with differences in both, either performance or patient-mix between this ICU and those used to develop the model. Case mix is one of the most important biases in health care economical evaluations and severity models are still inappropriate to fully adjust for case mix. The objectives of this research were to describe how differences in diagnostic covariate pattern mix affect model fit and to explore adjustment methods for case mix when the ratio of observed to expected deaths is used to compare the performance of a study ICU with the overall performance of other ICUs. The maximum likelihood adjustment of rate ratios and the dummy variable method of adjustment for case mix are useful tools to adjust for changes in patient mix and could be applied to compare ICU quality performance. The proportional sampling method of adjustment for patient mix is not applicable in real life situations because it fails to adjust for patient mix, especially when an ICU has a lower overall mortality ratio (attributable to a particular patient mix), than the developmental data set.

Background: The translation of new knowledge, such as research findings, new tools or methods into health care practice has gained increased  interest in recent years. Important factors that determine implementation outcome have been identified, and models and checklists to be followed in planning as well as in carrying out an implementation process have been produced. However, there are still knowledge gaps regarding what approach should be used in which setting and for which problems. Primary health care (PHC) in Sweden is an area where there is a paucity of research regarding implementation of new methods into practice. The aim of the thesis was to apply theory in the study of the implementation of an innovation in Swedish PHC, and identify factors that influenced outcome. Methods: The study was performed using a quasi-experimental design, and included six PHC units, two from each one of three county councils in the southeast part of Sweden. A computer-based lifestyle intervention tool (CLT) developed to facilitate addressing lifestyle issues, was introduced at the units. Two different strategies were used for the introduction, both aiming to facilitate the process: a theory-based explicit strategy and an implicit strategy requiring a minimum of effort. Data collection was performed at baseline, and after six, nine and 24 months. Questionnaires were distributed to staff and managers, and data was also collected from the CLT database and county council registers. Implementation outcome was defined as the proportion of eligible patients being referred to the CLT, and was also measured in terms of Reach, Effectiveness, Adoption, Implementation and Maintenance according to the RE-AIM framework. Interviews were performed in order to explore experiences of the implementation process as perceived by staff and managers. Results: A positive organizational climate seemed to promote implementation. Organizational changes or staff shortages coinciding with the implementation process had a negative influence on outcome. The explicit implementation strategy seemed to be more effective than the implicit strategy in the short term, but the differences levelled out over time. The adopters’ perceptions of the implementation seemed to be influenced by the existing professional sub-cultures. Successful implementation was associated with positive expectations, perceptions of the innovation being compatible with existing routines and perceptions of relative advantage. Conclusions: The general conclusion is that when theory was applied in the implementation of a lifestyle intervention tool in Swedish PHC, factors related to the adopters and to the innovation seemed to be more important over time than the strategy used. Staff expectations, perceptions of the innovation’s relative advantage and potential compatibility with existing routines were found to be positively associated with implementation outcome, and other major organizational changes concurrent with implementation seemed to affect the outcome in a negative way. Values, beliefs and behaviour associated with the existing sub-cultures in PHC appeared to influence how the implementation of an innovation was perceived by managers and the different professionals.

Evidence available shows that the ethics review process in Malaysia suffers from a range of problems (Kaur, 2011). These problems may be the result of a lack of training given for REC members and relatedly, it may stem from a lack of understanding of the role of RECs. Since Malaysia is striving to promote the country as a research hub for international collaboration, it is important that the ethics review system that is in place is well set up to ensure only ethical research are being approved. The aim of this thesis is to develop three important key elements of a framework that can be used to provide practical guidance for RECs and their governance in Malaysia. These three important elements of the ethics review process are: - the role of RECs, the criteria of REC membership and the acceptability of variation in decisions made between different RECs. These analysis is then applied to the Malaysian context. My initial recommendation is for RECs to adopt the Daniels and Sabin (1997) accountability for reasonableness model to assist with the decision-making process. The adoption of the model helps to clarify the role of RECs and can be used as a basis to develop the criteria for REC membership as well as to provide a better understanding of the acceptability of variation in decisions between different RECs.

Thesis (doctoral)--Rijksuniversiteit te Groningen. / Limited cataloging. Errata sheet tipped in. Includes bibliographical references.

Thesis (Ph.D.)--Victoria University of Wellington, 2008. / Includes bibliographical references.

Orientador: Carlos Eduardo Leite Arieta / Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-23T06:27:22Z (GMT). No. of bitstreams: 1 Oliveira_DeniseFornazaride_D.pdf: 3119870 bytes, checksum: 95b8a08b4d2cee7e0526e3af36a701ab (MD5) Previous issue date: 2013 / Resumo: Realizou-se estudo transversal com o objetivo de avaliar e caracterizar o modelo de atenção em saúde ocular em municípios da região de Campinas de acordo com a organização do Sistema Único de Saúde, e oferecer subsídios para a configuração da rede temática regionalizada de atenção à saúde em oftalmologia. Foram incluídos 62 municípios, que compõem a Rede Regionalizada de Atenção à Saúde (RRAS) 15 e RRAS 16 do Estado de São Paulo, para as quais o Hospital de Clínicas da Unicamp é referência de alta complexidade. Foram avaliados os serviços públicos de saúde municipais, estaduais e parcerias presentes na região. Não foram avaliados os serviços de saúde do sistema privado. Foram consultados os funcionários das Centrais de Regulação das Secretarias de Saúde dos municípios. O instrumento utilizado foi questionário semiestruturado, desenvolvido em estudo exploratório, aplicado por entrevista. Foram avaliadas estratégias de atendimento, com variáveis que permitiram caracterizar a assistência oftalmológica quanto ao modelo de atenção adotado, serviços ambulatoriais especializados, fluxo local e regional de pacientes, capacidade resolutiva das unidades, perfil das equipes, instalações físicas, programa de assistência farmacêutica, participação em consórcios e convênios com a assistência suplementar. A região estudada tem uma população de 4.805.691de habitantes. Há serviços de atendimento em oftalmologia em 77,4% dos municípios. Na região estão instalados 5 Ambulatórios Médicos de Especialidades (AME), 2 hospitais filantrópicos, um hospital estadual e 2 hospitais universitários, com atendimento referenciado. Estão presentes 3 consórcios regionais de saúde. O acesso da população ocorre principalmente pela atenção básica (95,2% dos municípios), encaminhada pelo médico clínico (74,2%). O tempo de espera da consulta de oftalmologia está entre 30 e 60 dias. Há lista de espera para consultas em 58,0% dos municípios, de 27.159 pacientes. O volume de consultas mensais disponibilizadas pelo sistema público é de aproximadamente 21.512. São 115 oftalmologistas atuando na rede pública, 87 na RRAS 15 e 28 na RRAS 16, em 57 consultórios com equipamento básico. Os pacientes de maior complexidade são encaminhados aos serviços de referência. Não há atendimento de urgência em oftalmologia em 77,4% dos municípios, e 82,3% dos municípios não têm centro cirúrgico para procedimentos de oftalmologia. Existem filas de espera para cirurgia de catarata em 80,6% dos municípios. São 5.796 pacientes na RRAS 15 e 796 na RRAS 16. Em 13 municípios com filas (26,0%), não há dados sobre números de pacientes nas filas. A maior parte da fila (81,8%) concentra-se em 8 municípios (12,9%). Não existem dados organizados de filas para atendimento em doenças da retina. O programa de assistência farmacêutica, com os medicamentos do glaucoma, está em 79,0% dos municípios, e o transporte sanitário em 100,0%. Os municípios apresentam sistema de referência e contrarreferência de pacientes (53,2%) e a maioria (82,3%) não tem protocolos clínicos de atendimento de oftalmologia. As principais dificuldades encontradas na organização do atendimento são relacionadas ao encaminhamento de pacientes com problemas de maior complexidade (referência, cirurgias e procedimentos de retina). Tal fato corrobora a necessidade da organização do fluxo de pacientes, para que os recursos disponíveis sejam mais bem aproveitados e os investimentos sejam realizados de forma a atender as necessidades detectadas / Abstract: A cross-sectional study was conducted to evaluate and characterize the model of eye care within the Brazilian Health System (SUS) in the region of Campinas and also provide support for configuration of the regionalized health care network in ophthalmology. The study included 62 municipalities from the State of São Paulo, which comprises the Regionalized Health Care Network (RRAS) 15 and RRAS 16. The Clinical Hospital of Unicamp is the reference for high complexity in this region. Only public health services and their partners were evaluated. To perform the study, professionals from de Regulatory Section of the Health Division of the municipalities were interviewed. The instrument was a semi-structured questionnaire, developed in the exploratory study and applied by direct interview. We evaluated service strategies with variables that allow for characterization of the eye care regarding the model of care adopted, specialized ambulatory services, local and regional flow of patients, service power of resolution, professional profile, pharmaceutical assistance programs, participation in consortia and partnerships with other health institutions. The study area has a population of 4.805.691 inhabitants. There are services in ophthalmology in 77.4% of the municipalities. There are 5 AMEs in the region, two philanthropic hospitals, a state hospital and two university hospitals with referenced assistance. There are presently three regional health consortia in the region. The entrance of patients into the system for eye care occurs mainly by primary care services (95.2% of municipalities) and clinician referral (74.2%). Waiting time for ophthalmology consultation is between 30 and 60 days. There is a waiting list for appointments in 58.0% of the municipalities totaling 27,159 patients. The total number of consultations available is approximately 21,512 a month. There are 115 ophthalmologists acting in the public service: 87 in RRAS 15 and 28 in RRAS 16. There are 57 offices with basic ophthalmologic equipment. Patients of greater complexity are referred to appropriate services. There is no emergency assistance in ophthalmology, and 82.3% of the municipalities do not have operating room facilities for ophthalmology. There are waiting lists for cataract surgery in 80.6% of the municipalities (5,796 patients in RRAS 15 and 796 in RRAS 16). In 13 municipalities with waiting lists (26.0%), there are no data regarding the number of patients. The majority of queues (81.8%) are concentrated in 8 cities (12.9%) and there are no data regarding queues for diseases of the retina. The pharmaceutical assistance program for glaucoma medications is present in 79.0% of the municipalities, and medical transportation in 100.0%. There is a system for reference and counter reference of patients in 53.2% of the municipalities and the majority (82.3%) does not have clinical protocols for ophthalmology. The main difficulties found in the organization of care are related to flow of patients with more complex problems (referral, surgeries and procedures of retina). This study corroborates the necessity of organizing flow patient so that the available resources are better placed and investments can be made in order to attend the identified needs / Doutorado / Oftalmologia / Doutora em Ciências Médicas

Thesis (M.S.)--University of Michigan, 1983.

Thesis (M.S.)--University of Michigan, 1983.