Thesis (M.S.)--Boston University

No / In 2005, the UK Department of Health recommended that a new role, the arrhythmia care coordinator (ACC), be created to guide patients through the diagnosis and treatment for arrhythmia. The belief was that this would improve the efficiency of care and improve their quality of life. The British Heart Foundation provided funding for 32 such posts, all of which were filled by arrhythmia specialist nurses, and commissioned an evaluation of the new service to assess its impact on patients. This paper focuses on the impact of the ACCs on their patients’ levels of anxiety and depression, hospital readmissions and costs to the National Health Service (NHS). From 2008 to 2010, using questionnaires, we conducted a longitudinal audit of the psychological status of the patients referred to the ACCs; we also assessed the ACCs’ impact on readmissions and cost benefits to the NHS using UK Hospital Episode Statistics. We found high levels of anxiety and depression amongst patients. Nearly one-third were at the ‘borderline’ or ‘clinically anxious’ and 18% were at the ‘borderline’ or ‘clinically depressed’ level at their first assessment with small changes at follow-up. In arrhythmia specialist nurse sites, readmission rates were reduced by half. After deducting the cost of the ACCs and their support, the estimated annual saving was £29,357 per ACC. This evaluation has shown that the NHS saves £29,357 per year over and above the costs of employing a British Heart Foundation ACC and that all arrhythmia centres should be encouraged to employ an appropriate number of such specialists.

The U.S.D.A. Model which compares food service systems was tested to determine its reliability and validity. The Model lists the costs and needs of each type of food service system for different hospital bed sizes and demonstrates how two systems can be compared. The Model concludes that the ready foods system is the least-costly food service system. The U.S.D.A. Model was tested using data from eleven hospitals which use the ready foods system. Labor, material and overhead costs were compared. A description of the cost analyses is included. A significant difference was found between the actual cost data from the elven ready foods hospitals and the costs the U.S.D.A. Model predicts these hospitals should have anticipated. The major area of difference was in the area of labor costs. The Model predicted that the man-hours required for each operation are much less than what actually occurred in the eleven hospitals tested. The U.S.D.A. Model was based on data from six conventional and six ready foods hospitals. The U.S.D.A did not look at these twelve hospitals in terms of complete systems, but rather looked at the dishroom from one and the tray delivery system from another. This research looked at eleven ready foods systems in detail as complete systems. This may help explain the significant difference between the actual costs from eleven hospitals with the same system and the U.S.D.A. Model which was based on calculated costs from twelve hospitals only six of which used the ready foods system. It is concluded that the U.S.D.A. Model is neither a reliable nor a valid tool for a food service manager to use in determining the type of food service system to integrate into his operation. It is further recommended that this Model not be used in determining the costs of a food service system because it may give an inaccurate measurement and cause a hospital to spend more money than planned. / Master of Science

This thesis follows the paper-based format and papers one and two have been prepared for submission to Attachment and Human Development and the British Journal of Clinical Psychology, respectively. The relevant submission guidelines are included in the appendices (Appendix A and B).Attachment theory (Bowlby, 1977a) has prompted a wealth of empirical research in its contribution to adult attachment patterns and subsequent psychopathology in mental health (Holmes, 2001; Wallin, 2007). More recently, attachment theory has been proposed as a suitable framework by which to inform the organisation, design and delivery of mental health services (Goodwin, 2003; Seager et al., 2007) but it is unclear what this would look like in practice. Adopting an attachment-informed service model has key implications for individual and service outcomes and the two papers presented in this thesis aim to contribute to research in this area, followed by a critical review of the research, its relevance and future implications. Paper one is a narrative overview of the literature discussing the practice implications of services adopting an attachment-informed framework, and describes how this might be conceptualised in front-line service delivery. Articles reviewed described the influence of attachment theory in predominantly inpatient, secure forensic and/or psychiatric rehabilitation services, and its application within more generic community mental health services was explored. Paper two aimed to investigate the importance of individual attachment and service attachment to client psychopathology, quality of life, service utilisation and service costs in community-based mental health services. The final section, the Critical Review, critiqued the literature review and aimed to place the research within a wider context. This section considers the findings from the research and the limitations of the study, while also highlighting important issues for services, with implications for clinical practice and future research.

Yes / Objectives: Young onset dementia is associated with distinctive support needs but existing research on service provision has been largely small scale and qualitative. Our objective was to explore service use, cost and satisfaction across the UK. Methods: Information about socio‐demographic characteristics, service use and satisfaction were gathered from people with young onset dementia (YOD) and/or a family member/supporter via a national survey. Results: Two hundred and thirty‐three responses were analysed. Diagnosis was most commonly received through a Memory Clinic or Neurology. The type of service delivering diagnosis impacted on post‐diagnostic care. Those diagnosed in specialist YOD services were more likely to receive support within the first 6 weeks and receive ongoing care in the service where they were diagnosed. Ongoing care management arrangements varied but generally care was lacking. Around 42% reported no follow‐up during 6‐weeks after diagnosis; over a third reported seeing no health professional within the previous 3 months; just over a third had a key worker and just under a third had a care plan. Satisfaction and quality of care were highest in specialist services. Almost 60% of family members spent over 5 h per day caring; median costs of health and social care, 3 months, 2018, were £394 (interquartile range £389 to 640). Conclusions: Variation across diagnostic and post‐diagnostic care pathways for YOD leads to disparate experiences, with specialist young onset services being associated with better continuity, quality and satisfaction. More specialist services are needed so all with YOD can access age‐appropriate care. / Alzheimer's Society. Grant Number: 278 AS-PG-15b-034

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal.

Thèse numérisée par la Division de la gestion de documents et des archives de l'Université de Montréal

Affective disorders (AD), including depression have important epidemiological impact on elderly morbi-mortality been also associated to elevate suicide rates. However, AD impact on trends elderly mortality, morbidity and Brazilian health service cost (hospitalization and outpatient care) need to be more deeply investigated. Therefore, this study evaluated the trends of AD and suicide mortality in Brazilian elderly population (1996-2015) and in use of health services (hospitalization and outpatient care) and their costs in 2009 to 2015 period by a socio-ecological analysis using databank evaluable for Health Unic System (DATASUS, Brazil Ministry). The study was performed just in elderly subjects (> 60 years old) considering as co-variables: sex and age. Linear, jointpoint and multivariate regressions were used to detect change in the trends of AD and suicide mortality. Total AD mortality was slightly higher in women (1.2/100.000) than men (1.0/100.000). At contrary, suicide mortality rate was higher in men (13.5/100.000) than females (2.5/100.000). In both mortality causes, occurrence was age-dependent, with higher rates in oldest-old group (> 80 years). Hospitalizations by AD were also higher in older group, in both sex. However, hospitalization costs trend to decrease in the last four years. The whole of results suggests the necessity to construct specific preventive and treatment programs for elderly people, since this population presents important biological, functional, health and social specificities that are different of find in adults. / Os transtornos afetivos (TA), incluindo a depressão, têm um importante impacto epidemiológico na morbi-mortalidade dos idosos, e também estão associados à elevação das taxas de suicídio. No entanto, o impacto dos transtornos afetivos sobre as tendências de mortalidade dos idosos, da morbidade e do custo do serviço de saúde brasileiro (hospitalização e atendimento ambulatorial) precisam ser investigados mais profundamente. Portanto, o objetivo deste estudo foi avaliar as tendências da (TA) e a mortalidade por suicídio na população idosa brasileira (1996-2015) e no uso de serviços de saúde (hospitalização e atendimento ambulatorial) e seus custos no período de 2009 a 2015 por uma análise socioeconômica com banco de dados avaliável para o Sistema Único de Saúde (DATASUS, Ministério do Brasil). O estudo considerou apenas os dados de indivíduos idosos (> 60 anos) considerando como co-variáveis: idade e sexo. Foram utilizadas regressões lineares, conjuntas e multivariadas para detectar mudanças nas tendências de transtornos afetivos e mortalidade por suicídio. A mortalidade total por transtornos afetivos foi ligeiramente maior nas mulheres (1,2/100,000) do que os homens (1,0/100,000). Ao contrário, a taxa de mortalidade por suicídio foi maior nos homens (13,5/100,000) do que as mulheres (2,5/100,000). Em ambas as causas de mortalidade, a ocorrência dependia da idade, com taxas mais elevadas no grupo mais longevo (> 80 anos). Hospitalizações por TA também foi maior em grupos mais velhos, em ambos os sexos. Todos os resultados sugerem a necessidade de construir programas específicos de prevenção e tratamento para idosos, uma vez que esta população apresenta importantes especificidades biológicas, funcionais, sociais e de saúde que são diferentes em relação a outros grupos etários.

Submitted by Renata Lopes (renatasil82@gmail.com) on 2016-06-16T12:06:51Z No. of bitstreams: 1 rogeriopinheironunes.pdf: 1834294 bytes, checksum: 9e40d1bb8f11aadc444547a7a54f78f9 (MD5) / Approved for entry into archive by Adriana Oliveira (adriana.oliveira@ufjf.edu.br) on 2016-07-13T14:12:52Z (GMT) No. of bitstreams: 1 rogeriopinheironunes.pdf: 1834294 bytes, checksum: 9e40d1bb8f11aadc444547a7a54f78f9 (MD5) / Made available in DSpace on 2016-07-13T14:12:52Z (GMT). No. of bitstreams: 1 rogeriopinheironunes.pdf: 1834294 bytes, checksum: 9e40d1bb8f11aadc444547a7a54f78f9 (MD5) Previous issue date: 2016-02-19 / A judicialização da saúde tem provocado discussões sobre a intervenção do Poder Judiciário na governabilidade e na gestão das políticas de saúde. O Poder Público vem sendo obrigado a garantir judicialmente procedimentos e serviços de saúde independentemente de sua cobertura ou incorporação pelo Sistema Único de Saúde, ou, quando cobertos, sem a observância às competências administrativas do gestor local de saúde num sistema público descentralizado e hierárquico. O objetivo desse trabalho foi estimar o custo direto das ações individuais no âmbito do SUS, em especial às competências administrativas do ente municipal, tomando como cenário o município de Juiz de Fora, MG. A amostra se constituiu de 575 processos judiciais (N = 575) que deram entrada num período de seis meses. As demandas judiciais ocorreram para garantia de internação hospitalar, fornecimento de medicamentos e de suplementos e complementos alimentares, além de exames e insumos de enfermagem. Estimou-se o custo pela perspectiva da Secretaria de Saúde de Juiz de Fora como gestora do SUS e compradora de serviço de saúde, totalizando R$ 3.506.701,95 para o período estudado, ou um custo mensal de R$ 1.016,44. Quanto às suas responsabilidades em ofertar tais serviços de acordo com a organização do Sistema Único de Saúde, estimou-se que 90,26% do custo dos pedidos judiciais para internação hospitalar correspondiam a ações que já eram de sua competência, em que a judicialização veio garantir ao cidadão serviços que já deveriam ser ofertados. Conquanto, os pedidos judiciais de medicamentos que não eram de sua competência fornecer ou dispensar representaram 99,70% do custo estimado para essa categoria, incluindo medicamentos de competência de outro ente federado, não cobertos pelo SUS ou em desacordo com os protocolos clínicos estabelecidos para a doença atestada. Ao final, analisando-se as maiores demandas judiciais contra o poder público municipal, pode-se afirmar que 75,28% do custo estimado para a judicialização se referiram a oferta de serviços que não eram da competência administrativa da Secretaria de Saúde de Juiz de Fora como gestora municipal do SUS. Tal fato levanta uma discussão sobre a judicialização no âmbito da saúde pública. Se por um lado busca a garantia do direito constitucional do cidadão, por outro impõe à esfera municipal o ônus de seu custo sem observar as responsabilidades comuns e privativas de cada ente federado na organização do Sistema Único de Saúde. / The judicialization of health has provoked discussions on the intervention of the judiciary in governance and management of health policies. The Government has been obliged to ensure court procedures and health services regardless of coverage or incorporation by the Unified Health System, or when covered, without complying with the administrative skills of the local health officer in a decentralized and hierarchical public system. The aim of this study was to estimate the direct cost of individual actions under the SUS, especially the administrative powers of the municipal entity, taking the backdrop of the city of Juiz de Fora, MG. The sample consisted of 575 court cases (N = 575) who were admitted within six months. The lawsuits occurred to hospitalization assurance, supply of medicines and supplements and food supplements, as well as examinations and nursing supplies. It estimated the cost from the perspective of Juiz de Fora Health Department as manager of the SUS and purchaser of health services, totaling R$ 3,506,701.95 for the period studied, or a monthly cost of R$ 1,016.44. As to their responsibilities in offering such services in accordance with the organization of the Unified Health System, it was estimated that 90.26% of the cost of judicial requests for hospitalization corresponded to actions that were already under its jurisdiction, where the legalization came assure citizens services that should already be offered. While the judicial requests for medications that were not within its competence to provide or dispense represented 99.70% of the estimated cost for that category, including competence of drugs from another federal entity, not covered by SUS or disagree with the clinical protocols established for attested the disease. Finally, analyzing the major lawsuits against the municipal government, it can be stated that 75.28% of the estimated cost for the legalization referred the provision of services that were not the administrative jurisdiction of the Health Department of Judge off as municipal manager of the SUS. This fact raises a discussion of legalization on public health. On the one hand seeks to guarantee the constitutional right of citizens, on the other requires the municipal level the burden of cost without observing the common and private responsibilities of each federal entity in the organization of the Unified Health System.

The aim of this thesis is to design the water-cooling system for a synchronous motor with an output of 10kW. The power loss was analytically determinated. For the initial water-cooling system and for two design proposals, thermal models were calculated in Ansys. The same boundary conditions were set for all three models. Then the analysis results of the temperature distribution on the machine surface and in the slots were compared. The comparison also includes the economical cost of the production and service of the machine. Then the production documentation was created, consisting of the assembly drawings and a simplified technological process.