BACKGROUND: Despite large investments in maternity care services, perinatal health outcomes in the U.S. are among the worst compared to other industrialized countries, with documented perinatal health disparities disproportionately impacting racial and ethnic minorities. Midwifery-led freestanding birth centers (FSBC) have emerged as an underutilized model for the safe and cost-effective care of women with low-risk pregnancies. Despite approximately 85% of all US pregnancies being considered low-risk, only 0.5% of all US births occurred in a FSBC in 2016. The goal of the study is to elucidate strategies used to develop and sustain freestanding birth centers (FSBCs) that are seeking to serve high proportions of publicly-insured women and women of color. METHODS: I conducted an embedded unit case study, including semi-structured in-depth interviews and focus groups with 49 stakeholders from three exemplary FSBCs. Supplemental interviews were led with five key informants from three additional FSBCs and a relevant national membership organization. Additional data sources used to complete this case study include, where relevant and permitted, observations of maternity care settings, patient-provider encounters, management meetings, community events, and review of pertinent documents. Qualitative analysis methods were used to identify common themes and variations. FINDINGS: Midwifery-led birth center care can improve the experience and outcomes of maternity care among publicly insured women of color. The study revealed persistent multi-level challenges, as well as the use of common approaches to overcome these organizational, financial, and cultural barriers, resulting in greater, yet still fragile, access to family-centered intrapartum care within the communities in which these FSBCs operate. CONCLUSIONS: The careful integration of FSBCs into health systems such as a Federally Qualified Health Center (FQHC) may contribute to the broad scale-up of this underutilized model of care. While integrating FSBCs into FQHCs may be helpful in expanding equitable access to birth center care, it is not necessary, and also not sufficient. Expansion efforts should include additional deliberate processes and strategies to ensure equitable uptake and sustainability of birth center care. / 2020-10-23T00:00:00Z

Die digitale Transformation im Gesundheitswesen ermöglicht durch die Entwicklung zahlreicher neuer Technologien und Standards eine zunehmend individualisierte, bedarfsgerechte und berufsgruppenübergreifende Versorgung von Patienten. Diese neue Generation von Digital Health Innovationen – die Digital Health Generation Alpha (in Anlehnung an die korrespondierende Alterskohorte) – erfüllt Informations‑, Kommunikations- und Interoperabilitätsanforderungen entlang des gesamten Versorgungsprozesses, die aufgrund von abgegrenzten Leistungs- und Zuständigkeitsbereichen sowie Vergütungsregelungen oft eine unüberwindbare Hürde dargestellt haben. Im Beitrag werden mit der i) Pfadorientierung, ii) Patientenorientierung und -einbeziehung, iii) Qualitätsorientierung und iv) Integrationsfähigkeit vier zentrale Gestaltungsdimensionen von Digital Health Innovationen der Generation Alpha vorgestellt. Diese werden literaturgestützt aufgearbeitet und deren praktische Umsetzung anhand einer Fallstudie im Bereich der Versorgung von Patienten mit Multipler Sklerose aufgezeigt. Zentrale Leitfragen, konkrete Umsetzungsmaßnahmen und literaturgestützte Gestaltungsziele werden anhand eines prototypischen Vorgehensmodells beschrieben. Anhand der Fallstudie werden anschließend Implikationen für die zukünftige Digital Health Agenda abgeleitet, welche insbesondere für die Realisierung innovativer Werteversprechen und deren Integration in komplexe Zielumgebungen des Gesundheitswesens notwendig sind. / Through the development of numerous new technologies and standards the digital health care transformation progressively enables an individualized, need-based, and interprofessional treatment provision. The new generation of digital health innovations—in analogy to the age cohorts, the digital health generation alpha—can therefore fulfill information, communication, and interoperability tasks along the entire care process, that previously often represented an insurmountable challenge. The four design dimensions of digital health generation alpha are introduced: i) pathway orientation, ii) patient orientation and involvement, iii) quality orientation, and iv) integration capability. These are first discussed on basis of current literature and their practical utilization is then demonstrated in a case study on patients with multiple sclerosis. A process model for pathway development is presented that incorporates the four design dimensions and transforms a treatment process into a digital, participative, and integrated care model. Central guiding questions, concrete implementation measures and literature-based design goals are described based on the process model. Finally, implications for the future digital health agenda are derived, which are particularly necessary for the realization of innovative value propositions and their integration into complex healthcare target environments.

Bakgrund: Användning av digital rådgivning ökar snabbt och teknologin utvecklas konstant. Distriktssköterskor ska driva utvecklingen framåt och arbeta med att förbättra omvårdnad. Digital rådgivning är en del i förbättringsarbetet och kan förbättra omvårdnadsarbetet och vården genom att öka möjligheterna att erbjuda personcentrerad vård och på sikt mer jämlik vård. Syfte: Att beskriva distriktssköterskors upplevelser av att arbeta med digital rådgivning. Metod: Kvalitativ studie med induktiv ansats. Datainsamlingen genomfördes med två semistrukturerade fokusgruppsintervjuer, med totalt nio deltagare, som analyserades med kvalitativ innehållsanalys med manifest ansats. Resultat: Analysen resulterade i tre kategorier.Verksamhetens betydelse i arbetet med digital rådgivning; Hur verksamheten är upplagd samt hur arbetsresurser fördelas har stor betydelse för upplevelsen av att arbeta med digital rådgivning. Möjligheter och utmaningar för att kunna arbeta patientsäkert; Det finns möjligheter att arbeta patientsäkert, till exempel underlättade det om alla systemets funktioner används. Att kunna se bilder var positivt, men den icke-verbala kommunikationen saknades. Potential för att kunna ge tillgänglig och nära vård; Digital rådgivning underlättade för att kunna ge tillgänglig och nära vård. Distriktssköterskor såg digital rådgivning som en del av framtiden. Slutsats: Digital rådgivning har förutsättningar att öka tillgängligheten till vård men det krävs en bra arbetsmiljö och tillräckligt med resurser, vilket verksamheten har ansvar för, samt ytterligare utbildning och utveckling för att kunna arbeta mer patientsäkert. Det finns behov av fortsatt forskning gällande digital rådgivning, både från personal- och patientperspektiv.

During recent decades, lumbar spinal stenosis (LSS) has become the most common indication for spine surgery, a change that coincides with a higher worldwide prevalence of overweight and obesity. Thus, surgical treatment of LSS in the overweight and obese population is common and increasing in scope. The overall aim of this thesis was to investigate whether body mass index (BMI) is related to the development of LSS, and whether BMI is linked to outcome after surgery for LSS. We further evaluated whether there are specific experiences of LSS from a patient perspective. Data were obtained for all patients registered in the Swedish Spine Register who had undergone surgery for LSS between January 1, 2006 and June 30, 2008. After adjusting for differences in baseline characteristics, patients with obesity showed both poorer results after surgery and a higher rate of dissatisfaction than patients with normal weight (odds ratio 1.73; 95% confidence interval, CI, 1.36-2.19). Furthermore, patients with obesity in the cohort reported modest weight loss at follow-up (2.0 kg; 95% CI, 1.5-2.4), and only 8% reported a clinical important weight loss 2 years after surgery. Our analysis of 389,132 construction workers, showed that overweight (incidence rate ratio, IRR 1.68; 95% CI, 1.54-1.83) and obesity (IRR 2.18; 95% CI, 1.87-2.53) were associated with an increased future risk in developing LSS when compared with patients with normal weight. To gain insight into the patients' perspective of LSS, we performed interviews with 18 patients who were on a waiting list for LSS surgery. The transcripts, analyzed with content analysis, revealed that living with LSS is a physical, mental and social challenge in which resources to cope with the condition are of major importance. In summary, obesity is associated with poorer results after surgery, and patients with obesity report modest weight loss during follow-up. In addition, obesity is associated with an increased risk to develop LSS. Our findings revealed that being a patient with LSS, naturally involves considerable suffering and pain, but it also implies being a person with his or her own resources who is able to cope with these adverse conditions.

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Made available in DSpace on 2014-07-29T15:04:38Z (GMT). No. of bitstreams: 1 dissertacao nilde.pdf: 578642 bytes, checksum: c81be58c892df249786559538371fba5 (MD5) Previous issue date: 2007-12-12 / Humanizing healthcare assistance has become an emergent theme being discussed over decades, and in the most recent years such debates have become more intense regarding how to take more effective actions on care by valuing the human condition. Nurses are considered a key element to visibility of humanized care in the hospital setting due to their sensitivity to the perception of patient s subjectivity and for having the sense of care solidified under ethical humanistic values as the existential reason of their profession. This is a qualitative descriptive exploratory study aimed at analyzing the concept on humanized care the nurses working in hospital assistance have. It was conducted in a school hospital, located in Midwestern Brazil, with the participation of 27 nurses acting on inpatients direct assistance. Data was collected through semi-structured individual interviews and were submitted to the content thematic analysis.Thus, we have come up with four main categories and their subcategories revealing the respondents perception concerning care humanization in the hospital context, namely: conception of humanized care; caregivers conception under the humanized assistance perspective; the paradox of the humanized care in the hospital setting; echoes of the Permanent Education Project on relative practice and concepts to the humanizado care. By the end of this study, we have noticed that nurses have various perceptions concerning this issue, correlating, however, the humanized care to holistic approach regarding patients assistance. The ethical humanistic principles were described by all the respondents when expressing humanization of care related to feelings such as love, empathy, presence, communication, and attention. They identified at the institution several aspects favoring or making it harder the effectiveness of humanized care, however, they have stressed the internal availability of staff and their valuing in the humane dimension, through symmetric respect and dialogue between workers and managers as determinant to humanizing process. We present the continuing education project of the institution which aims at discussing the humanization of assistance in the hospital ambit as an important initiative enabling changes in staff concepts and attitudes in what patient care regards. Thus, some outcomes have been assessed so that these project contributions can be highlighted in the construction of concepts and practices related to humanizing care among nurses participating in such activities. In general, throughout the research we could see that the institution can count on committed, responsible, sensitive nurses motivated to contribute to the effectiveness of humanized care. Thinking about the complexity of the assistance humanization process, we become aware that implementing humanized care in the hospital setting requires a long way demanding successful strategies, not always easy, but feaxible. / A humanização da assistência em saúde é um tema emergente que vem sendo discutido há décadas e nos últimos anos essas discussões têm se intensificado no sentido de tornar efetivas as ações do cuidado valorizando a condição humana. Consideramos o enfermeiro elemento-chave para a visibilidade do cuidado humanizado no ambiente hospitalar por ser um profissional sensível à percepção da subjetividade do paciente e por ter o cuidado solidificado em valores ético-humanistas como razão existencial da profissão. Este estudo, de natureza descritivo-exploratória, com abordagem qualitativa, teve como objetivo geral analisar a concepção sobre cuidado humanizado pelos enfermeiros que atuam na assistência hospitalar. Foi desenvolvido em um hospital universitário, localizado na região Centro-Oeste do Brasil, com a participação de 27 enfermeiros atuantes na assistência direta à pessoa internada. Os dados foram coletados por meio de entrevista individual semi-estruturada e foram submetidos à análise temática de conteúdo. Dessa forma, foram construídas quatro categorias principais e subcategorias, que revelaram a percepção dos participantes sobre a humanização do cuidado no contexto hospitalar, assim nomeadas: concepção do cuidado humanizado; concepção de cuidador na perspectiva da humanização da assistência; o paradoxo do cuidado humanizado no ambiente hospitalar; ressonâncias do Projeto de Educação Permanente sobre conceitos e práticas relativos ao cuidado humanizado. Ao finalizarmos este estudo, verificamos que os enfermeiros têm percepções diversas sobre a temática, correlacionando, entretanto, o cuidado humanizado ao holismo na assistência ao paciente. Os princípios ético-humanistas foram apontados pela totalidade dos entrevistados ao expressarem a humanização do cuidado relacionada a sentimentos de amor, empatia, presença, comunicação e atenção. Identificaram na instituição, vários aspectos que favorecem ou dificultam a efetividade do cuidado humanizado, entretanto, destacaram a disponibilidade interna do profissional e a valorização dele na sua dimensão humana, por meio do respeito e diálogo simétrico entre os trabalhadores e gestores como determinantes para processo de humanização. Apresentamos o Projeto de Educação Permanente da instituição, que tem entre seus objetivos, discutir a humanização da assistência no âmbito hospitalar como uma iniciativa importante que possibilita mudanças de conceitos e atitudes dos profissionais frente ao cuidado dos pacientes. Dessa forma, alguns resultados foram analisados no sentido de apontar a contribuição desse projeto na construção de conceitos e práticas relativas à humanização do cuidado entre os enfermeiros que participaram de suas atividades. De modo geral, no transcorrer da pesquisa, vimos que a instituição conta com profissionais de enfermagem comprometidos, responsáveis, sensíveis e motivados a contribuir no sentido de tornar efetiva a prática do cuidado humanizado. Pensando na complexidade do processo da humanização da assistência, temos a clareza que implementar o cuidado humanizado no ambiente hospitalar, requer uma longa trajetória, que demanda estratégias exitosas, nem sempre fácies, mas possíveis de serem alcançadas.

The subject of this diploma thesis is the involvement of users of psychiatric care in the process of planning and realization of psychiatric care reform at the macro level of policy making. The aim of the research is to describe and understand this involvement. In the research are describer possibilities of participation in the phases of involvement, its form, purpose, formal regulation of opportunities, expectations of respondents, perceived power and barriers in involvement. The data was collected during interviews with key actors and studies of relevant documents. The results relate to the theoretical concepts of coproduction, patient-oriented care, strategic and human rights documents (the Convention on the Human Rights of People with Disabilities). The element of power is described through the typology of Sherry Arnstein's participation ladder. Evidence of interviews indicates elements of tokenism and disadvantages. There is a low (one-person) representation of users in reform bodies, lack of time for discussion in consultative bodies, lack of information and lack of capacity (people, time, resources) for greater development of patient organizations. Respondents have identified barriers as the socio-economic situation, lack of capacity for macro-level involvement, mental health constraints or...

Indiana University-Purdue University Indianapolis (IUPUI) / Model-based drug development has become an essential element to potentially make drug development more productive by assessing the data using mathematical and statistical approaches to construct and utilize models to increase the understanding of the drug and disease. The modeling and simulation approach not only quantifies the exposure-response relationship, and the level of variability, but also identifies the potential contributors to the variability. I hypothesized that the modeling and simulation approach can: 1) leverage our understanding of pharmacokinetic-pharmacodynamic (PK-PD) relationship from pre-clinical system to human; 2) quantitatively capture the drug impact on patients; 3) evaluate clinical trial designs; and 4) identify potential contributors to drug toxicity and efficacy. The major findings for these studies included: 1) a translational PK modeling approach that predicted clozapine and norclozapine central nervous system exposures in humans relating these exposures to receptor binding kinetics at multiple receptors; 2) a population pharmacokinetic analysis of a study of sertraline in depressed elderly patients with Alzheimer’s disease that identified site specific differences in drug exposure contributing to the overall variability in sertraline exposure; 3) the utility of a longitudinal tumor dynamic model developed by the Food and Drug Administration for predicting survival in non-small cell lung cancer patients, including an exploration of the limitations of this approach; 4) a Monte Carlo clinical trial simulation approach that was used to evaluate a pre-defined oncology trial with a sparse drug concentration sampling schedule with the aim to quantify how well individual drug exposures, random variability, and the food effects of abiraterone and nilotinib were determined under these conditions; 5) a time to event analysis that facilitated the identification of candidate genes including polymorphisms associated with vincristine-induced neuropathy from several association analyses in childhood acute lymphoblastic leukemia (ALL) patients; and 6) a LASSO penalized regression model that predicted vincristine-induced neuropathy and relapse in ALL patients and provided the basis for a risk assessment of the population. Overall, results from this dissertation provide an improved understanding of treatment effect in patients with an assessment of PK/PD combined and with a risk evaluation of drug toxicity and efficacy.

Stroke is a leading cause of disability worldwide, and access to rehabilitation is crucial for recovery. This study examines the potential of digital technologies to improve the rehabilitation experience of stroke survivors in Scania, Sweden. The use of digital tools and telerehabilitation in stroke rehabilitation in Scania remains largely unexplored. Through qualitative interviews with 12 stroke survivors, 1 stroke survivor relative, and 6 healthcare professionals, this study identifies four key themes that play a significant role in the rehabilitation process: Access to care and rehabilitation, Motivation, Psychological and emotional needs, and Social support net. Based on these findings, the study proposes several "digital suggestions" to improve the rehabilitation process, including utilizing digital physio- and occupational therapy and improving alignment between various digital systems within the region. The study emphasizes the importance of individual adaptation in stroke rehabilitation, which aligns with the overarching goal of Swedish healthcare to provide patientcentered care. The findings of this study can inform future work with digital opportunities in Scania's stroke care and rehabilitation, potentially leading to better outcomes for stroke survivors.

AIM The purpose of this study was to explore and describe factors that contribute to the non-initiation of Antiretroviral Therapy (ART) amongst Pre-Antiretroviral Therapy eligible patients and to make recommendations for health care workers to enhance early initiation of pre-ART-eligible patients for primary health care facilities in Swaziland. METHOD A qualitative design was applied in rural primary health care (PHC) facilities in the Hhohho region of Swaziland. The target population for this study included nurses who have successfully completed the National Nurse Led Antiretroviral Therapy Initiation in Swaziland (NARTIS) training, and who actively initiated ART to eligible patients in rural PHC facilities. Data was collected through semi-structured interviews and field notes. Purposive, convenient sampling was applied. Eleven respondents were interviewed for the study, and data was collected until data saturation was reached. Data from transcripts and field notes was analysed and categorised with thematic analysis through Tesch’s open coding process. RESULTS The study identified the following three predominant themes: 1) systematic enablers of prompt ART initiation, 2) barriers to prompt ART initiation, 3) sources of support. Categories included public health care (PHC) factors, community level factors, the interdependence of the health care system, patient centred barriers, individual patient agency, and NARTIS nurse support. CONCLUSION The recommendations for health care workers that emerged from the study included continued HIV treatment scale-up and decentralisation to grass roots levels, aggressive treatment prioritisation among pre-ART patients, building the capacity of the local health care system and continued research initiatives. It is hoped that recommendations emerging from the findings of this study will have positive implications for programming and practice regarding the initiation of ART for eligible pre-ART patients in Swaziland. / Health Studies / M. PH.