To study the decision-making model behind how physicians making prescribing decisions, we studied the effects of the introduction of Medicare Part D in 2006 on numbers and characteristics of medications prescribed by physicians. We identified a significant increase in overall number of medications prescribed due to Medicare Part D but did not find any effects on the number of antibiotics. The result suggests there exist factors distinguishing antibiotics from other medications that led to a change in incentives to prescribe antibiotics, such as costs of antibiotics resistances. . We also identified the heterogeneity responses to Medicare Part D with respect to physician’s employment status, primary care relationship and patient’s gender and diagnostic categories.

Globally, higher healthcare demand strains existing systems, already overburdened by a lack of resources and funding while longer life expectancy and increased disease burden force higher patient loads. A majority of the South African population is medically uninsured and therefore depend on emergency care; consequently, the healthcare service demand easily exceeds available acute care to prevent life threat. When this happens, emergency centres suffer from overcrowding and long patient waiting times, which increases morbidity and mortality, associated patient risk. Moreover, critical resources such as staff and hospital beds are required for an even flow of patients through hospitals, but are distributed inefficiently. The South African healthcare system configuration therefore delays access to and compromises the delivery of equitable, unbiased life-saving healthcare in an environment moreover challenged by economic pressures. This calls for sustainable, cost-effective reform. Therefore, more efficient healthcare can save more lives by improving access to life-saving care. Research on current Healthcare Information Systems (HIS) shows an incoherent knowledge body with conceptual gaps in theories on healthcare, which disengages transformation potential. Comprehensive reform tactics thus require a priori concept discovery and diagnostics to make research practically useful. The systematic use of BPM theories allowed for the qualitative assessment of as-is process activity at patient touch-points at three hospitals – two public and one private – in the Western Cape of South Africa. Because a strategic Information Systems (IS) methodology, Business Process Management (BPM) poses business process activity improvement, this research draws from successful BPM activity as a means to improve patient flow processes in Emergency Centres (ECs). Success is evaluated by drawing from empirically supported enabler categories and prescriptive guidelines because BPM practice is not yet fully understood. The results show a clear correlation between the improvement areas at the three hospitals; improvements on aspects of actions and decisions taken during patient-flow process activity, therefore support a pragmatic approach to reform. The data confirms disparity between public and private healthcare. Healthcare appears to be a “doctor driven” service, which, based on qualitative decision-making, navigates patients along defined flows, enabled by supporting human capital and hospital assets. Optimal patient flow is a product of symbiotic working relationships and depends on efficient integration with wider hospital functions. Shorter waiting times and hospital stays reduce process burden. This leads to more efficient resource usage and regulated access to healthcare. However, integrated healthcare reform must consider the time demands and rigidity of clinical processes. The challenge lies in finding the space to invite parallel business agility to drive the reform of the stricken healthcare industry in South Africa.

Master of Arts / Department of Communication Studies / William Schenck-Hamlin / Many critics and scholars (e.g. Lippman, 1927, Putnam, 2000, Entman, 1989, McChesney, 2004, Funigiello, 2005), have argued that news media coverage of major political affairs and policy often fails to provided citizens with the information they need to engage in these issues in a thoughtful manner. The style of news utilized by networks as well as choices in framing have been found to have a significant impact on what is covered and how audiences perceive coverage (Bennett, 2005, Patterson, 2000, Prior, 2003, Zaller, 2003, Cappella & Jamieson, 1997, Ibrahim, 2010, ‘T Riet et al., 2009, Bizer & Petty, 2005, Ben-Porath & Shaker, 2010, Domke & Shah, 1995, and Esposito, 1996). According to the PEW Foundation (2010) a large portion of the 2009-2010 healthcare coverage focused on politics and not how the healthcare system functions (policy). This paper explores the coverage of the 2009-2010 heath care issue by the Network Nightly News through the use of a content analysis. For the purpose of this study, the proposed method of Budge et al. (2001) political party platform categories were used to code the content of the broadcast. These 46 codes contained issues that dealt with the policy of health care and the politics surrounding healthcare, as well as positive vs. negative framing. 30 broadcasts were randomly chosen, one day for each month, from the three nightly news networks during the ten months of highest coverage. Each broadcast was divided into “quasi-sentences”, where each sentence was broken down into individual actions. Results illustrate the frequency between policy and political content, and positive and negative content surrounding the 2009-2010 health care issue. KEYWORDS: Framing, Policy, Politics, Health Care Reform, Network Nightly News, Content Analysis, Quasi-Sentence

This medical anthropology dissertation is an intersectional study of the illness experiences of African-American women living with the chronic autoimmune syndrome systemic lupus erythematosus (SLE), commonly known as lupus. Research was conducted in Memphis, Tennessee from 2013 to 2015, with the aim of examining the healthcare resources available to working poor and working class women using public sector healthcare programs to meet their primary care needs. This project focuses on resources available through Tennessee’s privatized public sector healthcare system, TennCare, during the first phases of the Patient Protection and Affordable Care Act (ACA). A critical medical anthropological analysis is used to examine chronically ill women’s survival strategies regarding their daily health and well-being. The objectives of this research were to: 1) understand what factors contribute to poor women’s ability to access healthcare resources, 2) explore how shared illness experiences act as a form of community building, and 3) document how communities of color use illness narratives as a way to address institutionalized racism in the United States. The research areas included: the limits of biomedical objectivity; diagnostic timeline in relation to self-reported medical history; effects of the relationship between socio-economic circumstance and access to consistent healthcare resources, including primary and acute care, as well as access to pharmaceutical interventions; and the role of non-medical support networks, including personal support networks, illness specific support groups, and faith based organizations. Qualitative methods were used to collect data. Methods included: participant observation in support groups, personal homes, and faith based organizations, semi-structured group interviews, and open-ended individual interviews. Fifty-one women living with clinically diagnosed lupus or undiagnosed lupus-like symptoms participated in individual interviews. Additionally twenty-one healthcare workers, including social workers, Medicaid caseworkers, and clinic support staff were interviewed in order to contextualize current state and local health programs and proposed changes to federal and state healthcare policy.

. Abstract Health reform is forcing healthcare administrators to make rapid changes. A tendency to resist change can present problems for these organizations, including the large, not-for-profit Catholic healthcare systems. In order to make positive contributions towards healthcare, it's important to recognize the nature of the organization's involvement to change. The transformational leadership style has been shown to be positively correlated with change however, the relationship among leadership styles, employees' behaviors, and motivation to change are still not well understood and require further study. Further, although Oreg's Resistance to Change (RTC) approach has been researched in direct patient care areas, RTC research in non-patient settings is lacking and necessary in delivering the full spectrum of patient care. This study focused on the relationship of transformational leadership to RTC and if the relationships leaders' have with subordinates' influence change. A customized survey that included the Multifactor Leadership Questionnaire, RTC, and Leader Member Exchange (LMX 7) was emailed to 500 random individuals of various ages and races from 3 non-patient areas. Thirty leaders and 133 raters responded. The regression analysis showed a strong correlation between transformational leadership and RTC. Additionally, each of the variables from the LMX 7 section of the survey showed associations indicating the relationship leaders develop with their subordinates and leader transformational scores were positive. This study may contribute to the awareness of RTC and utilizing transformational leadership style to move change in a positive direction for a healthcare setting.

Este estudo problematiza a noção de coletivo na saúde, analisando os jogos e as disputas sobre essa expressão no campo das reformas sanitárias italiana e brasileira, visando compreender a singularidade da saúde coletiva. Tomando como ponto de partida o fato de que a saúde coletiva marca uma diferença no território da saúde, importa compreender a noção de “coletivo”, tomando-a como analisador, com a finalidade de acompanhar como ela se expressa na saúde e quais sentidos atualiza. Para fazer essa discussão, situamos nossa investigação em uma perspectiva genealógica, analisando a composição e a perda de sentidos dos territórios reformistas nos cenários italiano e brasileiro. Discutimos as imagens construídas para expressar o coletivo na saúde – a população, o grupo e a sociedade civil –, com o intuito de propor um modo diferente para pensar essa expressão, de caráter processual e intensivo, passando a entender o coletivo como potência. Não é a fixação dessa noção às formas que lhe são atribuídas que afirma a saúde coletiva, mas a força que caracteriza o coletivo como algo inespecífico, condição para a variação da potência. Acompanhando as experiências reformistas, ficou evidente que a imaginação e a composição de noções comuns são mecanismos disparadores da variação, ativando o desejo e as resistências. Analisar o coletivo na saúde coletiva de forma articulada com os movimentos reformistas italiano e brasileiro evidencia a singularidade dessa expressão no território da saúde. Considerar essa singularidade evita que, paradoxalmente, reproduza-se uma política que afirme os preceitos da medicina social ou da saúde pública no campo da saúde coletiva, abrindo a possibilidade para novas produções de sentido. / This study discusses the notion of the collective in healthcare through the analysis of the games and disputes that take place over this expression in the field of Italian and Brazilian healthcare reforms, with the objective of understanding the uniqueness of collective healthcare. Taking as its starting point the fact that collective healthcare marks a difference in the health area, it is impotant to understand the notion of "collective", taking it as an analyzer, with the objective of monitoring how it is expressed in healthcare and which concepts it updates. To make this discussion, we situate our research in a genealogical perspective, analyzing the composition and the loss of sense in reformist territories in the Italian and Brazilian scenarios. We discuss the images constructed to express the collective in healthcare – the people, the group and the civil society – in order to propose a different way to think this expression, that is procedural and intensive in character, comming to understand the collective as power. It is not the establishment of that notion to the forms assigned to it that asserts the public healthcare, but the strength that characterizes the collective as something unspecific, condition for the change in power. Following the reformist experiments, it became clear that the imagination and the composition of common notions are trigger mechanisms for variation, enabling desire and resistance. By analyzing the collective in collective healthcare in coordination with the Italian and Brazilian reform movements, we stress the uniqueness of this expression in the healthcare area. To consider this uniqueness prevents, paradoxically, the reproduction of a policy that affirms the precepts of social medicine or public healthcare in the field of collective healthcare, opening the possibility for new productions of meaning.

Este estudo problematiza a noção de coletivo na saúde, analisando os jogos e as disputas sobre essa expressão no campo das reformas sanitárias italiana e brasileira, visando compreender a singularidade da saúde coletiva. Tomando como ponto de partida o fato de que a saúde coletiva marca uma diferença no território da saúde, importa compreender a noção de “coletivo”, tomando-a como analisador, com a finalidade de acompanhar como ela se expressa na saúde e quais sentidos atualiza. Para fazer essa discussão, situamos nossa investigação em uma perspectiva genealógica, analisando a composição e a perda de sentidos dos territórios reformistas nos cenários italiano e brasileiro. Discutimos as imagens construídas para expressar o coletivo na saúde – a população, o grupo e a sociedade civil –, com o intuito de propor um modo diferente para pensar essa expressão, de caráter processual e intensivo, passando a entender o coletivo como potência. Não é a fixação dessa noção às formas que lhe são atribuídas que afirma a saúde coletiva, mas a força que caracteriza o coletivo como algo inespecífico, condição para a variação da potência. Acompanhando as experiências reformistas, ficou evidente que a imaginação e a composição de noções comuns são mecanismos disparadores da variação, ativando o desejo e as resistências. Analisar o coletivo na saúde coletiva de forma articulada com os movimentos reformistas italiano e brasileiro evidencia a singularidade dessa expressão no território da saúde. Considerar essa singularidade evita que, paradoxalmente, reproduza-se uma política que afirme os preceitos da medicina social ou da saúde pública no campo da saúde coletiva, abrindo a possibilidade para novas produções de sentido. / This study discusses the notion of the collective in healthcare through the analysis of the games and disputes that take place over this expression in the field of Italian and Brazilian healthcare reforms, with the objective of understanding the uniqueness of collective healthcare. Taking as its starting point the fact that collective healthcare marks a difference in the health area, it is impotant to understand the notion of "collective", taking it as an analyzer, with the objective of monitoring how it is expressed in healthcare and which concepts it updates. To make this discussion, we situate our research in a genealogical perspective, analyzing the composition and the loss of sense in reformist territories in the Italian and Brazilian scenarios. We discuss the images constructed to express the collective in healthcare – the people, the group and the civil society – in order to propose a different way to think this expression, that is procedural and intensive in character, comming to understand the collective as power. It is not the establishment of that notion to the forms assigned to it that asserts the public healthcare, but the strength that characterizes the collective as something unspecific, condition for the change in power. Following the reformist experiments, it became clear that the imagination and the composition of common notions are trigger mechanisms for variation, enabling desire and resistance. By analyzing the collective in collective healthcare in coordination with the Italian and Brazilian reform movements, we stress the uniqueness of this expression in the healthcare area. To consider this uniqueness prevents, paradoxically, the reproduction of a policy that affirms the precepts of social medicine or public healthcare in the field of collective healthcare, opening the possibility for new productions of meaning.

Este estudo problematiza a noção de coletivo na saúde, analisando os jogos e as disputas sobre essa expressão no campo das reformas sanitárias italiana e brasileira, visando compreender a singularidade da saúde coletiva. Tomando como ponto de partida o fato de que a saúde coletiva marca uma diferença no território da saúde, importa compreender a noção de “coletivo”, tomando-a como analisador, com a finalidade de acompanhar como ela se expressa na saúde e quais sentidos atualiza. Para fazer essa discussão, situamos nossa investigação em uma perspectiva genealógica, analisando a composição e a perda de sentidos dos territórios reformistas nos cenários italiano e brasileiro. Discutimos as imagens construídas para expressar o coletivo na saúde – a população, o grupo e a sociedade civil –, com o intuito de propor um modo diferente para pensar essa expressão, de caráter processual e intensivo, passando a entender o coletivo como potência. Não é a fixação dessa noção às formas que lhe são atribuídas que afirma a saúde coletiva, mas a força que caracteriza o coletivo como algo inespecífico, condição para a variação da potência. Acompanhando as experiências reformistas, ficou evidente que a imaginação e a composição de noções comuns são mecanismos disparadores da variação, ativando o desejo e as resistências. Analisar o coletivo na saúde coletiva de forma articulada com os movimentos reformistas italiano e brasileiro evidencia a singularidade dessa expressão no território da saúde. Considerar essa singularidade evita que, paradoxalmente, reproduza-se uma política que afirme os preceitos da medicina social ou da saúde pública no campo da saúde coletiva, abrindo a possibilidade para novas produções de sentido. / This study discusses the notion of the collective in healthcare through the analysis of the games and disputes that take place over this expression in the field of Italian and Brazilian healthcare reforms, with the objective of understanding the uniqueness of collective healthcare. Taking as its starting point the fact that collective healthcare marks a difference in the health area, it is impotant to understand the notion of "collective", taking it as an analyzer, with the objective of monitoring how it is expressed in healthcare and which concepts it updates. To make this discussion, we situate our research in a genealogical perspective, analyzing the composition and the loss of sense in reformist territories in the Italian and Brazilian scenarios. We discuss the images constructed to express the collective in healthcare – the people, the group and the civil society – in order to propose a different way to think this expression, that is procedural and intensive in character, comming to understand the collective as power. It is not the establishment of that notion to the forms assigned to it that asserts the public healthcare, but the strength that characterizes the collective as something unspecific, condition for the change in power. Following the reformist experiments, it became clear that the imagination and the composition of common notions are trigger mechanisms for variation, enabling desire and resistance. By analyzing the collective in collective healthcare in coordination with the Italian and Brazilian reform movements, we stress the uniqueness of this expression in the healthcare area. To consider this uniqueness prevents, paradoxically, the reproduction of a policy that affirms the precepts of social medicine or public healthcare in the field of collective healthcare, opening the possibility for new productions of meaning.

Recent reductions in healthcare funding in the United States has pressured clinical laboratories to provide the same quality of diagnostic testing with fewer resources. Testing cascades have been developed to assist in the diagnosis of various illnesses, which use fewer tests and subsequently reduce costs. However, the cost effectiveness of a celiac disease (CD) testing cascade compared to a panel is currently unknown. Therefore, the purpose of this study was to determine if a CD testing cascade was equivalent to a panel in identifying patients deemed likely for CD, and to compare their cost effectiveness in a sample of symptomatic patients from Northeast Tennessee. A retrospective analysis using a CD testing cascade was performed on 933 outpatient samples referred to our laboratory from 2012 to 2017 with a request for a celiac disease serology panel. The seroprevalence of CD for the panel and the cascade were the same in this population (1.82%, 95% binomial confidence interval: 1.06% to 2.90%). The total cost of the CD cascade was 268% less than the cost of the panel resulting in a savings of $44,705, which translates to a savings of $47.92/patient. Based on these findings, we recommend utilization of the cascade to identify patients with likely CD. In the future, creative use of novel testing strategies can have significant contributions to healthcare reform and afford patients more cost-effective clinical diagnostic testing.

京都大学 / 0048 / 新制・論文博士 / 博士(社会健康医学) / 乙第13005号 / 論社医博第9号 / 新制||社医||9(附属図書館) / 32933 / 京都大学大学院医学研究科社会健康医学系専攻 / (主査)教授 川上 浩司, 教授 玉木 敬二, 教授 小西 靖彦 / 学位規則第4条第2項該当 / Doctor of Public Health / Kyoto University / DFAM