This study examines specific organizational, operational, financial and environmental characteristics to identify factors that are associated with increased likelihood of hospitals' CPOE adoption decision in six rollout regions of the Leapfrog initiatives.Resource dependence theory provides theoretical basis for the study. The study is retrospective observational in design. Individual hospitals are the unit of analysis. The Leapfrog Group's 2002-survey collection serves the primary data source. Univariate statistical methods along with bivariate and ordinal logistic regression models are used to analyze the data. The models provided support for multiple hypotheses for both the adoption and early adoption decisions of study hospitals. The operational characteristics of ownership, in-house physician staff, case mix index and the environmental characteristic of HMO penetration rate had a positive effect on management's adoption decisions. The operational characteristic excess capacity, the organizational characteristic community orientation, the financial characteristic of operating income per admission, and the environmental characteristic of number of HMO contracts had a significant negative effect on CPOE adoption decisions.

The costs attributed to prescription errors negatively affect the profits of retail pharmacy businesses. The U.S. prescription error rate since 2010 was 0.1%, yet with more than 3.5 billion prescriptions filled annually in the United States, the outcome is more than 3.5 million prescription-dispensing errors and an annual cost of more than $16 billion. Using the performance prism theory, the purpose of this multiple case study was to explore strategies retail pharmacy managers used to increase profit by reducing prescription errors. Using purposeful sampling, 5 retail pharmacy managers in Miami, Florida, were selected as participants because they had implemented strategies to reduce prescription errors. Data were collected using semistructured, face-to-face interviews with 5 pharmacy managers, and company records consisting of quality improvement incident reports, income statements, and balance sheets. Data analysis occurred using methodological triangulation and following Yin's 5-step process of compiling, disassembling, reassembling, interpreting, and concluding the data. The 3 emergent themes were prescription error reducing strategy, profitability improvement strategy through reduced prescription errors, and technology strategy for reducing prescription error. The findings indicated that prescription error reducing strategies are essential for pharmacy managers to increase profits. The implications for positive social change include the potential for retail pharmacy managers to reduce the cost of health care in their communities, prevent prescription error-related hospitalizations and deaths, and improve employment conditions and economic activity in their communities.

Pharmaceutical drugs are one of the most socially important heath care products. They are part of many individuals' everyday lives, from the eradicating of diseases at birth to treating patients at the end of life. However, for many patients access is prevented due to expensive cost. This study explored cost-related non-adherence (CRN) and researched if reimportation of pharmaceutical drugs from other countries could increase patient drug adherence. The perceptions of 10 patients and 10 providers in Maine were assessed. Maine is the only state that allowed its citizens to purchase prescription drugs from abroad. The research questions addressed (a) how reimportation drugs could contribute to drug adherence, (b) the perceptions of patients, and (c) the perceptions of key providers of reimportation. This study was guided by a theoretical framework utilizing Kurt Lewin's theory of organizational change. Participants answered 15 open-ended questions. The study utilized a qualitative grounded theory approach; data were analyzed inductively. The research demonstrated that patients and healthcare providers had positive perceptions for a reimportation policy. Future research of other regions for this topic should prevail. Member checking was used to validate the emerging theories of increased long term drug adherence incentivized by affordable drug cost, which contributes to perception of competence, better management of current disease, and decreased safety concerns. Positive social change implications can be achieved through savings to the health-care industry by creating a pathway to affordable drugs that will bring more drugs to market and create a competitive structure that can drive down pricing.

A lack of available data exists regarding environmental factors related to prescription drug abuse (PDA), which could explain the ineffectiveness of efforts to reduce PDA in Florida. Prescription drug abuse among adults older than age 18 varies with the level of education achieved, and these metrics potentially reflect socioeconomic differences. The purpose of this quantitative study was to examine the connections between contextual aspects of prescription opioid abuse among Florida's middle and high school students to understand youth PDA in relation to their environments. This study consisted of a secondary analysis of existing PDA data (dependent variable) in relation to a number of independent variables, including the incidence of female-headed households, the nature of residential environment, adherence to religious precepts, and students' ability to achieve educational goals. Incidence of female-headed households, the nature of residential environment, and adherence to religious precepts were not found to predict youth PDA. The only finding of significance was that PDA predicted lowered students' ability to achieve educational goals (p = .015). Data collected from this study might be used by school counselors and administrators when developing drug abuse prevention, intervention, and educational programs, thereby leading to positive social change in helping to reduce PDA among youth.

Ce travail présente le développement d’une nouvelle approche pharmacoépidémiologique, reposant sur les bases de données de l'assurance maladie, permettant de caractériser et d’estimer le détournement d’usage de médicaments psychoactifs. Cette approche utilisant la méthode de classification, regroupe, a posteriori, les sujets en différents sous-groupes, menant à l’identification, la caractérisation et la quantification de différents profils de comportement dont le comportement déviant. Nous avons appliqué cette méthode sur plusieurs médicaments. Pour chaque médicament, nous avons inclus l'ensemble des sujets affiliés au régime général des régions PACA et Corse ayant eu un remboursement. Leurs délivrances ont été suivies sur 9 mois. Après une analyse descriptive, une méthode de classification est appliquée, suivie d’une analyse des différents sous-groupes.Un premier travail a permis de confirmer l'importance du détournement d'usage d'une molécule émergente, le clonazépam (publication n°1). Ensuite nous avons adapté notre méthode afin de pouvoir suivre l'évolution sur plusieurs années de ce détournement (publication n°2). Nous avons appliqué cette méthode pour souligner l’existence, sur plusieurs années, du détournement d'usage du méthylphénidate (publication n°3). Notre équipe avait également développé une autre méthode pour estimer la polyprescription (publication n°4). Enfin, nous avons appliqué de façon conjointe ces deux méthodes (publication n°5). La méthode de classification est de plus en plus utilisée afin de surveiller l'évolution du détournement d'usage de médicaments et commencent à être intégrés au système français de surveillance de l’abus de médicament.aux cotés des autres outils pharmacoépidémiologiques plus traditionnels (OSIAP, OPPIDUM, OPEMA, ASOS, DRAMES). / This work presents the development of a new pharmacoepidemiologic method. This methodallows to estimate abuse of psychoactive prescription drugs in real life using prescriptiondatabase. The method is based on a cluster analysis which is a statistical method used todetermine, a posteriori, different subgroups of subjects. According the subgroups’characteristics, we can determine and estimate different behaviours whose subjects with adeviant behaviour. It assesses the rate of subjects with a deviant behaviour among all thesubjects that obtain the drug from a pharmacy.We used this method on several prescription drugs. For each prescription drug, we includedall individuals, affiliated to the French health reimbursement system of two southern Franceareas (Provence-Alpes-Côte-d’Azur and Corsica), who have had a prescription drugreimbursed during the first weeks of the year. Their deliveries have been monitored over a 9month-period. After a descriptive analysis, a clustering method has been used. The fourquantitative variables used to establish profiles of consumers were : number of differentprescribers, number of different pharmacies, number of dispensings and quantity dispensed(DDD). Finally, the characteristics of different subgroups have been presented, especiallythose with a deviant behavior.The first study using this method allows to confirm and assess the magnitude of the abuseliability of an emerging prescription drug as clonazepam (publication n°1). Then we adapt thismethod in order to follow the abuse evolution during several years. In the second publicationon clonazepam, we identified that the proportion of deviant subjects has increased between2001 and 2006 (from 0.86% to 1.38%). We also applied this method to estimatemethylphenidate abuse during several years (from 2005 to 2008) (publication n°3).Methylphenidate abuse is already describe in other countries whereas few data are available inFrance. This study estimates the proportion of subjects with a deviant behaviour (from 0.5%9in 2005 and in 2006 to 2.0% in 2007 and 1.2% in 2008) and assesses its evolution since theapplication of a specific regulation.Our research team has also developed an other method using prescription database : thedoctor shopping indicator which measures the quantity obtained by doctor shopping amongthe overall quantity reimbursed (publication n°4). The objective of the last publication is toanalyze and compare results from those two methods applied to High Dosage Buprenorphine,a product well-known to be diverted in France.Actually, clustering method is more and more used on prescription drugs in order to assesstheir abuse. The results obtained by this method begin to be included in the other postmarketing surveillance of CNS drugs (OSIAP, OPPIDUM, OPEAM, ASOS, DRAMES)which are used by French public health authorities.

Previous studies have shown that Medicare Part D beneficiaries tend not to switch plans even though they are encouraged to reevaluate their current plans and switch plans if needed every year. Little is known about why this "plan stickiness" occurs, so there is a critical need to better understand this non-switching behavior. This dissertation project aimed to describe how Part D beneficiaries processed information and how they perceived the plan switching process. It also aimed to describe how switchers and non-switchers were different and to test a model of Part D plan information processing that adapted from Motivation, Opportunity, and Ability (MOA) model. To achieve these objectives, this study had a cross-sectional descriptive design and used a mixed- methods approach consisting of focus groups, interviews, and mailed survey. The qualitative study sample was recruited from two cities in Iowa and transcripts of audio-recorded discussions were analyzed. The population studied in the quantitative phase was voter registered Iowa Part D beneficiaries who were older than 65 and did not receive Low Income Subsidies (LIS). Stratified random sampling was used to identify survey subjects. An eight page survey assessing factors related to Part D plan decisions was developed and mailed to 2,250 subjects, with reminder postcards as well as phone calls used to increase response rate. Finally, confirmatory factor analysis and structural equation modeling (SEM) were used to test a model of Part D plan information processing. A total of 16 participants from three focus groups and three interviews were included in the qualitative analysis. The results indicated that Part D beneficiaries processed different amounts of information even though they made the same decision (i.e. non-switching); whether to receive help from others in reviewing coverage options emerged as an important theme in the plan switching decision. A usable response rate of 22.5 percent was obtained. Of this sample, 264 respondents were non-LIS Part D beneficiaries and were used for further analysis. About one fifth of the sample switched plan between 2012 and 2013, supporting existing literature that has reported a low plan switching rate. Switchers and non-switchers had few demographic differences, but twice as many switchers as non-switchers received help from others in reviewing coverage options. The results from the SEM analysis indicated that those who had lower risk perception about plan switching, higher motivation, and higher self-efficacy were likely to read larger amounts of plan information. They also indicted that higher perceived risk, involvement, and self-efficacy were positively associated with motivation to process plan information. The findings of this dissertation suggest that plan stickiness has two types - active (i.e. informed choice) and passive (i.e. inertia) - depending on the amount of information processed, which was determined by beneficiaries' levels of perceived risk, motivation, self-efficacy, and needs. Furthermore, findings suggest that whether to receive help in understanding plan information may play a large role in leading informed beneficiaries to act on their knowledge and switch plans. The present study is the first to integrate the concept of information processing to understand Part D beneficiaries' plan switching decisions and the first to examine psychological factors affecting beneficiaries' information processing as well as their plan switching decisions. Study findings will help policy makers developing efficient communication strategies with beneficiaries to help them to make informed choices.

First established in the 1990's, the personal training industry in New Zealand has experienced unprecedented growth. Over 80% of New Zealand health clubs market the services of Personal Trainers and there are now over 1500 registered Personal Trainers working in a range of settings. Their primary professional role is one whereby they promote and support individuals to attain desired 'results' in relation to their physical fitness and particularly, to adopt a more physically active lifestyle. But despite the growth of this industry, little is known about how Personal Trainers actually go about supporting the clients who purchase their service to find a way into, as well as stay committed to a physically activity lifestyle. To date there has been no research in New Zealand exploring how Personal Trainers operate as agents of behaviour change. Furthermore, there appears only anecdotal evidence about how the intervention strategies used by Personal Trainers reflect those recommended in the 'behaviour-change' literature. This thesis focused on the daily, working experiences of ten Personal Trainers. Inspired by the interpretive paradigm, in-depth interviews were conducted and analysis of the data, guided by the tenets of grounded theory, allowed the story about the way each participant went about her/his work to emerge. The study highlights a variety of issues that these Trainers recognise as significantly influencing their ability to succeed in an increasingly competitive and demanding business. Specific reference was also given to the behavioural intervention strategies that each participant believed were the most beneficial in nurturing client lifestyle behaviour-change. The study outcomes reveal that although the Trainers worked independently of each other there was considerable commonality in the approaches they had developed. All agreed on the importance of presenting themselves as confident, competent professionals who modelled healthy life-styles to their clients. Some of the strategies they used were similar in some regards to those described in the intervention literature, but others were not. A salient point made by all was that, despite some of their practices lying outside the professional boundaries defined by their professional registration organisation, the provision of services to clients often went beyond the 'physical'. Nutritional counselling especially had become an integral part of the service they provided for clients and was, in fact, an area which clients 'expected' them to be experts in. Each acknowledged the challenge of devising strategies to keep their clients committed, motivated and returning to them. The study highlighted two distinct phases of intervention as the Trainers used different motivational approaches to firstly, initiate change and then maintain their client's progress. As the clients began to see results all of the trainers agreed that their relationship with their long-term clients became more collegial. As time progressed, and in order to facilitate and foster client belief in the inherent value of physical activity 'for life', the Trainers became their client's Life Coach. The Personal Trainers in this study described a multitude of roles that each believed they needed to fulfil in order that they achieved on-going success as a Trainer. This emphasises the need for a more expansive education programme for Personal Trainers. Programmes which move beyond a traditional fitness discourse and better reflect the complexities of what it truly means to be a one-on-one 'Trainer'.

<p>Most patients are non-adherent with their medication sometimes, i.e. that they do not always use their medicines as prescribed. This might result in both under- and overuse and can lead to therapy failure, resulting in both unnecessary suffering and high costs. Therefore, medication adherence should be as high as possible. </p><p>The aims of this thesis were to investigate the refill adherence to long-term drug treatment, especially for patients with asthma and chronic obstructive pulmonary disease (COPD), and to study treatment gaps for patients with undersupply and drug costs for patients with oversupply. Further aims were to compare different methods for assessing refill adherence and analyse whether the same patient has the same refill adherence pattern to two different chronic drug treatments, i.e. diabetes and asthma/COPD. </p><p>The thesis shows that satisfactory refill adherence (80-120% of the prescribed dose) was 57% for repeat prescriptions with long-term drug treatment; undersupply was 21% and oversupply 22%. Patients with undersupply were without drugs more than half of the prescribed treatment time and the median oversupply for 90-100 days dispensation interval was 28 days. Patients who were exempt from charges had significantly higher oversupply than non-exempt patients and that leads to unnecessary cost for society. The level of satisfactory refill adherence for repeat prescriptions dispensed for asthma/COPD was on average 30%. The same low level was displayed for the elderly, where undersupply was more common than oversupply. </p><p>Assessments of refill adherence during a one-year period gave the same results irrespective of whether the repeat prescriptions were from an individual pharmacy record database or were manually collected at a pharmacy.</p><p>Patients with concomitant use of diabetes and asthma/COPD drugs do not have the same dispensation pattern for both drug types. </p><p>The introduction of patient profiles as a new approach to complement the calculated refill adherence needs to be further studied in larger and more divergent populations. In the future, the new national pharmacy record database in Sweden has opened up for larger studies and will be valuable when studying patterns of drug utilization.</p>

In Sweden, about 10% of the adult population experienceshearing problems that cause them difficulties in everydaycommunication, and approximately 60 000 people are providedwith hearing aids each year. Despite the fact that modernhearing aids can facilitate speech communication in a widerange of listening environments, many hearing-aid users aredissatisfied with their hearing aids. It is likely that theclinical methods used for individual fitting of the hearingaids are not optimal. The current study investigates prescriptive methods fornonlinear, wide dynamic range compression (WDRC) hearinginstruments. The goal is to draw general conclusions about thepreferences of hearing aid users. Therefore, the prescriptionsare evaluated using well-established models of loudness andspeech intelligibility. Current methods differed considerably in prescribed gain.Evaluations in a laboratory test, with 20 hearing-impairedlisteners, showed that these differences led to largedifferences in perceived and calculated loudness, but only tominor differences in measured and predicted speech recognitionscores. The difference in loudness was explored in a studywhere 21 first-time hearing-aid users compared twoprescriptions. One method led to normal and the other toless-than-normal overall calculated loudness (according to theloudness model of Moore and Glasberg (1997)). The prescriptionthat led to less-than-normal overall loudness was clearlypreferred in field and in laboratory tests. Preferred overall loudness was then quantified.Hearing-impaired participants with mild to moderate hearingloss preferred considerably less-than-normal overall calculatedloudness in both eld and laboratory tests. There were nosignificant differences between inexperienced and experiencedhearing aid users. Normal-hearing participants, on the otherhand, preferred close-to-normal overall calculated loudness. Inaddition, a potential problem with the loudness model wasencountered: despite the fact that the hearing-impairedlisteners were provided with less than normal overallcalculated loudness, they rated loudness higher than thenormal-hearing listeners. The results refute the most commonly adopted rationale forprescriptive methods for WDRC hearing aids - that overallloudness should be restored to normal. Hearing-impairedlisteners with mild to moderate hearing loss preferredconsiderably less than normal overall loudness. This should betaken into account when deriving new prescriptive methods, andwhen providing clients with hearing aids. Key words:hearing impairment, hearing aid, nonlinear,WDRC, hearing aid experience, prescription, loudness, loudnessmodel, speech intelligibility, preference.

Most patients are non-adherent with their medication sometimes, i.e. that they do not always use their medicines as prescribed. This might result in both under- and overuse and can lead to therapy failure, resulting in both unnecessary suffering and high costs. Therefore, medication adherence should be as high as possible. The aims of this thesis were to investigate the refill adherence to long-term drug treatment, especially for patients with asthma and chronic obstructive pulmonary disease (COPD), and to study treatment gaps for patients with undersupply and drug costs for patients with oversupply. Further aims were to compare different methods for assessing refill adherence and analyse whether the same patient has the same refill adherence pattern to two different chronic drug treatments, i.e. diabetes and asthma/COPD. The thesis shows that satisfactory refill adherence (80-120% of the prescribed dose) was 57% for repeat prescriptions with long-term drug treatment; undersupply was 21% and oversupply 22%. Patients with undersupply were without drugs more than half of the prescribed treatment time and the median oversupply for 90-100 days dispensation interval was 28 days. Patients who were exempt from charges had significantly higher oversupply than non-exempt patients and that leads to unnecessary cost for society. The level of satisfactory refill adherence for repeat prescriptions dispensed for asthma/COPD was on average 30%. The same low level was displayed for the elderly, where undersupply was more common than oversupply. Assessments of refill adherence during a one-year period gave the same results irrespective of whether the repeat prescriptions were from an individual pharmacy record database or were manually collected at a pharmacy. Patients with concomitant use of diabetes and asthma/COPD drugs do not have the same dispensation pattern for both drug types. The introduction of patient profiles as a new approach to complement the calculated refill adherence needs to be further studied in larger and more divergent populations. In the future, the new national pharmacy record database in Sweden has opened up for larger studies and will be valuable when studying patterns of drug utilization.