Mental health has a long history of proving to be a tough concept to define. Multiple forms of knowledge and representation seek to inform as to the nature of mental health, all contributing to the production of immense complexity as to the experience of living with mental health difficulties. This thesis sets out to explore this, by getting as close as possible to mental health service users' actual experiences. A range of forms of knowledge that pertain to inform as to service users' experiences are explored, prior to analysing a corpus of interviews with service users. These are analysed through the development of a Deleuzian Discourse Analysis. Service users' experiences are analysed in terms of the relation between discursive and non-discursive factors, which include forms of mainstream psychiatric discursive practice, such as the application of diagnostic criteria and administration of treatments, along with how such practices are experienced in non-discursive dimensions of service user embodiment and space. The challenges facing service users are seen to operate around identity and control in relation to forms of psychiatric knowledge, along with presenting particular problems with regard to how user embodiment is felt, primarily in relation to psychiatric medication, and how these are driven into the production of service user spaces, i.e. day centres. Finally, a politics of affectivity is offered, as a way to unfold the complexity of service user experience, and to emphasise the existence and potential for change that can be gained through deterritorialising mental health.

A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Previous studies have shown that Parkinson’s disease (PD) patients are at an increased risk for a variety of complications impacting health related quality of life (HRQoL). Additionally, these various complications often lead to increased healthcare utilization. Wellness intervention in PD has shown to be effective in improving HRQoL and objective measures of disease burden such as motor functioning. What has not been demonstrated to date is whether patients who are given the opportunity to participate in regularly administered classes in these modalities will continue to attend and whether benefits will continue to be realized outside the strict confines of a controlled trial. This study examined whether intervening early in PD with a comprehensive Wellness Program is feasible and promotes lasting habits that will continue to provide sustained benefit. It was hypothesized that intervening early in PD with an intensive program involving structured exercise, socialization and PD specific education would serve to maintain or improve subject’s quality of life while decreasing healthcare utilization. Twenty‐one consenting ambulatory adult subjects diagnosed with PD within the last five years completed various screenings at baseline and following a required 6‐month Wellness Program intervention. Subjects were assessed at 12 and 18 months if they continued to participate. Patient demographics, disease specific quality of life, objective mobility, healthcare utilization and falls were assessed. Data were collected at Banner Sun Health Research Institute, located in Sun City, Arizona. All p‐values were 2‐tailed and P<0.05 was considered statistically significant. All data analyses were conducted using STATA‐14. Twenty of twenty‐one subjects completed the required 6‐month intervention. Continued participation was 70% at 12 months and 60% at 18 months. Overall HRQoL was stable at 18 months. Significant improvement was seen in patient reported mobility and emotion sub‐areas at 12 months. Communication specific HRQoL was significantly worsened at 12 months. Subjects demonstrated a stable level of physical activity while fatigue was significantly decreased. All objective measures were significantly improved from baseline. Healthcare utilization was decreased by 18 months. A total of 5 falls were reported by 3 subjects during the 6‐month interventional period. This pilot study demonstrates that comprehensive wellness intervention in early PD is feasible, effective, safe and valuable in establishing long‐term beneficial habits while potentially reducing healthcare utilization. The significant long‐term subject participation observed in this study establishes that wellness intervention may be practical for large scale implementation. The results also highlight the importance of addressing communication specific symptoms early in the course of the disease. Ultimately, this study will aid the design and implementation of future PD wellness interventions.

by Chung Sheung Chee, Sydney. / Thesis (M.D.)--Chinese University of Hong Kong, 1988. / Includes bibliographical references.

Typescript. / Digitized by Kansas Correctional Industries

Thesis (MPH)--University of Limpopo, 2009. / Background Primary Health Care is a basic mechanism that brings healthcare as close as possible to the people. In South Africa, it is seen as a cost effective means of improving the health of the population. It is provided free of charge by the government. This service should be accessible to the population so as to meet the millennium health goals. Aims The aims and objectives of the study were: • To investigate whether Primary Health Care services were accessible to the communities of Tshwane Region. • To determine the utilization of the health care services in the three Community Health Care centres of Tshwane Region. Methodology Data were collected at the three Community Health Care centres of Tshwane Region using self-administered questionnaires. A document review of the Community Health Care centres records was conducted to investigate the utilization trends of services. Descriptive statistics were used. The analysis was based on the information that was elicited from the questionnaires that the people who utilize the Community Health Care centres of Tshwane Region provided. The extracted data emanating from the records from the three centres were also used. Results The study demonstrated that in terms of distance, the Community Health Care centres of Tshwane Region are accessible as most participants lived within 5km. They traveled 30 minutes or less to the clinic. The taxi and walking was the most common form used to access the clinic. The services were utilized with the Tuberculosis clinic being the most visited. Generally, people were satisfied with the service and their health needs are met. Conclusion The Community Health Care centres of Tshwane Region are accessible and utilized effectively. Key words: Primary Health Care, accessibility, utilization.

Background: Nurses use of research findings is essential to the provision of quality patient care. As a result, a need to better understand how to implement research into nursing practice has emerged, triggering requirements for its measurement. Purpose: The purpose of this thesis was to provide an assessment of the state of measurement science underpinning research utilization in nursing. Methods: The thesis consisted of four inter-related studies: (1) a systematic review of the psychometric properties of instruments used to measure research utilization in healthcare, (2) a systematic review update of individual factors that are associated research utilization by nurses, (3) an item response theory assessment of the precision of a newly developed research utilization scale (the Conceptual Research Utilization Scale) when completed by unregulated nursing care providers in long-term care (nursing home) settings, and (4) a traditional psychometric assessment (reliability, validity, acceptability) using classical test score theory of the Conceptual Research Utilization Scale when completed by unregulated nursing care providers in long-term care settings. A unitary approach to validity was undertaken following the Standards for Educational and Psychological Testing (the Standards) whereby evidence is accumulated from four sources to build a construct validity argument: (1) content, (2) response processes, (3) internal structure, and (4) relations to other variables. Findings and Conclusions: Findings revealed that there is significant under development in the measurement of research utilization in nursing and that substantial methodological advances focusing on construct clarity, use of measurement theory, and conducting standard and advanced psychometric assessments is needed. Findings also suggest that: (1) adopting a unitary perspective of validity results in a substantially more comprehensive and accurate validity assessment compared to a traditional perspective of validity (which states that validity exists or not); (2) the Standards provides a useful framework for grouping instruments according to established validity sources, as well as for conducting and reporting findings from an instrument validation study; and, (3) item response theory is an appropriate method for evaluating precision of research utilization instruments, which can provide additional psychometric information that is not provided in traditional classical test score theory assessments.

Background: Diabetes is a common and serious chronic condition. If not well-managed, significant multi-system complications often arise, resulting in increased health care utilization and poor health outcomes. There is considerable evidence that people with diagnosed diabetes are not receiving recommended care. A comprehensive program aimed at improving adherence to recommended care can improve patient outcomes and result in cost-savings. The key aim of this study was to determine whether the long-term receipt of appropriate clinical procedures by patients with type 2 diabetes was associated with higher medical care costs. Methodology: A cohort of 20,288 diagnosed type 2 diabetes patients was identified using physician and hospital records. An analytic file was created by linking information on patient characteristics with utilization of physician and acute care services during a five-year period (1996 to 2001). Adherence to recommended clinical procedures for the assessment of blood glucose, blood pressure and cholesterol levels, as well as retinopathy and nephropathy, were measured during this same five-year period. Subjects were assigned to both a categorical (low, medium and high) and a binary (low and high) adherence group. Physician and acute care resource use was converted to constant 2000 Canadian dollars. Multivariate logistic regression was used to assess the relationship between patient characteristics, including adherence as a categorical variable, and utilization of physician and acute care services. Results: Long-term adherence was suboptimal, with patients receiving just 53% of recommended procedures. Adherence to recommended procedures, however, improved during the five year period. Patient characteristics associated with poor adherence include being male, younger, low socio-economic status, having no diabetes-specific complicating conditions and living in certain geographic areas. Patients with high long-term adherence (receiving 73% of recommended clinical procedures) were 59% more likely to use a high level of physician resources but 22% less likely to use a high level of acute care resources. On the other hand, patients with low adherence (receiving 31% of procedures) were 28% less likely to use a high level of physician resources but 17% more likely to use a high level of acute care resources. The utilization difference related to adherence was particularly noticeable in older adults with higher levels of morbidity. Elderly patients in this low adherence group were more likely to be hospitalized (64.3% vs. 55.8% over the five-year period) and, when they were hospitalized, tended to stay in hospital for longer periods of time (11.9 vs. 6.7 days) than patients in the high adherence group. Conclusion: Improving long-term adherence may result in the avoidance of $4 in acute care costs for every additional $1 in physician costs. If all patients moved into the high adherence category, as much as $3.1 million in annual costs might be avoided across the study sample. If this analysis is applied to all adults with diagnosed diabetes in the province of British Columbia, the annual costs avoided could reach the level of $34.4 million. Systemic changes are required in the provision of primary care to promote long-term adherence to recommended diabetes care.

Background: Diabetes is a common and serious chronic condition. If not well-managed, significant multi-system complications often arise, resulting in increased health care utilization and poor health outcomes. There is considerable evidence that people with diagnosed diabetes are not receiving recommended care. A comprehensive program aimed at improving adherence to recommended care can improve patient outcomes and result in cost-savings. The key aim of this study was to determine whether the long-term receipt of appropriate clinical procedures by patients with type 2 diabetes was associated with higher medical care costs. Methodology: A cohort of 20,288 diagnosed type 2 diabetes patients was identified using physician and hospital records. An analytic file was created by linking information on patient characteristics with utilization of physician and acute care services during a five-year period (1996 to 2001). Adherence to recommended clinical procedures for the assessment of blood glucose, blood pressure and cholesterol levels, as well as retinopathy and nephropathy, were measured during this same five-year period. Subjects were assigned to both a categorical (low, medium and high) and a binary (low and high) adherence group. Physician and acute care resource use was converted to constant 2000 Canadian dollars. Multivariate logistic regression was used to assess the relationship between patient characteristics, including adherence as a categorical variable, and utilization of physician and acute care services. Results: Long-term adherence was suboptimal, with patients receiving just 53% of recommended procedures. Adherence to recommended procedures, however, improved during the five year period. Patient characteristics associated with poor adherence include being male, younger, low socio-economic status, having no diabetes-specific complicating conditions and living in certain geographic areas. Patients with high long-term adherence (receiving 73% of recommended clinical procedures) were 59% more likely to use a high level of physician resources but 22% less likely to use a high level of acute care resources. On the other hand, patients with low adherence (receiving 31% of procedures) were 28% less likely to use a high level of physician resources but 17% more likely to use a high level of acute care resources. The utilization difference related to adherence was particularly noticeable in older adults with higher levels of morbidity. Elderly patients in this low adherence group were more likely to be hospitalized (64.3% vs. 55.8% over the five-year period) and, when they were hospitalized, tended to stay in hospital for longer periods of time (11.9 vs. 6.7 days) than patients in the high adherence group. Conclusion: Improving long-term adherence may result in the avoidance of $4 in acute care costs for every additional $1 in physician costs. If all patients moved into the high adherence category, as much as $3.1 million in annual costs might be avoided across the study sample. If this analysis is applied to all adults with diagnosed diabetes in the province of British Columbia, the annual costs avoided could reach the level of $34.4 million. Systemic changes are required in the provision of primary care to promote long-term adherence to recommended diabetes care.

Appropriate utilization of the operating room (ORs) requires a balance of many conflicting resources. This cannot be done without an understanding of the role of the OR in the finances of the institution, the missions of the institution, the actual data concerning utilization and costs. Economics of the OR environment have changed dramatically in the past 10 years. For example, technological advances have led to the introduction and advancement of minimally invasive surgical procedures, which are purported to decrease morbidity, reduce hospital length of stay, and improve outcome. However, many of these procedures actually increase OR cost, time and supplies. The increased costs of minimally invasive surgery would not have been a problem in the past, due to the additional costs would have been easily adsorbed because of the large profit margin associated with surgical procedure. Under the implementation of the NHI, the DRG, capitated payment, and global budget, it is not surprising that this area is earmarked by many hospitals as a place to reduce expenses. Therefore, all of us working in the OR must be cost efficient and maximize productivity for long-term success. Accurate estimation of operating times is a prerequisite for the efficient scheduling of the operating suite. In this study, authors sought to compare surgeons¡¦ time estimates for elective cases and to ascertain whether improvements could be made by statistical modeling. The study was conducted in the GYN department at the VGHKS from 2000, Jan. to 2003, June. Author calculates operation time distribution (lognormal) and variance, and operation time finishing probability, costs, and comparing operating time difference between surgeons.

ABSTRACT From August 1, 1999, ¡§Co-payment For the Frequent-Visit Outpatients¡¨ has gone into effect. Frequent visit outpatients have to pay more medical expenses out of their own pocket. How did the new co-payment scheme affect the medical expenditure and utilization of the outpatients, especially frequent-visit outpatients? Can this new co-payment scheme work efficiently and reach its goal: reduce the unnecessary waste of the medical resources? At Taiwan, Central Healthcare and Medical Service (CHMS) has a large outpatient database, which contains the basic information of the outpatients. This study chose the database about the ¡§Frequent Outpatients¡¨ from August-December 1998, and August-December, 1999 as population. Such data included the 157,613 cases from 1998 and 160,870 cases from 1999. By analyzing the 1998 and 1999 data provided by the Central Healthcare and Medical Service, this study found the followings have been changed since new scheme took effect: 1. Co-payment had broad and deep effect on the patients¡¦ medical care utilization. Due to the additional High Medical Utilization Co-payment Fee, NT 50 or NT 100, outpatients would be more cautious before they go to see the doctors. At the same time, trying to get more for what they pay, outpatients would rather go to the major regional hospitals or centers in the medical system than small hospitals or clinics. As for the prescribed drug, outpatients were inclined to ask doctors for prescription drugs that can be taken for more days, so they can reduce their visits and therefore save some co-payment fees. This study also found prescribed drug expenses per patient dramatically increase when the average drug expenses per day decrease. Apparently, the increased drug expenses were form the more prescribed-drug days per visit. With the drug expenditures going up, average outpatient expenses per visit increased and the detailed and combination of medical bill varies. 2. Male and female had different responses to this new co-payment scheme. The gender-oriental differences were found in the following areas: ¡]1¡^Regional hospitals (centers) or small clinics. ¡]2¡^The average prescribed-drug days for each visit. ¡]3¡^Drug expenditure per day per patient.¡]4¡^Total expenses per outpatient visit. ¡]5¡^The detailed breakdown of each outpatient visit¡¦s expenses. 3. No effect on the following outpatient age segments:¡¨ age 6-14 teenager¡¨,¡¨ age 15-24 young people¡¨, and ¡§age 25-44 adults¡¨. The new co-payment system had no effect on the above-mentioned age groups, but it did have big and deep influence on the ¡§age 45-64 mid-age adult¡¨ and ¡§age 65 + elderly¡¨, especially on the elderly. The elderly were the major medical service user, and a lot of them lived on their retire and lived on their pensions, so they got hit badly by the high co-payment. 4. In general the higher co-payment had big effect on following three groups: ¡]1¡^¡§Media-utilization Outpatient Group¡¨, ¡]2¡^¡§High- utilization Outpatient Group¡¨ ¡]3¡^¡§Extremely- utilization Outpatient Group¡¨ To save money, outpatients, whatever group they belong to, would reduce their doctor visit. After analyzing all of the above-mentioned aspects, impacts, differences, changes and effects this high co-payment have had on the different age and gender groups since August 1999, this study concluded that the new co-payment regulation had significantly reduced the medical service demands, especially from female or male age 45+.