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Survival following critical illness is associated with a significant burden of physical and psychosocial morbidity and recovery is often protracted and/or incomplete. Recovery has been measured using, almost exclusively, generic health-related quality of life (HRQoL) questionnaires. There is, however, an inexorable lack of consensus on the conceptual definition of HRQoL, and existing measures have tended to reflect overtly biomedical concerns such as morbidity and impairment at population level. Limited empirical or theoretical work has examined the extent to which widely used measures reflect the individual’s concerns, “health”-related and otherwise. The primary aims of this PhD are to examine HRQoL among a rarely studied sub group of the critically ill patient population: survivors of prolonged critical illness, and to explore the extent to which professionally endorsed measures capture their experiences of and perspectives on the recovery process. The implications of “patient-centredness” are both diverse and far-reaching in terms of policy, practice and critical care outcomes research, and are discussed throughout. A review of the literature among a well studied sub group of the patient population (survivors of Adult Respiratory Distress Syndrome) identified the widespread use of generic and ancillary measures which were invariably developed for use among other patient populations. This approach was seen to offer limited insight to the putative relationship between critical illness-related morbidity and HRQoL. Reflecting existing professional recommendations and practice, the Short Form 36 (SF-36) and the EuroQoL were administered by post to 20 survivors of prolonged critical illness at up to 6 months following ICU discharge. Each subsequently participated in a semi-structured interview, the purpose of which was to explore experiences and perceptions of ongoing morbidity within the contexts of the critical illness “journey” and, importantly, everyday life. A small number (n=5) participated in cognitive interview in order to explore both the everyday logistics of questionnaire completion and the often startling inconsistencies between verbal and questionnaire response. Analysis here revealed the unexpectedly diverse and normally hidden processes through which survivors interpreted and responded to standardised questionnaire items, challenging traditional (i.e. psychometric) notions of validity. Data from the semi-structured interviews were “mapped” onto the dimensions of the SF-36, revealing the highly contextualised and complex inter-relatedness of biomedically defined and ostensibly discrete aspects of experience. Morbidity was conceptualised by survivors in terms of the adaptive and interpretive processes adopted in everyday life (as opposed to a source of loss) and was generally under-reported in questionnaire form. An alternative explanatory framework for HRQoL was subsequently developed. Data were also analysed with reference to the “biographical narrative” of critical illness, a strategy which revealed the significance of survivors’ own stock of “life experience” (health-related and otherwise) in these interpretive and adaptive processes. The unexpectedly phlegmatic nature of survivors’ accounts directed attention to the narrative form, lending credibility to survivors’ claims that “things weren’t that bad”; accounts of seemingly intolerable morbidity were perceived, for example, as “a lucky escape”. This data also revealed, however, the influence of shortfalls in the processes and delivery of acute hospital rehabilitation upon the efficacy of these interpretive and adaptive processes. Mixed methods approaches to HRQoL, in summary, offer significant insights into survivors’ conceptualisations of morbidity, recovery, quality of life and the complex inter-relationships therein. Attention to the processes of adaptation also offers significant potential for the development of patient-centred measures of outcome and the expedition of the recovery process in ways which are most meaningful to survivors.

Background: Disease-specific patient-based questionnaires are being used increasingly to evaluate treatment outcomes in coronary heart disease (CHD) from the patient's perspective. However, most have been developed to evaluate health-related quality of life (HRQoL) in medically rather than surgically treated patients and many have not been rigorously evaluated against required standards. There are currently no validated questionnaires to measure patient- based outcomes after coronary revascularisation, the surgical treatment for CHD. Objectives: To develop a new patient-based instrument, the Coronary Revascularisation Outcome Questionnaire (CROQ), to measure health outcomes and HRQoL before and after coronary artery bypass graft surgery (CABG) and percutaneous transluminal coronary angioplasty (PTCA). To evaluate the psychometric properties of the CROQ using classical psychometric methods. Design: Psychometric study. Subjects: A total of 725 (79% male) patients undergoing CABG and 643 (71% male) patients undergoing PTCA at three hospitals in the UK. Methods: Qualitative methods (literature review, review of existing instruments, patient interviews, and expert opinion) were used to develop two versions of the eROQ (CROQ-CABG and CROQ-PTCA). Two field tests were then conducted by postal survey to patients before and 3-months after revascularisation firstly, to identify possible items for elimination (item reduction) and secondly, to evaluate the psychometric properties (reliability, validity, responsiveness) of the item- reduced CROa in independent samples. Results: The CROQ was acceptable to patients, satisfied tests of scaling assumptions, showed good internal consistency, test-retest reliability, validity, and responsiveness. 4 Conclusions: The CROQ is a new l psychometrically rigorous patient-based measure of outcome for coronary revascularisation. The CROQ has many potential uses in evaluative research l such as in clinical trials of effectiveness I and as a routine clinical audit tool to assist providers of CABG and PTCA in monitoring the outcomes of care

This study involves an exploration of the perceptions of four overseas Kenyan students about their educational experiences at La Trobe University. A related aim of this research is to find out how these four students� previous learning in Kenya affects their learning and living experiences in Australia, for instance, in terms of demands associated with differences in learning and teaching styles, cultural expectations and proficiencies in English. A non-positivist, qualitative methodology is adopted for this research which employs an interview-based case study approach. Qualitative research demands that the world be approached with the assumption that nothing is trivial and that everything has the potential of being a clue which might unlock more comprehensive understanding of what is being researched. While the findings of this study confirm current understandings of the issues that international students commonly face, they also provide a more complex and individualized picture of the needs and aspirations of overseas Kenyan students. As the case studies demonstrate, the academic and related challenges four Kenyan students have encountered at La Trobe University are best understood in relation to several contexts. The difficulties these international students have experienced in the context of transition or border crossing � between two countries, cultures and educational systems � were exacerbated by inadequate pre-departure preparation and orientation on arrival. Incongruities between two educational systems � in particular between their prior teacher-centred schooling in Kenya and the unfamiliar student-centred university education in Australia � colour the academic and related challenges such students struggle to address, at least in their initial year at University. The broader, global context of the commodification and marketization of higher education � along with increasing strains of an under-resourced university sector in Australia � also impinge upon the lives of these four La Trobe students, in a variety of ways.

Previous studies showed that emotional pictures capture attention. Further, this effect was decreased by manipulating spatial attention. In contrast, studies produced mixed findings for effects of perceptual load on attention to emotional pictures. Emotional pictures can be phobic or nonphobic. Because phobia might be an evolutionary adaption, it is possible that effects of phobic pictures on attention differ from effects of nonphobic emotional pictures. The present thesis aimed at investigating attention in spider phobia. Attention to emotional pictures was operationalized as event-related potentials (ERPs) (P1, early posterior negativity [EPN,] and late positive potential [LPP]). Two research questions were formulated. First, do phobic pictures evoke larger ERPs than what can be expected from arousal and valence? Second, are effects of spatial attention and perceptual load on ERPs the same for phobic and nonphobic emotional pictures? To investigate this, phobic and nonphobic negative pictures were presented to spider phobic and nonphobic participants. To determine effects of spatial attention on ERPs, participants were instructed to divert attention to a single letter that was presented in the periphery. To determine effects of perceptual load on ERPs, participants were instructed to perform a letter discrimination task on one, two, or three letters that were presented in the periphery. Study 1 showed enhanced LPP amplitudes to phobic pictures independent of arousal and valence. Further, this effect was present in both phobic and nonphobic participants. Study 2 showed that there was no effect of perceptual load on LPP to phobic pictures. Study 3 showed that spatial attention reduced LPP amplitudes, and to a similar extent for both phobic and nonphobic pictures. Further, perceptual load did not reduce EPN or LPP amplitudes to either phobic or nonphobic pictures. To conclude, the results suggest that phobic pictures evoke larger ERP amplitudes than nonphobic pictures. Still, ERPs to phobic and nonphobic pictures are moderated similarly by spatial attention and perceptual load. / <p>At the time of the doctoral defense, the following papers were unpublished and had a status as follows: Paper 1: Manuscript. Paper 3: Manuscript.</p>

Since the systems of health insurance of the whole people were run in March of the 84th year of the Republic of China, it is very near to offer medical treatment to the best patient in the whole world, the highly free right to choose of seeking medical advice, and high-quality medical care. But cause the expense expenditure of the hospital to rise continuously, is strong in protecting the office as because in conformity with the financial situation, pursue a lot of financial retrenchment policies successively, cause uncertainty and complexity of the medical industry's environment. Especially pay the system so far the total value of the hospital, decline in the development in economy of the whole world depressedly, domestic aging of population, unemployment increase, medical resources are insufficient day by day and strong in assuaring the financial affairs are left pressingly, the central health insurance bureau is paid the system and controls the cost, adjust and pay the standard progressively, towards pay, standardize while being single, so reform pay medical the intersection of institutes and way pay system for TW-DRGSs ' diagnose related group in hospital ' stage by stage year by year from January of 1999. Made in Singapore after setting out on a journey, future so long as medical resource more close part will be sorted out into the same class, in accordance with kinds of Diseases, operation, age, gender, amalgamate condition classification such as disease, divide into groups according to the weight grade of the condition, pay by norm, is lower than lower limit, will adopt and verify that declare the way, that is to say ' pay the system with severity and reward '. The government implements the policy purpose of ' TW-DRGSs ', except the efficiency of serving for raising medical treatment, reduce the waste, also can improve patient, look after quality and curative effect, let the intersection of hospital and the intersection of cost and optimization, but the implementation of DRG will cause the suitable impact of the hospital, may aggravate looking after and financial responsibility and risk of the medical organization. But hospital attribute( Set objectives, the intersection of role and localization, organization and the intersection of power and responsibility and structure,etc.) Different, the hospital faces being strong in assuaring that it and because will be different to pay the financial pressure that the system changes in conformity with ways, except army's hospital in the country shoulders the country and looks after soldier's healthy policy responsibility, pay attention to managing the performance even more. So because should be strong in assuaring that it will be different to pay measure and efficiency that the system's changing takes and lowers costs to some extent, and these differences will react on the manifestation of financial performance indicators such as its medical care amount, income and interests,etc.. Satisfied how to promote the financial performance of the hospital, give consideration to operations objective, medical care quality and patient of the hospital at the same time, key factor that will be managed continuously forever for the hospital. Until ' diagnose related group in hospital ', first serious the intersection of case and clinical route standardize, influence clinical the intersection of route and standardization make, act as, in hospital number for the first time, so this research institute builds the systematic dynamics model constructed, the ones that chose the first stage to implement 155 items of TW-DRGSs were in hospital in days, the hospital TW-DRGSs case number, take bed rate and satisfaction in hospital etc., these influence each other the simulation of the relation value adopts Table function to imitate. And Table function which this research institute puts forward passes the true data in often operation course on ordinary days of case hospital, observe and experience judgement or relevant literature consult materials of income, performance its weigh the intersection of indicator and system can represent the intersection of country and the intersection of army and the intersection of hospital and case only, can't prove why the other scale hospitals are appropriate; And this research is paid and imitated according to the systematic way of case hospital alone, as system way may present different results not simultaneously. Expect to give the case hospital some suggestions in managing, managing and is made with the clinical route through this research, the colleagues of staff of different levels work satisfiedly in safeguarding patient's whole rights and interests, courtyard, promote the quality of medical care, the purpose of this research: (1)Make use of system of macroscopic think way, canvass the intersection of case and hospital, implement, good for, protect TW-DRGSs at the system, the influence that the management in hospital stays runs to the case hospital for a long time, and can assist the case hospital to find the optimum management effect. (2)Set up systematic dynamics way, imitate the intersection of case and hospital, divide into annual to implement, good for, protect TW-DRGSs, in hospital management of day to the intersection of hospital and revenue and expenditure, medical behavior and influence to cure the desease relation at the system stage by stage. The concrete suggestion of this research is as follows: (1) Control and manage number in hospital, increase the turnover rate of the sick bed (2) Set up all kinds of disease clinical guiding or clinical routes (3) Improve the hospitalization cost and declare benefit (4) Research of project development at one's own expense

Thesis (JSD)--City University of Hong Kong, 2009. / "Submitted to School of Law for the degree of Doctor of Juridical Science." Includes bibliographical references (leaves 337-358)