Dissertations / Theses on the topic 'Coast care'

Thesis (MCur (Nursing Science))--University of Stellenbosch, 2009.
ENGLISH ABSTRACT: Every patient comes to a hospital with the expectation of getting quality care. It is not always within the ability of nursing personnel to give quality care in the work situation. Guided by the research question “What are the factors influencing the quality of nursing care in district hospitals in the West Coast Winelands Region of the Western Cape?” a scientific investigation was undertaken. The goal of this study was to identify the factors which influence the quality of nursing care in the eight (8) district hospitals of the West Coast Winelands Region of the Western Cape. The objectives set for the study were:  to determine whether staffing is adequate for all activities;  to evaluate what the perceptions of the nursing staff is about their current working situation;  to determine what the effect of the absence of full time doctors are on the management of patient care;  to evaluate whether adequate equipment is available for the execution of nursing care and to evaluate whether adequate provisions for the execution of nursing care is done. A descriptive non-experimental design with a quantitative approach was applied. The population for this study was all the nursing staff available at the time of data collection, working in the eight district hospitals of the West Coast Winelands Region. A structured questionnaire was used to collect the data. The final sample of nursing staff was N= 280 of a total population of 340 – all the members were invited to participate. Reliability and validity were assured by means of a pilot study and the use of experts in nursing research, methodology and statistics. Data were collected personally by the researcher. Ethical approval was obtained from Stellenbosch University and various health authorities. Informed written consent was obtained from the participants. The data was analyzed with the support of the statistician; it was expressed in frequencies, tables and histograms. Comparisons between variables were made using either ANOVA (Analysis of variance) techniques or cross-tabulations with the Chi-square test. The 95% confidence interval was applied to determine whether there was an association between the various variables. The analysis shows that participants of the separate wards hospitals N=142 (90%) and the mixed wards type hospitals N=113 (95%) disagree that staff provision (numbers) is adequate. From the analysis it is clear that the patient documentation is not up to standard. A statistical significant correlation between hospital type and adequate time for the completion of written records (Chisquare Test p=0.00) was shown. Management N=13 (100%), registered nurses N=80 (86%), enrolled nurses N=63 (86%) and nursing assistants N= 81 (83%) disagree that it is not necessary to act beyond their scope of practice. The following recommendations were made: Safe staffing levels have to be determined; qualify staff with the necessary skills; where unit managers are still lacking, they have to be appointed; to make personnel development possible for staff; continuous auditing of patient documentation. It is necessary that there is always adequate equipment and consumables. More training is necessary for the effective and efficient implementation of the Batho Pele principles.
AFRIKAANSE OPSOMMING: Elke pasiënt kom na ‘n hospitaal met die verwagting om kwaliteit verpleegsorg te ontvang. Dit is nie altyd binne die vermoë van die verpleegpersoneel om sodanige diens te kan lewer nie. “Watter faktore het ‘n invloed op die lewering van gehalteverpleegsorg in die distrikhospitale van die Weskus Wynlandstreek in die Wes Kaap? het die wetenskaplike ondersoek gelei. Die doel van die studie is om die faktore te identifiseer wat ‘n invloed het op die lewering van gehalteverpleegsorg in die ag (8) distrikhospitale van die Weskus Wynlandstreek in die Wes Kaap. Die doelwitte van die studie is:  om te bepaal of personeelvoorsiening voldoende is vir al die aktiwiteite;  om te evalueer wat die persepsies is van die verpleegpersoneel betreffende hulle huidige werksituasie,  om te bepaal watter effek die afwesigheid van voltydse geneeshere het op pasiënte sorg;  om te evalueer of toerusting voldoende is vir pasiënte sorg;  om te evalueer of daar voldoende voorsiening gemaak is vir die lewering van pasiënte sorg. ‘n Beskrywende, nie-eksperimentele ontwerp as metodologie is gebruik met ‘n kwantitatiewe benadering. Die bevolking betreffende die studie was alle verpleegpersoneel, werksaam tydens die insameling van die data in die ag distrikhospitale van die Weskus Wynlandstreek. ‘n Gestruktureerde vraelys was gebruik om die data te versamel. Die finale steekproef van die verpleegpersoneel was 280 uit die totale bevolking van 340. Betroubaarheid en geldigheid is verseker deur middel van ‘n loodstudie, en deur gebruik te maak van kenners betreffende verpleegnavorsing, metodologie en statistieke. Data is persoonlik deur die navorser ingesamel. Etiese goedkeuring was verkry vanaf die Universiteit van Stellenbosch en die verskeie gesondheidsowerhede. Ingeligde, skriftelike toestemming is van elke deelnemer verkry. Data is ontleed met die ondersteuning van die statistikus en is uitgedruk in die vorm van frekwensies, tabelle en histogramme. Vergelykings tussen die veranderlikes was gedoen deur gebruik te maak van ANOVA (analise met betrekking tot variansie) en kruis-tabulerings met die Chi-kwadraat toets. 95% Betroubaarheidsinterval is toegepas om te bepaal of daar ‘n assosiasie was tussen die onderskeie veranderlikes. Die analise het getoon dat deelnemers betreffende die hospitale met aparte afdelings N=142 (90%) en die gemengde sale hospitale N=113 (95%) verskil, betreffende die stelling dat daar voldoende personeelgetalle is. Dokumentasie is volgens die analise nie op standaard nie. ‘n Statistiese betekenisvolle korrelasie is verkry met betrekking tot die hospitaal tipe en voldoende tyd betreffende volledige geskrewe dokumentasie (Chi-kwadraat Toets p=0.00). Verpleegbestuur N=13 (100%), geregistreerde verpleegkundiges N=80 (86%), stafverpleegsters N=63 (86%) en verpleegassistente N=81 (83%) het verskil met die stelling dat dit nie nodig is om buite bestek van hul praktyk te werk nie. Die volgende aanbevelings is gemaak: die bepaling van veilige personeel vlakke moet gedoen word; voldoende personeel moet gekwalifiseer word met die nodige vaardighede. Eenheidsbestuurders moet aangestel word waar dit ontbreek; personeelontwikkeling moet moontlik wees en deurlopende oudits van dokumentasie moet plaasvind. Voldoende toerusting en voorraad is nodig om kwaliteit verpleegsorg moontlik te maak. Verdere opleiding in die beginsels van Batho Pele is nodig ten einde effektiewe en doeltreffende implementering daarvan moontlik te maak.

Philosophiae Doctor - PhD
Introduction: The overall aim of this study was to develop a programme to facilitate quality client-centred care in Primary Health Care clinics of the rural West Coast District. Research design and -method: Both quantitative and qualitative methods were applied for this study . Phase 1, a situational analysis collected and analysed quantitative data from the perspective of clients and clinical nurse practitioners via structured questionnaires. The population included all clients 18 years and older (N=137 991) of the fixed clinics (N=25) in the five subdistricts of the West Coast District. According to the Cochran formula a sample of (n=383) should be adequate to represent the population. Non-proportional sampling was applied to estimate the number of participants per clinic. An all-inclusive sample of (n=64) clinical nurse practitioners participated in the study. Phase 2, the qualitative part of the situational analysis, applied five focus group discussions to explore and describe the managers and allied health professionals’ perceptions about quality client-centred care. A semi-structured interview schedule was compiled to guide the focus group discussions. An all-inclusive sample was utilised to include all the managers and allied health professionals of the five subdistricts (N=43). Phase 3 included the development of the programme based on the study findings and literature. Quantitative results: The analysis revealed the following quality client-centred care challenges, namely: Patient Rights (Domain 1) were not always respected and adhered to as these were characterised by: language (statistical p<0.001 and practical significant with a large effect size d=0.74); Satisfaction and Safety (statistical p<0.001 and practical significant with a medium effect size d=0.55); Referral Procedures (statistical significant p<0.001); Waiting Times (statistical p<0.001 and practical significant with a medium effect size d=0.47) and Confidentiality difficulties (statistical p<0.001 and practical significant with a medium effect size d=0.68). The Domain 2, Clinical Governance, Care and Safety showed shortcomings as highlighted by the Client and his/her Family (statistical p<0.001 and practical significant with a large effect size d=0.77). Clinical Support Services, Domain 3, revealed inadequacies regarding the continuous availability of medication (statistical significant p<0.008) and the reporting of side-effects (statistical significant p<0.001). Furthermore, Public Health Domain 4, showed that clients identified community health promotion and disease prevention events (statistical p<0.01 and practical significant with a large effect size d=0.79), and home visits by the community healthcare workers (statistical p<0.001 and practical significant with a large effect size d=1.09) as both a “problem” and a “gap”. Leadership and Corporate Governance, Domain 5 was characterised by the lack of: visible organograms (clients mean 2.40), community communication (clients mean 2.12 & clinical nurse practitioners mean 2.36), visibility of goals, values and future plans of the Western Cape Department of Health (statistical p<0.001 and practical significant with a medium effect size d=0.59) and role and function of the clinic committees (statistical significant p<0.008). Moreover, Domain 6, Operational Management was challenged by inadequate staffing levels (statistical significant p<0.003). Lastly, Domain 7: Infrastructure was characterised by the lack of drinking water in the waiting areas (clients mean 2.08 & clinical nurse practitioners mean 2.02), inadequate clinic space (clients mean 2.10 & clinical nurse practitioners 2.23); maintenance not up-to-date (statistical significant p<0.002); physical appearance of the clinic (statistically significant p<0.001) did not have a positive effect on staff morale and evacuation plans (statistical p<0.001 and practical significant with a medium effect size d=0.54) were not visible. In addition, correlations between the domains showed that the domains are not in silos, but are interdependent on another. Qualitative results The qualitative, thematic data analysis revealed various inadequacies regarding quality client-centred care. Theme One about the Patient Rights revealed that patients were not always treated with the necessary respect and dignity. Theme Two concerning Patient Care, revealed that focus group participants were well-informed on what the concept client-centred care entailed. However, patients and or clients did not always experience their care as client-centred. Theme Three about the Clinical Support Services, indicated shortages of medication and medical equipment; long waiting time for specialists and rehabilitation referral appointments. Theme Four, referring to the Public Health confirmed that health promotion and prevention activities are limited, due to various organizational factors and community healthcare workers’ activities which are limited to home-based care activities. Theme Five, Corporate Governance and Leadership matters were characterised by too many processes or “red tape” resulting in inefficient procurement processes, inadequate staffing and inactive health committees. Theme Six, Operational Management highlighted the severe pressure under which the operational managers have to work, resulting from their twofold role of being the clinic manager and at the same time operate as a clinical nurse practitioner. Theme Seven refers to Infrastructure and Facilities and is characterised by inadequate maintenance and lack of space according to the number of clients and package of care. To summarise: The situational analysis revealed 81 problems. These problems form the evidence base for the development of the programme to facilitate quality client-centred care in primary helth care clinics of the rural West Coast District.

Thesis (MCur)--Stellenbosch University, 2012.
ENGLISH ABSTRACT: Primary Health Care (PHC) provide a quality, comprehensive health service to the community, based on the principles of equity, affordability, accessibility and community participation. It is a nurse driven service with the Clinical Nurse Practitioner (CNP), a registered nurse specialising in the clinical elements of primary, secondary and tertiary prevention at the forefront. It is against this background that this study was endeavored to investigate the community’s perceptions and lived experiences of the quality of care being rendered by CNPs in the West Coast rural district of the Western Cape. The objectives of this study included the following: - To explore and describe the perceptions of patients in the West Coast rural community regarding the attitudes, knowledge and skills of CNPs. - To provide policy makers with feedback and possible recommendations with regards to the implementation of this nurse driven PHC service. - To provide recommendations for improvement of the existing curricula at nursing education institutions based on whether the current training meets patients’ needs and thereby possibly influence curricular change. A qualitative, descriptive, research design was used. The guideline by Colaizzi (as cited in Streubert & Carpenter, 1999:14) was used for data collection and analysis. Twenty-six participants took part in five different group interviews. Semi-structured, open ended questions were used to encourage the participants to actively partake. Each interview was audio taped and field notes were taken. Thematic analyses was performed to highlight three main themes, i.e. the attitudes of the CNPs, the knowledge and skills of CNPs, and the impact of the current training programmes on the quality of care being rendered by these CNPs. Written approval from the Ethics Research Committee, University of Stellenbosch, as well as from the Research unit of the Western Cape Department of Health was obtained. Prior informed consent was further obtained from each participant, after being assured of voluntary participation, confidentiality and anonymity. Credibility, dependability and transferability were ensured by returning to two participants who validated that the transcripts were a true reflection of their experiencesand opinions. This study concluded that patients perceived CNPs as being unfriendly, uncompassionate and unprofessional. Dissatisfaction with the prevalence of unjust practices due to family members and certain race groups being attended to first by CNPs, were expressed. Participants found the competency levels of CNPs more than adequate when assessing, examining and providing health information and medicine. However, they expressed the need that CNPs should be able to prescribe a greater variety of medicines and perform more diagnostic tests than currently permitted by the scope of practice as set out by the South African Nursing Council. Therefore, these views of the participants indicated that the current postgraduate training programme do fulfill their health needs, although the need for expansion of the role and function of the CNP were expressed. Recommendations made included: - An in-depth investigation into the alleged rude attitudes of CNPs should be undertaken, soas to improve the professional behavior of CNPs towards patients. - Applicable policy makers should consider expanding the roles and functions of the CNP. - Enforcing continuous, professional competency through adequate and productive in-service training programmes. In conclusion, this study showed that CNPs need to be constantly aware that they work with human beings, with feelings and with health needs. The need for a therapeutic environment is thus crucial to the rendering of a quality, comprehensive service to the community they serve.
AFRIKAANSE OPSOMMING: Primêre Gesondheidsorg (PGS) voorsien ’n kwaliteit, omvattende gesondheidsdiens aan die gemeenskap, gebaseer op die beginsels van gelykheid, bekostigbaarheid, toeganklikheid en gemeenskaps-betrokkenheid.Dit is `n verpleegaangedrewe diens met die Kliniese Verpleegspraktisyn (KVP) wat gespesialiseerd is in die kliniese elemente van primêre, sekondêre en tersiêre voorkoming, aan die voortou. Dit is teen hierdie agtergrond wat hierdie studie aangepak is, ten einde ondersoek in te stel aangaande die gemeenskap se persepsies en geleefde ervarings van die kwaliteit van sorg wat deur KVPs in die plattelandse Weskusdistrik van die Wes-Kaap gelewer word. Die doelwitte van hierdie studie het die volgende ingesluit: - Om die persepsies van pasiënte, rakende die ingesteldhede (gedrag), kennis en vaardighede van KVPs te ondersoek. - Om toepaslike beleidsmakers metterugvoer en moontlike aanbevelings te voorsien aangaande die implimentering van verpleegaangedrewe, PGS. - Om aanbevelings te maak vir die verbetering van bestaande kurrikula aan verpleegopleidingsinstellings op grond van óf die huidige opleiding in pasiëntbehoeftes voorsien, en sodoende kurrikulumverandering moontlik te beïnvloed. ’n Kwalitatiewe, beskrywende navorsingsontwerp is gebruik. Die raamwerk van Colaizzi (soos beskryf in Streubert & Carpenter, 1999:14) is tydens datainsameling en analiese gebruik. Ses-en-twintig deelnemers het aan die vyf verskillende groepsonderhoude deelgeneem. Semi-gestruktureerde, oop-einde vrae was gebruik om die deelnemers aan te moedig om aktief aan die besprekings deel te neem. Elke onderhoud is op oudio band opgeneem en veldnotas is gemaak. Tydens analiese is drie hooftemas geïdentifiseer, nl die houdings van KVPs, die kennis en vaardighede van die KVPs sowel as die impak van die opleidingsprogram op die kwaliteit van sorg wat deur KVPs gelewer word. Skriftelike toestemming vir die studie is by die Etiese Navorsingkommittee, Universiteit van Stellenbosch, asook die Navorsingseenheid van die Wes- Kaapse Departement van Gesondheid verkry. Voorafgaande toestemming is voorts vanaf elke deelnemer verkry, nadat hulle verseker is van vrywillige deelname, konfidensialiteit en anonimiteit. Geloofwaardigheid, afhanklikheid en oordraagbaarheid is verseker, deur na twee van die deelnemers terug te gaan wat die transkripsies geverifieër het as juis en korrek. In hierdie studie is tot die slotsom gekom dat pasiënte KVPs as onvriendelik enongevoeligervaar het. Onbillike praktyke kom steeds voor, deurdat familielede en sekere rassegroepe voorkeur behandeling kry. Deelnemers se ervarings aangaande die bevoegdheid van KVPs was as toereikend beskryf aangaande die assessering, ondersoek en voorsiening van gesondheidsinligting en medisyne. Hulle het egter ook die behoefte uitgespreek dat die KVP’s `n groter verskeidenheid medisyne behoort voor te skryf en meer diagnostiese toetse behoort te kan uitvoer as wat tans binne die bestek van praktyk, soos neergelê deur die Suid-Afrikaanse Raad op Verpleging, moontlik is. Hierdie persepsie van die deelnemers impliseer dat die huidige nagraadse opleidingsprogram voldoende is en hul gesondheidsbehoeftes aanspreek. Die behoefte vir die uitbreiding van die rol en funksie van die KVP is egter uitgespreek. Die aanbevelings wat gemaak is sluit in: - ’n In-diepte ondersoek oor die onbeskofte ingesteldhede van KVPs behoort uitgevoer te word, ten einde die professionele gedrag van KVPs teenoor pasiënte te verbeter. - Beleidmakers behoort die uitbreiding van die rolle en funksies van die KVP te oorweeg. - Benadruk voortgesette, professionele bevoegdheid deur toepaslike en produktiewe indiensopleidingsprogramme. Ter aflsuiting: hierdie studie het aangetoon dat KVPs voortdurend bewus moetbly dat hulle met mense werk wat gevoelens het en wat gesondheidshulp benodig. Dit is uiters belangrik om aan die behoeftesvan ’n terapeutiese omgewing te voorsien, ten einde ’n kwaliteit, omvattende diens aan die gemeenskap te lewer.

This study is concerned with aspects of the quality of life of children in three residential child care facilities (Children's Homes) in Accra and Cape Coast Municipality. It is comparative in its nature and aims to investigate how the material and social structures and supplies of the Children’s Homes contribute to similarities and dissimilarities in aspects of the children’s quality of life, both between and within the homes. The theoretical framework of the study is based on a quality of life approach, where quality of life is seen as an all-embracing conception, which includes a basic needs approach (BNA) and is supplemented by a subjective well-being approach (SWB). The theory of structuration is used to understand how material and social structures and supplies at the Children's Homes affect aspects of the children’s quality of life. The theory of structuration is a framework to investigate to what degree the children are able to act as competent social actors. The study was carried out in two different regions; the Greater Accra Region and in the Central Region at three Children's Homes. Osu Children’s Home (governmental) is located in Accra, the capital of Ghana, Ahotokurom (private) in a peri-urban area outside the city of Cape Coast and Lighthouse Children’s Home (private) is located just outside the Cape Coast city centre. Methodologically this study applies a qualitative approach and includes the triangulation of a variety of qualitative instruments of data collection. The data has been collected through 14 interviews with children from the ages of twelve to nineteen and eight key-informant interviews with the staff at the Children's Homes, two interviews with additional informants, as well as observations and some quantitative data. The thesis concludes that the material and social structures and supplies available at the Children’s Homes have strong bearings on the children’s lives and aspects of their quality of life. The Children’s Homes represents sets of structures that both enable and restrict the children to act as competent social actors. Even though the material and social structures and supplies at the homes determine much of the children’s lives, the children have some degree of freedom to act within these structures and are able to influence their own lives. The degree of freedom to act as competent social actors varies between the homes. At Osu there exists a stronger accumulation of conditions creating poorer aspects of quality of life, such as poor food, shelter, clothing, education, safety, leisure, love and belonging and social networks. The children at Ahotokurom and Lighthouse generally enjoy conditions creating better aspects of quality of life, the only exception being perhaps healthcare. This difference seems to be connected to the type of ownership, gatekeeping,  finances, location and contact with the local community.

The study investigated the self-reported information needs and information-seeking behaviour of 143 general practitioners in their delivery of patient care to the elderly on the Gold Coast. The study sought to obtain an information profile in order to begin discussion on the need for possible infrastructures that may need to be considered in any planning strategies concerned with access to and provision of relevant, accurate and timely information to general practitioners which affects their delivery of patient care to the growing number of elderly patients. A ten-page questionnaire utilising both structured and unstructured questions was returned by 61.9 percent of the survey population. Demographic characteristics indicated that respondents were representative of general practitioners in Australia. Respondents frequently needed information with 40 percent requiring it '1 - 4 times a week' and 78 percent 'once a month or more often'. Information on medical fact was required most frequently, 29 percent, medical opinion 27 percent, and non-medical information 23 percent. The study found support for the proposition that computerised information systems need to be enhanced and made widely known and available to general practitioners to assist them in obtaining information that they need in delivery of patient care to the elderly. There is a great need by these general practitioners for non-medical information as well as medical information. Therefore, the development of a database of non-medical information containing information on local agencies and services is of high priority. Library information delivery services should also be de-institutionalised in terms of lifting restrictions to services provided to enable general practitioners greater access to information. Library services should aim to provide remote access to information via telephone, fax and modem with emphasis on value added services aimed at solving a particular specific information need as well as straight-out bibliographic search services and document delivery services. Continuing medical education in the form of CME courses, conferences and meetings should focus on specific information needs of general practitioners in this area of patient care to the elderly. The need for information on cardiology, orthopaedics, dermatology, physiotherapy, podiatry, pharmaceutical benefits, home help, Meals-on-Wheels and nursing home placement were areas of particular interest identified by respondents in this study.

Thesis (MA)--Stellenbosch University, 2000.
ENGLISH ABSTRACT: This study is aimed at exploring mental health services for low-income women in the West Coast I Winelands Region of South Africa. In order to understand the extent to which such services are empowering, the accessibility and theoretical underpinnings of these services are investigated. It was found that although services appear to be available, they are often not very accessible. They also often lack a specific gender focus. In certain instances, services need to increase their accessibility in order to accommodate the restrictive environments of women in this region. As such, it is believed that services require greater integration in their approach to intervention concerning both gender and the origins of mental health problems. Results of this study also highlight areas on which future research could focus. These areas include language of service provision, how organizations understand available theories surrounding service provision, and the service needs of women in this region themselves.
AFRIKAANSE OPSOMMING: Hierdie studie is gemik op die ondersoek van geestesgesondheidsdienste vir vroue van lae-inkomste groepe in die Weskus I wynverbouingstreek van Suid Afrika. Die toeganklikheid en teoretiese onderstuttngs van hierdie dienste word ondersoek in In poging om die graad waarin delke dienste bemagtigend is, te verstaan. Bevindinge toon dat dienste, albeit beskikbaar voorkom, dikwels nie baie toeganklik is nie. Dienste toon ook meestal 'n gebrekkige fokus ten opsigte van 'n spesifieke geslag. In sekere gevalle behoort die toeganklikheid van dienste verbeter te word in 'n poging om die beperkende omstandighede van vroue in hierdie streek tegemoet te kom. As sulks benodig dienste 'n hoër mate van integrasie in hul benadering tot intervensie, beide wat geslag en die oorsprong van geestesgesondheidsprobleme betref. Bevindinge lig ook areas uit waarop toekomstige navorsing kan fokus. Hierdie areas sluit die volgende in: die taal van diensvoorsiening, hoe organisasies beskikbare teorieë ten opsigte van diensvoorsiening verstaan, en die behoefts van die vroue in hierdie streek self ten opsigte van dienste.

Many of the known risk factors associated with low birth weight, such as socio-economic status, ethnicity, genetic makeup, and obstetric history, are not within a women's immediate control. However, there are many things that a woman can do to improve her chances of having a normal healthy child. Lifestyle behaviours, such as cigarette smoking, nutrition and the use of alcohol, play an important role in determining the growth of the fetus. The aim of this study was to establish the knowledge, attitudes and practices related to lifestyle factors such as alcohol use, smoking and nutrition among childbearing women and health care workers on the farms in Stellenbosch and Vredendal.

The rising cost of health care in the Philippines is a concern for the Department of Defense and TRICARE beneficiaries. The purpose of this quantitative cross-sectional research study was to determine the efficacy and acceptability of a different method to deliver health care to increase access to health care and decrease out-of-pocket costs while maintaining quality of care for TOP Standard beneficiaries who receive health care under the Philippine Demonstration. Secondary data was used to determine the acceptability of an alternative reimbursement methodology to decrease cost but maintain access to quality care. The Andersen's behavioral health care model and the Donabedian quality health care model were used to interpret the study results. A data set of 180 participants was evaluated using a cross-sectional quantitative methodology. Two Spearman correlations were used to examine the relationship between financial burden and satisfaction (r = .41, p < .001) and financial burden and confidence (r = .44, p < .001). Linear and binary regressions assessed the effects of age and gender on satisfaction with health care finder functionality when requesting a waiver (F (2,26) = 1.22, p = .313, R2 = .09). A computation of one-sample t-tests to determine the impact of a closed network, beneficiary out-of-pocket cost, and quality health care in Demonstration areas found the beneficiaries were satisfied with the demonstration. An analysis of the claims data pre and post demonstration showed a difference in the patients' out-of-pocket expenses and the acceptability and preference for a closed network. Social change was demonstrated by a decrease in the cost for TRICARE standard beneficiaries in the Philippines.

This research study was conducted to examine changes in cost and service utilization of nurse case managed clients. A secondary analysis was conducted using a pre-test/post-test design. Data for this analysis were collected by Papenhausen (1995) for a study to measure the effect of nurse case management intervention on client outcomes. Cost data for 53 subjects for the periods six months before and six months after nurse case management intervention was initiated were compared. Statistically significant decreases were found in the frequencies of inpatient admissions and emergency visits, as well as in inpatient length of stay and the total cost of services. This cost, including that of nurse case management service, as determined by Huggins (1996), represented a 61% decrease from the total cost before nurse case management was started.

A pollution survey was done in Milnerton industrial area along three transects, the coastal road, the R27 road, and the N7 road. In this project lichens were used as pollution monitors and their availability, abundance and percentage cover were used to estimate the level of pollution. Lichen specimens were collected from St. James, which is far from the pollution source and put in the vicinity of the Caltex oil refinery for four month after which they were analysed for their fluorescence and chlorophyll content. In all transects, lichen species richness and percentage cover increased with distance from the oil refinery, suggesting that indeed lichens are sensitive to pollution and are therefore good air pollution bio-monitors. The fruticose growth forms especially Teloschistes and Usnea were shown in this study to be the most sensitive to pollution because none of them was recorded close to the oil refinery. Photosynthetic pigment analyses revealed that Parmelia and Xanthoria are affected differently by pollution. Parmelia showed chlorophyll a and b injury under high pollution conditions while Xanthoria showed high carotenoid injury. The results of this study indicate that the atmosphere in the Milnerton industrial area is heavily polluted, with the Caltex oil refinery being the main pollution source.

Thesis (Ph. D.)--Michigan State University. Dept. of Statistics and Probability, 2006.
Title from PDF t.p. (viewed on June 19, 2009) Includes bibliographical references (p. 92-98). Also issued in print.

The purpose of this research was to understand cost containment strategies used by private hospitals under managed care plans and their relationship to quality of care within the South African environment. The data was collected using a questionnaire consisting of closed questions requesting respondents to rate statements about costs and quality of care, as well as open questions for additional information about costs and quality of care. The study found that managed care has the ability to control costs and that hospitals monitor LOS and prescribe generic medication in order to control costs. The study also found that cost control strategies have a negative impact on quality of care and that hospitals place more emphasis on cost control than quality of care. In addition, large hospitals that enjoy high occupancy rates experienced an increase in patient complaints since the introduction of managed care, compared to small and medium hospitals. The study found that managed care has had a better than average impact on controlling costs and a better than average impact in quality reduction, however the correlation between cost control and quality reduction was negative. Finally, the study found that technology has an impact on rising healthcare costs and that any constraints placed on rising costs associated with technology will have a negative impact on quality of care. Copyright
Dissertation (MBA)--University of Pretoria, 2010.
Gordon Institute of Business Science (GIBS)
unrestricted

Thesis (M.C.P.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning, 1985.
MICROFICHE COPY AVAILABLE IN ARCHIVES AND ROTCH.
Bibliography: leaves 141-149.
by Linda Ostreicher.
M.C.P.

Prior to the Gulf War, Iraq’s public health system was one of the most advanced in the Middle East region. Malnutrition rates were low, primary health care was easily accessible, and tertiary (hospital-based) care was becoming increasingly sophisticated. Infant mortality was 47 per 1000 live births per year and the mortality rate of children less than five years old was 56 per 1000 live births per year. When you are citing the document, use the following link http://essuir.sumdu.edu.ua/handle/123456789/32146

It is estimated that one out of every five household with children in the United States includes a Child with Special Health Care Needs (CSHCN). Families of CSHCN face many challenges including financial burdens beyond that of other families and difficulty accessing much needed pediatric specialty care. Telemedicine provides a potential solution or, at the least, an alternative to the traditional system of care, for health care providers and communities to address access and financial concerns of families of CSHCN. A quasi-experimental research design was used in this study to examine the differences in cost, caring, and family-centered care in relation to pediatric specialty services utilizing telemedicine technology compared to traditional face-to-face care. The study sample included a convenience sample of 222 parents/ guardians of CSHCN residing in rural, remote and medically underserved areas of Southeast Florida enrolled in the Children's Medical Services (CMS) program. The sample was comprised of two study groups: traditional (n = 110) which included families receiving traditional face-to-face pediatric specialty care; and the telemedicine group (n = 112) which included families who have received telemedicine visits along with traditional face-to-face pediatric specialty care. Measures of cost, caring, and family-centered care were obtained using three instruments including a Family Cost Survey, Caring Professional Scale (CPS), and Measure of Processes of Care- 20 Item Scale (MPOC-20). Results indicated that there were no significant differences in family costs when telemedicine was available locally compared to traditional face-to-face care in the local community. Family costs were anticipated to be significantly higher if telemedicine was not available in their communities. There were no differences in the families' perceptions of care as caring for the telemedicine and traditional groups. Results indicated significant differences between the groups in regards to family-centered care, with telemedicine group parents/ guardians reporting more positive perceptions of the system of care as family-centered compared to families receiving traditional face-to-face pediatric specialty care. These results together underscore the importance of assuring and facilitating access to pediatric specialty care for CSHCN and their families by further reducing their burdens and costs. The use of innovative systems of care such as telemedicine has promise to promote caring, family-centered systems of care in their home communities. Future research is recommended to further examine nursing roles and interventions in telemedicine programs, measurement tools, and family perceptions of systems of care across different populations.

Disparate healthcare experiences continue to pose a challenge; vulnerable populations such as low-income and racial and ethnic minorities may not be able to afford or utilize care when needed or receive quality care. The sources of disparities are complex and multi-factorial, which include health care system-level factors such as insurance and health care workforce. It is relatively less known to what extent these contribute to disparities related to a patient’s overall health care experience across three important domains – affordability, utilization and satisfaction with care. This dissertation has three objectives. First, to assess how insurance benefit design affects health care utilization among poorest adults. Second, examine the role of insurance in addressing racial and ethnic disparities in access to preventive care. Finally, examine the role of health care providers in differences related to satisfaction with care among low-income patients. To answer questions posed in this dissertation, two different types of datasets are used: a unique hospital administrative data from a coverage program for low-income adults and 2008-2014 Medical Expenditure Panel Survey (MEPS). To examine the role of insurance and health care providers in disparities related to different outcomes of patient experience, several models are estimated; including mixed effects linear probability and negative binomial regressions, decomposition and multivariate linear probability models. Several efforts are being made to address inequalities through coverage expansions, removal of financial barriers for preventive services and incentivizing health care providers to improve patient satisfaction. The findings suggest that differences in utilization and satisfaction with care continue to persist among low-income and racial and ethnic minorities. However, policy levers and system-level reforms including value-based insurance designs that may curb healthcare costs without shifting the cost burden to poorer adults, continued reforms to expand coverage and improve access to a usual of care, and policy interventions that extend beyond improving workforce diversity and enhance provider skills to elicit patient communication preferences may foster positive patient experiences and ameliorate existing disparities. Improving patient experiences of care will thus require policy efforts with a comprehensive multi-level strategy that targets broad sectors – including payers, health care providers and society at large.

Introduction. Lung recipients are faced with life-threatening complications which may impede in reaching an acceptable overall clinical and HRQOL level. Furthermore, the reported costs associated with the rigid follow-up care and expensive drug regimen raises the question whether this intervention is cost-effective.
Objectives. To determine the incremental cost-effectiveness (C/E) and cost-utility (C/U) of lung transplantation (L-Tx) according to the health system perspective.
Methods. A C/E and C/U analysis of L-Tx was carried out on 124 patients accepted unto the Quebec L-Tx waiting list (1997--2001). Survival was presented in mean life years (LY). HRQOL and utility were assessed using the SF-36 and standard gamble; they were studied cross-sectionally and longitudinally on a group of patients. Utility was used in the computation of the QALY. The economic impact of L-Tx was based on direct medical costs for 3 time periods: the waiting list, the transplant procedure and post-transplant phase. In the incremental C/E and C/U ratio, the costs for the procedure and follow-up care were compared to those during the waiting list, which served as an estimate for costs without transplantation. Estimates were modeled beyond the study period based on registry data. Simulating different person-time experiences during the waiting time (1 to 6 years) and post-transplant phase (1 to 8 years) tested key assumptions. Costs were based on provincial and national data and were discounted at a rate of 5%.
Results. The estimates were based on the 1,090.0 and 1,421.5 person-months contributed by the cohort (N = 124) to the waiting list and post-transplant phase (N = 91), respectively. The mean LYs and QALYs gained were 0.57 (95% CI: 0.36--0.78) and 0.62 (95% CI: 0.36--0.78), respectively. HRQOL was higher on average for all domains in lung recipients versus candidates. Utility scores were also higher in recipients as compared to candidates: 0.76 (95% CI: 0.69, 0.83) versus 0.17 (95% CI: 0.12, 0.22). The estimated total average cost per patient without Tx was $15,015 or $1,708 (95% CI: $1,327--$2,090) per month. The L-Tx program induced an additional screening cost of $9,622 per patient. The average cost of a transplant procedure was $49,314 (95% CI: $39,216--$69,465). The average post-Tx follow-up cost per patient per month in the first, second, third and fourth year was $2,804 ($1,840--$3,792), $1,643 ($1,090--$2,291), $1,749 ($804--$2,690) and $971 ($768--$1,175), respectively.

The value-based purchase requirement of the Patient Protection and Affordable Care Act puts pressure on hospital leaders to control cost while improving quality of care. The resource dependency theory was the theoretical framework for this correlational study. Archival data from the Centers for Medicare and Medicaid Services collected from 166 acute care urban hospitals for the Fiscal Year 2016. Multiple linear regression analysis was used to determine the relationship between nursing salaries per patient day, cost of uncompensated care as a percentage of net patient revenue, percentage of net income from patient services, and overall patient satisfaction for quality of care received. The multiple regression analysis results indicated the model as a whole to significantly predict overall patient satisfaction for quality of care for the Fiscal Year 2016, F (3,162) = 13.788, p = .000, and R2 = .203. In the final model, all 3 independent variables significantly predicted overall patient satisfaction for quality of care. Nursing salaries per patient day and percentage of net income from patient services were significant positive predictors of overall patient satisfaction for quality of care. Nursing salaries per patient day (� = .366, t = 5.120, p = .000) accounted for a higher contribution to the model than percentage of net income from patient services (� = .169, t = 2.374, p = .019). The cost of uncompensated care as a percentage of net patient revenue displayed a significant negative relationship with overall patient satisfaction for quality of care (� = .176, t = €2.458, p = .015). The implications of this study for positive social change include the potential to enhance the quality of care for patients while maintaining local hospitals' financial viability.

The full abstract for this thesis is available in the body of the thesis, and will be available when the embargo expires.
Education, Faculty of
Curriculum and Pedagogy (EDCP), Department of
Graduate

Until 1982, when the National Research Institute for Oceanology (NRIO) erected self-contained, automatic weather stations (AWS) on the Cape South Coast, no continuous coastal measurements were available. This Institute had erected an AWS on the drilling rig Sedco K in 1978, so that over 3 years of very valuable off- shore data was already available on the adjacent Agulhas Bank. Al though the weather offices at George and Port Elizabeth have made accurate meteorological observations for over 30 years, this data is shown here to differ significantly from actual coastal measurements. Thus the NRIO AWS network, which operated for just over a year, provided a detailed, short-term data set for the study of coastal weather processes. In order to acquire longer term data from coastal observations, five years of hourly wind observations from lighthouse keepers along the Cape South Coast were also utilised. Although these are estimates, it is shown that a coastal estimate may be more representative of marine conditions than an anemometer reading some distance inland. Voluntary Observing Ship's data (VOS) extracted from SADCO's Marine Climatology database, provided the long-term offshore information, whilst also supplying very useful 'present weather' (synoptic code ww) observations for case studies. Observations from synoptic stations for the period that the coastal AWS were deployed (February 1982 - March 1983), were provided by the South African Weather Bureau. With this unique and comprehensive data set, the various weather systems affecting the region are discussed. Twelve case studies form the main reference for this discussion, which includes relevant oceanographic parameters. The weather systems are considered firstly as individually propagating circulations with the AWS network providing details of propagation speeds and coastwise development. Secondly the combined 'weather producing' effects of these systems are discussed, with a strong emphasis being placed on man/weather interactions. It is shown that certain operations along the Cape South Coast and over the Agulhas Bank, are extremely weather sensitive, and would benefit considerably from an increased knowledge of weather processes. Recommendations aimed not only at those managing weather sensitive operations, but also at those involved in coastal meteorological measurement and research, complete the thesis.

The thesis describes the development, research and evaluation of the applicability of a new model of care that involves GPs being employed on a sessional basis in A&E departments to treat patients attending with primary care needs. The main aim of the study was to research its cost and clinical effectiveness. A multi-faceted approach was taken to include consideration of patients' needs and preferences, professional concerns, organisational and structural issues within the health service, and planning and policy issues. Clinical, sociological, epidemiological, and economic perspectives are drawn upon, reflecting the context of the service development and to provide a firm base for discussion about the generalisability and applicability of the findings. The first two chapters provide a detailed review of the epidemiological, sociological, clinical, and organisational literature relating to the primary care/A&E interface. The incentives and disincentives that may act to increase or reduce demand and supply are explored, in addition to issues relating to the 'appropriateness' of demand, the organisational culture of A&E departments, and strategies used to curtail or cope with demand. The demand for primary care at A&E departments appears to cross national boundaries and hence, literature from other countries (particularly the USA) is included and its applicability to the UK considered. Relevant literature relating to the quality of A&E care, patient satisfaction, and the costing of care is also discussed. The main study was a prospective controlled trial that was conducted at King's College Hospital. This compared process variables, clinical outcome and costs of 'primary care' consultations performed by senior house officers (SHOs), registrars, and general practitioners working three-hour sessions in A&E. A new system of nurse triage was implemented to allow the prospective identification of patients presenting with primary care needs. A total of 27 SHOs, three registrars and one senior registrar were included, and the patient sample comprised 1702 patients seen by GPs, 2382 by SHOs, and 557 by registrars or the senior registrar. GPs were found to practice considerably less interventionist care than A&E medical staff, and the resource implications were substantial. The findings are discussed critically, and their applicability is considered drawing on empirical data from recent evaluations of A&E Primary Care Service developments in other parts of London. The policy and service implications of the study are considered and further research needs identified.

Els test de tipus 'point-of-care' (POC) presenten un gran potencial per al maneig i el diagnòstic de malalties. Els dispositius POC permeten la realització de proves clíniques prop del pacient, permetent així un diagnòstic ràpid, una ràpida iniciació de tractaments, i en cas necessari, una derivació ràpida a altres centres mèdics. Aquests dispositius tenen a més el potencial de ser més econòmics, més robustos, i més fàcils d'usar que els dispositius mèdics tradicionals. Per aquests motius, els dispositius mèdics de tipus POC es consideren prometedors per als països en vies de desenvolupament, els quals són també els que necessiten de forma més urgent noves tecnologies mèdiques. En aquest context, aquesta tesi se centra en el desenvolupament de dispositius mèdics de diagnòstic in-vitro de tipus POC per salut global. Tenint en compte que els recursos per al desenvolupament i explotació de dispositius POC per a països amb baixos recursos són limitats, el Capítol 2 s'enfoca en el desenvolupament de prioritats d'investigació en salut. Mitjançant l'establiment d'aquestes prioritats es pretén facilitar la selecció d'objectius a fabricants d'instruments mèdics, així com incrementar l'impacte de les noves tecnologies desenvolupades. Els criteris de priorització considerats són molt amplis i inclouen l'impacte d'un nou test en la incidència d'una malaltia, la disponibilitat i preu dels tractaments de les malalties, la inversió tecnològica per al desenvolupament d'un nou dispositiu, i els principis bioètics. El tercer capítol descriu el desenvolupament d'un dispositiu mèdic senzill que pot ser fabricat fàcilment en laboratoris amb escassos recursos: tires reactives de diagnòstic de paper per a la detecció de biomarcadors presents en fluids biològics fabricats amb impressores de raig de tinta domèstiques i amb receptes senzilles per la preparació de les tintes. Aquesta tècnica de fabricació de tires reactives de diagnòstic va ser provada per a la detecció de deficiència de iode, un problema sever de salut global al món. En aquest capítol es presenten experiments de preparació de tintes químiques, impressió en paper, detecció de iode en les concentracions presents en l'orina, i consells per al desenvolupament de noves tintes per a la detecció d'altres biomarcadors de malalties. Aquest simple i versàtil procés de fabricació de tests de diagnòstic permetria a hospitals i laboratoris amb pocs recursos dissenyar els seus propis diagnòstics per a malalties rellevants, i en la forma i quantitat adaptada a les necessitats de cada comunitat. Desafortunadament, no totes les malalties es poden diagnosticar usant senzilles tires reactives de diagnòstic, i freqüentment es necessiten dispositius més complexos. El capítol 4 està enfocat en el desenvolupament de dispositius de PCR i RT-PCR de baix cost, a temps real, i de tipus POC que permeten detectar quantitativament patògens basats en DNA i RNA respectivament. El nostre sistema es basa en PCR de flux continu, el qual manté zones de temperatura fixes i empeny la solució de PCR entre les àrees calefactades, permetent així una transferència de calor més ràpida i conseqüentment, una PCR més veloç. Tots dos sistemes de PCR i RT-PCR van ser fabricats a partir d'un xip microfluídic sol ús dissenyat per a ser produït a baix cost industrialment mitjançant mètodes de 'roll-to-roll'. El sistema òptic permet la detecció de patògens en temps real mitjançant mesures de fluorescència. Per demostrar la funció del xip, dos bacteris infeccioses i un virus van ser seleccionats: Chlamydia trachomatis, Escherichia coli O157: H7, i Ebola virus. Per als tres patògens, es van provar diferents velocitats de flux, es va determinar el límit de detecció del sistema, i es van calcular les eficiències de les PCRs. L'èxit dels resultats obtinguts i la versatilitat del sistema, fa que aquests dispositius es considerin prometedors per al diagnòstic d'altres patògens com Zika o chikungunya, que constitueixen amenaces mundials a la salut pública. Tots dos dispositius de diagnòstic in vitro presentats en aquesta tesi són bons exemples de dispositius de diagnòstic apropiats per a salut global.
Los test de tipo ‘point-of-care’ (POC) presentan un gran potencial para el manejo y el diagnóstico de enfermedades. Los dispositivos POC permiten la realización de pruebas clínicas cerca del paciente, permitiendo así un diagnóstico rápido, una pronta iniciación de tratamientos, y en caso necesario, una derivación rápida a otros centros médicos. Estos dispositivos tienen además el potencial de ser más económicos, más robustos, y más fáciles de usar que los dispositivos médicos tradicionales. Por estos motivos, los dispositivos médicos de tipo POC se consideran prometedores para los países en vías de desarrollo, los cuales son también los que necesitan de forma más urgente nuevas tecnologías médicas. En este contexto, esta tesis se centra en el desarrollo de dispositivos médicos de diagnóstico in vitro de tipo POC para salud global. Teniendo en cuenta que los recursos para el desarrollo de dispositivos POC para países con bajos recursos son limitados, el Capítulo 2 se enfoca en el desarrollo de prioridades de investigación en salud. Mediante el establecimiento de estas prioridades se pretende facilitar la selección de objetivos a fabricantes de dispositivos médicos, así como incrementar el impacto de las nuevas tecnologías desarrolladas. Los criterios de priorización considerados son muy amplios e incluyen el impacto de un nuevo test en la incidencia de una enfermedad, la disponibilidad y precio de los tratamientos de las enfermedades, la inversión tecnológica para el desarrollo de un nuevo dispositivo, y los principios bioéticos. El segundo Capítulo 3 describe el desarrollo de un dispositivo médico sencillo que puede ser fabricado fácilmente en laboratorios con escasos recursos: tiras reactivas de diagnóstico de papel para la detección de biomarcadores presentes en fluidos biológicos fabricados con impresoras de chorro de tinta domésticas y con recetas sencillas para la preparación de las tintas. Esta técnica de fabricación de tiras reactivas de diagnóstico fue probada para la detección de deficiencia de yodo, un problema severo de salud global en el mundo. En este capítulo se presentan experimentos de preparación de tintas químicas, impresión en papel, detección de yodo en las concentraciones presentes en la orina, y directrices para el desarrollo de nuevas tintas para la detección de otros biomarcadores de enfermedades. Este simple y versátil proceso de fabricación de tests de diagnóstico permitiría a hospitales y laboratorios con pocos recursos diseñar sus propios diagnósticos para enfermedades relevantes, en una forma y cantidad adaptada a las necesidades de cada comunidad. Desafortunadamente, no todas las enfermedades pueden diagnosticarse usando sencillas tiras reactivas de diagnóstico, y frecuentemente se necesitan dispositivos más complejos. El Capítulo 4 está enfocado en el desarrollo de dispositivos de PCR y RT-PCR de bajo coste, de tiempo-real, y de tipo POC que permiten detectar cuantitativamente patógenos basados en DNA y RNA respectivamente. Nuestro sistema se basa en PCR de flujo continuo, el cual mantiene zonas de temperatura fijas y empuja la solución de PCR entre las áreas calefactadas, permitiendo así una transferencia de calor más rápida y consecuentemente, PCR más veloces. Ambos sistemas de PCR y RT-PCR fueron fabricados en base a un chip microfluídico desechable diseñado para ser producido a bajo coste industrialmente mediante métodos de ‘roll-to-roll’. El sistema óptico permite la detección de patógenos en tiempo real mediante medidas de fluorescencia. Para demostrar la función del chip, dos bacterias infecciosas y un virus fueron seleccionados: Chlamydia trachomatis, Escherichia coli O157:H7, y Ebola virus. Para los tres patógenos, se probaron diferentes velocidades de flujo, se determinó el límite de detección del sistema, y se calcularon las eficiencias de las PCRs. El éxito de los resultados obtenidos y la versatilidad del sistema, hace que estos dispositivos se consideren prometedores para el diagnóstico de otros patógenos como Zika o chikungunya, que constituyen amenazas mundiales a la salud pública. Ambos dispositivos de diagnóstico in vitro presentados en esta tesis son buenos ejemplos de dispositivos de diagnóstico apropiados para salud global.
Point-of-care (POC) testing has great potential for the management and diagnosis of disease. POC devices allow for testing close to the patient permitting rapid diagnosis, prompt treatment initiation, and when needed, quick referral to other health-care units. They have the potential to be lower-cost, more robust, and more user-friendly than traditional medical devices. For these reasons, POC diagnostic tests are a promising approach for the developing world, where there is also the most urgent need for new health technologies. In this context, this thesis is focused in the development of POC in vitro diagnostic tests for global health. Considering that the resources for developing POC devices for low-resource settings are limited, during Chapter 2 we focused on setting health research priorities to aid test developers setting their targets to increase the impact of the technology. The criteria for prioritization considered were very broad and took into account the impact of a new test on the burden of disease, the availability and expense of disease treatments, the technological investment to develop a new device, and the bioethical principles. Chapter 3 describes the development of a medical device that can be easily manufactured in limited resources laboratories: paper diagnostic chemical dipsticks to detect biomarkers present in biological fluids produced with domestic inkjet printers and simple ink preparation recipes. This fabrication technique for diagnostic strips was tested for the detection of iodine deficiency, a severe global health problem worldwide. In this chapter we present successful experiments for chemical inks preparation, printing on paper, detection of iodine in the concentrations present in the urine, and guidelines for new ink development to target other disease biomarkers. This simple and versatile manufacturing process for diagnostic tests would allow hospitals and laboratories with limited infrastructure to design diagnostics for relevant diseases in a format and quantity adapted to each community needs. Unfortunately, not all diseases can be diagnosed using simple chemical dipstick assays and more complex diagnostic devices are required. Chapter 4 is focused on the development of a low-cost, real-time, point-of-care PCR and RT-PCR systems for quantitative detection of DNA and RNA-based pathogens. Our systems are based on continuous-flow PCR which maintains fixed temperatures zones and pushes the PCR solution between heated areas allowing for faster heat transfer and as a result, faster PCRs. Both PCR and RT-PCR systems were built around disposable microfluidic chips designed to be economically produced industrially by roll-to-roll embossing methods. The optical system allows for pathogen detection via real-time fluorescence measurements. To demonstrate the function of the chips, two infectious bacteria and one viral target were selected: Chlamydia trachomatis, Escherichia coli O157:H7, and Ebola virus. For the three pathogens, different flow velocities were tested, the limit of detection of the system was determined, and PCR efficiencies were calculated. Our successful results, and the versatility of our system, make it promising for the detection of other DNA and RNA-based pathogens such as Zika or chikungunya, which constitute global health threats worldwide. The two in vitro diagnostic tests presented in this thesis are good examples of promising POC diagnostic devices appropriate for global health.

This thesis is concerned with the issues of placement, process and cost in care of the elderly. Each of these aspects of care are treated separately, though some effort is made to explore the relationship between them. Placement has an affect on process, in the sense that care in the home is very different to care in an institution. However, there may also be variation in the process of care among institutions, with the result that care patterns may not be homogenous, even for similarly dependent elderly persons. The caring process and the manner in which resource use is quantified and valued has implications for costs; this is obvious when the care provided by family and friends is included in the analysis. Finally, the cost of care has a major influence on placement, particularly in recent years, as budget constraints have become tighter and decisions on where to treat old people are being made, more and more, on the basis of value for money. The thesis has three main objectives. The first is to investigate the factors that affect the placement of old people. An analysis of placement using a logit estimation procedure will facilitate a discussion as to why some old people are more likely to end up in institutional care than others. The second objective is to examine the process of care within institutions and at home. Of particular interest is the quantitative relationship between the dependency of old people and the care provided by health care professionals in institutions. If differences in the caring process do emerge among institutions caring for similarly dependent old people, it may be evidence of technical inefficiency, and an important first step in the identification of optimal practice. The final objective is to provide an estimate of the cost of care for vulnerable old people living in the community. An opportunity cost framework is used to calculate costs. Consequently, the contribution of informal carers is both quantified and valued. Four main conclusions emerge from the research. First, the placement of old persons is affected by disability characteristics, social factors and the availability of community care services. Second, there is not a simple positive linear relationship between dependency and care provision in long-stay institutions, at least for some disability characteristics. Third, different practices exist among institutions in respect of the care of long-stay patients. Finally, the opportunity cost of care in the community is relatively high and increases with dependency.

Background: High quality evidence on the cost-effectiveness of planned birth in alternative settings (at home, in a midwifery unit or an obstetric unit) has been lacking, and is a priority area for maternity policy. Aim: To provide evidence about the efficiency of the configuration of maternity care in England and to estimate the cost-effectiveness of alternative settings for intrapartum care for ‘low risk’ women, thereby providing guidance for commissioners, clinicians and for pregnant women and their families. Methods: A literature review of existing evidence was followed by four stand-alone empirical studies using different methods to determine the efficiency and cost-effectiveness of alternative settings for intrapartum care. Data from the Birthplace in England Programme of Research were analysed to explore whether there are differences in the efficiency of maternity units when they are stratified according to the type and scale of unit. Incremental cost-effectiveness ratios were used to estimate the short-term cost-effectiveness of different planned settings for birth for ‘low risk’ women and to develop a template for the design of decision-analytic models to estimate life-long cost-effectiveness for the mother and baby dyad. Findings: The larger obstetric units (OUs) tended to be more efficient than the smaller OUs. Less than half of free-standing midwifery units (FMUs) were operating at full efficiency. The cost of intrapartum and after birth care, and associated related complications, was less for births planned at home, in a free standing midwifery unit (FMU), or in an alongside midwifery unit (AMU) compared with planned births in an obstetric unit (OU). Planned birth in a FMU or in an AMU compared with an OU will generate incremental cost savings but with uncertainty surrounding the outcomes for the baby. Planned birth in all non-OU settings generated incremental cost savings and improved outcomes for mothers. For ‘low risk’ women having a second or subsequent birth, planned birth at home was found to be the most cost-effective option.

Insurance is a vital factor in the billed cost to the patient, but to what degree does insurance explain the amount a patient is left to pay? Also, does obesity further influence patient’s billed cost? This thesis assesses the type of thoracic trauma patient, insurance status, and their billed cost. Database variables were analyzed in IBM SPSS 25. Table 1 characteristics were evaluated based on demographics and systematic hospital factors. Linear regressions used Private0_Government1 and BMI Obese n_y_ as independent variables while Total Patient Cost was the dependent variable. Private0_Government1 insurance explained .03% of Total Patient Charges. Private0_Government1 and BMI Obese n_y_ explained 1.4% of Total Patient Charges. Private0_Government1 and BMI Obese n_y_ explained a low percentage of Total Patient Charges. This shows that there are factors other than insurance type and obesity that are influential upon patient charges.

Thesis (MBA)--University of Stellenbosch, 2010.
The aim of this research report is to identify and quantify the cost drivers of three district hospitals in the Western Cape, namely Knysna Hospital, Oudtshoorn Hospital and Mossel Bay Hospital, and to simultaneously measure value-driven performance indicators. An environmental scan identified various driving forces that would significantly affect change in the healthcare industry such as the brain drain of health professionals, consumerism and cost containment and efficiency initiatives. The Department of Health’s understanding of the eighth Batho Pele principle of value for money is generally understood as providing quality health care within prescribed cost limits. An attempt is made to establish the effect of the quadruple burden of disease (the HIV/AIDS pandemic, persistent infectious diseases, injury arising from violence and road traffic collisions and emerging chronic conditions) on hospital expenditure in the Eden District. Research identified Mossel Bay as a high TB burden area known as a TB “hotspot” and it is a recognized immigration transit point en route to Cape Town. The population analyses revealed that Mossel Bay is the growth point of the Eden District, showing extraordinary growth of 25% between 2007 and 2009. Personnel costs: This study revealed that personnel costs are responsible for the overwhelming majority of the total expenditure of the district hospitals.Staff numbers, occupation specific dispensation (OSD) implementation and annual wage negotiations are the cost drivers of personnel costs. This study also found a clear correlation between an over-expenditure in personnel expenses and over-expenditure in the total expenditure of all three hospitals. Health care costs: Expenditure on blood products is considered a major cost driver of clinical expenses. Laboratory expenditure is clearly the largest cost driver for clinical expenses at all three hospitals. Together with laboratory expenses, medicine and medical supplies are the cost drivers for clinical expenses. Costs not related to health care: The three most significant administrative expenses are communication, stationery and printing as well as travel and subsistence allowances. The cost driver for subsistence and travel expenses is the number of vehicles followed by the preference of vehicle, which in turn determines the daily tariff and the kilometre tariff. This study revealed that Knysna Municipality has the cheapest electricity cost of the three towns. It is clear that cost and consumption of electricity and water are the two variables that affect municipal service expenditure the most. Equity: When the district hospital expenditure is combined with the primary health care expenditure in the three sub-districts, the figures show that Oudtshoorn is spending 3% more than its equitable share of the total budget at a higher cost of R978 per capita, in excess of R100 above the district average. Efficiency: The cost per patient day equivalent (PDE) per economic classification for all three hospitals is less than the average cost per PDE of the district hospitals in the Western Cape. The cost/PDE of Oudtshoorn Hospital is considerably higher than that of Knysna and Mossel Bay in all economic classifications, with the single exception of the agency cost of Mossel Bay Hospital. The cost of health care always reflects a combination of price, quantity and value, and it is impossible to consider individual cost drivers in isolation. Several cost-saving initiatives and managerial control measures are recommended.

Antalet anhörigvårdare i Sverige är många. För att de anhöriga ska orka vårda sina närstående 24 timmar om dygnet, sju dagar i veckan behöver det finnas ett stöd. De anhörigstöd som finns varierar från kommun till kommun. Ett anhörigstöd som har utarbetats för att underlätta insatsbehovet är COAT- Carers Outcome Agreement Tool som syftar till att kartlägga anhörigas behov, planera och följa upp anhörigstöd. COAT har en grund i partnerskapsmodellen och i modellen ses den anhörige som experten på situationen runt den närstående. De studier som är gjorda med anhöriga har mycket positiva resultat. Det är få studier gjorda utifrån personalperspektivet därför avsåg vi att undersöka deras individuella erfarenheter utav att använda COAT. Tio stycken kvalitativa intervjuer med personal är utförda i studien och analyserades med hjälp av en innehållsanalys. Fem kategorier trädde fram i analysen och presenteras i resultatet. I kategorierna beskriver vi det som personalen berättat i intervjuerna. Personalen är uteslutande positiva till instrumentet och de anser att det bör användas i större utsträckning. Diskussionen är formad utifrån våra forskningsfrågor och diskuteras med stöd av tidigare forskning. Vi diskuterar olika begrepp och relaterar dem ur personalens synvinkel gentemot den anhörige och dennes familj.
Program: Specialistsjuksköterskeutbildning med inriktning mot distriktssköterska

The objective of this work is the evaluation of the impact of new direct acting antivirals for Hepatitis C as a case of disruptive healthcare innovation that challenged healthcare systems. Two systematic reviews address cost-utility analyses of new therapies and productivity costs of Hepatitis C. Then we present an assessment of clinical guidelines update at a European level from 2016 to 2018 and the method addresses methodological issues identified as lacking in previous works. Specifically, the Markov model included productivity cost measurement and real drug acquisition costs. The results confirm that European update on Hepatitis C treatment recommendations was efficient as it yielded health gains and savings on the cost side. Economic evaluation can be useful not only to assess healthcare innovations, but also as an efficiency test of clinical decisions.
L’objectiu d’aquest treball és l’avaluació de l’impacte de nous antivirals d’acció directa per a l’hepatitis C com a innovació sanitària disruptiva que va desafiar els sistemes sanitaris. Dues revisions sistemàtiques analitzen els estudis de cost-utilitat de les noves teràpies i els costos de productivitat de l’hepatitis C. A continuació s’avalua l’actualització de les recomanacions clíniques a nivell europeu entre el 2016 i el 2018 i el mètode inclou qüestions metodològiques que s’han identificat com a mancances en treballs anteriors. En concret, el model Markov incorpora els costos de productivitat i els costos reals d’adquisició dels medicaments. Els resultats confirmen que l’actualització europea sobre les recomanacions de tractament contra l’hepatitis C va ser eficaç, ja que va generar guanys en salut i estalvis en costos. L’avaluació econòmica pot ser útil no només per avaluar les innovacions sanitàries, sinó també com a test d’eficiència de les decisions clíniques.