Thèses sur le sujet « Quality of health performance »

Home health aides' performance can help home health clients achieve quality of life. This quantitative, cross-sectional study examined which work-related factors of home health aides influence home health clients' quality of life. A socioecological perspective was used to understand influences on behaviors. Participants in this study were 400 home health clients who received services from home health agencies. A binary logistic model was used to determine the predictor variables of home health aides that contributed to home health clients' quality of life. Findings indicated that psychosocial skills were among the most predicted work-related performance of home health aides that lead to quality of life for home health clients. All independent variables (professional care; teaching clients about medication management, pain, and home safety; and social and communication skills) showed significance (p < .05). The implications of this study for positive social change include contributing evidence to support improving home health practices and informing policies, which might increase the quality of life for home health clients.

Reduced levels of health-related quality of life (HRQL) post-stroke are an important issue to address in rehabilitation. Despite improvement in function over time, HRQL remains poor for many stroke survivors. This longitudinal study is aimed at estimating the extent to which physical performance, social, and psychological functioning influence HRQL.
Forty-three community-living persons with stroke were recruited to participate in a six-week intervention preceded and followed by a performance- and interview-based evaluation assessing different levels of disability and functioning. HRQL was measured by the VAS of the EQ-5D.
Regression models generated cross-sectionally demonstrated that physical performance, social, and psychological functioning explained up to 90% of the variation in HRQL. A GEE model revealed that, over time, only upper extremity functioning had a significant relationship with HRQL.
Much attention has already been focused on increasing physical performance in rehabilitation. However, clinicians should consider other components that affect HRQL directly or indirectly through physical performance. Only by treating the different components of functioning at various levels can HRQL be ultimately increased.

Healthcare is an organizational field that has undergone profound change in the last few decades, an era characterized by market reform. Healthcare production has revealed both economic and quality problems in past eras, and reporting on these problems can be seen to have contributed to pressures for social reform. Yet, the move toward more market-oriented governance structures and design solutions also reflects a wider isomorphic institutional tendency for organizing social order.The conceptual frame work of this study takes a pessimistic stance on whether the market reform has achieved the intended goals with respect to advancing organizational quality performance. The framework draws on institutional theory and complementary collective action notions in organization theory concerned with boundedly rational decision-making to reason that healthcare evidences certain contextual characteristics that are not a good fit with the market enterprise model of organizing organizations. Specifically, hazards to the efficient market thesis were considered to include uncertain outcomes, a high degree of technical and coordination complexity, and the need to account for intertemporal process transformations of significant duration.A longitudinal design was used to test efficient market thesis propositions. Inpatient administrative data was used to develop two latent hospital quality performance variables, a Mortality quality indicator and an Errors quality indicator. The two latent variables were derived from three selected AHRQ patient safety indicators and an inpatient mortality rate. The measurement model was validated as evidencing significant systematic between-hospital variation. Audited survey data, along with inpatient discharge data was used to develop hospital economic performance variables and process control variables.A set of predictive supply-and-demand models were used to test: 1) whether there is evidence of any trend in quality performance, and how market competition relates to observations of improvement; 2) whether quality cost more; and, 3) whether preferences for better quality outcomes related to hospital economic performance. A hierarchical linear model growth-curve design was employed to assess the predicted relationships and to account for unmeasured organizational dependent relations determinant of hospital quality performance. The unaccounted for systematic between-hospital variance was taken to estimate an "unspecified" hospital-specific institutional effect, independent of material-resource factors. The measurement model results for each of the quality indicators selected evidenced construct validity for patient-level risk-adjustment. Each quality indicator demonstrated a significant systematic between-group variance component in all of the four years studied. The two latent hospital quality performance variables also demonstrated systematic between-hospital variance in growth trajectories in the linear growth-curve model.The predictive models evidenced no significant growth rate trend for either of the quality indicators, indicating the competitive bar on quality performance was unaffected during this period of market reform. Neither was there any evidence that pricing mechanism were able to price the utility of better outcomes, as higher quality did not cost more. Neither was there evidence that consumer preferences for better quality related to better hospital economic performance, as measured by hospital operating margins.

Quality-based payment in healthcare—also known as pay-for-performance—is a popular policy intervention aimed at improving healthcare quality. However, there has been little theoretical work characterizing the underlying quality problem or the interaction between pay-for-performance and existing payment mechanisms. Furthermore, there is little empirical evidence that pay-for-performance has a substantial effect on healthcare quality.

Medicaid provides coverage to approximately 60 million individuals and is the largest single payer of healthcare for children. Given this scope of the program and the concentration of low-income and minority recipients, improvements to the quality of care delivered to Medicaid members represents a significant opportunity to reduce health care disparities and improve the overall delivery and quality of healthcare within the U.S. The current study sought to evaluate the various approaches that state Medicaid agencies are taking to assess and improve the quality of care to their managed care enrollees and the degree to which they have implemented recommendations of various policy experts. A survey was distributed to the Medicaid Directors of all 50 states. A total of 23 states with risk based managed care programs responded, representing 62% of the states that have managed care programs. The results indicated that nearly all states are utilizing standard performance measures as one method to assess quality, with virtually all relying on HEDIS measures for this purpose. Additional strategies that are being used include public reporting of quality data and the use of pay-for-performance incentives; few states are currently focusing on health information technology. Recommendations are made for steps that the Medicaid program could take at both the state and federal level to further develop quality improvement programs.

A significant amount of evidence existed in support of the positive effect on the quality of healthcare that resulted from transitioning to electronic health information systems, equally compelling evidence suggests that the development process for electronic health information systems falls short of achieving its potential. The objective of this research was to assess the existing HIT standards and health information management (HIM) principles to determine if they are robust enough to inform the development of national and international interoperability standards. The research question asked; How do HIT standards and HIM principles and practices influence the quality of EHR performance? This study’s goal was to maintain focus on the collaborative challenges revealed by the lack of understanding and shared vision that commonly exists between HIM professionals, HIT developers, and HIT vendors that obstruct synergy and enfolding of health information standards-based capabilities and HIM practice (business) standards. The complex electronic health record (EHR) universe proved well suited for testing by a combination of complexity science and the unified theory of acceptance and use of technology (UTAUT) information management theories. Through analysis of research literature and qualitative interviews, the research identified nine factors defined into drivers and barriers that influenced the actions of healthcare organizations; leadership, patient focus, planning, communication, alignment with lifecycle models people, processes, dynamics, training and user input, change management standard adoption, and recognition of the power of technology. Analysis of the data obtained from exploratory qualitative interviews of health information technology professionals selected from a professional healthcare management organization supported conclusions that leadership, collaboration, planning, and training limiters, have a direct impact on EHR system success or failure.

Determinants of nursing home performance: examining the relationship between quality and efficiency By Nailya O. DeLellis, MPH, Ph.D. A dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Philosophy at Virginia Commonwealth University. Virginia Commonwealth University, 2010 Director: Dr. Yasar Ozcan, Professor, Department of Health Administration To assess the relationship between quality of care and efficiency of nursing homes this study used 10% random sample of non-hospital based nursing homes of size 20-360 beds and occupancy rate of 5-100% in OSCAR database 2008 (n=1430). Data Envelopment Analysis was used to calculate efficiency score and Structural Equations Modeling was used to assess the effect of environmental factors on efficiency score and quality measures as well as relationship between efficiency and quality of care. Logistic regression was performed to find the factors that affect high performance, defined as high efficiency and high quality. In the study’s sample, 149 facilities (10.4%) had an efficiency score of 1, which indicates perfect efficiency. The average efficiency score of nursing homes in the sample was 0.854 (0.079 min; 0.145 std). Competition positively affects efficiency, with a path coefficient 0.09 (t-value = 2.65). Although the path coefficients relating competition with process and with outcome quality were positive (0.08 and 0.04, respectively), the results were not statistically significant. Stronger position of payers in the market positively affects process quality of care (path coefficient = 0.15, (t-value = 2.48). Higher efficiency of nursing homes is associated with higher outcome quality (path coefficient of 0.06, t-value = 1.99), but lower process quality (path coefficient of –0.20 , t-value = –2.95). Only 7.4% of nursing homes in the sample could efficiently provide high quality services, which was defined as high performance in the study. Among the factors that demonstrated statistically significant coefficients in the regression were the size of a facility, the availability of registered nurses, excess demand, and for-profit status. The study provides evidence of the trade-off between efficiency and process quality, in which higher efficiency of a nursing home is associated with lower process quality of care. Findings in the study also suggested that higher efficiency is associated with higher outcome quality.

This dissertation was a two-phase effort. Phase I investigated the physical image quality of 16 mesh, etched, and quarterwave antireflection filters for varying levels of filter transmissivity. Three levels of ambient lighting and two levels of monochrome CRT resolution were combined factorially with the filters. In addition, user measures of readability, legibility, and perceived image quality were obtained for these same filter and environmental conditions. Quantitative models were developed to predict the performance and subjective data based on signal and noise measures derived from the physical measurements. Phase II examined the effects of a wide range of filter transmissions and diffuse illuminance on measured image quality and the same user measures as in Phase I. Phase I showed that while none of the glare filters yielded improved readability or legibility over a baseline condition, the etched and low transmission filters were notable for their degradation of human performance. Mesh and quarterwave filters were found to improve perceived image quality when a specular glare source was present. Modeling was minimally successful for the reading and legibility tasks, but yielded good fit models for perceived image quality. Phase II showed that when even extreme losses in display contrast occurred, users were capable of good reading and legibility performance. Perceived image quality was inversely related to illuminance level. Prediction of performance by image quality metrics was generally not too successful. It was concluded that in office-type environments, mesh or quarterwave filters can be used to improve perceived image quality when specular glare sources are present, but that no anti-glare filters yielded enhanced short-term readability or legibility over a baseline. Etched filters were not recommended. Measures of physical image quality proved to be good predictors of perceived image quality, but not of timed measures of readability or legibility. Under moderate lighting conditions, monochrome CRTs should be fitted with fairly high transmission filters as it was found the contrast enhancement offered by low transmission filters had negligible effects on performance. Finally, consistent and repeatable findings of degraded legibility for high luminance contrast levels (low illuminance) generated questions as to the existing standards regarding maximum contrast requirements for CRT use.
Ph. D.

The healthcare industry, and more specifically the nursing home sector, is changing operations and services due to a healthcare mandates and enactment of the 2010 Affordable Care Act. Such changes are termed quality assurance performance improvements (QAPI), to receive government subsidies and indemnification compensations. The purpose of this single case study was to explore effective strategies implemented by 4 healthcare leaders to comply with QAPI regulations. Total quality management theory was the conceptual framework used in this study. Data were collected through semistructured, open-ended, face-to-face interviews with 4 participants who serve in a management capacity at an organization located in northwest Missouri. Member checking was used to strengthen the credibility and trustworthiness of the interpretation of the participants' responses. The emergent themes from the study were (a) quality planning using systematic and strategic approaches, (b) quality control using business instruments and tools to measure performance and progress, (c) quality assurance through internal and external systematic analysis, and (d) quality improvements using an integrated systems approach. The implications for positive social change include the potential optimization of care provided to consumers in nursing homes by identifying best practices and strategies healthcare and business professionals have used to modify their business processes and operations.

The trend in medical education and in general, among health professionals, is based, on the current changes of health systems aimed to improve relevance equity, and cost effectiveness of health care. With respect to human health resources, there is lack of agreement among the competence level, performance and the needs of both the system using them and the target population. Therefore, it is important and necessary to consider both the community and health services as partners in the task of defining these changes and in the provision of health services to meet the above mentioned criteria.
The main purpose of this partnership is to encourage efforts to promote, oversee, and apply the actions in each one of the instances in order to improve training of human resource, strengthen local health systems, and empower the communities. Human resource competence and performance, the capacity to provide services, and the degree of community participation and commitement to health, are key elements in improving service quality.
The philosophy of current curricula reform at the Valle University stresses the partnership relationship between academic institutions, services centers, and the community, in the training of health professionals. The proposed investigation focuses on the community-based training aspect of student performance assessment and its relation to the health care system and academia. Specifically, the study will focus on designing valid and reliable instruments for community assessment of student performance, using both qualitative and quantitative aspects of data collection and analysis to assess "patient satisfaction" as an indicator of quality of care.
The results of this study demonstrate that the proposed assessment activity will allow the educational and health services institutions to have relevant and dynamic information as feedback for planning and adjustment of their programs. At the same time, it will allow the community to participate in an effective way in aspects related to their health care. The results of this study will be used as a basis for producing guidelines for involving communities (users) in the health care students evaluation process.

Abstract This national cross-sectional study aimed to measure the oral health status, and oral health related-quality of life (OHRQoL) among Nepalese schoolchildren. Another aim was to investigate the association of dental caries and its consequences with OHRQoL, sociodemographic factors, oral health-related behaviours, anthropometrics, and school attendance and performance. The study was conducted in 18 out of total 75 randomly selected districts of Nepal representing 5 developmental, and concurrently 3 simultaneously ecological regions. Altogether 1137 of the invited 1157 schoolchildren from 27 conveniently selected schools participated both in the survey and clinical examination. Information on sociodemographic factors and oral health-related behaviours was collected using a structured questionnaire. Validated Nepali Child-OIDP was used for assessing children’s OHRQoL. Clinical oral examinations were conducted as per the WHO guidelines and assessed dental caries, its consequences (pufa/PUFA) and periodontal status. BMI, waist-to-hip ratio, and waist-to-height ratio were computed from anthropometric measurements. School-related information included data on school absenteeism was collected from school registry and school performance (percentage of the sum of scores in three core subjects). Gingival bleeding was highly prevalent among all participants. The youngest ones had most often need for dental caries treatment; 79% vs. 64% among the oldest ones. Dental caries and its consequences were most prevalent among those living in the Kathmandu Valley or in the rural areas or in mountain or hilly ecological regions, as well as those consuming sweets or candy, or tea with sugar, and brushing teeth infrequently. Most of the participants had problem with eating, cleaning the mouth, and sleeping. Dental caries and its consequences were associated with poor OHRQoL. They were also associated with both high and low BMI and central obesity (high waist-to-hip and waist-to-height ratios) as well as high school absenteeism (>13% of total schooldays missed) and poor school performance. Both low and high BMI, and poor OHRQoL, as well as high school absenteeism were all inversely associated with school performance. In conclusion, dental caries and gingival bleeding are common among Nepalese schoolchildren. Dental caries and its consequences are associated with poor OHRQoL. These conditions are also associated with sociodemographic factors, poor oral health-related behaviours, and anthropometrics (BMI and central obesity) as well as high school absenteeism and poor school performance
Tiivistelmä Tämän poikkileikkaustutkimuksen tavoitteena oli tutkia nepalilaisten koululaisten suunterveyttä ja siihen liittyvää elämänlaatua (OHRQoL). Toiseksi tavoitteena oli tutkia karieksen ja sen seurausten mm. oireet ja tulehdus, yhteyttä suunterveyteen liittyvään elämänlaatuun, sosiodemografisiin ja antropometrisiin tekijöihin, suunterveyskäyttäytymiseen, koulupoissaoloihin sekä -menestykseen. Tutkimus toteutettiin 18/75 satunnaisesti valitussa Nepalin piirikunnassa, jotka edustivat sekä viittä kehitysaluetta että kolmea ekologista aluetta. Mukaan kutsutuista 1157 koululaisesta (27 koulua, mukavuusotos), 1137 osallistui sekä kysely- että kliiniseen tutkimukseen. Sosiodemografiset taustatiedot sekä tiedot suunterveyskäyttäytymisestä kerättiin strukturoidulla kyselylomakkeella. Suunterveyteen liittyvää elämänlaatua arvioitiin käyttäen validoitua nepalin kielistä Child-OIDP –lomaketta. Kliinisessä tutkimuksessa tutkittiin kariestilanne, sen kliiniset seuraukset (pufa/PUFA) sekä kiinnityskudosten tila WHOn ohjeiden mukaan. BMI, vyötärön ja lantion ympärysmitan suhde sekä vyötärön ympärysmitan ja pituuden suhde laskettiin mittaustulosten perusteella. Kouluista saatiin tiedot poissaoloista viimeisen kouluvuoden aikana sekä koulumenestys kolmessa keskeisimmässä oppiaineessa viimeisimmässä todistuksessa. Lähes kaikilla todettiin ienverenvuotoa. Nuorimmassa ikäryhmässä oli muita useammin korjaavan karieshoidon tarvetta (79% vs. 64%). Kariesta sekä sen seurauksia esiintyi eniten niiden keskuudessa, jotka asuivat Kathmandun laaksossa tai vuoristossa. Karieksen esiintyvyys oli myös yhteydessä mm. sokerin, makeisten ja sokeriteen kulutukseen sekä epäsäännölliseen hampaiden harjaukseen. Karies seurauksineen oli yhteydessä huonoon suunterveyteen liittyvään elämänlaatuun (OHRQoL), erityisesti syömiseen, suun puhdistamiseen sekä nukkumiseen. Sillä oli myös yhteys sekä matalaan että korkeaan BMIhin, lisääntyneisiin koulupoissaoloihin sekä huonoon koulumenestykseen. Matala ja korkea BMI, huono suunterveyteen liittyvä elämänlaatu sekä poissaolot olivat käänteisesti yhteydessä koulumenestykseen. Karies ja ienverenvuoto ovat yleisiä nepalilaisten koululaisten keskuudessa. Karies seurauksineen on yhteydessä huonoon suunterveyteen liittyvään elämänlaatuun (OHRQoL), haitalliseen suunterveyskäyttäytymiseen, sosiodemografisiin ja antropometrisiin tekijöihin (BMI, keskivartalolihavuus) sekä lisääntyneisiin koulupoissaoloihin ja huonoon koulumenestykseen

Master of Science in Biomedical Sciences
Diagnostic Medicine/Pathobiology
Daniel U. Thomson
Auction derived feeder calves (n=1,601; initial BW = 273.5 ± 4.7 kg) were used to examine the effects of delayed administration of the initial steroid implant on health, performance, and carcass characteristics of feedlot cattle. Steers were procured from multiple-source auction markets in the southeastern United States and shipped to a central Kansas feedyard over a 6 week period from December 2009 to January 2010. Steers were rested overnight prior to processing, then were randomly assigned, within arrival block, to 1 of 2 treatments: 1) implanted with Revalor-XS (40 mg estradiol and 200 mg trenbolone acetate) immediately upon arrival (ARRIVAL); or 2) implanted with the same implant after 45 d (DELAYED). Cattle were weighed on a group scale immediately following processing of each block. Feed deliveries were measured using load cells on feed trucks and recorded daily. Cattle were evaluated daily for morbidity and mortality by trained feedyard health personnel. Sick or injured cattle were removed from the home pen for further diagnosis and treatment. Individual animal health data were obtained and recorded daily. Final BW was calculated by dividing HCW by the average dressing percent of the pen. Carcass data (quality grade and yield grade) were obtained by USDA personnel; presence of lung lesions, pleural adhesions, and liver abscesses was evaluated by trained university personnel. Delaying the initial implant tended to reduce morbidity (24.7 vs. 28.5%; P = 0.13) and reduced railer rates (1.8 vs. 3.3%; P = 0.02); however, there were no effects of timing of implant administration (P ≥ 0.31) on rates of retreatment, mortality, lung lesions, or pleural adhesions. Implanting immediately upon feedlot arrival resulted in numerical improvements in ADG and feed conversion, but these differences were not statistical (P ≥ 0.56). Cattle implanted upon arrival had numerically greater HCW and yield grade vs. cattle implanted on d 45; however, these differences were not statistical (P ≥ 0.16). Delaying the initial implant 45 d did not influence animal health, performance parameters or carcass characteristics in high risk feeder calves.

Understanding brain health is crucial in diagnosing, preventing and treating neurocognitive conditions (e.g., dementia). However, the literature reveals discrepancies around the interpretation of brain health and differences between populations. This thesis investigates brain health measures from different disciplines, including: resting cerebral blood flow (CBF) and cerebrovascular reactivity (CVR) (using transcranial Doppler (TCD) ultrasound and magnetic resonance imaging (MRI)); cognition (including attention and memory); and quality of life (QoL) questionnaires. Differences between age (younger versus older) and cardiorespiratory fitness (fit versus unfit) groups were also investigated. Importantly, these multimodal brain health measures were completed in the same cohort. Declines were observed between younger and older groups in resting CBF measures (derived using TCD and MRI), and cognitive performance measures (attention-switching, learning and memory). In the older group, higher fitness offset declines in resting CBF and improved markers of cognition. In both groups, fitness significantly positively correlated with better QoL. However, no differences between age or fitness groups were observed in CVR measures. Further, CVR differed significantly depending on the imaging and analysis approach used. Future research is required to elucidate the cause of discrepancies and determine differences between groups (i.e., age/fitness/disease). Further, robust approaches to assess brain vascular health are needed.

The health care system within the United States is in a state of transition. The industry, confronted with a variety of new technologies, new ways of organizing, spiraling costs, diminishing service quality and new actors, is changing, almost on a daily basis. Reports issued by the Institute of Medicine raise quality issues such as avoidable errors and underuse/overuse of services; other studies document regional variation in care. Improvement in the quality of care, according to health care experts is accomplished through measuring and comparing performance, but there are a number of disparate actors involved in this endeavor. Through a network of both public and private actors, collaboration on the development of a set of national performance measures is underway. Organizations such as the National Quality Forum (NQF), the Agency for Healthcare Research and Quality (AHRQ), the Centers for Medicare & Medicaid Services (CMS) and other have formed networks to develop and standardize performance measurement systems that can distinguish between quality services and substandard ones. While there is some available research about the processes involved in performance measurement system design, there is little known about the factors that influence the development and work of the network, particularly the selection of hospital performance measures. This dissertation explored the development of a national performance measurement system for hospitals, using an institutional rational choice perspective and actor-network theory as frameworks for discussion. Through qualitative research methods such as direct observation, interviews, participant observations and document review, a theoretically informed case study of the NQFâ s Hospital Steering Committee was performed, to address the following questions: How is a national performance measurement system developed and what is the role of federal agencies (e.g., AHRQ and CMS) in the process?
Ph. D.

The purpose of this dissertation is to examine the organizational and environmental correlates of hospital EMR use and to examine the relationship between hospital EMR use and performance. Using a theoretical framework that combines resource dependence theory with Donabedian's structure, process, outcome model, a conceptual model is created. To test the hypotheses of this model, logistic regression and Data Envelopment Analysis (DEA) are used. The data included in this analysis come from the AHA, HIMSS, CMS, ARF, and HQA. In the analysis of hospitals correlates of EMR use, three hypotheses were supported, and one was partially supported. Hospital system affiliation, bed size, and environmental uncertainty were found to be positively associated with hospital EMR use. Hospital rurality was found to be associated with EMR use for all categories except one; at every other level of rurality, as the hospital moves on a continuum from least rural to most urban, the likelihood of hospital EMR use also increases. Hospital EMR use was not found to be associated with teaching status, environmental munificence, competition, operating margin, ownership, or public payer mix. In the hospital performance analyses, one hypothesis was supported, and one was partially supported. Regarding quality, hospitals with EMRs were found to provide higher quality than those without EMRs. In efficiency performance, only small hospitals with EMRs were found to be more efficient than hospitals without EMRs. No support was found that hospitals with EMRs improve their efficiency over time more than hospitals without EMRs. Hospital EMR use does vary by certain organizational and environmental characteristics. For this reason, hospitals and policy makers must take action that enables and encourages all hospitals to implement and use EMRs because some hospitals do not have the motivation or resources to begin using EMRs on their own. Hospital EMR use is positively associated with high quality care, thus justifying the practice. Hospital efficiency was not found to be associated with EMR use in medium or large hospitals, but it was found to be associated with EMR use in small hospitals. Interestingly, larger hospitals are more likely to use EMRs than small hospitals. It is possible that the efficiency gains of EMR use in hospitals will not be realized until a standardized, fully interoperable system is developed, allowing health care provides to quickly and easily share the medical charts of their patients.

Although prior research has found differences in costs and financial performance across different types of hospital systems, there has been no systematic study of variations in patient quality of care or safety indicators across different systems. Our study examines whether five main types of health systems - centralized (CHS), centralized physician/insurance (CPIHS), moderately centralized (MCHS), decentralized (DHS), and independent (IHS) - as well as other hospital characteristics are associated with differences in quality of patient care. Data were assembled for 6 years (1995 - 2000) from multiple sources. We used 4 AHRQ risk adjusted inpatient quality indicators (IQIs) and 5 risk-adjusted patient safety indicators (PSIs) as dependent variables. Random effects models were used in the analysis.It was found that the IQI and PSI models have different patterns. In the IQI models, CHS hospitals have lower AMI, CHF, Stroke, and Pneumonia mortality rates than hospitals in other system types. The PSI models did not indicate any systems' effects on adverse event rates. It was also found that system hospitals' compliance with the JCAHO performance area indicator for availability of patient specific information was associated with lower rates of CHF, Stroke, Pneumonia, and Infection due to medical care.The findings suggest that centralization of hospital structures may improve internal clinical processes by enhancing coordination of activities, communication between providers, timely adjustments of processes of care delivery and structures to external pressures. A lack of systems' effect on adverse events may be explained by a newness of the patient safety issues for hospitals and possible changes in reporting patterns of medical errors after the Institute of Medicine report of 1999. A system hospitals' compliance with the JCAHO performance area indicator may indicate improvements in information and clinical record systems.Hospital systems hold much potential for hospitals in improving patient quality of care and safety because they provide a laboratory for studying the health care process and sharing lessons across multiple institutions. Based on our findings, we recommend that future studies use a combination of IQIs and PSIs when examining institutional quality of care because both provide different and complementary information.

Three chapters constitute the main structure of this contribution. The first chapter investigates the relationship between fiscal decentralization and regional health outcomes, as measured by infant mortality rates, in Italy. The paper employs a panel of all Italian regions over a period of 17 years (from 1996 to 2012), applying a linear Fixed-Effect model. Two different quantitative measures of fiscal decentralization are used, which capture the degree of regional decision-making autonomy in the allocation of tax revenues and the extent of regional transfer dependency from the central government (i.e vertical fiscal imbalance). Methodologically, to account for the temporal dynamics of the decentralization impact, the robustness of the findings is checked, among others, with respect to the use of an Error Correction Model, which allows to disentangle short and long run effects. The analysis also deals with the issue of heterogeneous distributional geographical responses by modelling the asymmetric impact of decentralization on infant mortality rates according to the level of regional wealth. The second chapter addresses the issue of convergence. Here the main research questions are whether health outcomes in Italy converge/diverge over time and, more importantly, whether decentralization has played a somewhat role in the convergence/divergence process. Using a pooled dataset with the same time span as the previous one, the conventional measures of sigma- and beta- (both absolute and conditional) convergence are estimated for two different regional health outcomes (i.e. infant mortality rate and life expectancy at birth). Again, two measures of decentralization are employed in order to catch both the degree of fiscal regional decision-making autonomy (i.e. the same indicator as in chapter 1) and the political decentralization dynamics (i.e. a dummy variable taking the value of 1 after the introduction of the 2001 constitutional reform). From a methodological point of view, the real novelty of the analysis is to take spatial dependence and neighbourhood effects among the regions into consideration. Modelling the impact of decentralization through an interaction term, the speed of convergence is found to be significantly affected by the level of decentralization. The third and last chapter deals with the issue of the effects of decentralization from a different but related viewpoint. Compared to the previous chapters, it examines descriptively the administrative aspects of decentralization by a lower (micro) level perspective, looking at the managerial autonomy of local healthcare structures. The emphasis is here on the role of intrinsic and extrinsic motivations in enhancing accountability and improving the performance of healthcare system, in general, and the quality of hospital care, in particular. Though the focus is not specifically on the Italian system, the analysis is particularly relevant for this country, where regional governments, in charge of the responsibilities for the financing and the delivery of healthcare, act through a network of Local Health Authorities i.e. public entities with their own budgets and management, which directly run small public hospitals -, public hospital trusts with full managerial autonomy and accredited for-profit private providers. The understanding research hypothesis here is that the way in which the financial incentive schemes for providers are designed and structured is likely to affect their effectiveness in pursuing the expected results (e.g. improved efficiency and quality of healthcare service delivery). However, the same incentive is expected to work differently according to the provider s degree of decision-making autonomy and its utility function.

In a 9-month prospective study, sleep and daytime functioning were compared in a community sample of 86 participants aged 25-50 years: 43 meeting DSM IV criteria for primary insomnia (26 women & 17 men); and 43 controls (32 women & 11 men). Assessments were conducted at baseline, 4 and 8 months, and included: the Pittsburgh Sleep Quality Index; Spielberger StatefTrait Anxiety Inventory; Eysenck Personality Questionnaire, Beck Depression Inventory; Fatigue Severity Scale; SF-36; Epworth Sleepiness Scale; Dysfunctional Beliefs About Sleep Scale; Sleep Hygiene and Practices Scale, Sleep Disturbance Questionnaire and the Psychomotor Vigilance Task PVT. An instrument to assess the occupational consequences of insomnia (the Occupational Impact of Sleep Questionnaire; OISQ) was also developed in the course of the study. PWI versus control group comparisons were made with repeated measures multivariate ANOVAs. Differences were consistently and significantly maintained on measures of state (F = 15.85 P <0.001) and trait anxiety (F = 23.46; P < 0.001), depression (F = 18.37; P < 0.001), fatigue (F = 22.20; P < 0.001), and neuroticism (F = 11.09; P < 0.001). Among PWI, mental health (F = 14.04; P < 0.001), pain (F = 6.92; P < 0.001), role-emotion (F = 10.94; p < 0.001), general health perceptions (F = 4.77; P < 0.05), social functioning (F = 6.58; P < 0.01) and energy and vitality (F = 32.08; P < 0.001), on the SF-36, were consistent with inferior health related QoL. In addition, pre-sleep arousal (F = 14.76; P < 0.001), sleep hygiene (F = 35.26; P < 0.001) and sleep disturbance (F = 72.32; P < 0.001) were significantly worse within PWI. Subjectively reported TIB (F = 9.38; P < 0.01), SOL (F = 11.17; P < 0.01) and WASO (F = 21.10; P < 0.001), remained greater within PWI, with SE (F = 15.29; P < 0.001), TST (F = 9.38; P < 0.01) and subjective sleep quality (F = 29.57; P < 0.001) greater within controls. Data averaged over the duration of data collection (252 days) found PWI reported an average SOL >30 minutes, an average WASO of> 30 minutes, SE < 80%. Analysed in terms of night to night sleep quality, both PWI and controls showed a pattern of 'good' (sleep efficiency >80%) and 'poor' (sleep efficiency <80%) nights. However, the probability of individual poor nights remained consistently and significantly higher for PWI across the 9 months of the study. Actigraphy data failed to confirm between group differences in sleep, and correlation with diary measures was low in both groups. PVf performance showed instability. Significant group differences found at baseline, were no longer present at subsequent data collection points. Data support the inconsistency surrounding objective performance among PWI within the literature. However, the inconsistency can be attributed to greater change within control participant's performance, rather than within PWI. Data identified the existence of a stable subgroup of PWI reporting symptoms of daytime sleepiness. Daytime sleepiness was found to be a temporally stable feature for this sub-group of PWI, who also Showed a distinctive psychological profile compared to PWI who did not report daytime sleepiness. No difference, however, was observed in subjectively reported sleep structure, quality or daytime performance between these subgroups of PWI. Insomnia subgroup analyses suggest a trait-like difference between sleepy and non sleepy PWI.The OISO showed an acceptable level of internal consistency reliability (alpha 0.93); and successfully discriminated between PWI and controls. The OISO also showed consistent correlations with measures of global sleep quality and subjective sleep parameters. Expressed in terms of comparative percentage decrement, PWI showed a consistent 10% decrement in subjective occupational performance when compared with controls. The OISO shows that absenteeism and punctuality may not capture the full impact of insomnia on workplace performance.

Thesis (M.Sc.)--Saint Mary's University, 2009.
Running head: Factors affecting applicant attraction Includes abstract. Supervisor: Victor Catano. Includes bibliographical references (leaves 41-46).

A business process is a defined collection of linked structured tasks, activities, and decisions performed together to produce a desired set of results in order to achieve business goals on behalf of the organization. Companies are increasingly moving their business processes online using Business Process Management (BPM) tools and technologies. With BPM, online business processes are defined by an explicit business process model that flexibly combines and orchestrates forms delivered through a web browser to integrate tasks performed by people, and web services accessible through Internet protocols to integrate tasks performed by software. Often the approach to quality assurance for online business processes is similar to what would be done with any other web application. This is insufficient since it only provides rudimentary verification of single user behavior whereas the orchestration of tasks across many users and software systems can be quite complex. As well, a simple web application testing approach does not leverage the defined model for a business process to ensure consistency, completeness and enable automation. Nor will such an approach validate that a business process is contributing towards the achievement of business goals. A more systematic approach is required. This thesis proposes a quality assurance framework to provide a repeatable, systematic, cost-efficient approach to quality assurance for BPM. A prototype framework was implemented and evaluated using two case studies, including one case study that was developed in collaboration with a local hospital to support a business process for cancer care assessment.

Low back syndrome affects 20% of people, and it is estimated that 30% of patients are unable to return to work after surgery. The monitoring of health care outcomes could improve the delivery of health services. The health performance conceptual framework, derived from the Donabedian model, was used to evaluate the functional outcome, clinical recovery, response to surgery, and physician performance of the surgical management of lumbar spine degeneration. A quantitative study (n=685) was undertaken using an administrative database in a repeated-measures design. The clinical and functional outcome improvements were analyzed using t tests. Surgical complexity on health outcome was examined with ANOVA. Predictors of patient satisfaction was explored using Pearson's correlation and regression analyses. The results demonstrated highly significant improvements in functional (mean change 30%; ODI=16.79 ± SD 19.92) and clinical recovery (mean change 50%; modified-JOA=6.983 ± SD 2.613) with surgery at 3 months; a >50% positive response to surgery; and a > 90% patient satisfaction, sustained over a 2 year period. Complexity of surgery did not impact health performance. Strong correlations between the health performance metrics were detected up to 6-months from surgery. Poor clinical recovery and persistent functional disability were predictive of patient dissatisfaction. The social change implications for health policy are that a constellation of health performance metrics could predict the potential for functional and clinical recovery based on presurgery disability while avoiding medical expenditures for procedures with no health benefit; aid in health quality monitoring, peer comparisons, revision of practice guidelines, and cost benefit analysis by payers.

While the importance of assessing the occupational consequences of insomnia and other sleep disorders is emphasised in clinical nosologies and research guidelines, there is little consensus on which aspects of occupational performance should be assessed, how such impairment should be measured, and how outcomes should be reported. The research programme described in this thesis aimed to address this issue. Chapter 1 presents a systematic review and methodical critique of studies reporting those aspects of occupational performance most impacted by (or most frequently associated with) insomnia symptoms and degraded sleep quality. Equivocal results, wide variations in reporting conventions, and the overall lack of comparability among studies, strongly indicated the need to develop a standardised metric able to quantify sleep related occupational performance and serve as an assessment and outcome instrument suitable for use in research and clinical settings. Informed by the literature review, Chapters 2-4 describe the development and validation of the Loughborough Occupational Impact of Sleep Scale ( LOISS ), a unidimensional 19 item questionnaire that captures sleep-related occupational impairment across a number of workplace domains over a 4-week reference period. Chapters 5-7 describe LOISS outcomes from: i) surveys in a random population sample; ii) a representative sample of the UK workforce; and iii) a clinical sample of patients with obstructive sleep apnoea (before and after treatment with CPAP). Overall, the scale showed strong internal consistency (Cronbach s alpha range=0.84-0.94) and test-retest reliability (r=0.77, r2=0.59, p<0.001), high levels of criterion validity (significantly discriminating between good and poor sleepers), and proved an effective outcome measure in OSA. From the survey data reported in Chapters 2-7, LOISS score distributions showed no consistent gender difference but did show a significant ageing gradient, with sleep-related occupational impairment declining with increasing age. In conclusion, the work presented here supports the usability, validity and reliability of the LOISS as an assessment and outcome instrument, and also demonstrates the utility of this instrument in exploring the dynamics of sleep-related occupational performance

The efficiency and efficacy of the U.S. healthcare system has been in question for decades. We spend more per capita than any other industrialized nation while consistently realizing inferior health outcomes for our population as a whole when compared with many industrialized nations. In 1965, the proportion of U.S. gross domestic product (GDP) attributed to healthcare was approximately 6%. Today, the share of GDP spent on healthcare by the United States is almost 18%. This number is 5% higher than the next two countries, the Netherlands and France (spending 12.0% and 11.8% of their GDP on healthcare respectively) according to the Organization for Economic Co-operation and Development (OECD). The proportion of GDP spent on healthcare in 2020 is estimated to reach 20%, with the nation's increasing healthcare expeditors reducing resources available for other worthy government programs, eroding wages, and undermining the competitiveness of U.S. industry.

This dissertation explores longitudinal outcome data for Malcolm Baldrige National Quality Award recipients in healthcare in the dimensions of patient outcomes (mortality, complications and patient safety), as well as hospital financial and efficiency measures (average length of stay, expense per discharge and profitability). Source data from Truven Health Analytics (formerly Thomson Reuters) are used to evaluate changes in level, immediacy/latency and trend in the years prior to versus the years after becoming a Malcolm Baldrige National Quality Award recipient. In support of the hypothesis, being a recipient of the Malcolm Baldrige National Quality Award in healthcare explains slight enhancements in clinical outcomes, while hospital financial and efficiency measures all showed overwhelmingly positive operating results.

The recent reports by Institute of Medicine, `To Err is Human' and `Crossing Quality Chasm', revealed a large prevalence of medical errors and substandard care in US hospitals. Since then there has been a substantial increase in the efforts to measure and improve quality of care. The objective of this study was to compare the quality of care across hospitals using available performance indicators and examine the association between organizational factors and hospital performance. The main focus of this study was on important structural attributes of hospitals, namely - teaching status, location and market competition. The Nationwide Inpatient Sample for years 2003 and 2005, and the State Inpatient Database for years 2004 to 2006 were used for analyses. Two types of hospital performance indicators were examined to compare quality of care - Patient safety indicators developed by Agency for Healthcare Research and Quality, and process of care indicators developed by Centers for Medicare and Medicaid services. Multivariable regression analyses were performed using generalized estimating equations and random effects regression models. Several organizational factors as well as patient characteristics were included in the multivariable models as control variables. Overall, the results from this study showed an inconsistent relationship between teaching status, location of hospitals or market competition and quality of care in hospitals. In addition, the results demonstrated that isolating potential effects of hospital structure on outcomes requires controlling for the variation in patient characteristics, such as age and comorbidities, which increase patients' risk for incurring patient safety events. The findings from this study provide useful insight into the areas where the patient safety and quality initiatives should be focused. Moreover, the results identified the organizational factors that are relevant to certain types of hospitals and which should be considered before evaluating quality of care and enacting any policies about publicly reporting of performance or payment initiatives that are relevant to these hospitals.

Master of Science
Department of Animal Sciences and Industry
Christopher D. Reinhardt
Angus steers (n = 17,919) fed at a single feedlot in southwestern Kansas between 1997 and 2007 were used to evaluate the effects of various demographic and phenotypic characteristics (season of arrival, geographic origin, health status, rate of gain, quality grade, and yield grade) on feedlot health, performance, and carcass traits. Cattle were not commingled and were predominantly preconditioned and backgrounded prior to shipment to the feedlot. Season of arrival was categorized as winter (December, January, and February), spring (March, April, and May), summer (June, July, and August), or fall (September, October, and November). Regions were: SC = Texas, Oklahoma, and New Mexico; C = Colorado and Kansas; NC = Montana, Nebraska, and Wyoming; and SE = Georgia, Mississippi, South Carolina, Tennessee, Virginia, and West Virginia. Steers that originated in SC had the poorest ADG (P < 0.01) and those originating in C had the greatest ADG, HCW, and quality grade (P < 0.01). Steers that arrived during fall had the lowest ADG and those arriving during the summer had the greatest morbidity (P < 0.01). Morbidity decreased and performance increased with increasing initial BW; quality grade was only minimally related to arrival BW in steers which were not treated for disease. After accounting for yield grade differences, the association between morbidity and carcass quality and between quality grade and heavier final BW and HCW were diminished, although ungraded cattle had lower ADG, final BW, and HCW (P < 0.01). Increasing yield grade from 1 and 2 to yield grade 3 increased percentage Choice by 12.1 points (P < 0.01); there was no additional gain in quality grade moving to yield grade 4 and 5. More rapidly gaining steers were heavier and fatter at marketing; this translated to greater quality grade in all but steers with initial BW > 375 kg. Performance was very similar among cattle which graded Prime, Choice, and Select, suggesting that producers do not need to choose between performance and quality grade; instead, much of the difference in quality grade can be explained by differences in yield grade.

Improving the role the nurse plays in health care delivery should be embodied in the performance improvement initiatives to successfully improve the quality of care that is delivered. The purpose of this evidence-based practice project was to collect performance improvement data and present it to staff who, in turn, used the information to improve practice and influence patient safety outcomes. The practice-focused question addressed what would occur if a tool that allowed frequent data trending was used to measure effectiveness of care and thereby influence key outcome measures. Duffy's quality caring model provided a framework for the study to support the need for the development of a dashboard for staff and to ensure that staff were informed as they developed interventions to improve patient outcomes. Publicly available data published by the Centers for Medicare/ Medicaid (CMS) for the Quality Star Report were explored to inform the project. Workgroups, comprised of volunteers from leadership and staff providing care at the bedside, were formed to implement practice changes based on the dashboard reports. By bringing the data to the attention of nurses within the organization, improvements were made in the overall score for safety of care from below national average (25th percentile of the reported 3,647 hospitals across the nation) to the same as national average (47th percentile) as reported by CMS. Through staff involvement, social change occurred as strategies were hardwired to improve categories of the Quality Star Report and ultimately patient care. The project showed that quality improvement tools can assist in empowering staff to understand the data needed to implement process improvement strategies.

Consumers are concerned about antibiotic and ractopamine usage; therefore, alternatives need to be found. Objectives of this study were to investigate the effects of using seaweed as an alternative feed supplement and comparing performance, carcass, pork quality, and immune traits in pigs fed seaweed, control, and ractopamine diets. Pigs were allocated to one of three treatments (CON, SWE, RAC) at weaning (n = 40/treatment). Pigs were weighed every two weeks. Carcass characteristics, pork quality, and immune data were collected post-mortem. No differences were found between treatments for feed intake, growth, or feed efficiency. Pigs on RAC treatment had greater hot carcass weight and dressing percentage (P < 0.05). Chops from RAC pigs were lighter (P = 0.05), less red (P < 0.05), and tougher (P = 0.08). There were no differences between treatments for FABP2 gene expression, cell proliferation percentages, or crypt depths. Therefore, no negative effects of feeding seaweed to pigs were found in this study.

Le polyhandicap est consécutif à une lésion sur un cerveau immature, il associe déficience mentale profonde, déficit moteur, restriction de l’autonomie. Objectifs 1) décrire les caractéristiques médicales, la prise en charge du PLH et son adéquation, 2) évaluer l’impact du polyhandicap sur le vécu des aidants. Méthodologie : étude de cohorte. Sept centres (SSR et médico sociaux) ont participés. Patients inclus: répondant à la définition du PLH, pour chaque patient sont inclus aidants professionnels et familiaux. Données recueillies : patient :médicales, modalités de prise en charge, aidants: sociodémographiques et vécu. Résultats : 875 patients ont été inclus, âge moyen 24 ans, enfants 45.8%, adultes 54.2, principales comorbidités :infections pulmonaires, troubles orthopédiques, épilepsie. L’adéquation objective de la prise en charge en SSR est de 60% au regard de la sévérité du PLH. Le polyhandicap de l’enfant a un retentissement considérable sur le vécu des parents et des soignants
Polyhandicap (PLH) is a chronic affliction occurring in an immature brain, leading to the combination of profound mental retardation and serious motor deficit. The French health system allows care management in specialized rehabilitation centers (SRC), residential facilities (RF), and home care. The aims of this study were i) To describe PLH patients ‘health status and to estimate the adequacy of care management ii) To assess the QoL of parents and health-care workers.Method: inclusions: PLH patients, parents and institutional HCWs of each included patients. Data collection: socio demographic, clinical, modalities of care management, caregivers' QOL. Results: 875 PLH patients were included: main comorbidities were pulmonary infections, orthopedic and epilepsy. Global objective adequacy was higher for patients cared for in SRC.The QoL scores of all dimensions were significantly lower for parents and health care workers than for controls

A qualidade em saúde é cada vez mais uma prioridade estratégica para o Serviço Nacional de Saúde. O desempenho organizacional é um indicador que mede quão bem uma organização realiza os seus objetivos, sendo as unidades funcionais dos cuidados de saúde primários monitorizadas através do Índice de Desempenho Global (IDG). Pelo que, pretende-se com este estudo analisar a relação entre a perceção da qualidade dos profissionais de saúde, das diferentes unidades funcionais, do Agrupamento de Centros de Saúde do Alentejo Central e o nível de desempenho das respetivas unidades. Como instrumento de avaliação usou-se o Questionário de Auto Perceção da Qualidade para os Cuidados de Saúde Primários, que permitiu avaliar a perceção da qualidade dos profissionais de saúde e o IDG, que monitoriza e avalia a contratualização interna, de cada unidade funcional, através dos registos eletrónicos. Concluiu-se que não existem diferenças estatisticamente significativas entre a perceção da qualidade dos profissionais de saúde, dos diferentes tipos de Unidades Funcionais e, globalmente, todas as dimensões apresentam correlações estatisticamente significativas com o IDG; Abstract: The quality and performance in primary health care of the Alentejo Central Health Centers Grouping Quality in health care is increasingly becoming a strategic priority for the National Health System. The organizational performance is an indicator that measures how well an organization accomplishes its goals, and the functional units of primary health care monitored by the Global Performance Index (GPI). Therefore, the aim of this study is to analyze the relationship between the perception of the quality of health professionals, of different functional units, the Health Centers Grouping Alentejo Central and the performance level of the respective units. As an evaluation tool used to the Quality Auto Perception Questionnaire to Primary Health Care, that allowed evaluate the perception of the quality of health care professionals and the GPI, which monitors and evaluates the internal contracting of each functional unit, through the electronic registers. It was concluded that there are no statistically significant differences between perception of quality, of different types of functional units and, generally, all dimensions, have statistically significant correlations with the GPI.

The U.S. health care delivery system faces serious challenges such as an increasing demand for services due to an aging population, unhealthy lifestyles, growth in the number of uninsured individuals, and an increase in chronic diseases. At the same time, the system has to cope with a limited supply of money, physicians, and nurses inferior quality of care delivered by U.S. hospitals. While the U.S. hospital industry is adapting to address these issues, not much progress in improving the quality of care delivered has been made over the last decade. However, theories exist that management systems, organizational traits, and leadership are key factors for hospitals to improve quality of care outcomes. This study takes a holistic look at these factors to identify and analyze critical drivers for better quality of care outcomes of U.S. hospitals. The study also aims to identify differences between chief executive officers' (CEOs) leadership traits among lean (mediocre performance), high (top 20th percentile), and low performing (bottom 20th percentile) U.S. hospitals in regards to their quality of care measures. Two separate online surveys were conducted. The first online survey was targeted at all 4,697 U.S. hospitals that are required to disclose quality of care measures to the Federal government. Results of this first survey revealed that two management system factors drive quality of care outcomes of U.S. hospitals. Furthermore, findings also show that critical access hospitals have a lower quality of care performance than acute care hospitals. Thus, based on the results from this survey, we concluded that management system factors are main drivers of hospital performance, whereas organizational trait and leadership factors did not significantly contribute to hospital performance. A second survey to CEOs and CEO followers in 9 selected hospitals found significant differences between CEO traits leading lean and low performing hospitals, and, to a lesser degree, significant differences among high and low performing hospitals. However, the study did not find any significant differences in CEO traits between lean and high performing hospitals. Findings also include that some management system factors differed significantly between lean and high performing hospitals, but no evidence for such differences could be found between lean and high and high and low performing hospitals, respectively. These results suggest that management systems and CEO leadership traits play an important role in determining U.S. hospital performance as measured by their quality of care.
Ph. D.

Asthma is an inflammatory disorder (Koterba & Saltoun, 2012) and a common chronic condition of childhood (McCowan, Bryce, Neville, Crombie, & Clark, 1996) that can cause children to experience poorer academic outcomes (Stingone & Claudio, 2006), a lower quality of life (Everhart & Fiese, 2009), hospitalizations, and in some cases death (Center for Disease Control, [CDC], 2017). This mixed methods study explored the relationship of asthma, school attendance, grades in mathematics and reading, and the quality of life in predominantly minority children with asthma and in those without asthma. Data for this study was collected at the Children’s National Health Systems (CNHS) in the District of Columbia. A total of 36 children without asthma and 30 children with asthma enrolled in the study at the hospital’s Emergency Department (ED) and the Improving Pediatric Asthma Care in the District of Columbia (IMPACT DC) clinic. The children were in grades three to five, 8 to 11 years old, and attended schools in the District of Columbia Public Schools (DCPS) during the 2015–2016 school year. Descriptive statistics, t-tests, ANCOVA, ANOVA, Spearman ranked order correlations, and hierarchical multiple linear regression were used to analyze the data.

The quantitative analysis indicated children with asthma visited the ED significantly more frequently than those without asthma (p < .001, d= 0.8). The quality of life scores were lower for children with asthma compared to those without asthma. Further, as asthma severity increased, the quality of life scores decreased. In addition, children without asthma reported more unexcused days and absence from school than those with asthma. Lastly, children without asthma achieved a lower GPA in mathematics and reading than those with asthma. The findings indicate asthma impacts the quality of life scores in children, and that further research is warranted to determine how asthma impacts academic performance in children.

Recent trends of financial distress for non-profit hospitals and the uptick in acquisition of these hospitals by for-profit entities indicate different focuses from the management of each type of hospital. Using data on hospital quality and basic financial measures, this study examines shift in the balance of financial and quality performance. The dataset focuses on private non-profit and for-profit hospitals with low bed counts, ranging from 50-200 total beds. Results indicate a positive relationship between for-profit status and basic financial performance measures, such as profitability, and a negative relationship with patient experience, cost reduction for the patient, and overall quality. This signals a tradeoff between financial performance and quality, especially measures relating to the customer. For-profit hospital management places more of an emphasis on the financial performance while non-profit hospital management demonstrates a balance between financial performance and high quality performance. Without being involved in hospital management decision-making, examining hospital outcomes is the best way to give insight into how hospital management is shifts performance priorities by different types of ownership.

The prolonged wars in Iraq and Afghanistan have taken a toll on the United States as a whole and the United States military in particular. The primary aim of this research is to determine what impact the wars in Iraq and Afghanistan have had on the performance of military hospitals over the fiscal years 2001-2006. Specifically, what direct effect has the war in Iraq and Afghanistan had on the productivity and quality of military hospitals, and, do productivity and quality trends differ based on hospital characteristics? Since observations over multiple time periods are nested within hospitals, multilevel mixed effects regression and Poisson regression models are used to evaluate changes in productivity and quality while accounting for differences within hospitals. Using a contingency theory framework, this study fills the gap in looking at the impact of war on permanent military hospitals’ productivity and quality using nationally developed and implemented quality indicators (Agency for Healthcare Quality and Research Inpatient Quality Indicators and Patient Safety Indicators). Structural characteristics of the hospital, teaching status and branch of Armed Service influenced productivity and certain quality indicators. The structural components were not able to reliably predict differences in productivity and all quality indicators, but overseas hospitals and non-teaching hospitals were most likely to differ from major teaching hospitals. The wars in Iraq and Afghanistan, denoted by the variables for wounded discharges and deployed staff, were only partially related to the productivity of military hospitals. Only an increase in the percentage of wounded discharges was related to productivity of military hospitals, and none were related to the quality indicators. In essence, the war affected the workload and productivity of military hospitals, but it did not affect the quality provided in the hospitals, as measured by AHRQ inpatient and patient safety quality indicators. Structural characteristics account for more of the variation in quality among military hospitals than the impact of war within the timeframe studied.

Thesis advisor: Julie Mortimer
Essays on the effects of health policy payment systems in long-term care and end-of-life care institutions are studied. In the arena of long-term care, state Medicaid agencies have recently implemented pay-for-performance (P4P) programs to address poor quality of care in nursing homes. Using facility-quarter level data from 2003 to 2010, we evaluate the effects of Medicaid nursing home P4P programs on clinical quality measures, relying on variation in the timing of P4P implementation across states. Further, we exploit variation in the structure of states' programs to investigate whether programs that reward certain dimensions of quality are associated with larger improvements. We find P4P decreases the incidence of adverse clinical outcomes by as much as 8%, and the improvements are concentrated among the measures that experienced an increase in their relative returns and share strong commonalities in production. In the Hospice industry, changes to the current reimbursement system are mandated by the Patient Protection and Affordable Care Act. The motivation stems from noticeable hospice utilization changes since the Medicare Hospice Benefit (MHB) introduced a per-diem reimbursement in 1983. This research analyzes the abilities of a multi-tiered payment system, and a simpler two-part pricing system, to accurately match Medicare payments with hospice patient costs. Both systems improve on the current payment mechanism, while two-part pricing is the only system to maintain access to care for all MHB eligible patients. In addition, consumer disutility incurred by driving to airports is estimated and used to define air travel markets. Though an accurate definition of an economic market is important for any study of industry, there is no rule governing what exactly constitutes a market. To define a market we must ask the question ``between which products do consumers substitute,'' knowing that the answer to this question will depend on how ``close'' products are to one another in product space, as well as how close they are to one another, and to consumers, in geographic space. We estimate a discrete choice model of air travel demand that uses known information about the locations of products and consumers, which allows us to study substitution patterns among air travel products at different airports. We evaluate the commonly used city-pair and airport-pair definitions of a market for air travel, and conclude that a city-pair is the appropriate definition. We also employ the Hypothetical Monopolist test for antitrust market definition, as defined by the Department of Justice and Federal Trade Commission, and conclude that the relevant geographic market for antitrust analysis is frequently more narrowly defined as an airport-pair
Thesis (PhD) — Boston College, 2013
Submitted to: Boston College. Graduate School of Arts and Sciences
Discipline: Economics

The hospitals and their healthcare providers need to optimize simultaneously three outcomes: healthcare costs, healthcare options offered to customers, and information utilization efficiency. The adoption of electronic healthcare record (EHR) technologies is a potential managerial mechanism for balancing these outcomes. EHR offers patient management and decision support capabilities that can ameliorate health delivery outcomes for patients, doctors, and hospitals through better-informed business and care decisions. The analysis of data collected in an EHR system may lower costs and improve health care delivery (or both). In sum, it could be argued that EHR is a source of competitive advantage. Despite this prima facie appeal, many hospitals remain reluctant to adopt and implement EHR due to lack of insights into return on investment, unavailability of tested systems and data entry obstacles. To address this gap between the potential of EHR system and lack of its adoption, the purpose of this research is to investigate the role of EHR as a resource of competitive advantage for hospital. Essay 1, titled "Implementation and Adoption of EHR: A Conceptual Model based on Resource Advantage Theory", describes the antecedents and consequences of EHR adoption and implementation. Essay 2, titled "Exploring the Relationship Between Electronic Healthcare Record Adoption and Quality of Care", delves deeper into the operational performance of a hospital. This essay focuses on the impact of EHR on different aspects of patient care and thereby on the financial performance of the hospital. Essay 3, titled "The Effect of Resources on a Hospital's Financial Performance: The Moderating Role of Electronic Health Records Implementation and Adoption", is an empirical inquiry into the key factors that may influence hospitals' financial performance. These include organizational factors (such as, number of nurses and beds) and environmental factors (such as, location and received donations). Further, this essay explores the interaction effects between EHR and these factors. In summary, this research provides a conceptualization and an empirical investigation of EHR adoption and implementation and its impact on hospitals' operational and financial performance, an area receiving widespread attention from health care organizations, patient rights activists, public policy makers and the media. Future research can take two paths. First, further research should address questions related to the integration of EHR with other production and inventory management systems, and the prospective benefits attained from system integration. Second research is needed to investigate how parallel information transfer across multiple stakeholders may concurrently preserve Health Insurance Portability and Accountability Act, reduce health care delivery costs and optimize service quality.

To-date primary care delivery - defined here as first-contact patient care delivered at the first level of health systems - in low- and middle-income countries (LMICs) has been an under-researched topic, with researchers tending to focus on specific diseases or vulnerable groups (e.g. children, pregnant women). Yet as vertical programs have evolved and expanded in the past two decades, interest in primary care has been renewed, specifically as operational challenges to delivering integrated care have surfaced. There is also growing recognition that vertical interventions benefit from a basic foundation of general clinical quality, which in turn, requires integration at the point-of-care. One of the few notable, yet comparably under-researched, efforts to advance integrated primary care delivery in LMICs, is the World Health Organization (WHO)'s Integrated Management of Adolescent & Adult Illness (IMAI). IMAI consists of simplified protocols addressing common adult and adolescent illness and targeted at health workers at first-level facilities. Unlike the better-known Integrated Management of Childhood Illness (IMCI) for children under-five, however, IMAI lacks an evidence base either for its validation or its impact on care. This thesis addresses this gap and describes an implementation research trial - using a pre-/post- intervention plausibility design - of the impact of IMAI training combined with a program of sustained mentoring and supervision, on the quality of care and on the performance of primary care nurses in one district in rural Rwanda. The main finding of this trial is that IMAI training and sustained supervision leads to significant improvements in basic quality indicators and behaviors such as taking of vital signs and screening and counseling for priority conditions, while also resulting in a greater than two-fold increase in the odds of agreement in diagnosis and treatment decisions by nurses, when compared to the reference standard. This effect remained for diagnosis with exposure to supervision alone, but in the absence of classroom-based didactic IMAI training, highlighting the importance of sustained mentorship to improving health worker performance and quality. This study is one of the first of its kind to focus specifically on the quality of integrated primary care delivery in itself, rather than through the lens of a specific proxy disease or population subgroup. It is also the first study to provide impact data on IMAI, and thus offers early evidence of its utility as an organizing protocol to improve integrated primary care delivery in LMICs.

La tecnologia di iniezione in ovo consente di somministrare componenti bioattivi di origine naturale, quali pre- e probiotici, direttamente nella camera d’aria dell’uovo al 12° giorno di incubazione. Questa via di somministrazione permette di veicolare tali composti il prima possibile ed in condizioni altamente controllate, aumentandone così l’efficacia. Tuttavia, gli studi condotti finora per provare e validare l’efficacia dei prebiotici somministrati in ovo sulla salute intestinale, sulle performance di crescita e qualità della carne non sono del tutto esaustivi, essendo stati tutti condotti su polli da carne, trascurando sia la ricchezza della biodiversità avicola, nonché le diverse condizioni climatiche di allevamento. L’obiettivo del presente lavoro di tesi, articolato in due studi, è stato quello di valutare l'efficacia dei prebiotici iniettati in ovo sulla schiudibilità delle uova, sulla salute dell'intestino, sulle performance produttive e sulla qualità della carne di polli Ross 308 e Kuroiler allevati in zone climatiche temperate e tropicali, rispettivamente. Il primo studio, condotto in Italia, ha inteso valutare gli effetti della somministrazione in ovo di un prebiotico commerciale Bi2tos (Clasado Ltd., Malta) sulle performance produttive, e sulle caratteristiche qualitative e stabilità ossidativa della carne di polli allevati in condizioni climatiche temperate. Per lo studio sono state utilizzate uova di polli da carne di razza ibrida (Ross 308). Al 12° giorno di incubazione, 300 uova fertili sono state divise a random in 3 gruppi: BI, gruppo iniettato con 0,2 ml di Bi2tos (3,5 mg/uovo di trans-galactooligosaccaridi); S, gruppo di controllo positivo iniettato con 0,2 ml di soluzione fisiologica; C, gruppo di controllo negativo non trattato. Dopo il sessaggio, 120 pulcini maschi (40 pulcini/gruppo) sono stati pesati e trasferiti presso un’azienda agro-zootecnica ed allevati in box a terra (n = 10 polli per box, 4 repliche), con libero accesso ad un’area esterna. Gli animali sono stati alimentati ad libitum con diete commerciali formulate in funzione della loro età ed hanno usufruito di acqua fresca, sempre disponibile. Per tutto il periodo di allevamento i polli sono stati monitorati e rilevato il peso vivo, per ogni singolo box, e calcolato il relativo accrescimento medio di riferimento. A 42 giorni d’età, sono stati scelti 20 polli per gruppo, presi a random tra quelli di peso simile, sono stati pesati e macellati. È stato registrato il peso della carcassa e calcolata la relativa resa. La carcassa è stata quindi sezionata nei principali tagli commerciali (petto, cosce e ali), pesati e calcolate le rispettive rese. A 24 ore post-mortem, sul muscolo pettorale, sono stati misurati il pH, colore e la capacità di ritenzione idrica (WHC); inoltre, sul muscolo pettorale sono state condotte analisi chimiche per la determinazione del profilo lipidico e della stabilità ossidativa (TBARS). I dati sono stati analizzati mediante ANOVA ad una via. Le differenze tra le medie sono state valutate mediante il test di Scheffé. L’iniezione in ovo del prebiotico e della soluzione salina non hanno avuto alcun effetto negativo sulla percentuale di schiusa, che è risultata elevata (> 90%) e simile tra i tre gruppi sperimentali. Il tasso di mortalità è stato molto basso (2%) ed indipendente dalla sostanza iniettata in ovo. Il peso iniziale dei pulcini è risultato simile tra i 3 gruppi sperimentali. Gli animali del gruppo BI, iniettati in ovo con il Bi2tos, hanno mostrato nei primi 21 giorni di vita un miglior (P < 0,01) incremento ponderale rispetto a quelli dei gruppi C (+2,5%) e S (+1,9%). I valori dell’incremento totale di peso registrati nell’arco dell’intero periodo di sperimentazione (6 settimane) sono risultati significativamente superiori (P < 0,05) nei gruppi BI e S rispetto al controllo (+7,5% and 6,8%, rispettivamente). Per quanto riguarda il peso vivo degli animali macellati, i polli dei gruppi iniettati in ovo (S e BI) sono risultati più pesanti (P < 0,05) rispetto a quelli di controllo. Anche il peso della carcassa è risultato maggiore nel gruppo BI ed S rispetto a C (P < 0,05); mentre la resa in carcassa e la resa dei principali tagli commerciali (petto, cosce ed ali) sono risultate simili tra i gruppi. Il pH24, il colore (L*, a*, b*) e WHC sono risultati simili tra i gruppi sperimentali. La carne del gruppo trattato con prebiotico (BI) ha mostrato un contenuto di lipidi totali significativamente più elevato rispetto al gruppo C, con valori intermedi per il gruppo S. Il trattamento con prebiotico non ha avuto alcun effetto sia sul contenuto totale di acidi grassi saturi (SFA) che su quello dei singoli acidi grassi saturi. Gli acidi saturi più abbondanti sono risultati l’acido palmitico (C16:0, da 23,45 % a 24,95 %) e l’acido stearico (C18:0, da 9,49 % a 10,21 %). Il contenuto totale di acidi grassi monoinsaturi (MUFA), come anche quello dei singoli MUFA è risultato simile tra i gruppi sperimentali. L’acido oleico (C18:1) è risultato essere il più abbondante (da 24,49 % a 25,53 %). Il contenuto totale di acidi grassi polinsaturi (PUFA, da 33,80 % a 36,40 %) è risultato significativamente più basso (- 2,6%) nel gruppo BI rispetto al gruppo S, così come il contenuto totale degli acidi grassi PUFA n-3 e n-6. Relativamente al contenuto dei singoli PUFA, ad eccezione dell’acido docosaesaenoico (C22:6 n-3), risultato più basso (P < 0,05) nel gruppo BI rispetto ai gruppi S e C, il contenuto dei restanti PUFA è risultato simile tra i gruppi sperimentali. Gli acidi grassi polinsaturi più abbondanti sono risultati l’acido linoleico (C18:2, da 25,13 % a 25,73 %) e l’arachidonico (C20:4, da 5,22 % a 6,44 %). Riguardo gli indici nutrizionali, il rapporto n-6/n-3 è risultato significativamente più elevato (+16,2%) nel gruppo BI rispetto a quello S. Il rapporto acidi grassi polinsaturi/saturi (P/S) è risultato tendenzialmente più basso nel gruppo BI rispetto ai gruppi S e C. Il trattamento non ha avuto alcun effetto sull’indice aterogenico e quello trombogenico. L’ossidazione lipidica non è stata influenzata negativamente dal trattamento. Infatti, il gruppo BI ha mostrato un più basso contenuto di TBARS dopo 72 ore di refrigerazione aerobica rispetto al controllo. Concludendo, i risultati ottenuti dal presente studio consentono di affermare che la somministrazione in ovo di un prebiotico commerciale ha avuto effetti positivi sulle performance di crescita, mentre non ha avuto alcun effetto negativo sulle caratteristiche chimico-fisiche e nutrizionali della carne. Il secondo studio, condotto in Uganda, ha inteso valutare gli effetti della somministrazione di un prebiotico, di una formulazione antibiotica, e della loro combinazione, sulle performance produttive, sulle caratteristiche qualitative della carne, nonché sulla salute intestinale (in seguito ad un'infezione naturale di coccidiosi) di polli Kuroiler allevati in condizioni climatiche tropicali. Per lo studio sono state utilizzate uova di galline Kuroiler, razza a duplice attitudine. Al 12° giorno di incubazione, 150 uova fertili sono state divise a random in 2 gruppi. Un gruppo è stato iniettato con 0,2 ml di Bi2tos (3,5 mg/uovo), l’altro gruppo non iniettato è stato lasciato come controllo. Alla schiusa, i pulcini di ciascun gruppo sono stati ulteriormente divisi in due gruppi: un gruppo a cui è stata somministrata la formulazione antibiotica (ossitetraciclina, 1g/l in acqua per 7 giorni), mentre l’altro gruppo non ha ricevuto antibiotici. I gruppi, quindi, erano i seguenti: controllo (C), antibiotico (A), Bi2tos (B) e Bi2tos + Antibiotico (AB). Gli animali (metà maschi e metà femmine) sono stati allevati presso una piccola azienda avicola nel distretto di Gulu dove l'infezione da coccidiosi era stata confermata da veterinari. I polli sono stati allevati per 18 settimane in regime semi-intensivo. Gli animali sono stati alimentati ad libitum con diete commerciali formulate in funzione della loro età ed hanno usufruito di acqua fresca, sempre disponibile. Per tutto il periodo di allevamento, a cadenza settimanale, è stato rilevato il peso vivo dei polli, per ogni singolo box, e prelevati campioni di feci per le analisi parassitologiche al fine di evidenziare possibili infezioni da Eimeria. A 12 giorni e alla fine dell’esperimento, sono stati sacrificati 6 animali per gruppo per valutare il grado di severità delle lesioni da coccidi a livello intestinale. Le caratteristiche della carcassa, così come le caratteristiche chimico-fisiche e nutrizionali della carne sono state determinate come precedentemente descritte nell’esperimento 1. L’iniezione in ovo con Bi2tos (B) ha determinato un aumento significativo del peso dei polli a 6 settimane di età; mentre, a 18 settimane, i polli del gruppo AB sono risultati più pesanti rispetto ai polli degli altri gruppi sperimentali. Anche il peso della carcassa è risultato lievemente maggiore nel gruppo B rispetto agli altri gruppi. In generale, la resa del petto è risultata superiore nei gruppi trattati (A, B e AB) rispetto al controllo, anche se le differenze sono risultate statisticamente significative solo tra i gruppi AB e C. Il peso e la resa delle cosce sono risultati simili tra i gruppi sperimentali anche se il gruppo trattato con prebiotico ha mostrato valori tendenzialmente più elevati. L’incidenza delle ali è risultata superiore nel gruppo AB rispetto al gruppo C, con valori intermedi per gli altri due gruppi. Come atteso, per il dimorfismo sessuale, i maschi sono risultati più pesanti e con caratteristiche della carcassa migliori rispetto alle femmine. Un’interazione significativa tra trattamento e sesso è stata riscontrata per il peso del petto e l’incidenza delle ali. Per quanto riguarda il profilo degli acidi grassi, la carne del gruppo trattato con prebiotico (B) ha mostrato un contenuto maggiore di PUFA rispetto al controllo; mentre, il contenuto totale di MUFA è risultato essere più basso nei gruppi B ed AB rispetto agli altri due gruppi sperimentali. Il contenuto totale di SFA è risultato simile tra i gruppi. Il contenuto di PUFA n-3 è risultato maggiore nel gruppo B rispetto a quello A, con valori intermedi per il gruppo AB. Nessuna differenza statisticamente significativa è stata rilevata sia per il contenuto di PUFA n-6, che per il rapporto PUFA/SFA. Al contrario, il rapporto n-6/n-3 è risultato inferiore nei gruppi B ed AB rispetto agli altri due gruppi. Marginale è stato l’effetto del sesso sulla composizione acidica. La carne dei maschi ha mostrato un contenuto superiore di MUFA ed inferiore di PUFA rispetto alle femmine. Il contenuto di SFA e gli indici nutrizionali sono risultati simili. Sono state evidenziate interazioni significative tra trattamento e sesso per alcuni acidi grassi, per PUFA n-3 e per il rapporto n-6/n-3. Nel complesso, il prebiotico (Bi2tos) con o senza antibiotici, ha ridotto la gravità delle lesioni indotte da infezione naturale con Eimeria spp. e l'escrezione di oocisti rispetto al controllo, nonché ha migliorato alcune caratteristiche qualitative della carne. In conclusione, lo studio ha dimostrato che l'uso di prebiotici iniettati in ovo può contrastare gli effetti negativi della coccidiosi sulle performance di crescita degli animali nonché sulla qualità della carne.
In ovo technology has been developed to enable delivery of sustainable bioactives, such as pre-/probiotics, directly into the egg air chamber at day 12 of embryonic incubation. Thus, improving the effectiveness of these compounds by administering them to the animals under fully controlled conditions and as early as possible. However, research on the efficacy of prebiotics delivered in ovo on gut health, performance and meat quality is still in exhaustive having been concentrated mainly on meat-type chickens. This neglects the richness of chicken biodiversity and climatic variations. The aim of the current thesis (divided in two parts) was to evaluate the efficacy of prebiotics delivered in ovo on egg hatchability, gut health, performance, and meat quality of Ross 308 broiler and Kuroiler chickens reared under temperate and tropical climatic conditions. Study one carried out in Italy used a commercial prebiotic Bi2tos (BI) injected in ovo to assess the effects of prebiotics on performance, quality and oxidative stability of meat from broiler chickens reared under temperate climatic conditions. The eggs used in this experiment were from Ross 308 broiler (meat-type) chickens. On day 12 of incubation, 300 eggs that had viable embryos were randomly divided into three experimental groups: prebiotic group (BI), injected with 200 μL Bi2tos (3.5 mg/embryo); saline group (S), injected with 200 μL of physiological saline solution; and un-injected control (C). Hatched chicks were scored and sexed for each experimental group and 120 males (40 chicks/group) were grown to 42 days of age in floor pens (4 replicates of 10 birds each), with free access to an outdoor area. Birds were fed ad libitum starter and grower-finisher diets with free access to water. Along the rearing period, chickens were weighed and counted within each pen. At 42 d, 20 randomly chosen birds per treatment, of similar estimated body weight, were individually weighed and slaughtered. Hot carcass weight was recorded and carcass yield was calculated. Main commercial cuts were removed from the carcass and weighed and their percentages (yield) calculated. Pectoral muscle pH, colour and water holding capacity (WHC) were measured 24 hours post-mortem. In addition, fatty acid composition and meat oxidative stability were also analyzed. Data were analyzed by one-way ANOVA. The multi-comparison Scheffe’s test was used to separate the differences among the mean for statistical significance (P < 0.05). Results from the study showed a satisfactorily high hatchability (> 90%) though similar among experimental groups. Mortality of the chickens during this study was very low (2%) and not dependent on the substance injected in ovo. Initial body weights were the same among all experimental groups. In the period from week one to three, BI group showed a significantly higher weight gain in comparison to the C (+2.5 %) and S (+1.9 %) groups. While for the entire rearing period (week 1 - 6), both BI and S groups showed higher BWG in comparison to the C group (+7.5% and 6.8%, respectively). Chickens from BI group were significantly heavier at slaughter than those from C group, but similar to those of S group. Similarly, carcass weight was higher in S and BI groups as compared to C. However, no significant differences among experimental groups were found for carcass yield, main commercial cut yields (breast, legs and wings) and back+neck yield. pH24, colour (L*, a*, b*) and WHC were the same among treatments. Intramuscular fat (IMF) content was higher in BI group compared to C group, with intermediate values for S group. The treatment did not affect total amounts of saturated fatty acids (SFA) and individual SFA content of meat. The most concentrated SFA in all experimental groups were palmitic acids (C16:0; 23.45 – 24.95%) followed by stearic acid (C18:0; 9.49 – 10.21%). No effect of treatment was observed in the composition of monounsaturated fatty acids (MUFA) as well as total MUFA contents. Quantitatively, oleic acid (C18:1n 9) was the most abundant MUFA (24.49 – 25.53%). In ovo delivered prebiotic lowered (-2.6%) the total poly unsaturated fatty acid (PUFA) content compared to the S group. Total n-6 and n-3 PUFA contents of meat from BI group birds were also significantly lower than those of the S group. For individual fatty acid, only docosahexanoic acid (C22: 6n 3) was affected by the treatment being lower in the BI group in comparison with the S group (-0.31%) and C group. Regardless of the treatment, the most abundant PUFA were linoleic (C18:2n 6; 25.13– 25.73%) and arachidonic acids (C20:4n 6; 5.22 – 6.44%). Regarding selected fatty acid indices, n-6/n-3 ratio was significantly higher in the prebiotic treated group (+16.2%) than in S group. In addition, P/S tended to be lower in BI group compared to S and C. The treatment did not have any effect on atherogenic and thrombogenic indices. The treatment had no negative effect on lipid peroxidation. In fact, TBARs values were slightly lower in BI compared to the control group after 72 hours of storage. All in all, the results obtained from this study clearly proved that the in ovo prebiotic administration improved production performance in Ross 308 broiler chickens throughout the rearing period without negatively affecting meat quality. In the second study, the efficacy of prebiotics, antibiotic-chick formula and a combination of the two on growth performance, carcass traits and gut health in the face of a natural coccidiosis infection was assessed in Kuroiler chickens reared under field condition in Uganda. At the 12th day of incubation, 150 eggs from Kuroiler (dual purpose) chickens with viable embryos were randomly divided into two equal groups. One group was injected with 0.2 mL of Bi2tos (3.5mg/embryo); and the other was left uninjected as control. Hatched chicks from each of the two experimental groups above where further randomly divided into two groups: one group received antibiotic chick formula (poltricin with oxytetracycline at a dose of 1g/litre of drinking water for 7 days) while the other was left without the antibiotic chick formula. Thus, giving rise to four experimental groups: Control (C), Antibiotic (A), Bi2tos (B) and Bi2tos + Antibiotics (AB). The birds (half males and half females) were reared in a local poultry farm in Gulu District where coccidiosis infection was previously confirmed by field veterinarians. All birds were reared under semi-intensive confined system for a period of 18 weeks. Chickens were fed ad libitum starter, grower and finisher diets and had constant access to water. Body weights were taken per pen on a weekly basis and also faecal samples were collected for parasitological analysis to check for possible infection with Eimeria parasites. At d 12 and at the end of the experiment, 6 birds/group were randomly chosen to assess the severity of coccidial lesions in the intestines. At slaughter, carcass and meat quality traits were evaluated as described in experiment one above. The treatment with Bi2tos (B) significantly increased body weight and body weight gain especially at 6 weeks of age. On the other hand, AB group was the heaviest of all experimental groups at the end of the experiment. The B group had a slightly higher carcass weight compared to the rest of the treatments. Breast yield was generally higher in all treatment groups compared to the C, although significant differences were found only with AB group (+6.0%). Leg weight and yield were not significantly different among experimental groups but tended to be higher in prebiotics treated groups. Wings yield was higher in AB group compared to the C group, intermediate values were observed in A and B groups. Sexual dimorphism was clearly evident with males being heavier at slaughter and displaying better carcass traits. pH and WHC values were similar among experimental groups and between the two sexes. Significant interaction between treatments x sex was observed for breast yield and wings weight. With reference to the effect of the treatment on fatty acid composition, meat from the B group displayed the highest (+ 3.72 %) amount of total PUFA compared to the control group. Conversely, breast muscles of the B group as well as those of the AB group had, in general, lower amounts of total MUFA compared to C and A groups. Total amount of SFA was not affected by the treatments. Total n-3 fatty acids were higher in B compared to the control groups A and AB had intermediate values. Total n-6 fatty acids were the same among treatment groups. The ratio of PUFA to SFA was not significantly different among experimental groups. On the other hand, the n-6/n-3 ratio was lower in B and AB groups compared to C and A groups. A comparison of the two sexes showed only minimal effects on fatty acid profile. Total MUFA was higher in males compared to the females; while PUFA were higher in females than males. The fatty acid ratios were not affected by sex. There were significant treatments x sex interaction effects on total n-3 as well as n-6/n-3 ratio though. Overall, prebiotic (Bi2tos) with or without antibiotics reduced the severity of coccidiosis lesions induced by natural infection with Eimeria spp. as well as oocyst excretion compared with the control and also improved meat quality. In conclusion, the study has demonstrated that use of in ovo delivered prebiotics in broiler production can lessen the depression in growth due to coccidial challenge with positive effects on meat quality. Regardless of the treatment and experimental conditions, Kuroilers had lower n-6/n-3 ratio compared to Ross 308 broiler chickens.

Abstract According to members of the Institute of Medicine, about 98,000 hospitalized patients in the United States die each year because of poor quality care. The problem of poor healthcare quality may exist in part due to limited information on effective performance measurement processes. A multiple case study design was used to gain broad insight into possible solutions to the problems of determining the quality of healthcare services using performance measurements. Hospital/healthcare organization leaders in North Carolina who had implemented optimal performance measurements for quality care were interviewed. The conceptual frameworks that served as a proposition for the study were Goldratt's theory of constraint, Deming's 14 point model and Lewin's model of the change process in human systems. The data collection process involved semistructured interviews of 12 individuals. Data sources and conceptual framework triangulations were used in the data analysis process(coding approaches, study dependability, credibility, transferability methods and case study protocol use) . The themes that emerged from the study were strategies for performance measurement and strategies to enhance service quality in healthcare organizations etc. Results might contribute to social change by helping healthcare leaders and patients improve their knowledge and understanding of optimal performance measurement strategies, which may effect positive organizational changes.

Nearly all functional magnetic resonance imaging (fMRI) studies are conducted in the supine body posture, which has been discussed as a potential confounder of such examinations. The literature suggests that cognitive functions, such as problem solving or perception, differ between supine and upright postures. However, the effect of posture on many cognitive functions is still unknown. Therefore, the aim of the present study was to investigate the effects of body posture (supine vs. sitting) on one of the most frequently used paradigms in the cognitive sciences: the N-back working memory paradigm. Twenty-two subjects were investigated in a randomized within-subject design. Subjects performed the N-back task on two consecutive days in either the supine or the upright posture. Subjective sleep quality and chronic stress were recorded as covariates. Furthermore, changes in mood dimensions and heart rate variability (HRV) were assessed during the experiment. Results indicate that the quality of sleep strongly affects reaction times when subjects performed a working memory task in a supine posture. These effects, however, could not be observed in the sitting position. The findings can be explained by HRV parameters that indicated differences in autonomic regulation in the upright vs. the supine posture. The finding is of particular relevance for fMRI group comparisons when group differences in sleep quality cannot be ruled out.

Orientador: Fabio Luiz Mialhe
Tese (doutorado) - Universidade Estadual de Campinas, Faculdade de Odontologia de Piracicaba
Made available in DSpace on 2018-08-26T11:32:04Z (GMT). No. of bitstreams: 1 Paula_JaniceSimpsonde_D.pdf: 2936736 bytes, checksum: b902ec93fa51db820dff8577e0662b77 (MD5) Previous issue date: 2015
Resumo: O objetivo geral dessa Tese foi avaliar os determinantes sociais da saúde (DSS) associados à saúde bucal, ao rendimento escolar e a qualidade de vida em crianças e adolescentes, além de testar as propriedades psicométricas longitudinais de questionários de Qualidade de Vida Relacionada à Saúde Bucal (QVRSB) e comparar um questionário genérico de qualidade de vida com outro de QVRSB. Para isso, foram usadas duas amostras: uma composta por crianças de 8 a 10 anos, participantes do Programa Sempre Sorrindo (PSS), no município de Piracicaba, São Paulo, e outra composta por escolares de 12 anos provenientes de escolas públicas e privadas do município de Juiz de Fora, Minas Gerais. Foram coletados dados referentes às condições clínicas e aplicados questionários para avaliação da qualidade de vida (Child Perception Questionnaire ¿ CPQ8-10 e CPQ11-14 e AUQUEI ¿ Autoquestionnaire Qualité de Vie Enfant Image), bem como do nível socioeconômico, do ambiente familiar e do rendimento escolar das crianças. Os resultados demonstraram que os DSS apresentaram associações com cárie dentária e que, em particular, os aspectos socioeconômicos possuíram maior associação com a experiência de cárie, quando comparados com variáveis relacionadas ao ambiente familiar. Observou-se, ainda, que tanto aspectos socioeconômicos, do ambiente familiar e a presença de lesões de cárie, mesmo que tratadas, foram indicadores de risco para o pobre rendimento escolar, e a experiência de cárie foi um importante preditor para mudanças na QVRSB de adolescentes ao longo do tempo. Sobre a responsividade dos instrumentos de QVRSB, verificou-se que o questionário CPQ11-14 apresentou-se responsivo às mudanças longitudinais, avaliadas pelo critério de Longitudinal Construct Validity, mas com pequena alteração quando avaliada pela análise de effect size. Os resultados também demonstraram que o CPQ11-14 apresentou correlação com o instrumento genérico de qualidade de vida AUQUEI e que ambos apresentaram associações com variáveis clinicas e socioambientais. Por fim, verificou-se que o tratamento da cárie dentária impactou positivamente na melhora da QVRSB de escolares, e o CPQ8-10 apresentou boas propriedades psicométricas para avaliar estas mudanças ao longo do tempo. Conclui-se, a partir dos resultados dos estudos supracitados, que houve associações entre DSS e a cárie dentária, e que ambos estiveram associados a um pior rendimento escolar. Da mesma forma, verificou-se que a QVRSB esteve correlacionada à qualidade de vida nesta população. Quando os escolares foram avaliados longitudinalmente, constatou-se que a experiência de cárie foi um preditor importante para mudanças da QVRSB ao longo do tempo nesta população, mensurada pelos questionários Child Perception Questionnaire, que apresentaram boas propriedades psicométricas de responsividade às mudanças de qualidade de vida relacionada à saúde bucal. Dentro deste contexto, o acesso ao tratamento odontológico foi um importante fator para a melhoria da qualidade de vida relacionada à saúde bucal de escolares que vivem sob vulnerabilidade social
Abstract: The overall objective of this thesis was to evaluate the social determinants of health (SDH) associated with oral health, school performance and the quality of life in children and adolescents, as well as test the longitudinal psychometric properties of Oral Health realte Quality of Life (OHRQoL) questionnaires and compare a generic questionnaire of quality of life with other of OHRQoL. For this, two samples were used: one consisting of children 8-10 years participating in the Program Always Smiling (PSS), in Piracicaba, São Paulo, and another composed of schoolchildren of 12 years from public and private schools in the city Juiz de Fora, Minas Gerais. Data were collected regarding on clinical conditions and questionnaires to assess quality of life (Child Perception Questionnaire - CPQ8-10 and CPQ11-14 and AUQUEI - Autoquestionnaire Qualité de Vie Enfant Image) and socioeconomic status, home environment and school performance of schoolchildren. The results showed that the SDH were associated with dental caries and, in particular, the socioeconomic aspects contained higher association with caries experience compared to variables related to the home environment. It was observed also that both socioeconomic aspects of the home environment and the presence of caries lesions, even if treated, were risk factors for poor school performance, and caries experience was an important predictor of changes in QVRSB adolescents over time. On the responsiveness of OHRQoL instruments, it has been found that the questionnaire is presented CPQ11-14 responsive to longitudinal changes, as evaluated by Longitudinal Construct Validity, but with little change as determined by the effect size analysis. The results also showed that CPQ11-14 correlated with the generic instrument of quality of life AUQUEI and both were associated with clinical, social and environmental variables. Finally, it was found that treatment of dental caries has impacted positively on improving of OHRQoL, and had good psychometric properties of CPQ8-10 for measuring changes over time. In conclusion, from the results of the aforementioned studies, there were associations between SDH and tooth decay, and both were associated with poorer school performance. Likewise, it was found that the OHRQoL was correlated to quality of life in population. When the students were assessed longitudinally, it was found that caries experience was an important predictor of changes OHRQoL over time in this population, as measured by the Child Perception Questionnaire questionnaires, which showed good psychometric properties of responsiveness to quality of life changes related to oral health. Within this context, access to dental treatment was an important factor in improving the quality of life related to oral health of children living under social vulnerability
Doutorado
Odontologia em Saude Coletiva
Doutora em Odontologia

Research has shown that direct-fed microbials (DFM) and enzyme supplementation can impact the dry matter intake (DMI), milk production, and milk composition. However, limited research has evaluated the impact of DFM and enzyme supplementation on colostrum quality and the uptake of the Immunoglobulins A and G (IgA and IgG) by calves. In this study, 36 multiparous Holstein cows were blocked by expected calving date and randomly assigned to 1 of 3 treatments 3 weeks prior to calving and remained on these treatments until week 8 postpartum. These treatments were: 1) 0 g of DFM and enzyme (control), 2) 45.40 g/d of Tri-Lution® (Tri), or 3) 45.40 g/d of Tri-Lution® and 18.16 g/d of Zy-mend® (Tri + Zy). The amount of total mixed ration (TMR) fed and orts refused were measured each day to determine DMI. Blood samples were taken on the cows every Monday, Wednesday, and Friday at 1100 h from the coccygeal veins and arteries to be analyzed for β-hydroxybutyrate (BHBA), glucose, and nonesterified fatty acids (NEFA). Cows were also weighed once a week throughout the course of the study. Colostrum was harvested and weighed at parturition and later analyzed for IgA and IgG concentration via radial immunoassay. Calves were fed 4 L of maternal colostrum within 2 h after calving. Blood samples were also taken from the calves at 0 and 24 h in order to be analyzed for IgA and IgGconcentrations and to determine apparent efficiency of absorption of IgA and IgG. Finally, milk yields were taken daily for 8 wk postpartum and samples were taken once a week and sent to DairyOne (Ithaca, NY) to be analyzed for quality. Prepartum body weight (BW), BW, efficiency of gain, DMI, BHBA, NEFA, and glucose concentrations were not impacted by treatment. There was also no impact of treatment on colostrum yield, IgA and IgG content, and composition with the exception of IgA yield and ash percentage. The ash percentage of colostrum tended (P = 0.07) to increase with the Tri and Tri + Zy treatments while the IgA yield (P = 0.05) decreased with the Tri treatment. Treatments did not impact BW, serum IgA and IgG concentrations or apparent efficiency of absorption of IgA and IgG of the calves. Postpartum BW, DMI, blood metabolites, milk production and composition, with the exception of BW gain and somatic cell score (SCS), of the cows were not impacted by treatment. Cows on the Tri treatment gained more BW (P =0.03) and tended to have a greater efficiency of gain (P = 0.09) in comparison to those on the Tri + Zy treatment, but both treatments did not differ from the control. This suggests that there is a negative effect of applying the Tri-Lution® and Zy-mend® together which might be due to negative interactions among ingredients and microorganisms. An increase in SCS (P = 0.04) was also observed with the Tri treatment. All these results indicate that the supplementation of DFM and enzymes is not beneficial in improving the health and performance of dairy cattle during the transition period and early lactation.

This study sought to identify the effect of family history of dementia and sleep quality on cognitive performance in a cohort of healthy older adults (n=89). Cognitive abilities were assessed using a comprehensive neuropsychological battery. The tested domains included memory, executive function, visuospatial abilities, motor function, processing speed, and language abilities. Subject family history was obtained by self report, and sleep quality was quantified using the Pittsburgh Sleep Quality Index (PSQI). Participants were divided into four groups by family history of dementia and sleep quality. Results indicated no significance effects for memory or executive function, but effects were found in visuospatial and motor tasks. It was observed that subjects without family history of dementia and good quality sleep had better performance on visuospatial tasks, supporting the notion that these factors may have protective functions in cognitive decline.