Dissertations / Theses on the topic 'Continuity of care'

'Continuity' is frequently cited as a core value for UK general practice, and in this context usually appears conceptualised in terms of personal continuity or ongoing relationships between patients and general practitioners (GPs). Formal definitions include other dimensions such as continuity of information, and the co-ordination of care, and these are more promoted in recent UK policy documents and by organisational change. Two studies were conducted for this thesis. The first used multilevel regression analysis of survey data from over 25,000 patients in 53 general practices to explore the distribution of 'continuity' in the sense of whether or not patients were seeing their 'usual or regular' GP. The key findings were that measured 'continuity' was lower in larger practices and those with shared lists where patients can see any GP. Younger patients and those without chronic disease were less likely to be seeing their usual or regular GP, although whether the age association represents a cohort or lifecycle effect cannot be addressed with cross sectional data. In the second study, thirty-two patients and sixteen GPs were interviewed about what they valued about general practice. Interviews were semi-structured, and the data were analysed qualitatively. A thematic analysis of which dimensions of 'continuity' were valued by patients and GPs, and how these related to other valued processes and outcomes of general practice care was developed. Further analysis focused on the ways that GPs used 'continuity' to construct a particular kind of professional identity, and whether patients accepted or rejected the claims to a particular identity made by GPs. Both GPs and the majority of patients emphasised the importance of personal continuity. A key difference was that patients talked about routinely balancing personal continuity against access, with their preference varying with the nature of the problem to be discussed. The majority of patients said that they usually preferred to wait to see 'their' GP, but a few solely prioritised speed or convenience of access. GPs and patients ascribed a similar range of advantages to personal continuity, but GPs focused on benefits in terms of better diagnosis and management of problems, whereas patients emphasised feeling more at ease, being able to be more active in consultations, and increased trust and legitimacy. In formal definitions, the different dimensions of'continuity' are made conceptually distinct. But for these GPs and patients, different dimensions of continuity were interwoven. Personal continuity (an ongoing relationship) and longitudinal continuity (seeing the same GP) were routinely conflated, and GPs described complex interactions between the different ways of knowing the patient associated with personal continuity and with continuity of information embodied in the medical record. Personal continuity was frequently deployed by GPs to distinguish themselves from hospital doctors. This boundary was repeatedly constructed without prompting throughout the GP interviews, suggesting that it was a problematic area. This appeared to be because of hospital doctors' greater expertise in diagnosis and management of particular diseases or problems, something acknowledged by GPs and taken for granted by patients. In contrast, GPs appeared to assume that their control of medical knowledge made their identity with regard to nurses unproblematic. Supporting this, patients talked about nurses' work largely in terms of the tasks done, and said they did not greatly value ongoing, personal relationships with nurses. Underpinning both of these boundaries was a shared assumption of medical work as primarily being the diagnosis and management of problems, with a stronger biomedical emphasis than was immediately apparent in talk about 'personal continuity'. The data are used to discuss the ways in which personal continuity appeared central to patients' and GPs' experience of general practice, and to the construction of a stable professional identity for GPs. The usefulness of 'continuity' as a research or policy concept is then explored. Although formal definitions of'continuity' are conceptually helpful, different dimensions of'continuity' are likely to be interdependent within an individual health care system. Understanding 'continuity' therefore requires a sensitivity to this wider context. Finally, possible implications of current organisational change for the experience of 'continuity' by patients and the professional identity of GPs and general practice are examined.

In Ontario, the population of older adults is increasing. While the provincial government is taking action to address increasing demand on health systems, older adults are still suffering the consequences of a health system that is not able to meet their complex care needs. Older adults face barriers to continuity of care including difficulties with memory, reliance on informal caregivers, frailty, and difficulties scheduling appointments. These barriers also exist within the long-term care setting. Long-term care facilities are making efforts to provide more effective care, including designing care approaches aimed to meet the complex care needs of older adults. Aspects of a goal-oriented approach suggest that it has the potential to reduce fragmentation and positively impacting continuity of care. However, the impact of goal-oriented care on continuity of care in a long-term care setting has yet to be explored. This thesis uses an exploratory case study methodology to describe how a goal-oriented care approach influenced continuity of care in a long-term care setting, as perceived by residents, staff, and administrators. The case study setting is the Perley & Rideau Veterans Health Centre in Ottawa, Ontario, where the SeeMe program, a frailty-informed approach with a goal-oriented component, was recently introduced. Factors associated with the SeeMe program and other organizational factors perceived to facilitate and inhibit informational, relational and management continuity were identified. Aspects of the SeeMe program that facilitated informational continuity were: goals-of-care meetings with residents, their care team and family; care conferences that helped residents understand their care options; and, procedures that ensured consistency in where resident’s goal information is stored. Aspects that facilitated relational continuity were: understanding residents’ values and preferences; staff increasing awareness of the program for families; and, integration of the family perspective into a resident’s care. Program aspects that facilitated management continuity were: discussions that led to informed decision-making; use of assessments as a reference tool in the case of an acute health event; discussions that empowered residents to talk to external care providers; and, creation of a structure that facilitated consistencies in care. These factors can be targeted when designing care approaches aimed to improve continuity in long-term care settings.

Background Communication regarding medicines at hospital discharge via discharge summaries is notoriously poor and negatively impacts on patient care. With the process being dependant on the quality of patient records during admission, junior doctors who write them and General Practitioners (GPs) who receive them, the objectives of this thesis were, with respect to discharge summaries, to:-  assess their timeliness, accuracy and quality  describe GP preferences  explore experiences of junior doctors regarding their preparation. Methods Discharge summaries produced from one district general hospital were audited, as was the impact of changing the format of inpatient drug charts. A combination of observation, think-aloud and ethnographic interviews were conducted to investigate experiences of junior hospital doctors preparing summaries. A survey of GPs and junior doctors was undertaken to compare attitudes towards the discharge process. A pilot Discrete Choice Experiment (DCE) was developed and undertaken with GPs to determine their preferences with respect to the format, quality and timing of discharge summaries. Results A large proportion of discharge summaries were found to be inaccurate, however this was reduced when checked by a pharmacist. Key barriers to summary preparation identified were lack of time, training and knowledge of the patient. GPs perceived medicine changes on discharge summaries to be more important than did junior doctors. The DCE found that GPs were willing to trade timeliness of discharge summaries with accuracy. Discussion and conclusions The error rate within discharge summaries highlights the importance of a pharmacy accuracy check. The national requirement to deliver discharge summaries within 24 hours of discharge results in the pharmacist being bypassed and places additional pressure on junior doctors to prepare them in a timely manner, which might provide explanation for poor quality. Interestingly, GPs were willing to forego receipt of discharge summaries within 24 hours in preference for a reduced error rate. Keywords: patient discharge, discharge summary, patient transfer, interdisciplinary communication, medication errors.

The presented research focuses on sociocultural ability to sustain the built heritage as a dynamic living place. A human habitat is defined as a genius loci site - manifesting intangible qualities of a material site, perceived both psychically and spiritually. From this perspective, the heritage conservation doctrine often does not correspond to spiritual qualities of genius loci ‘living’ sites. From the theoretical perspective the author defines the preservation of genius loci sites as a care for continuity. To sustain the continuity and to provide day-to-day life happening in the building, the main objective is the inside perspective of the dweller or doer, as through the commitment of human interaction the spirit of place brings the environment to a life. The case of Riga Circus Building, seen as a genius loci site, is accordingly sustained as a care for continuity. In order to provide for local communities to continue inhabiting the building, while maintaining the spirit of place, the author outlines several design principles. The research and its application into a real genius loci site resulted in four basic conclusions. First, that - genius loci sites can not be recreated deliberately, because they are ‘accident’, and not inventions. Second, as those sites are not creations, they are not able to accept radical changes, while minor ones are tolerable. Third, that the present conservation policy is, perhaps, able to protect the genius loci sites against threats, however, often it neither aims in maintaining continuity, nor is able for a comprehensive engagement in general domains of human interactions. Forth, the best possible way to preserve genius loci site, as such - Riga Circus Building, is to assure its continuity.

Continuity of care in mental health care is considered both an important objective of NHS policy and vital to clinical practice. However, it remains poorly defined and there is little research into its association with outcomes. Mental health services are unique in their ability to legally compel patients to adhere to treatment in the community and there has been no research into how this may affect continuity. My thesis aims to critically appraise the definition of continuity of care and systematically review the literature on its association with outcomes. It also measures its association with readmission by conducting a longitudinal study, and measures the association between community compulsion and continuity of care. The literature review confirmed that continuity of care is best understood as the process of care of an individual patient over time. This is perceived by both the patient and providers of care as comprehensive, consistent, and connected. The systematic review found little evidence for an association between continuity of care and outcomes but that this may be due to persisting variation in both measures and outcomes. Results from the longitudinal study suggested that better continuity was associated with both better and worse hospital outcomes. Community compulsion had no association with continuity of care. My findings suggest that patient follow-up has improved considerably in the last three decades and, because of this, some traditional measures of continuity may be redundant. Measures of frequency of contact do not accurately measure the flexible, assertive practice that is a feature of current services. Continuity of care is useful as an indicator of the process of care but for it to be an effective research tool there needs to be a radical change in the way it is measured. Current mental health services are characterised by separation and specialisation into different components of care. Therefore, the most useful measures of continuity of care may be ones which successfully measure how it can be maintained between these services.

The aim of this study is to determine the effect of two approaches of social work intervention, a continuity approach, and a team approach, upon the three dependent variables of subject satisfaction, control, and mood. In order to determine differences in outcome, subjects were administered psychological tests to determine changes in their reported sense of control and mood (hopelessness) in relation to their response to the diagnosis and treatment of cancer. At follow-up, subjects also completed a questionnaire designed to determine their satisfaction with social work services received. The amount of time spent in contact with social workers was also assessed at this time. The analysis of the relationship between these variables revealed that there were no statistically significant differences between the study groups; subjects were equally satisfied with the two approaches in social work intervention, and there were no major differences between the reported changes in mood and control by the subjects in the study groups.
Medicine, Faculty of
Population and Public Health (SPPH), School of
Graduate

Not much has changed for the migrant farmworker in the last thirty years. In one of the wealthiest countries on earth, migrant farmworker health status remains comparable to that found in Third World countries because of poor sanitation, poor nutrition and exposure. Current estimates show that migrant clinics are serving less than 20% of this population, leaving about 2,000,000 farmworkers without medical care. The barriers to health care for this population are numerous. This study will focus on the barrier to care resulting from lack of continuity in care due to poor inter-clinic communication. In this study it has been shown that computer disks and a standard word-processing program can be used to create a portable medical health history for the migrant to improve inter-clinic communication. In the process of carrying out this study, it was also shown how other barriers to care for this vulnerable population might be removed as well.

Includes bibliographical references.
Continuity of care (COC) is a fundamental concept in Family Medicine. The rollout of antiretrovirals in the primary care setting of the public health care system in South Africa was 'vertically' isolated from the other clinics. This isolation provides a rich environment to research COC. The present project describes the longitudinal COC in the Ubuntu ART/TB Clinic in Site B, Khayelitsha, which is one of the oldest clinics with a total of 6000 patients on ARVs since May 2001. An observational period of the last five visits of patients to the clinic was used to measure the COC as a simple Continuity Fraction (CF)(alternatively called the Usual Provider Continuity/UPC), which was compared with more complex formulas for measuring COC including the K-index, SECON, COC-index and Alpha-index. The nature of the appointments was also explored, in terms of whether the patient was attended to by a nurse or a doctor and whether it was a proxy visit. Since viral loads are a very good indicator of adherence, they were compared to the COC over the observation period of the last five visits. The data showed a nurse-driven clinic achieved a CF below 50% (0.5). The 0.5 COC score seems to be a benchmark for good COC, yet it is difficult to statistically verify. The CF scored higher than the other COC formula scores, yet correlated well with other COC formulae. The CF scores with nurses were more positively related to better virological outcomes than the other COC formulae, though none were statistically significant. Unscheduled and proxy visits were not associated with higher VLs. The statistical test of General Linear Modelling with Poisson Regression with robust error variance could be an alternative way of proving that better COC has a measure of impact on the outcomes. Due to the different role of doctors, doctor visit(s) resulted in higher sequentiality scores, but a decrease in suppressed VL. These COC scores also do not completely explain the good virological outcomes in this clinic, which is considered a well managed public sector clinic in Khayelitsha. The CF places a simple tool in the hands of a clinician at the primary level to measure individual provider continuity; however there is need to test its reproducibility in other contexts of chronic care in order to develop standards. The K-index emerged as a simple measure of the dispersion of the longitudinal COC within the nurse team managing the stable chronic patient. In a broader perspective, this study has put the measuring of COC onto the 'radar' of the public health system in South Africa.

The fragmented nature of modern health care provision makes it increasingly difficult to achieve continuity of care. This is equally true in the context of the South African healthcare landscape. This results in a strong emphasis on the informational dimension of continuity of care which highlights the importance of the continuity of medical records. Paper-based methods of record keeping are inadequate to support informational continuity of care which leads to an increased interest in electronic methods of record keeping through the adoption of various Health Information Technologies (HITs). This research project investigates the role that various HITs such as Personal Health Records (PHRs), Electronic Medical Records (EMRs), and Health Information Exchanges (HIEs) can play in improving informational continuity of care resulting in the development of a standards-based technological model for the South African healthcare sector. This technological model employs appropriate HITs to address the problem of informational continuity of care in the South African healthcare landscape The benefits that are possible through the adoption of the proposed technological model can only be realized if the proposed HITs are used in a meaningful manner once adopted and implemented. The Delphi method is employed to identify factors that need to be addressed to encourage the adoption and meaningful use of such HITs in the South African healthcare landscape. Lastly, guidelines are formulated to encourage the adoption and meaningful use of HITs in the South African healthcare landscape to improve the continuity of care. The guidelines address both the technological requirements on a high level, as well as the factors that need to be addressed to encourage the adoption and meaningful use of the technological components suggested. These guidelines will play a significant role in raising awareness of the factors that need to be addressed to create an environment conducive to the adoption and meaningful use of appropriate HITs in order to improve the continuity of care in the South African healthcare landscape.

This research is about enhancing the continuity of patient care. It focuses on medication management at the time of patient discharge from a cardiology unit in an Australian acute care hospital. That is, during the time of the patients’ transition from tertiary to primary care. The philosophical concept underpinning the research is centred on continuity of patient care which is defined, and then described, in the context of each chapter study undertaken. The main aim of the overall research was to conduct an original, empirical research project to identify, characterise, and investigate a cohort of patients in need of ongoing care after discharge. Those subjects recruited into the Continuity of Care Project were 281 acute on chronic, cardiovascular patients. In this research, the individual chapter studies investigated the need for continuity of care by analysing the quality of prescribing recorded at hospital discharge and at medication review in the community.

When individuals with serious mental illness are discharged to the community, continuous and coordinated care are both desirable and necessary. A lack of continuity places the individual at risk for becoming lost to further services. This study explores continuity of care for persons discharged from state psychiatric facilities in Virginia to communities. Continuity of care is defined as the successful initiation and maintenance of face-to-face contact by CSB staff with individuals to be discharged from state hospitals, and the subsequent provision of services post-discharge. This study identifies factors that influence continuity of care, examines the degree to which these factors play a role and the relationships between continuity of care and client characteristics. Predictor variables include characteristics of the population-at-risk: predisposing factors (i.e., age, gender, race), enabling factors (i.e., living situation, catchment area change, and geographic location of the CSB) and need factors (i.e., length of stay, legal status, and primary diagnoses). Data sources include two large data bases, 1) survey of CSB staff on the outcome of individuals discharged to their area in FY 1992, and 2) demographic information from state mental health authority. Findings from the survey show that 83% of persons discharged had a record of the discharge at the CSB. Inhospital contact by CSB staff prior to discharge was lower (54%). Results show that individuals are more likely to receive continuity of care if they are discharged to a CSB in a rural area, have a diagnosis of schizophrenia, and do not have a primary diagnosis of substance abuse. The theoretical framework, based on the Community Support System principles and the notion of vulnerability, leads to important policy and practice implications. For example, the study suggests that new and different programs might be more effective for individuals with substance abuse diagnoses, especially in urban areas. Recommendations include a mandate for nursing provision of services, or oversight of services to assure continuity of care between service settings. Future research could improve upon the measurement of the variables, and examine consumer and provider perceptions of continuity of care as an outcome.

BACKGROUND: A comprehensive Primary Health Care approach includes clear referral and continuity of care pathways. South Africa lacks data that describe Intermediate Care (IC) services and its role in the health system. This study aimed to describe the model of service provision at an IC facility and the role it plays in the continuity of care in Cape Town. METHODS: Sixty-eight patients (65% Response Rate) were recruited in a prospective cohort design over a one-month period in mid-2011. Patient data were collected from a clinical record review and an interviewer-administered questionnaire, administered at a median interval between admission and interview of 11 days to assess primary and second ary diagnosis, knowledge of and previous use of Home Based Care (HBC) services, reason for admission, demographics and information on referring institution. A telephonic interviewer-administered questionnaire to patients or their family members post-discharge recorded their vital status, use of HBC post-discharge and their level of satisfaction with care received at the IC facility. A Cox regression model was run to identify predictors of survival and the effect of a Care-plan on survival. Seventy staff members (82%) were recruited in a cross-sectional study using a self-administered questionnaire to describe demographics, level of education and skills in relation to what they did for patients and what they thought patients needed. RESULTS: Of the 68 participants, 38 % and 24% were referred from a secondary and tertiary hospital, respectively, and 78% were resident of a higher income community. Stroke (35%) was the most common single reason for admission at acute hospital. The three most common reasons reported by patients why care was better at the IC facility than the referring institution was the caring and friendly staff, the presence of physiotherapy and the wound care. Even though a large proportion of the IC inpatients had been admitted in a health facility on the year preceding the study, only 13 patients (21%) had used a Community Health Worker (CHW) ever before and only 25% (n=15) of the discharged patients had a confirmed CHW visit post-discharge. The presence of a Care-plan was significantly associated with a 62% lower risk of death (Hazard Ratio: 0.380; CI 0.149-0.972). Notably, 46% of staff members reported performing roles that were outside their scope of practice and there was a mismatch between what staff reported doing and their actual tasks. In addition, of the 57 patients that could be traced on follow-up 21(37%) had died. CONCLUSION: Patients and family understood this service as a caring environment that is primarily responsible for rehabilitation services. Furthermore, a Care-plan which extends beyond admission could have a significant impact on reducing mortality. IC services should therefore be recognised as an integral part of the health system and it should be accessed by all who need it.

Introducción La alta especialización en la provisión de la atención, los rápidos avances en la tecnología y la diversificación de los proveedores promueve que los pacientes sean atendidos por varios profesionales de diferentes disciplinas en organizaciones y servicios diferentes. Estas tendencias, junto con los cambios demográficos y epidemiológicos, hacen que el paciente, cada vez más, esté expuesto a una atención fragmentada. La atención fragmentada, o la atención coordinada insuficientemente entre los proveedores, pueden perjudicar al paciente, debido a la duplicación de pruebas diagnósticas, la poli-medicación inapropiada y los planes de tratamiento incompatibles. Los sistemas de salud y las organizaciones disponen de diferentes intervenciones que pueden implementar para facilitar la coordinación de servicios que se proveen a los individuos y la población, como por ejemplo la introducción de organizaciones sanitarias integradas. Estas organizaciones son definidas como un conjunto de proveedores de salud que ofrece una atención coordinada a través del continuo asistencial a una población determinada y se responsabiliza de los costes y resultados de salud de la población. Sus objetivos finales son la mejora de la eficiencia global, equidad en el acceso y la calidad de la atención, a través de la mejora de la coordinación y de la continuidad entre niveles asistenciales. La continuidad asistencial es la percepción del paciente sobre la coordinación de los servicios y se puede definir como el grado de coherencia y unión de las experiencias en la atención que percibe el usuario a lo largo del tiempo. Abarca tres tipos: la continuidad de gestión clínica y la continuidad de información entre niveles de atención y la continuidad de relación con el médico de atención primaria y el médico de atención especializada. En Cataluña (España), organizaciones sanitarias integradas emergieron como una respuesta a la diversidad de proveedores en la gestión de la atención primaria, secundaria y sociosanitaria. No obstante, su desempeño ha sido analizado principalmente desde la perspectiva de los proveedores, es decir, en relación a la coordinación entre niveles asistenciales. Los estudios sobre la percepción de la continuidad asistencial, los factores que influyen y las consecuencias desde el punto de vista de los usuarios del sistema nacional de salud de Cataluña siguen siendo escasos. Objetivo Explorar la percepción del usuario sobre la continuidad entre niveles asistenciales en las diferentes áreas del sistema nacional de salud catalán, así como los factores que influyen y las consecuencias sobre la calidad de la atención, con la finalidad de contribuir a su mejora en el sistema de salud. Métodos La investigación consistió en tres estudios que abordan diferentes aspectos de la continuidad asistencial. 1) Análisis de la evidencia internacional sobre la continuidad asistencial desde la perspectiva del paciente, mediante una meta-síntesis de estudios cualitativos basada en la búsqueda bibliográfica en diferentes bases de datos electrónicas (Medline, Web of Science y Cochrane Library Plus). La estrategia de búsqueda incluyó la combinación de "continuidad asistencial" o términos relacionados, estudios cualitativos y la perspectiva del paciente. 25 estudios originales, publicados entre 1999 y 2009 que cumplieron con los criterios de inclusión fueron incluidos en la síntesis. Se realizó un análisis de contenido mediante la identificación de temas y categorías y la agregación de los resultados de los tres tipos de continuidad asistencial. 2) Análisis de la percepción de la continuidad asistencial de los pacientes con EPOC atendidos en cuatro organizaciones sanitarias integradas del sistema nacional de salud de Cataluña, mediante un estudio de caso múltiple de los pacientes con EPOC. Se seleccionó una muestra teórica en dos etapas: (i) cuatro organizaciones sanitarias integradas, (ii) dos casos de estudio de cada organización que incluían un paciente con EPOC, su médico de atención primaria, su neumólogo y su historia clínica. La información fue recogida mediante entrevistas individuales semiestructuradas con los pacientes y sus médicos y la revisión de las historias clínicas. Todas las entrevistas fueron grabadas y transcritas literalmente. Se llevó a cabo un análisis temático de contenido, segmentando la información por organización y caso, con una triangulación de fuentes y la participación de diferentes analistas. 3) Análisis de la continuidad asistencial en las diferentes áreas sanitarias del sistema nacional de salud catalán, enfocando el análisis en los tres tipos de continuidad asistencial, los factores que influyen y las consecuencias en la calidad de la atención. Se seleccionó una muestra teórica en dos etapas: (i) contexto de estudio: tres áreas sanitarias que representan la diversidad de modelos de gestión para la provisión de los servicios sanitarios y (ii) los usuarios de los servicios sanitarios. Se realizaron entrevistas individuales semiestructuradas con los usuarios de los servicios sanitarios (de 14 a 18 por área) hasta alcanzar la saturación de la información. Todas las entrevistas fueron grabadas y transcritas textualmente. Se llevó a cabo un análisis de contenido temático, segmentando la información por área de estudio, con una generación mixta de categorías y la participación de diferentes analistas para garantizar la calidad de los resultados. Se obtuvo la aprobación ética de los protocolos de estudio. Resultados En general, los pacientes atendidos en el sistema nacional de salud catalán percibieron la existencia de los tres tipos de continuidad asistencial con algunos elementos de discontinuidad identificados en todas las áreas y organizaciones sanitarias integradas de estudio. Con relación a la continuidad de la gestión clínica entre niveles asistenciales, los pacientes percibieron que habían recibido el mismo diagnóstico y tratamiento por los médicos de los diferentes niveles asistenciales, sin repeticiones innecesarias de pruebas, y con las derivaciones oportunas al otro nivel de atención cuando era necesario. Además, los pacientes señalaron de manera consistente tiempos de espera adecuados a la atención especializada en casos urgentes, incluidos las exacerbaciones de los pacientes con EPOC, y después de una derivación. Sólo unos pocos pacientes de todas las áreas identificaron elementos de discontinuidad, por ejemplo las diferentes opiniones sobre su tratamiento, algunas duplicaciones de pruebas, falta de derivaciones a la atención especializada cuando las necesitaban y tiempos de espera excesivos para algunas pruebas específicas y la derivación a la atención especializada no urgente. En referencia a la continuidad de la información entre niveles asistenciales, los pacientes de ambos estudios realizados en Cataluña, en general, percibieron que la información clínica se registró, fue transferida entre niveles mediante el ordenador y utilizada por los médicos, con la excepción de un área de estudio (Ciutat Vella en Barcelona), donde se percibió que la información fue compartida parcialmente. Además, algunos pacientes de todas las áreas destacaron que alguna información no fue compartida a través del ordenador y que algunos médicos, especialmente los médicos de urgencias y los médicos suplentes, no siempre consultaron la información de la historia clínica. Finalmente, en cuanto a la continuidad de relación, la mayoría de los pacientes señalaron que en general fueron atendidos por el mismo médico de atención primaria durante un largo periodo y por médicos suplentes en algunas ocasiones. Sin embargo, los pacientes con EPOC de algunas organizaciones sanitarias integradas destacaron una alta rotación del personal de atención primaria. Con referencia a la atención especializada, numerosos pacientes de ambos estudios señalaron inconsistencias; aunque muchos pacientes no las identificaron como un problema al considerar que todos los médicos de la atención especializada eran competentes para tratar su problema de salud y que se compartía la información clínica. Casi todos los pacientes que percibieron una consistencia del personal también desarrollaron una relación continua basada en la confianza con los médicos y el conocimiento acumulado. Se identificaron varios factores que influyen en (la falta de) la continuidad asistencial, que se clasificaron en los factores relacionados con el sistema de salud, las organizaciones y los médicos. En relación con el sistema de salud, los pacientes de ambos estudios consideraron que la clara distribución de roles y responsabilidades entre los médicos de atención primaria y especializada favoreció la consistencia del diagnóstico y tratamiento y evitó incompatibilidades en la medicación prescrita y duplicaciones de pruebas. Sin embargo, según algunos pacientes, la función de puerta de entrada del médico de atención primaria podría también extender los tiempos de espera o incluso impedir el acceso a la atención especializada. Con respecto a las organizaciones sanitarias, los usuarios consideraron que los mecanismos de coordinación implementados (historia clínica compartida, reuniones presenciales), los mecanismos de comunicación informal (uso del correo electrónico y teléfono) y la colocalización de los médicos en el centro de atención primaria, que emergieron sólo en algunas áreas de estudio, influyeron positivamente en la recepción de un tratamiento consistente, la transferencia y uso de información adecuada y las derivaciones oportunas a la atención especializada. Por otro lado consideraron que los insuficientes los recursos disponibles, evidenciados por la falta de médicos, causó largos tiempos de espera para la atención secundaria y un uso insuficiente de la información clínica. En cuanto a la continuidad de relación, según los pacientes, los pequeños centros de atención primaria en dos áreas de estudio y un sistema para la obtención de citas adecuado favorecen la consistencia del personal; mientras que la re-organización de listas de pacientes la dificultan. Por último, en relación con los factores relacionados con los médicos, la competencia técnica del médico de atención primaria promovió derivaciones adecuadas y oportunas a la atención secundaria. Consideraron que la disposición del médico a colaborar influyó en el uso de la información y evitó duplicaciones de pruebas e inconsistencias en el tratamiento. La práctica médica adecuada, así como una comunicación médico-paciente efectiva favorecieron el desarrollo de una relación médico-paciente basada en la confianza y el conocimiento acumulado mutuo. El compromiso del médico en el cuidado del paciente pareció influir tanto en el uso de la información como en el establecimiento de una confianza mutua. Los pacientes identificaron diferentes consecuencias de los tres tipos de continuidad asistencial relacionadas con la calidad de la atención y, en menor medida, con los resultados de salud. Respecto con la continuidad de la gestión clínica, los pacientes percibieron que la falta de consistencia de la atención y de acceso entre niveles resultó en un uso inadecuado de recursos, debido a que se duplicaron visitas. Además produjo angustia y posibles efectos negativos para la salud, cuando se dieron largos tiempos de espera a la atención especializada después de una derivación, que llevó a que el paciente buscara atención médica privada. En cuanto a la continuidad de la información, los pacientes destacaron que el intercambio de la información clínica entre niveles evitó la duplicación de pruebas e intervenciones médicas y la prescripción de medicamentos incompatibles. Además, los pacientes no necesitaban guardar y llevar los resultados de las pruebas al médico del otro nivel de atención. Por último, en cuanto a la continuidad de relación, los pacientes relacionaron la consistencia del personal con menos derivaciones innecesarias, sin modificaciones en el plan de tratamiento que pudieran perjudicar al paciente ni duplicaciones de pruebas. Además, percibieron que una relación continúa basada en la confianza y el conocimiento acumulado facilitó el diagnóstico y dio lugar a una sensación de seguridad y comodidad así como que el paciente siguiera adecuadamente el plan de tratamiento. Conclusiones Esta tesis contribuye con el aporte de información sobre la continuidad asistencial, un tema escasamente analizado, mediante una mejor comprensión del fenómeno percibido por los usuarios de los servicios sanitarios del sistema nacional de salud de Cataluña. Los resultados sugieren que el paciente es capaz de percibir los tres tipos de continuidad asistencial refiriéndose a atributos concretos de cada dimensión. Los tres tipos de continuidad asistencial parecen estar relacionados entre sí; particularmente la continuidad de información afecta a la continuidad de gestión clínica, y la continuidad de relación juega un papel importante al influir en la continuidad de gestión clínica y de información. Los pacientes en general perciben la existencia de los tres tipos de continuidad asistencial. Sin embargo, también señalan algunas interrupciones en la continuidad en todas las áreas de estudio. Se identificaron varios factores que influyen en la (dis)continuidad asistencial, relacionados con el sistema de salud, las organizaciones sanitarias y los médicos. Como resultado del estudio, se identificaron diferentes consecuencias de los tres tipos de continuidad asistencial en la calidad de la atención y la salud del paciente. Los elementos de discontinuidad identificados sirven para indicar donde hay margen de mejora, y los factores que influyen en la continuidad pueden ofrecer información valiosa a los directivos y profesionales de las organizaciones sanitarias en estos y otros contextos sobre dónde dirigir sus esfuerzos de coordinación asistencial; que supuestamente también mejoraría la experiencia de una trayectoria fluida a lo largo del continuo asistencial del paciente.
Introduction: Specialization in health care, rapid advances in technology and the diversification of providers cause that patients receive care from several professionals of different disciplines in various settings and institutions. These trends together with demographic and epidemiological changes increasingly expose the patient to fragmented care delivery, which can be harmful to them due to duplication of diagnostic tests, inappropriate poly-pharmacy and conflicting care plans. Continuity of care is the patient’s perception of the coordination of services and can be defined as how one patient experiences care over time as coherent and linked. It embraces three types: continuity of clinical management and information across the care levels and continuity of relation with the primary and the secondary care physician. Studies on continuity of care from the point of view of healthcare users of the national health system of Catalonia are still scant. The objective is to explore the user’s perception of continuity of health care in different healthcare areas in the Catalan national health system, as well as its influencing factors and consequences on quality of care, in order to contribute to its improvement in the healthcare system. Methods: The research consisted of three individual studies addressing different aspects of continuity of care: 1) Analysis of the international evidence on continuity of care from the patient’s perspective, employing a meta-synthesis of qualitative studies based on a literature search in various electronic databases. 2) Analysis of COPD patients’ perceptions of continuity of care in four integrated health care networks of the national health system of Catalonia, using a multiple-case study of patients. Data were collected by means of individual semi-structured interviews with patients and physicians and the review of clinical records. 3) Analysis of continuity of care in different healthcare areas of the Catalan national health system (representing the diversity of management models for the delivery of service). Individual semi-structured interviews with healthcare users (49) were employed until data saturation was reached. Ethical approval of the study protocols was obtained. Results: Results suggest that patients are able to perceive the three types of continuity of care by referring to concrete attributes of each dimension. Patients served in the Catalan national health system generally perceived that the three types were existent with a few elements of discontinuity identified in all study areas including the integrated health care networks. A number of factors influencing (dis)continuity of care were identified, which were classified into factors related to the healthcare system, the organizations and the physicians. Different consequences of continuity of care for quality of care and the patient’s health emerged from the study findings. The three types of continuity of care appeared to be interrelated; particularly continuity of information affecting continuity of clinical management, and relational continuity playing an important role by influencing the other two types. Conclusions: This thesis contributes to filling the existing knowledge gap on continuity of care by providing a better understanding of the phenomenon as perceived by users of the national health system of Catalonia. The identified elements of discontinuity serve to indicate where there is room for improvement, and the factors influencing continuity can offer valuable insights to managers and professionals of health care organizations in these and other contexts on where to direct their care coordination efforts; which supposedly would also enhance the patient’s experience of a smooth trajectory along the care continuum. Introducción: La alta especialización en la provisión de la atención, los rápidos avances en la tecnología y la diversificación de los proveedores promueve que los pacientes sean atendidos por varios profesionales de diferentes disciplinas en diferentes organizaciones y servicios. Estas tendencias, junto con los cambios demográficos y epidemiológicos, hacen que el paciente, cada vez más, esté expuesto a una atención fragmentada, lo que le puede perjudicar debido a la duplicación de pruebas diagnósticas, la poli-medicación inapropiada y los planes de tratamiento incompatibles. La continuidad asistencial es la percepción del paciente sobre la coordinación de los servicios y se puede definir como el grado de coherencia y unión de las experiencias en la atención que percibe a lo largo del tiempo. Abarca tres tipos: la continuidad de gestión clínica y la continuidad de información entre niveles de atención y la continuidad de relación con el médico de atención primaria y el médico de atención especializada. Los estudios sobre la continuidad asistencial desde el punto de vista de los usuarios del sistema nacional de salud de Cataluña son escasos. El objetivo es explorar la percepción del usuario sobre la continuidad asistencial en las diferentes áreas del sistema nacional de salud catalán, así como los factores que influyen y las consecuencias sobre la calidad de la atención, con la finalidad de contribuir a su mejora en el sistema de salud. Métodos: La investigación consistió en tres estudios que abordan diferentes aspectos de la continuidad asistencial: 1) Análisis de la evidencia internacional sobre la continuidad asistencial mediante una meta-síntesis de estudios cualitativos basada en la búsqueda bibliográfica en diferentes bases de datos electrónicas. 2) Análisis de la percepción de la continuidad asistencial de los pacientes con EPOC atendidos en cuatro organizaciones sanitarias integradas del sistema nacional de salud de Cataluña, mediante un estudio de caso múltiple de los pacientes. La información fue recogida mediante entrevistas individuales semiestructuradas con los pacientes y sus médicos y la revisión de las historias clínicas. 3) Análisis de la continuidad asistencial en diferentes áreas sanitarias (representando la diversidad de modelos de gestión para la provisión de servicios sanitarios). Se realizaron entrevistas individuales semiestructuradas con usuarios de los servicios sanitarios (49) hasta alcanzar la saturación de la información. Se obtuvo la aprobación ética de los protocolos de estudio. Resultados: Los resultados sugieren que los pacientes son capaces de percibir los tres tipos de continuidad asistencial refiriéndose a atributos concretos de cada dimensión. En general, los pacientes atendidos en el sistema nacional de salud catalán percibieron la existencia de los tres tipos de continuidad con algunos elementos de discontinuidad identificados en todas las áreas y organizaciones sanitarias integradas de estudio. Se identificaron varios factores que influyen en la (dis)continuidad, relacionados con el sistema de salud, las organizaciones sanitarias y los médicos. Se identificaron diferentes consecuencias en la calidad asistencial y la salud del paciente. Los tres tipos parecen estar relacionados entre sí; particularmente la continuidad de información afecta a la continuidad de gestión clínica, y la continuidad de relación juega un papel importante al influir en los otros dos tipos. Conclusiones: Esta tesis contribuye al conocimiento sobre la continuidad asistencial, un tema escasamente analizado, mediante una mejor comprensión del fenómeno percibido por los usuarios del sistema nacional de salud catalán. Los elementos de discontinuidad identificados sirven para indicar donde hay margen de mejora, y los factores que influyen pueden ofrecer información valiosa a los directivos y profesionales de las organizaciones sanitarias en estos y otros contextos sobre dónde dirigir sus esfuerzos de coordinación asistencial; que supuestamente también mejoraría la experiencia de una trayectoria fluida a lo largo del continuo asistencial.

South Africa is one of the countries with the highest burden of Mycobacterium tuberculosis (TB) in the world. The fact that adult patients diagnosed with TB frequently do not attend their primary healthcare clinics after discharge from hospital for continued treatment remains a challenge for public health in South Africa. This qualitative study employed semi-structured interviews, focus group discussions and observations explored the experiences of patients, their families, healthcare workers and policy makers, with continuity of TB care following diagnosis in hospital. The key research question was what factors were shaping patients’ attendance at primary healthcare clinics following TB diagnosis and start of treatment in tertiary and district hospitals. Sub questions were: how did patients diagnosed with TB interpret and act upon their diagnosis and treatment at the tertiary/district hospital? What roles did patients play in the discharge process? What were their home circumstances and experiences at the clinics they were referred to, regarding their registration and follow-up plan? What were the perceptions of patients, healthcare workers and policy makers on what influences patients’ attendance/non-attendance at clinics? The objective of this study was to contribute to our understanding of patients’ experiences and perceptions of treatment of TB and how services to patients could be improved to enhance better continuity of care. I drew on a three-fold theoretical framework: patient-centred care, Foucault’s concept of the 'medical gaze’ and social determinants of health. My study built upon previous and ongoing research on the topic of continuity of care for TB in Cape Town. I argued that problems in the provision of TB services to hospital patients could be understood as failures of the services at the hospital to achieve some of the core components of patient-centered care. Furthermore, I argued that better systems for following-up patients from the hospitals to their homes and clinics would provide more understanding of the challenges patients faced when they have been referred from a tertiary or district hospital to continue with their treatment. Insights gained from qualitatively following patients from diagnosis to discharge and their home circumstances helped to better understand the problem South Africa faced with continuity of care for TB treatment.

Background. Continuity of care as a principle of health care planning is losing ground in favor of new principles such as accessibility and plurality of provision, but the long-term effects of these changes on the utilization of expensive health services such as hospitalizations and emergency department utilization are still unknown.
Objective. To investigate among individuals aged 66 years or older who have had an index visit to an emergency department (ED) whether there is an association between the continuity with a primary care provider and the likelihood of having an ED return visit 14 days after the index ED visit.
Conclusions. Among Quebec seniors, relational continuity of care measured by UPC may not be an important protective factor against returning to the ED after an index visit. The main study limitations to be considered in the interpretation of these results relate to the use of administrative data, and include potential misclassification of ED visits and return visits, inability to distinguish planned from unplanned return visits, and residual confounding due to covariates that were either not measured or measured at the ecological level (e.g., socioeconomic status).
Research and policy implications. Further research, using different data sources and measures, is needed to investigate the association between continuity of care and ED utilization among seniors in Quebec. (Abstract shortened by UMI.)

Background: Despite national guidance and empirical support for its clinical and cost-effectiveness, cardiac rehabilitation (CR) is underused. Only 44% of patients go to CR, with angioplasty (Percutaneous Coronary Intervention; PCI) patients being least likely to attend (31% of 87,000). Aim: To investigate the relationship between ‘continuity of care’ and patients’ motivation towards CR, through the lens of self-determination theory, and develop a model to inform service design to increase CR uptake and adherence. Methods: A mixed methods approach was used. In Study 1, a theoretical model of continuity of care and motivational antecedents was tested with a cross-sectional sample of 107 PCI patients. To further explore interactions between continuity of care and motivation towards cardiac rehabilitation, a Critical Interpretive Synthesis of the extant literature was used in Study 2, and focus groups were carried out with patients and service providers in Study 3. Results: In Study 1, continuity of care positively predicted patients’ autonomous motivation towards CR, and this was partially mediated by autonomy support. Autonomy support was associated with CR attendance. In Studies 2 and 3, aspects of continuity of care with positive effects on attendance were identified. These included timely, appropriate information provision, relationships bridging CR phases and settings, and continuing management strategies incorporating trusting, warm staff-patient relationships, and positive encouragement and feedback about progress. The SDT constructs of autonomy support, need satisfaction, internalisation and quality of motivation helped to explain positive and negative influences of continuity on attendance. Conclusion: Continuity of care has a positive effect on patients’ motivation towards CR. The most enduring motivation comes from delivering continuity of care in an autonomy-supportive and competence-supportive way. Longitudinal research is needed to compare how need-supportive and need-thwarting aspects of continuity of care affect CR attendance and adherence, and whether these relationships are influenced by need satisfaction and need frustration.

Purpose: A majority of childhood and adolescent cancer survivors face life-long cancer- and treatment-related sequelae. Long-term follow-up is necessary to facilitate timely diagnosis and management of these health conditions. As part of strategic long-term follow-up, provider continuity of care (PCOC) may improve outcomes through appropriate use of surveillance, screening, and coordination of services. The purpose of this thesis was to assess physician services utilization and PCOC among survivors of childhood cancer compared with general population subjects, and to examine factors associated with survivors' use of physician services and PCOC scores. Methods: Physician services utilization and PCOC were assessed in a population-based cohort of 1322 five-year cancer survivors diagnosed between 1981 and 1995 under age 20 in British Columbia, and a group of 13,220 age- and gender-frequency matched, randomly selected population-based subjects, whose records were linked to individual-level administrative healthcare datasets. Effects of clinical and sociodemographic modifiers on utilization and PCOC were examined using generalized linear modeling. Changes in utilization and PCOC by age were estimated using a longitudinal, repeated measures modeling approach. Results: Survivors incurred an average of 8.94 medical visits per year: 4.82 to primary care physicians, 2.69 to specialists, and 1.43 to non-physician providers. Survivors had more visits than comparators in all visit categories (p<0.0001 for all). As they age, survivors' use of primary care services increases significantly, while their use of specialist services declines, trends that are not mirrored by the comparison population. The average PCOC score for survivors was 0.54 ± 0.22, indicating survivors saw the same primary care provider for only 50% of their primary care visits. Mean score did not differ between survivors and comparators; however, in the population sample scores improved with age (p=0.02), while among survivors, scores worsened (p=0.05). Conclusions: The dramatic age-related increase in primary care visits observed in the survivor group suggests that primary care physicians play a key role in ensuring quality long-term follow-up care. Survivors are at heightened risk for poor PCOC as they age and transition into adult-oriented community care, raising concerns about whether they are receiving the appropriate follow-up care encompassing screening, surveillance and psychosocial support.

Diabetes is emerging as a major threat to health, with global economic and social implications. Recent research has shown that the morbidity and mortality associated with diabetes can be reduced by timely and effective treatment. However, unless people with diabetes have access to this treatment, the impact of diabetes will continue to rise. This thesis therefore explores the current standards of care which people with diabetes receive. It also looks at factors likely to impact on delivery of diabetes care. Studies were conducted at two levels. In the studies described in Chapters 2 and 3, general data applicable to all or nearly all patients with diabetes were collected. This approach substantially eliminates selection bias but precludes the ability to examine clinical outcomes. In the other studies, detailed in Chapters 4, 5 and 6, specific aspects of diabetes care pertaining to more select groups of diabetic subjects were examined. This approach allows clinical parameters to be examined in more detail but is more subject to selection bias. It is hoped that the combination of these two approaches provides a more balanced view of the topic under examination. In Australia, the Medicare Program, a single government controlled universal health insurance fund, provides access to medical services for all residents. Medicare occasions of service data therefore represent the most comprehensive source of information regarding health service utilisation in Australia. The data does not account for people receiving diabetes care through public hospital based services. However, a survey of public hospitals within NSW (n=198), described in Chapter 2, showed that the number of individuals in this category is relatively small and represents only 5.2% of the diabetic population. Using Medicare item codes, and with the permission and assistance of the Commonwealth Department of Health and Aged Care, data were extracted on attendance to medical practitioners and utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997. All data were stratified by the presence of diabetes, gender and age group. Individuals were deemed to have diabetes if an HbA1c, which can only be ordered for a person with known diabetes, had been performed over the 5-year period and the sample size adjusted for the incidence of diabetes. Once adjusted, the number of people with diabetes in NSW for the individual years 1993 to 1997 were 143,920, 156,234, 168,216, 177,280 and 185,780. Comparison with 1996 census data confirmed a 91.7% capture of the total NSW population (5,495,900/5,995,545 individuals). The data were retrieved for NSW as a whole and for individual postcodes. Postcodes were then classified by population density as either major urban, urban or rural. On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. As seen in Chapter 2, a large proportion of people with diabetes were also under the care of specialists and consultant physicians, up to 51.2% and 41.8% respectively, a 3 to 4 fold increase when compared with their non-diabetic counterparts. In regard to geographical location, once adjusted for age and gender, the odds ratio of attending a specialist was only slightly higher for people with diabetes living in areas of high population density when compared to people with diabetes living in rural areas. This ratio reached as high as 1.85 in regard to attendance to consultant physicians (Chapter 3). The odds ratio for the non-diabetic population was similar indicating that the difference in access to consultant physicians was not disease specific. Analysis of results showed that despite the increase in service utilisation, large proportions of people with diabetes were not routinely monitored in regard to diabetes and its complications across the State. By 1997, HbA1c was still not performed in over 40% of people with diabetes each year and only 11.6% of the diabetic population had undergone microalbuminuria estimation. Interestingly, the differences in levels of monitoring between rural and urban areas were surprisingly small. Monitoring of diabetes and its complications did improve in all parts of the State over the study period. However, the greatest improvement was seen in rural areas, despite rural patients having fewer attendances to general practitioners and fewer patients attending specialist care. In the face of finite resources and the rising prevalence of diabetes, an increasing number of patients will need to rely on general practitioners to provide diabetes care regardless of where they live. A 'shared care' approach which encourages and supports general practitioners to manage patients with diabetes, while giving them access to specialist services for those patients that require them, is increasingly being advocated as a way of maximising efficacy while minimising costs. Yet if health care professionals leave undone what they think is done by others, shared care can become neglected care. Chapter 4 reports a detailed audit of 200 randomly selected shared care patients who were assessed on two or more occasions. This study showed that the majority of specialist treatment recommendations are implemented by general practitioners. Doctors formally registered with the Diabetes Shared Care Programme and those who write longer referral letters were more likely to implement recommendations than their counterparts. Moreover, the average HbA1c and the complication profile of these patients were similar to those found in various studies around the world. This suggests that diabetes can be well managed by a shared care approach that is adequately integrated. To overcome the problem that data is lacking on those patients that did not return for specialist review, a further 200 shared care patients who were lost to follow up from the shared care system were traced. Information regarding whether treatment recommendations had been implemented was sought from both the referring doctor and the patient. Overall, information on 182 of the 200 patients could be obtained. As discussed in Chapter 5, comparison of the returned and non returned patients' demographic and clinical profiles at time of their initial specialist review showed that general practitioners differentiated between the 'more complicated' patients, choosing to re-refer those with macrovascular disease, while maintaining the care of 'less complicated' patients. Re-referral for specialist review was also dependent on the patient remaining under the care of their original doctor. Encouragingly, general practitioners seemed to take a more active role in the non-returned group. They included more details regarding type and duration of diabetes in the referral letters of patients who were not re-referred for specialist review. They also implemented more treatment recommendations in the non-returned group, with the difference in implementation rate for metabolic recommendations reaching statistical significance. This study also showed that movement of patients between doctors raises concern regarding continuity of care. The multi-factorial nature of diabetes means that best practice is not easily accommodated within a single appointment. Thus continuity of care becomes an important issue. To assess the current status, 479 consecutive patients referred to the Royal Prince Alfred Hospital Diabetes Centre in a 6-month period were recruited and underwent a detailed clinical assessment. They were also questioned regarding the number of general practitioners they attended and the length of time they had been under the care of the referring doctor. The results outlined in Chapter 6 showed that the majority of people with diabetes (87.7%) attended only one general practitioner and had been under the care of that doctor medium to long term. Younger patients, who were relatively healthy apart from the presence of diabetes, were more likely to attend several general practitioners or have changed their general practitioner within the last year. This lack of continuity had little difference on acute outcomes such as glycaemic and blood pressure control. Appropriately, continuity of care increased with increasing age and the increasing prevalence of diabetes complications, mainly macrovascular disease. These studies indicate that further efforts are required to improve the overall standard of diabetes care within Australia. At present there is a heavy dependency on specialist services. As the population ages and the number of people with diabetes increases, much of this burden will fall on general practitioners, as is already evident in rural areas. When provided with appropriate support and infrastructure, general practitioners are able to maintain standards of care through referral of patients with more complex medical problems and by maintaining the degree of continuity appropriate to the patient's needs. However, the collection of relevant information to monitor future trends in diabetes services provision is important. As shown in this thesis, Medicare data represents an easy and cost effective method with which to do so.

Diabetes is emerging as a major threat to health, with global economic and social implications. Recent research has shown that the morbidity and mortality associated with diabetes can be reduced by timely and effective treatment. However, unless people with diabetes have access to this treatment, the impact of diabetes will continue to rise. This thesis therefore explores the current standards of care which people with diabetes receive. It also looks at factors likely to impact on delivery of diabetes care. Studies were conducted at two levels. In the studies described in Chapters 2 and 3, general data applicable to all or nearly all patients with diabetes were collected. This approach substantially eliminates selection bias but precludes the ability to examine clinical outcomes. In the other studies, detailed in Chapters 4, 5 and 6, specific aspects of diabetes care pertaining to more select groups of diabetic subjects were examined. This approach allows clinical parameters to be examined in more detail but is more subject to selection bias. It is hoped that the combination of these two approaches provides a more balanced view of the topic under examination. In Australia, the Medicare Program, a single government controlled universal health insurance fund, provides access to medical services for all residents. Medicare occasions of service data therefore represent the most comprehensive source of information regarding health service utilisation in Australia. The data does not account for people receiving diabetes care through public hospital based services. However, a survey of public hospitals within NSW (n=198), described in Chapter 2, showed that the number of individuals in this category is relatively small and represents only 5.2% of the diabetic population. Using Medicare item codes, and with the permission and assistance of the Commonwealth Department of Health and Aged Care, data were extracted on attendance to medical practitioners and utilisation of diabetes related procedures for people living in New South Wales (NSW) for the individual years between 1993 to 1997. All data were stratified by the presence of diabetes, gender and age group. Individuals were deemed to have diabetes if an HbA1c, which can only be ordered for a person with known diabetes, had been performed over the 5-year period and the sample size adjusted for the incidence of diabetes. Once adjusted, the number of people with diabetes in NSW for the individual years 1993 to 1997 were 143,920, 156,234, 168,216, 177,280 and 185,780. Comparison with 1996 census data confirmed a 91.7% capture of the total NSW population (5,495,900/5,995,545 individuals). The data were retrieved for NSW as a whole and for individual postcodes. Postcodes were then classified by population density as either major urban, urban or rural. On average over the study period, persons with diabetes accounted for 3.1% of the population but they used 5.5% of general practitioner services. As seen in Chapter 2, a large proportion of people with diabetes were also under the care of specialists and consultant physicians, up to 51.2% and 41.8% respectively, a 3 to 4 fold increase when compared with their non-diabetic counterparts. In regard to geographical location, once adjusted for age and gender, the odds ratio of attending a specialist was only slightly higher for people with diabetes living in areas of high population density when compared to people with diabetes living in rural areas. This ratio reached as high as 1.85 in regard to attendance to consultant physicians (Chapter 3). The odds ratio for the non-diabetic population was similar indicating that the difference in access to consultant physicians was not disease specific. Analysis of results showed that despite the increase in service utilisation, large proportions of people with diabetes were not routinely monitored in regard to diabetes and its complications across the State. By 1997, HbA1c was still not performed in over 40% of people with diabetes each year and only 11.6% of the diabetic population had undergone microalbuminuria estimation. Interestingly, the differences in levels of monitoring between rural and urban areas were surprisingly small. Monitoring of diabetes and its complications did improve in all parts of the State over the study period. However, the greatest improvement was seen in rural areas, despite rural patients having fewer attendances to general practitioners and fewer patients attending specialist care. In the face of finite resources and the rising prevalence of diabetes, an increasing number of patients will need to rely on general practitioners to provide diabetes care regardless of where they live. A 'shared care' approach which encourages and supports general practitioners to manage patients with diabetes, while giving them access to specialist services for those patients that require them, is increasingly being advocated as a way of maximising efficacy while minimising costs. Yet if health care professionals leave undone what they think is done by others, shared care can become neglected care. Chapter 4 reports a detailed audit of 200 randomly selected shared care patients who were assessed on two or more occasions. This study showed that the majority of specialist treatment recommendations are implemented by general practitioners. Doctors formally registered with the Diabetes Shared Care Programme and those who write longer referral letters were more likely to implement recommendations than their counterparts. Moreover, the average HbA1c and the complication profile of these patients were similar to those found in various studies around the world. This suggests that diabetes can be well managed by a shared care approach that is adequately integrated. To overcome the problem that data is lacking on those patients that did not return for specialist review, a further 200 shared care patients who were lost to follow up from the shared care system were traced. Information regarding whether treatment recommendations had been implemented was sought from both the referring doctor and the patient. Overall, information on 182 of the 200 patients could be obtained. As discussed in Chapter 5, comparison of the returned and non returned patients' demographic and clinical profiles at time of their initial specialist review showed that general practitioners differentiated between the 'more complicated' patients, choosing to re-refer those with macrovascular disease, while maintaining the care of 'less complicated' patients. Re-referral for specialist review was also dependent on the patient remaining under the care of their original doctor. Encouragingly, general practitioners seemed to take a more active role in the non-returned group. They included more details regarding type and duration of diabetes in the referral letters of patients who were not re-referred for specialist review. They also implemented more treatment recommendations in the non-returned group, with the difference in implementation rate for metabolic recommendations reaching statistical significance. This study also showed that movement of patients between doctors raises concern regarding continuity of care. The multi-factorial nature of diabetes means that best practice is not easily accommodated within a single appointment. Thus continuity of care becomes an important issue. To assess the current status, 479 consecutive patients referred to the Royal Prince Alfred Hospital Diabetes Centre in a 6-month period were recruited and underwent a detailed clinical assessment. They were also questioned regarding the number of general practitioners they attended and the length of time they had been under the care of the referring doctor. The results outlined in Chapter 6 showed that the majority of people with diabetes (87.7%) attended only one general practitioner and had been under the care of that doctor medium to long term. Younger patients, who were relatively healthy apart from the presence of diabetes, were more likely to attend several general practitioners or have changed their general practitioner within the last year. This lack of continuity had little difference on acute outcomes such as glycaemic and blood pressure control. Appropriately, continuity of care increased with increasing age and the increasing prevalence of diabetes complications, mainly macrovascular disease. These studies indicate that further efforts are required to improve the overall standard of diabetes care within Australia. At present there is a heavy dependency on specialist services. As the population ages and the number of people with diabetes increases, much of this burden will fall on general practitioners, as is already evident in rural areas. When provided with appropriate support and infrastructure, general practitioners are able to maintain standards of care through referral of patients with more complex medical problems and by maintaining the degree of continuity appropriate to the patient's needs. However, the collection of relevant information to monitor future trends in diabetes services provision is important. As shown in this thesis, Medicare data represents an easy and cost effective method with which to do so.

Introduction Recently, the Italian national health system has shifted from a hospital-based model of health services to territorial-centred solutions for the increase of people with chronic diseases and long-term needs of assistance. So, Community Health Centres (CHCs) have been recently introduced in Italy including in the Vercelli's ASL. Aims i) Describe the 5 CHCs in Vercelli's ASL; ii) Measure the level of professional integration and the perceived continuity of care by patients in CHC's area; iii) Evaluate effect of CHCs implementation on organisational, health, and economic outcomes. Method A descriptive observation was performed through individual semi-structured interviews, administrative data collection, and questionnaires to professionals worked in the 5 CHCS and to a random sample of patients living near CHCs. Questionnaires were composed by two 5 point-scales about professional integration and continuity of care. Besides, an interrupted time series analysis (ITSA) with control was performed for impact evaluation on organisational, health, and economic outcomes. Regression models were adjusted for autocorrelation and were performed by age classes. Results 37 professionals answered to the survey on integrated care. No differences emerged by the 5 CHCs for integrated care: total scores ranged from 2.3 to 3. The lowest partial scores were for communication among professionals in the last 12 months. Differences emerged between general practitioners and nurses. About patients, out of 1000, only 117 patients answered to the survey. Overall scores for continuity of care diverged between CHCS and ranged from 2.78 to 3.09. The intensity level of physician-patient relationship was very low, whereas the quality of the relationship was judged highest. Finally, the ITSA showed that the Vercelli's ASL led to a considerable reduction of inappropriate accesses to emergency departments (EDs) in comparison to control in all age classes. About health outcomes, CHCs resulted effective in hospitalizarion reduction for diabetes and COPD among adult and A better effect was seen for total accesses to EDs and accesses for several conditions, but mortality at 30 days after hospitalization dropped only in elderly. Finally, CHCS appeared to be less efficient respect to the effectiveness. Conclusion Although some weakness, this was the first attempt to measure integrated care and continuity of care perceived by patients in relation to Italian CHCs. Results suggest that invest on CHCs in isolated areas is effectiveness at organizational and health levels

The ageing population of Sweden is expected to increase throughout the future decades. Changing life-style trends and smaller families in the modern society has decreased the population’s access to informal care. This is expected to entail an increase in the services provided by specialized home care. This thesis studies the work performed by nurses within the department of specialized home care (ASIH) in Stockholm County. The nurses represent the majority of all professions active at ASIH in Stockholm County, which puts their work in particular interest for this thesis. The thesis focuses on the ways the nurses’ work procedures may influence continuity of care and patient safety. Continuity of care is an essential component in qualitative care and is characterized by well-executed coordination and minimization of broken patient appointments. A high level of continuity of care consequently entails a high level of patient safety. Descriptions of continuity of care at ASIH in Stockholm County can therefore provide indications on current care quality and areas of improvement. The thesis consists of two parts – a literature review containing international research on continuity within home care and an empirical study containing a retrospective analysis based on the Functional Resonance Analysis Method (FRAM). The empirical study creates an overview of work tasks related to nursing performed at three units of ASIH in Stockholm County. The interdependencies between work tasks are identified and important chain reactions are analyzed. The findings from this thesis indicate that extended training programs for nurses in the initial phase of employment is likely to decrease the number of disruptions in the nurses’ work. Furthermore, well-developed routines could facilitate work task procedures which would decrease the number of delays and disruptions in the nurses’ work. It was found that these findings together with information continuity between all parties involved represent significant factors for attaining continuity of care and patient safety at ASIH in Stockholm County.
Den äldre befolkningen i Sverige förväntas öka under de kommande årtiondena. Det moderna samhället har dessutom medfört förändrade livsstilar och allt mindre familjekonstellationer, vilket har resulterat i en minskad tillgång till anhörigvård. Detta förväntas medföra en ökad efterfrågan av tjänster som tillhandahålls av specialiserad hemsjukvård. Den specialiserade hemsjukvården ansvaras av Avancerad Sjukvård I Hemmet (ASIH) i Stockholms län. Sjuksköterskor utgör den största andelen anställda av de yrken som är verksamma vid ASIH. Denna rapport undersöker sjuksköterskornas arbetsflöden vid tre ASIH-enheter i Stockholms län. Rapporten fokuserar på att undersöka på vilka sätt sjuksköterskornas arbetsprocesser kan påverka vårdens kontinuitet och patientsäkerhet. Vårdkontinuitet är ett centralt begrepp i kvalitativ hemsjukvård och kännetecknas av välkoordinerad vård och lågt antal otillfredsställande patientbesök. God vårdkontinuitet förväntas medföra hög patientsäkerhet. Återgivningar av den nuvarande vårdkontinuiteten på ASIH i Stockholms län tros därför kunna skapa en uppfattning om den nuvarande vårdkvaliteten samt eventuella förbättringsområden. Denna rapport utgörs av två delar – en litteraturstudie som innehåller internationell forskning om vårdkontinuitet i hemsjukvård samt en empirisk studie som innehåller en retrospektiv analys baserad på Functional Resonance Analysis Method (FRAM). Den empiriska studien skapar en översikt över sjuksköterskors huvudsakliga arbetsuppgifter vid de tre undersökta ASIH-enheterna belägna i Stockholms län. Arbetsuppgifternas korrelationer samt ömsesidiga påverkan kartläggs och signifikanta kedjereaktioner analyseras. Resultaten i denna rapport påvisar att utökad undervisning för sjuksköterskor i anställningens inledande skede kan troligen minska antalet störningar i sjuksköterskornas dagliga arbete. Dessutom påvisar resultaten att fler tydliga rutiner skulle kunna underlätta sjuksköterskornas arbetsprocesser, vilket skulle kunna minska antal förseningar och störningar i deras dagliga arbete ytterligare. Dessa fynd i kombination med välfungerande kommunikationer mellan alla berörda parter utgör de huvudsakliga åtgärderna för att erhålla vårdkontinuitet och patientsäkerhet hos ASIH i Stockholms län.

Thesis (Ph.D.)--Michigan State University. Dept. of Family and Child Ecology, 2008.
Title from PDF t.p. (viewed on Sept. 9, 2009) Includes bibliographic references (p. 160-188). Also issued in print.

Avoidable use of the Emergency Departments (EDs) constitutes a significant public health problem, which has health, economic and ethical implications. The factors that affect avoidable use of the EDs are complex and poorly understood. The goal of this dissertation was to examine the role of medical home in avoidable pediatric ED visits, assess the impact of Medicaid policy on ED visits for dental problems and assess the factors affecting follow-up dental care after a dental ED visit. Iowa Household Health Survey data was used for the first study, which included a sample of families with at least one child residing in Iowa. It was found that 68% of parents who took their child to an ED in the previous year thought the ED visit could have been avoided if primary care was available to them. Having a medical home was not found to be associated with pediatric ED visits; however, food insecurity was significantly associated. Parents of children with public insurance, those who were not referred by a healthcare provider and those who reported difficulty in getting routine care appointments were more likely to report an avoidable ED visit by their child. The second study examined a policy change in California where Medicaid eliminated its comprehensive adult dental coverage on July 1, 2009. State Emergency Department Database were obtained from Agency for Healthcare Research and Quality for California for 2006 through 2011. Interrupted time series, a quasi-experimental approach of was used to examine the impact of the policy change on rate of dental ED visits by Medicaid enrolled adults. Segmented linear regression revealed that policy change led to an immediate significant increase in the rate of dental ED visits. The policy had a differential impact on various subgroups based on age, race-ethnicity and residential location. The annual costs associated with dental ED visits made by Medicaid adults also increase 68%. Survival analytic approach was used in the final study to examine the patterns of dental care following a dental ED visit by Medicaid enrolled adults in Iowa. Medicaid claims and enrollment data were used to identify adults with an index dental ED visit in 2011, and then each subject was followed for up to 6 months. About 52% of all adults who satisfied the study inclusion criteria, had a follow up dental visit within 6 months of the index dental ED visit. Cox regression model revealed that adults who had visited a dentist in the year prior to the ED visit had greater hazards of having an early dental follow up after the ED visit. Having repeated dental ED visits was found to have a dose-response relationship to follow-up time to dentist visit, with those having 1 repeat ED visit having 53% hazards and those with 2 or more repeat ED visits having 34% hazards of having a follow-up dentist visit, compared to those with no repeat ED visits. Collectively, the results from this dissertation provide important insights in understanding the complex problem of avoidable ED visits. Factors such as food insecurity and medical home need to be further investigated in their association with avoidable ED visits. State Medicaid policy plays an important role and limiting Medicaid adult dental coverage may lead to an increased reliance of the affected population on EDs for dental care. However, EDs do not provide any definitive dental care, and our results indicate that almost half of the adults with dental ED visit do not have a follow-up dentist visit in the next 6 months.

Bakgrund: Kontinuerlig barnmorskeledd vårdmodell för kvinnor under graviditet, förlossning och eftervård tillämpas i flera länder runtom i världen. Modellen har visat sig positiv både ur medicinska och ekonomiska aspekter. Kvinnor i Sverige uttrycker en önskan om att kontinuiteten i vården kring graviditet, förlossning och eftervård ska öka. Trots detta tillämpas inte kontinuerlig barnmorskeledd vårdmodell i Sverige idag, bortsett från enstaka nyligen påbörjade projekt. Syfte: Att beskriva kvinnors upplevelser av kontinuerlig barnmorskeledd vårdmodell under graviditet, förlossning och eftervård. Metod: Kvalitativ metasyntes med metaetnografisk innehållsanalys. Femton (15) artiklar inkluderades i resultatet. Resultat: Tre huvudkategorier och sju underkategorier identifierades som centrala och övergripande teman för kvinnors upplevelser av kontinuerlig, barnmorskeledd vårdmodell. De tre huvudkategorierna var personcentrerad vård, relationen till barnmorskan och kommunikationen. Överlag var kvinnornas upplevelser av kontinuerlig, barnmorskeledd vårdmodell positiva. Slutsats: Kvinnor upplever kontinuerlig barnmorskeledd vårdmodell som stödjande, stärkande och personcentrerad. Kontinuerlig barnmorskeledd vårdmodell är en personcentrerad vårdform som stödjer och stärker kvinnorna genom graviditet, förlossning och eftervård. De positiva upplevelserna av kontinuerlig barnmorskeledd vårdmodell verkar minska när vården under graviditeten bedrivs i gruppform istället för individuellt. Klinisk tillämpbarhet: Resultatet av denna studie kan vara till stöd för att utveckla mödrahälsovården och förlossningsvården i Sverige. Den här studien kan inspirera till förändring för att uppnå personcentrerad vård för kvinnor under graviditet, förlossning och eftervård.
Background: Midwife-led continuity of care model for women during pregnancy, childbirth and postpartum care is applied in several countries around the world. The model has proved positive both from medical and economic aspects. Women in Sweden express the wish that the continuity of care regarding pregnancy, childbirth and aftercare should increase. Despite this, midwife-led continuity of care model is not applied in Sweden today, apart from single recently initiated projects. Aim: To describe women's experiences of midwife-led continuity of care model during pregnancy, childbirth and aftercare. Method: Qualitative meta-synthesis with etnographic content analysis. Fifteen (15) items were included in the result. Results: Three main categories and seven subcategories were identified as central and overarching themes for women's experiences of midwife-led continuity of care model. The three main categories were person-centered care, the relation to the midwife and the communication. Overall, women's experiences of midwife-led continuity of care model were positive. Conclusion: Women experience midwife-led continuity of care model as supportive, strengthening and person-centred. Midwife-led continuity of care model is a person-centered form of care that supports and strengthens the women through pregnancy, childbirth and postpartum care. The positive experiences of midwife-led continuity of care model seem to decrease when the care is given in group form during pregnancy instead of individually. Clinical implications: The result of this study can be of value for developing maternity care in Sweden. This study can inspire to create new ways to achieve person-centered care for women during pregnancy, childbirth and postpartum care.

Philosophiae Doctor - PhD (School of Public Health)
South Africa has an estimated two million documented and undocumented immigrants. In addition, Statistics South Africa (2014) notes very significant internal migration. This mobile population is affected by chronic communicable and non-communicable diseases such as TB, HIV, and diabetes, although it has a Constitutional right to health and healthcare. Their quality of healthcare and disease control also affects the general population and the burden on the health system can be increased by inadequately managed chronic conditions as well as acute health care needs. Access to healthcare and continuity of care reflect both patient agency and the health system. Community Health Workers (CHWs) play an important role in linking communities and patients to health services and vice versa. The aim of this study was to understand how agricultural migrants in the Cape Winelands District of Western Cape Province of South Africa navigated the healthcare system to access healthcare services including securing continuity of care, and in particular the role of CHWs in this process, in order to inform policy and practice.

博士
國立臺灣大學
健康政策與管理研究所
102
Background and Objectives: With the trend of population aging, the society faces the challenge of increasing needs on long-term care and medical care. People with long-term care needs also have high demand on medical care. In addition to the factors of sociodemographic characteristics and health status, long-term care arrangement, which is shaped by policy design, could also exert influences on medical care utilization. Long-term care users usually have multiple and complex health care needs; therefore, the continuity of care could influence their health-care outcomes and subsequent medical care uses. At the present time, Taiwan is developing the formal long-term care system. It is needed to analyze experimental data to clarify the relationship between long-term care arrangement and medical care utilization, and provide this base information for system planning. The aims of this study include: 1) describing the medical care utilization of the middle-aged and older adults with long-term care needs, 2) exploring the relationship between long-term care arrangement and medical care utilization, 3) analyzing the association between continuity of care and medical care utilization, 4) examining the joint effects of long-term care arrangement and continuity of care on medical care utilization, and 5) comparing the effects of realted factors of medical care utilization among different long-term care arrangements. Methods: The data analyzed in this study was from the 2002 interview data of the Assessment of National Long-Term Care Need in Taiwan (ANLTCNT) and 2002-2003 claims data of the National Health Insurance (NHI). To estimate the long-term care needs in Taiwan, the ANLTCNT, a two-stage nationwide survey, was first launched in 2001. Subjects who met one of the following four criteria were defined as with long-term care needs and entered the second-stage survey: 1) one or more ADLs disability; 2) five or more IADLs disabilities; 3) cognitive impairment as measured with the Short Portable Mental Status Questionnaire (SPMSQ); or 4) unable to response SPMSQ due to dementia. A total of 13,110 individuals were analyzed in this study. Dependent variables were medical care utilization of outpatient visit, emergency department (ED) visit, hospitalization, and potentially avoidable hospitalization (PAH). For each type of medical care, whether used, number of episodes, length of stay (LOS) in one year (for hospitalization and PAH), and expenditures in one year were analyzed, In addition, the total medical expenditure in one year was also included in analyses. Independent variables were long-term care arrangement and continuity of care. Long-term care arrangement was categorized as 1) family caregiver or home- and community based services (HCBS), 2) without caregiver, 3) full-time, in-home care assistant, and 4) long-term care institution. Continuity of care index was computed by applying the method proposed by Bice &; Boxerman. Control variables included 1) predisposing factors: sex, age, and educational level, 2) enabling factors: copayment exemption, level of urbanization, and marital status, and 3) need factors: morbidity burden, depressive symptom, cognitive impairment, disability level, and unmet need. Descriptive statistics, χ2 test、ANOVA、t-test、multiple logistic regression, and generalized linear models (GLM) were used in statistical analyses. Results: Of the study samples, 60.7% were cared by family caregiver or HCBS, 14.3% had no caregiver, 16.0% hired care assistant, and 8.9% resided in institutions. The rates and numbers of using were 94.1% and 26.1 visits/year(yr) for outpatient visit, 32.6% and 0.7 visits/yr for ED visit, 36.3% and 0.8 episodes/yr for hospitalization, and 17.5% and 0.3 episodes/yr for PAH. Comparing with the family caregiver/ HCBS group, the individuals without caregiver had less hospitalization utilization and medical expenditures in all types of medical care. The care assistant group had higher utilization in outpatient and ED visits, hospitalization, and PAH, and total medical expenditure. The institution residents used more in outpatient visit, hospitalization, PAH, and total medical expenditure, but less in ED visit. Higher continuity of care was associated with lower risk and numbers of using outpatient and ED visits, hospitalization, and PAH. After controlling for continuity of care, the effects of long-term care arrangement on medical care utilization were still significant, but the magnitude of influence weakened, in particular for hospitalization and PAH. In the analyses stratified by long-term care arrangements, the effect of continuity of care on outpatient visit utilization was most significant in the care assistant group; however, the effects on ED visit, hospitalization, PAH, and total medical expenditure were more significant in the institutionalized group. The effects of morbidity burden on increased medical utilization were more relevant for those without caregiver. Higher disability was associated with lower outpatient visit and higher hospitalization utilization for the community-dwellers, but for the institution residents, the direction of effects was reverse. Conclusions: Long-term care arrangement could affect medical care utilization, and this association is partly mediated by continuity of care. Under different long-term care arrangements, the effects of the related factors of medical care utilization might be different. The findings of this study indicate the linkage between long-term care and medical care systems. Long-term care arrangement, which is directed by long-term care policy, could greatly influence the amount of medical care utilization in medical system. To improve the quality and efficiency of health care, policy makers shoud reinforce developing diverse HCBSs to support family caregiving, and modify the trend of over-dependency on foreign care assistants and institutionalization.

Background: Individuals who make multiple visits to EDs for mental health complaints are a highly visible and challenging group. Recent healthcare priorities aimed at reducing inappropriate or unnecessary service use call for improved continuity of care. Implementing effective continuity interventions is contingent on sound foundational knowledge including population profiling and conceptual understanding. A deficit in these key elements is apparent in existing literature. These gaps in knowledge must be addressed to ensure quality continuity research targeting frequent presenters. Furthermore, there is a paucity of research available that implements evidence-informed methods and theory-driven measurement strategies. Objective: To strengthen the knowledge base on frequent mental health-related ED use and continuity in mental healthcare by addressing existing gaps in foundational knowledge and examining the phenomena at a regional tertiary healthcare centre. Method: This was a three-phase emergent study design using mixed methods. Phase 1 was an integrative study to synthesize research on frequent presenters to the ED for mental health complaints. Phase 2 was a theory analysis to explore the conceptual understanding of continuity in mental healthcare. Phase 3 was an observational case-control study of an exemplar population at a regional tertiary healthcare centre using the evidence-informed methods emerging from the first two phases. Results: From this enquiry, I proposed an evidence-informed profile for frequent presenters to the ED for mental health complaints, summarized parameters used to identify the frequent presenter population, highlighted existing areas of theoretical consensus not yet recognized in continuity research, and provided a global understanding of continuity in mental healthcare and an approach for selecting measurement strategies for continuity research. The observational study strengthened the emerging frequent presenter profile and explored CoC using a comprehensive tool. Conclusion: This doctoral thesis addresses important gaps in foundational knowledge by providing an evidence-informed frequent presenter population profile and global theoretical summary of continuity in mental healthcare. The observational study appears to be the first to use a theory-driven measurement tool and results differ from previous studies in which simple measurement approaches are used. Given this, new hypotheses/questions about the focus and role of CoC with frequent ED use need to be explored.
Thesis (Ph.D, Nursing) -- Queen's University, 2013-04-26 10:47:19.626

碩士
國立臺灣大學
健康政策與管理研究所
107
Background: Taiwan is facing the problem of fragmented care, with repeated use of drugs and repeated examinations. This phenomenon not only affects care results but also consumes medical resources. However, we still do not have a universal primary care system and referral system to enhance continuity of care and care coordination. Therefore, we need a suitable alternative for Taiwan medical system. Objective: This study was to understand whether the Taiwanese have usual sources of care and the characteristics of these people. Then, we explore whether having usual sources of care is related to continuity of care and care coordination. This study aimed to investigate whether usual sources of care can be an alternative to improve continuity of care and care coordination in Taiwan. Methods: This study was cross-sectional and used secondary data. The data was randomly sampled across who were over 60 years old and had a nationality and registered households in Taiwan. With structured interviews conducted by professional interviewers, we understand the patient-perceived continuity of care and care coordination. After that, this research analyzed the 2143 valid samples to response the research purpose. Result: This study found that 88.24% of the population over 60 years old in Taiwan had usual places of care, 76.57% had usual providers of care, 43.76% had usual places of care cross clinics and hospitals. After the analysis, it was found that there was a significant positive correlation between the presence or absence of chronic diseases and the usual sources of care, and there were significant positive correlations between patients with multiple chronic diseases and two or more usual sources of care. There was a significant positive correlation between usual sources of care and the continuity of care, but there is no significant correlation with care coordination. Conclusion: The usual sources of care may be used to improve continuity of care and care coordination. However, it may not succeed to achieve the goal by a single physician or location. We should organize usual sources of care from different locations and providers, and strengthen the care coordination. This study suggests that integrating the usual sources of care may be a feasible strategy to improve our medical quality.

碩士
國立臺灣大學
衛生政策與管理研究所
97
Background: The accessibility to health care in our country has improved after the implementation of National Health Insurance. Nevertheless, the doctor-shopping phenomena are still widely seen, which will erode health resource. While our major focus in monitoring the quality of hospitalization, it is the quality of primary care that determines the quality and efficiency of our healthcare system. Hospitalization for ambulatory care sensitivity conditions, the avoidable hospitalization, has been widely accepted as the indicator to evaluate the accessibility, quality and efficiency of primary care. It has been well documented that continuity of care may be an important factor related to the outcome of healthcare. Since the family doctor and patient referral system has not been well established in Taiwan, it is our major concern to interrogate the cost-effectiveness of our health care system through continuity of care and reduction of avoidable hospitalization. Purpose: This study aims to investigate factors related to continuity of care to determine if better continuity of care will cause reduction of avoidable hospitalization. Materials and methods: The longitudinal analysis was employed in this study. The academic database of National Health Insurance in National Health Research Institute was used. From year 2004 to 2006, there were about forty thousand records in section one as our total samples. The putative index of continuity of care (COC) was used as independent variable and divided into three groups. The hospitalization and avoidable hospitalization were the dependent variables. The controlled variables in this study included age, gender, accessibility of health care (location and physician density), and health inquiry (presence of chronic diseases and total ambulatory physician visits). Results: In this study, a total of 34728 patients were recruited. Of which, 31825 patients (91.64%) had not hospitalized, while 2903 patients (8.36%) had hospitalized. There were 431 patients (1.24%) presented with the hospitalizations in ambulatory care sensitivity conditions (ACSC), the avoidable hospitalization. As examined with a single provider, the mean COC index was 0.26. In this cohort, high COCI could be seen in the minority, the elderly, male, patients with chronic diseases, and those of higher ambulatory physician visits. In multiple logistic regression, groups of low and moderate COCI showed higher probability both in hospitalization and ACSC hospitalization than the group of high COCI, with 1.33 and 1.14 folds in hospitalization and 1.96 and 1.44 folds in ACSC hospitalization, respectively. The result of negative-binomial regression analysis also revealed similar trend. The trend for both hospitalization risk and frequency was significant suggesting a dose-response relationship. Higher COC would present with lower risk and frequency in both hospitalization and ACSC hospitalization. Conclusion: According to this study, the continuity of care plays an important role in hospitalization for ACSC. It is therefore an important issue to facilitate the continuity of healthcare and to promote correct pattern of doctor visit instead of doctor-shopping

碩士
臺灣大學
衛生政策與管理研究所
95
Emergency department is an indispensable part of the health care delivery system.Increased emergency department utilization may contribute to emergency department overcrowding, and may divert the scarce emergency health care resource away from those who really need them. The health care quality may therefore be jeopardized. The reasons involved with emergency department overcrowding are multi-factorial. The continuity of care among health care system has important effect on the emergency department utilization, yet the results remained controversial in the relevant literatures. The purpose of the study was to explore the effect of continuity of care on emergency department utilization. The ambulatory visit file of the first 50000-person cohort database from the National Health Research Database in year 2001, 2002, and 2003 were analyzed. Those with at least 4 ambulatory visits in year 2001 and 2002 were included in the study. The dependent variable was non-traumatic emergency visit frequency in year 2003. Continuity of care score derived from year 2001 and 2002 ambulatory visits was used as independent variable. Control variable included age, sex, residency location, and health care need. The health care need factor were represented by comorbidity and total ambulatory visits in year 2001 and 2002. Negative binomial regression was used in the analysis. The analysis was repeated by applying logistic regression when the dependent variable was dichotomized as whether use emergency department or not. In 36510 people who met the inclusion criteria, 4597(12.59%) people ever visited emergency department in year 2003. The average emergency department visits was 0.19 (SD 0.66, Max 24, Min 0). The average continuity of care score was 0.33(SD 0.22, Max 1, Min 0). The result of negative binomial regression revealed that more emergency department visits was associated with lower continuity of care score (RR, 0.70; 95% CI 0.60, 0.81). When logistic regression was applied, the Odd Ratio of aving at least one emergency department for those with the highest continuity of care score was 0.65 (95% CI 0.56, 0.76), when those with the lowest continuity of score were compared with. The results of the study may provide insights for health policy makers and health care facility administrators when dealing with emergency overcrowding. Methods facilitating the continuity of care may improve emergency overcrowding.

碩士
國立成功大學
工業與資訊管理學系
104
Personnel scheduling is an important issue for many 24hour industries, and nurse scheduling is one of the classic case. In practice, nurse scheduling in intensive care take laws, scheduling related rules, nurse preferences, and patient condition into account. But many studies don’t consider patient condition. A nurse schedule that considers daily patient condition could not only improve the efficiency of handoffs-the transfer of patients from the care of one nurse to another but also the medical care quality. This study proposes a two-stage solving process that takes daily patient condition into consideration. Our goal is to satisfy as many soft constraints as possible by constructing 0-1 goal programming mathematical models. Two month cases in a particular intensive care unit are used as an example to make comparisons between the proposed approach and the existing manual solution.

Objective: This study sought to answer the question “What feasible changes can be made to care processes and clinical information systems to improve Continuity of Care for end of life patients?” Methods: This study adapted Genre Theory and Soft Systems Methodology into a new systems approach, the Circle of Care Modeling Approach. Thirty-four healthcare providers and health IT professionals were interviewed in two communities in British Columbia, Canada. The interviews sought to discover the nature of care provided for end of life patients and how clinical information systems supported care. Interviews were centered on two simulated end of life patients. The patient centric healthcare system, or Circle of Care, was described for each of these patients in each community. Rich Pictures and Conceptual Models were developed based on interview findings. These diagrams were used with participants to discuss gaps in continuity and to seek improvements during a series of structured discussion groups. Results and Discussion: The Circle of Care for end of life patients was found to be large and complex in both communities. Potentially dozens of providers would have been involved in each patient’s care over their last year of life. No provider knew all members of the Circle of Care. All communication activities that were described by participants could be described within the Circle of Care with ten Abstracted Genres. Patient information was housed in many disparate repositories (both paper and electronic) and access to these repositories was limited. The participants described several aspects of Continuity of Care. A new model to describe Continuity of Care was developed based on the findings and taking into account the systems orientation of this study. Six suggested improvements were generated with the study participants to better support Continuity of Care within the communities in this study. These are described in the dissertation. The suggested improvements were compared to existing functionality of clinical information systems. This novel approach to exploring and visualizing the healthcare system from a patient-centric lens, the Circle of Care Modeling Approach, provided a new way of describing and reasoning about the complexities associated with Continuity of Care.

博士
國立臺灣大學
健康政策與管理研究所
107
Background Taiwan is entering an aging society, therefore the continuity of care for chronic diseases and the decision-making for palliative care in non-cancer stages have become important issues. Chronic obstructive pulmonary disease (COPD) is a chronic respiratory tract disease that causes decreased lung function, repeated hospitalization, and increased mortality. According to the World Health Organization, COPD will jump into the 3rd leading cause of death in the world in 2030. Increasing care continuity for COPD patients can reduce patient re-hospitalization and mortality. Poor care continuity may cause COPD patients delay to receive palliative care that caused these patients eventually being repeated intubation and progress to ventilator dependent status. However, the initiate of palliative care in late stage COPD patients is often too late. It may due to lackeness of consensus or criteria to initiate palliative care for COPD patients. The current study will firstly explore the association among the care continuity, the medical resources utilizations and the use of palliative care in patients died in COPD. Secondly, we will develop the consensus and criteria of initiate the palliative care in COPD by Taiwan expertis. Finally, we will validate these criteria to predict the 1-year mortality of COPD after hospitalization. We want to establish the useful clinical criteria to be the reference for promoting the palliatve care treatment of chronic lung disease. Material and Method (1) To explore the association of care continuity among COPD patients for their medical resources and palliative care utilizations, and the timing of “Do not resuscitate” (DNR) decisions. This study used clinical data from a medical center in central Taiwan. We use three indexs of care continuity to conduct the current study. These indexs include continuity of Care Index (COCI), modified modified continuity index (MMCI), and usual provider of care index (UPC index). (2) To develop the expert consensus of palliative care intervention for late stage COPD patients by using modified Delphi method. The expert consensus adopts the RAND/UCLA Appropriateness Method developed by the American RAND Corporation and the University of Los Angeles. We enrolled the experts from public medical center, private medical center and regional hospital located in the north, central, south and easten of Taiwan. Through the three rounds of Delphi methos of 14 experts, the feedback and consensus meeting results are used to assess the appropriateness of those indicators. (3) To validate the power of modified Delphi criteria in the prediction of 1-year mortality in COPD This study used clinical data from a medical center in central Taiwan. Patients hospitalized due to acute exacerbation of COPD were enrolled. We validated the power of modified Delphi criteria in the prediction of 1-year mortality in COPD. Results The first part of the results showed that high care continuity (MMCI) did reduce the number of hospitalizations and emergency visits in the year before the death of COPD patients, but in terms of medical expenses, it showed an increase. There is no correlation between care continuity and palliatve care utilization. The most relevant factor for medical expenses is the time when the DNR is signed at the end of the COPD. Patients who had DNR requested in their last admission is defined as late DNR, and those who had a DNR directive prior to their last (terminal) admission to the hospital were classified as Early DNR. The total annual medical expenditure of Late DNR group was 1.42 times higher than the early DNR group. We suggested this phenomenon is related to the lackness of consensus for when to start the palliative care in COPD patients in Tawain. In the second part, 9 criteria of initiating palliative care in COPD were developed by modified Delphi method. Nine indicators were selected as follows: (1) age > 80 years; (2) Modified Medical Research Council (mMRC) Dyspnea Scale ≧3; (3) pulmonary function Parameters: Forced Expiratory Volume in one second (FEV1) ≦30% predicted value; (4) Arterial blood oxygen parameters; (5) Body Mass Index (BMI) <20 or unplanned weight (6) severe or multiple comorbidities; (7) Past medical history - hospitalization due to acute exacerbation; (8) Past medical history - use of non-invasive respirators or invasive respirators due to acute exacerbations; (9) Daily life ability: disability requires care, and it is necessary to use a nasogastric catheter to assist others in daily life. ADO (Age, Dyspnea & Obstruction) index was also thought to be a comprehensive indicator to predict COPD mortality. In the third part, we validated the power of modified Delphi criteria in the prediction of 1-year mortality in COPD. The Delphi criteria have statistically significant differences in the prediction of 1-year of death (p = 0.004, C index = 0.558). The higher of the total score, the higher the predictive power of death (p<0.001, C index= 0.630). The ADO index also be confirmed as a good predictor for death in COPD in this study. We found that ADO plus the medical hx of acute exacerbation and BMI (ADO+ AE+ BMI), this model has the highest predictive value of COPD death (p<0.001, C index= 0.662). Conclusions In this study, we evaluated the relationship between the continuity of care and the utilization of medical resources and palliative care in COPD patients. We not only developed the expert consensus of palliative care intervention for late stage COPD patients by using modified Delphi method, but also verified the mortality prediction ability by actual hospital data. Through the serial review of these indicators, we want to provide the physicians, the patient themselves and their family members the guidance that COPD patients may progress to death within one year. The results of this study can provide the indicators to initiate palliative care or non-invasive care for late stage COPD patients. We suggest these indicators can not only be used by physicians and COPD patients, but also as an assessment tool or criteria to reimburse the palliative care in national health care system, thereby improving the quality of COPD terminal care in the future.