<p>The purpose of this thesis is to describe a research strategy for evaluating the efficacy of a reduced dose maternal tetanus immunization schedule in reducing neonatal tetanus deaths in Sierra Leone.</p> <p>Neonatal tetanus has been demonstrated to be a major cause in infant death in areas where sanitary midwifery is unavailable. A review of the literature reveals evidence for reduction in neonatal tetanus deaths by maternal immunization using a conventional three dose adsorbed tetanus toxoid.</p> <p>In Sierra Leone, as in many developing countries, the resources are unavailable to maintain a three-dose schedule in the relatively inaccessible interior of the country. A two-dose schedule of a concentrated adsorbed toxoid has been recommended as an alternative by the World Health Organization. Research on simplified immunization schedules has been reviewed; the results are inconclusive.</p> <p>A double-blind randomized placebo-controlled design has been selected to address the research questions. Various aspects of this design are discussed with respect to methodologic and ethical issues.</p> <p>Procedures for carrying out the trial and for the assessment of neonatal tetanus death in a remote chiefdom in Sierra Leone are proposed. A procedure for the analysis of outcome data is presented.</p> / Master of Science (MS)

<p>The introduction of a new radiologic imaging technology requires an assessment of its proper place in the diagnosis and treatment of specified conditions. In terms of its use in diagnosis, computed tomography must be evaluated with reference to the existing diagnostic process to determine whether its contribution is likely to have any beneficial impact on the patient. In terms of its use in therapy, the special ability of computed tomography to make an image of soft tissue points to its potential use in the initial staging of malignant neoplastic disease.</p> <p>The objective of this thesis is to propose a methodology of evaluation of Computed Body Tomography that may be carried out in association with normal clinical practice, and to illustrate this with a diagnostic example and a therapeutic example. In both instances there are two steps to the evaluation. First, a comparison of the accuracy of the information of computed tomography against the conventional diagnostic tests. Second, the strategy for evaluating the benefit of the introduction of computed tomography in the diagnostic and therapeutic examples.</p> / Master of Science (MS)

<p>The objective of this thesis is to propose a methodology of the evaluation of the effectiveness of therapeutic ultrasound and exercise in physiotherapy outpatients with shoulder stiffness. The comparison group is to obtain exercise alone. The results of the study are to be analysed using an analysis of covariance with suspected confounding variables as the covariates.</p> / Master of Science (MS)

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.

This work is the continuation of previous research by A. Raza and other contributors to the field of fibre optic plethysmography. Plethysmography is defined as the volume estimation of an object according to its external dimensions. fu particular, this technique can be used to produce an estimation of the respiratory volume of a human subject according to the dimension of his chest, measured at the thoracic and abdominal levels. A respiratory plethysmograph simply attempts to deliver a signal being the closest possible estimation of the true respiratory volume, as measured by a spirometer or a pneumotachometer. There are essentially two instrumental approaches to respiratory plethysmography: 1) The Respiratory Inductive Plethysmograph (RIP) estimates the cross section area of the chest by monitoring the variation of inductance in an electrical wire encircling the chest. 2) The Fibre Optic Respiratory Plethysmograph (FORP) sees the contribution of fibre optic sensors to measure the chest's circumference variations. The purposes of the present investigation were to improve the performance of previous FORP prototypes, and to extend its capabilities to cardiac monitoring. Both these targets have been reached, and the new prototype is now demonstrating the potential of plethysmography as a sound investigation technique for both cardiac and respiratory monitoring. Overall, the improved sensor and acquisition system permitted the resolution of details of the plethysmographic waveforms that were beyond the reach of the previous prototype. The new FORP prototype is generally more reliable and more precise, if not less compact. From a medical point of view, research carried out with the new FORP prototype has had two major outcomes: 1) The increased temporal resolution-of the new acquisition system has given us the possibility to precisely measure the phase shifts between the plethysmographic signals, and the spirometric signal. Such measurements have contributed. to producing a better estimation of the spirometric signal, therefore increasing the credibility of the FORP as a non-invasive, respiratory volume monitoring device. 2) The increased amplitude resolution of the new acquisition system, coupled with the better linearity, better precision and smaller hysteresis of the new sensor, has enabled the FORP to detect body circumference variations due to cardiac activity around head, neck, thorax and abdomen of a patient. Observations of heart movements at thoracic level had already been reported with the RIP, the direct analogue of the FORP. The signal processing required by the RIP for such monitoring only permitted offline, Electro-Cardio-Gram (ECG) assisted interrogation of cardiac displacements. However, thanks to better signal processing, the FORP has been made capable of real time cardiac position monitoring, without referencing to a simultaneous ECG signal. The combined impact of this research and previous research by A. Raza and A. Augousti on respiratory gating with the FORP, is potentially important in the field of cardiac imaging with Magnetic Resonance and Computed Tomography scanners. The FORP should permit better synchronisation with cardiac movements, while helping the patient to maintain stable chest position, subsequently increasing the image resolution by limiting motion blur.

Hospitals are joining multihospital systems (MHSs) with growing frequency. About 80% of MHSs are small, composed of 2-7 hospitals. An important management issue in MHSs is the extent to which member hospitals retain control over their own strategic directions. Using a contingency framework, this study uses both system and hospital—level determinants to explain the extent to which hospital members of MHSs control their own strategies. Survey and secondary data from 272 member hospitals of 62 small multi hospital systems (size 2-7 hospitals) are analyzed. System dispersion, size, ownership, strategic type, and age along with hospital occupancy, size, relationship to the MRS, and market factors are determinants of hospital control of strategy. Two types of hospital strategic decisions were revealed by factor analysis: tactical and periodic. For tactical decisions, such as those relating to hospital budgets, service additions, and formulation of strategies, Catholic system ownership is a significant predictor of greater hospital control. Prospector system strategy and older system age are significant predictors of reduced hospital control. For periodic decisions, such as appointment of hospital board members, sale of hospital assets, and changes in bylaws, older system age is negatively associated with hospital control, and a hospital which is owned by the system has significantly less control. The results are analyzed using the framework of the Hickson, Butler, Cray, Mallory, & Wilson (1986) typology of strategic decisions. Thus the results of this work can be useful to managers in identifying the nature of a decision and understanding its associated decision process.

This study investigated the financial performance of not-for-profit hospitals in 10 Southern states acquired by either the for-profit or not-for-profit multihospital systems between the years 1978 through 1982. The impact of system affiliation on acquired hospitals was investigated by looking at average financial performance from the two years before acquisition to 1984/1985. Differences between the performance of hospitals acquired by for-profit and not-for-profit multihospital systems were examined as well. with regard to the latter, major findings revealed both for-profit and not-for-profit multihospital systems increased debt in acquired hospitals and made improvements to plant and equipment. For-profit multihospital systems additionally increased profitability and appeared to operate their acquisitions in a more business-like fashion than the not-for-profit multihospital systems did. Comparing acquired hospitals with matched independents revealed that both for-profit and not-for-profit multihospital facilities used more debt and had newer plant and equipment than the not-for-profit independents did. Multihospital systems decreased liquidity in acquisitions as compared with independent not-for-profit hospitals. Only for-profit multihospital system facilities showed increased profitability, and this was largely due to higher prices. Little or no improvement in efficiency was observed in either for-profit or not-for-profit multi hospital system hospitals; however, the financial indicators used to measure efficiency proved to be problematic.

This study was undertaken to address the need of professionals responsible for assuring the quality of hospital care for a framework for understanding and evaluating quality assurance mechanisms and their impact on hospital quality of care. Primary data were collected from 70 Virginia short term acute care general hospitals on the design and resources of their quality assurance programs in 1986. Adverse outcome data for 1986 were collected from the Medical Society of Virginia Review Organization. Hospital structural data were obtained from the American Hospital Association computer data base and the Federal Register. The intermediate outcome variables are: rate of unexpected return to the operating room, rate of treatment/medication problems, rate of in-hospital trauma, rate of medical instability at discharge, and rate of unexpected deaths. Exploratory analyses of hospital size and specialization demonstrate that size positively affects the numbers of RNs in quality assurance, the number of quality assurance professionals with academic degrees above the associate level, and negatively affect the ratio of quality assurance personnel full-time equivalents (FTEs) — both total and professional — to total hospital FTEs. Hospital specialization negatively affects the ratio of quality assurance personnel FTEs — both total and professional — to total hospital FTEs. Structural equation models, causally relating the adequacy of quality assurance design and resources to adverse outcomes of hospitalization, were used to test the causal relationships. The model supports the work of Donabedian and of Deming. The model demonstrates the effects of quality assurance constructs on perceived organizational commitment to quality assurance and commitments effect on process-related outcomes. Process-related outcomes are strongly and positively related to the terminal measure of unexpected deaths. When size and specialization are controlled, some changes are noted in the model. The R2 increases, the Chi-square/df ratio increases and the adjusted goodness of fit ratio decreases. This change was not unexpected due to the statistical significance of the percent of board certified physicians (BRDCERT) on the outcome variable unexpected death (DEDPROBR).

Posttraumatic stress disorder (PTSD) has a persistent nature: PTSD troubles patients even decades after the occurrence of traumatic events. The “health behavioral model” is adopted to examine the effects of external environmental, predisposing, enabling, and need for care factors on the use of VA post-discharge ambulatory care and readmissions. Data were obtained from the Patient Treatment File (PTF) and the Outpatient Care File (OPT), the Area Resource File (ARF), American Hospital Association data sets (AHA), and the Uniform Crime Report (UCR). The use of VA post-discharge ambulatory care is analyzed by using structural equation modeling (SEM). The readmission to VAMCs is evaluated by Cox regression with forward selection. A cross-sectional study is performed on 1,420 PTSD veterans admitted to Veterans Affairs Medical Centers (VAMCs) in 1994 and 1,517 veterans in 1998 in the Veterans Integrated Services Networks 6 (VISN 6). In both years, the most important determinants of the use of VA post-discharge ambulatory care is “prior use of outpatient care services.” For the 1994 sample, prior use of inpatient services impeded the utilization of post-discharge ambulatory care. For the 1998 sample, barriers to access to care and the length of stay for other mental health encounters in the last year reduced the utilization of post-discharge ambulatory care. For readmission in both years, higher numbers of medical or mental VA post-discharge visits reduce the likelihood of readmission to VAMCs. The service lines program was found to increase the use of VA post-discharge ambulatory care and decrease readmission rates for PTSD veterans. The application of the “health behavioral model” can be extended to outcome research to investigate the contributing factors. A risk adjustment system can also be developed based upon the findings. Communities, VAMCs, and PTSD patients and their families should work to raise awareness of the factors that contributing to both use of care and outcomes, and should form a comprehensive network to improve the wellbeing of PTSD veterans.

The relationship between technical efficiency and quality of care in hospitals is studied in the context of resource availability in hospital organizations. The resource availability of hospitals is conceptualized by organizational slack. An integrated model is developed encompassing the source of organizational slack, its impact on technical efficiency and on quality of care, and its impact on the relationship between efficiency and quality. Organizational threat as an environmental factor affecting the level of slack is measured by the level of competition and regulation. Organizational slack is measured using financial and operational indicators of the hospitals. Technical efficiency is estimated by efficiency "scores generated using the Data Envelopment Analysis. Mortality rates of Medicare patients are used as the proxy for quality of care in individual hospitals. The sample is composed of 832 urban, not-for-profit hospitals in the United States. The data are compiled from the Health Care Finance Administration data set and the American Hospitals Association annual survey data set. Hypotheses are tested using ordinary least squares regression and logistic regression. The analysis reveals that the level of and change in organizational slack have a negative relationship with efficiency and a positive relationship with quality of care. The results also indicate that environmental threat has a negative effect on level of slack, and efficiency has a negative effect on quality of care. The findings are discussed in terms of the theoretical implications for the concept of organizational slack and the implications for health policy and hospital management.