This dissertation uses population-based administrative healthcare data to evaluate the outcomes, processes-of-care and practice variation associated with preoperative medical consultation in Ontario, Canada. First, a multicentre cross-sectional study was conducted to develop a novel algorithm for identifying preoperative medical consultations using administrative data. The optimal claims-based algorithm was a physician service claim for a consultation by a cardiologist, general internist, endocrinologist, geriatrician, or nephrologist within 120 days before the index surgery. This algorithm had a sensitivity of 90% (95% confidence interval [CI], 86 to 93) and specificity of 92% (95% CI, 88 to 95). Second, we conducted a population-based cohort study to evaluate the association of preoperative medical consultation with outcomes and processes-of-care. After adjustment for measured confounders using propensity-score methods, consultation was associated with increased preoperative testing, preoperative pharmacological interventions, 30-day mortality [relative risk (RR) 1.16; 95% CI, 1.07 to 1.25], 1-year mortality (RR 1.08; 95% CI, 1.04 to 1.12), and mean hospital stay (difference 0.67 days; 95% CI, 0.59 to 0.76). These findings were stable across subgroups, as well as sensitivity analyses that tested for unmeasured confounding. Third, temporal trends and practice variation in consultation were evaluated within the population-based cohort. The proportion of patients undergoing consultation remained relatively stable over the study period, at approximately 39%. Although patient-level and surgery-level factors did predict consultation use, they explained only 6.8% of variation in consultation rates. By comparison, inter-hospital differences in rates were substantial (range, 1.9% to 86.8%), were not explained by surgical volume or teaching status, and persisted after adjustment for patient-level and surgery-level factors. Overall, this dissertation highlights the need for research to identify interventions for safely decreasing perioperative risk, define mechanisms by which consultation influences outcomes, examine factors that influence practice variation in medical consultation, and identify patients who benefit most from preoperative medical consultation.

The importance and benefits of involving community members in health policy making-­-from the first step of needs assessment through to actual policy development--are increasingly being recognized. This thesis describes the evaluation of a community consultation process which was part of a needs assessment conducted by Saskatoon District Health, in Saskatchewan, Canada. In September 1995, a Children and Youth Working Group was formed, made up of volunteers representing service providers, users, and families. Their mandate was to develop and priorize recommendations on ways to improve the health status of children and youth in the District, which has a total population of approximately 300,000. In addition to a comprehensive epidemiological assessment, the Working Group engaged in a community consultation process which solicited input from the general community, with a specific emphasis on key groups such as youth, Aboriginal, immigrant/refugees, and service providers in health, education, social services, and justice. In this process, information on perceived needs of children and youth was collected through 20 focus groups (n=213) and a questionnaire (n=1,985). Based on a synthesis of the quantitative and qualitative data, the Working Group drafted a set of recommendations, which were then discussed at a community meeting for input and feedback. <p> This research evaluates the effectiveness of the consultation process in facilitating community participation using three sources of data: the entire consultation process was observed (from January 1996 until February 1997), including the focus groups, Working Group meetings, and the final community meeting; interviews (2) were held with the Working Group (n=9), with selected individuals who had participated in the consultation (n=7), and with non-participants (n=2); and documentation produced by the Working Group (i.e., minutes, notes, background material) was reviewed. These data were analyzed thematically according to criteria established jointly by the representatives of the member groups of the Population Health Project (Working Group, Coordinating Group, Research Advisory Group) and the researcher. The effectiveness was gauged by comparing the findings with the criteria and with the components of meaningful community consultation as defined by the Working Group (appropriateness, timeliness, completeness, accuracy, representativeness, relevance). The themes which emerged from the analysis deal with the participants' feelings about their participation or non­participation, the success of the consultation process, the nature of the data collected; by-­products of the process, and the consultation's influence on the outcome of the needs assessment. The results of this analysis are presented and conclusions drawn regarding factors that contribute to or impede effective public participation in health needs assessment.

The purpose of this study was to determine whether radiologists could accurately assess osteopenia on chest plain films. Two chest radiologists evaluated lateral chest films from 100 patients (80 female and 20 male), ranging in age from 16 to 86 years, for osteopenia and its associated findings. Intra- and interobserver agreement was determined using weighted kappa statistics, and accuracy was assessed by making comparisons to bone mineral density as measured by the non-invasive gold standard of dual-energy x-ray absorptiometry (DXA). Overall, radiologists were good at identifying signs of late, but not early, disease. Intraobserver consistency was substantial for fish vertebrae (Kw1=0.638; Kw2=0.0.712) with moderate interobserver agreement (Kw=0.45). Similarly for wedged vertebrae, intraobserver consistency was substantial to moderate (Kw1=0.654; Kw2=0.533) with substantial interobserver agreement (Kw=0.622). These radiographic signs correlated with true disease as shown by high specificity values. Therefore, this study indicates that if osteopenia is suspected (i.e., there is a wedge or fish vertebra) or its associated features are seen on a CXR, it is crucial for radiologists to comment on it. The literature suggests that referring physicians do not pay attention to such findings in radiology reports. Radiologists could effect change in clinical treatment by not burying these findings in the report body, but instead putting it in the impression, along with a recommendation that the finding be followed up with DXA. Because effective interventions for women with osteoporosis exist, the results of this study will contribute to a major change in the practice of chest radiology and improve womens health by preventing the devastating disability associated with osteoporosis.

Reproduction de : Thèse d'exercice : Médecine. Médecine générale : Nantes : 2008. / Bibliogr.

Thesis (D. Min.)--Dallas Theological Seminary, 2003. / Abstract. Includes bibliographical references (leaves [189]-193).

No description available.

The research literature has repeatedly emphasized the importance of parent involvement and parent training in the early intervention of young children with autism spectrum disorder (ASD). In fact, parent mediated Early Intensive Behavioral Intervention (EIBI) programs have become a popular method of treatment in recent years. Studies examining these programs have demonstrated that a number of variables may significantly impact the outcomes of EIBI. Moreover, an examination of the psychotherapy literature underscores the importance of a strong parent-therapist alliance as a correlate of positive processes and outcomes in child therapy; while there is very little research examining the working alliance as a factor in parent consultation.The purpose of the present study was to examine the relationship between the working alliance and the consultation process in parent-mediated EIBI for young children with ASD. Forty-four parents of children with an ASD, who were also conducting home-based EIBI programs, completed the Working Alliance Inventory (WAI) (Horvath & Greenberg, 1989) plus other measures that assessed treatment process and outcome. In addition, eight independent consultants completed similar measures to assess perceptions of alliance, process, and outcomes of their consultees.The results showed parent ratings of the working alliance were significantly correlated with parent ratings of treatment acceptability for child treatment as well as for parent consultation. Parent ratings of alliance also correlated significantly with parent ratings of parent progress in consultation and child progress in treatment. Consultant ratings of alliance were significantly correlated with both parent progress and parent improvement in consultation. This suggests that the working alliance may be a contributing factor to the process and outcome of consultation with parents of children with ASD.The results of the present study were compared to the current literature on the therapeutic alliance and relationship factors in consultation. The limitations of the present study and suggestions for future research are also discussed.

This dissertation aims to use a system thinking approach to describe and evaluate the Lead-Acid Battery Recycling Program in British Columbia, compare it with other provincial regulated recycling programs and identify strategies on how it can be improved. The research is presented in the manuscript based format, comprised of four interrelated chapters. Following the introduction, chapter 2 describes a multiple regression analysis to assess how various factors identified by informed stakeholders have contributed to recycling rate in 14 transportation zones from 1995 to 2005. This study demonstrates that the existing recycling scheme ineffectively promotes recycling as it has achieved an average of 75% over the past 13 years with large fluctuations among transportation zones. The regression also shows that recycling rate of transportation zones are not highly influenced by LME lead prices and Transportation Incentive (which can be explained by the strong market power of the recycling plants responsible for setting up the price of scrap lead to which the collectors respond). Chapter 3 identifies key components that influence the performance of varied recycling systems based on a comparative analysis of provincial recycling systems informed by expert interviews. In chapter 4, comprehensive evaluation criteria for the lead-acid battery recycling program is developed based on objectives and performance measures elicited through an extensive stakeholder consultation process with various individuals and organizations. Fundamental objectives identified by stakeholders include: reduce environmental impacts, reduce occupational health impacts, reduce net costs, increase equity in resource consumption patterns and increase systematic learning. In chapter 5, we use multiple criteria decision analysis (MCDA) to design and assess effective recycling strategies to meet societal objectives previously identified in the chapter 4. Recycling strategies were compiled using the results of chapter 3. The results reveals that the optimal policy for the lead-acid battery recycling system combines a return to retailer program financed through an advanced disposal fee included in the battery price in combination with increased plant or recycling capacity domestically. This research also provides relevant contributions to the refining and application of value-focused thinking and decision analysis methodologies.

Daugelis svarbių įvykių, turinčių įtakos tolesniam gyvenimui, nutinka jaunystėje ir per gana trumpą laiką. Vienas iš tokių svarbių įvykių yra jauno žmogaus pirmasis įsidarbinimas. Lietuvos padėtį Europos Sąjungos šalių bendrijoje lemia ne tik gera infrastruktūra, investicijos, laisvas asmenų judėjimas, kitos socialinės bei ekonominės sąlygos, bet ir darbo jėgos kvalifikacija. Didžiausia Lietuvos vertybe tampa Lietuvos žmonių profesinis ir kultūrinis pasirengimas veikti didžiulėje naujoje vientisos rinkos erdvėje. Demografiniai pokyčiai, Europos ekonomikos globalizacijos poveikis ir besikeičianti visuomenė reikalauja iš naujo pažvelgti į jaunimo problemas. Jaunimo karta vaidins didžiulį vaidmenį Europos plėtrai. Tačiau nemaža dalis jaunų žmonių lieka „neįtraukti į darbo rinką“, o tai didžiulis potencialo švaistymas ir rizika socialinei sanglaudai. Pastarųjų metų tendencijos rodo, jog nekvalifikuotų jaunų bedarbių dalis ne mažėja, o, palyginus 2006 m. ir 2007 m., jaučiamas jų skaičiaus augimas. 2008 m. situacija panaši: 60 proc. jaunų bedarbių neturi profesijos, nekvalifikuoti (Jankauskienė, 2008). Nemažai jaunų bedarbių neturi vidurinio ar net pagrindinio išsilavinimo, neturi motyvų dirbti ir mokytis, nepasirengę konkuruoti darbo rinkoje. Dažniausiai tai jaunuoliai iš socialinės rizikos šeimų, kurių nepalaiko aplinka, kurie sulaukę pilnametystės paliko globos namus, kurie nesimoko, nedirba ir dažnai neturi pagrindinio išsilavinimo. Darbo biržai tenka spręsti nelengvą... [toliau žr. visą tekstą] / The Lithuanian status in the EU depends not only on infrastructure, investment, free movement of persons, and other social and economic factors, but also on the qualification of the labour force. The professional and cultural readiness of Lithuanian people for acting in the enormous EU market space is becoming one of the main Lithuanian assets. Demographic changes, the impact of European economy globalization and the changing society require a new approach to youth problems. Thus, referring to this situation, the thesis problem has emerged: the Lithuanian Labour Exchange does not provide enough services of youth career planning that could contribute to a successful development of youth professional career. Thesis subject: the adequacy of Labour Exchange youth career planning services to meet youth needs. Thesis question: in what ways do Labour Exchange career planning services meet youth needs? Thesis aim: reveal how Labour Exchange career planning services meet youth needs. Thesis objectives: 1. Reveal the conception and role of employement and unemployment in the contemporary world. 2. Describe the problems of youth integration into the labour market. 3. Describe Labour Exchange youth career planning services. 4. Using empirical data, evaluate the adequacy of Labour Exchange career planning services to meet youth needs (both from career counsellors' and youth points of view). One of the main conclusions of this thesis is that school education serves as the crucial... [to full text]

Socio-cultural activity theory (SCAT) was used to examine the nature of collaborative working in a case study of school-based occupational therapy (SBOT) in Ontario. Collaborative consultation has been widely adopted in SBOT practice. However, we know little about the impact of collaboration for students and lack understanding about how the organization of SBOT service contributes to collaborative working among educators and occupational therapists. Grounded in theoretical understanding about the distributed nature of group learning, SCAT was used as a conceptual and analytical tool in this study to describe SBOT collaborative consultation from multiple stakeholder perspectives. The research took place in two phases. Phase One involved case study research to describe SBOT for three students with disabilities from multiple stakeholder perspectives. Data were gathered using a combination of observation, document analysis, and interviews involving participants directly involved in the delivery of SBOT with each focal participant. SCAT provided a framework for describing the nature of joint effort. Dilemmas emerging from incongruence between elements in the activity system were identified and described. Common characteristics in two cases enabled cross-case analysis to also identify features of collaborative working that facilitated educational programming and outcomes for students with developmental disability. In Phase Two, program administrators participated alongside service recipients and service providers in a series of focused discussion workshops to reflect on case study findings and prioritize areas for program improvement. Developmental Work Research (Engeström, 2000) and Appreciative Inquiry (Cooperrider, Whitney, & Stavros, 2003) methods were used within a participatory action research approach to facilitate organizational learning among stakeholders. Engagement of stakeholders supported program administrators in critically examining decision-making for the delivery of SBOT service in the region studied. Combining practice-driven dilemmas with conceptual tools of analysis enabled a multiple-perspective understanding about the social, cultural, and historical work practices that have influenced collaborative interactions in SBOT practice and led to the development of principles for improving how work is shared. Program administrators used their shared understanding to propose a new model for delivering SBOT services. / Thesis (Ph.D, Education) -- Queen's University, 2011-09-28 21:31:58.308