Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2006.

Abstract Purpose This study is designed to determine whether managed care has had an influence on the number and distribution of procedures with demonstrated volume and outcome endogeneity in Florida healthcare markets; in addition, methods are developed to determine which measures of managed care activity best predict the impact of managed care on surgical procedure utiliation. Rationale A shift in surgical procedure volume on the basis of preferred provider arrangements has the potential to redistribute surgical procedures within hospital markets. The surgical procedures for which such a distribution could have the greatest impact on population health are those for which the volume of cases performed has a strong inverse influence on the outcomes observed. A shift in high risk surgical procedures to low volume hospitals could potentially reduce the number of cases performed at high volume centers and increase cases at low volume centers, adversely impacting quality in both. Methods A retrospective population based cohort design is used to capitalize on the variability among Florida metropolitan statistical areas between 1995 and 1999, a period which captured the full business life cycle of managed care plans in Florida. Multiple regression models are used to measure the impact of changes in managed care activity as measured by penetration, index of competition and consolidation on the change in the number and distribution of seven procedures for which volume is associated with patient outcome, controlling for socio-demographic and market factors known to influence surgical procedure utilization. Difference scores derived for each of the model variables were used to measure change from the baseline in 1995 to 1999. Post hoc analysis of the count data models was performed using the cases from all study years in a log linear generalized estimating equation to provide validation of the difference score approach. Key Findings Study procedure volume increased over the period, and remained a consistent proportion of the total inpatient surgical procedure volume. Procedure rate remained stable over the study period with substantial small area variation. Change in managed care concentration was consistently and negatively associated with procedure volume at both the MSA (&betaâ&beta = -19.67; p = 0.0489) and hospital level (&betaâ&beta = -4.088; p = 0.0027).Change in the total population and the number of specialty surgeons had a substantial, consistent and positive relationship to change in procedure volume at both the market and hospital level. The change in the index of competition was positively associated with change in hospital market share (&betaâ&beta = 0.1005; p = 0.05); whereas, neither change in managed care penetration nor change in managed care index of competition was predictive of change in procedure volume at the market level. The managed care variables were not correlated when difference scores were tested providing evidence that the managed care variables measure different constructs and behave differently. Implications As markets for managed care became more concentrated, the number of surgical procedures with volume and outcome endogeneity declined; the specific reasons for the observed decline require additional study. Competitive managed care markets have a favorable impact on hospital market share for these high risk, high margin procedures. Studies of managed care require consideration of the stage of managed care development in order to understand its influence and the use of difference scores as a method to measure change over time has substantial potential for the study of health care markets.

"Diabetes mellitus" refers to a spectrum of conditions, which all present with hyperglycaemia as a common medical finding. Diabetes was once thought of as a single disease, but according to Setter et a/. (2000:378), it includes a heterogeneous group of disorders that are secondary to various genetic predispositions and precipitating factors. Type 1 diabetes mellitus (DM) accounts for 10 to 15% of all cases of diabetes mellitus and is clinically characterised by hyperglycaemia and a propensity to diabetic keto-acidosis. Its control requires chronic insulin treatment. Although it may occur at any age, it most commonly develops in childhood or adolescence and is the predominant type of diabetes mellitus diagnosed before age 30 (Beers & Berkow, 2004). Type 2 DM is usually the type diagnosed in patients older than 30 years of age. It is also commonly associated with obesity (Berkow, 1992:1108). The objective of this study was to review the usage and cost of antidiabetic drugs and to determine the influence of the pricing regulations on the cost of these drugs. This research can be classified as retrospective and quantitative. Data were obtained from a prescription claims database, and the study population consisted of all the antidiabetic prescriptions for the year 1 January 2004 to 31 December 2004. The one-year period was divided into three study periods, namely January to April, May to August and September to December. Firstly diabetes mellitus was investigated in order to understand the disease and to determine the prevalence and treatment thereof. It was found that diabetes mellitus is a heterogeneous disorder acquired from both genetic and environmental factors and that education for the general population, and in particular for the patients, is the key to preventing and controlling diabetes and reducing the complications arising from it. Secondly managed health care, pharmaco-economics and a drug utilisation review were investigated in order to understand these concepts. The influence of the South African Government on health care was discussed, including the new pricing regulations of medicine in South Africa. Thirdly, the utilisation patterns of antidiabetic drugs were reviewed, analysed and interpreted. It was determined that the oral antidiabetic agents are relatively less expensive than the insulins and that they are prescribed more frequently, and secondly that the biguanides presented almost half (49.4%, n = 116 138) of all the oral antidiabetic agents. It was also determined that the average cost of the oral antidiabetic drugs was between 21 .O% and 28.0% lower in 2004 than in 1996 - an indication that, despite inflation, the antidiabetic drugs were less expensive in 2004 than eight years ago in 1996. It was also calculated that the total cost savings in antidiabetic medication could have been R1 448 682.26 if the lower price of antidiabetic agents had been implemented during the period January to April. And finally it was also determined that further substantial "cost savings" could have been possible if all the innovator antidiabetic products had been substituted for less expensive generic antidiabetic products. Abstract / Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2006.

"Diabetes mellitus" refers to a spectrum of conditions, which all present with hyperglycaemia as a common medical finding. Diabetes was once thought of as a single disease, but according to Setter et a/. (2000:378), it includes a heterogeneous group of disorders that are secondary to various genetic predispositions and precipitating factors. Type 1 diabetes mellitus (DM) accounts for 10 to 15% of all cases of diabetes mellitus and is clinically characterised by hyperglycaemia and a propensity to diabetic keto-acidosis. Its control requires chronic insulin treatment. Although it may occur at any age, it most commonly develops in childhood or adolescence and is the predominant type of diabetes mellitus diagnosed before age 30 (Beers & Berkow, 2004). Type 2 DM is usually the type diagnosed in patients older than 30 years of age. It is also commonly associated with obesity (Berkow, 1992:1108). The objective of this study was to review the usage and cost of antidiabetic drugs and to determine the influence of the pricing regulations on the cost of these drugs. This research can be classified as retrospective and quantitative. Data were obtained from a prescription claims database, and the study population consisted of all the antidiabetic prescriptions for the year 1 January 2004 to 31 December 2004. The one-year period was divided into three study periods, namely January to April, May to August and September to December. Firstly diabetes mellitus was investigated in order to understand the disease and to determine the prevalence and treatment thereof. It was found that diabetes mellitus is a heterogeneous disorder acquired from both genetic and environmental factors and that education for the general population, and in particular for the patients, is the key to preventing and controlling diabetes and reducing the complications arising from it. Secondly managed health care, pharmaco-economics and a drug utilisation review were investigated in order to understand these concepts. The influence of the South African Government on health care was discussed, including the new pricing regulations of medicine in South Africa. Thirdly, the utilisation patterns of antidiabetic drugs were reviewed, analysed and interpreted. It was determined that the oral antidiabetic agents are relatively less expensive than the insulins and that they are prescribed more frequently, and secondly that the biguanides presented almost half (49.4%, n = 116 138) of all the oral antidiabetic agents. It was also determined that the average cost of the oral antidiabetic drugs was between 21 .O% and 28.0% lower in 2004 than in 1996 - an indication that, despite inflation, the antidiabetic drugs were less expensive in 2004 than eight years ago in 1996. It was also calculated that the total cost savings in antidiabetic medication could have been R1 448 682.26 if the lower price of antidiabetic agents had been implemented during the period January to April. And finally it was also determined that further substantial "cost savings" could have been possible if all the innovator antidiabetic products had been substituted for less expensive generic antidiabetic products. Abstract / Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2006.

HIV/AIDS is already the leading cause of death worldwide (Unicef et al., 2004:10) with more than 5 million people out of a total of 46 million South Africans that were HIV positive in 2004, giving a total population prevalence rate of 11 per cent (Dorrington et al., 2004:1). Many people infected do not have access to even the basic drugs needed to treat HIV-related infections and other conditions (Wikipedia, 2004:3). The relative high price of many of the antiretroviral (ARV) drugs and diagnostics on the other hand are one of the main barriers to their availability in developing countries (Unicef et al., 2004:77). ARV drugs registered in South Africa include the Nucleoside/Nucleotide Reverse Transcriptase Inhibitors (NRTIs), Non-Nucleoside Reverse Transcriptase Inhibitors (NNRTIs) and Protease Inhibitors (PIs) (MCC, 2004:1). The objective of this study was to review, analyse and interpret the prescribing patterns of antiviral drugs, with special reference to antiretroviral drugs, in the private health care sector in South Africa by using a medicine claims database. A quantitative, retrospective drug utilisation review was performed. The data ranging from 1 January 2001 to 31 December 2001, 1 January 2002 to 31 December 2002, and 1 January 2004 to 31 December 2004 were used, dividing each year into three four-month periods, namely January to April, May to August, and September to December. It was found that 0.38 per cent (n=1 475 380) for 2001, 0.72 per cent (n=2 076 236) for 2002, and 1.68 per cent (n=2 595 254) for 2004 of all studied prescriptions for the research periods 2001, 2002, and 2004 respectively, contained ARV drugs. ARV drugs constituted 0.33 per cent (n=2 951 326) for 2001, 0.87 per cent (n=4 042 145) for 2002, and 1.92 per cent (n=5 305 882) for 2004 of the total number of medicine items prescribed for the study years 2001, 2002 and 2004 respectively. The total cost of ARV drugs amounted to R4 990 784.29, thus constituting 1.31 per cent of the total cost (R379 708 489) of all medicine items on the database for 2001, increased to R18 235 075.75, thus constituting 3.03 per cent of the total cost (R601 350 325) of all medicine items on the database for 2002, and increased to R34 714 483.64, thus constituting 5.25 per cent of the total cost (R661 223 146) of all medicine items on the database for 2004. It was found that 35.31 per cent (n=5 599) for 2001, 52.68 per cent (n=15 004) for 2002, and 74.27 per cent (n=43 482) for 2004 of all studied antiviral prescriptions for the research periods 2001, 2002, and 2004 respectively, contained ARV drugs. ARV drugs constituted 46.25 per cent (n=21 183) for 2001, 70.20 per cent (n=50 246) for 2002, and 85.87 per cent (n=118 718) for 2004 of the total number of antiviral medicine items prescribed for the study years 2001, 2002 and 2004 respectively. The total cost of ARV medicine items, represented 67.33 per cent (n=R4 990 784.29) during 2001, 84.72 per cent (n=R18 235 075.75) during 2002, and 91.20 per cent (n=R34 714 483.64) during 2004 of the total cost of all antiviral medicine items claimed through the database (n=R7412577.73 for 2001, n=R21523365.56 for 2002, and n=R38 064 347.38 for 2004). The average cost per ARV medicine items for 2004 increased from R317.93i190.80 for the period January to April to R369.2W219.50 for the period May to August, and decreased to R324.79±212.48 for the period September to December and resulted in a cost saving of R41 044.35 for the period May to August versus September to December for the ARV medicine items. The implementation of the pricing regulations could thus be a possible reason for this cost saving, due to fact that the single exit price only came into effect from May 2004. The weighted average number of ARV medicine items per prescription was 1.75*0.31 for 2001, increased to 2.35±0.03 to 2002 and remained stable on 2.35±0.02 for 2004. It was found that majority of prescriptions contained more combination ARV medicine items than single ARV medicine items, ranging from 6 834 (69.76 per cent; n=9 796) prescriptions containing combination ARV medicine items in 2001 and 32 941 (93.39 per cent; n=35 271) prescriptions containing combination ARV medicine items in 2002 to 98 805 (96.93 per cent; n=101 938) prescriptions containing combination ARV medicine items in 2004. Lastly, it was perceived that didanosine was the active ingredient with the largest prevalence for all three four-month periods of 2001 and also for the periods January to April and May to August of 2002, whilst efavirenz represented the active ingredient with the largest prevalence for the period September to December of 2002, and also for all three four-month periods of 2004. Didanosine represented the active ingredient with the highest total cost for the period January to April of 2001, whilst the combination of lamivudine/zidovudine represented the active ingredient with the highest total cost for the periods May to August and September to December of 2001, and also for all three-four month periods of 2002 and 2004. Nelfinavir has the highest average cost for period January to April of 2001, ritonavir for period May to August of 2001, and saquinavir mesylate for period September to December of 2001. Nelfinavir has the highest average cost for all three-four month periods of 2002, while didanosine has the highest average cost for all three four-month periods of 2004. / Thesis (M.Pharm. (Pharmacy Practice))--North-West University, Potchefstroom Campus, 2006

Private practice as a career option for nurses has been slowly increasing since the 1980's. However, the reasons for this development have not been fully investigated so that it can be understood and placed within the changing contexts of health care and health services. The expansion and extension of nurses' roles is a contemporary topic in health care reform and therefore one that deserves investigation. The aims of this study were to develop a theory on private practice nursing and to describe the characteristics and work of the self-employed nurse in Australia. Nurses working in a variety of settings have been able to provide information on being self-employed. In doing so, this study was able to describe the persona of the nurse entrepreneur, explore the reasons why nurses and midwives in Australia establish private fee-for-service practices, identify the factors which have influenced this action and describe the scope of practice of nurses and midwives in private practice. This combined Delphi technique and Grounded Theory study is the first in-depth study of Australian nurses and midwives in private practice. The study enables nurses to provide direct information on being self-employed and enhances the profession's ability to articulate about this area of nursing. The significance of the research is in increasing the understanding of this area of practice development and affords greater insight into its efforts to improve and maintain quality nursing services within the Australian health care system. One hundred and six nurses and midwives were invited to participate in the study, in which participants completed two rounds of semi-structured postal questionnaires. Delphi technique was applied to rate responses on Likert scales to ascertain respondents' consensus on certain topics. Participants were also provided the opportunity to make additional comments. Results indicated that nurses in private practice are well experienced with an average of 21 years nursing experience and hold several qualifications. Job satisfaction, being able to be more involved in achieving quality health outcomes and maximising skills and abilities are significant influences for private practice. These results suggest that private practice nursing can contribute effectively to broadening the range of primary health services available to the population and to addressing the issues of retention and recruitment of nurses. Self-employed nurse entrepreneurs push the boundaries of the profession and expand the realm of nursing practice. Entrepreneurship is a path for the future of nursing as it offers expanded career opportunities for nurses and opportunities for increased ambulatory health services. In addition, the broad, expert knowledge nurses hold on many aspects of health can be disseminated throughout the health sector to the advantage of corporate health partners. There is further development required in this innovative and expanding area of the nursing profession. / Thesis (Ph.D.)--Department of Clinical Nursing, 2003.

Pa., Carnegie Mellon Univ., H. John Heinz III School of Public Policy and Management, Diss.--Pittsburgh, 2001. / Kopie, ersch. im Verl. UMI, Ann Arbor, Mich.

M.Cur. / Managed healthcare was introduced in South Africa largely in order to control the rampant increase of medical costs, more especially in the private healthcare industry. Managed healthcare is a system of healthcare delivery, which ensures that cost effective quality care is provided to patients without jeopardising the health of the patient. Positive working relationships are necessary among the role players in the provision of cost effective quality care within the managed healthcare context. Role players experience problems in the delivery of healthcare, affecting their working relationships, which in turn affects the quality of care provided to patients. Because managed healthcare is a new concept in South Africa, little is known about the problems. As a result, there are no guidelines for the formulation of a strategy to enhance positive working relationships among the role players within the context of managed healthcare. Understanding the problems experienced by the role players will provide guidelines to the researcher to formulate a strategy to enhance positive working relationships, hence the reseacher sought to explore and describe these problems in the study. The purpose of the study is to formulate a strategy to enhance positive working relationships among the role players within the managed healthcare context in Gauteng. The specific objective is to explore and describe the problems experienced by the role players, as well as the possible solutions within the managed healthcare context in Gauteng. The relevant research questions are: * What are the problems experienced by the role players within the managed healthcare context in Gauteng, and what are the recommended solutions to counteract these problems? * What strategy can be formulated to enhance positive working relationships among the role players within the managed healthcare context in Gauteng? A qualitative, exploratory, descriptive and contextual design was followed to answer the research questions. Focus group interviews and a workshop were conducted to collect data and a content analysis was conducted as described by Tesch (1990). The results were analysed in two phases: the problems experienced and the suggested solutions to counteract these problems. A strategy to enhance positive working realtionships was suggested. The strategy, which is based on role player empowerment, staff development, staff recruitment and selection, use of advanced information technology and standardisation of methods across managed healthcare industry, was derived from a synthesis of solutions suggested by the participants. Guba and Lincoln's (1983:290) principles of trustworthiness were employed by the researcher and the ethical standards as set by DENOSA (1998) were adhered to by the researcher to facilitate the quality of the study. It was recommended that the strategy be implemented and evaluated for its effectiveness by evaluating the quality of working relationships among the role players and that ethical standards be formulated in managed healthcare.

The rising costs of health care and burgeoning government deficits have prompted new ways to control costs, while continuing to provide necessary health care. One method increasingly chosen by states to achieve these objectives is managed health care. There are many forms of managed care organization today. There are HMOs that provide the financing and delivery systems under the control of a single for-profit or non-profit organization; preferred provider organizations consisting of providers that have a pre-negotiated and usually discounted rate for services; administration service organizations that provide claims adjudication; and managed indemnity services organizations that use case management to control costs, while providing beneficiary freedom of choice.

No description available.