Background: Palliative gemcitabine has been shown to prevent the deterioration of well-being and to prolong survival of patients with pancreatic cancer in phase III randomized controlled trials (RCTs). It is unknown whether the efficacy reported in RCTs has translated into effectiveness in routine clinical practice. Objectives: 1) To describe the characteristics of patients with pancreatic cancer treated with palliative gemcitabine at the regional cancer centres (RCCs) of Ontario, 2) To describe: clinical benefit at two months, defined as stable or improved well-being; time to treatment discontinuation; and overall survival, 3) To identify factors associated with clinical benefit, and 4) To compare the effectiveness of gemcitabine with its reported efficacy in RCTs. Methods: This was a retrospective analysis of prospectively collected data. The study included patients with pancreatic cancer treated with palliative gemcitabine at the RCCs of Ontario between 2008 and 2011. Information about well-being was patient self-reported as captured by the Edmonton Symptom Assessment System (ESAS) at the RCCs. The proportions of patients that achieved clinical benefit were reported. Time to treatment discontinuation and overall survival were calculated using Kaplan –Meier survival analysis. Logistic regression was used to identify factors associated with clinical benefit. iii Results: The study population included 423 patients. Only 168 (39.1%) patients completed a pre-treatment ESAS. Patients completing a pre-treatment ESAS were not different than those that did not. Patients treated at RCCs were not different than those in RCTs. The median age of the study population was 65 years, 50% were male, 57% had stage IV disease and 94% had adenocarcinoma morphology. Thirty-seven percent of patients achieved clinical benefit at two months. Median time to treatment discontinuation and overall survival was 2 and 5.7 months, respectively. Stage and pre-treatment wellbeing were associated with clinical benefit at two months. Similar proportions of patients at RCCs and RCTs experienced clinical benefit. Time to treatment discontinuation and survival were similar as well. Conclusions: Efficacy of gemcitabine in RCTs has translated into effectiveness for patients treated at the RCCs of Ontario. It is unknown if this is true for patients not treated at the RCCs. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2012-08-01 17:50:00.185

Background: We evaluated geographic patterns for immediate and delayed breast reconstruction (IBR, DBR) in Ontario. The influence of plastic surgeon availability on rates and service provision was determined. Methods: We examined IBR and DBR from 2002 through 2011 across Ontario counties. Regional availability of plastic surgeons was described. Geographic patterns were examined using funnel plots, random-effects models and migration indices. Results: Over ½ Ontario counties have no plastic surgeons. IBR ranged from 0 to 21.5% across counties and differences in plastic surgeon availability explained 41% of variation (p < 0.0001). For DBR there was less variation. 5/45 counties performed ¾ of BR, however rates among local residents were not highest. Interpretation: Nearly 1/3 of the population has limited access to plastic surgeons, contributing to low rates of BR. Geographic access is a major determinant of IBR but is less important for DBR, however service provision for both was highly regionalized.

The goals of this dissertation were to investigate aspects of the health services utilization of marginalized persons living with HIV (PLWH), including women, recent immigrants, heterosexual men and individuals living in low income neighborhoods. In the first study, an algorithm of three physician claims for HIV-infection within a three-year period was validated for case-ascertainment of PLWH in administrative databases. The sensitivity and specificity of the algorithm were 96.2% [95% confidence intervals (CI) 95.2% to 97.9%] and 99.6% (95% CI 99.1% to 99.8%), respectively. The algorithm was used to conduct a population-based study examining rates of hospitalization among all PLWH receiving care in Ontario. The introduction of combination antiretroviral therapy was associated with more pronounced reductions in rates of total (-89.9 vs. -60.5 per 1000 PLWH; p = 0.003) and HIV-related hospitalizations (- 56.9 vs. -36.3 per 1000 PLWH; p < 0.001) among men relative to women. Between 2002 and 2008, higher rates of total hospitalization were associated with female sex [adjusted relative rate (aRR) 1.15; 95% CI: 1.05 to 1.27] and low socioeconomic status (aRR 1.21; 95% CI: 1.14 to 1.29). Higher rates of HIV-related hospitalizations were associated with low socioeconomic status (aRR 1.30; 95% CI: 1.17 to 1.45). Recent immigrants had lower rates of both total (aRR 0.70; 95% CI 0.61 to 0.80) and HIV-related hospitalizations (aRR 0.77; 95% CI 0.61 to 0.96). Finally, a theoretically-informed qualitative study was conducted to characterize the help-seeking experiences of heterosexual men living with HIV. The results indicate that without the symbolic appeal of women and the social connections of gay men, heterosexual men lack the composition of capital required to benefit fully from or improve their positions within the existing HIV health and social service fields. The findings of this dissertation illustrate important disparities in health services utilization among PLWH in Ontario.

The goals of this dissertation were to investigate aspects of the health services utilization of marginalized persons living with HIV (PLWH), including women, recent immigrants, heterosexual men and individuals living in low income neighborhoods. In the first study, an algorithm of three physician claims for HIV-infection within a three-year period was validated for case-ascertainment of PLWH in administrative databases. The sensitivity and specificity of the algorithm were 96.2% [95% confidence intervals (CI) 95.2% to 97.9%] and 99.6% (95% CI 99.1% to 99.8%), respectively. The algorithm was used to conduct a population-based study examining rates of hospitalization among all PLWH receiving care in Ontario. The introduction of combination antiretroviral therapy was associated with more pronounced reductions in rates of total (-89.9 vs. -60.5 per 1000 PLWH; p = 0.003) and HIV-related hospitalizations (- 56.9 vs. -36.3 per 1000 PLWH; p < 0.001) among men relative to women. Between 2002 and 2008, higher rates of total hospitalization were associated with female sex [adjusted relative rate (aRR) 1.15; 95% CI: 1.05 to 1.27] and low socioeconomic status (aRR 1.21; 95% CI: 1.14 to 1.29). Higher rates of HIV-related hospitalizations were associated with low socioeconomic status (aRR 1.30; 95% CI: 1.17 to 1.45). Recent immigrants had lower rates of both total (aRR 0.70; 95% CI 0.61 to 0.80) and HIV-related hospitalizations (aRR 0.77; 95% CI 0.61 to 0.96). Finally, a theoretically-informed qualitative study was conducted to characterize the help-seeking experiences of heterosexual men living with HIV. The results indicate that without the symbolic appeal of women and the social connections of gay men, heterosexual men lack the composition of capital required to benefit fully from or improve their positions within the existing HIV health and social service fields. The findings of this dissertation illustrate important disparities in health services utilization among PLWH in Ontario.

Thesis (M.H.A.)--University of Michigan, 1961.

Thesis (M.H.A.)--University of Michigan, 1961.

This thesis reports on an evaluation of an intervention to improve the quality of care for adults with epilepsy. The intervention comprised an epilepsy specialist nurse working in 14 general practices in north west Bristol, England. A multi-method approach was employed. As part of a quasi-experimental trial, baseline and two annual follow-up questionnaires were sent to all patients in the practices aged 16 years and over and currently on drugs for epilepsy. In addition, interviews were undertaken with those having seizures to explore further some questionnaire findings and to appraise the appropriateness, acceptability and accessibility of the nurse service. The epilepsy nurse was interviewed to assess the feasibility of providing the new service. Baseline results highlighted deficiencies in services for people with epilepsy and suggested the need for structured care and increased discussion. The main effects of the nurse service were improved communication about epilepsy between health care providers and patients and increased access, especially for those with the greatest needs. The nurse service had limited impact on patients’ health status. There were indications of a negative impact on the perceived effect of epilepsy on aspects of everyday life. After one year, an intention-to-treat analysis suggested improvements in satisfaction with care from GPs, but decreased adherence to medication. A comparison of nurse service users with non-users after two years showed a reduction in the use of polypharmacy in users, and an increased proportion who queried GPs’ knowledge about epilepsy. Users reported increased visits to their GP. Interview data showed that the decision to use the nurse service depended on factors other than the severity and frequency of seizures. The service was most appropriate for those who perceived themselves to need care or information. This method of delivering care was feasible, but several operational problems were identified. The study supports the use of specialist nurses in primary care. Impact is, however, limited. The greatest contribution to improving care is by supporting and advising patients with specific and defined needs.

Cigarette smoking causes many chronic diseases that are costly and result in frequent hospitalization and re-hospitalization. Smoking cessation leads to improved morbidity and reduced risk of death. Hospital-initiated smoking cessation interventions increase the likelihood that patients will become smoke-free. Despite this, few Canadian hospitals have in place policies, protocols, and reminder systems that support the consistent and effective identification and treatment of tobacco users. The Ottawa Model for Smoking Cessation (OMSC), developed at the University of Ottawa Heart Institute (UOHI), is a systematic approach to identifying and treating smokers in the hospital setting. In order for health care funders and hospital administrators to begin supporting effective prevention interventions, like the OMSC, a compelling cost-effectiveness argument must be made. Few studies have looked at the downstream health, health care, and cost implications of such programs, particularly in the Canadian context and none using actual health care administrative data. In response to this gap, three studies were completed, applying theories and methodologies related to health services and population health research. Study 1: From the hospital payer’s perspective, what is the short-term (one year) and long-term (lifetime) cost-effectiveness of the OMSC intervention, as compared to a usual care condition, among high-risk smokers with chronic diseases? A cost-effectiveness analysis was completed based on a decision-analytic model to assess smokers hospitalized in Ontario, Canada for acute myocardial infarction, unstable angina, heart failure, and chronic obstructive pulmonary disease, their risk of continuing to smoke, and the effects of quitting on re-hospitalization and mortality over a one year period. Short- and long-term cost-effectiveness ratios were calculated. The primary outcome was one-year cost per quality-adjusted life year (QALY) gained. Study 2: What are the effects of the OMSC intervention on: 1) mortality, and 2) downstream health care utilization? An effectiveness study was completed comparing patients who received the OMSC intervention (n=726) to usual care controls (n=641). The study took place at 14 hospitals in Ontario. Baseline data was linked to Ontario health care administrative data. Unadjusted and adjusted competing-risks regression models were constructed, clustered by hospital, to compare the cumulative incidence of death, re-hospitalization, emergency department (ED) visits, and physician visits at 30 days, one, and two years following index hospitalization between groups. Study 3: From the health system perspective, what are the cumulative mean health care costs at 30-day, 1-year, and 2-year follow-up among smoker-patients that receive the OMSC compared to those that do not? What are the predictors of direct health care costs for patients that receive the OMSC compared to those who do not? Expanding on Study 2, a cost-analysis was completed to assess 30-day, 1-year, and 2-year health care costs between intervention and control groups. Costs were broken down by service type (e.g. inpatient, ED visits, laboratory, physician visits). To calculate cumulative mean costs, costs were grouped into the study’s 24 monthly intervals and weighted by the inverse probability of not being censored at the beginning of each month. Covariate-adjusted generalized linear models were performed for each of the 24 monthly intervals to determine the association between independent variables and health care costs.

The purpose of this study was to examine the relationships between perceived organizational support, perceived coworker support, and debriefing on the one hand, and compassion satisfaction, burnout, and secondary traumatic stress on the other hand in Florida law enforcement, fire, emergency medical services, and dispatch public safety workers. In order to explore the relationships between these constructs, the research questions examined the relationships of the work environment of Florida public safety by administering surveys gauging perceived organizational support, perceived coworker support, psychological resilience, and debriefing activities that the personnel participate in. The Professional Quality of Life: Compassion Satisfaction and Compassion Fatigue Version 5 was also sent out to establish the self-reported levels of compassion satisfaction, burnout, and secondary traumatic stress. The study found that there were differences in the levels of compassion satisfaction, burnout, and secondary traumatic stress between the public safety fields. It also found that there was a positive relationship between the presence of perceived organizational support, perceived coworker support, psychological resilience, and debriefing activities on at least one of the constructs of compassion satisfaction, burnout, or secondary traumatic stress within the different public safety fields. This study furthers the literature by being the first study to compare the four different public safety fields in the state of Florida and with regards to those constructs.

The implications of rising healthcare expenditures are of great concern nationally and internationally. Performing procedures in the outpatient setting can be one solution to this crisis. However, there is a lack of research on systematic approaches for transitioning procedures to the outpatient setting. Unicondylar knee arthroplasty (UKA) presents an opportunity, as it is already in the early stages of transitioning to the outpatient setting. The key step in facilitating an effective transition to the outpatient setting is comparing outpatient UKAs with inpatient UKAs with a focus on process time, quality outcomes, and patient satisfaction. This study retrospectively compares 400 UKA patients in the outpatient setting with 675 UKA patients in the inpatient setting. The primary analytical tools for this study are Ordinary Least Squares Regression, Logistic Regression, and Ordinal Regression adjusting for comorbidity, social history, demographics, and surgery related characteristics. Outpatient UKAs outperformed inpatient UKAs across 11 of 18 variables analyzed. Process Time will be less for outpatient UKAs in all phases with the exception of Surgery Breakdown Time. The risk-adjusted quality outcomes of UKAs in the outpatient setting were better across Non-Surgery Related Complications, Follow-Up Pain, and Follow-Up Functional Range of Motion Limitation. Patient Satisfaction was higher for outpatient UKAs. There was a lack of consistent and appropriate information to conduct a substantial statistical analysis of the costs. These findings point towards outpatient UKAs being a viable option in the future. This research serves as a platform to launch a system-wide effort of transitioning procedures to the outpatient setting across different specialties.