The current crisis in the distribution of health care resources in the U.S. derives largely from insufficient access to health care, on the one hand, and inadequate control of rising costs, on the other hand. The response to the problem of insufficient access should not be the recognition of a moral right to health care but rather the establishment of a legal right to health care for all. In turn, the contours of this legal right can be the means to create the needed cost controls. To this end, they should include a laundry list of covered condition-treatment pairs, which would be informed by the measuring stick of quality-adjusted-lifeyears, and which would be the product of input from the public, the medical profession, and the Congress. The resultant structure of universal coverage, under a system of explicit rationing, would include a morally mandated second tier. Universal coverage, explicit rationing, and a second tier are the indispensable building blocks of meaningful health care reform in the U.S.

<p> This research study used a quantitative comparative method to investigate the relationship between consumer satisfaction and communication based on the format of health record. The central problem investigated in this research study related to the format of health record used and consumer satisfaction with care provided and effect on communication with provider. The purpose of this current research was to ascertain if statistically significant differences existed between the format of health records (electronic versus paper) and the level of consumer satisfaction with care provided and communication with provider. The results of this research study found no support for the ideas that consumer satisfaction and consumer communication with their doctor were related to the format of the health record. Based on the results, further investigation is suggested to specify how the implementation of electronic health records may affect consumer satisfaction with health care provided and how this may affect communication with health care provider. </p>

Data required for the surveillance of the population of small areas and the implementation and evaluation of health preventive programmes are usually obtained from surveys conducted within each relevant small area. The substantial cost of local surveys has encouraged the search for other methods of obtaining the required information. One alternative consists of using small area estimators. Despite extensive applications of these procedures in diverse fields, guidelines concerning their use for the prediction of health variables are still lacking. In an effort to explore the applicability of small area estimators to the prediction of health parameters of Quebec's health areas, we conducted two empirical evaluations of these methods. Using data from Canadian surveys, estimates of health variables were produced for several Quebec's areas according to different techniques of small area estimation. The estimates were compared to a "standard" for each area and health variable, on the basis of average mean square error percents and Spearman correlations. Synthetic, regression-sample, and empirical Bayes estimators were evaluated. We observed that the more variable a health characteristic was among areas, the more difficult it was to predict accurately. While no small area estimator performed uniformly well for all the variables considered, the linear regression-sample estimators were generally at advantage according to the different criteria of evaluation. In the studied context, no gain was obtained by using more sophisticated procedures like the empirical Bayes estimators.

Stroke creates a substantial economic burden on the patients and society. With more emphasis being placed on community-based services, it has been advocated that more importance should be placed on early supported discharge for stroke patients. Studies have shown that early supported discharge is as effective as conventional care. However, very few of these studies have associated costs. / The purpose of this study was to estimate the cost effectiveness of prompt discharge with home rehabilitation compared with usual post acute care for stroke patients. / A cost effectiveness analysis was performed on data originating from a prior randomized controlled trial designed to evaluate the effectiveness of prompt discharge combined with home rehabilitation. / Information on health care utilization and the associated costs were obtained from the Quebec Health Insurance Board and determined for the first three months following discharge. Scores from the Short Form 36 health survey were used as the measure for effectiveness. / Results demonstrated that early supported discharge with home rehabilitation is a cost effective alternative to conventional hospital discharge procedures.

Introduction. Lung recipients are faced with life-threatening complications which may impede in reaching an acceptable overall clinical and HRQOL level. Furthermore, the reported costs associated with the rigid follow-up care and expensive drug regimen raises the question whether this intervention is cost-effective. / Objectives. To determine the incremental cost-effectiveness (C/E) and cost-utility (C/U) of lung transplantation (L-Tx) according to the health system perspective. / Methods. A C/E and C/U analysis of L-Tx was carried out on 124 patients accepted unto the Quebec L-Tx waiting list (1997--2001). Survival was presented in mean life years (LY). HRQOL and utility were assessed using the SF-36 and standard gamble; they were studied cross-sectionally and longitudinally on a group of patients. Utility was used in the computation of the QALY. The economic impact of L-Tx was based on direct medical costs for 3 time periods: the waiting list, the transplant procedure and post-transplant phase. In the incremental C/E and C/U ratio, the costs for the procedure and follow-up care were compared to those during the waiting list, which served as an estimate for costs without transplantation. Estimates were modeled beyond the study period based on registry data. Simulating different person-time experiences during the waiting time (1 to 6 years) and post-transplant phase (1 to 8 years) tested key assumptions. Costs were based on provincial and national data and were discounted at a rate of 5%. / Results. The estimates were based on the 1,090.0 and 1,421.5 person-months contributed by the cohort (N = 124) to the waiting list and post-transplant phase (N = 91), respectively. The mean LYs and QALYs gained were 0.57 (95% CI: 0.36--0.78) and 0.62 (95% CI: 0.36--0.78), respectively. HRQOL was higher on average for all domains in lung recipients versus candidates. Utility scores were also higher in recipients as compared to candidates: 0.76 (95% CI: 0.69, 0.83) versus 0.17 (95% CI: 0.12, 0.22). The estimated total average cost per patient without Tx was $15,015 or $1,708 (95% CI: $1,327--$2,090) per month. The L-Tx program induced an additional screening cost of $9,622 per patient. The average cost of a transplant procedure was $49,314 (95% CI: $39,216--$69,465). The average post-Tx follow-up cost per patient per month in the first, second, third and fourth year was $2,804 ($1,840--$3,792), $1,643 ($1,090--$2,291), $1,749 ($804--$2,690) and $971 ($768--$1,175), respectively.

The rapid growth of medical sciences and technologies created the need of increased use of computers to address the recognized problems associated with information overload, and to help health care professionals provide better quality decisions. / This thesis presents the development, implementation, and evaluation of a real-time expert monitoring system (EMS) developed for the patient data management system (PDMS) of a pediatric intensive care unit. The objective of the EMS is to generate real-time warning signals in the event of life threatening patient conditions. / The research in this thesis concentrated on the analysis of the performance of the expert system in the intensive care environment by monitoring several patients over a period of days. The results obtained were generally in agreement with the actual medical interpretations given by the health care professionals at the MCH. However, some false positive and false negative results were observed and these are discussed in the thesis.

The electromagnetic environment outside and inside five urban hospitals, due to fixed, EXTERNAL TRANSMTTERS (30-1000 MHz range), was characterized by measurement. Measured fields generally remained below 130 dB$ mu$V/m (3 V/m). Four computational prediction methods, based on line-of-site free-space propagation, Uniform Geometric Theory of Diffraction, and urban clutter models, were evolved. Fields predicted outside these hospitals were compared to the measured fields. A simple line-of-sight method predicted fields within 20 dB of those measured, thereby easily providing an estimate of the worst-case fields at a hospital. The most complex of these prediction methods estimated field levels to within 10 dB. / Measurements were also used to analyze signal propagation characteristics inside buildings due to INTERNAL SOURCES operating at 433, 861, and 1705 MHz. Cross-floor propagation paths, where multiple floors and walls were traversed, showed fields were independent of the transmitter-receiver separation distance. Signals measured for a separation of one floor were higher than same-floor signal levels.

A randomized clinical trial was undertaken to compare the effectiveness and direct costs of shock wave lithotripsy (ESWL) and laparoscopic cholecystectomy (LC) for the treatment of symptomatic gallbladder stones. Over a period of 24 months from a total of 468 patients screened, 35 patients were randomized to ESWL, and 25 to LC. 32 ESWL patients were treated, all as out-patients, with a mean convalescence post-ESWL of 0.5 $ pm$ 1.2 days. In contrast, all LC patients were admitted to hospital for a mean duration of 2.8 $ pm$ 1.5 days with a mean post-operative convalescence of 18.2 $ pm$ 16.8 days as measured by research nurses. The two patient groups did not differ with respect to McGill Pain scores administered immediately after treatment. Three Quality of Life (QOL) tools improved similarly in both groups within the month following treatment. The only differences in QOL questionnaire results between both groups when administered 3 months following treatment and at six monthly intervals thereafter occurred for LC as greater incremental improvements were noted at 6 and 12 months follow-up. The overall stone disappearance rate in the ESWL group after a median of 15 months was 38%. Direct costs to the Quebec Health Care system during the study period were determined by analysis of patients in both treatment groups. In 1993 canadian dollars, average costs and their range were 2,889$ (1,704 $-5,830$) for patients undergoing LC, and 3,936 $ (2,367$--6,243 $) for patients treated by ESWL. The cost effectiveness ratios using the incremental differences in direct costs and duration of disability favoured ESWL at a cost of 58.9$/day of disability saved over the 15--18 months follow-up period. (Abstract shortened by UMI.)

Functional disability assessments are recognized as being important for the diagnosis of Dementia of the Alzheimer's type (DAT) as well as for monitoring the impact of intervention and determining the need for home assistance or institutionalization. Existing instruments designed for the assessment of functional disability with this population are generally unsatisfactory with regards to their content or psychometric properties. The objective of this research project was to develop a more appropriate French and English assessment of functional disability for use with proxy-respondents of community-dwelling individuals who have DAT. The Disability Assessment for Dementia (DAD) was developed in several stages using three panels composed of health care professionals and caregivers of individuals with DAT. Forward-backward translation procedures were performed at each stage to ensure that the French and English versions of the scale were comparable. Content validity was verified by a fourth panel of experts. The DAD was then administered to 59 community-dwelling DAT subjects and their caregivers to determine internal consistency and the need to eliminate items. The instrument developed, which consisted of 46 items, was reduced to 40 items, 17 related to basic self-care and 23 to instrumental activities of daily living, as a result of this process. The content validity of the final version was established by a majority of members from the panel of experts. It also demonstrated a high degree of internal consistency (Cronbach's alpha = 0.96) and excellent interrater (N = 31) and test-retest (N = 45) reliability (Intraclass correlation coefficients of 0.95 and 0.96 respectively). In addition, it was found not to have gender bias. Estimates of its validity were determined in another study. The DAD represents a valid and reliable instrument which is short and easy to administer. This instrument should have a positive impact on geriatric rehabilitation, and on clinical and

This thesis presents the design and implementation of a Nursing Workload Manager module for a Patient Data Management System in an intensive care unit. The Nursing Workload Manager aids in the planning and documentation of the nurse's workload. It automates the generation of the nursing care plan and automatically assigns a score to the care plan based on a nursing workload measurement system. In the thesis a literature survey of patient data management systems, nursing workload measurement systems and system evaluation methods is presented. This is followed by an overview of the work environment of an intensive care unit. The functionality of the Nursing Workload Manager is described and details of the software environment and application implementation are discussed. Finally, the results of a user evaluation of the module are presented, and future work on the module is discussed.