A Estratégia de Saúde da Família foi implantada pelo Ministério da Saúde, em 1994, para orientar o sistema de saúde brasileiro em direção a Atenção Primária à Saúde. A partir de então, a ampliação da cobertura de equipes de ESF tem estado entre as metas de governo. Para consecução deste propósito, o perfil dos profissionais e a formação se caracterizam como um grande diferencial, com papel determinante em uma reorientação desta magnitude e abrangência. A Residência Multiprofissional em Saúde foi uma das políticas criadas neste sentido. O Grupo Hospitalar Conceição oferece esta modalidade de formação desde 2004. Objetivo: Avaliar a adequação do Programa da Residência Integrada em Saúde, na ênfase Saúde da Família e Comunidade, do GHC, como uma tecnologia de formação de profissionais em APS para o SUS, através de dados coletados junto aos seus egressos. Métodos: O delineamento é um estudo de caso descritivo com associação da metodologia quantitativa e qualitativa, orientado pela avaliação de inferência causal proposta por Habicht et al. A coleta das informações se deu de maneira virtual através de um questionário semiestruturado em formato autoaplicável. A população pesquisada foram 74 profissionais egressos do Programa formados entre os anos de 2005 e de 2008. Resultados: O estudo contou com a participação de 77% dos egressos do Programa. Os dados encontrados revelam uma população de profissionais jovens, predominantemente, do sexo feminino. Estes profissionais exercem suas atividades em 19 cidades, sendo que, na cidade de Porto Alegre se concentram mais de metade deles. 76% dos egressos estão vinculados ao setor público e 49% atuam diretamente na APS. A maioria dos participantes afirma que a formação alterou a forma de perceber a realidade em APS, melhorou suas habilidades e aumentou os conhecimentos. Conclusões: As evidências produzidas no estudo fornecem subsídios para considerar o Programa como uma tecnologia adequada à formação de profissionais de saúde em APS para o SUS. / The Family Health Strategy, an initiative from the Ministry of Health, started in 1994, providing guidelines to the Brazilian Health System towards Primary Health Care. Since then, there was a remarkable increase in the strategy coverage. To pursue this objective, the professional profiles and their formation are characterized as great differentials, with a pivotal role in a reorientation of such magnitude. The Health Interprofessional Residency was one of these government policies created with this scope, and the Grupo Hospitalar Conceição has been offering this continuum education course since 2004. Objective: To evaluate the fitting adequation of The Health Interprofessional Residency, emphasis in Family and Community Health, as a good technology to train health professionals in Primary Health Care in the context of Brazilian Health System, using data collected from professionals graduated in the Residency program. Methods: The design is based on a descriptive study case, associating quantitative and qualitative methodologies, relying on the evaluation of causal inference proposed by Habicht et al. The information was collected by a virtual mode with a semi structured and self-administered questionnaire. Professionals (74) that concluded the program between 2005 and 2008 were selected to be included in the sample. Results: The response rate was 77%. The population was mainly composed by young individuals, predominantly females. These individuals perform their professional activities in 19 different cities; more than 50% were working in the State capital city (Porto Alegre). From the individuals interviewed, 76% of them were public servants and 49% were working directly in Primary Health Care. Most of the participants stated that the training during Residency had significantly changed their view in relation to the reality in Primary Health Care, improving their skills and increasing their knowledge. Conclusion: The findings from this study show that the Residency Program could be considered a good technology for training Primary Health Care professionals for the Brazilian Health System.

A nanotecnologia surge como uma promessa revolucionária na economia mundial. Diversas discussões sobre os benefícios do controle de materiais em escala nanométrica estão acontecendo pelo mundo. No entanto, até que ponto essas promessas irão se tornar realidade? Grandes setores industriais têm investido em pesquisa em nanotecnologia com objetivo de criar produtos com funções nunca antes imaginadas. Do ponto de vista tecno-econômico, a nanotecnologia tem um grande potencial para empresas e para a sociedade. Disto surge uma questão importante: uma tecnologia emergente não teria impactos do ponto de vista social e ambiental a considerar? As lições dos casos com outras tecnologias como, por exemplo, o tema dos Alimentos Geneticamente Modificados, devem ser consideradas, e, por isso, as discussões sobre a nanotecnologia devem ocorrer em uma perspectiva mais ampla, além da perspectiva tecno-econômica. A consideração de múltiplas dimensões (tecnológica, econômica, social e ambiental) é muito importante para o desenvolvimento da tecnologia na economia atual. Neste sentido, esta tese utilizou uma pesquisa de campo com a seguinte configuração: uma pesquisa exploratória, caracterizada por entrevistas com quatro atores envolvidos no desenvolvimento da nanotecnologia, e uma segunda pesquisa exploratória somente com representantes do ator empresa; e a segunda foi uma pesquisa descritiva, caracterizada pela aplicação de uma survey entre pesquisadores do ator universidade e centro tecnológico. O principal objetivo da pesquisa foi propor um modelo multidimensional de análise de impactos de uma nova tecnologia, onde são analisadas as relações dos impactos entre quatro dimensões de análise. Os resultados se compõem da discussão dos elementos do modelo multidimensional de análise de uma nova tecnologia para o caso da nanotecnologia, onde se conclui que as novas dimensões, social e ambiental, são importantes para o devido desenvolvimento de uma nova tecnologia, mas não compreendidos pelos atores do atual cenário de desenvolvimento da nanotecnologia. / The nanotechnology emerges with the promise to revolutionize the world. There are many discussions about the “great” things that could be done from the control of material in the nanoscale. However, until what point all these promises will become reality? International big industries has invested in nano’s research with the goal of create unimaginable daily products. From the techno-economic point of view, the nanotechnology has a great potential for the enterprises and for the society. Nevertheless, the question that emerges is: an emergent technology like that won’t have also the impacts in the environmental and social points of view? The lessons of the OGM cases have to be taken into account, and for this, the nanotechnology discussions have to be done in a broader perspective, that only the techno-economic level. The consideration of these multiples dimensions (technologic, economic, social and environmental) is very important for the development of this technology in the economy. In this sense, this thesis is a result of two phases: first is qualitative, and characterized by the experts interviews; the second is quantitative, and characterized by a survey application for the nanobiotechnology network integrants. The main goal of this research is to propose a model to analyse the impacts from nanotechnology in a multidimensional framework including macroeconomic view and the relationships among different dimensions of impacts. As results it proposed a matrix of “impacts x actors” that allowed a better comprehension of the brazilian nanotechnology scenario (in the nanobiotecnology domain), and the an overview about the initial stage of nanotechnology development considering the potential impacts for future. The main finding is that environmental and social dimensions are strongly related to technological and economic dimensions and are very important to consider during the economic development path.

In the early 1990s claims were made that in all areas of health care, “30-40% of patients do not receive treatments of proven effectiveness”, and, “20-25% of patients have treatments that are unnecessary or potentially harmful”. Many such practices were diffused prior to the acceptance of modern evidence-based standards of clinical- and cost-effectiveness. I define disinvestment in the context of health care as the processes of withdrawing (partially or completely) resources from any existing health care practices, procedures, technologies or pharmaceuticals that are deemed to deliver little or no health gain relative to their cost, and thus are not efficient health resource allocations. Arguably disinvestment has been central to Evidence-Based Medicine(EBM) for well over a decade yet despite general advances in EBM, this topic remains relatively unexplored. This thesis examines the ongoing challenges that exist within the Australian context relating to effective disinvestment. Upper airway surgical procedures for the treatment of adult Obstructive Sleep Apnoea Syndrome (OSA) are used as a case study to contextualise these challenges. This thesis has six sections: 1. A review of the literature outlines developments in EBM broadly and provides a detailed background to OSA, including the numerous treatment options for the condition. This review examines evidence that highlights the importance of ‘highly effective treatment’ over ‘subtherapeutic treatment’ as a necessity to confer improved health outcomes in OSA. It is argued that claims of surgical success inherent in most published results of surgery effectiveness fail to assimilate contemporary evidence for clinically significant indicators of success. 2. Section two comprises the first reported meta-analysis in this area. It presents the pooled success rates of surgery according to various definitions. Specifically, when the traditional ‘surgical’ definition of success is applied the pooled success rate for Phase I (i.e. soft palate) surgical procedures is 55% (that is 45% fail). However, using a more stringent definition (endorsed by the peak international sleep medicine body), success is reduced to 13% (that is 87% fail). Similarly for Phase II (i.e. hard palate) procedures success rates decrease from 86% to 43% respectively when moving from a surgical to a medical definition of success. That various medical specialties differentially define treatment success, I argue, creates uncertainty for observers and non-clinical participants in this debate (eg policy stakeholders and patients). This represents a barrier to disinvestment decisions. 3. Results are presented from a clinical audit of surgical cases conducted as a component of this thesis. Both clinical effectiveness and procedural variability of surgery are reported. A unique methodology was utilised to capture data from multiple centres. It is the first time such a methodology has been reported to measure procedural variability alongside clinical effectiveness (inclusive of a comparative treatment arm). The observed cohort (n=94) received 41 varying combinations of surgery in an attempt to treat OSA. Results on effectiveness demonstrate an overall physiological success rate of 13% (according to the most stringent definition; phases I and II combined). This demonstration of procedural variability combined with limited effectiveness highlights clinical uncertainty in the application of surgical procedures. 4. Section four outlines how a qualitative phase of enquiry, directed at exploring the perspectives and experiences of surgery recipients, was approved by three independent research ethics review boards but was not supported by a small group of surgeons, resulting in the project being canceled. Potential consequences of this for impeding health services research (HSR) are discussed. 5. Two sets of results are reported from a qualitative phase of enquiry (semi-structured interviews) involving senior Australian health policy stakeholders. The first results are of policy stakeholders’ perspectives on the surgical meta-analysis and clinical audit studies in 2 and 3 above. The second results are from an extended series of questions relating to challenges and direction for effecting disinvestment mechanisms in Australia. Stakeholder responses highlight that Australia currently has limited formal systems in place to support disinvestment. Themes include how defining and proving inferiority of health care practices is not only conceptually difficult but also is limited by data availability and interpretation. Also, as with any policy endeavour there is the ever-present need to balance multiple interests. Stakeholders pointed to a need, and a role, for health services and policy research to build methodological capacity and decision support tools to underpin disinvestment. 6. A final discussion piece is presented that builds on all previous sections and summarises the specific challenges that exist for disinvestment, including those methodological in nature. The thesis concludes with potential solutions to address these challenges within the Australian and international context. Systematic policy approaches to disinvestment represent one measure to further improve equity, efficiency, quality of care, as well as sustainability of resource allocation. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1297655 / Thesis (Ph.D.) -- University of Adelaide, School of Population Health and Clinical Practice, 2007

Human production needs are met through the use of modern technology that is increasingly recognised as a threat to the planetary ecosystem and social sub-system. In light of this recognition, there is evidence that a planned transition towards more sustainable technological infrastructure is occurring across various production sectors. This change is often associated with re-orientating technology based on the concept of sustainable development and national-level strategies such as <i>ecological modernisation</i>, which prescribes phasing-out environmentally malignant conventional technology for cleaner post-industrial solutions. There is evidence, however, that a transition towards cleaner technological options is occurring at the local level. In southern Ontario, Canada ecological technology (<i>ecotechnology</i>) has been adopted in small-scale agricultural and educational facilities for the management of manure and domestic sewage. Ecotechnology is designed to meet human production requirements and to restore the environment through combining natural systems and engineered components to achieve cleaner production. Two types of ecotechnologies were investigated during this research: <i>constructed treatment wetlands</i> for the management of manure and <i>greenhouse-based biological technologies</i> for the management of domestic sewage. These options are novel and can be expected to encounter barriers resulting from a <i>selection environment</i> favouring pre-existing technological options that have previously become established. The overall objective of the research was <i>to identify key factors both driving and constraining the adoption and implementation of the ecotechnology</i> across four case studies. This objective was accomplished through employing a qualitative, collective case study approach. The case studies revealed the motivation behind the adoption of the ecotechnology arose from the environmental values of users and formed the basis for rejecting the conventional options because they were not viewed as capable of improving the environment. However, the ecotechnology also exceeded user's aesthetic and operational level expectations. Barriers to the implementation of ecotechnology were also identified. The investigation revealed the existence of a <i>perspective-gap</i> between the ecological engineering science and traditional engineering science, which constrained implementation of the ecotechnology. Skepticism was found to arise due to the unique performance parameters and <i>soft</i> operational characteristics of ecotechnology, which contrast the <i>hard</i> technological fixes that are familiar to traditional engineering science. This perspective-gap may account for the institutional inertia, which became clear after the 1996 provincial budget reductions decreased the level of support for research and environmental technology development programs in Ontario. These reductions also devolved authority for small-scale wastewater treatment to the municipal level where lack of technical expertise and reliance on standardised regulations has constrained the development of alternatives. Constructive technology assessment suggests that the development of technology must be guided in cooperative <i>social learning</i> processes capable of reflecting the needs and values of stakeholders in order to achieve beneficial social and technological change. Evidence from the case studies revealed that a significant amount of capacity was developed when stakeholders collaborated and legitimated the <i>social experiments</i> where the ecotechnology was applied. These experiments demonstrate the significance of creating settings where users, technology proponents and provincial and local approval agents can collaborate. Through collaboration, social learning can be facilitated during the development of alternative technological solutions that may be congruent with ecological modernisation and the re-orientation of technology towards options that are ecologically-oriented.

Human production needs are met through the use of modern technology that is increasingly recognised as a threat to the planetary ecosystem and social sub-system. In light of this recognition, there is evidence that a planned transition towards more sustainable technological infrastructure is occurring across various production sectors. This change is often associated with re-orientating technology based on the concept of sustainable development and national-level strategies such as <i>ecological modernisation</i>, which prescribes phasing-out environmentally malignant conventional technology for cleaner post-industrial solutions. There is evidence, however, that a transition towards cleaner technological options is occurring at the local level. In southern Ontario, Canada ecological technology (<i>ecotechnology</i>) has been adopted in small-scale agricultural and educational facilities for the management of manure and domestic sewage. Ecotechnology is designed to meet human production requirements and to restore the environment through combining natural systems and engineered components to achieve cleaner production. Two types of ecotechnologies were investigated during this research: <i>constructed treatment wetlands</i> for the management of manure and <i>greenhouse-based biological technologies</i> for the management of domestic sewage. These options are novel and can be expected to encounter barriers resulting from a <i>selection environment</i> favouring pre-existing technological options that have previously become established. The overall objective of the research was <i>to identify key factors both driving and constraining the adoption and implementation of the ecotechnology</i> across four case studies. This objective was accomplished through employing a qualitative, collective case study approach. The case studies revealed the motivation behind the adoption of the ecotechnology arose from the environmental values of users and formed the basis for rejecting the conventional options because they were not viewed as capable of improving the environment. However, the ecotechnology also exceeded user's aesthetic and operational level expectations. Barriers to the implementation of ecotechnology were also identified. The investigation revealed the existence of a <i>perspective-gap</i> between the ecological engineering science and traditional engineering science, which constrained implementation of the ecotechnology. Skepticism was found to arise due to the unique performance parameters and <i>soft</i> operational characteristics of ecotechnology, which contrast the <i>hard</i> technological fixes that are familiar to traditional engineering science. This perspective-gap may account for the institutional inertia, which became clear after the 1996 provincial budget reductions decreased the level of support for research and environmental technology development programs in Ontario. These reductions also devolved authority for small-scale wastewater treatment to the municipal level where lack of technical expertise and reliance on standardised regulations has constrained the development of alternatives. Constructive technology assessment suggests that the development of technology must be guided in cooperative <i>social learning</i> processes capable of reflecting the needs and values of stakeholders in order to achieve beneficial social and technological change. Evidence from the case studies revealed that a significant amount of capacity was developed when stakeholders collaborated and legitimated the <i>social experiments</i> where the ecotechnology was applied. These experiments demonstrate the significance of creating settings where users, technology proponents and provincial and local approval agents can collaborate. Through collaboration, social learning can be facilitated during the development of alternative technological solutions that may be congruent with ecological modernisation and the re-orientation of technology towards options that are ecologically-oriented.

Η τελικού σταδίου χρόνια νεφρική ανεπάρκεια (ΤΣΧΝΑ) είναι η αμετάκλητη απώλεια της νεφρικής λειτουργίας. Όταν η απώλεια της νεφρικής λειτουργίας φτάσει στο σημείο όπου οι νεφροί δεν μπορούν να συντηρήσουν τον ασθενή στην ζωή, τότε απαιτείται θεραπεία υποκατάστασης της νεφρικής λειτουργίας (ΘΥΝΛ). που είναι η αιμοκάθαρση (ΑΜΚ), η περιτοναϊκή κάθαρση, ή η μεταμόσχευση νεφρού. Η ενδονοσοκομειακή ΑΜΚ πραγματοποιείται 3 φορές την εβδομάδα και διαρκεί 3-5 ώρες. Η κατ' οίκον ΑΜΚ λαμβάνει χώρα στο σπίτι του ασθενούς, προσφέροντας ευελιξία στην επιλογή της συχνότητας (3-7 οορές εβδομάδα) και της διάρκειας της συνεδρίας ΑΜΚ (4-10 ώρες). Ειδικότερα η καθημερινή νυχτερινή κατ' οίκον ΑΜΚ, που πραγματοποιείται κατά την διάρκεια του ύπνου, προσφέρει σημαντικά κλινικά οφέλη, δυνατότητα κοινωνικής και επαγγελματικής αποκατάστασης, μείωση της φαρμακοληψίας, ελευθερία στην διατροφή και την πόση, καθώς και βελτίωση στην ποιότητα ζωής των ασθενών. Σύμφωνα με πρόσφατα στοιχεία, περισσότεροι από 10.000 Έλληνες ασθενείς υποφέρουν από ΤΣΧΝΑ και το 74% χρησιμοποιεί την ΑΜΚ ως θεραπεία υποκατάστασης, ενώ παράλληλα υπάρχει αυξανόμενη πίεση στις μονάδες ΑΜΚ, εξαιτίας της μεγάλης προσαύξησης του αριθμού των ασθενών τους. Για το 2004, η Ελλάδα παρουσίασε την μεγαλύτερη συχνότητα νεοεισαχθέντων ασθενών ανά εκατομμύριο πληθυσμού στην ΑΜΚ σε σύγκριση με 24 Ευρωπαϊκές χώρες και κατείχε την 3η θέση παγκοσμίως στην αντίστοιχη συχνότητα σε ΘΥΝΛ, μετά τις ΗΠΑ και την Ιαπωνία. Η κατάταξη της Ελλάδας στην 8η θέση, στην παγκόσμια σύγκριση του επιπολασμού σε ΘΥΝΛ, παρόλο που είναι ευνοϊκότερη, παραμένει πολύ υψηλή, υποδεικνύοντας το μέγεθος του αυξημένου αριθμού ΤΣΧΝΑ στην χώρα μας. Στους παράγοντες που συντελούν στην ύπαρξη του φαινομένου, είναι ο πολύ χαμηλός αριθμός μεταμοσχεύσεων νεφρού στην Ελλάδα, η οποία κατέχει την 20η θέση ανάμεσα σε 24 Ευρωπαϊκές χώρες, για το 2004, καθώς και η αύξηση της επιβίωσης των ασθενών σε ΘΥΝΛ. Η παρούσα διδακτορική διατριβή εστιάζεται στην αποτίμηση τεχνολογίας υγείας της κατ' οίκον αιμοκάθαρσης, στην μελέτη των παραγόντων που επιδρούν την υιοθέτηση της και στην αξιολόγηση της ποιότητας ζωής των αιμοκαθαιρομένων στην Ελλάδα. Συγκεκριμένοι στόχοι της είναι: i) Να εκτιμηθεί, πέρα από την ποιότητα ζωής, η προθυμία των Ελλήνων αιμοκαθαιρομένων να συμμετάσχουν σε πρόγραμμα κατ' οίκον ΑΜΚ και ii) Να διεξαχθεί βιβλιογραφική ανασκόπηση για να αποτιμηθεί αν η κατ' οίκον αιμοκάθαρση είναι πιο αποτελεσματική και με καλύτερο δείκτη κόστους -χρησιμότητας από την ενδονοσοκομειακή, καθώς και να συγκεντρωθούν και να αναλυθούν δεδομένα από την ερευνητική επίσκεψη σε έμπειρα κέντρα κατ' οίκον αιμοκάθαρσης του εξωτερικού. Η συγκέντρωση δεδομένων για την σχετιζόμενη με την υγεία ποιότητα ζωής 146 Ελλήνων αιμοκαθαιρομένων, πραγματοποιήθηκε σε 10 κέντρα ΑΜΚ της Ελλάδας, με ποσοστό απόκρισης 84%. Χρησιμοποιήθηκε το εξειδικευμένο στη νεφροπάθεια εργαλείο KDQOL-SF (που ενσωματώνει το εργαλείο γενικής υγείας SF-36) και ένα συμπληρωματικό ερωτηματολόγιο που συνοδευόταν από ενημερωτικό κείμενο για την* νυχτερινή κατ' οίκον ΑΜΚ, ώστε να συλλεχθούν δημογραφικά δεδομένα και να εκτιμηθεί η προθυμία συμμετοχής σε πρόγραμμα κατ' οίκον ΑΜΚ. Η συμπλήρωση των ερωτηματολογίων έγινε με επιτόπου συνέντευξη. Στην έρευνα συμμετείχαν 99 άνδρες και 47 γυναίκες, με μέση ηλικία 57 +/- 15,7 έτη. Παρόλο που το 61% των ερωτηθέντων ήταν σε παραγωγική ηλικία, μόνο το 23% είχαν παραμείνει στην εργασία τους και οι υπόλοιποι ήταν είτε άνεργοι, είτε σε άδεια ασθενείας, είτε είχαν συνταξιοδοτηθεί λόγω μερικής αναπηρίας, ενώ το 62% των ασθενών δήλωσε ετήσιο εισόδημα μικρότερο από 10.000€. Ο σακχαρώδης διαβήτης ήταν η πιο συχνά εμφανιζόμενη πρωτογενής αιτία νεφρικής ανεπάρκειας (20%) και η πλειοψηφία των ασθενών (73%) τελούν ΑΜΚ για λιγότερα από πέντε χρόνια. Τρεις ασθενείς αναγκάστηκαν να αλλάξουν τόπο διαμονής για να βρίσκονται πιο κοντά στην μονάδα ΑΜΚ, ενώ περίπου το 45% των αιμοκαθαιρομένων διανύουν συνολικά περισσότερα από 40km, 3 φορές την εβδομάδα, για κάθε συνεδρία ΑΜΚ. Από τις κλίμακες του KDQOL-SF, χαμηλότερες τιμές καταγράφηκαν στην εργασία, την σεξουαλική λειτουργία και τον φόρτο της νεοροπάθειας. Η σύγκριση των κλιμάκων SF-36 του δείγματος με τον Ελληνικό γενικό πληθυσμό παρουσίασε στατιστικά σημαντικές διαφορές (p<0,01) σε όλες τις κλίμακες, πλην του σωματικού πόνου. Επίσης, η σύνοψη συνιστωσών ψυχικής υγείας του δείγματος των αιμοκαθαιρουμένων ήταν ελαφρώς χαμηλότερη από του γενικού πληθυσμού, ενώ η σύνοψη συνιστωσών σωματικής υγείας ήταν αρκετά χαμηλότερη. Τα αποτελέσματα του δείγματος της παρούσας έρευνας (Ν=146) συγκρίθηκαν με αντίστοιχο δείγμα Ισπανών ασθενών ΤΣΧΝΑ (Ν=194) που συμπλήρωσαν το ίδιο ερωτηματολόγιο. Το γεγονός ότι και σ" αυτή την σύγκριση δεν εμφανίστηκε στατιστικά σημαντική διαφορά στην κλίμακα του σωματικού πόνου, ενδυναμώνει την εγκυρότητα της μέτρησης και υποδεικνύει ότι οι ασθενείς ΤΣΧΝΑ δεν υπέφεραν σημαντικά από σωματικό πόνο εξαιτίας της ασθένειας τους, σε σημείο τέτοιο, που να έχει αρνητική απήχηση στην αντίληψη τους για την σχετιζόμενη με την υγεία ποιότητα ζωής τους. Διάθεση συμμετοχής στην νυχτερινή κατ’ οίκον ΑΜΚ εξέφρασε το 84% των ασθενών και το 75% για την κατ΄ οίκον ΑΜΚ. Έντονη προθυμία σημειώθηκε στο 53% και το 38% των 146 ερωτηθέντων αντίστοιχα, ενώ διατεθειμένοι να δαπανήσουν κάποιο χρηματικό ποσό για να συμμετάσχουν ήταν το 38%. Στην ερευνητική επίσκεψη σε δύο μεγάλα και έμπειρα κέντρα κατ’ οίκον αιμοκάθαρσης του εξωτερικού, στο Lund και το Helsinki. συγκεντρώθηκαν πολύτιμα δεδομένα που αφορούν στην οργάνωση, την διεξαγωγή, την εμπειρία και την τεχνογνωσία τους. και τα οποία σχετίζονται με την δομή του προγράμματος, οικονομικές εκτιμήσεις, ιατρικά δεδομένα, στατιστικά αποτελέσματα, μεθόδους εκπαίδευσης και τα πιθανά ρίσκα ή προβλήματα που ενδέχεται να ανακύψουν, μαζί με τους τρόπους αποφυγής ή επίλυσης τους. Τα δημογραφικά δεδομένα σε συνδυασμό με το υψηλό κόστος, καθιστούν την ενδονοσοκομειακή αιμοκάθαρση μια από τις πιο δαπανηρές υγειονομικές παρεμβάσεις και διαπιστωμένα την πιο δαπανηρή μεταξύ των υπολοίπων μεθόδων ΘΥΝΛ. Το κόστος της στην Ελλάδα ξεπερνά το 2% των δαπανών της υγείας. Από την ανασκόπηση της παγκόσμιας βιβλιογραφίας, αλλά και από την μελέτη των κέντρων ΑΜΚ της Σκανδιναβίας, επιβεβαιώνεται ότι η κατ’ οίκον και η δορυφορική ΑΜΚ στοιχίζουν λιγότερο και έχουν καλύτερο δείκτη κόστους-αποτελεσματικότητας από την ενδονοσοκομειακή ΑΜΚ. ενώ παράλληλα εμφανίζουν αυξημένη επιβίωση και καλύτερη ποιότητα ζωής. Κατά συνέπεια, η ανάπτυξη αυτών των εναλλακτικών μεθόδων στην Ελλάδα θα μπορούσε να αμβλύνει την αύξηση του προβλεπόμενου συνολικού κόστους των μεθόδων ΘΥΝΛ στο υγειονομικό σύστημα, συμβάλλοντας και στην ανακούφιση από το πρόβλημα της αυξανόμενης πίεσης στις νοσοκομειακές μονάδες ΑΜΚ. αλλά και της έλλειψης του νοσηλευτικού προσωπικού, με την ταυτόχρονη βελτίωση της ποιότητας ζωής των αιμοκαθαιρομένων. Με την κατάλληλη οργάνωση και στελέχωση, η κατ* οίκον ΑΜΚ θα μπορούσε να γίνει εφικτή και στην Ελλάδα, αφού μεγάλη μερίδα ασθενών δηλώνουν πρόθυμοι να συμμετάσχουν, γεγονός που αποτελεί και την βασικότερη προϋπόθεση επιτυχίας ενός τέτοιου προγράμματος. Επιπρόσθετα, με δεδομένο ότι η Ελλάδα παρουσιάζει πολύ υψηλή συχνότητα νεοεισαχθέντων ασθενών ΤΣΧΝΑ, πρέπει να ενταθούν οι προσπάθειες για την συγκράτηση και τον περιορισμό αυτού του φαινομένου, μέσω προγραμμάτων ενημέρωσης και πρόληψης, που μαζί με την μεταμόσχευση παραμένουν οι αποτελεσματικότεροι τρόποι αντιμετώπισης του προβλήματος. / End stage renal failure is the irreversible loss of kidney function. When loss of kidney function reaches the point at which die kidneys fail to support life, then renal replacement therapy (RRT) is required, that is hemodialysis (HD), peritoneal dialysis or renal transplantation. Hospital hemodialysis is conducted 3 times per week and lasts 3-5 hours. Home hemodialysis takes places at patient’s home, offering flexibility in choosing the frequency (3-7 times Week) and the length of the hemodialysis session (4-10 hours). Daily nocturnal home hemodialysis in particular, which is conducted while the patient is asleep, offers significant clinical benefits, the opportunity of social and professional rehabilitation, reduction of drugs, freedom in diet and drinking intake, as well as improvement in patients' quality of life. According to recent records, more than 10.000 Greek patients suffer from end stage renal disease (ESRD) and 74% of them use hemodialysis as replacement therapy, while at die same time there is increasing pressure on hemodialysis units because of the growing number of patients who are receding hemodialysis. In 2004, Greece appeared to have the highest incidence per million population in hemodialysis, in comparison with 24 European countries and the 31 place in die world in the incidence per million population in RRT, after USA and Japan. The rating of Greece in the 8th place of global comparison in prevalence in RRT, although more propitious, remains very high suggesting die extent of the increasing number of ESRD m Greece. Among the factors that contribute to the existence of this phenomenon are the very low numbers of renal transplantation in Greece, which holds the 20th place among 24 European countries m 2004 and the increase of survival of patients on RRT. This doctoral thesis focuses on technology assessment of home HD, the study of the factors that affect its adoption and finally die evaluation of Greek hemodialysis patients' quality of life. The specific objectives are: i) To evaluate the quality of life of Greek hemodialysis patients, as well as their willingness to participate in a home HD program and ii) To conduct a review of the literature in order to assess whether home hemodialysis is more effective and with better cost-utility than hospital hemodialysis and to gather and analyze data taken from the inquiring visit in experienced home hemodialysis units of foreign countries. Data concerning die health related quality of life of 146 Greek hemodialysis patients were gathered from 10 HD units in Greece and the response rate was 84%. The renal disease specific instrument KDQOL-SF was used (which incorporates the general health instrument SF-36), accompanied with an additional questionnaire and an informative leaflet on nocturnal home hemodialysis, in order to gather demographic data and to evaluate the willingness of participation m a home hemodialysis progρam. Questionnaires were completed with on site interview. This study included 99 men and 47 women, with mean age 57 +/- 15,7 years. Although 61% of the participants were in productive age, only 23% were employed and the rest were either unemployed, on sick leave or receiving a disability pension, while 62% of the patients reported annual income less than l0.000 Euros. Diabetes mellitus was the most common primary kidney disease (20%) and the majority of patients were on hemodialysis for less than five years. Three patients were obliged to change place of residence so as to be closer to the hemodialysis unit, while almost 45% of the patients had to navel more than 40km, 3 times per week, for every HD session. The lowest scores in KDQOL-SF scales were found in work status, in sexual functioning and m the burden of kidney disease. The comparison of the SF-36 scales of die study sample with the Greek general population identified statistically significant differences (p<0.01) in all scales, except of the bodily pain scale. Moreover, the Mental Component Summary was slightly worse compared with the general population's, while the Physical Component Summary was quite lower. The results of the present study sample (N=146) were compared with an equivalent sample of Spanish ESRD patients (N=194) who completed the same questionnaire. The fact that m this comparison no statistically significant difference was found in the scale of bodily pain, strengthens the validity of the measurement and suggests that ESRD patients did not experience severe suffering from pain due to their disease that could worsen their perception of health related quality of life. Inclination to participate in nocturnal home HD was expressed by 84% of the patients and by 75% of the patients for home hemodialysis. Strong willingness was reported in 53% of the patients for nocturnal home HD and in the 38% for home HD respectively, while the 38% of the patients were also willing to contribute financially in order to participate. The inquiring visit in two experienced home hemodialysis units in Lund and Helsinki, provided valuable information concerning their organization, their waging, their experience and their know-how. which are related with the structure of the program, economical evaluations, medical data, statistical outcomes, methods of training and potential risks or problems that might emerge, together with advices on how to avoid or solve them. The demographical data in combination with the high cost renders hospital hemodialysis one of the most expensive medical interventions and certainly the most expensive among the other RRT methods. Hemodialysis cost in Greece absorbs more than 2% of total health expenditure. The review of the global literature and the study on the Scandinavian home HD units verified that both home and satellite hemodialysis are less costly and more cost-effective than hospital hemodialysis, while at the same time they present increased survival and better quality of life. Hence, the development of these alternative modalities of dialysis in Greece could mitigate the anticipated net cost increases of RRT to the health system. This could contribute to the alleviation of the increasing pressure on hospital HD units and the nursing shortage, with the simultaneous improvement of hemodialysis patients' quality of life. With the appropriate organization and staff, home hemodialysis could be feasible also in Greece, since big part of the patients are reporting willingness to participate and this fulfils the basic requirement for such a program to succeed. In addition, considering that Greece reports very high incidence, efforts must be intensified in order to restrain and reduce this phenomenon, through informing and prevention programs, which next to renal transplantation are the most effective ways to confront the problem.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal

This study looks at the National Citizens' Technology Forum (NCTF), a modified version of the consensus conference, which took place in March, 2008 in six cities across the U.S. to understand how inclusive these methods of public participation are in practice. The research focused on two of these sites. Inclusion of participants was defined in terms of presence, voice and being heard. Transcripts of the audio-visual recordings of the proceedings were the main data of analysis. By focusing on the talk within these deliberative forums, the study looked at how the rules of engagement and status (ascribed and achieved) differences between participants can affect inclusion. The analysis did not reveal any substantial effects of ascribed characteristics on deliberation. Facilitation and the presence of expertise among the participants were found to influence inclusion and equality among participants. These findings suggest that organizers and facilitators of deliberative exercises have to be reflexive of their role as well as aware of the group dynamics. The results also address the larger questions within science and technology policy like the role of expertise and the public in decision making, the institutional design of participatory exercises, and their relation to the political culture and the policy process.

In the early 1990s claims were made that in all areas of health care, “30-40% of patients do not receive treatments of proven effectiveness”, and, “20-25% of patients have treatments that are unnecessary or potentially harmful”. Many such practices were diffused prior to the acceptance of modern evidence-based standards of clinical- and cost-effectiveness. I define disinvestment in the context of health care as the processes of withdrawing (partially or completely) resources from any existing health care practices, procedures, technologies or pharmaceuticals that are deemed to deliver little or no health gain relative to their cost, and thus are not efficient health resource allocations. Arguably disinvestment has been central to Evidence-Based Medicine(EBM) for well over a decade yet despite general advances in EBM, this topic remains relatively unexplored. This thesis examines the ongoing challenges that exist within the Australian context relating to effective disinvestment. Upper airway surgical procedures for the treatment of adult Obstructive Sleep Apnoea Syndrome (OSA) are used as a case study to contextualise these challenges. This thesis has six sections: 1. A review of the literature outlines developments in EBM broadly and provides a detailed background to OSA, including the numerous treatment options for the condition. This review examines evidence that highlights the importance of ‘highly effective treatment’ over ‘subtherapeutic treatment’ as a necessity to confer improved health outcomes in OSA. It is argued that claims of surgical success inherent in most published results of surgery effectiveness fail to assimilate contemporary evidence for clinically significant indicators of success. 2. Section two comprises the first reported meta-analysis in this area. It presents the pooled success rates of surgery according to various definitions. Specifically, when the traditional ‘surgical’ definition of success is applied the pooled success rate for Phase I (i.e. soft palate) surgical procedures is 55% (that is 45% fail). However, using a more stringent definition (endorsed by the peak international sleep medicine body), success is reduced to 13% (that is 87% fail). Similarly for Phase II (i.e. hard palate) procedures success rates decrease from 86% to 43% respectively when moving from a surgical to a medical definition of success. That various medical specialties differentially define treatment success, I argue, creates uncertainty for observers and non-clinical participants in this debate (eg policy stakeholders and patients). This represents a barrier to disinvestment decisions. 3. Results are presented from a clinical audit of surgical cases conducted as a component of this thesis. Both clinical effectiveness and procedural variability of surgery are reported. A unique methodology was utilised to capture data from multiple centres. It is the first time such a methodology has been reported to measure procedural variability alongside clinical effectiveness (inclusive of a comparative treatment arm). The observed cohort (n=94) received 41 varying combinations of surgery in an attempt to treat OSA. Results on effectiveness demonstrate an overall physiological success rate of 13% (according to the most stringent definition; phases I and II combined). This demonstration of procedural variability combined with limited effectiveness highlights clinical uncertainty in the application of surgical procedures. 4. Section four outlines how a qualitative phase of enquiry, directed at exploring the perspectives and experiences of surgery recipients, was approved by three independent research ethics review boards but was not supported by a small group of surgeons, resulting in the project being canceled. Potential consequences of this for impeding health services research (HSR) are discussed. 5. Two sets of results are reported from a qualitative phase of enquiry (semi-structured interviews) involving senior Australian health policy stakeholders. The first results are of policy stakeholders’ perspectives on the surgical meta-analysis and clinical audit studies in 2 and 3 above. The second results are from an extended series of questions relating to challenges and direction for effecting disinvestment mechanisms in Australia. Stakeholder responses highlight that Australia currently has limited formal systems in place to support disinvestment. Themes include how defining and proving inferiority of health care practices is not only conceptually difficult but also is limited by data availability and interpretation. Also, as with any policy endeavour there is the ever-present need to balance multiple interests. Stakeholders pointed to a need, and a role, for health services and policy research to build methodological capacity and decision support tools to underpin disinvestment. 6. A final discussion piece is presented that builds on all previous sections and summarises the specific challenges that exist for disinvestment, including those methodological in nature. The thesis concludes with potential solutions to address these challenges within the Australian and international context. Systematic policy approaches to disinvestment represent one measure to further improve equity, efficiency, quality of care, as well as sustainability of resource allocation. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1297655 / Thesis (Ph.D.) -- University of Adelaide, School of Population Health and Clinical Practice, 2007

In the early 1990s claims were made that in all areas of health care, “30-40% of patients do not receive treatments of proven effectiveness”, and, “20-25% of patients have treatments that are unnecessary or potentially harmful”. Many such practices were diffused prior to the acceptance of modern evidence-based standards of clinical- and cost-effectiveness. I define disinvestment in the context of health care as the processes of withdrawing (partially or completely) resources from any existing health care practices, procedures, technologies or pharmaceuticals that are deemed to deliver little or no health gain relative to their cost, and thus are not efficient health resource allocations. Arguably disinvestment has been central to Evidence-Based Medicine(EBM) for well over a decade yet despite general advances in EBM, this topic remains relatively unexplored. This thesis examines the ongoing challenges that exist within the Australian context relating to effective disinvestment. Upper airway surgical procedures for the treatment of adult Obstructive Sleep Apnoea Syndrome (OSA) are used as a case study to contextualise these challenges. This thesis has six sections: 1. A review of the literature outlines developments in EBM broadly and provides a detailed background to OSA, including the numerous treatment options for the condition. This review examines evidence that highlights the importance of ‘highly effective treatment’ over ‘subtherapeutic treatment’ as a necessity to confer improved health outcomes in OSA. It is argued that claims of surgical success inherent in most published results of surgery effectiveness fail to assimilate contemporary evidence for clinically significant indicators of success. 2. Section two comprises the first reported meta-analysis in this area. It presents the pooled success rates of surgery according to various definitions. Specifically, when the traditional ‘surgical’ definition of success is applied the pooled success rate for Phase I (i.e. soft palate) surgical procedures is 55% (that is 45% fail). However, using a more stringent definition (endorsed by the peak international sleep medicine body), success is reduced to 13% (that is 87% fail). Similarly for Phase II (i.e. hard palate) procedures success rates decrease from 86% to 43% respectively when moving from a surgical to a medical definition of success. That various medical specialties differentially define treatment success, I argue, creates uncertainty for observers and non-clinical participants in this debate (eg policy stakeholders and patients). This represents a barrier to disinvestment decisions. 3. Results are presented from a clinical audit of surgical cases conducted as a component of this thesis. Both clinical effectiveness and procedural variability of surgery are reported. A unique methodology was utilised to capture data from multiple centres. It is the first time such a methodology has been reported to measure procedural variability alongside clinical effectiveness (inclusive of a comparative treatment arm). The observed cohort (n=94) received 41 varying combinations of surgery in an attempt to treat OSA. Results on effectiveness demonstrate an overall physiological success rate of 13% (according to the most stringent definition; phases I and II combined). This demonstration of procedural variability combined with limited effectiveness highlights clinical uncertainty in the application of surgical procedures. 4. Section four outlines how a qualitative phase of enquiry, directed at exploring the perspectives and experiences of surgery recipients, was approved by three independent research ethics review boards but was not supported by a small group of surgeons, resulting in the project being canceled. Potential consequences of this for impeding health services research (HSR) are discussed. 5. Two sets of results are reported from a qualitative phase of enquiry (semi-structured interviews) involving senior Australian health policy stakeholders. The first results are of policy stakeholders’ perspectives on the surgical meta-analysis and clinical audit studies in 2 and 3 above. The second results are from an extended series of questions relating to challenges and direction for effecting disinvestment mechanisms in Australia. Stakeholder responses highlight that Australia currently has limited formal systems in place to support disinvestment. Themes include how defining and proving inferiority of health care practices is not only conceptually difficult but also is limited by data availability and interpretation. Also, as with any policy endeavour there is the ever-present need to balance multiple interests. Stakeholders pointed to a need, and a role, for health services and policy research to build methodological capacity and decision support tools to underpin disinvestment. 6. A final discussion piece is presented that builds on all previous sections and summarises the specific challenges that exist for disinvestment, including those methodological in nature. The thesis concludes with potential solutions to address these challenges within the Australian and international context. Systematic policy approaches to disinvestment represent one measure to further improve equity, efficiency, quality of care, as well as sustainability of resource allocation. / http://proxy.library.adelaide.edu.au/login?url= http://library.adelaide.edu.au/cgi-bin/Pwebrecon.cgi?BBID=1297655 / Thesis (Ph.D.) -- University of Adelaide, School of Population Health and Clinical Practice, 2007