Objective measures of clinical performance are needed before economics or Benchmarking can successfully maximize the efficiency of the health care system. In the Intensive care unit (ICU), mortality is one of the most important clinical outcomes and different tools have been developed to estimate its probability of occurrence (Acute Physiology and Chronic health Evaluation (APACHE), the Simplified Acute Physiology Score (SAPS), and the Mortality Probability Model (MPM)). By assigning probabilities of hospital mortality to each patient, these systems classify patients by severity and are useful for the control of confounding by severity, the discussion of prognosis with patients and their families and in the evaluation of performance. However, if poor fit exists in one particular ICU, this is consistent with differences in both, either performance or patient-mix between this ICU and those used to develop the model. Case mix is one of the most important biases in health care economical evaluations and severity models are still inappropriate to fully adjust for case mix. The objectives of this research were to describe how differences in diagnostic covariate pattern mix affect model fit and to explore adjustment methods for case mix when the ratio of observed to expected deaths is used to compare the performance of a study ICU with the overall performance of other ICUs. The maximum likelihood adjustment of rate ratios and the dummy variable method of adjustment for case mix are useful tools to adjust for changes in patient mix and could be applied to compare ICU quality performance. The proportional sampling method of adjustment for patient mix is not applicable in real life situations because it fails to adjust for patient mix, especially when an ICU has a lower overall mortality ratio (attributable to a particular patient mix), than the developmental data set.

Despite the large proportion of clients who use psychotherapy more than once in their lifetimes, little empirical, theoretical, or technical literature focuses on conducting subsequent therapy. This qualitative study used in-depth interviews of 8 experienced doctoral-level psychologists (all with over 15 years experience conducting therapy) to examine the process of conducting psychotherapy with experienced clients. Psychotherapists in the sample were all trained with a psychodynamic or psychoanalytic orientation and continued to work partially or exclusively in that tradition. Results include analysis by interviewee including presentation of specific cases, as well as thematic analysis across interviewees. Thematic analysis is divided into three sections: classifications of subsequent therapy in relation to previous therapy, practice considerations and recommendations, and therapists' subjective experience and beliefs about experienced clients and subsequent therapy. Findings relate to issues of mental health service utilization such as help-seeking and intermittent use of psychotherapy throughout the life cycle. Findings also address psychotherapy process issues such as beginning the treatment, therapist-directed exploration of previous therapy, deciding whether to contact previous therapists, working with clients' unresolved feelings from previous therapy, making therapeutic use of talking about previous therapy, working with clients who return to the same therapist, and triangulation of previous therapist, subsequent therapist, and client. Therapy with experienced clients was found to be different from therapy with inexperienced clients in certain cases; however, in generalizing about their practices as a whole, the therapists interviewed judged these differences to be small in comparison with other client characteristics affecting therapy.

This research examined the structural properties of individual’s organizational change schemas. An organizational change schema is a particular sensemaking framework that contains knowledge about organizational change, including change attributes and relations among those attributes. Understanding the properties of these schemas is important because existing research suggests that the way individuals think about change influences their responses to it. Specifically, the present study investigated health care managers’ sensemaking regarding implementation of a quality initiative by examining: (1) the structure and content of organizational change schemas; (2) the extent to which schemas were shared by organizational members; and (3) the nature of the relationship between shared understanding and organizational inertia. A sample of 28 health care managers from a large hospital in the Northeastern U.S. completed the repertory grid, a method originating in cognitive psychology (Kelly, 1955). This method allowed organizational members to identify meaningful dimensions that distinguished between organizational change attributes while minimizing the imposition of the researcher’s frame of reference. The content and structure of members’ change schemas were also examined using a pre-designed instrument by Lau and Woodman (1995). Content analysis revealed that in their effort to make sense of organizational change, organizational members rely on a relatively small number of widely shared evaluative dimensions, and a larger number of essentially idiosyncratic dimensions. An analysis of change schemas by organizational level revealed important differences in the way top managers and middle managers make sense of change. The results of cluster analysis indicated that discrete shared organizational change schemas could be identified and meaningfully understood in terms of current and ideal orientations. Contrary to expectations, incongruence between members’ current and ideal change schemas did not give rise to negative emotions. However, incongruence between these schemas was positively related to resistance to change. Comparison of the two methods used in this study suggests that the preservation of the terms and dimensions people themselves use to describe organizational change represents an important consideration for future cognitive-based organizational change research. Implications for theory and practice as well as directions for future research are discussed.

An original AIDS Attitude Scale was distributed to registered nurses employed in intensive care, medical, medical-surgical, and surgical units of four western Massachusetts hospitals. 439 completed questionnaires, representing a 64.6% response rate, were returned by mail. Results of data analysis indicated that nurses would be more cautious than necessary in using precautions while handling body secretions of or doing nursing procedures with patients with AIDS. Nurses form a small community hospital and those with less experience in caring for AIDS patients would be more cautious than those from a teaching medical center and those who had cared for six or more AIDS patients. Two-thirds of the nurses would feel a great deal of stress in caring for seriously ill adult AIDS patients. Significant differences in mean stress scores for caring for patients with five diagnoses indicate that AIDS patients evoke the most amount of stress, and those with extensive burns, multiple trauma, metastatic cancer, or hepatitis B evoke decreasing amounts of stress, in that order. More than one-half of the respondents indicated that more than one-half of their family members/significant others had expressed concern about their becoming infected with HIV as a result of caring for AIDS patients. Teaching hospital respondents reported a significantly greater percent of concerned persons than did those from community hospitals. Multiple regression analysis of the twelve Likert items indicated that having a family member/personal friend with AIDS, having a greater percent of concerned persons, being male, or being employed in a small community hospital were associated with a less favorable attitude about caring for AIDS patients. The coefficient alpha (Cronbach's alpha) for the Likert scale was.72. Factor analysis of the Likert scale identified five subconcepts: stigma; pregnancy concern; mortality/prognosis stress; resource utilization; and HIV-status knowledge. Study results are limited to the respondents. Implications of the results for health services managers include implementation of a multi-faceted educational and support program for nurses caring for AIDS patients. Suggestions for further research include replication of the study with nurses in different clinical specialties, settings, and geographic regions.

Includes bibliographical references. / Objective: A waiting time survey (WTS), conducted in 2007 at 94% of clinics in Cape Town, measured length of patient waiting times (WT) for services and provided recommendations to shorten waiting times. Whether subsequent implementation of these recommendations occurred was unknown, hence a study was conducted to assess the impact of the previous waiting time survey recommendations on stimulating efforts to reduce waiting times and whether waiting times had reduced. Methods: A cross-sectional analytical study design assessed the perceptions of 92% of clinic managers in Cape Town, regarding the 2007 survey, while a before and after study design assessed changes in waiting time between 2007 and 2011, using a random sample of 22 clinics. Results: The overall median waiting time of all clinics in the sample decreased by 21 minutes in 2011 (95% CI 11.77-30.23), a 28% decrease from 2007. This reduction was manifest at individual clinic level as well, with 55% of clinics reducing their median waiting time by at least 15 minutes. No specific factors, including whether recommendations to reduce waiting times were implemented, were associated with decreases in waiting times. Implementation of recommendations to reduce waiting times was 2.67 times (95% CI 1.33-5.40) more likely amongst those who received written recommendations and 2.3 times ) 95% CI 1.28-4.19) more likely amongst managers with 5 or more years' experience. Conclusion: The decrease in waiting times in primary care urban clinics subsequent to a waiting time survey, demonstrates the utility of waiting times surveys, although no specific factors associated with the decrease in waiting time were identified.

Bibliography: pages 150-158. / Health care systems all over the world are in crisis. The presenting symptom is a cost spiral that is out of control. Money supply is finite, and if this problem continues the system will eventually collapse. There are a number of causes associated with the problem that are usually analysed by reduction, an approach based upon an assumption of simple linear causal relations. This study shows the problem to be the dialectic opposite, in other words these problems are all interrelated through complex causal interactions. Therefore, the health care system is a complex social system and solutions to its problems may be found in terms of the interactions in such a system. An investigation into the history of the health care system shows that the system started with a simple one on one interaction between patients and physicians. At the time of its initiation, very little empirical knowledge was available about illness. After the renaissance, this changed dramatically with a subsequent increase in the ability to diagnose, but also in the complexity to treat illness. However, modern beliefs about illness and illness processes do not reflect the complexity of this knowledge. Beliefs about both illness and knowledge contribute to the process of diagnosis (medical decision making, or problem solving). Furthermore, the expectations, wants, and needs of patients and physicians, as well as the decision environment, increases the complexity and difficulty of this decision making process. These decisions initiate treatment processes that are ultimately represented in the health care system as cost. Therefore, the patient-physician system as the simplest initial interaction is an event that ultimately affects cost. This system is not functioning efficiently at present and a system of inquiry that can improve it may make a contribution to an improved system, and therefore a saving in cost. Altering the diagnostic system from a linear into a circular process, in other words into a learning system, improves both decision making and the use of knowledge. However, an inquiring system is needed in addition that can enhance the rigour of this process. Charles West Churchman devoted a large part of his work to knowledge and the way we acquire knowledge, in other words inquiring systems. His belief is that problem solving ought to be approached in a comprehensive way in order to minimise the risk for making incorrect decisions. Furthermore, because decisions are made upon incomplete information, the solutions will be the cause of new problems. Therefore, problem solving is a never ending cycle of learning. In order to have as complete information as possible about the problem, we have to: know the history of the problem, take a broad view that includes the environment of the problem (use a systems approach), and consider all the alternative solutions to the problem. Virtually all of our knowledge is based upon underlying assumptions. In order to test the validity of the knowledge we use for inquiry and decision making, it is important to test the assumptions upon which the knowledge is based. This is valid in regard to empirical knowledge as well. Finally, according to Churchman, decision making has to be ethical. Therefore, we have to do all we can to ensure that the implementation of the decision will improve the situation, not only now, but also in the future. The application of Churchman's approach to the patient-physician interaction, assists in the synthesis of a more comprehensive world view of health care and illness. This study shows that this leads to important changes in the negative interactions identified as contributing to the health care crisis. In terms of Churchman's approach, the role of physicians can be seen as managers of illness. Their purpose is therefore to plan for the improvement of illness (the problem) in an ethical way. Such planning should include the values of patients in deciding upon appropriate treatment. It is the submission of this study that only a methodology that is able to address complex human systems, such as a systems approach, and a comprehensive philosophy of inquiry, such as that of C West Churchman is appropriate to address the current problems of the health care system.

Bibliography: leaves 89-94. / Starting oral contraceptives immediately, under direct observation, increase OC initiation rates and may increase effective use and continuation However, if adverse bleeding pattern occur, then such an approach may paradoxically decrease continuation rates. The purpose of this study is comapare 90-day bleeding patterns following immediate ("Quickstart) versus conventional OC initiation.

Includes bibliographical references. / Metabolites of DDT (1, 1, 1-trichloro-2,2-bis(p-chlorophenyl)ethane), used in many developing countries including South Africa for the control of malaria vectors, have been shown to be endocrine disruptors in vitro and in vivo. The study hypothesis was that male vector control workers highly exposed to DDT in the past should demonstrate clinically significant exposure-related anti-androgenic and/or estrogenic effects reflected in abnormalities in hormone levels, semen, sexual function and fertility. A cross-sectional study of 60 workers from 3 camps situated near Malaria Control Center (MMC) in Tzaneen was performed.

Bibliography: p. 171-172. / South Africa's HIV epidemic has increased rapidly over the last 10 years, and developing effective strategies to curb it is a priority. The presence of other sexually transmitted infections (STIs) facilitates the sexual transmission of HIV, and the control of STIs has been shown to be an effective way of reducing HIV incidence. One component of the process of STI control is partner notification: a process whereby the sexual partners of patients who have been diagnosed with an STI are informed of their exposure to infection and of the importance of obtaining effective treatment. Partner notification is one of the two strategies to reach and treat asymptomatic and unrecognised STIs, which are highly prevalent in South Africa. Unfortunately, current partner notification strategies are not very effective, and there is a need to improve their effectiveness. This thesis investigates strategies to improve partner notification in South Africa. This aim is achieved through three separate studies. The first is a systematic review of published and unpublished randomized controlled trials (RCTs) conducted around the world, comparing the effects various partner notification strategies, in an attempt to uncover evidence of effective strategies. The review uses methods advocated by the Cochrane Collaboration. Eleven RCTs were found, including 8014 participants, only two of which were conducted in developing countries. The review found moderately strong evidence that either provider referral alone, or the choice between patient and provider referral, or contract referral, when compared with patient referral, improved partner notification. This evidence is of limited value in South Africa, where public health services have not been able to implement provider or contract referral due to the prohibitive staffing costs involved. The review also found that verbal, nurse-given health education together with intense patient-centred counselling by lay workers, when compared with standard care results in small increases in the rate of partners treated. The review concludes that there is a need for evaluations of patient education interventions (including audiovisual presentations), of interventions combining provider training and patient education, and for evaluations to be conducted in developing countries. Further, there is a need to measure potential harmful effects, such as domestic violence, to ensure that partner notification does more good than harm.

Includes bibliographical references (p. 196-245). / A multicenter hospital-based case-control study with incidence density sampling was conducted between November 2001 and February 2003 to assess the impact of social and dietary habits, and the consumption of dietary and medicinal wild plants on the risk of developing oesophageal cancer (OC) among residents of the Eastern Cape Province of South Africa. The study was conducted on 670 incident cases (98/% response rate) and 1188 controls (96/% response rate) attending either of the three major referral hospitals in the Province, i.e Umtata General, Frere and Cecilia Makiwane Hospitals.