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Background: International guidelines provide recommendations for early chronic kidney disease care. This thesis was completed to 1) measure the quality of chronic kidney disease care and identify gaps, 2) identify reasons why patients do not receive recommended care, and 3) determine if these guideline-recommended practices are associated with better patient outcomes. Methods: Population-based cohort studies were conducted for studies 1, 3 and 4. Using consensus-based indicators, study 1 quantified the quality of care for patients with early chronic kidney disease. Study 2 was a qualitative descriptive study eliciting primary care physicians’ perceived enablers and barriers to follow-up laboratory testing to confirm chronic kidney disease. Study 3 assessed the association between non-steroidal anti-inflammatory drug (NSAID) use versus non-use and adverse clinical outcomes among older adults. Study 4 assessed whether routine serum creatinine and potassium monitoring (versus no monitoring) following angiotensin converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) initiation among older adults associated with better outcomes. Results: In study 1, most recommendations were being followed; however, some care gaps were identified. For example, half of the patients with initial abnormal kidney test results did not receive follow-up tests. This finding prompted study 2, where enablers and barriers to this practice were identified. Providers were aware that they should be ordering follow-up tests and had the resources to do so. However, some providers perceived this practice as low priority. In study 3, NSAID use was associated with a higher risk of complications. In study 4, routine ACEi / ARB monitoring did not prevent adverse outcomes. Conclusions: This thesis provides a better understanding of care gaps for patients with early chronic kidney disease in Ontario, and reasons for one of these care gaps. This research also provides evidence to help strengthen guideline recommendations (NSAID avoidance) or refute them (ACEi / ARB monitoring). / Thesis / Doctor of Philosophy (PhD) / Chronic kidney disease is a medical condition where a person’s kidney function is permanently reduced. Family doctors are responsible for the care of patients with early chronic kidney disease. However, many patients may not be receiving the right treatments from their family doctors to keep their kidneys healthy. This research used Ontario healthcare data to identify care gaps for patients with early chronic kidney disease. Interviews were then done with family doctors to identify reasons for one of these care gaps; specifically, why doctors do not always repeat blood and urine tests to confirm if patients have chronic kidney disease. Finally, this research looked at whether providing certain treatments led to better patient outcomes. This information can be used to update current guidelines and to inform strategies which help patients with chronic kidney disease receive the best possible care.

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O presente trabalho descreve, inicialmente, o papel desempenhado pela Secretaria de Higiene e Saúde (SHS) do Município de São Paulo, no contexto da assistência a saúde e das políticas nacionais que orientam suas atividades. Historicamente, a SHS vem atuando em duas linhas bem definidas e independentes: o atendimento às urgências e, paralelamente, a assistência materno-infantil que, face às novas diretrizes políticas, tende a se transformar em assistência integral à saúde. Como consequência das novas orientações políticas, várias tentativas têm sido realizadas no sentido de integrar essas duas linhas de atuação. Para tanto, a presente pesquisa, realizada no Posto de Assistência Médica (PAM) e no Pronto Atendimento (PA) Jardim São Jorge, localizado na zona oeste do Município de São Paulo, apresenta como proposta de trabalho a integração das ações de assistência médica individual de caráter curativo com as ações de assistência médico-sanitária. Partindo-se do pressuposto de que qualquer ação no campo da saúde depende da participação da comunidade, busca-se a forma pela qual a população recebe e utiliza os serviços localmente integrados. Nesse sentido, foram coletadas junto à clientela de ambos os serviços, informações tais como: motivo de procura, resolutividade, satisfação e outras, obtidas por meio de formulários. A análise das características das queixas, da resolutividade e da satisfação referida pela clientela, do objetivo e do processo de trabalho desses serviços, leva a conclusão de que o PAM e o PA são utilizados de forma seletiva pela clientela, visando principalmente, ao atendimento de suas necessidades diretamente relacionadas à resolução das manifestações de doença. / The present study describes, initially, the role played by the Higiene and Health Secretariat (SHS) of the City of São Paulo (Brasil), in the context of health assistance and of the national policies which govern these activities. Historically the SHS has acted within two well - defined and independent fields: emergency treatment and, parallel to this, mother and child health care. The latter, considering the new political guide-lines, is tending to be transformed into general health assistance. As a result of these new political guide-lines, various attempts have been made to integrate these two fields of activities. With this in view, this research project was carried out at the Public Health Clinic (PAM) and the Emergency Medical Service (PA) in the Jardim São Jorge, situated in the western zone of São Paulo City, and presents a working proposal for the integration of the individual medical care of a curative type and the activities of public health assistance. Taking as a starting-point that all activity in the health sector depends on community participation, this study seeks to discover how the population has received and used the geographically integrated health services. For this purpose, information was collected, by means of a questionnaire, from the users of both of these services, on the motive for the recoursing to the service, the service\'s ability to meet the need, the degree of satisfaction of the user, etc. The analysis of the above information as well as of the objective and the working method of these services, has led to the conclusion that the PAM and the PA are used by the public in a selective way, aiming at satisfying those immediate needs related to some present illnesses.

O presente trabalho descreve, inicialmente, o papel desempenhado pela Secretaria de Higiene e Saúde (SHS) do Município de São Paulo, no contexto da assistência a saúde e das políticas nacionais que orientam suas atividades. Historicamente, a SHS vem atuando em duas linhas bem definidas e independentes: o atendimento às urgências e, paralelamente, a assistência materno-infantil que, face às novas diretrizes políticas, tende a se transformar em assistência integral à saúde. Como consequência das novas orientações políticas, várias tentativas têm sido realizadas no sentido de integrar essas duas linhas de atuação. Para tanto, a presente pesquisa, realizada no Posto de Assistência Médica (PAM) e no Pronto Atendimento (PA) Jardim São Jorge, localizado na zona oeste do Município de São Paulo, apresenta como proposta de trabalho a integração das ações de assistência médica individual de caráter curativo com as ações de assistência médico-sanitária. Partindo-se do pressuposto de que qualquer ação no campo da saúde depende da participação da comunidade, busca-se a forma pela qual a população recebe e utiliza os serviços localmente integrados. Nesse sentido, foram coletadas junto à clientela de ambos os serviços, informações tais como: motivo de procura, resolutividade, satisfação e outras, obtidas por meio de formulários. A análise das características das queixas, da resolutividade e da satisfação referida pela clientela, do objetivo e do processo de trabalho desses serviços, leva a conclusão de que o PAM e o PA são utilizados de forma seletiva pela clientela, visando principalmente, ao atendimento de suas necessidades diretamente relacionadas à resolução das manifestações de doença. / The present study describes, initially, the role played by the Higiene and Health Secretariat (SHS) of the City of São Paulo (Brasil), in the context of health assistance and of the national policies which govern these activities. Historically the SHS has acted within two well - defined and independent fields: emergency treatment and, parallel to this, mother and child health care. The latter, considering the new political guide-lines, is tending to be transformed into general health assistance. As a result of these new political guide-lines, various attempts have been made to integrate these two fields of activities. With this in view, this research project was carried out at the Public Health Clinic (PAM) and the Emergency Medical Service (PA) in the Jardim São Jorge, situated in the western zone of São Paulo City, and presents a working proposal for the integration of the individual medical care of a curative type and the activities of public health assistance. Taking as a starting-point that all activity in the health sector depends on community participation, this study seeks to discover how the population has received and used the geographically integrated health services. For this purpose, information was collected, by means of a questionnaire, from the users of both of these services, on the motive for the recoursing to the service, the service\'s ability to meet the need, the degree of satisfaction of the user, etc. The analysis of the above information as well as of the objective and the working method of these services, has led to the conclusion that the PAM and the PA are used by the public in a selective way, aiming at satisfying those immediate needs related to some present illnesses.

Using grounded theory methodology this study examined the acquisition and exercise of nephrology nursing expertise, seeking to answer the following questions: what constitutes expertise and how it develops in nephrology nursing; and whether expert nephrology nurses practice differently from non-expert nephrology nurses and, if so, how. Sampling consisted of 6 non-expert and 11 expert nurses from a renal unit in New South Wales, and data were obtained from participant observation of the nurses and subsequent interviews. A substantive theory was generated utilising an orchestral metaphor to explain the skills-acquisitive/exercise process. Findings revealed a three stage skills-acquisitive process: non-expert, experienced non-expert and expert. Each stage was typified by four characteristics that altered during the acquisitive process: knowledge, experience, skills and focus. The findings also identified features of the skill-acquisitive/exercise process either not reported or left implicit in previous studies, including the centrality of recognition of expertise; blurring the boundaries to expert practice; and the role of motivation, enjoyment and commitment to the acquisition of / Doctor of Philosophy (PhD)

Objective: To describe the levels of ANC adequacy and factors related in 3 provinces of Vietnam: Long an, Ben tre and Quang ngai. Method: Data from three rural provinces of Vietnam collected by the Vietnam Australia Primary Health Care Project were analysed using descriptive and analytical statistical techniques including multivariate regression, multipart analysis and hierarchical techniques. A sample of 1335 eligible women was available for analysis. The Andersen Health Behaviour Model was utilised in analyses of ANC utilisation. The Donabedian Quality of Health Model was used in analyses of ANC content and overall adequacy. Results: ANC was inadequate with only 71% of women having some ANC, 51% having initial visits within the first four months, 41% having three or more visits, 35% having three or more visits with the initial visits within the first four months, 17% of women reported three quarter or more of recommended ANC procedures/advice, 12% of women had enough ANC utilisation and fair ANC content. Factors that existed prior to contact with health care providers such as external environment, predisposing and need were related to whether the women seek any ANC and to pregnancy duration at first visits. However, factors that resulted from initial contact with health care providers, such as satisfaction of women with ANC services and health care provider related characteristics, were important in the models examining total number of ANC visits, overall ANC utilisation, content of ANC reported and overall ANC adequacy. Province of residence related to all aspects of ANC adequacy. Different aspects of ANC adequacy were related to each other. Conclusion: ANC adequacy levels in Vietnam were low. To increase the proportions of women who use ANC services and attend ANC early, promotion of ANC should be targeted at women at risk. However, to improve continuation with ANC, ANC content, and overall ANC adequacy, the quality of services provided needs to be improved. To reduce the gap between provinces, priority should be given to less developed provinces. / PhD Doctorate

This thesis reports on an evaluation of an intervention to improve the quality of care for adults with epilepsy. The intervention comprised an epilepsy specialist nurse working in 14 general practices in north west Bristol, England. A multi-method approach was employed. As part of a quasi-experimental trial, baseline and two annual follow-up questionnaires were sent to all patients in the practices aged 16 years and over and currently on drugs for epilepsy. In addition, interviews were undertaken with those having seizures to explore further some questionnaire findings and to appraise the appropriateness, acceptability and accessibility of the nurse service. The epilepsy nurse was interviewed to assess the feasibility of providing the new service. Baseline results highlighted deficiencies in services for people with epilepsy and suggested the need for structured care and increased discussion. The main effects of the nurse service were improved communication about epilepsy between health care providers and patients and increased access, especially for those with the greatest needs. The nurse service had limited impact on patients’ health status. There were indications of a negative impact on the perceived effect of epilepsy on aspects of everyday life. After one year, an intention-to-treat analysis suggested improvements in satisfaction with care from GPs, but decreased adherence to medication. A comparison of nurse service users with non-users after two years showed a reduction in the use of polypharmacy in users, and an increased proportion who queried GPs’ knowledge about epilepsy. Users reported increased visits to their GP. Interview data showed that the decision to use the nurse service depended on factors other than the severity and frequency of seizures. The service was most appropriate for those who perceived themselves to need care or information. This method of delivering care was feasible, but several operational problems were identified. The study supports the use of specialist nurses in primary care. Impact is, however, limited. The greatest contribution to improving care is by supporting and advising patients with specific and defined needs.