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.

<p><strong>Background and Objectives: </strong>Previous research has examined the effect of family physician continuity of care within end-of-life care cancer patients and its association with reduced use of acute care services. However, such research has not been examined in the end of life homecare cancer population.<strong> Objectives: </strong>To investigate the association of family physician continuity with location of death, hospital and emergency room (ER) visits in the last 2 weeks of life in end of life homecare cancer patients.<strong> Research Design: </strong>Retrospective study involving secondary data analysis of 7 linked databases<strong>. Subjects: </strong>All those who died of cancer between January 1, 2006 to December 31, 2006 in Ontario who had at least 1 visit to a family physician and enrolled in homecare for at least 2 weeks.<strong> Methods: </strong>The relationship of family physician continuity of care and location of death, and hospital and ER visits in the last 2 weeks of life was examined using logistic regression.<strong> Results: </strong>The Usual Provider of Care (UPC) measure demonstrated a dose response relationship with increasing continuity resulting in decreased odds of dying in the hospital and visiting the hospital and ER in the last 2 weeks of life. The Family Physician visits per week measure demonstrated a threshold effect relationship with location of death and hospital visits and dose response relationship with ER visits in the last 2 weeks of life. <strong>Conclusions:</strong> These results demonstrate an association between family physician continuity of care and location of death and visits to the hospital and ER in the last 2 weeks of life. This indicates the need for more involvement of family physicians in end of life cancer care.</p> / Master of Science (MSc)

<p><strong>Objective: </strong>Despite the known benefits of prenatal care, not all women access it equally. Evidence suggests women in Nunavut utilize prenatal care less than in any other jurisdiction in Canada and there is an absence of literature that explains why. This study seeks to improve our understanding of the factors influencing utilization of prenatal care for women in Nunavut by exploring the barriers, facilitators and motivators to utilization.</p> <p><strong>Methods: </strong>A qualitative, descriptive approach was used. Community collaboration informed the research process. Data were analyzed from 21 semi-structured interviews conducted with pregnant and postpartum women and maternity care providers in two Nunavut communities. Using a socioecological model of health services utilization and inductive content analysis, transcribed interviews were analysed to determine the factors that influence prenatal care utilization.</p> <p><strong>Findings: </strong>Utilization of prenatal care was influenced by personal, situational and system-related barriers, facilitators and motivators. Personal and situational barriers, facilitators and motivators to care were similar among women from both communities. System-related barriers and facilitators, related to the model of prenatal care and its delivery, differed between the two communities with barriers including language, appointment scheduling and waiting times.</p> <p><strong>Conclusion: </strong>System-related barriers reduced access to prenatal care for women in one Nunavut community. Access may be improved in communities with low utilization by revising the current model of prenatal care to reflect care delivered in communities where care providers have dedicated prenatal care roles.</p> / Master of Science (MSc)

<p>Patient safety in healthcare has become a national objective. Hospital safety concerns are not isolated to patient safety, occupational safety is also important. One initiative adopted by healthcare is improving patient safety climate – shifting from one of a "no harm, no foul" approach to a culture of learning that encourages the reporting of errors, even those in which patient harm does not occur. Lacking from the literature, however, is an understanding of how to encourage reporting and how safety perceptions are formed among hospital employees. In addition, although safety-related reporting and safety perceptions are deemed important, the majority of research has been conducted in nursing populations. In order to create a safer hospital, it is crucial to investigate safety-related reporting and safety perceptions among all hospital employees.</p> <p>The purpose of this cross-sectional study is to test and refine a model that explains the influence of perceived procedural justice, interpersonal justice, informational justice, and distributive justice on comfort with safety-related reporting and, ultimately, hospital safety perceptions among hospital employees.</p> <p>The proposed model was tested on a sample of 652 hospital employees from a regional children’s hospital with a 76% return rate. Consistent with the hypothesized model, perceptions of higher interpersonal justice predicted higher comfort with safety reporting, which in turn predicted perceptions of hospital safety. In addition, comfort with safety reporting, interpersonal justice, and informational justice contributed directly to the prediction of hospital safety perceptions.</p> <p>This study illustrates why different dimensions of organizational justice, specifically interpersonal justice and informational justice, should be considered above and beyond safety-specific climate when individuals are intent on improving hospital safety. Thus, hospital managers and administrators should enhance interpersonal justice along with comfort with safety-related reporting and informational justice to create a safer hospital. Study limitations and recommendations for new research methods and areas are discussed.</p> / Master of Health Sciences (MSc)

<p>Variations in the rate of use of health care services (a.k.a. medical practice variations) have been described in the literature for over eighty years. The literature suggests three general sources of variation: patients, physicians, and environment. The relative influence of these sources and the specific mechanisms that produce observed variations are not well understood. This thesis presents four studies that identify and examine methodological issues that preclude our ability to understand the variation phenomenon.</p> <p>It is commonly believed that the physician is in part responsible for observed variation in health care services use. However, determining the influence of the physician in this regard is problematic, as it is difficult to isolate the effect of the physician from that of the patient and environment (including available resources). The first study presented in this thesis suggests there is meaningful variation in treatment recommendations between physicians working in a common environment, even after controlling for important patient clinical characteristics. Next, I present an experiment that suggests that factors related to the patient’s unique social context might influence how the physician intends to manage a patient’s care. As variations studies do not measure or adjust for social context, this might indicate an important methodological limitation of those studies if indeed context is an important (and justifiable) determinant of what care the patient will receive.</p> <p>Not all variation is necessarily bad. The third study I present explores how previous researchers discriminate between warranted and unwarranted variation. This study indicates that few researchers explicitly do so, and that a clear, consistent, and functional definition of unwarranted variation is lacking – a feature that potentially limits the interpretation of study results. The final study argues that traditional methods for examining regional variations are inadequate for informing health care managers because they examine variation in health care service use rather than needs.</p> / Doctor of Philosophy (PhD)

D. Cur. / The model "Facilitating mental health promotion through mobilising comfort for homeless mentally ill persons in urban areas" was developed by using a theory generative design that is qualitative, contextual, explorative and descriptive in nature. To achieve the research purpose specific objectives were formulated. This model was developed according to Chinn and Kramer's (1995:162) approach to theory generation as indicated in the first step. Identification of the central concepts for the model took place by conducting a field study to explore and describe the lived experiences of the homeless mentally ill persons and their views of what they think would alleviate their situation. A multiple case study strategy was followed. The sample consisted of three homeless mentally ill persons, purposively selected from the Soweto urban vii areas. Informed verbal consent had been obtained from all participants, and the reasons for conducting the research study were explained to them. Data collection was obtained through in-depth semi-structured interviews using the phenomenological perspective and communication techniques to elicit relevant information. Data from transcripts of recorded audiotapes and field notes were analysed using the methods of Tesch's steps (in Creswell, 1994:154; Yin, 1994:102; and Merriam, 1998:16). An independent coder assisted in coding the results. Reasoning strategies used were analysis, synthesis, inductive and deductive according to Tesch's method. The results were verified through a literature review. Further analysis of data for defining the major concepts of the model which are "HOPE and COMFORT", were determined according to the method described by Wandelt and Steward (1983:64). The concepts of the model were analysed thoroughly by going through different dictionaries and subject usage. The other related concepts were identified and classified by using a survey list of Dickoff, James and Wiedenbach (1968:430). In Step Two the defined concepts were related to each other to show interrelationships. Classification of central and relational concepts were followed to create relationship-statements as the conceptual framework of the model. In Step Three the structure and process description of the model was designed according to Chinn and Kramer (1995:108). The model was evaluated by a panel of experts. Step Four dealt with guidelines to operationalise the model in practice, education and psychiatric nursing research. Guba and Lincoln's (1985) model for trustworthiness of qualitative research was also employed. It is based on the identification of four strategies for ensuring trustworthiness used in this study, namely: truth value, applicability, consistency and neutrality. Recommendations and limitations of the research were also discussed.

Angiogenesis is essential for the growth of a tumour, as it provides tumour cells with nutrients and oxygen for their survival. As the tumour expands, neovascularisation is facilitated by the release of enzymes called proteases, which degrade extracellular matrix and facilitate the metastatic spread of cancer. TNF[alpha] and IL-1[beta] are potent cytokines that share the ability to stimulate angiogenesis, hence their possible significance in metastasis has been a focus of intense research. TNF[alpha] and IL-1[beta] have been shown to regulate the activity of proteases such as MMP's and serine protease. The aim of this study was to investigate the effect of TNF[alpha] and IL-1[beta] on cathepsin B and DPP IV activity and their protein levels in HRT 18, HT 29 cells and HUVEC's. Further experiments were conducted to assess the viability of the cells upon treatment with the cytokines. In addition the potency of inhibitors Mu-Phe-Hph-FMK, for cathepsin B enzyme, and Gly-Pro-Gly-Gly, for DPP IV enzyme were assayed in the three cell lines studied. Addition of TNF[alpha] and IL-1[beta] resulted in the reduction of intracellular cathepsin B and DPP IV activity and an increase in its extracellular activity in HRT 18 and HT 29 cells, suggesting that the cytokines induced the release of the enzymes or may have inactivated intracellular enzyme while activating the latent extracellular enzyme. However, in HUVECs, both the cytokines led to an increase in intracellular as well as extracellular cathepsin B activity, possibly by activating the latent form of enzyme present within and outside the cell. With respect to DPP IV, there was an increased intracellular and extracellular activity with TNF[alpha], but with IL-1[beta], an increase in intracellular activity and a decrease in extracellular activity were observed, suggesting involvement of a different mechanism for the exopeptidase enzyme in HUVECs. The two Cytokines had a cytotoxic/cytostatic effect on all three cell lines, with prominent reduction in cell viability of HUVECs. In conclusion the varied response of intracellular and extracellular activity and protein levels of cathepsin B and DPP IV, in different cell lines suggests that TNF[alpha] and IL-1[beta] may act as important modulators of proteases in the process of angiogenesis in cancer and normal endothelial cells. Thus understanding the pleiotropic nature of these cytokines will further broaden the knowledge of involvement of these cytokines in cancer progression/cancer regression.

The diagnostic radiography curriculum and the process of its enactment are under researched in the United Kingdom. To date, there have been no published studies which have investigated the curriculum and the role of radiography educators from the multiple perspectives of radiography students, university radiography educators and clinical radiography educators, that is, a radiography education community. Accordingly, this study describes the perceptions and experiences of a radiography education community in relation to three research questions: 1. How does a radiography education community conceptualise the radiography knowledge and skills required of a diagnostic radiographer? 2. How does a radiography education community conceptualise the role played by university based and clinically based radiography educators in helping the radiography student acquire radiography knowledge and skills? 3. How does the community in this study compare with Lave and Wenger’s theoretical constructs of a situated learning, legitimate peripheral participation and Communities of Practice (CoP)? The epistemological foundation of the study is constructivism and the overarching methodology is a case study conducted within a single higher education institution and three of its associated clinical practice partner settings. The primary data collecting method comprised semi-structured interviews, supplemented by a critical review of germane literatures, government policy and the curriculum guidance provided by the relevant professional and statutory bodies. The theoretical framework in which the study is situated is based upon Lave and Wenger’s theories of situated learning, legitimate peripheral participation and communities of practice. The findings of the study reveal a radiography education community which is lacking any unifying pedagogic discourse. In particular, there is an absence of opportunities for cross-community working, especially in collaborative curriculum development and the process of its enactment. This is further compounded by the community’s narrow interpretation of what a curriculum should comprise. Currently there is a clear focus on knowledge content and curriculum as a product which fails to take into account praxis and the social context in which learning takes place. These findings have been summarised by a representation of the enacted curriculum as compared with the ‘ideological’ function of a radiography curriculum. Specific developments required of the curriculum include: (i) placing a greater emphasise on the vocational relevance of radiography knowledge; (ii) gaining a better understanding of tacit radiography knowledge; (iii) ensuring greater familiarity with the curriculum and (iv) enhancing the standard of clinical supervision. The radiography education community in this study evidences both convergence and divergence with Lave and Wenger’s theoretical constructs of situated learning, legitimate peripheral participation and community of practice. Within the context of radiography education the study also highlights the consequence of power relationships, the complexity of learning in and across multiple communities of practice and the importance of individual learner biographies, all of which are underdeveloped in Lave and Wenger’s theoretical discourse. These findings have been summarised in a proposed theoretical model for a radiography education community of practice. Three specific pedagogic and managerial inferences may be drawn from this study which will require staff development and consideration of how the diagnostic radiography programme is managed across the community. Firstly, context, process and praxis need to be carefully considered in the collaborative development, design and implementation of the curriculum. Secondly, the university and clinical educators need to reflect on their own learning and teaching skills by engaging more fully with pedagogy. Thirdly, communication across the radiography education community of practice must be improved.

Research on the effects of progress feedback and clinician problem-solving tools on patient outcome has been limited to a few clinical problems and settings (Shimowaka, Lambert & Smart, 2010). Only one randomized clinical trial has examined feedback-assisted treatment in an inpatient eating-disordered population. Results from this study suggested that those who received feedback-assisted (Fb) treatment were more likely to meet Jacobson and Truax's (1991) criteria for recovery than participants in the treatment-as-usual (TAU) condition; however, while these interventions appear to have worked well in the inpatient setting, the long-term effects of this treatment have not been investigated. This is especially pertinent in an eating disorder population, where outcomes tend to be poor and course of illness tends to be chronic. In this study, the effect of feedback interventions on long-term outcome was investigated. Fifty-three of the individuals from the aforementioned original study were contacted by mail, email, or telephone three to four years after leaving the inpatient facility to assess their current level of distress (as measured by the OQ-45) and overall psychological functioning. Comparisons were made between the outcomes of patients assigned to the experimental feedback condition and the TAU condition. Results suggested that both treatment conditions were nearly indistinguishable from one another and did not significantly differ at follow-up; however, the study was significantly underpowered. Our effect size suggested that the Fb group slightly deteriorated over time, while the TAU group slightly improved; however, effect sizes were minimal and did not meet criteria for "small" change according to Cohen's d. Patients’ Body Mass Index (BMI) largely remained the same since leaving the hospital, with a small portion deteriorating. The vast majority of women sought out multiple forms of treatment over the follow-up period, regardless of treatment condition. This is consistent with past research that suggests women with more severe pathology, and who thus require inpatient treatment, tend to experience a more chronic pattern of symptoms even after receiving intensive treatment. Overall, the superiority of feedback-assisted treatment that was found post-treatment appeared to diminish over time and was not detected at follow-up. Suggestions for further research are delineated.

The purpose of this study was to assess the relationship between meaning in life and utilization of health care services. An epidemiological, cross-sectional study was performed on a sample of 282 students at Western Kentucky University and 49 employees at the Barren River District Health Department. Study participants completed the Life Attitude Profile--Revised and the Participant Data Sheet. The data gathered and analyzed via correlation analysis showed no overall significant relationship between the two variables for this sample. The possible impact that overall mental health status has on the utilization rates of health care services rust be examined in the future in order to better meet the medical needs of the general population of United States.