Background: Pre-eclampsia (PET) is one of the major causes of maternal and neonatal morbidity and mortality1. Misclassification of PET can lead to biased or erroneous results in epidemiologic studies resulting in false conclusions. Objectives: The objectives of this thesis are to determine the validity of PET diagnosis in pregnant women in administrative database using the ICD-10-CA codes, to explore the nature of misclassification, and to estimate whether misclassification of PET diagnosis in administrative database may result in biased conclusions. Methods: Pregnant women who participated in the Ottawa and Kingston (OaK) Birth Cohort study and delivered in the Ottawa Hospital were included in the study. All cases with hypertensive disorder of pregnancy in the study population were adjudicated to confirm diagnosis of PET. This adjudicated dataset was used as a reference standard. The PET incidence in hospital discharge database was compared with PET incidence calculated from the reference standard database. Results: 2887 of the requested charts were available for review. The PET incidence was much lower in administrative database (1.47%) than in the OaK Birth Cohort Study (3.6%). The results of the study demonstrated that hospital discharge database via ICD-10-CA was not very sensitive to determine incidence of PET since sensitivity of ICD-10-CA diagnostic codes for PET was low (35.92% with 95% Confidence Intervals (CI): 26.7; 45.9) but specificity, PPV, and NPV were high. The majority of misclassified cases belonged to the category (according to the proposed classification) “PET pregnancies coded with incorrect ICD-10-CA code” (78.88%) followed by the category “Pregnancies affected by PET coded as normal” (14.08%). Conclusion: Using hospital discharge database and ICD-10-CA coding to determine incidence of PET in certain settings may yield low sensitivity. Researchers should validate the results when using the hospital discharge database for PET research to ensure that the findings based on analyses of such data demonstrate what they claimed to demonstrate.

Background: An Implantable Cardioverter Defibrillator (ICD) is a technical device used in the treatment of ventricular arrhythmias. After the implantation of an ICD the entire life situation can be affected with psychological and social consequences for the patient and his/her next of kin. The healthcare professionals play a vital role in providing educational information, support, and technical follow-up of the device. During recent years more and more hospitals have introduced a more team based organisation where the physicians collaborate with specialised ICD nurses. Aim: The overall aim of the thesis was to explore how patients with an ICD experienced their life situation and howhealthcare professionals described their experiences of delivering care to ICD patients. Methods: The design was descriptive, combining both quantitative and qualitative approaches, and the data was collected from Sweden and the USA. The Uncertainty of Illness Scale (MUIS-C) and Quality of life Index (QLI) instruments were used to determine the level of uncertainty and satisfaction with life (I), in-depth interviews with a phenomenographic approach was used to describe how Swedish and US patients living with an ICD conceived their life situation (II, III) and how healthcare professionals’ experienced delivering care to patients with an ICD, (IV). Finally, to explore clinical aspects of ICD care in Sweden, the Delivery of ICD Questionnaire (DOIQ) was used to describe the healthcare professionals’ experiences and a content analysis was used to describe the written educational information material provided to patients (V). Results: There were no differences in uncertainty between pre and post ICD implantation either in Swedish or the US patients. Satisfaction with life was significantly higher among US patients compared to Swedish patients both before and after ICD implantation within the health-functioning, socio-economic and psychological-spiritual domains. The Swedish ICD patients experienced a significantly higher satisfaction with life within the socioeconomic domain after 3 months. (I). The patients felt safe in having an ICD implanted, but the conceptions varied from seeing the device as a life saver to being worried about what could happen. Gratitude at having an ICD varied from happiness at being alive to something that was alien and disturbed the patient. Being more or less dependent included how patient experienced feelings from well-being to grief. Having a network varied from having sufficient support to loneliness. Having a belief in the future ranged from having confidence to look forward to resignation. Gaining awareness described patients’ adaptation to living with an ICD and limitations due to the ICD (II). The patients also underwent a transition from becoming aware of the restriction in the life situation through a process of adaption and having trust in the ICD. This phase was followed by a reorientation phase where they adapted to their life situation and the patient and his/her family regained of their lives (III). The healthcare professionals strove to provide competent and individualised care and infuse confirmation to the patients in form of information, education and support. They gave the patients tools to handle their life situation, through existential support and mediating security (IV). Half of the hospitals had nurse-based clinic and others planned to introduce them. Three hospitals performed follow-up in the form of remote home monitoring. The nurse had specific ICD education from ICD companies and/or various university courses. In the educational information material the biophysical dimensions dominated while the emotional dimension was scarcely described, and the spiritual-existential was not referred to at all (V). Conclusions: This thesis offers a further contribution to the scholarly discussion about the relationship between technology and human existence and how to cope with this transition. Our studies revealed that the embodiment of the ICD reflects a merger of experiences about its presence and potential from both patients’ and healthcare professionals’ perspective. This research hopefully encourages healthcare professionals to carefully reflect on what it is like to live with an ICD and to consider practice improvement for the patients’ and the next of kin.

The thesis builds up on the significance of the social aspect of the statistics giving direct reference to the standards of the European Union (EU) on statistics. The study concentrates on the modernization, reformation and transformation process of the Turkish Statistical System, particularly the health statistics on the basis of a specific Programme called &ldquo / Upgrading the Statistical System of Turkey&rdquo / funded by the EU and the Law on Turkish Statistics (No: 5429) within the process of the harmonization of the Turkish Statistical System, which aims the integration of the current system to the international one via the EU acquis communautaire. This thesis presents the causes of the death statistics as one of the most significant dimensions of statistics since it is the most extensive and the oldest public health surveillance system in the world. The reformation in the certification process, the classification stage and the analysis of the cause of the death statistics (COD) are examined in detail hereby. Improvement of the coverage, introduction of the International Classification of Diseases-10th Revision (ICD-10), development of institutional coordination and a new formation of the causes of death statistics in line with the EU requirements are analyzed in depth. Based on the findings of this study, it is proposed that the introduction of ICD-10 and improvement of the coverage of the COD statistics are not sufficient to ameliorate the shortcomings of the current death certificate system rested upon on the two documents including the &ldquo / COD forms&rdquo / and the &ldquo / burial licence&rdquo / in Turkey. The study also suggests that solutions to be proposed should be radical and effective since the problems encountered in the death certificate system are deep-rooted. Consequently, with regard to the issues of increasing the coverage of physical autopsy and providing training for the COD forms and with the aim of reducing diversified and complex chain of bureaucratic transactions, it is essential to bring an encompassing new legal base for the current death certificate system.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) surgery is the most common reason for elective pediatric orthopaedic surgery. Minimization of adverse events is an important goal. Institute of Medicine (IOM) outlined 6 facets of healthcare quality improvement within the acronym STEEEP. Two of these facets, Safety and Timeliness for AIS surgery in Canada, are examined in this thesis. METHODS: A three - part study, using clinical records at the largest Canadian pediatric hospital and CIHI national administrative data, determined i) the relationship between surgical wait times and rates of adverse events, along with determination of an empirically derived access target, ii) accuracy of ICD-10 coding of surgical AIS cases along with an optimal search strategy to identify surgical AIS cases, and iii) the volume – outcome relationships for scoliosis surgery using hierarchical and conventional single level multi-variate regression analysis. RESULTS: Access target of 3 months minimized the adverse events related to waiting. Optimal search strategy for AIS surgical cases using ICD-10 coding required combination of codes as each code in isolation was inaccurate due to limitations in coding definitions. There was no significant volume – outcome relationship using appropriate modeling strategies. CONCLUSIONS: Ensuring timeliness of surgical treatment of less than 3 months is important in surgical cases of AIS given the potential for curve progression in higher risk individuals who are skeletally immature with large magnitude curves at time of surgical consent. At the administrative database level, knowledge of coding accuracy and optimal search strategies are needed to capture a complete cohort for analysis. In AIS, several ICD-10 codes need to be combined. AIS surgery cases captured through this optimal search strategy, revealed no significant volume-outcome relationships with appropriate modeling. Based on these results, minimum volume thresholds and regionalization of care for AIS surgery does not appear to be justified. However, a larger sample size was needed to determine whether there was a clinically significant difference in wound infection and blood transfusion rates. Furthermore, clinical variables, not part of an administrative database such as curve pattern were not included.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) surgery is the most common reason for elective pediatric orthopaedic surgery. Minimization of adverse events is an important goal. Institute of Medicine (IOM) outlined 6 facets of healthcare quality improvement within the acronym STEEEP. Two of these facets, Safety and Timeliness for AIS surgery in Canada, are examined in this thesis. METHODS: A three - part study, using clinical records at the largest Canadian pediatric hospital and CIHI national administrative data, determined i) the relationship between surgical wait times and rates of adverse events, along with determination of an empirically derived access target, ii) accuracy of ICD-10 coding of surgical AIS cases along with an optimal search strategy to identify surgical AIS cases, and iii) the volume – outcome relationships for scoliosis surgery using hierarchical and conventional single level multi-variate regression analysis. RESULTS: Access target of 3 months minimized the adverse events related to waiting. Optimal search strategy for AIS surgical cases using ICD-10 coding required combination of codes as each code in isolation was inaccurate due to limitations in coding definitions. There was no significant volume – outcome relationship using appropriate modeling strategies. CONCLUSIONS: Ensuring timeliness of surgical treatment of less than 3 months is important in surgical cases of AIS given the potential for curve progression in higher risk individuals who are skeletally immature with large magnitude curves at time of surgical consent. At the administrative database level, knowledge of coding accuracy and optimal search strategies are needed to capture a complete cohort for analysis. In AIS, several ICD-10 codes need to be combined. AIS surgery cases captured through this optimal search strategy, revealed no significant volume-outcome relationships with appropriate modeling. Based on these results, minimum volume thresholds and regionalization of care for AIS surgery does not appear to be justified. However, a larger sample size was needed to determine whether there was a clinically significant difference in wound infection and blood transfusion rates. Furthermore, clinical variables, not part of an administrative database such as curve pattern were not included.

Many manual biomedical annotation tasks can be categorized as instances of the typical multi-label classification problem where several categories or labels from a fixed set need to assigned to an input instance. MeSH term assignment to biomedical articles and diagnosis code extraction from medical records are two such tasks. To address this problem automatically, in this thesis, we present a way to utilize latent associations between labels based on output label sets. We used random indexing as a method to determine latent associations and use the associations as a novel feature in a learning-to-rank algorithm that reranks candidate labels selected based on either k-NN or binary relevance approach. Using this new feature as part of other features, for MeSH term assignment, we train our ranking model on a set of 200 documents, test it on two public datasets, and obtain new state-of-the-art results in precision, recall, and mean average precision. In diagnosis code extraction, we reach an average micro F-score of 0.478 based on a large EMR dataset from the University of Kentucky Medical Center, the first study of its kind to our knowledge. Our study shows the advantages and potential of random indexing method in determining and utilizing implicit relationships between labels in multi-label classification problems.

Until recently, the development and maintenance of the standard international disease classification for diagnostic, epidemiological and health management purposes has been handled by a closed group of experts with little input from other members of the medical community, interested organizations, or patient groups. The eleventh revision of the World Health Organization's International Classification of Diseases (ICD-11) represents an attempt to involve a much broader stakeholder group in the process of redesigning a standardized classification. Our research is an exploratory case study of this revision effort. We examine the socio-technical ecosystem of the ICD-11 project and produce a set of five recommendations for developing inclusive standardization systems. These recommendations are supported by an analysis of two additional projects in the health information and informatics domain, as well as a varied collection of literature. Our first recommendation implores system designers to consider technology-readiness and collaboration-readiness. We also advocate for the support of articulation and coordination work, and address the need for a distinct purpose and clearly defined process surrounding any introduced technology. Finally, we shed light on the need for incremental openness when attempting to involve a wide audience of stakeholders in the development process. / Graduate

Background The effects of prolonged, interpersonal trauma have long been recognised. Such traumatic events can lead to the development of post-traumatic stress disorder (PTSD), but are also associated with a range of other psychological difficulties. The forthcoming ICD-11 has proposed the inclusion of a new diagnostic category to cover such trauma reactions, named complex-PTSD (CPTSD). CPTSD is conceptualised as including the core elements of PTSD with additional difficulties with affect regulation, self-concept, interpersonal relationships. This thesis presents a systematic review of the research into the proposed CPTSD diagnosis. In addition, this thesis investigates the association between difficulties with emotional regulation, interpersonal problems and PTSD symptoms in a group of male prisoners, and a male community sample. Aims This project aims to investigate whether the proposed CPTSD diagnosis accurately describes the difficulties seen following complex trauma, and examines whether it is best to view CPTSD is different from exiting disorders, including PTSD and borderline personality disorder (BPD). In addition, it aims to investigate the association between difficulties with emotional regulation, interpersonal problems and PTSD among men in prison. Methods We systematically assessed and synthesised the available research regarding the proposed ICD-11 CPTSD diagnosis. In the second paper, data regarding PTSD, emotional regulation, and interpersonal problems were collected from HMP Glenochil, a male-only prison in Scotland (n=51), and matched to an existing community data set (n=46). Results The results of the systematic review provide partial support for the factorial validity of CPTSD. In addition, they indicate that CPTSD can be conceptualised as distinct from both PTSD and BPD, and that CPTSD is more closely related to prolonged interpersonal trauma than PTSD. However, there is overlap between PTSD and CPTSD in terms of both symptomology and aetiology. The results also indicate high levels of PTSD among male prisoners. In addition, PTSD was found to be strongly associated difficulties with emotional regulation, but not interpersonal problems, in the forensic sample. In the community sample emotional regulation was a less strong predictor of PTSD symptoms, and both emotional regulation, and interpersonal problems were associated with the severity of PTSD. Conclusions This thesis supports the inclusion of CPTSD as a distinct diagnostic entity. Inclusion of CPTSD may allow survivors a better understanding of the aetiology of their difficulties, and may initiate research into effective ways of working with individuals who have experienced complex-trauma. I addition, they demonstrate the need for trauma-informed prison services, which prioritise the development of emotional regulation strategies in recovery and rehabilitation.

A Organização Mundial de Saúde tem hoje duas classificações de referência para a descrição dos estados de saúde: a CID-10 (Classificação Estatística Internacional de Doenças e Problemas Relacionados à Saúde) e a CIF (Classificação Internacional de Funcionalidade, Incapacidade e Saúde). A utilização da CIF vem sendo aguardada com grande expectativa pelas organizações de pessoas com deficiências e instituições relacionadas. A falta de definição clara de “deficiência” ou “incapacidade” tem sido apontada como um impedimento para a promoção de saúde de pessoas com deficiência. Este trabalho tem como objetivo apresentar definições de deficiência, discutindo a utilização da CID-10 e da CIF e a contribuição da CIF para melhorar a compreensão sobre definições de deficiência a partir do conceito de funcionalidade e dos fatores contextuais. Foram revisados alguns diferentes conceitos/definições de deficiência, bem como publicações envolvendo a aplicação da CIF. São apresentadas algumas categorias de diagnósticos de estados de saúde da CID-10 hoje utilizadas em alguns sistemas, além de elementos da recém-apresentada CIF, que podem contribuir para diferentes campos de aplicabilidade no que diz respeito ao entendimento das definições de deficiência ou incapacidade. / The World Health Organization has nowadays two reference classifications for description of health conditions: ICD-10 (International Statistical Classification of Diseases and Health Related Problems) and ICF (International Classification of Functioning, Disability and Health). Organizations of people with disabilities and related institutions are waiting with high expectation for the ICF utilization. Lack of clear definition of “disability” is being pointed out as a deterrent for promoting the health of people with disabilities. The objective of this work is to evaluate definitions of disability, and discuss the use of ICD-10 and ICF and the contribution of ICF to improve understanding of definitions of disability through functioning and contextual factors. Some different definitions of disability have been reviewed, as well as publications involving ICF application. Diagnostic categories of health conditions of ICD-10 used in some systems are presented, as well as ICF components that could contribute for different fields of applicability regarding the understanding of definitions of disability.

In larger developments, a use of configuration management is crucial; the company UIQ Technology is no exception. The configuration management method controls how the flow within a software developer should go, so the configuration management method and code complexity is something that works affects each other. Therefore, you might be able to combine multiple configuration methods to try to use the best from each method to decrease code complexity. That is the goal of this thesis, to see if the COTS, Single repository or Component Based could combine with the UIQ method to decrease code complexity. This have been tested through theoretical use cases for each method and the conclusion of the study is that, Single repository and Component Based works best in the UIQ method. However, COTS is not suited for the UIQ method because of the need of secrecy for large parts of the UIQ platform. UIQ wants to do as much as possible in-house, rather than give it out to other third-party companies that they are not in absolute need of. Some improvements have been achieved throughout Single repository, that the other third-parties companies needs to be upto- date before starting development, that is something that have not been valued before.