A equidade na utilização de cuidados de saúde deve ser considerada como questão central em qualquer política de saúde que pretenda contribuir para uma sociedade mais justa. Desse modo, o objetivo desta tese é analisar o desempenho da entrega de cuidados no Brasil em termos de equidade por meio de violações do princípio de equidade horizontal na utilização dos serviços de cuidados de saúde e da decomposição dos determinantes da desigualdade na utilização do cuidado relacionada à renda. A desigualdade na distribuição de cuidado médico pela renda é capturada por índices de iniquidade para a utilização de serviços de consultas médicas e internações hospitalares. Esses índices mostram se existem diferenças no uso de serviços de cuidados de saúde entre indivíduos com similares necessidades de saúde. Para explicar as causas da desigualdade, Wagstaff, van Doorslaer e Watanabe (2003) propõem que a medida do grau de desigualdade seja decomposta nas contribuições dos fatores explicativos do uso. A análise também considerou a perspectiva da desigualdade, o que permitiu observar não apenas desigualdades sociais mas também variações regionais na entrega de cuidados de saúde. Os resultados mostraram iniquidade horizontal pró-rico no uso de consultas médicas e pouca evidência de iniquidade no uso de internações. O padrão de iniquidade horizontal no uso se repetiu para todas as regiões, mas regiões menos desenvolvidas como, o Norte e o Nordeste, apresentaram maior grau de iniquidade. A decomposição da desigualdade mostra que contribuições de fatores de necessidades de saúde são principalmente pró-pobre, uma vez que pessoas mais pobres tendem a possuir maiores necessidades de cuidado. Por outro lado, as contribuições dos determinantes sociais foram bastante diversificadas. Renda e escolaridade contribuem para aumentar a distribuição pró-rico no uso de consultas e reduzir a contribuição pró-pobre no uso de internações hospitalares. A contribuição da condição de atividade foi, em geral, pró-pobre, podendo ser explicada pelo maior custo de oportunidade das pessoas ocupadas em procurar cuidados com a saúde. As contribuições dos plano de saúde e das desigualdades regionais são examinadas com maior atenção por serem alvo direto de políticas de saúde. Assim, contribuições pró-rico do plano de saúde e das desigualdades regionais poderiam ser reduzidas, por exemplo, por estratégias com foco em grupos de renda mais baixa e pela ampliação de recursos físicos e humanos das áreas menos desenvolvidas. / Equity in healthcare utilization should be considered as a basic issue at any health policy that you want to contribute to a fairer society. Thus, the aim of this thesis is to analyze the performance of medical care delivery in Brazil in terms of equity through violations of the horizontal equity principle of healthcare use and of the decomposition of the determinants of income-related inequality in the use of medical care. The inequality in the distribution of medical care by income is captured by inequity indices. This indices show if there are differences in the use of healthcare services among individuals with similar health needs. To explain the causes of the income-related inequality, Wagstaff, van Doorslaer, Watanabe (2003) proposed that the measure of the degree of inequality is decomposed into the determinants of use. The analysis also considered the regional perspective of inequality, which allowed us to observe not only social inequalities but also regional variations in the delivery of healthcare. The results find evidence horizontal inequity pro-rich in the utilization of doctor visits and little evidence de inequity in inpatient care use. The pattern of horizontal inequity in use is repeated for all regions, but less developed regions like the North and Northeast had a higher degree of iniquity. The decomposition of inequality shows that contributions of factors of health needs are mainly pro-poor, because poorer people tend to have greater care needs. On the other hand, the contributions of the social determinants were enough diverse. Income and education contributed to increase the pro-rich distribution of use of doctor visits and reduce the distribution pro-poor inpatient care. The contribution of status of activity was mostly pro-poor because probably economically active people have a higher cost of opportunity in seeking healthcare. The contributions from the health insurance and regional inequalities are examined more closely by being a direct target of health policy. Accordingly, contributions pro-rich of health insurance and of regional inequalities could be reduced, for example, by strategies focused on lower income groups and by the expansion of physical and human resources of less developed areas.

Identifying and communicating a disease diagnosis has historically been the center of the medical encounter. Recent advances in molecular biology and genetics have increased the amount of care devoted to disease screening and risk assessment. In this era of prevention, risk itself has become a ‘problem’ requiring intervention where once such problems were left unidentified. Treating risk as a diagnosis itself allows it be treated in a familiar manner, but marginalizes the patient experience. It is important to understand how adopting a biomedical view of risk and prevention influences participation in care and patient willingness to engage with the medical system, despite a lack of manifest disease. This is a critical gap in knowledge at a time when there is increased emphasis on preventive medicine. This dissertation contains three chapters that seek to characterize how identifying, labeling, and developing interventions for patients 'at risk' affects service provision and use. Study 1, Explanatory Models of Risk: The Role of Social Context in Breast Cancer Risk Perception and Decision-Making, sought to characterize explanatory models of risk among women at risk for developing breast cancer. Qualitative interviews demonstrated the importance of perceptions of risk and control in combination with elements of explanatory models and social context in their decision-making. Study 2, Associations between Breast Cancer Risk and General Health Service Use, considered the possibility that patterns of health service utilization may change following a medical finding that is often perceived as increased risk. Results showed a greater increase in the rate of outpatient visits and referrals in the year following a false positive mammogram, suggesting such utilization is driven by both patients and providers. Study 3, An Assessment of Patient Navigator Activities in Breast Cancer Patient Navigation Programs Using a Nine-Principle Framework, described similarities and differences in the execution of patient navigation programs designed to increase engagement in care among individuals who have been labeled as ‘at risk’ upon having an abnormal mammogram. Activities conducted by navigators where shown to vary according to the local context and population of women that they served.

Using data collected in 2007 for Addis Ababa Mortality Surveillance, the paper examines the effect of cause of death/type of illness on choice of health care in adults 12 years and above. The multinomial logit model using bootstrapped standard errors is used to investigate the relationship between dominant type of treatment and the covariates: cause of death, gender, age, education, occupation, ethnicity and religion. Availability of water, television and telephone in the household are used as a proxy for economic status. After controlling for duration of illness (exposure), type of illness, gender and marital status are significant. Those who die of HIV/TB and cancer behave similar in way they seek help, and have high likelihood of using traditional healers as the first point for help compared to those who died as a result of other illnesses. Thus the study concludes that cause of death; gender and marital status affect choice of health service.

Sickle cell disease (SCD) is the most common group of genetic, chronic hematologic disorders, and is characterized by chronic pain resulting from vaso-occlusive episodes. As such, youth with SCD utilize a disproportionately high amount of health care resources. Youth with frequent health care utilization (HCU) are at increased risk for psychosocial consequences, including disruptions in family functioning and decreased academic performance. While studies have separately examined HCU, family functioning, and academic achievement in this population, there is a dearth of research examining the association between these variables. The present study aimed to: (1) examine associations between family environment and patterns of HCU, (2) examine associations between patterns of HCU and academic achievement scores in math and reading, and (3) evaluate the indirect effect of family environment on academic achievement scores in math, as explained by patterns of HCU. This study included 41 youth with HbSS or HbS beta-thalassemia. Youth were administered the Woodcock-Johnson III Achievement, and caregivers completed the Family Environment Scale. Sociodemographic characteristics were collected, and medical history information was obtained via retrospective medical chart review. Overall, participants reported a more positive family environment, demonstrated less pain-related ED visits and hospital admissions, and obtained below average scores on academic achievement in math and reading. The present study did not provide evidence of associations between family environment, HCU, and academic achievement. Unique characteristics of the study sample, as well as clinical implications and next steps for future research are discussed.

This study was an analysis of social work practice in a medical setting: analyzing the work of a medical social worker in an outpatient clinic located in a metropolitan area. The primary purpose of this descriptive study was to evaluate the performance of a medical social worker in a Kaiser-Permanente outpatient clinic and to determine if there were possible associations between social work intervention and patient utilization of existing services offered by the Kaiser Health Care system, also referred to herein as Kaiser. Specifically, the study attempted to determine if there were quantitative changes in patient contacts, and utilization of certain services such as clinic visits, telephone contacts, prescriptions, emergency room visits, hospitalizations, and physicians seen before and after social worker intervention. If there were changes, what were the direction and quantity? Did changes vary according to type of service? Did patient utilization of medical care vary according to the number of social work contacts?

No description available.

No description available.

Home and community participation is measured by a multitude of determinant factors based within the context of a health system. Three studies were completed to understand relationships between environment and personal factors with service utilization and outcomes of participation among children with disabilities. In the first study, a scoping review was completed to identify factors that influenced rehabilitation service utilization among Canadian children with disabilities. Key findings of this review indicated higher rates of service utilization are associated to younger age, males and those with lower cognitive or motor functioning. Occupational therapists, physiotherapists and speech-language pathologists were the most commonly utilized disciplines. Higher perceptions of service satisfaction related to increased presence of family-centered practices. Areas requiring further research include family needs, barriers, personal health practices and participation outcomes. Based on the findings of this review, a survey was created to administer to parents using a large children’s rehabilitation treatment centre in Ontario. Findings from the survey conducted with 279 parents are reported in the second study by providing a descriptive profile of families and children using geographically-based rehabilitation services. Families using the centre typically have younger aged children, with more boys than girls, and a large proportion use the centre for speech services. Complexity scores correlated significantly and positively with service need and service utilization, indicating children with lower functioning desired and received more rehabilitation services. Age, sex, and diagnosis did not predict total time in therapy, but complexity was a significant predictor of total time in therapy. Participation frequency scores showed weaker relationships to complexity in comparison to participation involvement scores. The final study explored the relationship between environmental and personal factors of service utilization and participation using structural equation modeling. Predictors of participation include child’s age, environmental barriers, complexity, and mother’s participation. Findings support that exploring children’s complexity and promoting mother’s participation by removing environmental barriers and modifying inaccessible structures are important to examine from a young age. / Dissertation / Doctor of Philosophy (PhD) / This study examines the relationship between factors of service utilization and participation outcomes for children with disabilities. Currently, there is little knowledge pertaining to the characteristics of children receiving rehabilitation services and the influence of these services on health outcomes. Such information is vital to understand how health conditions, service utilization, service planning, and service satisfaction differ across children with disabilities. Use of health services (type and number of rehabilitation services used, duration of services), environmental barriers, maternal leisure practices, and socioeconomic factors are examined with consideration to the child’s diagnosis and complexity in relation to scores of participation. This is the only study in Canada so far to comprehensively explore relationships between rehabilitation utilization and participation. The study informs health care providers and researchers about patterns and variations in children’s needs that can be utilized to improve service quality and plan services, as well as to understand participation patterns.

Obstructive sleep apnea (OSA) is underrecognized. Between 10% and 69% of preoperative patients have undiagnosed OSA. To reduce the risk of peri-operative complications related to undiagnosed OSA, patients planned to undergo bariatric surgery are screened for OSA. To understand the OSA detection rate with screening practices, the prevalence of OSA within patients who underwent publicly funded bariatric surgery in Ontario between 2010 and 2016 was measured. Secondly, to understand the effect of OSA screening practices on perioperative and longer-term health care costs, health care utilization and costs were compared between patients with OSA and matched patients without OSA in the 30 days post-bariatric surgery, as well as in the 1 year post-bariatric surgery. The Ontario Bariatric Registry (OBR) linked to the ICES health administrative databases were used. A diagnosis of OSA was identified if recorded in the OBR at time of initial bariatric consultation, or if recorded in ICES databases from the bariatric surgery admission records. Costs were calculated based on the “Guidelines on Person-Level Costing Using Administrative Databases in Ontario” using ICES costing algorithms. The overall prevalence of OSA was 47% (95% CI 46% to 47%). Total health care costs per patient, in the 30-day post-operative period, were 1% lower (95% CI 1% to 1%, p < 0.001) in patients with OSA compared to matched patients without OSA. Similarly, at 1 year postbariatric surgery, total health care costs per patient, were 1% lower (95% CI 1% to 1%, p < 0.001) in patients with OSA compared to matched patients without OSA. At 30 days and 1 year, this difference was driven by lower hospitalization-related costs. OSA screening practices at surgical centers in our network led to similar rates of OSA detection as reported in the literature. However, the literature suggests that screening practices lead to missed OSA diagnoses. Further study is required to understand the reduced post-bariatric surgery costs in patients with OSA compared to matched controls without OSA; and, we postulate that missed OSA diagnoses may be a contributor. / Thesis / Master of Science (MSc) / Obstructive sleep apnea (OSA) is underrecognized and a good proportion of patients with OSA are undiagnosed. To reduce the risk of peri-operative complications related to undiagnosed OSA, patients planned to undergo bariatric surgery are screened for OSA. To understand the performance of OSA screening practices, using a province-wide registry, the proportion of patients diagnosed with OSA within patients who underwent publicly-funded bariatric surgery in Ontario between 2010 and 2016 was measured at 47%. Furthermore, to understand the effect of OSA screening practices on peri-operative costs and longer-term health care costs, health care utilization and costs were compared between patients with OSA and matched patients without OSA in the 30 days and 1 year post-bariatric surgery. Total health care costs per patient were 1% lower in patients with OSA compared to patients without OSA, and this difference was driven by lower hospitalization-related costs.

No description available.