Purpose: Assess for an association of wait times to melanoma treatment with overall survival. Methods: Retrospective review of Ontario patients with melanoma, with descriptive and survival analyses. Results: Median wait times were 43 days (interquartile range (IQR), 24-64) for wide local excision (WLE), 59 days (IQR, 41-81) for sentinel lymph node biopsy (SNB), 63 days (IQR, 43-91) for lymph node dissection (LND), 124 days (IQR, 96-150) for medical therapy, and 130 days (IQR, 89.5-157.5) for radiation therapy. In multivariate analysis, wait times to treatment were not associated with overall survival for WLE (hazard ratio (HR), 0.97; 95% confidence interval (CI), 0.87-1.08; p=0.62), SNB (HR, 0.89; 95% CI, 0.74-1.07; p=0.21), LND (HR, 0.99; 95% CI, 0.89-1.11; p=0.92), medical therapy (HR, 0.94; 95% CI, 0.80-1.10; p=0.41) or radiation therapy (HR, 0.80; 95% CI, 0.61-1.03; p=0.08). Conclusion: Overall survival for patients with melanoma was not associated with wait times to surgical, medical or radiation therapy.

国立情報学研究所で電子化したコンテンツを使用している。

Syftet med den här studien var att öka kunskapen om hur lärare använder tystnad då de ställer frågor tillelever i matematikundervisningen. Inom forskningsfältet för pedagogik är samtalets fördelar förutvecklandet av matematiska kunskaper vida spritt, mindre berörs tystnadens fördelar inom samma område.Vi utförde en flermetods-studie vars främsta metod var ljudupptagningar i syfte att mäta längden avtystnader i anslutning till frågor under lektioner. Det insamlade materialet analyserades i flera steg, främstgenom att använda Rowes (1974) teori om wait-time. Resultaten visade att lärarna i studien använde tystnadi låg utsträckning, sällan mer än 3 sekunder i anslutning till frågor. Den genomsnittliga tystnaden var mellan0 och 2,3 sekunder, där 0 betyder att tystnaden var obefintlig. Resultatet blev i slutändan för småskaligt föratt kunna generaliseras men kan ge både blivande och verksamma lärare en tankeställare om hur deanvänder tystnad i matematikundervisningen. Vårt resultat stämde överens med resultat från tidigareforskning inom samma område, att lärare använder tystnad i liten utsträckning. Varför tystnad används i såliten utsträckning är ett område som behöver vidare forskning.

This study investigates the components within teacher questioning and how they affect communication within the mathematics classroom. Components examined are the type of question, the amount of wait time allowed, the use of follow-up questions, and the instructional setting. The three types of questions analyzed in this study were highorder, low-order, and follow-up questions. High-order questions are defined as questions which promote analysis, synthesis or evaluation of information versus low-order questions which only seek procedural or knowledge of basic recall of information. The third type of question, follow-up, is the second question asked of a student when the initial question is not answered or answered incorrectly. This study observed video of three teachers from three different adjacent school districts. Upon watching three lessons of each teacher and recording data, conclusions were made. All three teachers were found to use low-order questions at least 50% of the time during instruction. Wait time following high-order questions met the minimum three second time as suggested from previous researchers. Follow-up questions were found to occur more frequently after high-order questions, but followed similar trends as stated above related to the type of question asked. Instructional setting does differ in the types of questions asked with a small group setting more likely to elicit high-order questions than a whole group setting. The researcher concluded that high-order questions with a minimum of three seconds wait time in a small group setting encourage communication within the mathematics classroom.

The purpose of this project was to determine the time between arrival, assessment, and treatment for patients presenting with alcohol withdrawal syndrome (AWS) to the emergency department (ED) as well as to identify patient and environmental factors that may prolong initiation of the implementation of the clinical institute withdrawal alcohol (CIWA-Ar) protocol for assessment and treatment of AWS. There is clear evidence that rapid assessment and treatment of AWS improves cost, quality, risk, safety and patient outcomes. This project found that patients in the emergency department at Banner University Medical Center South campus (BUMCS) in 2016 on average waited 2 hours and 20 minutes for initial CIWA-Ar assessment and 50 minutes for medication to be administered. When taking into account the physiological process of AWS and the highly variable nature of ethanol metabolism this timeline is suboptimal and significant reduction of these times are recommended. The only factor that was significantly associated with increased wait times was elevated blood alcohol content (BAC). With higher BAC resulting in longer wait times. This is a concerning finding since patients experiencing symptoms of withdrawal in the presence of elevated BAC are at significantly higher risk for the most severe AWS including delirium tremens and seizure.

The first two chapters of this dissertation focus on the child health outcomes in brief, child diarrheal incidence in India, and child growth measures in Rwanda. The third chapter examines the determinants of timely access to health care in emergency departments in the United States. All three essays are different in their area of interest, data sources, and methodology.ESSAY 1 India has recorded the highest number of child diarrheal deaths at the global level. Oral Rehydration Therapy (ORT) would just provide hydration and few mineral supplements for infected children. However, their malnutrition and weakened immune system cannot be reversed. Malnutrition affects child growth, and causes stunting, and makes them susceptible to other forms of infections. The rotavirus vaccine provides a pseudo-sense of protection from non-rotaviral diarrhea. Preventing diarrhea right away from the source of the infection would be a better solution. Since most diarrheal pathogens are water borne, disinfection treatment of drinking water at the point of use could prevent diarrheal incidence of children and adults as well. Household data from the National Family and Health Survey and their estimators viz., Propensity Score Matching (PSM), and Inverse Probability Weights Regression Adjustment (IPWRA) have been employed to examine the effects of water treatment techniques in households. This chapter attempted a novel approach in studying all the popularly used water treatment techniques currently practiced in India in one study. They have been ranked for multi-value treatment effects model. Water filters with ceramic candles are more effective than other point-of-use water treatment techniques, followed by chlorination, water purifiers, and boiling. ESSAY 2 Rwanda is a sub-Sahara African country affected by genocide with a patriarchal family structure system. Higher poverty and gender imbalance were not alleviated by gender equality being on the political agenda. Despite the highest female representation in the parliament in the world, gender equality and liberty are confined to elite women. Additionally, flawed laws for women's equality made women's empowerment a paradoxical phenomenon. Women at the gross root levels, i.e., community and household, are still dependent or interdependent on men (husband/father). This has been confirmed by the findings in Chapter 3, that is, for most decisions, women are taken jointly with their partners. A minimal percentage of women are autonomous in their decisions and in their home. This study made an attempt to examine the mother’s autonomy in Rwanda and its impact on child health. Mother’s autonomy is negatively related to child’s height and weight for their age. Although the expected association between mother’s autonomy and child height/weight is positive, it would also depend on the historical and cultural context of the country of interest. Instrumental variable analysis is used to study women’s autonomy due to its complex and endogenous nature. Spousal educational difference and marriage-to-birth interval are valid instruments but weakly identified. ESSAY 3 An increasing burden on emergency services that exceeded its resources led to congestion in the emergency department (ED), with patients waiting for physicians on the examination bed and for inpatient bed transfer. This creates a blockage between access to healthcare and emergent patients. ED measures adopted to reduce ED congestion, boarding, and waiting times, such as ambulance diversion management, fast tracking of patients with low acuity, and bed coordination do not effectively control waiting time and boarding. ED crowding is a patient flow, but not necessarily a hospital resource deficiency. This is evident from the findings that even EDs with new treatment spaces still keep patients waiting for an inpatient bed, however, they reported a shorter wait time for the physician. Optimal utilization of nurses by floating them to needy units is effective in timely transfers of patients to inpatient beds compared to EDs without floating nurses.

Emergency surgeries are serviced by three main forms of capacity: dedicated operating room time reserved for emergency surgeries, alternative (on call) capacity, and lastly, canceling of elective surgeries. The objective of this research is to model capacity implications of meeting wait time targets for multiple priority levels in the context of emergency surgeries. Initial attempts to solve the capacity evaluation problem were made using a non-linear optimisation model, however, this model was intractable. A simulation model was then used to examine the trade-off between additional dedicated operating room capacity (and consequent idle capacity) versus increased re-scheduling of elective surgeries while keeping reserved time for emergency surgeries low. Considered performance measures include utilization of operating room time, elective re-scheduling, and wait times by priority class. Finally, the instantaneous utilization of different types of downstream beds is determined to aid in capacity planning. The greatest number of patients seen within their respective wait time targets is achieved by a combination of additional on call capacity and a variation of the rule allowing low priority patients to utilize on call capacity. This also maintains lower cancelations of elective surgeries than the current situation. Although simulation does not provide an optimum solution it enables a comparison of different scenarios. This simulation model can determine appropriate capacity levels for servicing emergency patients of different priorities with different wait time targets.

Emergency surgeries are serviced by three main forms of capacity: dedicated operating room time reserved for emergency surgeries, alternative (on call) capacity, and lastly, canceling of elective surgeries. The objective of this research is to model capacity implications of meeting wait time targets for multiple priority levels in the context of emergency surgeries. Initial attempts to solve the capacity evaluation problem were made using a non-linear optimisation model, however, this model was intractable. A simulation model was then used to examine the trade-off between additional dedicated operating room capacity (and consequent idle capacity) versus increased re-scheduling of elective surgeries while keeping reserved time for emergency surgeries low. Considered performance measures include utilization of operating room time, elective re-scheduling, and wait times by priority class. Finally, the instantaneous utilization of different types of downstream beds is determined to aid in capacity planning. The greatest number of patients seen within their respective wait time targets is achieved by a combination of additional on call capacity and a variation of the rule allowing low priority patients to utilize on call capacity. This also maintains lower cancelations of elective surgeries than the current situation. Although simulation does not provide an optimum solution it enables a comparison of different scenarios. This simulation model can determine appropriate capacity levels for servicing emergency patients of different priorities with different wait time targets.

In this thesis, I explored the relationship between patient experience of wait time for consultation and scheduled surgery, type of illness (orthopaedic or cardiac), and descriptions of time using qualitative methodology. Thirty two patients awaiting orthopaedic or cardiac surgery were recruited by surgeons in Saskatoon, Saskatchewan during the period of September 2009 to November 2010. Those patients awaiting orthopaedic surgery were interviewed when the decision to treat was made and again at the midpoint of their waiting period. Cardiac surgery patients were interviewed after their angiography and consent to surgery, and again the day prior to surgery. Patients were asked about their perceptions of time while waiting, maximum acceptable wait time for consultation and surgery, and the effects of waiting. Interpretative phenomenology (1) was the method and data were analysed using interpretative phenomenological analysis.Participant suffering, the meaningfulness given to the experience, and the agency participants felt they had over the waiting period determined the lived duration of time experience. Participants considered pain, mobility restriction, disease progression and lethality of condition to be the primary determinants of wait time maximums. Waiting effects included restriction, uncertainty, resignation, coping with waiting, and opportunity. Few subtle differences between groups emerged indicating other variables may be more relevant to the quality of waiting experience. Participant suggestions for improving experience consisted of managing patient conditions and navigating the system. The findings suggest uncertainty in illness impacts the quality of wait time experience. The study denotes the experience of waiting for scheduled surgery is complex and not necessarily a linear relationship between greater symptom severity and less tolerance for wait time.

BACKGROUND: Adolescent idiopathic scoliosis (AIS) surgery is the most common reason for elective pediatric orthopaedic surgery. Minimization of adverse events is an important goal. Institute of Medicine (IOM) outlined 6 facets of healthcare quality improvement within the acronym STEEEP. Two of these facets, Safety and Timeliness for AIS surgery in Canada, are examined in this thesis. METHODS: A three - part study, using clinical records at the largest Canadian pediatric hospital and CIHI national administrative data, determined i) the relationship between surgical wait times and rates of adverse events, along with determination of an empirically derived access target, ii) accuracy of ICD-10 coding of surgical AIS cases along with an optimal search strategy to identify surgical AIS cases, and iii) the volume – outcome relationships for scoliosis surgery using hierarchical and conventional single level multi-variate regression analysis. RESULTS: Access target of 3 months minimized the adverse events related to waiting. Optimal search strategy for AIS surgical cases using ICD-10 coding required combination of codes as each code in isolation was inaccurate due to limitations in coding definitions. There was no significant volume – outcome relationship using appropriate modeling strategies. CONCLUSIONS: Ensuring timeliness of surgical treatment of less than 3 months is important in surgical cases of AIS given the potential for curve progression in higher risk individuals who are skeletally immature with large magnitude curves at time of surgical consent. At the administrative database level, knowledge of coding accuracy and optimal search strategies are needed to capture a complete cohort for analysis. In AIS, several ICD-10 codes need to be combined. AIS surgery cases captured through this optimal search strategy, revealed no significant volume-outcome relationships with appropriate modeling. Based on these results, minimum volume thresholds and regionalization of care for AIS surgery does not appear to be justified. However, a larger sample size was needed to determine whether there was a clinically significant difference in wound infection and blood transfusion rates. Furthermore, clinical variables, not part of an administrative database such as curve pattern were not included.