abstract: The United States elderly population is becoming increasingly larger, there is a need for a more adequate housing type to accommodate this population. It is estimated that by 2020, there will be a need for approximately 1.6 to 2.9 million units of affordable Assisted Living (Blake, 2005). With limited income and higher health bills, adequate housing becomes a low priority. It is estimated that 7.1 million elderly households have serious housing problems. (Blake, 2005) The scope of this research will look at literature, case studies, and interviews to begin to create and understand the necessary design aspects of Assisted Living and Affordable Housing to better create a housing typology that includes both low income residents and Assisted Living needs. This research hopes to have an outcome of Design Recommendations that can be utilized by designers when designing for an Affordable Assisted Living typology. / Dissertation/Thesis / M.S.D. Design 2014

abstract: Some disabled users of assistive technologies (AT) have expressed concerns that their use of those AT devices brings particular attention to their disability and, in doing so, stigmatizes them in the eyes of their peers. This research studies how a wide range of design factors, influence how positively or negatively users of wearable technologies are perceived, by others. These factors are studied by asking survey respondents to estimate the degree to which they perceive disabilities in users of various products. The survey was given to 34 undergraduate Product Design students, and employed 40 pictures, each of which showed one person using a product. Some of these products were assistive technology devices, and some were not. Respondents used a five-bubble Likert scale to indicate the level of disability that they perceived in this person. Data analysis was done using SPSS software. The results showed that the gender of the respondent was not a significant factor in the respondent's estimation of the level of disability. However, the cultural background of the respondent was found to be significant in the respondent's estimates of disability for seven of the 40 pictures. The results also indicated that the size of AT, its familiarity to the mainstream population, its wearable location on the user's body, the perceived power of the user, the degree to which the AT device seemed to empower the user, the degree to which the AT device was seen as a vehicle for assertion of the user's individuality, and the successfulness of attempts to disguise the AT as some mainstream product reduced the perceived disability of the user. In contrast, symbols or stereotypes of disability, obstructing visibility of the face, an awkward complex design, a mismatch between the product's design and its context of use, and covering of the head were factors that focused attention on, and increased the perception of, the user's disability. These factors are summarized in a set of guidelines to help AT designers develop products that minimize the perceived disability and the resulting stigmatization of the user. / Dissertation/Thesis / M.S.D. Design 2014

Master of Science / Department of Industrial & Manufacturing Systems Engineering / Malgorzata J. Rys / Emergency Medical Systems (EMS) are designed to handle emergencies. Fortunately, most emergencies faced have only one patient. The every day system is not designed to respond to emergencies in which there are many casualties. Due to natural disasters and terrorist attacks that have occurred over the past decade, mass-casualty disaster response plans have become a priority for many organizations, including EMS. The resources available for constructing such plans are limited. Physical simulations or practices of the plan are often performed; however, it is not until a disaster strikes that the capabilities of the plan are truly realized. In this paper, it is proposed that discrete-event simulations are used as part of the planning process. A computer simulation can test the capability of the plan under different settings and help planners in their decision making. This paper looks at the creation of a discrete-event simulation using ARENA software. The simulation was found to accurately simulate the response to the Greensburg tornado that occurred May of 2008. A sensitivity analysis found that the simulation results are dependent upon the values assumed for Volunteer Injury Rate, Injury Level, Information Dissemination Rate and Transportation Decision variables. When a disaster occurs, the local resources are overwhelmed and outside aide must be called in. Decision rules for when to request more outside ambulances and when to release them to send them home are evaluated. The more resources that are made available, the quicker patients receive medical care. However, when outside ambulances are called in, they are putting their home area at risk because it no longer has complete (or any) ambulance coverage. As the percent of coverage decreases, the amount of time that victims spend waiting for ambulances also decreases. Many decision rules were evaluated, resulting in various combinations of ambulance wait times and average percent coverage. It is up to Disaster Planners to determine how much of an additional wait can be assumed by the disaster victims to prevent outside districts from taking on unwarranted risk of low coverage.

This dissertation evaluates one of the key determinants of health care quality and costs – practice patterns of physicians. For decades, rapid health care spending growth and suboptimal quality of care have been fundamental issues of the U.S. health care system. A large body of literature has demonstrated substantial geographic variation in health care utilization without concomitant improvement in patient outcomes in higher spending regions. This literature has spurred debate about whether current levels of health care utilization are indeed socially wasteful – i.e., generate higher spending with no improvement in patient outcomes. While informative, however, this literature has not investigated variation due to individual physician behaviors, despite the central role of physicians as key decision makers in health care. In fact, surprisingly little is known about how individual physicians vary in their care, the determinants of that care, and the implications of that variation for patient outcomes. This dissertation attempts to shed light on these questions by analyzing the productivity of health care spending at the physician level. Chapter 1 investigates the proportion of service use variation that can be explained by variation in individual physician practice patterns, and examines the impact of that variation on patient outcomes. I analyze data on Medicare beneficiaries hospitalized with medical conditions treated by general internists. Using a cross-classified multilevel model, I find that variation in spending across physicians exceeds variation across hospitals (10.9% and 6.2% of overall spending, respectively). As for evaluating the impact of between-physician variation in spending on patient outcomes, I exploit a natural experiment of physicians who specialize in hospital-based care – hospitalist physicians. Hospitalists routinely work in shifts and therefore patients are plausibly quasi-randomized to these physicians within a hospital based on physician work schedule. Among 272,979 hospitalizations treated by 8,489 hospitalists, hospitalists in the highest-spending quartile had lower 30-day patient mortality than hospitalists in the lowest quartile within the same hospital, despite similar patient characteristics (adjusted mortality rate 10.7% vs. 11.2%; adjusted odds ratio 0.94, 95%CI: 0.90 to 0.98, p=0.002). I observe no relationship between physician spending and patients’ readmission rates. Given larger variation in spending across physicians than across hospitals, our findings suggest that policies focused on individual physicians may be as or more effective than those targeted toward hospitals or regions. Moreover, interventions targeted at high-spending physicians to reduce spending, without accounting for their quality of care, may have the unintended consequence of negatively impacting patients’ health. Chapter 2 begins my evaluation of the upstream determinants of variation in quality of care across physicians with a special focus on physicians’ years in practice. Physicians with longer years in practice may accumulate, or conversely exhibit obsolescence of, knowledge and skills. However, the association between physicians’ years in practice and patient outcomes is poorly understood. Using data on Medicare beneficiaries aged 65 years or older hospitalized during 2011-2013 with a medical condition, I investigate the association between hospitalist physicians’ years since residency completion and patient outcomes, adjusting for patient and physician characteristics and hospital-specific fixed effects. I again rely on quasi-randomization of patients to hospitalists to circumvent the possibility that physicians with greater years in practice may treat patients that are sicker on unobserved dimensions. Of 386,159 hospitalizations treated by 14,650 hospitalists, hospitalists in practice longer had higher patient mortality than hospitalists in practice for fewer years, despite similar patient characteristics. Each additional 10 years in practice was associated with 0.5% increase (95% CI: 0.3% to 0.7%, p<0.001) in patients’ mortality. Significant effects were present for low- and medium-volume physicians, but not high-volume physicians. Readmissions and costs of care were not meaningfully associated with physician years in practice. This study has implications for recent debates in the medical community regarding how best to ensure maintenance of clinical skills over a physician’s career. Our findings suggest that evaluating patient outcomes, particularly among older physicians with low-to-medium patient volume, may be necessary to guarantee that quality care provided by physicians is high throughout their careers. Chapter 3 assesses another upstream determinant of between-physician variation in quality of care – physician sex. Studies have found differences in practice patterns between male and female physicians, with female physicians more likely to adhere to clinical guidelines and evidence-based practice. However, whether patient outcomes differ between male and female physicians is largely unknown. While physician sex is not a modifiable factor, understanding whether quality of care differs between male and female physicians is critically important, as it allows us to further investigate which aspects of practice patterns that vary between male and female physicians lead to better patient outcomes. Using nationally representative data on Medicare beneficiaries in 2012-2013, I examine the association between physician sex and patient outcomes among general internists. Despite similar observed illness severity of patients, female physicians have lower 30-day patient mortality (adjusted mortality rate 10.9% vs 11.4%; adjusted risk difference -0.5%, 95%CI: -0.7% to -0.4%, p<0.001) and lower 30-day readmissions (adjusted readmission rate 15.1% vs 15.8%; adjusted risk difference -0.7%, 95%CI: -0.8% to -0.5, p<0.001) within same hospital. These findings are unaffected when restricting analyses to hospitalist physicians for whom patients are plausibly randomized. Although the exact mechanism underlying these differences remains unclear, understanding why these differences in care quality exist, and what we might do to alleviate them, is critical to ensuring that all patients get high quality care. / Health Policy

Non-communicable diseases (cardiovascular diseases, cancers, chronic respiratory diseases, diabetes, and mental illnesses) and associated risk factors (unhealthy diets, physical inactivity, harmful use of alcohol, physical inactivity) are on the rise in developing countries, posing a threat to the health and financial systems of emerging economies. In response, international organizations and Ministries of Health alike have started to tackle chronic diseases and associated risk factors with policies and treatment programs. Yet to this day, the body of evidence for best practices regarding the monitoring, prevention, and control of non-communicable diseases in low- and middle-income countries remains small. This doctoral thesis adds to this body of evidence. The first paper of my thesis assesses the impact of a national tobacco control program in high schools in Chile. Specifically, it evaluates the effectiveness and makes several policy recommendations based on the findings. My second dissertation paper assesses the modifying effect of a change in anti-retroviral treatment among HIV-positive subjects in KwaZulu-Natal, South Africa on cardiovascular disease risk factors of high body mass index and high blood pressure. The third paper is based on a randomized controlled trial assessing the effectiveness of a social-network-based diabetes and weight management program in Jordan. / Global Health and Population

The South African Department of Health, like the health departments of many other countries, has reviewed its policies to focus on the delivery of comprehensive Primary Health Care (PHC). The South African health care sector is undergoing major restructuring in an attempt to address the inadequacies resulting from the fragmentation and duplication of health services in apartheid South Africa. Following this restructuring, the decentralisation to health services has been adopted as the model for both the governance and management of health issues (Department of Health, 2002:7). Before 1994, local government health departments were rendering certain primary health care services in terms of the Health Act 63 of 1977. Post 1994, the Constitution of the Republic of South Africa 1996 (Act 108 of 1996) classified primary health care as a provincial function. Based on this classification, primary health care services in South Africa are now being provided by two authorities, namely local government and provincial government, in the same community. Thus, in the Nelson Mandela Bay Municipality District, primary health care services are rendered by two authorities, namely the Nelson Mandela Bay Municipality and the Nelson Mandela Health District of the Eastern Cape Department of Health. These authorities are targeting the same community, with the same PHC package, with different sets of conditions of service, salary structures, infrastructure, accountability and authority. Such differences are believed to have impeded functional integration, depleted human resource capacity in rendering an effective and efficient PHC system and resulted in inefficient budget spending by both authorities. The problems of location, duplication and fragmentation of primary health care provision in the Nelson Mandela Bay Municipality District are not conducive to optimal service rendering. This will be resolved only once a unified, single integrated health service has been established. This study was undertaken to explore and describe the views of health practitioners with respect to the location of primary health care within the Nelson Mandela Bay Municipality District. The research design of this study was a quantitative, explorative, descriptive survey. Healthcare practitioners, like management, doctors and nurses, were asked to respond to a structured questionnaire. The findings of the study indicate that while health practitioners may hold diverse views on where primary health care should be located, they agree that a unified, single PHC authority would be desirable. Although primary health care is a combination of task-orientated basic health services and the process of community development, it is important that the authority of choice should ensure the highest possible quality through an integrated process, taking into account local needs. The recommendations made by the researcher on the conclusion of this study cover the principles on which a successful strategy for implementing primary health care should be based, including the need to create sustainable communities. It is hoped that the recommendations offered, will contribute to the more effective and efficient implementation of comprehensive primary health care services in Nelson Mandela Bay and also elsewhere in South African local government.

This study intended to discover whether there was consensus among Canadians about the state's responsibility for health care and education from an analysis of the 1996 International Social Survey Programme, Role of Government. The weighted sample size was 1239. Ornstein's and Stevenson's 1977--81 study was also partially replicated. Results showed that welfare state retrenchment in health care and education during the '90s and state ruling by coercion led to dissent among Canadians about government intervention in health care and education. Drawn upon the competing region-class struggle theories, findings indicated that high public support for government intervention in health care was an interaction of regional---Prairie and Alberta---and class struggle---lower, working and middle classes, differences. Quebec showed the lowest increase in support for government role in health care over time. Women favoured much greater government role in health care than men. Younger and low-income people were more favourable to government intervention in education.

Introduction. Adverse drug events (ADEs) caused by medication errors occur regularly in hospitals. Research questions. (1) How effective are in-hospital drug-distribution technologies at improving medication safety? (2) How prevalent are such technologies in Canada's acute-care hospitals? Methods. A systematic review synthesized publications from 1985 to 2002 about the effectiveness of inpatient drug-distribution technologies. A cross-sectional survey of pharmacy directors at Canada's 100 largest acute-care hospitals described technology use, plans for change, and pharmacy-directors' attitudes to technology use and medication error. Results. The systematic review categorized 154 technology comparisons into 23 technology groupings. The evidence consistently favoured the new technologies but its strength was limited. The survey response rate was 78%. Clinical pharmacy services, computerized decision support for pharmacists, and unit-dose system were common; bar-coding and computerized physician order entry were not. Conclusion. This thesis offers a unique compilation of evidence to guide decision-makers in their uptake of technologies intended to improve medication safety.

Breast cancer is the commonest cancer affecting Canadian women. Recent decades have seen a trend of decreasing breast cancer mortality. This has been attributed to several causes, including greater use of screening mammography and increased efficacy of adjuvant chemotherapy. We studied the effect of these two factors on the overall survival of breast cancer patients at the Ottawa Hospital Regional Cancer Centre. Data were collected from 2985 charts from the years 1985, 1988, 1992, 1995, 1998, and 2001. Adjuvant chemotherapy was associated with a decreased hazard of death from any cause (HR=0.783 p=0.0208). A decrease in mean tumour size seen over the time period of the study is potentially attributable to mammography screening. Decreased tumour size was associated with a decreased hazard for death (HR 0.986 p&lt;0.0001). No difference in overall survival between earlier and later cohorts could be demonstrated, perhaps due to shorter follow up in later cohorts.

Web services composition is an emerging paradigm for enabling inter and intra organizational integration, and a landscape of languages and techniques for modeling business processes in web service based environments has emerged and is continuously being enriched. With the advent of modeling standards, different business sectors are investigating the options for modeling their workflows. In terms of business process modeling, healthcare is a rather complex sector of activity. Indeed, modeling healthcare processes presents special requirements dictated by the complicated and dynamic nature of these processes as well as by the specificity and diversity of the actors involved in these processes. Little effort has been dedicated to evaluating the capabilities and limitations of modeling languages based on healthcare requirements. This thesis presents a set of healthcare requirements and proposes an evaluation framework for process modeling languages based on these requirements. The suitability of three major process-based service composition languages, namely BPEL, BPMN and WS-CDL, is evaluated.