Background: Variation exists in quality of life (i.e., utility) estimates depending on the utility elicitation method utilized. Using the EQ-5D, VAS, and HUI-III, the aim of this thesis was to determine whether these measures adequately capture HRQOL in a CRC population and assess the relationship between utility estimates generated. Methods: A mixed methods study design was employed to collect health status scores and interview data from a sample of 50 CRC patients in Toronto, Ontario. Results: Mean utility scores between the EQ-5D and HUI-III were identical at 0.76 (95% CI), with an overall VAS score of 0.72 (95% CI). Conclusion: The fact that the EQ-5D and HUI-III resulted in identical mean utility scores provides assurance for future studies using these tools in CRC. However, many factors that CRC patients identify as important to their HRQOL are not captured by these instruments. These findings have implications for informing economic evaluations.

Health system restructuring combined with the preferences of palliative care recipients to be cared for at home has lead to a shift in the delivery of care from the hospital to the home setting. An analysis was conducted on five main home-based palliative care health service components: home-based nurse visits, home personal support worker visits, home-based physician visits, ambulatory physician visits, and other ambulatory and home-based visits. First, we assessed the proportion of total cost associated with the main services at different time points over the palliative care trajectory. Second we examined the socio-demographic and clinical factors that predict the propensity and intensity of service use, using a two-part model. The results suggest that the greatest contributor to the total cost of home-based palliative care was personal support worker visits, followed by nurse visits. The regression analysis revealed that patient age as well as functional status most often predicted health service use.

Background: Variation exists in quality of life (i.e., utility) estimates depending on the utility elicitation method utilized. Using the EQ-5D, VAS, and HUI-III, the aim of this thesis was to determine whether these measures adequately capture HRQOL in a CRC population and assess the relationship between utility estimates generated. Methods: A mixed methods study design was employed to collect health status scores and interview data from a sample of 50 CRC patients in Toronto, Ontario. Results: Mean utility scores between the EQ-5D and HUI-III were identical at 0.76 (95% CI), with an overall VAS score of 0.72 (95% CI). Conclusion: The fact that the EQ-5D and HUI-III resulted in identical mean utility scores provides assurance for future studies using these tools in CRC. However, many factors that CRC patients identify as important to their HRQOL are not captured by these instruments. These findings have implications for informing economic evaluations.

Versorgungsforschung untersucht die Wirkungen und Kosten der Kranken- und Gesundheitsversorgung unter Routinebedingungen und berücksichtigt dabei alle Aspekte der gesundheitlichen Beratung, Prävention und klinischen Versorgung. Als wesentliche Determinanten der Effektivität und Effizienz der medizinischen Versorgung fließen in Studien der Versorgungsforschung häufig auch die Rahmenbedingungen und die Organisation des Gesundheitswesens und der sozialen Sicherungssysteme ein. Versorgungsforschung stellt jedoch nicht nur die sogenannte „letzte Meile“ der Gesundheitsforschung dar, sondern generiert darüber hinaus neue Hypothesen für klinische und experimentelle Forschung und trägt damit als Translationsforschung auch zur Klärung von Erkrankungsursachen bei. Aufgrund ihrer zentralen Rolle in der Gesundheitsforschung und einer langjährigen Tradition in diesem Forschungsfeld ist Versorgungsforschung/Public Health neben regenerativer Medizin und Onkologie einer von drei Profilschwerpunkten der Medizinischen Fakultät Carl Gustav Carus an der Technischen Universität Dresden. So bestehen beispielsweise in den Bereichen Dermatologie/Allergologie, Klinische Pharmakologie, Arbeits- und Sozialmedizin, Psychiatrie, Innere Medizin, Orthopädie, Allgemeinmedizin und Neurochirurgie bereits überregional bekannte und renommierte Arbeitsgruppen im Bereich Versorgungsforschung am Standort Dresden. Zur weiteren Profilschärfung in diesem Forschungsbereich wurde im Juni 2011 an der Medizinischen Fakultät Carl Gustav Carus der TU Dresden ein neuer Lehrstuhl „Sozialmedizin und Versorgungsforschung“ eingerichtet. Eines der selbsterklärten Ziele ist es dabei, durch multiprofessionelle Vernetzung von methodischer und klinischer Expertise Innovationen zu entwickeln, zu evaluieren und nachhaltig in der Gesundheits- und Krankenversorgung umzusetzen. Dahinter steht das Primat, dass Versorgungsforschung auf hohem Niveau und mit dem Ziel einer evidenzbasierten Politikberatung letztlich nur im interdisziplinären Austausch zu sichern ist. Unter dem Titel „Versorgungsforschung - Standortbestimmung und Perspektiven“ zielt das 6. Symposium der AG Versorgungsforschung darauf ab, die Akteure der Versorgungsforschung der Medizinischen Fakultät und des Universitätsklinikums Dresden vorzustellen und untereinander sowie mit gesundheitspolitischen Entscheidungsträgern, gesetzlichen Krankenversicherungen, mit Wissenschaftlerinnen und Wissenschaftlern, Studierenden und allen weiteren Interessierten ins Gespräch zu kommen. Kolleginnen und Kollegen aus 20 Kliniken und Instituten des Universitätsklinikums und der Medizinischen Fakultät Dresden haben insgesamt 36 Poster eingereicht, die die vielen unterschiedlichen Facetten der Versorgungsforschung in Dresden präsentieren. Diese 36 Poster, deren Abstracts in dieser Publikation zusammengestellt sind, stehen im Zentrum des 6. Symposiums der AG Versorgungsforschung. Auch wenn eine eindeutige Zuordnung nicht in allen Fällen möglich ist, wurden die Beiträge unter den Überschriften „Versorgungsepidemiologie“, „Prävention/Früherkennung“, „Ambulante Versorgung“ und „Stationäre Versorgung“ in vier thematisch gegliederte Postersessions eingeteilt.

Diss. (sammanfattning) Uppsala : Uppsala universitet, 2005. / Härtill 4 uppsatser.

Orientadora: Suzely Adas Saliba Moimaz / Banca: Marcelo de Castro Meneghim / Banca: Ana Claudia Okamoto / Banca: Ricardo Coelho Okida / Banca: Eduardo Daruge Júnior / Resumo: A participação da comunidade é um importante instrumento para a organização das ações e serviços públicos de saúde. O objetivo nesse estudo foi conhecer a avaliação e a resolutividade do serviço odontológico no Sistema Único de Saúde a partir da visão do usuário, e suas associações com humanização e acesso ao atendimento, respectivamente. Essa pesquisa fez parte de um projeto multicêntrico desenvolvido em três municípios brasileiros, nas regiões centro-oeste, sudeste, e sul. Nela são apresentados resultados da fração sudeste do projeto maior, executada em Araçatuba, estado de São Paulo. Tratou-se de uma pesquisa transversal tipo inquérito, com abordagem quantitativa, na qual 461 usuários do serviço público odontológico responderam a entrevistas individuais, realizadas nas unidades de saúde do referido município paulista. Foram incluídos usuários do Sistema Único de Saúde com idade mínima de 18 anos, que concordaram em participar da pesquisa, e que no dia da entrevista encontravam-se em tratamento odontológico ou o haviam concluído. Foram excluídos os portadores de necessidades especiais cognitivas, bem como aqueles cuja consulta odontológica seria a primeira na referida unidade. O questionário aplicado foi adaptado a partir do modelo utilizado para pesquisa de satisfação do usuário no Programa Nacional de Avaliação de Serviços de Saúde, e de instrumentos de avaliação externa do Programa da Melhoria do Acesso e da Qualidade. Para o cálculo amostral, utilizou-se a prevalência de 50% para cada condição possível, com a finalidade de maximizar o tamanho da amostra. Ao total encontrado, foram acrescidos 20% para potencializar o efeito do estudo, alcançando 461 indivíduos na amostra final. Foram empregados os testes qui-quadrado e exato de Fisher nas análises bivariadas, e a regressão de Poisson na análise... / Abstract: Community participation is an important tool for organizing actions and services of public health. The aim of this study was to determine the evaluation and the case-resolving capacity of dental care in the Unified Health System from the users' point of view, and their associations with humanization in care and access to oral health care, respectively. This research was part of a multi-centric study carried out in three municipalities in the midwest, southeast, and south of Brazil. It shows the results of the southeastern part of the larger project, carried out in Araçatuba, State of São Paulo. It was a cross-sectional survey-type research, with a quantitative approach, in which 461 users of the public dental service responded to individual interviews conducted in the health centers of the said municipality in São Paulo. Unified Health System users at or over the age 18, who agreed to participate in the study, and who, on the day of the interview, were undergoing or had completed dental treatment, were included. Users with special cognitive needs, and those who visited the said center for the first time were excluded. The questionnaire was adapted from the model used in the users' satisfaction survey of the National Health Service Evaluation Program, and from instruments of external evaluation of the Improvement Access and Quality National Program of Primary Health Care. For sample calculation, we used the prevalence of 50% for each possible condition in order to maximize the size of the sample. To the total found, 20% was added to leverage the effect of the study, reaching 461 individuals in the final sample. Chi-square and Fisher exact tests were used in bivariable analyses and Poisson regression, in the multivariable analysis. The dental care was positively evaluated by 90.4% of the participants. The negative evaluation of care was statistically... / Doutor

D.Cur. / A qualitative approach was followed to conduct a case study. Data was collected through participative observation, document analysis and interviewing of team members representing seven different disciplines. The practice model of Dickoff, James and Wiedenbach (1986:415-435) was utilized as theoretical framework to explore and describe the role players involved in team functioning within the context of primary health care. Team objectives and processes relevant to team functioning as well as the dynamics of team work were described and compared to a guide for team functioning, the elements which were derived from a literature study. The credibility of the research was enhanced through long term involvement in the activities of the study case as participative observer, through triangulation of methods to collect and verify data and through peer evaluation and auditing. It was determined that within the context of a home care service at primary health care level, it was mainly the nurse, being the team member with whom the patient and family have continued personal contact, who acts as team leader and initiates involvement of members from other disciplines. The decisions regarding whom to involve and how and when to involve them, are based on the knowledge and skills of the nurse in relation to the situation he/she has to manage, the acceptability of the team approach and compliance by the patient and family, the attitude, commitment and perception of other team members as well as the availability of facilities and infrastructure to enable team functioning. The organizational and philosophical framework within which service is delivered have a direct impact on team functioning. Community involvement and its acceptance of responsibility for health, enhances quality team functioning, but is dependant on effective empowerment strategies, a sound trust relationship and a reliable support system. Clear and agreed upon goals and objectives for team functioning are essential for effective team work. Innovative and creative strategies are necessary to enable team members representing different disciplines, who function in the context of primary health care, to have sufficient contact with each other to discuss objectives, give feedback and communicate effectively. Processes for and dynamics in team functioning are complex in nature and need to be identified, evaluated and, if necessary, adapted on a regular basis to promote effective team functioning. The objectives of the research, namely to explore and describe team functioning at primary health care level and to formulate guidelines for effective team functioning, were realized. A structure for working from the basis of a core team was proposed, as well as interdisciplinary training of team members, commencing at undergraduate level and continuing throughout professional life. The researcher recommends that the guidelines formulated with regard to the role players, context, objectives, processes and dynamics of team functioning at primary health care level be implemented. Aspects related to team functioning to be further researched have been identified, namely: assessing the quality of team functioning at primary health care level; the effect of interdisciplinary training on team functioning; the relationship between team functioning and the health status of communities; cost-efficiency of team functioning; utilizing latest technological developments for communication between and support for team members at primary health care level; the relationship between community empowerment, community involvement and interdisciplinary team functioning and the design of a model for team functioning at primary health care level. The research report is written in Afrikaans, but the conclusions reached in each of the nine chapters have also been translated into English to enhance the accessibility of research findings.

Asthma has been reported in children as a leading chronic illness in the US and around the world. It is also the third leading cause of hospitalization among children under the age of 15, and is also one of the most common causes of school absenteeism. Children are at higher risk of asthma attacks and they pose a higher burden on health care system. Nearly 20.6% of middle and high school children in Florida have been told they have asthma, this prevalence has grown over 3% from 2006 to 2012. Changes in air pollutant levels are often related to health outcomes, e.g. prevalence of chronic asthma. Exposure to ambient air pollutants have been reported to exacerbate asthma attacks especially in children. Often agencies and governing bodies utilize national level health impact assessments (HIAs) to estimate local levels of health impacts. The US EPA (Environmental Protection Agency) developed the Benefit Mapping and Analysis Program (BenMAP) to estimate impacts on health due to changes in air pollution. Recent studies have shown that assessment of regional exposure is important to understand health impacts of pollutants at the local level. To use BenMAP effectively for HIA in Florida, one may have to update the prevalence rates and concentration response (CR) functions in BenMAP with Florida data. The main purpose of the research was to develop a method which can estimate impact of change in criteria pollutants on childhood asthma outcomes in Florida. The rates present in BenMAP are based on national estimates, which are higher than the rates for Florida. If these rates are used for the HIA method then the change in asthma emergency department visits estimated by BenMAP may be an overestimate with higher uncertainties. There are no baseline rates for asthma exacerbation ED visits in BenMAP, an asthma exacerbation is a more severe and poorly managed case of asthma. Asthma ED visit prevalence rates will tend to overestimate the asthma exacerbation rates by 64%, if used. Detailed review of US-EPA’s BenMAP software and peer reviewed literature was performed to identify the gaps in BenMAP for asthma assessments. The CR functions were developed using local pollutant and outcomes data. CR functions were added to BenMAP to bridge the gaps. The baseline prevalence and exacerbation rates at county level by age group, gender and race ethnicity were developed. This study highlights that an increase of 10 µg/m3 of PM2.5 contributes about 2% to asthma ED visit rate, in children 5-12 and is lower, for 13-18 olds (0.6%). The baseline prevalence and exacerbation rates at county level for asthma in children differed by race/ethnicity. This study publishes the ED rates by county and by gender, race and ethnicity from 2010 to 2014, which are recent rates and have not been published to such granularity by the State or by any other researcher. Current pollutant data in BenMAP is only available through 2008, and EPA has recommended it should be updated for analysis purposes. This study has updated the monitor data in BenMAP for Florida counties for 2010-2014. There are three major contributions of this study. Firstly, the study contributes to publishing childhood emergency department prevalence rates for asthma and exacerbation in the State of Florida by age group, race/ethnicity and gender. Secondly, development of concentration response functions specific to Florida using the time series analysis to show the impact of PM2.5 on asthma exacerbation emergency department visits, incorporating both temporal and spatial variability of PM2.5 during the study period. Finally, the study demonstrates the utility of using local (county-level) baseline asthma prevalence rates and local pollutant data for State HIA in Florida. The local PM2.5 data in BenMAP can be used for other health outcome assessments, researchers will only have to update the prevalence rates for the health outcome used in their study. Estimation using local data will be less prone to uncertainties using National level data, the use of local data has been emphasized by several researchers. The study recommends future work in refining spatial grid resolution in BenMAP to zip code level to facilitate studies at neighborhood level. Another recommendation is to further design research to study SES in context to dietary changes and better understand social injustices in areas with diverse population. A population-based study in conjunction with Florida Asthma Coalition (FAC) asthma cases from doctors’ offices is recommended which will be able to control for misclassifications, and include weather and allergens in analysis while studying individual pattern of exposure and diet.

Infants who experience multiple risk factors, such as preterm birth, developmental delay, and low socioeconomic status, are at greater risk for mental health problems. Mental health interventions for infants typically target infants from high-risk groups, and there is strong evidence that some intervention programs for infants can prevent long-term negative outcomes and promote long-term positive outcomes. Despite emerging research and federal initiatives promoting early intervention, minimal research has examined community-based mental health services during infancy. Improving the effectiveness and efficiency of routine care requires close examination of current practices. The current study characterized current usual care practices in infant mental health through a survey of mental health providers. Provider, practice, and client characteristics, provider use of intervention strategies and intervention programs, and provider attitudes toward and knowledge of evidence-based practices are described. Study findings are discussed in the context of previous usual care research. Implications and directions for future research are discussed.

Unintended pregnancies, defined as either being unwanted or mistimed, represent a major public health challenge. Roughly half of all pregnancies in the United States are unintended, and have been associated with poor health and economic outcomes for infants, children, women, and families. Modern contraceptives have been proven to be both safe and effective in reducing unintended pregnancy. This is particularly true for long-acting reversible contraceptive (LARC) methods, which are associated with both higher user satisfaction and overall efficacy as compared to short-acting methods. We therefore investigated types of contraceptive services offered among rural and non-rural clinics in South Carolina. A survey was developed; all clinics in South Carolina who offer contraceptive services were invited to participate. Completion of the survey was voluntary and an incentive was provided. The survey was multi-faceted, covering several aspects of contraceptive care including scope of services provided, availability of resources, and training received. Of primary interest to this research, is the extent to which highly effective contraception methods, such as LARCs, are available in both urban and rural clinics. Findings suggest that access to highly effective LARCs is not equitable among rural and urban clinics. Approximately 62% of urban clinics offered LARC methods, compared to 36% among rural clinics (p=0.0015). These data indicate that women who reside in a rural locale have significantly lower access to these more effective contraceptive methods. As nearly 25% of women within the United States reside in a rural locale, the need to address barriers to access to contraceptive care is essential. This work will be a useful tool in understanding barriers to contraceptive care utilization and can lead to the development of novel programs to reduce the rate of unintended pregnancy, births and abortions, and corresponding savings in health care costs.