acase@tulane.edu

As healthcare and health systems become increasingly complex, expectations of what constitutes high quality care continue to evolve. Stakeholders now require contemporary and meaningful measures of system performance. As such, valid healthcare quality metrics are rapidly becoming essential for those providing and receiving healthcare to assess performance and motivate change. This thesis investigates the utility of quality indicators in trauma care. Multiple in-hospital indicators have been promulgated by various bodies for assessing quality of trauma care. The properties of ideal indicators have been widely documented however few published data have reported these properties for many trauma measures. The emphasis on trauma process measures (eg. time to interventions) highlights the need for indicators with known links to patient outcomes. This process-outcome link may be viewed as a measure of an indicator’s construct validity. As this property is unknown for many trauma indicators, this thesis focuses on the construct validity of a number of routinely utilised trauma indicators. In this thesis, the available in-hospital indicators proposed by The American College of Surgeons Committee on Trauma and additional indicators used in the Victorian State Trauma System were investigated for their relationships with patient outcomes. A small number of indicators were found to have statistically significant relationships with patient outcomes, however many indicators demonstrated counter-intuitive relationships, whereby high quality care was linked with poorer patient outcomes. These results suggested that links between indicators and outcomes may not be best measured using individual indicators for individual patients. Rather, a strategy for measuring patient outcomes at the hospital level may be needed. To combine multiple indicators into a single measure of hospital level performance, a number of composite methods were explored using two trauma registries. Three composite weighting schemes were employed. As composite measures are often used for provider ranking or benchmarking, the stability of hospital ranks between providers and over time was investigated. The composites were found to have moderate to strong correlations (0.76-0.99) however variability in composite hospital rankings existed, particularly for middle ranking facilities. The construct validity of each available indicator and composite score was investigated through the relationship with hospital level risk-adjusted mortality using Poisson regression models, risk adjusting for expected deaths using the TRISS formulation. Each composite measure demonstrated a significant association with mortality, with the mortality decrease across the middle 50% of each composite score ranging from 12.06% – 16.13%. These findings suggest that complex measures such as trauma composite indices may be better able to measure the interactions between processes within complex systems that influence quality of care. This thesis adds valuable insight into the use of indicators for assessing quality of care in trauma systems. The combination of individual indicators into composite forms appears to strengthen the construct validity of these measures. By demonstrating the process-outcome link for trauma composite indices, this thesis has identified a means of utilising process measures to assess hospital level performance that may become important for future public reporting and hospital funding schemes.

Background: Health systems internationally face a common set of challenges: ageing populations, increasing numbers of patients suffering from multiple long-term conditions (multimorbidity) and severe pressure on health and care budgets. ‘Integrated care’ is pitched as the solution to current health system challenges. But, in the literature, what integrated care actually involves is complex and contested. Aims: 1. What does ‘integrated care’ currently look like in practice in the NHS? 2. What is the effectiveness of current models of ‘integrated care’? 3. To what extent are there differential effects of ‘integrated care’ for different types of multimorbidity? Methods: The thesis utilises routinely collected data, systematic review and meta-analysis, combined with quasi-experimental methods (difference-in-differences, and subgroup analysis, difference-in-difference-in-differences). Results: The current implementation of the concept of integrated care is predominantly carried out through multidisciplinary team (MDT) case management of ‘at risk’ (usually of secondary-care admissions) patients in primary care. This approach, however, has not proven capable of meeting health outcome and utilisation/cost aims. Patient satisfaction, though, is consistently improved by the approach. There might also be positive spill-over effects of increased team-working through MDTs for the wider practice population. There does not appear to be a multimorbidity subgroup which benefits significantly more than others in terms of secondary-care utilisation or cost. However, patients at the end of life and/or those with only primary-care sensitive conditions might benefit slightly more than others. Conclusions: Integrated care, in its current manifestation, is not a silver bullet that will enable health systems to simultaneously accomplish better health outcomes for those with long-term conditions and multimorbidity while increasing their satisfaction with services and reducing costs. The current financial climate might mean that other means of achieving prioritised aims are required in the short-term, with comprehensive primary care and population health strategies employed to better prevent/compress the negative effects of lifestyle-associated conditions in the longer-term.

Orientador: Gastão Wagner de Sousa Campos / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-22T14:11:19Z (GMT). No. of bitstreams: 1 Monte-Cardoso_Felipe_M.pdf: 1128961 bytes, checksum: 79bf3c446afd7b22c866befd436b70ff (MD5) Previous issue date: 2013 / Resumo: Dentre os impasses vividos pelo Sistema Único de Saúde (SUS), discutem-se atualmente questões relativas à privatização da gestão e da assistência, ao subfinanciamento, à separação entre ações de saúde curativa e de saúde preventiva e às profundas assimetrias sociais no acesso aos bens de saúde. Este estudo busca colocá-las em perspectiva histórica, ao analisar a formação do modo de produção de saúde durante a ditadura civil-militar de 1964 a 1985. Para tanto, se buscará compreender o problema da saúde nos marcos da questão social dentro do processo de formação histórica da sociedade brasileira a partir de revisão bibliográfica. O debate sobre a formação compreende o Brasil como uma sociedade capitalista dependente, caracterizada por uma dupla articulação que combina subordinação externa e segregação social, e advoga a necessidade histórica da superação deste padrão. Durante a ditadura, a lógica dos negócios como estruturante da política de saúde e a modernização dos padrões de consumo no setor foram aspectos estimulados pelo regime, reproduzindo o caráter segregador da saúde no Brasil. Com relação ao primeiro aspecto, a unificação do aparelho previdenciário favoreceu o aprofundamento do modelo de privatização, através do estímulo ao setor privado contratado, bem como aos convênios firmados com empresas, e incentivo estatal para construir e equipar hospitais privados para servir ao sistema previdenciário. O caráter dispendioso do modelo, o uso do fundo previdenciário para outros fins (grandes projetos de infraestrutura) e o acúmulo de casos de corrupção contribuiu para agravar a crise financeira da Previdência Social de fins da década de 1970. Os serviços de saúde previdenciários passaram por um processo de integração aos demais serviços do sistema público como forma de superar a crise, sem, no entanto, transformar o caráter segmentado, lucrativo, privatista e heterogêneo do sistema de saúde. Com relação ao segundo aspecto, a chegada das empresas transnacionais farmacêuticas e de equipamentos e insumos ao Brasil, potencializada pelo regime ditatorial, transformaram as práticas de saúde, aprofundando em escala inédita o trabalho centrado no médico e em procedimentos com alto grau de incorporação tecnológica e dissociados da realidade sanitária brasileira. Estas transformações, afinadas com a expansão do modelo previdenciário privatista, baseadas no mimetismo cultural dos países centrais, terminaram por agravar a dependência brasileira dos produtos das transnacionais, bem como as distorções geradas por este modelo. A crise dos anos 70 e 80 explicitou estas contradições e acelerou a maturação dos movimentos de contestação ao regime e ao modelo de saúde brasileiro, que se aglutinaram em torno da necessidade de uma Reforma Sanitária. Estes movimentos questionaram as bases das práticas sanitárias vigentes e propôs uma estratégia de mudança do setor centrada em reformas do aparelho de Estado apoiadas pela pressão popular. No entanto, a transição pelo alto que caracterizou o fim da ditadura representou a manutenção do monopólio de poder político nas mãos da burguesia dependente, sob a tutela dos organismos financeiros internacionais e em vigência de mais um ciclo de privatização da assistência à saúde, comprometendo o caráter profundamente transformador e democrático das proposições reformistas / Abstract: Among the dilemmas experienced by the Brazilian Unified Health System (SUS), current issues are related to the privatization of management and assistance, the underfunding, the separation between health actions curative and preventive health and the profound social inequalities in access to health goods. This study tries to put them in historical perspective, to analyze the formation of the health production mode during the civil-military dictatorship (1964 to 1985). To do so, it will be tried to understand the health problem in the framework of social issues within the historical process of the Brazilian society formation from a literature review. The debate over the formation comprises Brazil as a dependent capitalist society, characterized by a double articulation that combines external subordination and social segregation, and advocates the necessity of overcoming this historical pattern. During the dictatorship, the business logic structuring of health policy and modernization of consumption patterns in the sector aspects were encouraged by the regime, reproducing the segregated character of healthcare in Brazil. Regarding the first aspect, the unification of the social security favored deepening of the privatization model, by encouraging the private sector contractor, as well as agreements with companies and state incentives to build and equip hospitals to serve the social security health system. The expensive nature of the model, the use of social security fund for other purposes (such as large infrastructure projects) and the accumulation of corruption gates contributed to aggravating the late 1970s' financial crisis of Social Security. Health services went through a process of integration with other services in the public system as a way to overcome the crisis, without, however, transforming the segregated, profitable, privatized and heterogeneous character of the health system. Regarding the second aspect, the arrival of transnational corporations (pharmaceutical and medical equipment and supplies) to Brazil, boosted by the dictatorial regime, transformed health practices, deepening in an unprecedented scale work focused on medical procedures and with a high degree of technological incorporation disassociated from reality of Brazilian health needs. These transformations, in tune with the expansion of privatizing social security model, based on cultural mimicry of central countries, ended up aggravating the dependency of Brazilian products of transnational as well as the distortions generated by this model. The crisis of the 70's and 80 made these contradictions explicit and accelerated maturation of movements against the regime and Brazilian health model, which coalesced around the need for health reform. This movement questioned the basis of the existing sanitary practices and proposed a strategy for change in the sector based on reforms of the state apparatus supported by popular pressure. However, the "transition from above" that characterized the end of the dictatorship represented maintaining the monopoly of political power in the hands of the dependent bourgeoisie, under the tutelage of international financial organizations and in the presence of another cycle of health care privatization, compromising the profoundly transformative and democratic character of the reformists' propositions / Mestrado / Política, Planejamento e Gestão em Saúde / Mestre em Saude Coletiva

Introduction The Northwest Territories as a rural and remote region of Canada has higher colorectal cancer rates and lower uptake of colorectal cancer screening compared to the rest of the country. Understanding the complex health system processes involved in screening is necessary to develop informed solutions to improve screening access amongst marginalized populations. A systems approach to describe and understand the health care processes and system-level factors influencing colorectal cancer screening access was undertaken. Methods Semi-structured interviews with health care providers (N=29) involved in colorectal cancer screening in all health authorities within the Northwest Territories (N=8) were performed from September to December 2015. Interview transcripts were analyzed using qualitative content analysis methods within a Collaborative Information Behaviour (CIB) and Continuity of Care framework. Exploratory models of colorectal cancer screening processes were developed and translated into quantitative parameters for simulation modelling. Results Colorectal cancer screening access was defined by patient health care interactions supported by foundational information processes. Eighteen models of colorectal cancer screening access within the territory were identified, with varying complexity in care access seen across communities. Screening access problems included screening initiation, colonoscopy scheduling, screening recall and information silos, and were influenced by multiple contextual factors including a transient health work force, social health determinants, and patient travel. Qualitative models were translated into a system dynamics (SD) design framework for development of further quantitative modeling. Conclusions Colorectal cancer screening access in the Northwest Territories is a complex process comprising patient interactions and information processes linking primary care and hospital care processes, which are influenced by challenging contextual factors in the rural and remote health care environment. In developing screening access solutions the foundational role of information support and the need for system trade-offs in restructuring health system processes are necessary considerations. Optimizing information processes through the utilization of health informatics tools such as standardized referral forms and EMRs may also support health system transformation to improve screening access across the Northwest Territories. Understanding and evaluating system trade-offs may be best achieved using a combination of qualitative and quantitative modeling through future application of SD modeling research.

archives@tulane.edu / Public health finance is still a relatively young field and, as such, many questions have yet to be asked—and answered. To date, few have examine how specific revenue streams—alone or in combination—shape local health departments’ (LHD) resources and capacity to accomplish their public health missions. Given ongoing policy conversations about financing for public health, it’s important for researchers to rigorously examine the and the potential costs and benefits associated with different revenue sources. Introduction Chapter: The central thesis for the body of work encapsulated by this dissertation is simple: where money comes from matters. This chapter critically examines published evidence and theory linking public health financing mechanisms and their interactions to LHD operations, outputs, and even outcomes. The chapter also introduces situates the specific research questions addressed in this dissertation within a broader conceptual framework. Paper 1: The first paper examines the relationship between revenue diversification and revenue volatility among Washington State LHDs. Using fixed effects linear regression models and revenue data reported during 1998-2014 by all LHDs operating in Washington State, the paper finds little evidence to suggest revenue diversification is significantly associated with revenue volatility. Paper 2: The second paper evaluates whether available revenue sources differentially effected the scope of programs provided by Washington State LHDs between 2000 and 2011. Using two measures of program scope and both linear and non-linear fixed effects panel regression models, the paper finds that only funding received from federal Medicaid was consistently and significantly associated with both measures of program scope. Paper 3: The third paper examines changes in total LHD expenditures in Washington State between 2006 and 2013 following introduction of a new state funding program to support core public health services and infrastructure. Using a pre-post design regression model to evaluate changes in LHD expenditures, the paper finds overall spending among LHDs significantly increased with receipt of the new state funds in the first years of the program. However, those increases were not sustained over the longer term Conclusion Chapter: The final chapter reviews findings from the three papers and discusses their implications for public health policy, practice, finance, and research. / 1 / Abigail Hope Viall

Context: The Western Cape Province's Department of Health, South Africa, implemented a complex intervention aimed at changing organisational culture across health facilities in the province called the C²AIR² club challenge, in phases, starting from August 2013 and was still ongoing in 2016 at the time of the research. A group of front-line staff from each participating health facility called C²AIR² club champions were capacitated to implement the intervention in their respective facilities. This study aimed to explored the process of introduction, diffusion, adoption and implementation of the C²AIR² club challenge in one of the primary health facilities where the challenge was implemented, using a diffusion of innovation lens. Methods: We examined the process of implementing the C²AIR² club and the contextual and other factors that constrained and enabled this process. Working in one primary health care facility selected as a representative case, we explored the experiences of the champions and other staff members of the C²AIR² club. Our methods included 21 in-depth interviews, informal conversations, document review, and non-participant observation. Results: Innovation-fit, leadership, champions, adopters' characteristics, and contextual issues were the main factors that influenced the spread of the C²AIR² club. Contextual issues particularly those related to resource constraints played a central role in determining the successful spread of the complex organisational culture change intervention. Sufficiently trained champions could successfully spread the intervention without onsite external change consultants' facilitation, however this took time and caution should be taken not to evaluate implementation success too early. Involvement of not only top leadership but of all other multi-levels and multi-disciplines facilitated the spread of the intervention. Conclusions: When introducing an innovation like the C²AIR² club challenge the impact of which is not immediate neither tangible, in an organisation where there are tangible problems such as lack of working space, staff shortages and shortages in working equipment, it is important that efforts are made to address these immediate challenges and where they cannot be addressed that this is openly acknowledged by the implementers and management. If this is not considered, organisational members are likely to acknowledge the innovation as a good initiative but one that they would not actively rally around as it does not speak to their problems.

Background: The health systems in many low-middle income countries are faced with an increasing number of patients with non-communicable diseases within a high prevalence of infectious diseases. Integrated chronic disease management programs have been recommended as one of the approaches to improve efficiency, quality of care and clinical outcomes at primary healthcare level. The South African Department of Health has implemented the Integrated Chronic Disease Management (ICDM) Model in Primary Health care (PHC) clinics since 2011. Some of the expected outcomes on implementing the ICDM model have not been achieved, and there is a dearth of studies assessing implementation outcomes of chronic care models, especially in low-middle income countries. This thesis aims to assess the degree of fidelity, moderating factors of fidelity and costs associated with the implementation of the ICDM model in South African PHC clinics. Methods: The study was a cross-sectional study design using mixed methods and following the process evaluation conceptual framework. A total of sixteen PHC clinics in the Dr. Kenneth Kaunda (DKK) health district of the North West Province as well as the West Rand (WR) health district of the Gauteng Province, that were ICDM pilot sites were included in the study. The degree of fidelity in the implementation of the ICDM model was evaluated using a fidelity criterion from the four major components of the ICDM model as follows: facility reorganization, clinical supportive management, assisted self-support and strengthening of the support systems. In addition, the implementation fidelity framework was utilized to guide the assessment of ICDM model fidelity moderating factors. The data on fidelity moderating factors were obtained by interviewing 30 purposively selected healthcare workers. The abbreviated Denison Organizational Culture (DOC) survey was administered to 90 healthcare workers to assess the impact of three cultural traits (involvement, consistency and adaptability) on fidelity. Cost data from the provider's perspective were collected in 2019. The costs of implementing the ICDM model current activities for three (facility reorganization, clinical supportive management and assisted self-management) components and additional costs of implementing with enhanced fidelity were estimated. Costs data was collected from budget reviews, interviews with management teams, and other published data. Descriptive statistics were used to describe participants and clinics. Fidelity scores were summarized using medians and proportions and compared by facilities and health districts. Qualitative data were analysed thematically. Pearson correlation coefficient was utilized to assess the association between fidelity and culture. The annual ICDM model implementation costs per PHC clinic and patient per visit were presented in 2019 US dollars. Results: The 16 PHC clinics had comparable patient caseload, and a median of 2430 (IQR: 1685-2942) patients older than 20 years received healthcare services in these clinics over six months. The overall implementation fidelity of the ICDM model median score was 79% (125/158, IQR: 117-132); WR was 80% (126/158, IQR: 123-132) while DKK was 74% (117/158, IQR: 106-130), p=0.1409. The highest clinic fidelity score was 86% (136/158), while the lowest was 66% (104/158). The fidelity scores for the four components of the ICDM model were very similar. A patient flow analysis indicated long (2-5 hours) waiting times and that acute and chronic care services were combined onto one stream. Interviews with healthcare workers revealed that the moderating factors of implementation fidelity of the ICDM model were the existence of facilitation strategies (training and clinical mentorship); intervention complexity (healthcare worker, time and space integration); and participant responsiveness (observing operational efficiencies, compliance of patients and staff attitudes). Participants also indicated that poor adherence to any one component of the ICDM model affected the implementation of the other components. Contextual factors that affected fidelity included supply chain management, infrastructure and adequate staff, and balanced patient caseloads. The overall mean score for the DOC was 3.63 (SD = 0.58), the involvement cultural trait had the highest (3.71; SD = 0.72) mean score, followed by adaptability (3.62; SD = 0.56), and consistency (3.56; SD = 0.63). Although there were no statistically significant differences in cultural scores between PHC clinics, culture scores for all three traits were significantly higher in WR (involvement 3.39 vs 3.84, p= 0.011; adaptability 3.40 vs 3.73, p= 0.007; consistency 3.34 vs 3.68, p= 0.034). The mean annual cost of implementing the ICDM model was $148 446.00 (SD: $65 125.00) per clinic, and 84% ($124 345.00) was for current costs while additional costs for higher fidelity accounted for were 16% ($24 102.00). The mean cost per patient per visit was $6.00 (SD:$0.77). Conclusion: There was some variability of fidelity scores on the components of the ICDM model by PHC clinics, and there are multiple (context, participant responsiveness, intervention complexity and facilitation strategies) interrelated moderating factors influencing implementation fidelity of the ICDM model. Organizational culture needs to be purposefully influenced to enhance adaptability and consistency cultural traits of clinics to enhance the ICDM model's principles of coordinated, integrated, patient-centred care. Small additional costs are required to implement the ICDM model with higher fidelity. Recommendations: Interventions to enhance the fidelity of chronic care models should be tailored to specific activities that have low degree of adherence to the guidelines. Addressing some of the moderating factors like training and mentoring of staff members, role clarification and supply chain management could contribute to enhanced fidelity. Organizational culture enhancements to ensure that the prevailing culture is aligned with the planned quality advancements is recommended prior to the implementation of new innovative interventions. Further research on the cost-effectiveness of the ICDM model in middle-income countries is recommended.

Objectives. To determine the factors associated with mortality during the first hospitalization of patients admitted to a hemodialysis unit. Materials and methods. Observational and retrospective study of patients admitted to “Dos de Mayo” National Hospital between January 2012 and December 2013. For the survival analysis we used the Kaplan-Meier method. A multivariate logistic regression was performed to evaluate the factors associated with hospital mortality. Results. 216 patients with a mean age of 56.9 ± 15.5 years were studied. 24% of patients (n = 51) died during their hospital stay. The mortality rate was 9.3 deaths/100 person-weeks (95% CI: 7.0 to 12.3). We found a tendency of less risk of death in patients with between 1 and 6 months from chronic kidney disease diagnosis (OR 0.84, 95% CI: 0.32 to 2.26) and in those with more than six months from chronic kidney disease diagnosis compared with those who had less than a month from chronic kidney disease diagnosis (OR 0.55, 95% CI: 0.19 to 1.57). Previous care by a nephrologist was not associated with differences in lower mortality (OR 1.14, 95% CI: 0.39 to 3.31). Conclusions. There is poor prior care among hemodialysis patients that form part of an inadequate health care structure and this is associated with high inhospital mortality. / Objetivos. Determinar los factores asociados a la mortalidad durante la primera hospitalización de una población incidente en hemodiálisis. Materiales y métodos. Estudio observacional y retrospectivo de pacientes que ingresaron al Hospital Nacional Dos de Mayo entre enero de 2012 y diciembre de 2013. Para el análisis de la supervivencia utilizamos el método de Kaplan-Meier. Se realizó un análisis de regresión logístico multivariado para evaluar los factores asociados a mortalidad intrahospitalaria. Resultados. Se estudiaron 216 pacientes con edad promedio de 56,9 ± 15,5 años. El 24% de los paciente (n=51) fallecieron durante la estancia hospitalaria. La tasa de mortalidad fue de 9,3 muertes/100 personas-semanas (IC 95%: 7,0 a 12,3). Se evidenció una tendencia a menor riesgo de fallecer en pacientes que tenían entre uno y seis meses con diagnóstico de enfermedad renal crónica (OR 0,84; IC 95%: 0,32 a 2,26), y en aquellos con más de seis meses comparado con aquellos que lo tenían hace menos de un mes (OR 0,55; IC 95%: 0,19 a 1,57). La atención previa por un nefrólogo no estuvo asociada a diferencias en la mortalidad menor (OR 1,14; IC 95%: 0,39 a 3,31). Conclusiones. Existe una deficiente atención previa entre los pacientes en hemodiálisis que forman parte de una inadecuada estructura de atención de salud y que está asociado a una alta mortalidad intrahospitalaria.

Philosophiae Doctor - PhD / National community health worker (CHW) programmes are to an increasing extent being implemented in health systems globally, mirrored in South Africa in the ward-based outreach team (WBOT) strategy. In many countries, including South Africa, a major challenge impacting the performance and sustainability of scaled-up CHW programmes is ensuring adequate support from and supervision by the local health system. Supervisory systems, where they exist, are usually corrective and hierarchical in nature, and implementation remains poor. In the South African context, the absence of any guidance on CHW supportive supervision has led to varied practices across the country. Improved approaches to supportive supervision are considered critical for CHW programme performance. However, there is relatively little understanding of how this can be done sustainably at scale, and effective CHW supervisory models remain elusive. Research to date has mostly positioned supervision as a technical process rather than a set of relationships, with the former testing specific interventions rather than developing holistic approaches attuned to local contexts.