Empowered patient or empowered physician. An analysis of the importance of the gatekeeper in the health delivery system. This paper examines the important role of the gatekeeper in the health delivery system. A simple theoretical model is developed which compares the resource allocation when physicians act as gatekeepers with the decisions taken when patients are empowered. It is shown that even when there is no asymmetry of information---and so patients and doctors are equally able to identify the appropriate therapy---that the institutional arrangement matters. Patients demand more time with physicians when they are empowered whereas physicians want to spend more time developing their expertise when they are empowered. The reaction of physicians and patients to changes in policy instruments also differs across institutional arrangements. The analysis also draws attention to the design of the compensation scheme for physicians, and investigates the benefits of using a non-linear scheme. Wealth, health, and the pursuit of happiness. This paper provides a theoretical framework to illustrate the relationship between income, utility maximization, and healthy choices. The analysis indicates that the choices of individuals who maximize utility are not the same as those arising were the individual to maximize wellness. In fact, rational individuals will over-eat and under-exercise relative to health maximizing levels. Yet as individuals get wealthier, they have better health. The paper also compares different strategies for health promotion. Income redistribution may lead to a net increase in population health and in social welfare. By contrast, policies that specifically target lifestyle choices may succeed in persuading citizens to choose a health-maximizing lifestyle, but result in a net welfare loss to society. An empirical investigation of household income and income polices on obesity in Canada. Using the master files of the Canadian Community Health Survey (CCHS), this paper examines the effect of income on obesity and individuals' body-mass index. An instrumental variable technique is employed to derive consistent estimates of this effect and to take account of the possible endogeneity between income and body weight. It is found that higher income will lead to lower body weight for women, while its effect on the body-weight outcome of men is unclear. This chapter uses the estimates of the relationship between income and body weight to simulate the impact of government income policies---like social assistance and child support---on obesity. It is shown that incomes policies may not only decrease income inequality but may also contribute to a lower incidence of obesity amongst the poorer population thus decreasing overall health care costs.

Essay One: Genetic Health Risks: The Case for Universal Public Health Insurance. This paper examines the appropriate role for the public sector in providing genetic and health insurance when health risks are genetically determined at conception. The ex ante efficient outcome (when individuals are ignorant about their health risks) is characterized. It is demonstrated that this outcome cannot be achieved by private health insurance markets or by a government which cannot commit to a once-and-for-all transfer policy. In contrast, the desired outcome is attained through public provision of universal health insurance and of genetic testing, coupled with a public pension scheme. Essay Two: Fee-for-Service vs. Capitation: Anything You Can Do - I Can Do Better (and Cheaper). This paper recasts the analysis of optimal physician remuneration - generally presented as a contest between prospective (capitation) and retrospective (fee-for-service) schemes - as a problem in price theory. This approach abstracts from problems of asymmetric information and concentrates on the design of the price mechanism. It demonstrates that when the demand for health care is price-inelastic, the appropriately designed fee-for-service and capitation schemes both lead to Pareto efficient outcomes. When a patient's demand for care is uncertain, or the risk of poor health outcomes depends on the preventive care provision, standard arguments concerning risk bearing are used to prove that paying physicians on a fee-for-service basis can deliver socially-optimal outcomes at a lower cost than if they are paid under a capitation scheme. Essay Three: Comparative Efficiency Assessment of Primary Care Models Using Data Envelopment Analysis. This paper compares the productive efficiency of four models of primary care service delivery in Ontario, Canada, using the methodology of Data Envelopment Analysis. Particular care is taken to include quality of service in the output measure. The influence of the delivery model on productive efficiency is disentangled from patient characteristics using regression analysis. The traditional fee-for-service arrangement ranks highest and the Community Health Centre model (which involves a multidisciplinary team of health care professionals paid on a salary basis) the lowest in efficiency scoring. The reliance of input measures on the costs of running a practice and on the number of patients favours the fee-for-service model.

The current study used the comprehensive costing methodology of Knapp and Beecham (1990) to examine the comprehensive costs of community support services over the last six months (18--24 months) of a two-year study. The sample consisted of 77 clients with severe and persistent mental illness and a history of homelessness receiving either intensive case management (ICM) or standard care. Costs from the overall societal perspective were calculated by summing the direct and 'hidden' (e.g., travel time) costs associated with: (1) Agency costs (case management services), (2) governmental costs (e.g., non-agency health care costs, non-health care costs), and (3) family/friend costs. Subtracted from this initial total to reach a final societal cost were employment and/or volunteer 'benefits'. Of interest in the study was: (1) Examining the relationship between clients needs at 18 months of a two year trial, global societal costs per client for the six-month period from 18 to 24 months, and 24-month outcomes, and (2) cost-effectiveness of intensive case management over standard care from three costing perspectives (e.g., agency, government, society). Results yielded an overall average comprehensive cost of treatment (both ICM and standard care combined) per client of $57.08/day which is comparable to previous research investigating the costs of community support services. Needs did not predict six month total societal costs; however, receiving ICM and reporting more severe symptomatology predicted higher six-month agency costs. Higher total costs of services and supports predicted poorer housing stability at 24 months for our participants. Higher expenditures related to non-health care costs predicted poorer community ability at 24 months. In general, it seems that higher costs are related to poorer client functioning. Cost-effectiveness analyses revealed that ICM is more cost-effective than standard care from the perspective of the government (i.e., health-related expenses) and society overall, despite agency costs being significantly greater in ICM. Nonparametric bootstrapping methods using net monetary benefit revealed a 0.77 to 0.80 chance of ICM being a cost-effective alternative to standard care. It is clear from this study that increased costs are associated with clients who are doing the poorest in terms of symptoms, housing stability, and community ability. Despite the finding that more intensive treatment does not guarantee better clinical outcomes within our six month window, ICM is shown to be a more cost-effective treatment in the community when compared with standard care. Implications of this research are discussed.

The need for effective interfaces to translate research into policy-making is one of the most important challenges in addressing population health in low- and middle-income countries (LMICs). The capacity to acquire, manage and apply research findings in programs' decision-making is essential for all health systems actors, including health professional associations in their roles as civil society organizations. The purpose of this dissertation was to understand better how organizational capacity to utilize research influences the knowledge translation performance of LMICs health professional associations. The research used a mixed methods exploratory sequential design. Phase one was an interview-based case study of the Burkina Faso Public Health Association. Phase two consisted of a survey of all nineteen LMICs health professional associations in a CIDA-funded partnership program focussing on institutional capacity strengthening. Triangulation of data was carried out, applying the concept of organizational "absorptive capacity" to shape the foundations of a framework. The qualitative inquiry identified factors influencing the capacity to utilize research, such as the organizational motivation to utilize research, triggers that persuade an association to invest in this capacity, and the processes to exploit and present the research findings in a useful way. The quantitative inquiry revealed that the utilization of research findings is a priority for these associations. Key organizational elements that underlie associations' organizational capacities to utilize research were identified. For example, half have used evidence from scientific journals and over a third have developed arrangements with researchers. However, associations' capacities are jeopardized by scarcity of resources to ensure that research is accessed, adapted and applied, and to recruit staff for knowledge translation strategies. Finally, the potential relationships among identified determinants were integrated in an operational framework capturing the organizational capacity to utilize research (OCUR). This multi-method study was the first to map institutional capacity needs for research utilization of LMICs health professional associations. The framework provides a guide to investigate associations' organizational capacity to utilize research and can aid in tailoring capacity-building strategies to strengthen associations' knowledge translation potential.

M.Com. (Business Management) / The purpose of the present study was to investigate the perceptions of medical practitioners towards managed health care and its implications for patient care. The study population was the medical practitioners in the northern suburbs of Johannesburg. A questionnaire was distributed to 224 medical practitioners in the northern suburbs of Johannesburg. The total number of the respondents was 81 with 53% being general practitioners and 47% being specialists. The findings of the study indicated that the majority of respondents perceived managed healthcare to have a negative impact on doctor-patient relationship, the ability to carry out their ethical obligations towards the patients, and that the limitations implemented by managed health care have a negative impact on the quality of care. The respondents also perceived managed healthcare to be consistent in reducing unnecessary procedures and reducing the expenditure. Recommendations made to remedy the situation include introducing a topic of managed health care as part of undergraduate studies to empower practitioners before they start a private practice. It would be advisable to include medical practitioners to help reform the strategies that will enable medical practitioners to carry out their ethical obligations towards the patients and to deliver quality care to the patients. The study concluded that medical practitioners hold negative perceptions towards managed health care and perceive managed health care to impact the quality of care negatively.

A qualitative transcendental phenomenological methodology was used to identify the essence of healthcare workers' perceptions at the workplace. In-depth interviews were conducted on 25 physical therapists and physical therapist assistants consisting of over 214 years of clinical experience representing 11 clinical sites in the South Florida area. The perceptions towards their coworkers and managers during times of change were explored from a variety of angles and yielded an insightful essence of the work they do on a day to day basis as front-line medical professionals. There were eight major concerns identified as influential factors that impact job performance, coworker and manager relationships, and patient care in this segment of the healthcare system. Based on the essence derived from the therapists' and assistants' experiences, 14 functional propositions were posited and lay the foundation for future research. Managerial recommendations along with the Healthcare Workers Systematic Daily Flow Model were offered to guide in the development of the recommended initiatives.

Prostate cancer is the most commonly diagnosed cancer in men and nearly 30,000 patients will die this year due to complications arising from the disease. Prostate cancer patients are frequently treated with androgen deprivation therapies, but the duration of response is variable, and patients frequently progress to an incurable stage of the disease referred to as castration-resistant prostate cancer (CRPC). Second-generation AR antagonists such as enzalutamide and apalutamide are effective therapies that block androgen receptor (AR) transactivation and signaling in over 50% of CRPC patients. However, an estimated 30% of responders will develop resistance to these therapies within two years. There is another class of AR antagonists which are referred to as pan AR antagonists, that have shown to inhibit the activity of wild-type AR as well as several mutated versions of AR. Currently, there are several pan AR antagonists in preclinical development and approved for the treatment of CRPC in patients harboring pathogenic point mutations in AR. We chose four genetically distinct AR-positive prostate cancer preclinical models to generate enzalutamide, JNJ-pan-AR, or apalutamide resistant cell lines. We then performed transcriptomic and proteomic profiling on the AR antagonist sensitive and resistant cell lines to uncover molecular alterations that may be critical to the maintenance and/ or predictive biomarkers of the resistant phenotype. Global profiling uncovered significant variability in molecular alterations across the AR antagonist resistant cell lines as well as the prostate cancer preclinical models. However, we uncovered upregulation of AKR1C3 protein expression across all three AR antagonist resistant cell lines using the LNCaP and LNCaP/AR preclinical models. Further characterization of the functional significance of AKR1C3 upregulation demonstrated that AKR1C3 protein expression contributes to JNJ-pan-AR resistance. Similar findings have reported the correlation between AKR1C3 expression and changes in drug efficacy across several chemotherapeutic agents approved to CRPC treatment. Collectively the findings from this study support the rationale of AKR1C3 as a target for AR antagonist resistant prostate cancer disease progression.

abstract: Background: Process mining (PM) using event log files is gaining popularity in healthcare to investigate clinical pathways. But it has many unique challenges. Clinical Pathways (CPs) are often complex and unstructured which results in spaghetti-like models. Moreover, the log files collected from the electronic health record (EHR) often contain noisy and incomplete data. Objective: Based on the traditional process mining technique of using event logs generated by an EHR, observational video data from rapid ethnography (RE) were combined to model, interpret, simplify and validate the perioperative (PeriOp) CPs. Method: The data collection and analysis pipeline consisted of the following steps: (1) Obtain RE data, (2) Obtain EHR event logs, (3) Generate CP from RE data, (4) Identify EHR interfaces and functionalities, (5) Analyze EHR functionalities to identify missing events, (6) Clean and preprocess event logs to remove noise, (7) Use PM to compute CP time metrics, (8) Further remove noise by removing outliers, (9) Mine CP from event logs and (10) Compare CPs resulting from RE and PM. Results: Four provider interviews and 1,917,059 event logs and 877 minutes of video ethnography recording EHRs interaction were collected. When mapping event logs to EHR functionalities, the intraoperative (IntraOp) event logs were more complete (45%) when compared with preoperative (35%) and postoperative (21.5%) event logs. After removing the noise (496 outliers) and calculating the duration of the PeriOp CP, the median was 189 minutes and the standard deviation was 291 minutes. Finally, RE data were analyzed to help identify most clinically relevant event logs and simplify spaghetti-like CPs resulting from PM. Conclusion: The study demonstrated the use of RE to help overcome challenges of automatic discovery of CPs. It also demonstrated that RE data could be used to identify relevant clinical tasks and incomplete data, remove noise (outliers), simplify CPs and validate mined CPs. / Dissertation/Thesis / Masters Thesis Computer Science 2020

abstract: ABSTRACT Academic literature and industry benchmarking reports were reviewed to determine the way facilities benchmarking reports were perceived in the healthcare industry. Interviews were conducted through a Delphi panel of industry professionals who met experience and other credential requirements. Two separate rounds of interviewing were conducted where each candidate was asked the same questions to determine the current views of benchmarking reports and associated data in the healthcare industry. The questions asked in the second round were developed from the answers to the first-round questions. The research showed the panel preferred changes in the data collection methods as well as changes in the way the data is presented. The need for these changes was unanimous among the members of the panel. The main recommendations among the group were: 1. An interactive method such as a member portal with the ability to customize, run scenarios, and save data is the preferred method. 2. Facilities Management (FM) teams are often not included in the data collection of the benchmark reports. Including FM groups would allow more accuracy and more detailed data resulting in more accurate and in-depth reports. 3. More consistency and “apples to apples” comparisons need to be provided in the reports. More categories and variables need to be added to the reports to offer more in depth comparisons and assessments between buildings. Identifiers to help the users compare the physical condition of their facility to others needs to be included. Suggestions are as follows: a. Facility Condition Index (FCI)- easily available to all participants and allows an idea of the comparison of upkeep and maintenance of their facility to that of others. b. An indicator on whether the comparison buildings are Centers for Medicare and Medicaid Services (CMS) accredited. 4. Gross Square Footage (GSF) is not an accurate assessment on its own. Too many variables are left unidentified to offer an accurate assessment with this method alone. / Dissertation/Thesis / Masters Thesis Construction Management 2020

Studies indicate that voluntary reporting detects relatively few adverse events (AEs) (Ehland et al., 1999, Cooper et al., 1984). At Boston Children’s Hospital (BCH), several systems exist to document AEs. First, anesthesiologists document clinical care and AEs in the patient medical record (the Anesthesia Information Management System (AIMS)). Second, in an effort to capture AEs, the Department of Anesthesiology, Critical Care and Pain Medicine developed an internal tool, the Anesthesia System for Clinical Event Tracking (ASCENT), which is integrated into clinicians’ electronic documentation. Finally, a BCH hospital-wide reporting system, the Safety Event Reporting System (SERS), allows all employees and patients to report an AE.  The goals of this study are 1) to compare the effectiveness of documentation in AIMS, ASCENT, and SERS, 2) to determine the incidence of AEs in January 2018 and June 2019, independently, and 3) compare the effectiveness of documentation AEs in ASCENT after implementation of an improved, integrated reporting system. After IRB approval, a manual chart review of 3,3204 cases requiring anesthesia in January 2018 and 3,387 cases requiring anesthesia in June 2019 was conducted. Anesthesia notes, vital signs, and administered medications documented in AIMS were reviewed to determine if an AE had occurred. Descriptions of each case were recorded, and cases with indications for AEs were verified by clinicians. Next, each AE was categorized by event type. Both ASCENT and SERS were then queried for the reported adverse events during the same time period. The total number of AEs was described using counts with the distribution of types of AEs presented using percentages.     Among the 3,204 cases reviewed in January 2018, there were 569 events documented in AIMS, out of which, 39 (6.9%) were documented in ASCENT, and 2 (0.4%) in SERS. The overall rate of AEs was determined to be 1.8 events/10 cases. For June 2019, a total of 3,387 cases were reviewed for the occurrence of AEs. Among the reviewed cases, there were 396 events documented in AIMS, out of which, 106 (26.8%) were documented in the ASCENT database, and 3 (0.8%) in SERS. The overall rate of AEs was determined to be 1.2 events/10 cases. This study demonstrates that voluntary reporting of AEs may be improved if the reporting systems are better-integrated with patient medical records. In agreement with existing literature, this study also illustrates that hospital-wide reporting systems, such as SERS, fail to collect most adverse events (Levinson, 2012). To achieve comprehensive reporting of AEs, systems must be integrated into clinicians’ workflow. Education regarding the reporting systems along with technology improvements may further enhance the capture of AEs. Further investigation will be conducted to determine severity, preventability and association with anesthesia.