This thesis explores how decision-making agency roles played by doctors, pharmacists and government affect the social efficiency of choices in the prescription drug market. The primary objective is to contribute to the quality of expenditure decompositions in this sector and, thereby, to draw attention to the real cost of drug consumption in Canada. Expenditure growth in the pharmaceutical sector may occur because Canadians are purchasing more drugs or more in terms of the health outcomes sought through drug consumption. Prices may also be rising for the drugs that patients consume. Furthermore, with new generations of prescription drugs replacing older and often equally effective ones, expenditure inflation may be due, at least in part, to growing inefficiencies in consumption. Deflating nominal expenditures with traditional economic price indexes is a commonly used approach to decomposing expenditure changes into changes in price, changes in productivity or both. This method may be biased because decision-making agency relationships and non-standard financial incentives give rise to possible inefficiencies in the pharmaceutical sector that would not commonly be found in other sectors. This proposition is explored theoretically and empirically. Potential biases stemming from financial incentives are explored in the context of the measurement problem posed by the entry of generic drugs. Traditional techniques of the economic approach to measurement do not capture the full effect of generic competition because decision-making agents do not always have incentive to consider the full price of drugs consumed. Potential information-related problems in pharmaceutical price and productivity measurement are explored within the context of the hypertension market. Health outcomes based indexes are constructed for this treatment category based on recognized national guidelines for the treatment of hypertension. Economic indexes of price and productivity appear to overstate social productivity in this segment because persistent non-compliance with national guidelines has resulted in higher costs without corresponding health improvements. / Arts, Faculty of / Vancouver School of Economics / Graduate

Sustainability is a complex system of interaction between a hospital, individual, community, and environmental factors that is required to work in harmony to keep a patient healthy. With the complexities that exist within healthcare, the nurse leader is required to ensure that the care environment, processes and the safety behaviours required from nurses to provide safe healthcare is in place and sustained to contribute to the enhancement of patient safety, whilst in the care of the diverse nursing workforce. The aim of the study is to develop an action plan to sustain best safety culture practices for improved patient outcomes in hospitals with a culturally diverse nursing workforce. Methodology: A multiple method design was utilised to study the safety culture and positive work environment (hospital climate) that exists among culturally diverse nurses and how it is managed by the nurse managers in order to identify and describe actions that can be included in an action plan to sustain best safety culture practices for improved patient outcomes. Purposeful and convenience sampling methods were used in the study. Two hospitals, with a very diverse nursing workforce were purposefully selected to participate in the study. Pretesting of the questionnaire and e-Delphi embedded assessment validation instrument were done by participants not part of sample groups. Phase 1: The Hospitals outcomes data for nursing admission assessment within 24-hours, falls and hospital acquired pressure ulcer incidences and hand hygiene rates were collected on a checklist. Phase 2: Two questionnaires (1) nurses capturing: biographical data and culture, patient safety (nursing admission assessment within 24-hours, falls and HAPU and hand hygiene), and safety culture and positive work environment (hospital climate); (2) nurse managers capturing: biographical data and culture, patient safety (nursing admission assessment within 24- hours, falls and HAPU and hand hygiene), safety culture and Positive Work Environment (hospital climate) and just culture practices. Phase 3: the Draft e-Delphi action plan with embedded assessment validation instrument was developed. Phase 4: The panel experts selected to validate the e-Delphi draft action plan with embedded assessment validation instrument in pre-determined rounds. Data analysis: Phase 1: The outcomes data was displayed in bar graphs and illustrated that (1) the nursing admission assessment within 24 hour period not been sustained over time for the medical, surgical, paediatric and critical care areas; (2) a hundred and sixty two fall incidence; (3) ninety six HAPU incidences and (4) hand hygiene rate of between 80-94% being reported. Phase 2: A participation rate of 46.33% by nurses and 73.91% by nurse managers were achieved. The data for the 2 questionnaires indicated the need to include 54 action statement to address the culture, patient safety, hospital climate (PWE), safety culture and just culture gaps identified. Phase 3: the e-Delphi draft action plan developed based on literature review and data from phase 1 and phase 2. Phase 4: 100% participation rate was achieved. Consensus was reached within two rounds that the 54 action statements are essential and important for patient safety and identified the responsible persons required enacting on action statement and timeframe required to complete action. Recommendation: The Action Plan to enhance a sustainable Culture of Safety to improve patient outcomes were decided by panel experts. Plan to disseminate the plan among the CNO for implementation. / Health Studies / D. Litt. et Phil. (Health Studies)

The ability to monitor client change in psychotherapy over time is vital to quality assurance in service delivery as well as the continuing improvement of psychotherapy research. Unfortunately, there is not currently a comprehensive, affordable, and easily utilized outcome measure for psychotherapy specifically normed and standardized for use in psychology training clinics. The current study took the first steps in creating such an outcome measure. Following development of an item bank, factor analysis and item-response theory analyses were applied to data gathered from a stratified sample of university (n = 101) and community (n = 261) participants. The factor structure did not support a phase model conceptualization, but did reveal a structure consistent with the theoretical framework of the research domain criteria (RDoC). Suggestions for next steps in the measure development process are provided and implications discussed.

Background: Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in the U.S. Acute myocardial infarction (AMI), with or without ST-segment elevation, is a common presentation of coronary heart disease and affected more than 800,000 American adults in 2010. The overall goal of this dissertation was to examine decade-long trends in the extent of delay in the receipt of a primary percutaneous coronary intervention (PCI) among patients hospitalized with ST-segment elevation myocardial infarction (STEMI), 30-day hospital readmission rates in patients having survived an AMI, and multiple decade long trends in 1-year post-hospital all-cause mortality, as well as factors associated with these outcomes, among patients hospitalized with AMI. Methods: Data from the Worcester Heart Attack Study, a population-based chronic disease surveillance project that has been carried out among adult residents of the Worcester, MA, metropolitan area, hospitalized with AMI on a biennial basis from 1975 through 2009 at all medical centers in central MA, were used for this dissertation. Results: Between 1999 and 2009, among patients hospitalized with STEMI, the likelihood of receiving a primary PCI within 90 minutes after emergency department arrival increased dramatically from 1999/2001 (11.6%) to 2007/2009 (70.5%). Between 1999 and 2009, among hospital survivors of an AMI, the 30-day all-cause rehospitalization rates decreased from 1999/2001 (20.3%) to 2007/2009 (16.7%). The overall cause-specific 30-day rehospitalization rates due to CVD, non-CVD, and AMI were 10.1%, 7.1%, and 1.8%, respectively, during the years under study. Between 1975 and 2009, among hospital survivors for a first AMI, the 1-year post-discharge mortality rates remained relatively stable from 1975-1984 (12.9%) to 1986-1997 (12.5%), but increased during 1999-2009 (15.8%). We identified several demographic, clinical and in-hospital treatment factors associated with an increased risk of failing to receive a primary PCI within 90 minutes after emergency department arrival, 30-day readmissions, and 1-year post-discharge mortality. Conclusions: Our findings can hopefully lead to the enhanced development of innovative, patient-centered, intervention strategies which can further improve the treatment and transitions of care, as well as short and long-term prognosis, of men and women hospitalized with AMI.

Background: Following passage of the Affordable Care Act in 2010, 30-day hospital readmissions have come under greater scrutiny. Excess readmissions for certain medical conditions and procedures now result in penalizations on all Medicare reimbursements. We examined the risk factors, outcomes, and costs of 30-day readmissions after colorectal surgery (CRS). Methods: The University HealthSystem Consortium database was queried for adults (≥ 18 years) who underwent colorectal resection for cancer, diverticular disease, inflammatory bowel disease, or benign tumors between January 2008 and December 2011. Our outcomes of interest were readmission within 30-days of the patient’s index discharge, hospital readmission outcomes, and total direct hospital costs. Results: A total of 70,484 patients survived the index hospitalization after CRS during the years under study, 13.7% (9,632) of which were readmitted within 30 days of discharge. The strongest independent predictors of readmission were: LOS ≥4 days (OR 1.44; 95% CI 1.32-1.57), stoma (OR 1.53; 95% CI 1.45-1.61), and discharge to skilled nursing (OR 1.63; 95% CI 1.49-1.76) or rehabilitation facility (OR 2.93; 95% CI 2.54-3.40). Of those readmitted, half occurred within 7 days of the index admission, 13% required ICU care, 6% had a reoperation, and 2% died during the readmission stay. The median combined total direct hospital cost was over twice as high ($26,917 v. $13,817) for readmitted than for nonreadmitted patients. Conclusions: Readmissions following colorectal resection occur frequently and incur a significant financial burden on the healthcare system. Future studies aimed at targeted interventions for high-risk patients may reduce readmissions and curb escalating healthcare costs. Categorization: Outcomes research; Cost analysis; Colon and Rectal Surgery

Objective: Chronic obstructive pulmonary disease (COPD) is a common comorbidity in patients with heart failure, yet little is known about the impact of this condition in patients with acute decompensated heart failure (ADHF), especially from a more generalizable, community-based perspective. The primary objective of this study was to describe the in-hospital and post discharge mortality and treatment of patients hospitalized with ADHF according to COPD status. Methods: The study population consisted of patients hospitalized with ADHF at all 11 medical centers in central Massachusetts during 4 study years: 1995, 2000, 2002, and 2004. Results: Of the 9,748 patients hospitalized with ADHF during the years under study, 35.9% had a history of COPD. The average age of this population was 76.1 years, 43.9% were men, and 93.3% were white. At the time of hospital discharge, patients with COPD were less likely to have received evidence-based heart failure medications, including beta-blockers and ACE inhibitors/angiotensin receptor blockers, than patients without COPD. Multivariable adjusted in-hospital death rates were similar for patients with and without COPD. However, among patients who survived to hospital discharge, patients with COPD had a significantly higher risk of dying at 1 (adjusted RR 1.10; 95% CI 1.06, 1.14) and 5-years (adjusted RR 1.40; 95% CI 1.28, 1.42) after hospital discharge than patients who were not previously diagnosed with COPD. Conclusions: COPD is a common co-morbidity in patients hospitalized with ADHF and is associated with a worse long-term prognosis. Further research is required to understand the complex interactions of these diseases and to ensure that patients with ADHF and COPD receive optimal treatment modalities.

In recent years, the transplant community has explored and adopted tools for quantifying clinical insight into illness severity and frailty. This dissertation work explores the interplay between objective and subjective assessments of physical health status and the implications for liver transplant candidate and recipient outcomes. The first aim characterizes national epidemiologic trends and the impact of Centers for Medicare and Medicaid quality improvement policies on likelihood of waitlist removal based on the patient being too frail to benefit from liver transplant (“too sick to transplant”). This aim includes more than a decade (2002–2012) of comprehensive national transplant waitlist data (Scientific Registry of Transplant Recipients (SRTR)). The second aim will assess and define objective parameters of liver transplant patient frailty by measuring decline in lean core muscle mass (“sarcopenia”) using abdominal CT scans collected retrospectively at a single U.S. transplant center between 2006 and 2015. The relationship between these objective sarcopenia measures and subjective functional status assessed using the Karnofsky Functional Performance (KPS) scale are described and quantified. The third aim quantifies the extent to which poor functional status (KPS) pre-transplant is associated with worse post-transplant survival and includes national data on liver transplantations conducted between 2005 and 2014 (SRTR). The results of this dissertation will help providers in the assessment of frailty and subsequent risk of adverse outcomes and has implications for strategic clinical management in anticipation of surgery. This research will also to serve to inform national policy on the design of transplant center performance measures.

Background: Overtreatment of localized prostate cancer (PCa) is a concern as many men die of other causes prior to experiencing a treatment benefit. This dissertation characterizes the need for assessing other cause mortality (OCM) risk in older men with PCa and informs efforts to identify patients most likely to benefit from definitive PCa treatment. Methods: Using the linked Surveillance Epidemiology and End Results-Medicare Health Outcomes Survey database, 2,931 men (mean age=75) newly diagnosed with clinical stage T1a-T3a PCa from 1998-2009 were identified. Survival analysis methods were used to compare observed 10-year OCM by primary treatment type. Age and health factors predictive of primary treatment type were assessed with multinomial logistic regression. Predicted mortality estimates from Social Security life tables (recommended for life expectancy evaluation) and two OCM risk estimation tools were compared to observed rates. An improved OCM prediction model was developed fitting Fine and Gray competing risks models for 10-year OCM with age, sociodemographic, comorbidity, activities of daily living, and patient-reported health data as predictors. The tools’ ability to discriminate between patients who died and those who did not was evaluated with Harrell’s c-index (range 0.5-1), which also guided new model selection. Results: Fifty-four percent of older men with localized PCa underwent radiotherapy while 13% underwent prostatectomy. Twenty-three percent of those treated with radiotherapy and 12% of those undergoing prostatectomy experienced OCM within 10 years of treatment and thus were considered overtreated. Health factors indicative of a shorter life expectancy (increased comorbidity, worse physical health, smoking) had little to no association with radiotherapy assignment but were significantly related to reductions in the likelihood of undergoing prostatectomy. Social Security life tables overestimated mortality risk and discriminated poorly between men who died and those who did not over 10 years (c-index=0.59). Existing OCM risk estimation tools were less likely to overestimate OCM rates and had limited but improved discrimination (c-index=0.64). A risk model developed with self-reported age, Charlson comorbidity index score, overall health (excellent-good/fair/poor), smoking, and marital status predictors had improved discrimination (c-index=0.70). Conclusions: Overtreatment of older men with PCa is primarily attributable to radiotherapy and may be reduced by pretreatment assessment of mortality-related health factors. This dissertation provides a prognostic model which utilizes a set of five self-reported characteristics that better identify patients likely to die of OCM within 10 years of diagnosis than age and comorbidity-based assessments alone.

OBJECTIVE: To investigate the cross-cultural validity of international Dutch-English comparisons when using the Dutch Rivermead Mobility Index (RMI), and the intra-test reliability and construct validity of the Dutch RMI. METHODS: Cross-cultural validity was studied in a combined data-set of Dutch and English patients undergoing rehabilitation after stroke, who were assessed with the Dutch version of the RMI and the original English RMI, respectively. Mokken scale analysis was used to investigate unidimensionality, monotone homogeneity model fit, and differential item functioning between the Dutch and the English RMI. Intra-test reliability and construct validity were studied in the Dutch patients by calculating the reliability coefficient and correlating the Dutch RMI and the Dutch Barthel Index. RESULTS: The RMI was completed for Dutch (n = 200) and English (n = 420) patients after stroke. The unidimensionality and monotone homogeneity model fit of the RMI were excellent: combined Dutch-English data-set (coefficient H = 0.91); Dutch data-set (coefficient H = 0.93); English data-set (coefficient H = 0.89). No differential item functioning was found between the Dutch and the English RMI. The intra-test reliability of the Dutch RMI was excellent (coefficient rho = 0.97). In a sub-sample of patients (n = 91), the Dutch RMI correlated strongly with the Dutch Barthel Index (Spearman's correlation coefficient rho = 0.84). CONCLUSION: The Dutch RMI allows valid international Dutch-English comparisons, and has excellent intra-test reliability and construct validity.

No description available.