Low back syndrome affects 20% of people, and it is estimated that 30% of patients are unable to return to work after surgery. The monitoring of health care outcomes could improve the delivery of health services. The health performance conceptual framework, derived from the Donabedian model, was used to evaluate the functional outcome, clinical recovery, response to surgery, and physician performance of the surgical management of lumbar spine degeneration. A quantitative study (n=685) was undertaken using an administrative database in a repeated-measures design. The clinical and functional outcome improvements were analyzed using t tests. Surgical complexity on health outcome was examined with ANOVA. Predictors of patient satisfaction was explored using Pearson's correlation and regression analyses. The results demonstrated highly significant improvements in functional (mean change 30%; ODI=16.79 -± SD 19.92) and clinical recovery (mean change 50%; modified-JOA=6.983 -± SD 2.613) with surgery at 3 months; a >50% positive response to surgery; and a > 90% patient satisfaction, sustained over a 2 year period. Complexity of surgery did not impact health performance. Strong correlations between the health performance metrics were detected up to 6-months from surgery. Poor clinical recovery and persistent functional disability were predictive of patient dissatisfaction. The social change implications for health policy are that a constellation of health performance metrics could predict the potential for functional and clinical recovery based on presurgery disability while avoiding medical expenditures for procedures with no health benefit; aid in health quality monitoring, peer comparisons, revision of practice guidelines, and cost benefit analysis by payers.

This research investigates and develops a new approach to the management of service quality with the emphasis on patient and staff satisfaction in the healthcare sector. The challenge of measuring the quality of service in healthcare requires us to view the problem from multiple perspectives. At the philosophical level, the true nature of quality is still debated; at the psychological level, an accurate conceptual representation is problematic; whilst at the physical level, an accurate measurement of the concept still remains elusive to practitioners and academics. This research focuses on the problem of quality measurement in the healthcare sector. The contributions of this research are fourfold: Firstly, it argues that from the technological point of view the research to date into quality of service in healthcare has not considered methods of real-time measurement and monitoring. This research identifies the key elements that are necessary for developing a real-time quality monitoring system for the healthcare environment.Secondly, a unique index is proposed for the monitoring and improvement of healthcare performance using information-theoretic entropy formalism. The index is formulated based on five key performance indicators and was tested as a Healthcare Quality Index (HQI) based on three key quality indicators of dignity, confidence and communication in an Accident and Emergency department. Thirdly, using an M/G/1 queuing model and its underlying Little’s Law, the concept of Effective Satisfaction in healthcare has been proposed. The concept is based on a Staff-Patient Satisfaction Relation Model (S-PSRM) developed using a patient satisfaction model and an empirically tested model developed for measuring staff satisfaction with workload (service time). The argument is presented that a synergy between patient satisfaction and staff satisfaction is the key to sustainable improvement in healthcare quality. The final contribution is the proposal of a Discrete Event Simulation (DES) modelling platform as a descriptive model that captures the random and stochastic nature of healthcare service provision process to prove the applicability of the proposed quality measurement models.

Introdução: A assistência pré-natal adequada é importante para redução da morbimortalidade materna e perinatal, identificando fatores que possam colocar a gestante e o feto frente a maior risco de resultados adversos. A avaliação da adequação da assistência pré-natal se faz por meio de diferentes medidas que envolvem o acompanhamento, acesso e qualidade da assistência. Objetivo: Comparar resultados de diferentes índices de inadequação da assistência pré-natal, como desfechos, em modelos de equações estruturais a partir de um modelo teórico de fatores de risco. Métodos: O estudo empregou dados da Pesquisa Nacional de Saúde (PNS) 2013, que contou com 1.851 mães que fizeram o último parto entre 2011 e 2013, representando 3.818.936 mulheres, a partir de amostragem complexa. Foram utilizados modelos de equações estruturais para a parte de mensuração das variáveis latentes envolvidas no modelo teórico e modelagem de fatores de risco para a inadequação da assistência. Medidas de ajuste foram empregadas para avaliar os modelos. Resultados: Quatro índices foram considerados para estimar a variável de inadequação da assistência pré-natal. A Vulnerabilidade Socioeconômica esteve fortemente associada ao desfecho inadequação do pré-natal e outras covariáveis das dimensões psicossociais e biológicas. Efeitos de hipertensão foram identificados para alguns desfechos. A presença de doenças crônicas influenciou a autoavaliação de saúde, porém esse não apresentou efeito sobre o desfecho. Modelos com e sem peso amostral apresentaram resultados distintos. Conclusão: O aspecto socioeconômico deve ser considerado quando se avalia a inadequação da assistência pré-natal. Os resultados obtidos sugerem que diferentes caminhos causais podem estar associados a diversos aspectos da assistência. / Introduction: The adequate prenatal care is important to reduce maternal and perinatal morbidity and mortality, identifying factors that may put the pregnant woman and the fetus at greater risk of adverse outcomes. The assessment of the adequacy of prenatal care is done through different measures that involve the monitoring, access and quality of care. Objective: Compare results of different indices of inadequacy of prenatal care, as outcomes, in structural equation models from a theoretical model for risk factors. Methods: The study used data from the Brazilian 2013 National Health Survey (PNS), with a sample of 1,851 mothers who had their last births between 2011 and 2013, representing 3,818,936 women, applying the complex sampling weight. Structural equation models were employed for the measurement of the latent variables involved in the theoretical model and for the modeling of risk factors for the inadequacy of the assistance. Fit indices were used to evaluate the models. Results: Four indices were considered to estimate the variable of inadequacy of prenatal care. Socioeconomic Vulnerability was strongly associated with the inadequate outcome of prenatal care and other covariates of the psychosocial and biological dimensions. Effects of hypertension were identified for some outcomes. The presence of chronic diseases influenced the health self-assessment, but had no effect on the outcome. Models with and without sample weight presented different results. Conclusion: The socioeconomic aspects should be considered when assessing the inadequacy of prenatal care. The results suggest that different causal pathways may be associated with different aspects of care.

Introdução: A assistência pré-natal adequada é importante para redução da morbimortalidade materna e perinatal, identificando fatores que possam colocar a gestante e o feto frente a maior risco de resultados adversos. A avaliação da adequação da assistência pré-natal se faz por meio de diferentes medidas que envolvem o acompanhamento, acesso e qualidade da assistência. Objetivo: Comparar resultados de diferentes índices de inadequação da assistência pré-natal, como desfechos, em modelos de equações estruturais a partir de um modelo teórico de fatores de risco. Métodos: O estudo empregou dados da Pesquisa Nacional de Saúde (PNS) 2013, que contou com 1.851 mães que fizeram o último parto entre 2011 e 2013, representando 3.818.936 mulheres, a partir de amostragem complexa. Foram utilizados modelos de equações estruturais para a parte de mensuração das variáveis latentes envolvidas no modelo teórico e modelagem de fatores de risco para a inadequação da assistência. Medidas de ajuste foram empregadas para avaliar os modelos. Resultados: Quatro índices foram considerados para estimar a variável de inadequação da assistência pré-natal. A Vulnerabilidade Socioeconômica esteve fortemente associada ao desfecho inadequação do pré-natal e outras covariáveis das dimensões psicossociais e biológicas. Efeitos de hipertensão foram identificados para alguns desfechos. A presença de doenças crônicas influenciou a autoavaliação de saúde, porém esse não apresentou efeito sobre o desfecho. Modelos com e sem peso amostral apresentaram resultados distintos. Conclusão: O aspecto socioeconômico deve ser considerado quando se avalia a inadequação da assistência pré-natal. Os resultados obtidos sugerem que diferentes caminhos causais podem estar associados a diversos aspectos da assistência. / Introduction: The adequate prenatal care is important to reduce maternal and perinatal morbidity and mortality, identifying factors that may put the pregnant woman and the fetus at greater risk of adverse outcomes. The assessment of the adequacy of prenatal care is done through different measures that involve the monitoring, access and quality of care. Objective: Compare results of different indices of inadequacy of prenatal care, as outcomes, in structural equation models from a theoretical model for risk factors. Methods: The study used data from the Brazilian 2013 National Health Survey (PNS), with a sample of 1,851 mothers who had their last births between 2011 and 2013, representing 3,818,936 women, applying the complex sampling weight. Structural equation models were employed for the measurement of the latent variables involved in the theoretical model and for the modeling of risk factors for the inadequacy of the assistance. Fit indices were used to evaluate the models. Results: Four indices were considered to estimate the variable of inadequacy of prenatal care. Socioeconomic Vulnerability was strongly associated with the inadequate outcome of prenatal care and other covariates of the psychosocial and biological dimensions. Effects of hypertension were identified for some outcomes. The presence of chronic diseases influenced the health self-assessment, but had no effect on the outcome. Models with and without sample weight presented different results. Conclusion: The socioeconomic aspects should be considered when assessing the inadequacy of prenatal care. The results suggest that different causal pathways may be associated with different aspects of care.

Made available in DSpace on 2016-01-26T12:51:42Z (GMT). No. of bitstreams: 1 helenaayakomukai_dissert.pdf: 6852127 bytes, checksum: a5131615278936863e837f975418aa5f (MD5) Previous issue date: 2012-05-08 / Introduction: Knowledge on hospitalized patients nursing care demands and the nursing team s workload permit implementing changes in the care process and in care management. Aims: This study aimed to: 1- Identify the sociodemographic and epidemiological profile of patients with mental disorders; 2- Assess their nursing care needs and, 3- Measure the mean number of care hours delivered and the nursing team s workload. Sample and Method: This descriptive and retrospective research (2006-2010) was conducted at a public neuropsychiatric hospital in the Brazilian Southeast. In this study, 105 mental disorder patients were examined through the application of a patient classification instrument. For statistical treatment, Main Components Analysis, Variance Analysis, Kruskal-Wallis test and Bonferroni s adjustment were used. Results: Hospitalization times of up to 15 years were predominant, with 84 (80%), schizophrenia diagnoses 50 (47.7%) and patients in the discrete care category (73.3%). The nursing/bed index ranged from 0.22 to 0.48, and the nurse/bed index from 0.06 to 0.13; the mean number of care hours from 0.57 to 0.88 (nurses) and from 1.97 to 3.16 (nursing auxiliaries) and the workload from 119.6 to 183 hours. Conclusion: The researchers hope these research results can contribute to the elaboration of mental health policies and equip managers for decision-making and the establishment of action strategies aimed at care planning and quantitative/qualitative staff adjustments. / Resumo:Introdução: O conhecimento da demanda de cuidados em relação à enfermagem de pacientes internados e carga de trabalho da equipe possibilitam implementar mudanças no processo de assistir e no gerenciamento da assistência. Objetivos: Este estudo teve como objetivos: 1- Identificar o perfil sóciodemográfico e epidemiológico de pacientes com transtornos mentais; 2- Avaliar suas necessidades cuidativas em relação à enfermagem e, 3- Mensurar as horas médias de assistência dispensadas e a carga de trabalho da equipe de enfermagem. Casuística e Método: Trata-se de uma pesquisa descritiva, retrospectiva (2006-2010) conduzida em hospital neuro psiquiátrico público localizado na região sudeste do Brasil. Foram investigados 105 pacientes portadores de transtorno mental mediante aplicação de instrumento de classificação de pacientes. O tratamento estatístico foi realizado por meio de Análise de Componentes Principais, Análise de Variância, teste de Kruskal-Wallis e ajuste de Bonferroni. Resultados: Houve predomínio de tempo de internação até 15 anos 84(80%), diagnóstico de esquizofrenia 50(47,7%) e pacientes na categoria de cuidados discreta (73,3%). A relação enfermagem/leito variou de 0,22 a 0,48 e a enfermeiro/leito de 0,06 a 0,13; as horas médias de assistência de 0,57 a 0,88 (enfermeiros) e de 1,97 a 3,16 (auxiliares de enfermagem) e a carga de trabalho de 119,6 a 183 horas. Conclusão: Almeja-se que os resultados dessa investigação possam contribuir na elaboração de políticas de saúde mental e instrumentalizar o gestor na tomada de decisão e estabelecimento de xiii estratégias de ação voltadas ao planejamento da assistência e ajuste quanti/qualitativo de pessoal.

The increased prevalence rate of childhood obesity in Saudi Arabia is a nationwide health issue. The doctoral project was instituted in the pediatric out-patient clinic (POPC) of a tertiary university hospital in Riyadh, Saudi Arabia. Child obesity clinic and clinical practice guideline (CPG) for primary prevention were not available in the pediatric outpatient clinic with a high incidence of newly diagnose obese children. The focus of this doctoral project was to improve the clinical nursing practice of POPC nurses through the adoption of CPG on primary prevention of childhood obesity. The knowledge translation into action framework provided a summary of descriptive series of ideal CPG implementation steps in POPC. The search for published CPGs was taken from DynaMed, National Guideline Clearinghouse, Guideline International Network, Pubmed, and Google Scholar. There were 2 tools applied for analysis and synthesis. First, the appraisal of guidelines for research and evaluation II instrument was used to assess the quality of the guidelines. Second, the BARRIERS' scale was used to assess the extent of nurses' perception of barriers in CPG utilization. The 1st findings from this study revealed that RNAO CPG was the best and high-quality CPG over the Endocrine Society and the Institute for Clinical Systems Improvement CPGs. The 2nd findings showed that most of the nurses perceived BARRIERS to utilization towards on the unclear implications of the CPG in their daily nursing practice. Hence, one of the vital recommendations was to have CPG awareness and education before the implementation. Overall, the doctoral project contributed to positive social change through guidelines, policies, and protocol provision for childhood obesity prevention in similar settings.

Total quality management (TQM) approach is often used to carry out company-wide continuous quality improvement plans in manufacturing and service industries. Similarly, TQM can also play a critical role for quality management in health care. Aiming to improve health care quality, experiences showed that major problems of non-patient care, patient records and vital signs monitoring are encountered. In this study, we aim to introduce TQM for quality improvement for intensive care unit (ICU) operations, including some solutions and the prototype of quality management. And vital signs monitoring at ICU is taken as an example of process. For quality improvement of non-patient care, Health Care Quality Development Life Cycle, including (1) quality requirement analysis, (2) quality specification review, (3) quality design, (4) quality implementation, (5) quality testing, (6) quality maintaining, and (7) quality validation, is discussed. The prototype of the first three phases for quality improvement at ICU is explored. Through quality requirement analysis, non-patient care quality at ICU is defined in areas of administration, facility and environment. For quality improvement of patient records maintaining, firstly, scope of health care information systems is categorized as administrative operational system, decision support system, clinical information system, and medical information system. According to this categorization and experience, some interesting result is found. For instance, the current applications of information systems for teaching hospitals in southern Taiwan surveyed are that most applications are administrative and clinical. And the essential information of patient records used in each information system is not complete or not easily accessed. Model of the patient record maintaining is introduced and the prototype design of patient records is recommended for quality improvement of patient records maintaining at ICU. To improve quality of vital signs monitoring is one essential requirement and specification for ICU quality improvement. Effective outcome measures of vital signs monitoring and early detecting of abnormal vital signs is considered important. For quality improvement of vital signs monitoring at ICU, heart rate graphs are taken as examples in our study through the heart rate graphs monitoring. Health professionals can understand the interactions of human autonomic nervous system. By use of digitizer, the computable heart rate data is acquired from each graph and grouped into mortality and near-to-normal cases. Then spectrum form of heart rate data, describing more about heart function, is used for statistical analysis. Several control chart methods have been experimented to detect small heart rate shifts from target, cumulative sum control chart (Cusum) is adopted in our study. The observable variable is the patient¡¦s heart rate, the purpose is to check the alarms pointed out by Cusum that could be partially be ascribed to changes of heart rate trend over time, and to a shift in the monitoring process mean. From summaries of nonconformities in the Cusum charts, mortality cases obviously have more nonconformities. It is obvious that Cusum control charts of mortality cases provide diagnostic information for vital signs monitoring process. In addition, Cusum charts may also inform ICU professionals that there is a small shift of patient heart rate, a continuously increasing or decreasing heart rate, and the adjustment of sympathetic nerve and parasympathetic nerve. In those cases, some special care is needed.

Diss. (sammanfattning) Linköping : Univ., 2004. / Härtill 5 uppsatser.

Diss. (sammanfattning) Linköping : Linköpings universitet, 2006. / Härtill 5 uppsatser. NB: Rätt ISBN från spikblad.

Made available in DSpace on 2014-12-17T14:47:07Z (GMT). No. of bitstreams: 1 SamillyMDL_DISSERT.pdf: 2432551 bytes, checksum: 39a06155ddac056ef776f3527c721cf7 (MD5) Previous issue date: 2014-08-01 / The therapeutic adherence is still a big problem among people with venous ulcers (VU) because the treatment is long, expensive and demand changes in lifestyle. In this context, this study aims to examine treatment adherence and quality of life (QOL) of people with VU assisted at primary health care. This is an analytical, cross-sectional study with a quantitative approach to treatment and data analysis. The study had the scenario 13 Family Health Units and 02 Units Mixed of Natal. The target population consisted of 44 persons with UV indicated by the teams of the Family Health Strategy between February and April 2014. Three instruments were used: an instrument to characterize the sociodemographic, health and care aspects, the Multidimensional Scale of Adherence Therapy composed of the dimensions: healthy lifestyle, compressive therapy and neurovascular monitoring and the Charing Cross Venous Ulcer Questionnaire (CCVUQ) that evaluates QOL in persons with VU composed by the domains: Total Score, Social Interaction, Domestic Activities, Aesthetics and Emotional State. The study was approved by the Ethics Committee in Research of the Federal University of Rio Grande do Norte, CAAE: 07556312.0.0000.5537. The data concerning the sociodemographic characteristics showed that there was a predominance of females (65.9%), age range as of 60 years (59.1%) and income of up to 1 minimum wage (81.8%). With the characterization of health, it was evident that most people reported chronic diseases (63.6%), sleep more than 6 hours (81.8%), present pain (81.8%), denying alcoholism (86 4%) and smoking (77.3%) and showed a number greater than or equal to 1 (77.3%) recurrences. Concerning the therapeutic adherence was found that in the dimension compressive therapy there poor adherence. No associations between the domains of adherence and sociodemographic and health variables were found. Was observed, however, better adherence among individuals without pain and with higher schooling. When analyzed the averages of the dimensions of therapeutic adherence with the care characteristics there was statistical significance between: adherence to compression therapy and guidance for use of compressive therapy (p = 0.002) and guidance for regular exercise (p = 0.026). Considering the mean of total score of CCVUQ (mean 51.47, SD 18.33) it is observed that the overall QOL of respondents has approximate value of the median of the scale (50). The mean of the domain Social Interaction (mean 44.23, SD 21.38) and Domestic Activities (mean 45.70, SD 23.21) were those who reported better QOL. There were weak correlations but significant between adherence to healthy lifestyle and Domains Total Score (p = 0.012), social interaction (p-value = 0.048), Aesthetics (p-value = 0.025) and Emotional State (0.017) of CCVUQ. From the data analysis it is concluded that among people with UV, there poor adherence to compressive therapy. Furthermore, we found no statistically significant association between treatment adherence and sociodemographic and health characteristics. It is added that there was a correlation between the healthy lifestyle dimension and domains CCVUQ / A ades?o terap?utica ainda ? um grande problema entre pessoas com ?lceras venosas (UV), uma vez que a presen?a dessa les?o demanda um tratamento longo, dispendioso, e altera??es no estilo de vida. Nesse contexto, este estudo tem como objetivo geral analisar a ades?o ao tratamento e a qualidade de vida (QV) das pessoas com UV atendidas na aten??o prim?ria ? sa?de. Trata-se de estudo anal?tico, transversal, com abordagem quantitativa de tratamento e an?lise de dados. O estudo teve como cen?rio 13 Unidades de Sa?de da Fam?lia e duas Unidades Mistas da cidade de Natal. A amostra foi composta por 44 pessoas com UV indicadas pelas equipes da Estrat?gia Sa?de da Fam?lia entre fevereiro e abril de 2014. Utilizaram-se tr?s instrumentos: instrumento de caracteriza??o dos aspectos sociodemogr?ficos, de sa?de e assistenciais; a Escala Multidimensional de Ades?o Terap?utica, composta pelas dimens?es: estilo de vida saud?vel, terapia compressiva e vigil?ncia neurovascular; e o Charing Cross Venous Ulcer Questionnaire (CCVUQ), que avalia QV em pessoas com UV atrav?s de quatro dom?nios: Intera??o Social, Atividades Dom?sticas, Est?tica e Estado Emocional, al?m de gerar um Escore Total. A pesquisa obteve parecer favor?vel do Comit? de ?tica em Pesquisa da Universidade Federal do Rio Grande do Norte, CAAE: 07556312.0.0000.5537. Os dados referentes ? caracteriza??o sociodemogr?fica demonstraram que houve predomin?ncia do sexo feminino (65,9%), da faixa et?ria a partir de 60 anos (59,1%) e renda de at? 1 sal?rio m?nimo (81,8%). A caracteriza??o de sa?de evidenciou que a maioria das pessoas relatou doen?as cr?nicas associadas (63,6%), sono maior que 6 horas (81,8%), presen?a de dor (81,8%) e mais de uma recidiva (77,3%). A maior parte negou etilismo (86,4%) e tabagismo (77,3%). Em rela??o ? ades?o terap?utica verificou-se pior ades?o na dimens?o terapia compressiva. N?o foram encontradas associa??es entre os dom?nios da ades?o e as vari?veis sociodemogr?ficas e de sa?de. Observou-se, no entanto, melhor ades?o entre os indiv?duos sem dor e com maior escolaridade. Ao analisar a rela??o das dimens?es da ades?o terap?utica com as caracter?sticas da assist?ncia observou-se associa??o entre: ades?o ? terapia compressiva e orienta??es para uso de terapia compressiva (p-valor = 0,002) e para exerc?cios regulares (p-valor = 0,026). Considerando a m?dia do escore total do CCVUQ (m?dia 51,47 e DP 18,33) observa-se que a QV geral dos pesquisados tem valor aproximado ao da mediana da escala (50). Os participantes apresentaram melhor qualidade de vida nos dom?nios Intera??o Social e Atividades Dom?sticas. Verificaram-se correla??es significativas, por?m fracas, entre ades?o ao estilo de vida saud?vel e o Escore Total (p = 0,012), Intera??o Social (p = 0,048), Est?tica (p = 0,025) e Estado Emocional (p = 0,017) do CCVUQ. A partir da an?lise dos dados conclui-se que a maior dificuldade de ades?o entre as pessoas com UV refere-se ? terapia compressiva. Observou-se correla??o apenas entre a dimens?o estilo de vida saud?vel e os dom?nios do CCVUQ