Doctor of Philosophy / Department of Anatomy and Physiology / David C. Poole / The components of the O2 transport pathway can be divided into (along with their respective circulations) the pulmonary, cardiovascular, and skeletal muscle systems. They must operate in tight conjunction with one another, especially during dynamic exercise, to sustain ATP production within muscle mitochondria. Any limitation placed on the O2 transport pathway will result in decreased performance. The purpose of this dissertation is to present four novel studies which examine specific limitations on (1) the pulmonary system (i.e. lungs and circulation) within the highly athletic Thoroughbred horse (Studies A & B), and (2) within the peripheral circulation (i.e. microcirculation) within a disease model of Type II diabetes, the Goto-Kakizaki (GK) rat (Studies C & D). Study A demonstrates that locomotory respiratory coupling (LRC) is not requisite for the horse to achieve maximal minute ventilation (VE) during galloping exercise because VE remains at the peak exercising levels over the first ~13 s of trotting recovery (VE at end exercise: 1391±88; VE at 13 s: 1330±112 L/sec; P > 0.05). The horse also experiences exercise-induced pulmonary hemorrhage (EIPH) which has been linked mechanistically to increased pulmonary artery pressure (Ppa) during high intensity exercise. Therefore, in Study B, we hypothesized that endothelin-1 (ET-1), a powerful vasoconstricting hormone, would play a role in the augmented Ppa and therefore, EIPH. However, contrary to our hypothesis, an ET-1 receptor antagonist did not decrease Ppa nor prevent or reduce EIPH. Studies C and D examine potential mechanisms behind the exercise intolerance observed in humans with Type II diabetes. Utilizing phosphorescence quenching techniques (Study C) within the GK spinotrapezius muscle, we found lowered microvascular PO2 (PO2mv; Control: 28.8±2.0; GK: 18.4±1.8 mmHg; P<0.05) at rest and a PO2mv “undershoot” during muscle contractions. After conducting intravital microscopy within the same muscle (Study D), we discovered the percentage of RBC-perfused capillaries was decreased (Control: 93±3; GK: 66±5 %; P<0.05) and all three major hemodynamic variables (i.e. RBC velocity, flux, and capillary tube hematocrit) were significantly attenuated. Both studies (C & D) indicate that there is reduced O2 availability (via decreased O2 delivery; i.e. ↓QO2/VO2) within Type II diabetic muscle.

Occupation of a general nurse belongs to demanding jobs in terms of professional preparation and performance. A nurse is expected to cope with professional activity, working with modern technology, administrative work, to bear the physical and mental load of her profession, to be able to influence and direct patients? feelings and behaviour and finally to be able to cope with professional as well as family problems she is faced to. All this is often dealt with in continuous operation on shift basis at various specialized workplaces. Questions how nurses working at a cardiac surgery department are satisfied or dissatisfied at their jobs, how the work experience length affects their satisfaction, whether possible discontent among nurses may affect quality of the nursing services provided by them and how the hospital management reduces the factors of discontent, became the subject of my thesis. The research was performed at the IKEM in Prague. Quantitative as well as qualitative research methods were used for data collection when mapping the problems in question. The quantitative part involved a questionnaire both, for general nurses working at the cardiac surgery department, aimed at investigation into the discontent factors involved in their occupation, and for the patients undertaking treatment at the cardiac surgery department, to examine their satisfaction with the nursing care. Analysis of the collected data was then performed. An interview with representatives of the hospital line, middle and top managements was the instrument of the qualitative research. It was focused on the question how they proceed in elimination or reduction the discontent factors. The following facts were found out by the quantitative research. Increased physical and mental load, non-cooperating patients and care about more patients at the same time, extensive administration related to patient care, insufficient remuneration, lack of communication from doctors and superiors, lack of auxiliary staff, projection of occupation to private life or the problem of sleeping after a night shift are the most frequent discontent factors. Despite the above negative factors nurses are satisfied with their jobs regardless the length of experience. The indentified factors of discontent do not affect quality of the care provided by the nurses. The qualitative research results show that personal talks, active interviews and direct communication from the staff are the most frequent methods the management uses to map staff satisfaction. The management representative is able to work herself on elimination or reduction of the discovered factors of discontent within her competences, which happens most often. She may also cooperate with the chief nurses or ward sisters. Unless she is able to solve a problem, it is passed to the authorized persons competent to deal with it (health care manager, social-legal department, HR department). The hospital director is also informed on the most serious cases. The management hardly ever cooperates with physicians on elimination or reduction of the discontent factors. The most important aspect of solving the problem of discontent factors is its subject, which affects the solution method, whether it is to be dealt with by an individual or the whole team. They inform the head physicians or the ward chief consultant on serious problems. The course of the problem solution is communicated to the employees by the ward sisters or chief nurses personally, orally.The goals of the thesis have been met, the set hypotheses have been refuted, and the research questions have been answered.

O gerenciamento de recursos materiais na área hospitalar tem assumido destaque principalmente com os avanços tecnológicos ocorridos nas últimas décadas. A incorporação de tecnologia sofisticada pode ser percebida pelo aumento da complexidade das práticas assistenciais e dos desafios que os gestores de instituições públicas e privadas enfrentam diante do aumento da oferta de produtos, que visam maior segurança aos pacientes e equipe de profissionais que lhes assistem, e do consumo dos materiais médico-hospitalares, com consequente elevação dos custos na prestação de serviços. A Agência Nacional de Vigilância Sanitária (ANVISA) tem como atribuição a regulamentação e regulação dos produtos para a área da saúde como forma de promover a vigilância em saúde e subsidiar as instituições quanto ao controle dos produtos na fase de pós-comercialização. Compete à Gerência de Risco Hospitalar o controle dos produtos das áreas de Tecnovigilância, Hemovigilância e Farmacovigilância. O objetivo desta pesquisa é analisar o processo de notificação da queixa técnica de material de consumo de uso hospitalar no contexto do gerenciamento de recursos materiais em um hospital universitário público, no período de 2007 a 2009. Trata-se de um estudo descritivo, retrospectivo, documental com abordagem quantitativa. Compreende a análise de 409 Impressos de Notificação, enviados para a Seção de Parecer Técnico, utilizados na instituição para formalizar o relato da ocorrência de queixa técnica. Destes, 260 preenchem os critérios de inclusão, constituindo-se na população investigada. As notificações analisadas estão agrupadas de acordo com sua finalidade, formando-se três grupos: material médico-hospitalar, material para higiene pessoal e material para uso no processo de esterilização. A construção do fluxograma do encaminhamento do Impresso de Notificação para material padronizado evidencia que a sequência de trabalho possibilita a caracterização da ação dos profissionais e das instâncias de decisão. No conjunto dos anos em análise, o mês de junho apresenta o maior número de notificações (36). Em relação à queixa técnica evidenciam-se os maiores índices no grupo de material médico-hospitalar. Os produtos identificados com maior frequência de notificação são representados pela luva cirúrgica, dispositivo de acesso venoso, equipo, seringa, papel toalha interfolha, fralda e embalagem para processo de esterilização. De acordo com a categoria de queixa técnica (embalagem, estrutura e aspecto alterado) destaca-se a presença das questões de estrutura nos três grupos de material. A participação da equipe de enfermagem é marcante, em especial a do profissional enfermeiro, totalizando 211 notificações; destas 69 enviadas pela Divisão de Centro Cirúrgico e 51 pela Divisão Materno Infantil. Em relação ao turno de trabalho, predomina o período diurno. Um dos objetivos do monitoramento das notificações de queixas técnicas é subsidiar informações para o sistema de Notificações em Vigilância Sanitária (NOTIVISA); sendo assim, foi possível a contribuição desta instituição com 20 notificações pertinentes à área de Tecnovigilância. Conclui-se que o Impresso de Notificação é uma ferramenta importante no gerenciamento de recursos materiais na área hospitalar. Através desse feedback é possível realizar o monitoramento da qualidade dos produtos na pós-comercialização, preservando a segurança para o paciente e equipe de saúde. / The management of material resources in the nosocomial field has gained prominence mainly due to the technological advances that have occurred in recent decades. The incorporation of sophisticated technology can be perceived by the increase in the complexity of care practices and the challenges that the managers of public and private institutions face due to both the increase in the supply of products that aim at greater safety for the patients and the team of professionals who assist them, and the consumption of medical-nosocomial material, with a consequent increase in costs in the provision of services. The National Health Surveillance Agency (ANVISA) is in charge of the rules and regulation of products for the health care area to promote health surveillance and assist the institutions as to the control of the products in the after sales phase. The Hospital Risk Management is in charge of the control of products in the areas of Tecnovigilância, Haemovigilance and Pharmacovigilance. This research aims to analyze the notification process of technical complaints about consumption material for hospital use in the context of material resources management in a public university hospital, in the period from 2007 to 2009. This is a documentary retrospective descriptive study with a quantitative approach. The analysis comprises 409 Notification Forms sent to the Section on Technical Advice, used by the institution to formalize the report of technical complaint occurrences. Of these, 260 met the inclusion criteria, thus composing the investigated population. The notifications under analyzes have been categorized according to their purpose, forming three groups: medical and nosocomial material, material for personal hygiene and material for use in the sterilization process. The construction of a flow chart of Notification Forms Reference for standardized material shows that the work sequence enables the characterization of the actions of professionals and decision-makers. In all the years under review, the month of June presents the greatest number of notifications (36). In relation to the technical complaints this research reveals that the group of medical nosocomial products received the highest indices. The products identified with increased notification rates are surgical gloves, devices for venous access, hoses, syringes, interfolha paper towels, diapers and packaging for the sterilization process. According to the category of technical complaints (packaging, structure and altered appearance), structure stands out in all three groups. The participation of the nursing team is notable, especially the professional nurses, totaling 211 notifications, 69 of which sent by the Surgical Center Division and 51 by the Infant Maternal Division. In relation to work shift, the day shift prevails. One of the objectives of monitoring technical complaints notifications is to feed the Sanitary Surveillance Notification System (NOTIVISA) with information. Thus this institution contributed with 20 pertinent notifications to the area of Tecnovigilância. It is concluded that the Notification Form is an important tool in material resources management in the nosocomial area. Through this feedback it is possible to carry out the monitoring of the quality of the products after sale while preserving the safety for the patient and the health care team.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-10-05T18:03:38Z No. of bitstreams: 1 annaclaudiarodriguesalves.pdf: 563145 bytes, checksum: c6d2ccd48c1c861d1dea2fbdf8fe4b54 (MD5) / Approved for entry into archive by Diamantino Mayra (mayra.diamantino@ufjf.edu.br) on 2016-10-06T12:30:42Z (GMT) No. of bitstreams: 1 annaclaudiarodriguesalves.pdf: 563145 bytes, checksum: c6d2ccd48c1c861d1dea2fbdf8fe4b54 (MD5) / Made available in DSpace on 2016-10-06T12:30:42Z (GMT). No. of bitstreams: 1 annaclaudiarodriguesalves.pdf: 563145 bytes, checksum: c6d2ccd48c1c861d1dea2fbdf8fe4b54 (MD5) Previous issue date: 2009-02-16 / O presente estudo tem por objeto a análise do modo tecnológico de gestão da assistência à saúde no hospital de ensino: HU/CAS/UJFJ, a partir da inter-relação da macro e micropolítica. Por macropolítica entende-se a relação entre o HU/CAS e a rede SUS e micropolítica, a relação institucional entre profissionais e gestores. A pesquisa foi iniciada com a revisão de literatura sobre os fundamentos da gestão do SUS e do conceito de assistência, com base no cuidado em saúde. O instrumento utilizado foi a pesquisa qualitativa com aporte na abordagem dialética, com o sentido de avaliar a concepção dos gestores e profissionais acerca dos processos de gestão e de assistência, considerando as atuais diretrizes organizacionais e políticas do HU/CAS/UFJF. Ao final, a análise dos dados contribuiu para a apresentação de um ensaio sobre o conceito de gestão da assistência, por acreditar no seu potencial de reorientar a operacionalidade das diretrizes do SUS no interior do espaço do hospital de ensino, tendo em vista uma administração qualificada e centrada nas necessidades e demandas da população-usuária. / The aim of this study was to analyze the technological way of health care’ management in the university hospital: HU/CAS/UFJF, from the inter-relationship of macro and micro-policies. It’s defined by macro-policies the relation between the HU/CAS and the SUS, and by micro-policies, the institutional relation between the professionals and the managers. The research started with a review of the literature, based in the health care, about the fundamentals of management of SUS and about the concepts of the health care. The qualitative research, with input in the dialectic approach, was used with the aim of evaluate the conception of managers and the professionals about the management and health care’s process, taking account the current organizational guidelines and policies of the HU/CAS/UFJF. At the end, the analysis of the results contributed for the presentation of a test about the health care’ management concept, that has a great potential at redirect the operationality of the SUS’ organizational guidelines in the university hospital, in a view of an administration qualified and focused on the necessities and demands of the population.

Submitted by Nadir Basilio (nadirsb@uninove.br) on 2016-04-05T23:41:21Z No. of bitstreams: 1 Anna Sofia Costa Neri.pdf: 1757298 bytes, checksum: b4e53d5be3ed8bb584b6b5da02489f69 (MD5) / Made available in DSpace on 2016-04-05T23:41:21Z (GMT). No. of bitstreams: 1 Anna Sofia Costa Neri.pdf: 1757298 bytes, checksum: b4e53d5be3ed8bb584b6b5da02489f69 (MD5) Previous issue date: 2015-12-07 / The service sector has shown steady expansion in the Brazilian economy, reflecting directly expressive financial results for the country. The health insurance sector is inserted in this context and in the face of disability in the provision of public health services to the population in a universal way, it presents itself as an indispensable element in the framework currently in force in Brazil. The sector's growth has provided an intense competition between operators of health plans by requiring these companies seek to capture and keep customers loyal to their services, thus remaining competitive. However, a considerable amount of customer complaints of this market is presented by the National Health Agency. Identifying the relationship between perceived quality, perceived value and cost of change as trainers concepts of customer loyalty, this study sought to understand that relationship with users of supplemental health services. These, in turn, provided information by completing a validated questionnaire that was used to build a theoretical model analyzed by structural equation modeling with the use of partial least squares technique (PLS). The theoretical framework used in this paper presents the trainers concepts and customer loyalty influencers. The results demonstrated an understanding of users and service aspects of the study, both in its relationship to the health insurance, as in its relationship with the hospital use most with your plan. Relations between the concepts presented in the model were mostly positive, except for the influence of the value perceived by the customer in relation to the health plan on loyalty to the hospital, and the influence of the value perceived by the customer in the hospital on customer loyalty to the health plan. / O setor de serviços tem apresentado constante expansão na economia brasileira, refletindo diretamente em resultados financeiros expressivos para o país. O setor de saúde suplementar está inserido nesse contexto e, diante da incapacidade na prestação de serviços públicos de saúde à população de forma universal, se apresenta como um elemento indispensável no quadro atualmente vigente no Brasil. O crescimento do setor proporcionou a competitividade entre as operadoras de planos de saúde, exigindo que estas empresas busquem captar e manter clientes leais aos seus serviços, consequentemente, mantendo-se competitivas. Entretanto, um considerável volume de reclamações dos clientes desse mercado é apresentado pela Agência Nacional de Saúde Suplementar. Identificando a relação entre qualidade percebida, valor percebido e custo de mudança como conceitos que influenciam a lealdade do cliente, este trabalho buscou entender a referida relação junto aos usuários dos serviços de saúde suplementar. Estes, por sua vez, forneceram informações por meio do preenchimento de um questionário que foi utilizado para construção de um modelo teórico analisado por meio da modelagem de equações estruturais com a utilização da técnica dos mínimos quadrados parciais (PLS). O suporte teórico utilizado neste trabalho apresenta os conceitos formadores e influenciadores da lealdade do cliente. Os resultados demonstraram o entendimento dos usuários quanto ao atendimento dos aspectos estudados, tanto em sua relação com o plano de saúde, como em sua relação com o hospital que mais utiliza com seu plano. As relações entre os conceitos apresentados no modelo foram, em sua maioria, positivas, com exceção da influência do valor percebido pelo cliente em relação ao plano de saúde sobre a lealdade ao hospital, e a influência que do valor percebido pelo cliente no hospital sobre a lealdade do cliente ao plano de saúde.

abstract: Sensitive data sharing presents many challenges in case of unauthorized disclosures, including stigma and discrimination for patients with behavioral health conditions (BHCs). Sensitive information (e.g. mental health) warrants consent-based sharing to achieve integrated care. As many patients with BHCs receive cross-organizational behavioral and physical health care, data sharing can improve care quality, patient-provider experiences, outcomes, and reduce costs. Granularity in data sharing further allows for privacy satisfaction. Though the subjectivity in information patients consider sensitive and related sharing preferences are rarely investigated. Research, federal policies, and recommendations demand a better understanding of patient perspectives of data sensitivity and sharing. The goal of this research is to enhance the understanding of data sensitivity and related sharing preferences of patients with BHCs. The hypotheses are that 1) there is a diversity in medical record sensitivity and sharing preferences of patients with BHCs concerning the type of information, information recipients, and purpose of sharing; and 2) there is a mismatch between the existing sensitive data categories and the desires of patients with BHCs. A systematic literature review on methods assessing sensitivity perspectives showed a lack of methodologies for characterizing patient perceptions of sensitivity and assessing the variations in perceptions from clinical interpretations. Novel informatics approaches were proposed and applied using patients’ medical records to assess data sensitivity, sharing perspectives and comparing those with healthcare providers’ views. Findings showed variations in perceived sensitivity and sharing preferences. Patients’ sensitivity perspectives often varied from standard clinical interpretations. Comparison of patients’ and providers’ views on data sensitivity found differences in sensitivity perceptions of patients. Patients’ experiences (family history as genetic data), stigma towards category definitions or labels (drug “abuse”), and self-perceptions of information applicability (alcohol dependency) were influential factors in patients’ sensitivity determination. This clinical informatics research innovation introduces new methods using medical records to study data sensitivity and sharing. The outcomes of this research can guide the development of effective data sharing consent processes, education materials to inform patients and providers, granular technologies segmenting electronic health data, and policies and recommendations on sensitive data sharing. / Dissertation/Thesis / Doctoral Dissertation Biomedical Informatics 2020

Health information technology (HIT) owner-practitioners who adopt effective strategies for HIT implementation can improve primary facility care delivery and profitability. However, some HIT owner-practitioners have ineffective implementation strategies, so they have not realized the total revenue increases of more than 8%. Grounded in general systems theory, the purpose of this multiple case study was to explore successful strategies primary care practitioners (PCPs) use to implement HIT to improve primary facility care delivery and profitability. The participants included 6 owner-practitioners located in Queens County, NY, who successfully implemented HIT to improve facility care delivery and profitability. Data were collected through face-to-face interviews and a review of relevant practice documents. Data were analyzed using thematic analysis, yielding 3 themes: HIT education and training, costs of transitioning to HIT, and focusing on expected benefits of successful HIT implementation. By providing information on effective HIT strategies, the findings from this study could impact social change because PCPs may rely on faster and more accurate health information data to offer better diagnoses and enhance treatments for patients.

Der medizinisch-technische Fortschritt (MTF) gilt als wesentlicher Treiber der Gesundheitsausgaben und Hauptursache düsterer Beitragssatzprognosen für die Gesetzliche Krankenversicherung (GKV). Übersehen wird hierbei zumeist, dass der MTF zugleich Produktivitätszuwächse im Gesundheitswesen sowie eine bessere Gesundheit der Erwerbstätigen generiert. Dies sorgt für gesamtwirtschaftliches Wachstum und damit letztlich für eine Verbreiterung der Einnahmenbasis der Sozialversicherung. In diesem Beitrag wird die Auswirkung des MTF sowohl auf die Ausgaben- als auch auf die Einnahmenseite der GKV zwischen 2002 und 2010 berechnet und einander gegenübergestellt. Wir zeigen auf Basis konservativer Rechnungen, dass sich der MTF allein durch zwei seiner Teilaspekte – Produktivitätsgewinne in der Gesundheitswirtschaft und Rückgang des krankheitsbedingt verlorenen Arbeitsvolumens – zu mindestens rund 20 Prozent selbst finanziert. Dieses Ergebnis relativiert allzu pessimistische Aussichten einer fehlenden Finanzierbarkeit des MTF. Der Druck zu weiteren Strukturreformen im Gesundheitswesen wird hierdurch allerdings keinesfalls aufgehoben.

abstract: The use of Red Blood Cells (RBCs) is a pillar of modern health care. Annually, the lives of hundreds of thousands of patients are saved through ready access to safe, fresh, blood-type compatible RBCs. Worldwide, hospitals have the common goal to better utilize available blood units by maximizing patients served and reducing blood wastage. Managing blood is challenging because blood is perishable, its supply is stochastic and its demand pattern is highly uncertain. Additionally, RBCs are typed and patient compatibility is required. This research focuses on improving blood inventory management at the hospital level. It explores the importance of hospital characteristics, such as demand rate and blood-type distribution in supply and demand, for improving RBC inventory management. Available inventory models make simplifying assumptions; they tend to be general and do not utilize available data that could improve blood delivery. This dissertation develops useful and realistic models that incorporate data characterizing the hospital inventory position, distribution of blood types of donors and the population being served. The dissertation contributions can be grouped into three areas. First, simulations are used to characterize the benefits of demand forecasting. In addition to forecast accuracy, it shows that characteristics such as forecast horizon, the age of replenishment units, and the percentage of demand that is forecastable influence the benefits resulting from demand variability reduction. Second, it develops Markov decision models for improved allocation policies under emergency conditions, where only the units on the shelf are available for dispensing. In this situation the RBC perishability has no impact due to the short timeline for decision making. Improved location-specific policies are demonstrated via simulation models for two emergency event types: mass casualty events and pandemic influenza. Third, improved allocation policies under normal conditions are found using Markov decision models that incorporate temporal dynamics. In this case, hospitals receive replenishment and units age and outdate. The models are solved using Approximate Dynamic Programming with model-free approximate policy iteration, using machine learning algorithms to approximate value or policy functions. These are the first stock- and age-dependent allocation policies that engage substitution between blood type groups to improve inventory performance. / Dissertation/Thesis / Doctoral Dissertation Industrial Engineering 2020

abstract: The Centers for Disease Control and Prevention (2017) note that gay, bisexual, and other men who have sex with men (collectively referred to as MSM) face more barriers to accessing health care compared to other men. Such barriers include, lack of cultural- and sexual identity-appropriate medical and support services, concerns about confidentiality, and fear of discussing sexual practices or orientation in a medical setting. In comparison to other MSM populations, Latino MSM (LMSM) report having the least amount of access to health care (McKirnan et al., 2012). The purpose of the present study is to elucidate how individual- (i.e., age, education level, and income level), community- (i.e., social support and neighborhood collective efficacy), and sociocultural-level factors (i.e., immigration status, heterosexual self-presentation, sexual identity commitment, sexual identity exploration, and ethnic identity affirmation and belonging) may relate with perceived access to healthcare. It is hypothesized that ethnic identity affirmation and belonging will moderate relations between the aforementioned predictors and perceived access to health care based on increasing evidence that ethnic identity, or one’s sense of affirmation and belonging to one’s ethnic group, may be a health protective factor. Among a sample of 469 LMSM, this study found that there were several predictors across all three levels (i.e., individual, community, and sociocultural) of perceived access to healthcare. Additionally, data supported evidence that ethnic identity affirmation and belonging (Phinney, 2003) acts as a moderator of other predictors of perceived access to healthcare in this sample. These findings can inform outreach interventions of researchers and healthcare providers about psychosocial and cultural barriers and facilitators of access to healthcare. / Dissertation/Thesis / Masters Thesis Counseling Psychology 2020