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Der ambulante Versorgungssektor hat in den letzten Jahren einen strukturellen Wandel der Angebotsformen hin zu Kooperationsmodellen erfahren. Ein Beispiel dafür sind Medizinischen Versorgungszentren (MVZ). MVZ sind auf städtische Gebiete konzentriert. Welche Kriterien für die Ansiedlung von MVZ entscheidend sind und inwiefern sie die ambulante Versorgungsstruktur beein-flussen, ist bisher nicht umfassend wissenschaftlich untersucht worden. Im Rahmen der Studie wurden Standortfaktoren von MVZ, deren raum-zeitliche Ausbreitung und ihr Einfluss auf die Sicherstellung der ambulanten Versorgung untersucht. Als Untersuchungsgebiet dient Mecklenburg-Vorpommern. Es wurde ein mehrstufiger Analyseansatz umgesetzt, der aus qualitativen und quantitativen Methoden besteht: einer systematischen Literaturrecherche, einer Bestandsanalyse inklusive einer Erreichbarkeitsmodellierung, einer GIS-gestützten Analyse der Standortfaktoren, einer Analyse raum-zeitlicher Ausbreitungsmuster, einer Ärztebefragung sowie Experteninterviews. Die Ergebnisse der Studie zeigen, dass auch in Mecklenburg-Vorpommern eine verstärkte Ansiedlung von MVZ in Städten stattfindet, jedoch im Laufe der Zeit zunehmend dezentrale Regionen gewählt werden. Dabei wurde in raum-zeitlicher Hinsicht eine signifikante Zunahme an MVZ in der Nähe zu Mittelzentren nachgewiesen. Die Standortanalyse konnte belegen, dass bei der Ansiedlung von MVZ weiche personenbezogene und harte Standortfaktoren entscheidend sind. Die Auswertungen von Behandlungsfällen und Bedarfsplanungsanteilen konnte aufzeigen, dass der Einfluss von MVZ auf die Sicherstellung in mittel-/großstädtischen Regionen am geringsten ist, während er mit zunehmender Ländlichkeit steigt. Jedoch wurde anhand der Ärztebefragung eine reduzierte Arbeits-stundenzahl für MVZ-Ärzte nachgewiesen. Insgesamt konnte die Studie den Mehrwert eines mehrstufigen Analyseansatzes sowie die Notwendigkeit der weiterführenden Forschung und der Bedeutung von MVZ im Bundesland aufzeigen. / The outpatient care sector has experienced changes of the supply structure in recent years towards cooperation models. One example of this are Medical Care Centres (MVZ). MVZs are concentrated in urban areas. Which criteria are crucial for the settlement of MVZs and how this form of operation influences the structure of outpatient care has not yet been scientifically investigated. The study therefore aimed to identify location factors, to analyse their spatio-temporal spread and to examine their influence on the assurance of outpatient care. The analyses were performed using the example of Mecklenburg-Western Pomerania. A multi-level analysis approach was implemented, consisting of various qualitative and quantitative methods: a systematic literature research, an analysis of the existing situation including accessibility modelling, a GIS-based analysis of location factors, an analysis of spatio-temporal dispersion patterns, a survey of doctors as well as expert interviews. The results of the study show that in the study area, MVZs are more frequently located in towns and cities, but that decentralised regions are increasingly being chosen over time. In this context, a significant increase in MVZ locations in the vicinity of medium-sized centres was demonstrated in spatial-temporal respect. The location analysis was able to show that soft person-related and hard location factors play a significant role in the settlement of MVZs. The evaluations of treatment cases and demand planning proportions were able to demonstrate that the influence of MVZs on ensuring outpatient care is lowest in medium-sized/large urban regions, while there is an increasing influence with greater rurality. However, a reduced number of working hours for MVZ physicians was demonstrated based on the physician survey. Overall, the study was able to show the added value of a multi-level analysis approach as well as the need for further research and the relevance of MVZs in the federal state.

Det inträffar omkring 17 000 självmordsförsök i Sverige per år och hälften av dessa leder till psykiatrisk vård. Suicidriskbedömningar görs i psykiatrisk öppenvård av bland annat psykologer. Genom fem intervjuer undersökte vi ett i stort sett outforskat område: hur psykologer inom psykiatrisk öppenvård upplevde sitt arbete med suicidnära patienter. Vi använde tematisk analys för att analysera materialet vilket resulterade i två huvudteman: Att jobba på gränsen – med undertemana Mellan liv och död, Mellan arbete och fritid och Mellan att vara psykolog och människa – respektive Att balansera mellan acceptans och intervention – med undertemana Förr eller senare så händer det samt Resurser och coping. En återkommande dimension i temana var Emotionella reaktioner. Resultatet ger en bild av att psykologerna känner oro för patienterna och att denna oro kan användas som en del i suicidriskbedömningen. Vår tolkning är att psykologernas arbete kan spilla över på deras fritid och att detta i förlängningen kan tänkas ge konsekvenser så som medkänsleutmattning. Vi har tolkat psykologernas berättelser som att de använder copingstrategier för att återhämta sig från sin arbetsbelastning. I vårt resultat framträder en bild av att arbetet med suicidnära patienter kan vara vardag för psykologer inom psykiatrin. Vidare kan arbetet utgöra en känslomässig belastning för psykologer som är annorlunda jämfört med den belastning som uppstår i arbetet med icke-suicidnära patienter. / About 17,000 suicide attempts occur in Sweden each year, half of which lead to psychiatric care. Psychologists are one of the professional groups that conduct suicide risk assessments in psychiatric outpatient care. In this study we examine an relatively unexplored area: how psychologists in outpatient psychiatric care experience their work with suicidal patients. A thematic analysis of five interviews was conducted. The analysis resulted in two main themes: Working at the boundary – with sub themes Between life and death, Between work and leisure time and Between being a psychologist and a human – and Balancing between acceptance and intervention – with sub themes Sooner or later it will happen and Resources and coping. A recurring dimension in all themes was Emotional reactions. The findings provide a picture that the psychologists worry about the patients and that this worry can be used as a part of the suicide risk assessment. Our analysis shows that the psychologists’ work can spill over into their leisure time. This may eventually have effects, such as compassion fatigue. Our interpretation of the narratives suggests that the psychologists use coping-strategies to recover from their workload. The results also show that working with suicidal patients can be part of the daily work of psychologists in psychiatric care. Further more, our analysis shows that working with suicidal patients can include an emotional exhaustion on psychologists that is different from the exhaustion that might arise in the work with non-suicidal patients.

適度的壓縮醫療資源，可以讓醫療資源使用得更有效率，進而產生更好的醫療品質；然而過度的壓縮醫療資源，卻會造成醫療品質的惡化。 因為醫療資源和醫療品質有高度的正相關，充足資源的投入，能提昇醫療品質，但在現行保險計量支付(Fee for Service)的制度下，醫療院所常藉由每節門診病人看診人次的增加，來得到較高的獲利和報酬，這種對醫療資源的壓縮經營方式，會對醫療品質產生某些負面的影響。本研究利用簡單的醫師看診時間控制方式，可以清楚的看到在不同的時間壓縮之下，醫師的醫療行為對於醫療品質所產生的直接影響。 醫師對每個病人投入的時間，是無法由其它資源的投入所取代的，換句話說，醫師時間的投入是決定醫療品質的一個重要因素，可以做為醫療院所對門診投入的資源指標。疾病的正確診斷率相對於病人問卷和回診率高低應該是個比較有信度和效度之門診品質評量標準，所以在衡量醫療資源的投入如何影響醫療品質的評估上，本研究把醫師時間的投入做為醫療院所對門診投入的資源指標，而正確的診斷率（確診率）則作為衡量門診品質的標準。透過醫師看診時間控制的方式，分析ICD-9（The International Classification of disease, Ninth Revisione:國際疾病分類第九版）代碼的比對結果，可以正確反應醫師疾病認定和醫師診斷的差異程度，進而探討醫師時間投入和門診品質的關係。 / Objective: The quality of health care is directly proportional to physicians’ time input. The reduction of physician time per patient will affect outpatient diagnostic accuracy. Materials & Methods: This study was designed to detect the difference of group A (Control) & group B (Experiment) diagnostic accuracy in 4 specific time lengths by analyzing the difference in ICD-9 (The International Classification of Disease, Ninth Revision) codes assigned by the physicians to each patient. A method was developed to control average physician time per patient using 8, 4, 2 and 1 minute average visit time intervals. This process was repeated in non-informed physicians (group C & group D) to access the difference between informed and non-informed physicians. Results: There are significant differences in diagnostic accuracies between the control and experimental groups with the variation of time length by Chi-Square (X=20.16, 23.89, p< 0.05). There are no significant differences in diagnostic accuracies between the four different times when informed and non-informed physicians are compared (Fishers Z = 0.467, 1.001, 1.072 and 1.054, p> 0.05) Conclusion: The length of physician time per patient interaction plays an important factor for determining the quality of outpatient care.

Introduction: There has been a continuous development of new technologies in healthcare that are derived from national quality registries. However, this innovation needs to be translated into the workflow of healthcare delivery, to enable children with long-term conditions to get the best support possible to manage their health during everyday life. Since children living with long-term conditions experience different interference levels in their lives, healthcare professionals need to assess the impact of care on children’s day-to-day lives, as a complement to biomedical assessments. Aim: The overall aim of this thesis was to explore and describe the use of instruments about health-related quality of life (HRQOL) in outpatient care for children with long-term conditions on the basis of a national quality registry system. Methods: The research was conducted by using comparative, cross-sectional and explorative designs and data collection was performed by using different methods. The questionnaire DISABKIDS Chronic Generic Measure -37 was used as well as semi-structured interviews and video-recordings from consultations. Altogether, 156 children (8–18 years) and nine healthcare professionals participated in the studies. Children with Type 1 Diabetes (T1D) (n 131) answered the questionnaire DISABKIDS and children with rheumatic diseases, kidney diseases and T1D (n 25) were interviewed after their consultation at the outpatient clinic after the web-DISABKIDS had been used. In total, nine healthcare professionals used the HRQOL instrument as an assessment tool during the encounters which was video-recorded (n 21). Quantitative deductive content analysis was used to describe content in different HRQOL instruments. Statistical inference was used to analyse results from DISABKIDS and qualitative content analysis was used to analyse the interviews and video-recordings. Results: The findings showed that based on a biopsychosocial perspective, both generic and disease-specific instruments should be used to gain a comprehensive evaluation of the child’s HRQOL. The DISABKIDS instrument is applicable when describing different aspects of health concerning children with T1D. When DISABKIDS was used in the encounters, children expressed positive experiences about sharing their results with the healthcare professional. It was discovered that different approaches led to different outcomes for the child when the healthcare professionals were using DISABKIDS during the encounter. When an instructing approach is used, the child’s ability to learn more about their health and how to improve their health is limited. When an inviting or engaging approach is used by the professional, the child may become more involved during the conversations. Conclusions: It could be argued that instruments of HRQOL could be used as a complement to biomedical variables, to promote a biopsychosocial perspective on the child’s health. According to the children in this thesis, feedback on their results after answering to web-DISABKIDS is important, which implies that healthcare professionals need to prioritize time for discussions about results from HRQOL instruments in the encounters. If healthcare professionals involve the child in the discussion of the results of the HRQOL, misinterpreted answers could be corrected during the conversation. Concurrently, this claims that healthcare professionals invite and engage the child.

Mémoire numérisé par la Division de la gestion de documents et des archives de l'Université de Montréal.

Accessibility of health care in the Czech Republic according to the geodemographic characteristics of the population Abstract Public healthcare is a subject that affects us all. The health and medical status of the population is a key measure of how advanced a country is. That is why healthcare issues attract so much debate. A number of factors affect the health of a nation. On one hand there are factors such as how individuals look after their health. Dietary habits, sufficient physical exercise and preventive care are all factors that the individual has control over. On the other hand, however, there are determinants affecting whether healthcare take-up is adequate. The cost of providing healthcare and medical equipment together with healthcare accessibility - the topic of this thesis - are factors affecting the population's health. It is the duty of all public healthcare stakeholders to limit the impact of these determiners. One of the main barriers to healthcare take-up is accessibility. On 1 January 2013 government decree no. 307/2012 Coll. came into effect quantifying healthcare accessibility for the first time. This law stipulates the local and travel time accessibility that ensures accessibility depending on type of healthcare on the basis of an upper travel time limit or waiting period....

The aim of the study is to analyze the understanding of how curators at Bloton Open Care look at collaboration with actors linked to their work. A qualitative method was used and the data was based on semi-structured interviews with six curators from Bloton Open Care and additionally one of the managers.   The findings point to that collaboration is crucial in the work with children and families if the child or family is in contact with several social service organizations. The curators emphasize the importance of being able to see their own part in collaborative work and consequently being humble while helping others. The understanding of others is grounded in transparency of the participant's shortcomings as well as the company´s. The prerequisites for collaborative work become more efficient if the purpose behind the collaboration is clear and all participants in the collaboration are familiar with the matter.

INTRODUÇÃO: O tabagismo é reconhecido, atualmente, como um dos maiores problemas de saúde em todo o mundo. Há uma \"epidemia\" global de uso de tabaco nos países em desenvolvimento, no século 21. OBJETIVOS: Analisar: as características gerais dos indivíduos matriculados espontaneamente em um ambulatório antitabágico; a eficácia geral do tratamento antitabágico e dos medicamentos; as mudanças nas características dos participantes antes e após a Lei Ambiente Fechado Livre do Cigarro em São Paulo e os níveis de cotinina urinária em fumantes ativos, passivos e controles. CASUÍSTICA E MÉTODOS: Foi realizado um estudo de coorte histórica cujo critério de inclusão foi a matrícula no ambulatório antitabágico do HU USP, no período de 2004 a 2011. Os dados foram coletados por meio de consulta a protocolos padronizados e ao sistema informatizado do serviço. Foram analisados os resultados de dosagens de cotinina e creatinina realizadas em amostras biológicas. RESULTADOS: Dentre os 1736 pacientes atendidos houve predomínio de mulheres (62,1%), brancos (75,3%) e indivíduos com idade entre 41 e 60 anos (63,1%). Aproximadamente 80% iniciaram o tabagismo antes dos 20 anos e 75% apresentaram grau de dependência moderado a grave. Dentre os 620 indivíduos acompanhados a partir de 2009, 34,5% abandonaram o tabagismo. Dentre eles, 21,5% obtiveram êxito até o quarto contato com o ambulatório. O uso de vareniclina e terapia de reposição de nicotina (TRN) aumentaram a probabilidade de sucesso (RRR= 2,73 e 2,78, respectivamente; p < 0,001 para ambas). Quanto maior o número de reuniões frequentadas no ambulatório, maior a probabilidade de sucesso terapêutico (p < 0,001). A análise da dosagem da cotinina urinária mostrou concentrações de cotinina urinária 18,7 vezes maior no grupo de tabagistas ativos comparados aos tabagistas passivos. CONCLUSÃO: O sucesso do ambulatório antitabágico do HU manteve-se em acordo com grande parte dos índices de sucesso terapêutico presentes na literatura médica. O abandono do hábito de fumar foi fortemente associado ao número de contatos dos fumantes com o grupo e a terapêutica medicamentosa. A cotinina urinária mostrou-se um bom marcador do tabagismo ativo / INTRODUCTION: Smoking is recognized today as one of the major health problems worldwide. There is a global \"epidemic\" of tobacco use in developing countries in the 21st Century. OBJECTIVES: Analyze: the general characteristics of individuals spontaneously enrolled in an outpatient smoking cessation clinic; the overall effectiveness of the smoking cessation treatment and medication; the changes in the characteristics of participants before and after the Smoke-Free Environment Act in São Paulo and the levels of urinary cotinine in active and passive smokers and controls. CASES AND METHODS: A historical cohort study was conducted, of which the inclusion criterion was the registration in the outpatient smoking cessation Clinic in the HU USP, in the period from 2004 to 2011. Data were collected by consultation of standardized protocols and of the computerized service system. The results of cotinine and creatinine measurements performed on biological samples were analyzed. RESULTS: Among the 1736 patients treated, there was a predominance of women (62.1%), whites (75.3%) and individuals aged between 41 and 60 years (63.1%). Approximately 80% began smoking before age 20 and 75% showed moderate to severe degree of dependence. Among the 620 individuals monitored from 2009 on, 34.5% quit smoking. Among them, 21.5% obtained success up to the fourth contact with the clinic. The use of varenicline and nicotine replacement therapy (NRT) increased the probability of success (RRR= 2.73 and 2.78, respectively; p < 0.001 for both). The greater the number of meetings attended at the clinic, greater the probability of treatment success (p < 0.001). The analysis of urinary cotinine dosage showed urinary cotinine concentrations 18.7 times higher in the active smokers group, compared to the passive smokers group. CONCLUSION: The success of the smoking cessation clinic in the HU remained largely in accordance with most therapeutic success rates found in medical literature. Quitting smoking was strongly associated to the number of contacts of the smokers with the group and drug therapy. Urinary cotinine proved to be an accurate marker for active smoking