Background: We evaluated the validity of a set of 11 quality indicators for prostate cancer radiotherapy and radical prostatectomy by examining their association with outcomes. The selected indicators were: hospital volume, pre-treatment risk assessment, patient consultation with a radiation oncologist, appropriate follow-up care, leg immobilization during radiotherapy, bladder filling during radiotherapy, portal film target localization, use of nerve sparing surgery, operative blood loss, margin status and pelvic lymph node dissection. The selected outcomes were: cause-specific survival, disease-free survival, late morbidity (urinary incontinence, gastrointestinal and genitourinary morbidity), change in node stage from clinical N0 to pathologic N1, and margin status. Methods: Our study sample consisted of 1570 prostate cancer patients who were diagnosed in Ontario between January 1, 1990 and December 31, 1998 who received radical prostatectomy within 6 months of diagnosis (n=646), or curative radiotherapy within 9 months of diagnosis (n=924). Quality of care, outcomes, and potential confounders were measured using patient chart and administrative data. Regression techniques were used to evaluate the associations between quality indicators and relevant outcomes. Results: For patients treated surgically, hospital volume met our test of validity. Patients treated in the lowest volume hospital (0-1 RP/month) were at greater risk of prostate cancer death than patients treated in the highest volume hospitals (7+ RP/month) (HR=5.37 95% CI=1.23-23.46). For patients treated with radiotherapy, leg immobilization and bladder filling during radiotherapy met our test of validity. Patients treated without leg immobilization were more likely to experience urinary incontinence (RR=2.18, 95% CI=1.23-3.87) and genitourinary late morbidities (RR=1.72, 95% CI=1.16-2.56) than patients who received leg immobilization. Patients who were treated with an empty bladder were more likely to experience GU late morbidities (RR=1.98, 95% CI=1.08-3.63) than those treated with a full bladder. The remaining indicators did not meet our test of validity. Conclusion: Our results support the validity of one surgical quality indicator and two radiotherapy quality indicators. Explanations for our non-significant findings, including limited study power, data quality, our definition and measurement of indicators, and a true failure to predict outcome(s) are discussed, and recommendations for further research are presented. / Thesis (Master, Community Health & Epidemiology) -- Queen's University, 2011-09-07 20:26:34.461

Background: Several international studies have been published on the importance of exploring and describing the perceptions of professional nurses to improve patient safety and quality of care. There is also a growing body of literature that has established the associations of qualifications on patient safety and quality of care. However, no comparable research has been conducted in South Africa, and little is known about the influence of personal characteristics, such as qualifications of the professional nurse, on his/her perception of patient safety and quality of care. Objective: To investigate the perceptions of professional nurses regarding patient safety and quality of care as well as the relationship between the qualifications of professional nurses and these perceptions in medical and surgical units in public and private hospitals in South Africa. Design: Cross-sectional survey of nurses. Setting and participants: 1187 professional nurses (161 Baccalaureate degree and 956 diploma-prepared) working in medical and surgical units of 55 private hospitals and 7 public national referral hospitals in South Africa completed the survey. Measurements: Perceptions of patient safety, quality of care and occurrence of adverse events, qualifications, age, job satisfaction, emotional exhaustion, experience, personal accomplishment and depersonalization. Results: 54.1% (n = 87) of Baccalaureate professional nurses and 51.2% (n = 490) diploma nurses feel as if their mistakes are held against them. 37.9% (n = 61) of Baccalaureate professional nurses and 42.4% (n = 404) diploma nurses perceive important information to be lost during shift changes. 39.1% (n = 63) of Baccalaureate professional nurses and 38.6% (n = 369) diploma nurses feel that things “fall between the cracks” when transferring patients from one unit to another. 43.5% (n = 70) of Baccalaureate professional nurses and 48.7% (n = 465) diploma nurses feel that their hospital‟s managements are not approachable. Almost half of professional nurses (49% [n = 79] Baccalaureate and 44.4% [n = 418] diploma) do not have confidence in hospital management to resolve reported problems regarding patient care. 26.6% (n = 26.8) of Baccalaureate professional nurses and 25.5% (n = 237) of diploma professional nurses perceive the quality of care in their hospitals to have deteriorated. Both Baccalaureate and diploma professional nurses reported adverse events to occur a few times a year or less. Verbal abuse towards nurses is reported to occur once a month or less. Qualifications revealed no correlation with perceptions of patient safety and quality of care, though emotional exhaustion and depersonalization showed a small to medium negative correlation and personal accomplishment a small to medium positive correlation with these perceptions. Conclusions: Supportive leadership and development of an environment in which professional nurses can freely report adverse events and hindering factors with regard to quality of care might benefit patients in terms of safety and better quality care. / Thesis(M.Cur.)--North-West University, Potchefstroom Campus, 2012.

Background: In health care services, equity is the delivery of similar care for similar needs (horizontal equity), and the delivery of more care for higher needs (vertical equity). This study assessed the extent to which primary care provision is equitable across gender, age and socioeconomic groups, and whether any observed disparity is associated with the type of primary care remuneration model to which a family practice belongs. Remuneration models include Fee For Service in which the physician is paid for each encounter, Salary where payment is fixed for the number of hours worked, and Capitation where payment is tied to the number of patients under the care of the provider, and very little or no additional compensation is provided for each patient encounter. // Methods: This thesis used data from a cross sectional study of 5,361 patients receiving care from practices (n) in which primary care providers were remunerated by Fee For Service (35), Salary (35), or Capitation (68). Multi-level linear or logistic regressions were used to assess the impact of gender, age and socioeconomic strata on quality of care. The quality of health service delivery and health promotion were assessed through surveys based on the Primary Care Assessment Tool (n=5,111). The quality of preventive care (n=4,108) and chronic disease management (n-514) were evaluated through chart abstraction using the Canadian recommendations for care as the standard. The analyses were conducted stratified by remuneration model to allow the impact of the model on the extent of disparity in quality of care between social strata to be assessed. // Results: Men and women reported similar quality of health service delivery. Women were significantly more likely to be up to date on their preventive care, but adherence to recommended guidelines for chronic disease management was better for men in the Fee For Service practices. Older individuals reported better health service delivery than younger ones. The quality of chronic disease management was also age dependent with better care delivered to individuals ages 60-69. Individuals of low income and education had better accessibility than those not disadvantaged in the Salaried model and Fee For Service, but not Capitation model. Despite their higher health risks, these individuals were not more likely to receive healthy lifestyle counseling. // Conclusions: Significant inequalities in the care of patients were found across social strata. In some cases, these inequalities are deemed appropriate; a justifiable response to differing health care needs. In other cases, they are deemed inappropriate and representing inequities in the delivery of care. Some of the observed disparities were present in one remuneration model but not others, suggesting that the payment approach may be contributing to these differences. The results raise the concern that the capitation remuneration structure may compromise accessibility.

Background: Several international studies have been published on the importance of exploring and describing the perceptions of professional nurses to improve patient safety and quality of care. There is also a growing body of literature that has established the associations of qualifications on patient safety and quality of care. However, no comparable research has been conducted in South Africa, and little is known about the influence of personal characteristics, such as qualifications of the professional nurse, on his/her perception of patient safety and quality of care. Objective: To investigate the perceptions of professional nurses regarding patient safety and quality of care as well as the relationship between the qualifications of professional nurses and these perceptions in medical and surgical units in public and private hospitals in South Africa. Design: Cross-sectional survey of nurses. Setting and participants: 1187 professional nurses (161 Baccalaureate degree and 956 diploma-prepared) working in medical and surgical units of 55 private hospitals and 7 public national referral hospitals in South Africa completed the survey. Measurements: Perceptions of patient safety, quality of care and occurrence of adverse events, qualifications, age, job satisfaction, emotional exhaustion, experience, personal accomplishment and depersonalization. Results: 54.1% (n = 87) of Baccalaureate professional nurses and 51.2% (n = 490) diploma nurses feel as if their mistakes are held against them. 37.9% (n = 61) of Baccalaureate professional nurses and 42.4% (n = 404) diploma nurses perceive important information to be lost during shift changes. 39.1% (n = 63) of Baccalaureate professional nurses and 38.6% (n = 369) diploma nurses feel that things “fall between the cracks” when transferring patients from one unit to another. 43.5% (n = 70) of Baccalaureate professional nurses and 48.7% (n = 465) diploma nurses feel that their hospital‟s managements are not approachable. Almost half of professional nurses (49% [n = 79] Baccalaureate and 44.4% [n = 418] diploma) do not have confidence in hospital management to resolve reported problems regarding patient care. 26.6% (n = 26.8) of Baccalaureate professional nurses and 25.5% (n = 237) of diploma professional nurses perceive the quality of care in their hospitals to have deteriorated. Both Baccalaureate and diploma professional nurses reported adverse events to occur a few times a year or less. Verbal abuse towards nurses is reported to occur once a month or less. Qualifications revealed no correlation with perceptions of patient safety and quality of care, though emotional exhaustion and depersonalization showed a small to medium negative correlation and personal accomplishment a small to medium positive correlation with these perceptions. Conclusions: Supportive leadership and development of an environment in which professional nurses can freely report adverse events and hindering factors with regard to quality of care might benefit patients in terms of safety and better quality care. / Thesis(M.Cur.)--North-West University, Potchefstroom Campus, 2012.

Background: There is little information on how the quality of oral health services in long-term care (LTC) facilities is conceptualized or assessed. Objectives: This study aims to develop a model for assessing the quality of oral healthcare services in LTC facilities. Methods: This study is divided into four main steps. Firstly, I examined literature for existing concepts relating to program evaluation and quality assessment in healthcare to build a theoretical framework appropriate to dental geriatrics. Secondly, I explored as an ethnographic case study a comprehensive oral healthcare program within a single administrative group of 5 LTC facilities in a large metropolis by interviewing 33 participants, including residents and their families, nursing staff, administrators and dental personnel. I also examined policy documents and made site visits to identify other attributes influencing the quality of the program. Thirdly, I drafted the assessment model combining a theoretical framework with empirical information from the case study. And lastly, I tested the feasibility and usability of the model in another dental geriatric program in northern British Columbia. I applied the assessment model by conducting 15 interviews with participants in the program, made site-visits to the 5 facilities, and reviewed documents on the development and operation of the program. Results: A combination of theory-based evaluation and quality assurance provided six sequential and iterative steps for quality assessment of oral health services in LTC. The empirical information supported the theoretical framework that a program of oral healthcare in a LTC context should be assessed for quality from multiple perspectives; it should be comprehensive; and it should include the three main attributes of quality - capacity, performance, and outcomes. Participants revealed 20 quality indicators along with suggested program objectives which encompass eight quality dimensions such as effectiveness, efficiency, and patient-centered. Conclusion: The model provides a unique system for assessing the quality of dental services in LTC facilities that seems to meet the needs of dental and non-dental personnel in LTC.

Background:  Depression is an increasing public health   problem in the world that leads to suffering among people in terms of   isolation. The number of depressed patients is growing. We as future nurses   will meet these patients in care and therefore it is important to be aware of   how they perceive their everyday lives, care and state to provide the best   possible care.  Aim: The aim   was to illustrate the patient's experience of suffering from depression.  Method: In this   literature study, twelve   scientific articles   were analyzed according to Friberg’s method. These articles were retrieved   from CINAHL, PubMed and PsycINFO that got reviewed and used to write the   result. The starting point was Katie Eriksson's theory about care suffering. Results:  In the result, four overall themes were identified, which one of   themes had two subthemes and one had one subtitle. The first theme was the experience of not having control over   oneself with subtitles: isolation   and experiencing changed identity.   Another theme was the desire to get   more information with the subtitle: wanting   to be involved in decision making. The third theme was the importance of trust and the last   theme was of experiencing good or lack   of skills in the staff. Discussion: The literature review discussed the patient's experiences of   depression based on Katie Eriksson's theory about care suffering. It turned   out that the patients felt isolated and insecure because of their lack of   information about depression, the environment's view of their illness and the   lack of knowledge of the care. In such a situation, suffering may come up   according to Katie Eriksson. / Bakgrund: Depression är ett ökande   folkhälsoproblem i världen som leder till stort lidande hos personer i form   av bland annat isolering, ovisshet och nedstämdhet. Antalet deprimerade   patienter blir fler. Vi som blivande sjuksköterskor kommer att möta dessa   patienter i vården och därför är det viktigt att vara medveten om hur de   upplever sin vardag, sin vård och sitt tillstånd för att kunna ge den bästa   möjliga vården. Syfte: Syftet var att belysa patienters upplevelse   av att vara drabbade av depression.  Metod: I denna litteraturstudie användes tolv vetenskapliga   artiklar som analyserades enligt Fribergs metod. Dessa artiklar hämtades från   CINAHL, PubMed och PsycINFO och granskades sedan och användes för att skriva   resultatet. Utgångspunkten var Katie Erikssons teori om vårdlidande. Resultat: I resultatet identifierades fyra   övergripande teman varav ett av teman hade två underteman och ett hade ett   undertema. Första temat innehöll upplevelsen   av att inte ha kontroll över sig själv med underteman: isolering och att uppleva förändrad identitet. Andra temat var önskan att få mer information med   underteman: att vilja vara delaktig i   beslutfattandet. Det tredje temat var den   betydelsefulla tilliten och sista temat var att uppleva god eller bristande kompetens hos personalen. Diskussion: Litteraturöversiktens diskussion belyste   patienternas upplevelser av depression utifrån Katie Erikssons teori om   vårdlidande. Det visade sig att patienterna kände sig isolerade och otrygga   dels på grund av deras bristande information om depression, omgivningens syn   på deras sjukdom samt vårdens brist på kunskap. Vid sådan situation kan   lidande uppstå enligt Katie Eriksson.

Magister Curationis - MCur / As early as 1993, the World Health Organisation declared Tuberculosis (TB) a global emergency and the South African Department of Health confirmed that TB was a national emergency. The primary cause of the rise in TB cases has been attributed to co-infection with HIV. TB is the leading opportunistic infection worldwide and the primary cause of mortality among people living with Human Immunodeficiency Virus (HIV). TB and HIV are two of the highest health threats globally and in South Africa. Tuberculosis and HIV combined are responsible for the deaths of over 4 million people annually. More than 65% of individuals diagnosed with TB in South Africa are co-infected with HIV. The importance of providing quality health services is a human right and non-negotiable. Better quality of health care is fundamental in improving South Africa's poor health outcomes and in restoring patient and staff confidence in the public and private health system. In 1996, the South African Department of Health introduced the topic of quality to raise its awareness and to make it an inherent part of the health care system. The South African health care consumers (patients) are increasingly becoming aware of their rights as patients and the gap between the actual and ideal health practices. They have broad knowledge and great expectations with regard to available care including effectiveness of service and treatment. Patients have desires for quality services when visiting a health care facility, and these desires are directly linked to the success of the healthcare system. If the desires are not met, they can negatively influence the outcome of healthcare processes such as treatment adherence and retention of patients on the system. This could possibly further escalate the TB/HIV co-infection rate in South Africa. The need to address TB and HIV together in the light of quality care is urgent so as to improve the provision of quality health services rendered to people co-infected with TB and HIV. The Institute of Medicine developed a framework that could guide on healthcare dimensions that need to be met for quality of care to be achieved and it is the underpinning theoretical framework for this study. The patients play a critical role in the healthcare system as they are the customers and therefore, the opinions of the patients need to be recognised to ensure that strategies and programmes that are developed are relevant. The purpose of this research was to explore and describe the perceptions of patients co-infected with TB and HIV regarding the quality of care at the Primary Health Care facilities, in the Chris Hani District. A qualitative, explorative and descriptive design was used which enabled the researcher to understand the perceptions of TB and HIV co-infected patients regarding quality of care. The population studied in this research consisted of TB and HIV co-infected patients attending the Primary Health Care facilities at the Lukhanji Sub-district within the Chris Hani District. Purposive sampling was used to select participants with the assistance of nurses working at the selected facilities. The sample size was determined by data saturation, which was reached after 18 semi-structured interviews were conducted. Data analysis was carried out simultaneously with data collection. In consensus discussions, the researcher and the co-coder reached an agreement on the main theme, sub-theme and sub-categories. From the research findings, two main themes were identified namely; satisfaction with delivered services and impediments to quality of care. These were further divided in sub themes and categories. The conclusion that could be made on the quality of care provided to the TB and HIV co-infected patients in this study is that the nurses in the facilities aim to provide four of the six IOM aims of quality of care to the TB and HIV co-infected patients namely: equitable, effective, efficient and patient-centred domains. Therefore, the quality of care provided to these patients is partial as they are not provided with all the six aims that are needed to achieve quality of care. Recommendations are made for the field of community health nursing practice and nursing research on how to improve quality of care provided to TB and HIV co-infected patients at Primary Health Care facilities.

Background: There is little information on how the quality of oral health services in long-term care (LTC) facilities is conceptualized or assessed. Objectives: This study aims to develop a model for assessing the quality of oral healthcare services in LTC facilities. Methods: This study is divided into four main steps. Firstly, I examined literature for existing concepts relating to program evaluation and quality assessment in healthcare to build a theoretical framework appropriate to dental geriatrics. Secondly, I explored as an ethnographic case study a comprehensive oral healthcare program within a single administrative group of 5 LTC facilities in a large metropolis by interviewing 33 participants, including residents and their families, nursing staff, administrators and dental personnel. I also examined policy documents and made site visits to identify other attributes influencing the quality of the program. Thirdly, I drafted the assessment model combining a theoretical framework with empirical information from the case study. And lastly, I tested the feasibility and usability of the model in another dental geriatric program in northern British Columbia. I applied the assessment model by conducting 15 interviews with participants in the program, made site-visits to the 5 facilities, and reviewed documents on the development and operation of the program. Results: A combination of theory-based evaluation and quality assurance provided six sequential and iterative steps for quality assessment of oral health services in LTC. The empirical information supported the theoretical framework that a program of oral healthcare in a LTC context should be assessed for quality from multiple perspectives; it should be comprehensive; and it should include the three main attributes of quality - capacity, performance, and outcomes. Participants revealed 20 quality indicators along with suggested program objectives which encompass eight quality dimensions such as effectiveness, efficiency, and patient-centered. Conclusion: The model provides a unique system for assessing the quality of dental services in LTC facilities that seems to meet the needs of dental and non-dental personnel in LTC. / Dentistry, Faculty of / Graduate

Background: In health care services, equity is the delivery of similar care for similar needs (horizontal equity), and the delivery of more care for higher needs (vertical equity). This study assessed the extent to which primary care provision is equitable across gender, age and socioeconomic groups, and whether any observed disparity is associated with the type of primary care remuneration model to which a family practice belongs. Remuneration models include Fee For Service in which the physician is paid for each encounter, Salary where payment is fixed for the number of hours worked, and Capitation where payment is tied to the number of patients under the care of the provider, and very little or no additional compensation is provided for each patient encounter. // Methods: This thesis used data from a cross sectional study of 5,361 patients receiving care from practices (n) in which primary care providers were remunerated by Fee For Service (35), Salary (35), or Capitation (68). Multi-level linear or logistic regressions were used to assess the impact of gender, age and socioeconomic strata on quality of care. The quality of health service delivery and health promotion were assessed through surveys based on the Primary Care Assessment Tool (n=5,111). The quality of preventive care (n=4,108) and chronic disease management (n-514) were evaluated through chart abstraction using the Canadian recommendations for care as the standard. The analyses were conducted stratified by remuneration model to allow the impact of the model on the extent of disparity in quality of care between social strata to be assessed. // Results: Men and women reported similar quality of health service delivery. Women were significantly more likely to be up to date on their preventive care, but adherence to recommended guidelines for chronic disease management was better for men in the Fee For Service practices. Older individuals reported better health service delivery than younger ones. The quality of chronic disease management was also age dependent with better care delivered to individuals ages 60-69. Individuals of low income and education had better accessibility than those not disadvantaged in the Salaried model and Fee For Service, but not Capitation model. Despite their higher health risks, these individuals were not more likely to receive healthy lifestyle counseling. // Conclusions: Significant inequalities in the care of patients were found across social strata. In some cases, these inequalities are deemed appropriate; a justifiable response to differing health care needs. In other cases, they are deemed inappropriate and representing inequities in the delivery of care. Some of the observed disparities were present in one remuneration model but not others, suggesting that the payment approach may be contributing to these differences. The results raise the concern that the capitation remuneration structure may compromise accessibility.

Introduction: The global burden of diabetes can be minimised by interventions focusing on the control of glucose levels. Effective self-management and quality of care have improved diabetes outcomes such as glycaemic levels. However, few studies directly evaluate the relative importance of individual aspects of self-management and quality of care on glycaemic control. Therefore, I evaluated the individual contribution and relative importance of specific aspects of self-management and quality of care on the glycaemic control of Mexican patients with type 2 diabetes. Methods: A longitudinal cohort study was conducted. Consecutive patients were recruited from the waiting rooms in five primary care practices in the city of Aguascalientes, Mexico (from December 2009 to April 2010). These practices are part of the largest social security institution in Mexico (the Mexican Institute for Social Security). Predictors of glycaemic control were measured from medical records and interviews with patients at baseline. Self-management was measured using four questionnaires: the Diabetes Knowledge Questionnaire (DKQ-24), the Medical Prescription Knowledge Questionnaire (MPKQ), the Summary of Diabetes Self-Care Activities (SDSCA), and the Diabetes Self Efficacy Scale. Quality of care was measured using three questionnaires and by extracting data from medical records to evaluate an index of continuity of care (MMCI) and treatment intensification. The questionnaires used were the continuity of care scale from the General Practice Assessment Questionnaire (GPAQ), the Patient–Doctor Communication Scale (PDCS), and the Patient Satisfaction with Diabetes Care scale (PSDC). Glycaemic control (HbA1c levels) was measured at two time points: baseline and six month follow-up. The main analysis was a multivariate regression model with HbA1c at six-month follow-up as the dependent variable and with self-management and quality of care as predictors and demographic and clinical factors as covariates. A secondary analysis considered the interaction between self-management and quality of care in the prediction of HbA1c at six-month follow-up using a multivariate regression model including HbA1c at baseline in the model. Results: The multivariate linear regression model, that included all variables, was significant and explained 36 % of the variance (P <0.01). Patients had lower HbA1c at follow-up if they had lower levels of HbA1c at baseline, received care at one particular practice in the city, had diabetes of shorter duration, and were prescribed monotherapy. When HbA1c at baseline was removed from the model it explained 14% of the variance (P <0.01). Practice and medical prescription remained significant. In addition, lower levels of HbA1c at follow-up were related to the patient undergoing appropriate treatment intensification by their general practitioner. In the secondary analysis, the interaction showed that if treatment was not intensified, good self-managers had lower HbA1c (P <0.01) but if treatment was intensified, the level of self-management had no effect. Conclusions: Treatment intensification was the main predictor of lower HbA1c levels at follow-up. Although none of the self-management predictors was significantly related to HbA1c, an exploratory analysis of self-management/quality of care interactions showed that patients who did not receive treatment intensification but performed more self-management behaviours had lower HbA1c levels at follow-up.