BACKGROUND: The VA is the nation’s largest hepatitis C virus treatment provider with a large cadre of HCV specialty care providers. Nevertheless, when highly effective, but expensive all-oral interferon-free medications (directly-acting antivirals, DAAs) for HCV were released, the unanticipated high demand created a VA pharmacy funding shortfall. As this shortfall became apparent, the Veterans Choice Program’s “Choice First” (Choice) initiative emerged. Through Choice, veterans could seek HCV care from non-VA community providers in lieu of waiting for VA care, which in turn complicated access and adoption of DAAs. This study examined VA patient and providers’ experience of and reactions to new DAAs and the implementation of Choice for HCV care.

 METHODS: A qualitative study informed by grounded theory methodology was conducted involving semi-structured interviews with 38 veteran patients and 10 of their HCV providers at three VA medical centers in New England. Patient and provider interviews focused on their experiences with the new HCV treatment, and the processes of care in the VA and through Choice.

 RESULTS: Five themes emerged: 1) the VA’s implementation was considerably more reactive than planned, 2) adopting highly effective HCV medication and Choice were both symbiotic and reciprocally confounding, 3) patient demand and provider awareness were attributed to direct-to-consumer-advertising, 4) the VA organizational structure was not perceived as conducive to rapid implementation of highly effective, demanded, yet costly medication, and 5) veterans and providers had similar perceptions of treatment candidacy. 

 CONCLUSIONS: The VA initially achieved a rapid pace of treating veterans with the DAAs, but eventually could not keep up with demand, leading to a largely unsuccessful attempt to refer patients to non-VA care for HCV treatment. The VA acted as a complex adaptive system and responded to implementation difficulties by applying new policies, which were often opaque, disrupted provider heuristics and practices, and impaired patient autonomy. Patients and providers embraced the HCV treatment innovation, but their experiences navigating community HCV care through Choice indicated a number of flaws in the execution of that program. Choice could have been implemented more effectively with proper recognition and measurement of system antecedents. / 2026-10-31T00:00:00Z

In this paper, we consider the peer-to-peer transfer of popular files between devices in a wireless mesh network. We address the problem that occurs when multiple nodes try to access the same file simultaneously, resulting in increased contention on the shared wireless channel. To counteract this problem, we propose a cooperative file transfer protocol which splits a file into fixed-sized pieces and allows simultaneous downloads of such pieces from multiple peers. Opposed to previous approaches, the proposed protocol selects the potential download peers such that the corresponding download paths possess minimum interference among each other. In a performance study where we compare our approach with other download schemes proposed in the literature, we show that our cooperative protocol roughly halves the time required for downloading a file.

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Clearly, many of the developments in computerized market systems are regarded as revolutionary in an industry which has undergone diminutive changes in marketing its products and acquiring current market information. Cognizance of the agricultural market situation is pertinent for maximum production efficiency, bargaining strength, and financial success for producers. Collectively, producers in Utah face the dilemma of receiving approximately ten percent less in cash receipts for their commodities than their counterparts in surrounding states. Market information that was attainable by producers was often obsolete, redundant, expensive, and irrelevant to the market situation in Utah. The implementation of a Computerized Market Information Systems (CIS) has the potential to eliminate the duplication of collection, analysis, and dissemination of information among state and federal agencies, freeing resources into other vital areas. Presently, the CIS is a "pilot" system concentrating primarily upon market reports which have an impact on the beef cattle and hay industries within the state. The increased usage has suggested that the system should be expanded to include more commodity reports and analyses to accommodate producers in different areas of production. The potential cost effectiveness of the system is demonstrated in several ways. First, a savings to producers who utilize the CIS in lieu of traditional sources of information. Second, a savings in duplication of labor and other resources within state and federal agencies through a cooperative effort. Third, the quality and timeliness of information has been improved.

The purpose of this study was to identify and determine attributes of vehicles which will bridge the communication gap between researchers and policymakers at the California State Legislature. The key policy actors, defined as those individuals who have the most effect on creation and content of educational policy in the area of education at the California State Legislature, were seen as operating in an atmosphere ideological in nature due to the absence of research data within the policy debate structure, and the effects of political pragmatics. The entire population of the Legislature, including the education committees consultants, were surveyed in order to obtain quantitative data. Qualitative data was generated by the use of selected interviews by the researcher as well as an open-ended survey question. A synthesis of the two methods of data collected generated the findings and recommendations. The findings of the study were that educational research should be presented in a very concise format with clearly marked headings and focused arguments as the rationale underlying the format. The information should be disseminated early and often to both houses' offices of research and educational committee consultants. Delivery of information just prior to votes on the legislation would be most effective. Financial reform in the area of school funding as well as restructuring were seen as the two most important issues research should be focused on currently. Recommendations for future study would be collection of data from the Assembly and Senate offices of research in order to determine the format and delivery of educational research most useful to these entities. Based upon the results, the research community should be surveyed to ascertain the best means for researchers and other educational professionals to link up with end users of research at the policy level. The same effort to determine most useful format and delivery should be conducted for the press since we saw in the results of currently used information that newspapers were ranked quite highly by the Legislature.

京都大学 / 0048 / 新制・課程博士 / 博士(医学) / 甲第17813号 / 医博第3811号 / 新制||医||999(附属図書館) / 30628 / 京都大学大学院医学研究科医学専攻 / (主査)教授 髙折 晃史, 教授 武藤 学, 教授 杉田 昌彦 / 学位規則第4条第1項該当 / Doctor of Medical Science / Kyoto University / DGAM

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