CHDS State/Local / This thesis focuses on the medical as part of the public health response to Hurricane Katrina, specific to the issues of the private, non-governmental health professional. A brief survey was completed by 39 state level Bioterrorism Hospital Coordinators. Information obtained highlights the issues of the inability to deploy these private health professionals. Traditional governmental mutual aid mechanisms do not cover private non-governmental health professionals for workers compensation and death benefits. A review of the potential deployment mechanisms provides insight to the challenges and complexity specific to private health professionals. The motivation for volunteerism highlights the importance of targeting volunteer activities to the motivation of the individual volunteer. Investigating the impact thwarting the private, nongovernmental health professionals may have on future planning and response activities reinforce the need to modify the structures currently in place. The National Response Plan stresses the importance of including private industry into emergency preparedness and response strategies. This thesis outlines a strategy to pilot a project working with an established state volunteer registry by providing mechanisms to federalize those pre-identified, pre-credentialed volunteer health professionals. Once completed, this pilot could be expanded to other states ensuring a solid mechanism to quickly and safely mobilize this critical response discipline. / Bioterrorism Hospital Coordinator, Michigan Department of Community Health

Einleitung: In Deutschland wird die steigende Zahl pflegebedürftiger Menschen zunehmend in stationären Einrichtungen versorgt. Dieser Zuwachs bringt neue Herausforderungen, nicht zuletzt für die medizinische Versorgung der Pflegebedürftigen, mit sich. Qualitative Interviews mit beteiligten Akteuren können Erkenntnisse zum „Status quo“ liefern. Die vorliegende Arbeit beschäftigt sich mit der Perspektive der Angehörigen, da diese häufig in die medizinische Versorgung eingebunden sind und einen differenzierten Blick auf die Versorgungsqualität haben. Fragestellung: Welche Erfahrungen haben Angehörige im Pflegeheim mit der medizinischen Versorgung gemacht und wie wird die Zusammenarbeit zwischen Ärzten und Pflegekräften wahrgenommen? Welche Aufgaben übernehmen Angehörige bei der medizinischen Versorgung? Methoden: Die Arbeit ist eingebettet in die qualitative, multizentrische Studie „INTERPROF - Interprofessionelle Zusammenarbeit und Kommunikation im Pflegeheim“. In drei Regionen Deutschlands wurden hier unter anderem 23 offene Leitfadeninterviews mit 27 privaten Bezugspersonen in 14 Pflegeheimen durchgeführt. Die Interviews wurden, angelehnt an die Methode der Grounded Theory, ausgewertet. Ergebnisse: Als zentrales Phänomen wurde das „Einbezogensein“ der Angehörigen in die medizinische Versorgung erarbeitet. Angehörige versuchen, aktiv auf die medizinische Versorgung der Bewohner Einfluss zu nehmen. So werden neben der aktiven Hilfe bei der Pflege und Medikamentenbeschaffung zum Teil Hausarztbesuche initialisiert, Facharzttermine ausgemacht und Bewohner bei deren Praxisbesuchen begleitet. Darüber hinaus zeigt sich Einbezogensein durch den Kontakt der Angehörigen zum Hausarzt. Die Gründe hierfür sind vielfältig und lassen sich etwa auf ein Verantwortungsgefühl für den Bewohner oder auch den Wunsch des Bewohners nach Beteiligung der Angehörigen zurückführen. Angehörige üben zum Teil eine gewisse „Kontrollfunktion“ aus, dies führt mitunter zu emotionaler und zeitlicher Belastung. Es vermittelt andererseits eine gewisse Sicherheit, über Vorgänge informiert zu sein und diese beeinflussen zu können. Angehörige sind jedoch weniger „einbezogen“ oder wollen weniger „einbezogen“ werden, wenn sie die medizinische Versorgung gewährleistet sehen oder die Bewohner noch selbstständig sind. Folglich fühlen sie sich durch die bewusste Verantwortungsabgabe an die Pflegeeinrichtung entlastet. Schlussfolgerungen: Angehörige von Pflegeheimbewohnern stellen eine wichtige Personengruppe im Pflegeheim dar und bringen sich häufig intensiv, auch hinsichtlich der medizinischen Versorgung, zum Wohle der Bewohner ein. Wesentliche Anliegen sind eine patientenzentrierte, regelmäßige medizinische Versorgung. Es erscheint erstrebenswert, die Akzeptanz und Einbeziehung der Angehörigen durch die beteiligten Akteure im Heim und die Politik zu fördern. Auch die Einrichtung von organisatorischen Strukturen im Heim, z. B. durch die selbstverständliche Aufstellung eines Angehörigenkreises und die zunehmende unaufgeforderte Berücksichtigung von Angehörigen in medizinischen Entscheidungen (bei Einverständnis des Bewohner) wäre wünschenswert. Zudem sollte ihre Position in Heimbeiräten gestärkt werden. Das übergeordnete Ziel wäre es, Angehörige so in die Heimarbeit einzubeziehen, dass letztlich der Bewohner hinsichtlich der medizinischen Versorgung profitiert.

Background Midwifery units (MUs) provide midwife-led care for women at low risk of complications. They may be located on the same site as an obstetric unit (OU), in a hospital without obstetric services or separate from any hospital. In MUs, if unforeseen complications arise, transfer to an OU may be necessary. Aim To provide evidence to contribute to the improvement of the transfer process, help make transfer safer and less distressing for women, thereby improving the care and experience of women planning to give birth in MUs. Methods A structured literature review of existing evidence was followed by three integrated component studies using different methods. The content and quality of local NHS transfer guidelines were evaluated. Data from the Birthplace national prospective cohort study were analysed to estimate transfer rates, describe the transfer process and identify factors associated with transfer. The experiences of women transferred were explored in qualitative interviews. Findings Transfer is a common event, affecting around 25% of women planning birth in MUs, although rates in different units vary. Primiparous women are more likely to be transferred than women having a second or subsequent baby. The risk of transfer for primiparous women increases with increasing age; around 50% of women having their first baby aged 40 years or over are transferred. Local NHS transfer guidelines are generally of poor quality and pay little attention to women’s experience. Women interviewed after transfer report feeling unprepared for transfer. Sensitive care and clear communication from midwives during labour facilitate feelings of control in women and help women accept transfer as the right decision and not a 'negative' event. Transfer that is perceived by women as “too late” can have potentially serious and long-lasting negative effects. Women’s experience of the transfer journey could be improved by the offer of choice in a number of areas which would help women feel 'cared for' rather than 'transported'. Having the MU midwife continue to care for the woman after transfer should be considered 'best practice'; where this is not possible a good handover is essential. Women who have experienced transfer should be offered the opportunity to talk to a midwife about their experience.

Background: Studies have shown that racial and ethnic Minorities have poorer access to medical care when compared to Whites. Much of the research regarding Minority access to care issues reflects national data that has made it difficult to extrapolate findings to accurately reveal disparities that exist within a particular community. The purpose of this study was to determine if there was an association between race and access to medical care in the state of Virginia.Objectives: To determine if there is an association between race/ethnicity and access to medical care when comparing different Minority populations to the White population; assess any differences between Minority populations with regards to access to medical care, and identify other risk factors that may modify the association between race/ethnicity and access to medical care. Methods: Data was collected from the 2002 Behavioral Risk Factor Surveillance System (BRFSS) for N= 4,392 Virginian respondents. Descriptive statistics and prevalences were done to assess the sample based on unweighted data. The weighted sample was then applied for univariate and multivariate analyses with 95% confidence intervals (CI) to examine the risk estimates (odds ratios/ORs) and assess the relationship between race/ethnicity and access to medical care. Pearson chi-square analyses determined which variables to control for in the logistic regression model. SPSS 13.0 software was used for all analyses.Results: Blacks and Hispanics were more likely to be at risk for not having access to medical care (crude ORs = 1.20, 95% CI = 1.19-1.21 and 1.64, 95% CI = 1.61-1.66, respectively) when compared to Whites. Relative to Whites, Asian/Pacific Islanders and Native Americans were more likely to have access to health care (crude ORs = 0.71, 95% CI = 0.70-0.73 and 0.90, 95% CI = 0.84-0.93, respectively). After adjustment for confounders, there was a significant inverse association found between Minority populations and not having access to medical care when compared to Whites. Adjusted ORs for Blacks = 0.71, 95%CI = 0.70-0.72, for Asian/Pacific Islanders 0.80, 95%CI = 0.75-0.80, for Native Americans = 0.74, 95%CI = 0.70-0.78, and Hispanics = 0.59, 95%CI = 0.58-0.60. With regard to the adjusted ORs, there were no notable differences found between the different Minority populations. The relationship between race/ethnicity and access to care appeared to be modified by other predictors in the model. Specifically, female gender, being young or of middle age, no insurance status, poor health status, and little or no income, became stronger predictors for determining those groups who were more at risk for not receiving access to medical care in Virginia as oppose to race. Conclusion: The study strongly recommends that continued surveillance is needed to monitor access to care for Minority populations in the state of Virginia. Further research would be needed to assess these populations access over time, determine how interactions between race and other risk factors affect access, and design interventions that will succeed in teaching us more about the causal pathways that lead to such racial inequalities in access to medical care.

A model for health care utilization was applied to a sample of low income women. Demographic Predisposing, Psychosocial Predisposing, Illness Level, and Enabling indicators were examined separately for African American (n = 266), Anglo American (n = 200), and Mexican American (n = 210) women. Structural Equation Modeling revealed that for African American and Anglo American women, Illness Level, the only significant path to Utilization, had a mediating effect on Psychosocial Predisposing indicators. The model for Mexican Americans was the most complex with Enabling indicators affecting Illness Level and Utilization. Psychosocial Predisposing indicators were mediated by Illness Level and Enabling indicators which both directly affected Utilization. Implications of the results for future research are addressed.

Health Studies / (D. Litt. et Phil. (Health Studies))

No description available.

Background: Dialysis is an intervention that involves the use of fairly advanced technology and is fairly expensive. Patients and health care funders are increasingly demanding evidence for the effectiveness for such high technology high cost interventions. While dialysis therapy has improved immediate prognosis in patients with kidney failure, the long-term survival of patients on chronic renal replacement therapy (dialysis or renal transplantation) is much lower than that of the general population and the mortality rates remain high for patients with acute renal failure needing dialysis. There are considerable variations between different countries and even between the dialysis centres within the same country with regards to the selection of the primary type of dialysis (haemodialysis or peritoneal dialysis) and in the different methods or equipment used to perform the various components of these various modalities. It is possible that variations in clinical practice are associated with variations in clinical outcomes such as mortality and morbidity. It is then important to identify the best practices from the various variations in current use and implementing these best practices may reduce morbidity and mortality of these patients. Methods: Systematic reviews, identifying and including only randomised trials, focusing on key clinical policy decision points in the dialysis process were undertaken. The review of literature was done in a systematic way according to a detailed scientific methodology. For all of the systematic reviews, a detailed protocol was written and agreed to by the authors of the review. The protocol detailed the clinical question, the types of studies, participants, interventions and outcomes to be included, search strategy and the statistical methods to be employed. Relevant randomised studies were then identified by systematically searching the electronic medical databases and reference lists of published studies; data relevant to predetermined outcome measures were extracted and where appropriate summary statistics were derived from meta-analysis. Recommendations and implications for clinical practice and future research studies were made following each review. The areas of dialysis policy reviewed were (1) Comparison of high-flux versus low-flux haemodialysis (HD) membranes for patients with end-stage renal disease (ESRD), (2) Comparison of extracorporeal renal replacement therapy technologies for patients with ESRD, (3) Comparison of intermittent (IRRT) and continuous renal replacement therapy (CRRT) for acute renal failure (ARF) in adults, (4) Comparison of antimicrobial interventions for the prevention of HD catheter related infections, (5) Comparison of continuous ambulatory peritoneal dialysis (CAPD) and automated peritoneal dialysis (APD) for patients with ESRD, and (6) Comparison of treatment measures for depression in dialysis patients. Conclusions: As the currently available evidence has not demonstrated superiority with high-flux membranes with respect to important clinical outcomes such as mortality, quality of life and hospitalisation, it is not possible to recommend the use of these membranes in preference to low-flux membranes. It has not been possible at present to demonstrate with the current evidence available that convective modalities (HF, HDF or AFB) have significant advantages over HD with regard to clinically important outcomes of mortality, dialysis-related hypotension and hospitalisation. It is not therefore possible to recommend the use of one modality in preference to the other. In ARF patients who are haemodynamically stable, the RRT modality does not appear to influence important patient outcomes, and therefore the preference for CRRT over IRRT in such patients does not appear justified in the light of available evidence. CRRT was shown to achieve better haemodynamic parameters such as MAP. APD appears to be more beneficial than CAPD, in terms of reducing peritonitis rates and with respect to certain social issues that impact on patients' quality of life. Further, adequately powered trials are required to confirm the benefits for APD found in this review and detect differences with respect to other clinically important outcomes that may have been missed by the trials included in this review due to their small size and short follow-up periods. APD may however be considered advantageous in select group of patients such as in the younger PD population and those in employment or education due to its psychosocial advantages. Firm conclusions on the efficacy of treatment measures for depression in chronic dialysis patients cannot be made as we identified only one small RCT that was of short duration. Current screening tools for depression are recognised to have poor specificity in the medically ill due to overlap of somatic symptoms of the medical illness. The development of a valid diagnostic tool would be helpful. The systematic reviews in general highlighted the paucity of large-scale randomised trials in nephrology even on topics of great practical relevance such as depression in dialysis. In many of the areas assessed adequate conclusions could not be reached as there was a lack of large-scale well designed randomised controlled trials raising the possibility that important clinical differences between the interventions assessed may have been missed due to Type 2 statistical error. We identified numerous RCTs which were small in size looking at surrogate end-points such as molecular markers of inflammation, especially in the areas of membrane flux and extracorporeal RRT technologies. Unfortunately benefits with surrogate end-points do not necessarily translate to better clinical outcomes. The urgent need of the hour is to conduct well-designed large scale RCTs in major areas of clinical importance such as the use of extracorporeal renal replacement therapy technologies looking at hard clinical end-points such as mortality, hospitalisation and quality of life.

M.Comm. / Organisations could previously succeed on the basis of having customers, but now customers are more educated and aware of their rights. This makes them demanding in their service expectations and affect their perceptions of the service rendered. Physical evidence is one of the 7 P’s in marketing a service. The service that is to be marketed has to be developed according to demand by market segment. Marketing the service is essential to differentiate the organisation’s service from other similar services, using the correct competitive advantage. Physical environment in a health care setting have a significant effect on customer satisfaction, perceived service quality, intention to re-patronize and willingness to recommend. Physical evidence is the servicescape and consists of the interior and exterior environment in a facility Hospitals and hospital environments are dependant on the physical evidence in their facilities and this is often the deciding factor when it comes to choice of a facility. Although the independent doctors play a role in South Africa when it comes to choice of a facility, it is often the patient that chooses the facility on their perceptions of previous experience and word of mouth. Service quality is the difference between expectations and perceptions of the outcomes experienced by the customers. Service quality is essential for customer service and customer services are an essential part of services in the hospital and hospital environment. Although physical evidence was chosen as the dimension for the research, physical evidence is only one dimension of service quality. Other dimensions include reliability, responsiveness, assurance and empathy. A questionnaire was formulated based on the five above dimensions of the SERVQUAL developed by Parasuraman to evaluate the perceptions of patients in a maternity unit in a hospital setting to determine the effect by changing the physical evidence. The outcome of the study identified important aspects that can be utilized in managing an organisation in the health industry. It was identified that adequate seating around a bed is always important for patients in any circumstances, noise levels must be acceptable at all times, the décor in a maternity does influence the perception of service quality, patient’s records kept up to date by the nursing staff are seen as adequate in any physical environment and patients perceive the nurses as having their best interest at heart. This study has shown its importance through the use of a Quasi-experiment that physical evidence is an important dimension in the perception of service quality for patients in a maternity unit in the private health sector. This should be considered by management for future planning in the strategies of an organisation in the healthcare industry.

M.Com. (South African & International Taxation) / The tax system in South Africa makes provision for everyday South African citizens to contribute to a greater or lesser extent towards health care funding in South Africa. However, as a result of the high unemployment rate, a large gap exists between tax contributors and non-tax contributors. This raises the question of whether it is fair that the burden to fund the proposed National Health Insurance (NHI) initiative in South Africa is borne by the small percentage of current tax contributors. The purpose of this research was to provide a taxation perspective on the different funding models and financing options available to the South African government for consideration in developing the NHI implementation strategy. The study evaluated the four traditional health care models used worldwide and assessed existing health care systems in selected first and third world countries in order to contribute towards the development of the proposed NHI system in South Africa. The health care models used by France, The United States, The United Kingdom, Brazil and Spain were evaluated in order to achieve an understanding of the funding approaches followed by these countries. It was found that although it is inevitable that South African tax contributors will have to be more heavily taxed in order to fund the NHI, as there are only limited possibilities for distributing the tax burden evenly. The main stumbling block in finding an equitable funding solution is the fact that there is a large disparity in South African income tax contributors.