Introdução. Desde 2006 a Assistência Farmacêutica da Coordenação de Atenção Básica da Secretaria Municipal da Saúde de São Paulo (SMS-SP) recebeu, por ano, em média, cerca de 125 solicitações de medicamentos não constantes da Relação Municipal de Medicamentos Essenciais - Remume-SP, antes de 2011, e a partir deste ano 250 solicitações, demanda que ainda não foi objeto de estudo para se conhecer de forma sistemática sua natureza e as implicações quanto à regulação sob o marco do acesso racional a fármacos.Objeto do estudo. Avaliou-se as solicitações de produtos farmacêuticos não constantes da Remume-SP, de 2008 a 2013. Método. Análise de documentos, segundo a prática médica com base em provas científicas, de solicitação de medicamentos não disponíveis na Remume-SP decorrente de prescrição médica por meio de Formulário de Justificação para aquisição de medicamentos não constantes da Remume-SP, e oriunda de serviços da SMS-SP no período do estudo. Resultado. Analisou-se os processos advindos de 1.174 solicitações, de 2008 a 2013, que levou à não autorização de aquisição de 58,9 por cento (N=692), pelos seguintes motivos: 1- não há prova suficiente na literatura, 15 (17 por cento ); 2- consta da Remume-SP, 11 (1 por cento ); 3- disponível na SES-SP, 56 (8 por cento ); 4- informação clínica insuficiente, 151 (22 por cento ); 5- fornecimento CACON, 10 (1 por cento ); 6- fármaco desnecessário, 18 (3 por cento ); 7- indicação de outro fármaco, ou outra concentração do fármaco solicitado, ou outro acessório, ou ainda outro tratamento (cirúrgico, por exemplo), 169 (24 por cento ); 8- solicitação de parecer de área técnica relacionada, 62 (9 por cento ); 9- paciente não acompanhado em serviço municipal de saúde, 12 (2 por cento ); 10- erro de prescrição, 39 (6 por cento ); 11- não há prova suficiente na literatura e informação clínica insuficiente, 49 (7 por cento ). As razões do não acolhimento do pedido do médico estão apresentadas em exemplos, das principais categorias farmacêuticas, considerando-se a variedade das solicitações, todos documentados pela literatura e extraídos dos processos de solicitações. Faz-se recomendações para a melhoria da regulação da prescrição farmacológica e possíveis ajustes na relação entre os formuladores e executores de políticas do município e os conjuntos dos prescritores, tendo como centro das preocupações a segurança do usuário do SUS e a melhoria do acesso a fármacos com a melhor relação benefício-risco. / Introduction. Since 2006, the Assistência Farmacêutica da Coordenação de Atenção Básica da Secretaria Municipal da Saúde de São Paulo (SMS-SP) (Coordination on Pharmaceutical Care of the Municipal Health Secretariat of São Paulo) received about 125 requests yearly, on average,before2011, and after this year, 250 requests yearly for drugs not listed in the Relação Municipal de Medicamentos Essenciais (Municipal Register of Essential Medicines) REMUME-SP, demand whose object of study was not known in a systematic nature and whose implications regarding regulation were not studied under the framework of rational access to drugs. Object of the study. Evaluate requests for pharmaceuticals not listed in REMUME-SP, from 2008 to 2013. Method. Analysis of documents, according to medical practice based on scientific evidence, of request for products not available in REMUMESP, prescribed via Form Justification for the purchase of drugs not listed in REMUME - SP, and generated from SMS-SP, during the studied period. Results. Analysis of processes arising from 1.174 requests, 2008 to 2013, has brought to the non-permit of acquisition of 58,9 per cent (N=692), due to the following reasons: 1- there is not enough evidence in the literature, 15 (17 per cent ); 2- listed in Remume-SP, 11 (1 per cent ); 3- available in SES-SP, 56 (8 per cent ); 4- insufficient clinical information, 151 (22 per cent ); 5- supplied by CACON, 10 (1 per cent ); 6- unnecessary drug, 18 (3 per cent ); 7- indication of other drug, or other concentration of the requested drug, or other device, or still other treatment (surgical, for example), 169 (24 per cent ); 8- solicitation of report from related technical area, 62 (9 per cent ); patient not cared by the municipal health service, 12 (2 per cent ); 10- prescription mistakes, 39 (6 per cent ); 11- there is not enough evidence in the literature and not sufficient clinical information, 49 (7 per cent ). The reasons of the non-acceptance of the medical requests are presented in examples, from the main pharmaceutical categories which were requested, considering its variety, all documented in the literature and extracted from the processes of solicitation. Recommendations on the improvement of medical prescription are done and possible arrangements of prescription in the relationship among policy makers and executors in the municipality and the sets of prescribers, whose main concern is the safety of users of SUS and improving access to drugs with the best benefit-risk relation.

Since the 1970s there has been a growing interest in, and utilisation of, Alternative Dispute Resolution (ADR) techniques to resolve environmental conflicts in western societies. ADR was incorporated into one of New Zealand's main environmental statutes, the Resource Management Act 1991(RMA). Under s.268 of the RMA the Environment Court (the Court) may, if the parties agree, conduct mediation in order to facilitate settlement of resource management disputes. The RMA, which has now been in operation for ten years, gives no guidance as to the way in which mediation is to be conducted. The Court has developed procedures and processes for administering and conducting mediation. This study critically evaluates the practice of Court assisted mediation of environmental disputes under the RMA. A literature review and interviews with stakeholder groups are used in this evaluation. The study shows that mediation generates benefits for the Court and participants. It also identifies limitations with the current mediation procedures and processes. These may impact the effectiveness of participants in mediation, their satisfaction with, and support for, the mediated settlement and with the environmental outcomes. The study recommends a series of guidelines be prepared on the functions and administrative procedures of the Court and on the mediation process promoted by the Court. Further research is also recommended. It is considered that these recommendations, if implemented, will enhance the process for participants, ensure more equitable and consistent environmental outcomes, in terms of present and future generations, and retain public confidence in the mediation process.

No description available.

Introduction: The epidemic of overweight and obesity both worldwide and in Canada is indicative of the need for proper growth monitoring beginning at birth. This study evaluated Family Physician’s (FP) Level of Use (LoU) of the recommended 2006 and 2007 World Health Organization (WHO) Growth Charts for monitoring their paediatric patients’ growth. It explored factors influencing LoU, utilizing the Diffusion of Innovations (DOI) theory and Ecological Framework for Effective Implementation (EFEI) as guiding models. FPs’ awareness of resources to support paediatric weight management was also assessed. Methods: A survey was distributed to FP in British Columbia (BC), Canada (N = 2853). The survey addressed provider and innovation characteristics, prevention delivery and support system factors, and barriers and facilitators to chart use. Correlations and multiple linear regression were used to determine correlates and predictors of LoU. Results: Sixty-two surveys were returned (2.2%). WHO Growth Chart LoU was 80.4%. Six variables significantly predicted LoU, including age (β = -.28, t = -3.15, p < .05), practicing in Fraser Health Authority region (β = -.24, t = -2.67, p < .05), assessing head circumference of birth to two year olds (β = .23, t = 2.45, p < .05), perceived growth chart accessibility (β = .39, t = 4.22, p < .05) and compatibility (β = .47, t = 5.27, p < .05), and innovativeness (β = -.37, t = -4.11, p < .05). These variables accounted for 69% of the variance in LoU. The most commonly identified barrier and facilitator to chart use was related to the Electronic Medical Record (EMR) system. FPs’ awareness of resources to support overweight paediatric patients was low. Conclusion: The majority of FP in BC in this sample had adopted the WHO Growth Charts. The results showed partial support for DOI theory and EFEI derived factors. Despite a small sample size, the findings highlighted the importance of installing the charts in the EMR systems, and can provide a foundation for future public health dissemination efforts and research on medical guideline implementation. / Graduate / 0573 / 0769 / erand@uvic.ca

Introduction: The epidemic of overweight and obesity both worldwide and in Canada is indicative of the need for proper growth monitoring beginning at birth. This study evaluated Family Physician’s (FP) Level of Use (LoU) of the recommended 2006 and 2007 World Health Organization (WHO) Growth Charts for monitoring their paediatric patients’ growth. It explored factors influencing LoU, utilizing the Diffusion of Innovations (DOI) theory and Ecological Framework for Effective Implementation (EFEI) as guiding models. FPs’ awareness of resources to support paediatric weight management was also assessed. Methods: A survey was distributed to FP in British Columbia (BC), Canada (N = 2853). The survey addressed provider and innovation characteristics, prevention delivery and support system factors, and barriers and facilitators to chart use. Correlations and multiple linear regression were used to determine correlates and predictors of LoU. Results: Sixty-two surveys were returned (2.2%). WHO Growth Chart LoU was 80.4%. Six variables significantly predicted LoU, including age (β = -.28, t = -3.15, p < .05), practicing in Fraser Health Authority region (β = -.24, t = -2.67, p < .05), assessing head circumference of birth to two year olds (β = .23, t = 2.45, p < .05), perceived growth chart accessibility (β = .39, t = 4.22, p < .05) and compatibility (β = .47, t = 5.27, p < .05), and innovativeness (β = -.37, t = -4.11, p < .05). These variables accounted for 69% of the variance in LoU. The most commonly identified barrier and facilitator to chart use was related to the Electronic Medical Record (EMR) system. FPs’ awareness of resources to support overweight paediatric patients was low. Conclusion: The majority of FP in BC in this sample had adopted the WHO Growth Charts. The results showed partial support for DOI theory and EFEI derived factors. Despite a small sample size, the findings highlighted the importance of installing the charts in the EMR systems, and can provide a foundation for future public health dissemination efforts and research on medical guideline implementation. / Graduate / 0573 / 0769 / erand@uvic.ca

Since the 1970s there has been a growing interest in, and utilisation of, Alternative Dispute Resolution (ADR) techniques to resolve environmental conflicts in western societies. ADR was incorporated into one of New Zealand's main environmental statutes, the Resource Management Act 1991(RMA). Under s.268 of the RMA the Environment Court (the Court) may, if the parties agree, conduct mediation in order to facilitate settlement of resource management disputes. The RMA, which has now been in operation for ten years, gives no guidance as to the way in which mediation is to be conducted. The Court has developed procedures and processes for administering and conducting mediation. This study critically evaluates the practice of Court assisted mediation of environmental disputes under the RMA. A literature review and interviews with stakeholder groups are used in this evaluation. The study shows that mediation generates benefits for the Court and participants. It also identifies limitations with the current mediation procedures and processes. These may impact the effectiveness of participants in mediation, their satisfaction with, and support for, the mediated settlement and with the environmental outcomes. The study recommends a series of guidelines be prepared on the functions and administrative procedures of the Court and on the mediation process promoted by the Court. Further research is also recommended. It is considered that these recommendations, if implemented, will enhance the process for participants, ensure more equitable and consistent environmental outcomes, in terms of present and future generations, and retain public confidence in the mediation process.

Le continuel développement des outils statistiques permet aujourd’hui la modélisation de nombreux phénomènes, toujours plus complexes. En combinant l’approche offerte par des modèles statistiques spécifiques, dit "multiniveaux", et leurs applications à différentes problématiques médicales, cette thèse s’inscrit à la croisée de divers domaines : celui des statistiques, de par la méthodologie sur laquelle reposent les résultats ; mais aussi, celui de l’économie de la santé et de la santé publique en général, au travers des applications présentées.La première partie de cette thèse s’intéresse aux aspects théoriques, et plus particulièrement à l’évolution des méthodologies, du modèle de régression linéaire simple aux modèles multiniveaux pour des liens non nécessairement linéaires. Le déroulé historique de la modélisation mais également les hypothèses, le principe, la stratégie d'analyse et enfin les limites y sont abordés.La seconde partie s’articule autour de deux applications multiniveaux distinctes. La première concerne les déterminants de l'observance et des interruptions de traitement, chez les personnes infectées par le virus du VIH/Sida suivant un traitement par antirétroviraux, dans le contexte du Cameroun. La seconde, quant à elle, s'intéresse au recours aux soins dentaires chez les personnes âgées de 60 ans et plus et vivant en domicile ordinaire. Ces deux applications sont comparables dans leurs méthodologies puisqu’il s’agit de déterminer les comportements étudiés par des variables individuelles habituellement retenues, mais aussi des variables de "contexte" (caractéristiques de l’offre de soins).La troisième partie est consacrée aux applications sur le panel de médecins généralistes et traite deux études autonomes. La première expose les réticences des médecins, et le rôle de leurs aprioris, face aux Recommandations de Bonnes Pratiques (RBP). Elle nous permet de déboucher sur quelques pistes pour améliorer l’usage des RBP en médecine de ville. La seconde analyse la similarité – ou parfois la dissimilarité – entre le cycle d’activité des médecins généralistes et la saisonnalité des épidémies, dans le but d’identifier les facteurs favorisant l’ajustement des médecins généralistes aux variations saisonnières des besoins des patients. Cette étude pourrait permettre, notamment, d’anticiper et de mieux gérer des situations de crise sanitaire, avec l’appui effectif de la médecine de ville. / The continual development of statistical tools allows the modelling of numerous phenomena, including the complex ones. Using a set of statistical techniques and applications, based on the so-called “multilevel” modelling, this thesis deals with different aspects related to the statistical methodology and applications as per health economics and public health.The first part reconsiders the evolution of methodology, starting from the simple linear regression techniques to the more complex multilevel modelling as applied to both the linear and non-linear relations. It addresses issues related to the historical development, the hypotheses, the strategy of analysis, and the scope of applications. The second part presents two distinct multilevel studies. The first concerns the determinants of observance and interruptions of treatment for persons infected by the HIV/AIDS and treated with antiretroviral in Cameroon. The second one focuses on the use of dental services for the elderly. The two studies are methodologically comparable in that, besides integrating the usually retained individual variables, the analyses examine health seeking behaviours, particularly, the utilisation of health care services, while accounting for contextual determinants such as the characteristics of health supply (clinic, department or region).The third part is dedicated to the applications on GPs' panel and contains two different studies. The first one explains the GPs’ behaviours and the role of their aprioris vis-à-vis Clinical Practice Guidelines (CPG), and suggests solutions to overcome their negative attitudes. The second study analyses the similarity – sometimes the differences – between the cycle of GPs’ activity and the seasonality of epidemics with the aim of better understanding determinants favouring the adjustment of the GP in the seasonal variations of the patients needs. This study helps anticipate and manage situations of sanitary crisis, with the effective support of general practitioners.

L’information est un des besoins les plus importants des patients atteints de cancer. Leurs attentes fortes, variables et hétérogènes, en matière d’informations sur les différents aspects de la prise en charge de la maladie, soulèvent la question de la qualité de ces informations mises à disposition des patients. L’élaboration d’outils d’information et d’aide à la décision de qualité, qu’ils soient destinés aux cliniciens, tels que les recommandations pour la pratique clinique (RPC), ou aux patients, tels que des documents écrits d’information, implique la prise en compte des trois composantes essentielles de la décision médicale : données actuelles de la science (evidence-based medicine), expertise professionnelle, et préférences et valeurs des patients. Pour pouvoir baser la décision médicale sur ces trois dimensions, l’enjeu est de partager avec les patients les données actuelles de la science, et d’intégrer les préférences des patients dans les RPC. Notre hypothèse est qu’il est possible d’intégrer les préférences des patients à deux niveaux de production des connaissances : l’élaboration de documents écrits d’information des patients dans le cadre du programme SOR SAVOIR Patient d’une part, et l’élaboration de RPC pour les cliniciens d’autre part. Les résultats de ces travaux fournissent une contribution méthodologique pour améliorer la qualité des documents écrits et impliquer les patients atteints de cancer dans le développement de ces informations / Information is one of the most important needs of cancer patients. Their strong, variable and heterogeneous expectations, in terms of information on different aspects of the management of the disease, raise the question of the quality of the information made available to patients. The development of good-quality information materials and decision aids, dedicated to clinicians, such as clinical practice guidelines (CPG), or dedicated to patients, such as patient information leaflets, requires taking into account the three essential components of medical decision: current scientific data (evidence-based medicine), professional expertise and patient values and preferences. To be able to base medical decisions on these three dimensions, the challenge is to share with the patients current scientific data, and incorporate patient preferences in the development process of CPG. Our hypothesis is that it is possible to integrate the preferences of patients at two levels of knowledge production: the development of written patient information in the French SOR SAVOIR Patient program on the one hand, and development of CPG for clinicians on the other hand. The results of this work provide a methodological contribution to improve the quality of written documents and involve cancer patients in the development of this information.

Cervical cancer, a completely curable disease with early detection and management, is an international concern. Early identification allows for treatment of the disease, which prevents or slows progression, ultimately reducing morbidity and mortality. Due to the regressive nature of most cervical lesions, the duration between cervical cytology has been lengthened to prevent over diagnosis and treatment. This was reflected in the 2012 United States Preventative Services Task Force (USPSTF) clinical practice guideline for cervical cancer screening. The purpose of this project was to determine the effectiveness of a quality improvement initiative to increase adherence to the 2012 USPSTF guideline at a volunteer medical clinic for the working uninsured. In this retrospective, time series observational evaluation, data were collected via chart review regarding adherence to the guideline. The intervention consisted of the placement of a visual algorithm educational tool for clinical decision-making for cervical cytology screening in each exam room. Data were collected during three time periods: (1) the 3 months prior to initial education of clinic staff regarding the guideline; (2) the 3months between initial education and introduction of the algorithm; and (3) the 3 months post introduction of the algorithm. A total of 335 charts were reviewed. There was a significant difference in the proportion of appropriate screening among the three groups (Χ2= 6.83 p=.03). There was also a significant difference in appropriate screening rates between the new and established patients’ group, controlling for group (p<.0001). The use of the interventional algorithm is recommended to improve adherence to evidence-based practice guideline related to cervical screening as it decreases harm(s) to the patient by reduction of fear, cost to the patient, and overtreatment of benign regressive lesions.

With the introduction of universal newborn hearing screening (UNHS) the need for quality early hearing intervention (EHI) services became critical. Screening is but the avenue to EHI services. Without appropriate intervention infants with hearing loss are at risk for language delay which might subsequently adversely influence academic success and vocational choices later on in life. The numerous socio-economic, cultural and healthcare barriers associated with developing countries such as South Africa, do not negate or diminish the need for optimal outcomes for infants with hearing loss through quality EHI services. The principle of quality EHI services, aligned with international standards, is endorsed by the HPCSA (2003: 2). In order to assure quality in EHI, service evaluation is critical. The necessary first step when evaluating service provision is to measure current service delivery. The main aim of this study was to determine whether South African audiologists provide EHI and support services aligned with international professional best practice to infants following the diagnosis of hearing loss. The first part of this study reviews the evidence available in EHI. The guidelines derived from the international evidence were stated as benchmarks against which South African EHI services were measured. These benchmarks were categorised using the so-called six M variation categories. These categories are: Man, machine (equipment), method (systemaric procedures), measurements, material (amplification devices) and Mother Nature. During the empirical research a descriptive design was followed comprising of questionnaire surveys to audiologists in different working sectors rendering EHI services to infants with hearing loss. The questionnaire survey explored the nature and scope of the EHI services offered to infants with hearing loss with regard to all the components (categorised in the six M categories) of the EHI programme of 40 South African audiologists. The results of this study indicate that respondents often do not use evidence-based measurements or methods during EHI services. Results suggest that undergraduate training in areas regarding the selection and fitting of amplification to infants with hearing loss is often inadequate (>20 respondents indicated that they are not trained). Evidence-based measurements are not typically performed when fitting amplification to infants (29 respondents do not perform probe-microphone or elctroacoustic measurements). Many respondents indicated that they do not have the necessary equipment to do these measurements. EHI services often (50% of respondents) do not provide A/R directly, but refer to other team members. From the results there seems to be significant delays in the rendering of EHI services to infants with hearing loss. Financial constraints of the family of the infants, accessibility problems, as well as a lack of infant support from their families often influence the EHI programmes of respondents. The implications of this study were discussed. Recommendations include the development of South African guidelines, aligned with international guidelines but taking into account the challenges posed by the unique South African context. Other recommendations include: Centres of excellence, relevant continuing education programmes and the evaluation of undergraduate training programmes. / Dissertation (M (Communication Pathology))--University of Pretoria, 2006. / Speech-Language Pathology and Audiology / M (Communication Pathology) / unrestricted