Lumbar degenerative disc disease is a remarkably common condition among patients presenting with chronic low back pain and physical disability. When a surgical treatment option is warranted, patients now have the option of undergoing lumbar total disc replacement (TDR), a relatively new procedure that is designed to replace lumbar fusion, the traditional surgical intervention for degenerative disc disease. The lumbar TDR procedure has demonstrated clinical efficacy equivalent to that of lumbar fusion, although concern remains about the longevity, safety, and costs related to the procedure. These issues were addressed in three separate observational studies using administrative claims data. The first study estimated the revision burden and economic revision burden of lumbar TDR. The second study examined the lumbar TDR hybrid procedure, where both a lumbar TDR and lumbar fusion are performed simultaneously. No observational data have been reported on the frequency, cost, and diagnostic indications related to the TDR hybrid procedure. The third study mapped the geographic variation of procedural rates of lumbar TDR. Previous research has found substantial geographic variation in lumbar spine surgery rates and a similar analysis of lumbar TDR variation has yet to be reported. The present series of studies found the revision burden and economic revision burden of lumbar TDR to be similar to data reported for this procedure from the mid-2000s, though the overall occurrence of the procedure appears to have declined. The economic revision burden made this a lower-cost procedure than lumbar fusion, with a tradeoff in terms of revision burden being higher for lumbar TDR. The lumbar TDR hybrid procedure was found to make up approximately 16% of the total number of TDR procedures, involving much higher costs than a single-level TDR procedure. Finally, geographic variation of the procedural rate of lumbar TDR varied dramatically across the U.S., surpassing the variation observed in lumbar fusion surgery. Limitations of the observational data used in these studies are described. Recommendations for future observational research are offered as well. Finally, implications for these studies on practice guidelines and reimbursement policies are provided.

Research Doctorate - Doctor of Philosophy (PhD) / The Equity Assessment Cardiac Rehabilitation (EACR) study uses a hospital outpatient cardiac rehabilitation (CR) program as the vehicle for demonstrating ways of using evidence to inform equity assessment in health services. This is achieved by demonstrating methods which policy and decision-makers can use to measure, deconstruct and interpret inequalities in service access, defined by selection and utilisation. Some of these methods are familiar in epidemiology and health services research and others less so. Chapter 1 defines equity and equality in health, and introduces the conceptual classification used here to analyse socio-behavioural factors that impact upon utilisation of the hospital outpatient CR program. Chapter 2 reports the results of a search of the international literature on ways of similarly addressing inequalities and inequities in healthcare services and programs, and also factors associated with the recruitment and retention of patients to hospital outpatient CR programs. Chapter 3 describes the methods used in the development and construction of the EACR patient cohort. Chapter 4 explains the theoretical basis for the statistical applications demonstrated in this dissertation. Analyses are conducted on the cohort in accordance with patients’ index hospitalisation. Chapter 5 applies multi-variable logistic regression to analyse factors associated with CR invitation and Chapter 6 uses similar methods to analyse factors associated with attendance for invited patients and Chapter 7 tests the effects of invitation and attendance on survival in accordance with age and gender. Using the results of the regression models presented in Chapter 5, Chapter 8 demonstrates post-estimation non-linear decomposition of gender-based inequalities in invitation to CR. This is a novel application in health services research. Chapter 9 concludes this body of work.

Pasienttilfredshet med polikliniske tilbud i det psykiske helsevernet – betydningen av organisatoriske faktorer Pasientenes opplevelse og tilfredshet med behandlingstilbudet har i økende grad blitt vektlagt ved evaluering av tjenester til mennesker med psykiske lidelser. Systematiske målinger av brukererfaringer i det psykiske helsevernet skal inngå som en av flere kvalitetsindikatorer for spesialisttjenesten. Dette skal blant annet gi brukerne beslutningsgrunnlag for å kunne velge hvor man ønsker å behandles, fagfolkene innspill til egen kvalitetsutvikling og staten nødvendig styringsinformasjon. Hensikten med avhandlingen var å undersøke i hvilken grad organisatoriske forhold har betydning for pasientenes tilfredshet med behandlingstilbudet. Resultatene i avhandlingen bygger på analyser av data fra flere større undersøkelser med spørreskjema til pasienter om deres erfaringer med det psykiske helsevernet. Samlet sett viser resultatene at misnøye eller tilfredshet med tjenestetilbudet i liten grad var avhengig av hvor behandlingen fant sted. Det vil si at pasientene var fornøyd eller misfornøyd relativt uavhengig av hvor de ble behandlet. For eksempel blant pasienter i poliklinikker for voksne kunne bare om lag to prosent av variansen i tilfredshet knyttes til hvilken behandlingsenhet som sto for behandlingen. Resultatene viste også at ulike mål på den psykiske lidelsens alvorlighet var assosiert med pasienttilfredshet, noe som vil ha betydning ved sammenlikning av behandlingsenheter med til dels ulike behandlingsoppgaver. Avhandlingen viser at aggregerte mål for pasienttilfredshet har klare begrensninger som indikator på organisatorisk kvalitet. Det er grunn til å tvile på om gjennomsnittlig tilfredshet ved for eksempel en poliklinikk er egnet som styringsinformasjon. Det synes som om metoden i liten grad er egnet til å identifisere poliklinikker med dårlig kvalitet og det er også usikkert om de poliklinikkene som metoden beskriver som dårlige, faktisk er dårlige. Kandidat: Johan Håkon Bjørngaard, Institutt for samfunnsmedisin Veiledere: Jon Magnussen, Torleif Ruud og Svein Friis Finansieringskilde: Rådet for psykisk helse og Stiftelsen Helse og Rehabilitering

Surgical services contribute to a large proportion of a hospital’s costs and revenues thus it is important to understand key performance drivers so that resources can be distributed in an informed way. Organizational policies can affect the performance of the peri-operative process, however, there is a lack of knowledge within the health services literature regarding how the organizational policies of a surgical service affect surgeons’ availability to perform operations. Additionally, simulation-based research has largely focused on operating room planning and scheduling, not on how surgeons’ operating time may be affected by organizational policies. The objective of this simulation study was to estimate the effects of organizational policies on surgeons’ availability to operate in the context of cardiac surgical care. The major finding was that surgeons’ availability to operate declines if surgeons are not permitted to be on-call and scheduled in the OR for non-emergency operations on the same day.

Surgical services contribute to a large proportion of a hospital’s costs and revenues thus it is important to understand key performance drivers so that resources can be distributed in an informed way. Organizational policies can affect the performance of the peri-operative process, however, there is a lack of knowledge within the health services literature regarding how the organizational policies of a surgical service affect surgeons’ availability to perform operations. Additionally, simulation-based research has largely focused on operating room planning and scheduling, not on how surgeons’ operating time may be affected by organizational policies. The objective of this simulation study was to estimate the effects of organizational policies on surgeons’ availability to operate in the context of cardiac surgical care. The major finding was that surgeons’ availability to operate declines if surgeons are not permitted to be on-call and scheduled in the OR for non-emergency operations on the same day.

Objective: To describe the epidemiology and health system impact of medium-chain acyl-CoA dehydrogenase deficiency (MCADD) in Ontario. Methods: Following a review of methods to estimating robust health event rates for small populations, this study described health services use among infants diagnosed with MCADD or received a false positive newborn screening result for MCADD from April 2006 through March 2010. Each cohort was compared with screen negative infants by linking to databases encompassing physician visits, emergency department care, and hospitalizations. Results: Relative to comparison birth cohorts, children with MCADD (n=40) experienced significantly higher rates of all health service types, regardless of age at the time of visit; infants with false positive results for MCADD (n=43) experienced significantly higher rates of physician visits and hospitalizations in the first year of life only. Conclusion: This study makes an important contribution to the limited existing research describing the health system impact of rare diseases.

BACKGROUND: The VA is the nation’s largest hepatitis C virus treatment provider with a large cadre of HCV specialty care providers. Nevertheless, when highly effective, but expensive all-oral interferon-free medications (directly-acting antivirals, DAAs) for HCV were released, the unanticipated high demand created a VA pharmacy funding shortfall. As this shortfall became apparent, the Veterans Choice Program’s “Choice First” (Choice) initiative emerged. Through Choice, veterans could seek HCV care from non-VA community providers in lieu of waiting for VA care, which in turn complicated access and adoption of DAAs. This study examined VA patient and providers’ experience of and reactions to new DAAs and the implementation of Choice for HCV care.

 METHODS: A qualitative study informed by grounded theory methodology was conducted involving semi-structured interviews with 38 veteran patients and 10 of their HCV providers at three VA medical centers in New England. Patient and provider interviews focused on their experiences with the new HCV treatment, and the processes of care in the VA and through Choice.

 RESULTS: Five themes emerged: 1) the VA’s implementation was considerably more reactive than planned, 2) adopting highly effective HCV medication and Choice were both symbiotic and reciprocally confounding, 3) patient demand and provider awareness were attributed to direct-to-consumer-advertising, 4) the VA organizational structure was not perceived as conducive to rapid implementation of highly effective, demanded, yet costly medication, and 5) veterans and providers had similar perceptions of treatment candidacy. 

 CONCLUSIONS: The VA initially achieved a rapid pace of treating veterans with the DAAs, but eventually could not keep up with demand, leading to a largely unsuccessful attempt to refer patients to non-VA care for HCV treatment. The VA acted as a complex adaptive system and responded to implementation difficulties by applying new policies, which were often opaque, disrupted provider heuristics and practices, and impaired patient autonomy. Patients and providers embraced the HCV treatment innovation, but their experiences navigating community HCV care through Choice indicated a number of flaws in the execution of that program. Choice could have been implemented more effectively with proper recognition and measurement of system antecedents. / 2026-10-31T00:00:00Z

Background: To assess the validity and reliability of the set of scales (general professional activity, health services management, and working conditions) on the different areas of job satisfaction in Peruvian physicians based on the data from the National Survey of Satisfaction of Users in Health (ENSUSALUD). Method: We carried out a psychometric study based on the secondary data analysis of Questionnaire 2 of ENSUSALUD-2016. Participants were selected from a two-stage stratified national probability representative sampling by political region. Validity was assessed by exploratory and confirmatory factor analyses, and measurement invariance analysis. We assessed the reliability using internal consistency coefficients (alpha and omega). The set of scales were composed of items related to three different areas of job satisfaction: 1) satisfaction with general professional activity, 2) satisfaction with the health services management, and 3) satisfaction with the working conditions of the health center. Results: We included 2137 participants in the analysis. The general professional activity scale with six items (Comparative Fit Index, CFI = 0.946; Root Mean Square Error of Approximation, RMSEA = 0.071; Standardized Root Mean Square Residual, SRMR = 0.035), the health services management scale with eight items (CFI) = 0.972; RMSEA = 0.081; SRMR = 0.028), showed good measurement properties for the one-dimensional model. The working conditions scale with eight items for individual conditions and three items for infrastructural conditions (CFI = 0.914; RMSEA = 0.080; SRMR = 0.055) presented adequate measurement properties with a two-dimensional model. The invariance analysis showed that comparisons between sex, age, civil status, medical speciality, working in other institutions, work-related illness, chronic disease, and time working in the healthcare center. All scales had adequate internal consistency (ω and α between 0.70 and 0.90). Conclusions: The set of scales has a solid factorial structure and measurement invariance, making it possible for group comparison. The study achieved stability in the scores as they showed adequate internal consistency coefficients. Based on our findings, these instruments are suitable for measuring job satisfaction among outpatient physicians throughout Peru, as our data is representative of the country level. / Revisión por pares

The nursing workforce increasingly faces issues that affect clinical and managerial practice. One such issue is work-family conflict (WFC) and family-work conflict (FWC). Nurses face role strain as they confront the pressures from often competing work-and-family roles. This study assessed WFC/FWC among varying nurse roles: staff nurses, managerial nurses, and nurse executives. A random sample of 5,000 nurses, generated from registered nurses practicing in the state of Florida, was surveyed for this research study. Nurses were surveyed on demographics, perceptions regarding the work environment, and perceptions of WFC/FWC. Descriptively, nurses experienced more work-family conflict than family-work conflict. Regression analyses and ANOVAs indicated that staff nurses experienced less work-family conflict than nursing managers (second most) and nursing executives (highest). None of the nurse roles experienced significant levels of FWC. White nurses, compared to non-white nurses, experienced less WFC and FWC. WFC increased with shift length but FWC was not significantly affected by it. Paid leave for childbirth was associated with lower FWC. This study holds significant implication for the nursing workforce. Nurse managers and executives showed significantly higher WFC than staff nurses. This may discourage a nurse from taking on leadership roles or lead to leaving them. In an era where nurse managers and leaders are needed, efforts must be taken to decrease WFC/FWC factors. Nonwhite nurses reported higher levels of both WFC and FWC. This may contribute to tension at the workplace and a difficult family life. Leaders must continue to create platforms for nurses of all races and ethnicities to voice their work and family needs, and to be supported when doing so. Nurses working shifts over 8 hours had higher WFC levels. Although 12-hour shifts have been popular among staff and management, their use should be reevaluated. Finally, paid leave for childbirth is a program worth supporting, as it was a factor in lower FWC.

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