Quality of care is identified as a major problem in the current health care system. Multidisciplinary teamwork has been proposed to address quality-of-care problems because, theoretically, a health-care team can expand knowledge and follow up patients more efficiently. However, questions about how to successfully implement team-based care in ambulatory settings and its long-term costs are still unanswered. The first objective of this dissertation is to estimate the marginal effects of process measures including number of counseling sessions about lifestyle modification and number of specified-dose antihypertensive medications provided by a physician-pharmacist collaborative intervention and usual care on blood pressure reduction and direct treatment costs by comparing the results from as-treated and instrumental variable methods. The second objective is to estimate the long-term cost changes attributable to the physician-pharmacist collaborative intervention by considering costs related to coronary heart disease, stroke, and heart failure. To accomplish both objectives, data from two prospective, clustered randomized controlled clinical trials implementing a physician-pharmacist collaborative intervention in the Midwest were used. In the first study, multiple linear regression models included blood pressure reduction and costs as outcome variables, and the two process measures and other control variables as explanatory variables. As-treated methods revealed insignificant associations between the two process measures and blood pressure reduction outcomes. On the other hand, both process measures were significantly associated with the costs. By using instrumental variable methods, utilizing two instruments of randomization and the trial indicator, the models were unidentified and showed no significant associations between the process measures and all of the outcomes. However, the post-hoc analysis of the instrumental variable models, evaluating one process measure at a time without controlling for the other process measure, showed significant associations between the process measures and all of the outcomes. The estimates from instrumental variable methods were larger than the estimates from the as-treated methods. The second study used a Markov model cohort simulation in a 10-year timeframe, transition probabilities estimated by several risk estimation systems and published statistics, and published event costs. The reference case employed a sample of patients aged 30 to 74 years from the trials and assumed that blood pressure after the intervention was constant. The total costs of the intervention for hypertension care and the costs related to the vascular diseases in the intervention group were shown to be lower than the usual care group at 6.5 years. However, cost-savings by the intervention were sensitive to patient risk profiles and sustainability of blood pressure after the intervention. To conclude, from the first study, combining multiple studies and using instrumental variable methods may be useful for evaluating marginal effects of the care process but further research is needed to address under-identification problems. The results of the second study suggested that it was likely that the physician-pharmacist collaborative intervention to treat hypertension was appropriate for high-risk patients.

Thesis (MBA.) --University of Limpopo, 2016 / The Ward Based Outreach Teams (WBOT) Programme is established in South Africa as part of a series of strategies to strengthen Primary Health Care (PHC) and to improve service delivery in the country. The purpose of the study was to gain an understanding of the experiences of Community Health Workers (CHW) in the implementation of the WBOT programme. The objectives of the study were to evaluate the experiences of CHWs in the WBOT, to evaluate factors that facilitate the implementation and to make recommendations and strategies on what can be done to improve the WBOT programme. A quantitative research design was used where self-administered questionnaires were provided to respondents for data collection. Respondents were asked to complete the questionnaires; completed questionnaires were returned by only 12 of the 27 respondents, resulting in a 44% response rate. The study’s findings indicate that the Community Health Workers (CHWs) regarded the WBOT as helping the community in many ways such reducing the long queues at the clinic and providing the care of the patients in their own homes, although concerns about poor participation by the community structures and nurses in the health facilities were expressed. CHWs expressed experiences that were positive and negative when conducting their work in the community. The results from the study have shown that there are successes, challenges and lesson learned. The results of the study further indicated that the programme is being implemented well even though it is still in a pilot phase in the sub-district. The programme has managed to improve and save many lives in the communities of Kgetleng Sub-district. Despite the level of depth in this study, there is a crucial need for more for more in-depth research regarding the experiences of users of the WBOT services and to conduct similar studies looking into urban areas and to compare and contrast the rural and urban findings.

The guideline development process can be challenging when diseases are rare. The development of the NHF-McMaster Guideline on Care Models for Hemophilia Management presented an opportunity to identify methodological challenges for guideline development in rare diseases. Several methodological challenges were identified in the evidence gathering and assessment stages. Eight challenges were presented in the development of a systematic review on care models for hemophilia management. The barriers to conducting the systematic review were mostly due to the paucity of high quality evidence in hemophilia care models. Due to the paucity of high-quality evidence typical of a rare condition such as hemophilia, indirect evidence from other chronic conditions were sought through an overview of reviews. Seven challenges were identified in the development of an overview on integrated multidisciplinary care for the management of chronic conditions in adults. The barriers were mainly due to unestablished methodology for conducting overviews, and the challenge of applying this evidence in the context of hemophilia for the guideline. To overcome the methodological challenges with evidence gathering and assessment for rare disease guideline development, the decision-making process to derive solutions were transparently presented. Overall, the methodological challenges as well as apparent facilitators from a rare disease setting are shown to be related to the barriers and facilitators at the research, clinical, and guideline development phase. As a result, using an example from hemophilia, this thesis has demonstrated that it is possible to develop high quality guidelines for rare diseases. / Thesis / Master of Science (MSc)

Mental illness in the United States is a major public health problem. According to the Substance Abuse and Mental Health Services Administration, in 2017, 18.9% of adults in the United States had a mental illness. The purpose of this study was to gain insight into the perceptions held by community health workers (CHWs) regarding their integration into the behavioral health care system in Maryland. Using a social constructivism paradigm and phenomenological approach, a purposive sample of 11 CHWs who supported patients with behavioral health conditions in 17 counties in the state were interviewed. Howlett, McConnell, and Perl'€™s five stream confluence policy process theory and Lipsky's street level bureaucracy theory provided the foundation to explore the perceptions of the CHWs about their integration into the behavioral health care system; the problems, policies, processes, and programs that impacted their ability to be integrated into the behavioral health team; and their function as a street level bureaucrat to facilitate their integration. A deductive iterative coding approach was used, culminating in the identification of the following 6 themes: health system utilization of CHW behavioral health integration, official policy recognition of the CHW profession, accountability for CHW integration, CHW practice support, integrated health care team management of physical and mental health and behavior, and building the CHW profession. The social change implications of this study are that CHWs'€™ integration into the broadly defined, integrated, physical and mental behavioral health team can support having a more cost-effective way toward having healthy people and communities because they link the community to health and social services and advocate for quality care.

La situation d’un patient trop malade pour une transplantation et qui est maintenu à long terme aux soins intensifs (SI) avec l’aide d’un dispositif d'assistance ventriculaire (DAV) peut évoluer de multiples façons. Malheureusement, plusieurs soignants vivent un malaise lorsque ce patient survit avec des complications, sans possibilité de transplantation cardiaque ni de retour à domicile. Par conséquent, différents buts thérapeutiques sont poursuivis au sein de l’équipe soignante. L’étude avait pour objectifs de cerner les buts poursuivis par les professionnels de la santé œuvrant auprès de ce type de patient, de clarifier les facteurs influençant les buts poursuivis et de mieux connaître les difficultés éprouvées par l’équipe soignante dans l’élaboration d’un but commun. La phénoménologie a été utilisée comme méthodologie de définition de la problématique. L’échantillon comprenait 12 participants représentant les infirmières, médecins et perfusionnistes d'une unité de SI, travaillant auprès de ce type de patient. Chacun des participants a fait l’objet d’une entrevue individuelle, semi-dirigée et enregistrée sur appareil audio. Il leur a d’abord été présenté une vignette à partir de laquelle ont été posées un certain nombre de questions identiques pour tous. Dans leurs réponses à ces questions, les participants ont eu la possibilité de s’exprimer autant sur leur expérience que sur le contexte du phénomène. Une seconde rencontre a été nécessaire afin de valider ou de corriger l’interprétation de ce que chacun avait exprimé durant l’entrevue. L'analyse des données témoigne d’un manque d’harmonie quant au but à poursuivre à l’égard du patient en question. Environ la moitié des participants visent la transplantation, alors que les autres poursuivent d’autres buts comme la sortie des SI, la limitation des traitements ou les soins palliatifs. Les participants sont influencés majoritairement par les volontés du patient, l'absence de mécanisme formel de communication entre eux et les facteurs professionnels tels que : les valeurs, les pratiques et l’environnement, sans oublier les rapports de pouvoir. Un certain nombre de barrières empêchent l’équipe de déterminer un but commun. Pour vaincre ces obstacles et s’entendre sur les buts à poursuivre en équipe, le développement de la communication multidisciplinaire s’impose. Pour y arriver, deux prérequis doivent être développés : l’intention éthique et l’engagement. / A non eligible transplant patient on long term ventricular assist device (VAD) support in intensive care unit (ICU), can evolve in multiple ways. Alot of health care professionnals live a malaise when the patient surves with complications without neither possibility of cardiaque transplantation nor return home. In consequence, defferent goals of care are pursued in the health care team. This is why, the researcher maintained all along the study, the objectives to understand the goals pursued by the health care professionnals working towards the particular patient, to clarify the factors influensing these pursued goals and to learn more on the health care team difficulties to elaborate a common goal. Phenomenology has been the method used to define the problem. Twelve participants working in ICU were included in the reasearch sample representing the nurses, physicians and perfusionists working towards the concerned patient. Each of the participants had collaborated to an individual, semi structured and audio recorded interview. First, the researcher presented a vignette with which she asked everyone a certain number of identical questions. The questions permitted the participants to express as much on there experience than on the context of the phenomenon. A second meeting has been necessary to validate or correct the interpretation of what has been expressed by each participant during the interview. The data analyisis testify a lack of continuity concerning the goal to pursue with the patient in question. Almost half of the participants aim for a transplantation when the rest of them pursue other goals like discharge of ICU, treatment limitation or paliative care. By a majority, the participants are influenced by the patient’s will, the absence of formal communication mecanism, profesionnal factors such as : values, practices and environment and power differential. Thus, health care profesionnals that would want to pursue a common team goal are facing a certain number of barriers. The resercher realises that to overcome these barriers, multidisciplinary communication has do be the driving force of team goal- setting. Although, to acheave this, two pre-requisits have to be developed: the ethical intention and the engagement.

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