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.

American hospitals have made serious efforts to implement and expand their health information technology capabilities and to integrate different specialized care or high-tech services in order to maximize the efficiency and quality of care. In providing a variety of HIT-related services, these hospitals expanded their national reputation in line with integrated care goals. As a result, hospitals are encouraged to establish effective communication channels to facilitate patient-physician sharing of the patient care experience, to enhance effective pain management, and to transform patient-centered care modalities to solidify the adequacy of patient care processes. By analyzing national data sets publicly available, this investigation explored the relationship of acute-care hospitals' performance to the contextual, organizational and patient characteristics, using a cross-sectional study design. This study developed and evaluated the quality and efficiency of hospitals with respects to the structural complexity, process adequacy, efficiency, and quality of care. The structure-process-outcome theory in quality of care developed by Donabedian (1980), is adopted for this investigation. Statistical methods such as confirmatory factor analysis (CFA) and covariance structure model are employed. The population surveyed by the American Hospital Association (AHA) are acute care hospitals throughout the United States, including more than 3000 acute care hospitals of all types of ownership. The data provided by HIMSS Analytics and AHA are available for 2015 and the data provided CMS quality indicators are available for 2016. The key finding of this research is that process adequacy mediates the relationship between hospital structure and performance variables. The efficiency variable played an important role in shaping quality. The location and hospital teaching status have a moderate impact in determining hospital performance by affecting the structure and process of hospitals.

The Government of Malawi has entered into agreements with Christian health association of Malawi (CHAM) health care facilities in order to exempt their catchment populations from paying user fees. These agreements are called service level agreements (SLAs). Government in turn reimburses the CHAM health care facilities for the health services that they provide. The agreements started in 2006 with 28 out of 166 CHAM health care facilities and increased to 68 in 2010. The aim of the exemption policy is to guarantee universal access to a basic package of health care services. Although the agreements were designed to cover every health service in the basic health care package, only maternal and neonatal health services are included due to limited resources. The main objective of this thesis was to evaluate the impact of the health care financing change on health care utilisation and health. The specific objectives were as follows: first, to examine whether health care facility visits for maternal health care changed due to user fee exemption; second, to evaluate whether user fee exemption affected the choice of the health care provider where women living in the catchment areas of CHAM health care facilities with user fee exemption sought maternal health care; third, to analyse the effect of user fee exemption on birth weight and; fourth, to explore and apply novel methods in the evaluation of user fee exemption. The gradual uptake of service level agreements by CHAM health care facilities provided a natural experiment with treated and control health care facilities. An additional control group comprised of other demographic groups apart from pregnant women and neonates at CHAM health care facilities with service level agreements. In household survey data, individuals were assigned to treatment and control groups based on their proximity to either a CHAM health care facility with SLA or a CHAM health care facility without SLA. This proffered the unique opportunity to estimate the effect of a single treatment on multiple outcomes. The difference-in-differences (DiD) approach was used to obtain causal effects of user fee exemption. It was implemented in the context of fixed effects, switching regression and multinomial logit models across different chapters. Health care facility level panel data for utmost 146 health care facilities for a maximum of 8 years, 2003-2010, were used. The data were obtained from the Malawi health management xiii information system (HMIS). Linked survey data were also used. Malawi demographic and survey data for 2004 and 2010 were linked to health care facility data and then merged. Analyses that utilised health care facility data showed that user fee exemption had led to increases in first antenatal care visits in the first trimester, first antenatal care visits in any trimester, average antenatal care visits and deliveries at CHAM health care facilities with SLAs. Results from survey data showed that the probability of using a CHAM health care facility with user fee exemption for antenatal care increased, the probability of using home antenatal care declined and the probability of not using antenatal care also declined due to user fee exemption. The probability of delivering at a CHAM health care facility with SLA also increased while the probability of delivering at home declined. User fee exemption did not affect the choice of where to go for postpartum care. Results of the effect of user fee exemption on birth weight were not reported because of potential endogeneity bias arising from lack of instrumental variables for antenatal care. The key policy messages from this thesis are that the user fee exemption policy is an important intervention for increasing the utilisation of maternal health care and needs to be extended to as many CHAM health care facilities as necessary. User fee exemption is not enough, however. Other factors such as education of the woman and her husband/partner, wealth status and cultural factors are also important. This thesis has contributed to the body of knowledge in the following ways. First, it has generated evidence on the impact of user fee exemption on maternal health care utilisation and birth weight in Malawi. Second, with respect to maternal health care utilisation, the thesis has looked at variables that capture the whole maternal health care process from early pregnancy to postpartum care and in a policy relevant way. Third, the thesis has evaluated the effect of user fee exemption on a variable that have not been looked at before, first antenatal care visits in the first trimester. Fourth, the thesis has examined the effect of a single treatment on multiple outcomes in a methodologically unique way. Treatment effects, which were the changes in the probabilities of using different alternatives summed up to zero, thus showing where any increase in the probability of using the outcome of interest came from. Fifth, this thesis is first to use disequilibrium theory of demand and supply in health economics. Application of this theory entailed using switching regression models with unknown sample separation, a seldom used estimation method in health economics. This was an important contribution to the methods xiv of analysing aggregate health care utilisation. Sixth, the STATA program that was written for the estimation of the disequilibrium models was itself a very important contribution to the methods for estimating aggregate supply and demand.

Healthcare has had a storied past in the United States, and to say that the two have had a complicated relationship would be an egregious understatement. Intertwined in the narrative of our healthcare system is the narrative of United States hospitals, both how they came to be and the nature of their structures. Over time, legislation at local, state, and federal levels has shaped hospital organization and cost-structure. Here, I aim to better understand the effect of the Patient Protection and Affordable Care Act (PPACA), and more specifically Medicaid expansion, on hospitals in a handful of Southern states.

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Key institutions and services are suggested to contribute to remote communities in ways that extend beyond their primary function.  For example, schools and health services are suggested to have important, social, symbolic or economic roles in small remote communities.  There is little empirical evidence identifying the nature and extent of such roles.  Consequently, service reconfiguration driven by economic, political, technological and demographic change may have wider, but currently inadequately understood, impact on remote communities.  This is important for policy. This study explored the nature and extent of added-value contributions, using remote health services as an exemplar (Part 1).  A method for measuring the impact, on remote communities, of added-value contributions from any sector was then constructed (Part 2). Part 1: Eight remote community case studies in Scotland and South Australia explored the added-value roles of the health sector.  Cross-case findings present evidence of health professionals’ behaviour and residents’ perceptions of the social, economic and symbolic importance of remote health service to communities.  Findings revealed a distinction between health service institutions’ contributions (built environment, employer role, health professional status and competencies and symbolic aspects) and those attributable to health professionals as individuals. Part 2:  Institutional and personal added-value contributions were conceptualised as contributing to stocks of different categories of capital insofar as they constitute tangible and intangible resources available for use by individuals and communities.  This conceptual framework provided the basis for developing a prototype generic quantitative instrument (C-CAT) capable of measuring the added-value contributions of institutions and individuals to community stocks of human, social, economic, symbolic and institutional capital. Uniquely, study outputs provide a potential method of quantifying complex and intangible aspects of remote community life that  underpin an innate sense of community ownership, but which have hitherto not been explicitly conceptualised or been capable of measurement.

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