Дисертації з теми "Health care pathway"
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1
Wilson, Nicola Ann. "Modelling intermediate care services as part of an integrated care pathway." Master's thesis, University of Cape Town, 2016. http://hdl.handle.net/11427/20290.
Анотація:
This study explores the implications of implementing enhanced or redesigned intermediate care initiatives in the Western Cape of South Africa from the 2014/15 financial year onwards. Using a dynamic modelling methodology, we developed an empirical model of an integrated care system to explain the linkages, relationships and interactions among service components and analyse the implications of one of the proposed Healthcare 2030 policy interventions - intermediate care - on hospital admissions, waiting times and length of stay of all patients. We tested and compared a number of alternative intervention points using a simulation model parameterised with service component data from the Department of Health Information Systems. The findings from the study show the inconsistencies between the perceived structure and the available data from the respective service components that describe the resultant behavioural effects on an integrated care system, especially when care pathways cross organisational boundaries. The main managerial learning was around the existence and nature of organisational boundaries that require joint working and sharing of information. We conclude from the simulation results for the alternative scenarios tested that the implementation of enhanced or redesigned intermediate care initiatives can moderate the rate of growth in the demand for hospital services by reducing a percentage of hospital readmissions.
2
Jones, Karen. "The remodelling of patient care pathway for e-health." Thesis, Brunel University, 2009. http://bura.brunel.ac.uk/handle/2438/3975.
Анотація:
The interdependencies within the health care system are seldom taken into account prior to implementation of e-health projects, and there tends to be little change management as part of the plan. Our proposal offers a systems analysis model that gives e-health a framework to consider and manage the introduction, changes and outcomes. This research describes the use of a modified Patient Care Pathway as a method to design and implement e-health projects, presenting as a case study the pre-implementation phase of a teleradiology project in rural Thailand. The proposal is that a modified version of Patient Care Pathways can be used as a prospective design model for e-health services. The method adopts systems engineering principles and applies a ―whole systems approach‖ thereby providing a much richer schematic representation of the patient care pathway illustrating both the patient‘s journey through the system and also the information flow. Our method was applied to the design of a new teleradiology service that was to be established in Thailand, to connect GP‘s in a rural hospital to the radiology department in a tertiary hospital with a further connection to a specialist radiologist in a medical school in Bangkok. By comparing the pre-implementation Patient Care Pathway with the proposed pathway using the teleradiology, a systems analysis model was developed to identify critical points in the system and identify and anticipate how the system would support the changes in clinical practices. The method produced a valuable framework to better understand and thereby manage the implications of change prior to implementation of an e-health project.
3
Boynton, Anna Lee. "Help-seeking, pathway mapping and barriers to mental health care : a literature review /." Title page, table of contents and abstract only, 2004. http://web4.library.adelaide.edu.au/theses/09HS/09hsb7928.pdf.
4
Bandong, Aila Nica. "Enabling change in whiplash management through a clinical pathway of care." Thesis, The University of Sydney, 2019. http://hdl.handle.net/2123/20845.
Анотація:
Best practice recommendations for whiplash management have changed considerably over the past few decades; however, have not been widely adopted in clinical practice. Clinical pathways are a promising strategy to enable practice change. The aim of this thesis was to explore selected aspects of practice change to support the implementation of a clinical pathway of care for whiplash and the administration of a randomised controlled trial that tests the effectiveness of the pathway. This thesis used several research methods, including retrospective audit of insurer files, focus group discussions, process evaluation, and a clinical trial. The audit of files showed that many aspects of practice in whiplash management were inconsistent with the guidelines. Themes generated from the focus groups suggested that recommendations requiring significant change in practice were not well accepted, explaining an important potential barrier to adherence. Other barriers identified included lack of clarity in recommendations and perceived patient expectations about management. The focus groups also supported the potential for wider use of whiplash specialists in a peer review role by better meeting the needs of the referring health professional. This finding supports one of the key components of the clinical pathway of care for whiplash and strongly shaped the further development of the pathway as an intervention in the randomised controlled trial. The thesis delivered a new and acceptable online tool, My Whiplash Navigator, as a resource to promote best practice. Finally, the thesis provided preliminary evidence that implementation of the clinical pathway of care has enabled change in aspects of practice. This thesis generated new knowledge that informed the implementation and evaluation of the clinical pathway of care for whiplash. Further, this thesis identified mechanisms to enable best practice management of whiplash and more broadly other high burden musculoskeletal conditions.
5
Scheepers, Lorna Lorraine. "An exploratory study of the referral pathway of patients discharged from a tertiary hospital to home-based care in the Western Cape." University of the Western Cape, 2012. http://hdl.handle.net/11394/4628.
Анотація:
Magister Curationis - MCurThe purpose of the study will be to explore the discharge referral pathway for patients that have been discharged from hospital to home in the Western Cape Province. A mix of quantitative and qualitative research, using a descriptive design will be undertaken. Quantitatively, following the patient paper trail from Tertiary Hospital to grassroots level. Qualitatively, to identify whether the referral pathway was user friendly. Records of discharged patients from the Tertiary Hospital will be used as the study population. Patient information will be accessed from patient files at the hospital. Interviews will be conducted with the relevant discharge liaison officers at the Tertiary Hospital, and Primary Health Care level. Relevant staff members within the non–governmental –organisations (NGOs), will also be interviewed in order to determine their perception of the discharge referral pathway. The findings of the study will be used to inform policy guidelines. Challenges encountered by staff members in referring patients for continuum of care, and the perception of consumers will also be described and documented.
6
Padilla, Danielle Jessica. "Cardiovascular and ventilatory limitations in the oxygen transport pathway." Diss., Kansas State University, 2005. http://hdl.handle.net/2097/137.
Анотація:
Doctor of PhilosophyDepartment of Anatomy and Physiology
David C. Poole
The components of the O2 transport pathway can be divided into (along with their respective circulations) the pulmonary, cardiovascular, and skeletal muscle systems. They must operate in tight conjunction with one another, especially during dynamic exercise, to sustain ATP production within muscle mitochondria. Any limitation placed on the O2 transport pathway will result in decreased performance. The purpose of this dissertation is to present four novel studies which examine specific limitations on (1) the pulmonary system (i.e. lungs and circulation) within the highly athletic Thoroughbred horse (Studies A & B), and (2) within the peripheral circulation (i.e. microcirculation) within a disease model of Type II diabetes, the Goto-Kakizaki (GK) rat (Studies C & D). Study A demonstrates that locomotory respiratory coupling (LRC) is not requisite for the horse to achieve maximal minute ventilation (VE) during galloping exercise because VE remains at the peak exercising levels over the first ~13 s of trotting recovery (VE at end exercise: 1391±88; VE at 13 s: 1330±112 L/sec; P > 0.05). The horse also experiences exercise-induced pulmonary hemorrhage (EIPH) which has been linked mechanistically to increased pulmonary artery pressure (Ppa) during high intensity exercise. Therefore, in Study B, we hypothesized that endothelin-1 (ET-1), a powerful vasoconstricting hormone, would play a role in the augmented Ppa and therefore, EIPH. However, contrary to our hypothesis, an ET-1 receptor antagonist did not decrease Ppa nor prevent or reduce EIPH. Studies C and D examine potential mechanisms behind the exercise intolerance observed in humans with Type II diabetes. Utilizing phosphorescence quenching techniques (Study C) within the GK spinotrapezius muscle, we found lowered microvascular PO2 (PO2mv; Control: 28.8±2.0; GK: 18.4±1.8 mmHg; P<0.05) at rest and a PO2mv “undershoot” during muscle contractions. After conducting intravital microscopy within the same muscle (Study D), we discovered the percentage of RBC-perfused capillaries was decreased (Control: 93±3; GK: 66±5 %; P<0.05) and all three major hemodynamic variables (i.e. RBC velocity, flux, and capillary tube hematocrit) were significantly attenuated. Both studies (C & D) indicate that there is reduced O2 availability (via decreased O2 delivery; i.e. ↓QO2/VO2) within Type II diabetic muscle.
7
Wikström, Git. "Women’s Perspectives on Pathway to Diagnosis of Pulmonary Tuberculosis : Women Voices from Community Level in Uganda." Thesis, Nordic School of Public Health NHV, 2011. http://urn.kb.se/resolve?urn=urn:nbn:se:norden:org:diva-3116.
Анотація:
Objectives: A qualitative study to explore the perceptions and ideas of women at community level in Uganda, about factors influencing their health care-seeking behaviour when symptoms that could indicate pulmonary tuberculosis. To let the women identify barriers to health care-seeking and to let them present ideas how to overcome barriers. Method: Focus Group Discussions (72 informants) and In Depth Interviews (19 informants) were conducted in rural Uganda with women of reproductive age. For triangulation purposes discussions and interviews also included health care providers, traditional healers and a few men. Main Results: The data showed a wide range of health care-seeking behaviours including no action at all, self-treatment using traditional herbs or western medicines, consulting traditional healers and consulting various formal or informal healthcare facilities. The data also identified many barriers that could prevent women from getting a proper diagnosis, including lack of financial resources, lack of power, male supremacy in decision-making, lack of knowledge, perceived corruption in healthcare facilities, fear of stigma and this fear heavily boosted by the idea that PTB equates HIV/AIDS. Conclusion: These data support the idea that successfully fighting PTB among Ugandan women and increasing case finding, demands recognition that tuberculosis is a multifaceted disease: economical, social, psychological and medical. Therefore, approaches to eradicating tuberculosis must target different sectors and reach all levels of societyISBN 978-91-86739-19-5
8
Webster, Sayumporn. "Maze to care : the process of pathway to initial care of young adults aged 18-25 with their first presentation of a mental disorder /." Access electronically, 2004. http://www.library.uow.edu.au/adt-NWU/public/adt-NWU20050307.111731/index.html.
9
Eshareturi, Cyril. "Mapping the offender health pathway : challenges and opportunities for support through community nursing." Thesis, University of Wolverhampton, 2016. http://hdl.handle.net/2436/614998.
Анотація:
The current context of offender health in England and Wales indicates that offenders re-enter their communities with limited pre-release preparation for the continuity of access to healthcare and an increased risk of release with a health condition and very little support to cope in the community. This study was aimed at mapping the ex-offender health pathway towards identifying ‘touch points’ in the community for the delivery of a nurse led intervention. The study was a qualitative case study underpinned by ‘The Silences Framework’ which enabled it to gain theoretically by situating power with offenders, thus, aiding their ‘Silences’ to be heard, explored and brought to light. Participants meeting the study inclusion criteria were quantitatively ranked on the basis of poor health with those scoring the lowest and confirming their ranking through a confirmation of a health condition selected as cases and interviewed over the course of six months. These interview narratives were confirmed by interviewing individuals in the professional networks of offenders. The study identified the site of post-release supervision as the ‘touch point’ where a nurse led intervention could be delivered. With regards to the delivery of the health intervention, the study indicated that the nurse led intervention be provided as an advisory and signposting service structured on a drop-in and appointment basis. Furthermore, the study indicated that pre-release, offenders were not prepared in prison for the continuity in access to healthcare in the community on release. On-release, offenders’ on-release preparation did not enquire as a matter of procedure on whether offenders were registered with a GP or had the agency to register self with a GP practice in the community. Post release, the study uncovered a disparity between services which address the physical health needs of offenders and those which address their mental and substance misuse health needs.
10
Bimerew, Million S. "Developing a framework for a district-based information management system for mental health care in the Western Cape." Thesis, University of Western Cape, 2013. http://hdl.handle.net/11394/3324.
Анотація:
Philosophiae Doctor - PhDA review of the literature has shown that there is a lack of mental health information on which to base planning of mental health services and decisions concerning programme development for mental health services. Several studies have indicated that the use of an evidence-based health information system (HIS) reduces inappropriate clinical practices and promotes the quality of health care services. This study was aimed at developing a framework for a district-based mental health information management system, utilising the experiences of health care providers and caregivers about a district mental health information system (DMHIS). Activity Theory was used as the philosophical foundation of the information system for the study. A qualitative approach was employed using semi-structured individual interviews, Focus Group Discussions (FGDs), systematic review and document analysis. The intervention research design and development model of Rothman and Thomas (1994) was used to guide the study, which was conducted in the Cape Town Metropole area of the Western Cape. A purposive, convenient sampling method was employed to select study participants. Ethical clearance for the study was obtained from the University of the Western Cape, and permission to use the health facilities from the Department of Health. The data collection process involved 62 individual interview participants, from mental health nurses to district health managers, health information clerks, and patient caregivers/families and persons with stable mental conditions. Thirteen caregivers took part in the FGDs. Document review was conducted at three community mental health centres. The data were analysed manually using content analysis. Core findings of the interviews were lack of standardized information collection tools and contents for mental health, information infrastructure, capacity building, and resources. Information processing in terms of collection, compiling, analysing, feedback, access and sharing information were the major problems. Results from document analysis identified inconsistencies and inaccuracies of information recording and processing, which in turn affected the quality of information for decision making. Results from the systematic review identified five functional elements: organizational structure; information infrastructure; capacity building; inputs, process, output and feedback; and community and stakeholders’ participation in the design and implementation of a mental health information system (MHIS). The study has contributed a framework for a DMHIS based on the findings of the empirical and systematic review. It is recommended that there is a need to establish a HIS committee at district health facility level for effective implementation of the framework and quality information processing. There is a need to ensure that staffs have adequate knowledge and skills required for effective implementation of an information system. It is recommended that higher education institutions include a course on HISs in their curriculum. It is suggested that the South African Mental Health Policy be reviewed to include an MHIS and ensure involvement of the community and stakeholders in this system as well as adequate budget allocation.
11
Kuwornu, John Paul. "Using the episode of care approach to analyze healthcare use and costs of chronic obstructive pulmonary disease exacerbations." Springer, 2013. http://hdl.handle.net/1993/31226.
Анотація:
Healthcare utilizations are typically measured independently of each other; neglecting the interdependencies between services. An episode of care is suitable for measuring healthcare utilizations of patients with complex health conditions because it tracks all contacts throughout the healthcare system. The overall goal of this research was to construct an episode of care data system to study healthcare utilizations and costs of chronic obstructive pulmonary disease (COPD) exacerbations. To achieve this goal, four related studies were undertaken.
The first study (Chapter 2) evaluated the agreement between emergency department (ED) data and hospital records for capturing transitions between the two care settings. Using the κ statistic as a measure of concordance, we found good agreement between the two data sources for intra-facility transfers; but only fair agreement for inter-facility transfers. The results show that linking multiple data sources would be important to identify all related healthcare utilization across care settings.
The second study (Chapter 3) linked hospital data, ED data, physician billing claims, and outpatient drug records to construct an episode of care data system for COPD patients. Latent class analysis was used to identify COPD patient groups with distinct healthcare pathways. Pathways were associated with outcomes such as mortality and costs. A few individuals followed complex pathways and incurred high costs.
Building on the previous study, the next one (Chapter 4) predicted whether high-cost patients in one episode also incurred high costs in subsequent episodes. Using logistic regression models, we found that patient information routinely collected in administrative health data could satisfactorily predict those who become persistent high users.
The final study (Chapter 5) used a cross-validation approach to compare the performance of eight alternative linear regression models for predicting costs of episodes of COPD exacerbations. The results indicate that the robust regression model, a model not often considered for cost prediction, was among the best models for predicting episode-based costs.
Overall, this research demonstrated how population-based administrative health databases could be linked to construct an episode of care data system for a chronic health condition. The resulting data system supported novel investigations of healthcare system-wide utilizations and costs.May 2016
12
Chang, Edward C., Emma R. Kahle, Elizabeth A. Yu, Jenny Y. Lee, Yvonne Kupfermann, and Jameson K. Hirsch. "Relations of Religiosity and Spirituality with Depressive Symptoms in Primary Care Adults: Evidence for Hope Agency and Pathway as Mediators." Digital Commons @ East Tennessee State University, 2013. https://dc.etsu.edu/etsu-works/864.
Анотація:
This study examined hope agency and pathway as potential mediators of the associations of religiosity and spirituality with depressive symptoms in an adult sample of 101 primary care adults. Results of conducting multiple mediation tests indicated that hope agency and pathway fully and significantly accounted for the associations of religiosity and spirituality with depressive symptoms. In contrast, an alternative mediation model involving religiosity and spirituality as potential mediators of the associations of hope agency and pathway with depressive symptoms failed to be supported. Overall, our findings offer support for the contention that hope agency and pathway play important roles in accounting for the associations of religiosity and spirituality with psychological adjustment in adults. Some implications of the present findings are discussed.
13
Känsäkoski, H. (Helena). "Value creation in childhood obesity care and prevention." Doctoral thesis, Oulun yliopisto, 2014. http://urn.fi/urn:isbn:9789526204130.
Анотація:
Abstract The aim of the thesis is to increase understanding about creation of value in health care. Value is created through knowledge processes in multiprofessional integrated care pathways (ICP) of childhood obesity and defined as health and well-being which benefits the patients, their families, health care organisations and society. An ICP is a practice among Finnish primary and special care which in this study is regarded as the value creating network. Knowledge processes take place in social networks of health professionals and families and information technology (IT) networks. The transdisciplinary study combines theories of Information Studies with theories of customer value in Business and Marketing research. The care and prevention of childhood obesity pursues permanent lifestyle changes through health counselling. Examination of value creation in networks based on knowledge processes has the potential to enhance health professionals’, patients’, and their families’ interaction in counselling. The qualitative case study involves the ICPs of two Finnish University Hospital districts. The empirical data, collected between 2009 and 2012, consists of semi-structured interviews of 30 health professionals in primary and special health care, of three children and their mothers, a family questionnaire (N=13), and care path instructions and memos of an ICP work group. The findings indicate that information practices and IT do not support knowledge processes and organisational learning in the ICP. Along with structural and IT-based boundaries in and between organisations, organisational culture confirms boundaries. Moreover, lack of time restricts the sharing of experiences. Knowing in health care is a complex phenomena; especially the care of childhood obesity appeared to include emotional aspects not addressed in previous research. Thus, the study contributes to theoretical knowledge by suggesting empathetic knowing to be included in the typology of knowing in the context of health care. Even if counselling was perceived well, it does not ensure permanent lifestyle changes. Actual value for the families is created in the everyday practices which should be supported by the environment. The theoretical framework can be tested further in similar constructions in health care organisations or in other ICPs to enhance Knowledge Management and value creation in health careTiivistelmä Tutkimus pyrkii lisäämään ymmärrystä siitä, miten arvoa luodaan lasten lihavuuden hoitoketjun tietoprosesseissa moniammatillisessa yhteistyössä. Hoitoketju on perusterveydenhuollon ja erikoissairaanhoidon välille luotu käytäntö, jota tarkastellaan arvoa luovana verkostona. Arvolla tarkoitetaan hyötyä, joka syntyy potilaille, heidän perheilleen, terveydenhuolto-organisaatioille ja yhteiskunnalle. Tietoprosessit muodostavat arvoverkoston ammattilaisten ja perheiden sosiaalisten verkostojen sekä hoitoketjun tietoverkostojen kautta. Tieteidenvälinen tutkimus yhdistää informaatiotutkimuksen teorioita liiketalouden tutkimuksen teorioihin asiakasarvon luomisesta. Lasten lihavuuden tärkein hoito- ja ennaltaehkäisykeino on terveysneuvonta, joka pyrkii pysyviin elämäntapamuutoksiin. Tietoprosessien tarkastelu arvoverkostoina mahdollistaa ammattilaisten ja perheiden vuorovaikutuksen kehittämisen terveysneuvonnassa. Laadullinen tapaustutkimus toteutettiin kahdessa suomalaisessa yliopistollisessa sairaanhoitopiirissä. Aineisto kerättiin vuosina 2009–2012. Se koostuu 30 terveydenhuollon ammattilaisen, kolmen potilaan ja heidän äitiensä teemahaastatteluista, 13 perheen lomakekyselyvastauksista sekä hoitopolkuohjeistuksista ja kokousmuistioista. Tulokset osoittavat, että tietoverkot ja informaatiokäytännöt eivät tue tietoprosesseja ja organisaatioiden oppimista hoitoketjussa. Rakenteellisten ja informaatio- ja viestintäteknologian luomien rajojen lisäksi erilaiset organisaatiokulttuurit muodostavat esteitä tietoprosessien etenemiselle. Kiire estää kokemusten jakamista. Tietämys ja osaaminen terveydenhuollossa ovat moniulotteisia seikkoja. Tutkimus nostaa esille lasten lihavuuden hoitoon liittyvät tunteet, joita ei ole tarkasteltu aikaisemmissa tutkimuksissa. Siten tulokset täydentävät teoriataustana sovelletun tietämisen typologiaa empaattisen tietämisen tyypillä terveydenhuollon kontekstissa. Perheet kokivat terveysneuvonnan hyväksi, mutta vaikutukset pysyviin elämäntapamuutoksiin eivät nouse vahvasti esille. Hoidon arvo muodostuu perheiden jokapäiväisen elämän käytännöissä, mitä myös ympäristön tulisi tukea. Tutkimuksessa sovellettua teoriaa ja viitekehystä voidaan testata vastaavissa yhteistoimintahankkeissa ja hoitoketjuissa. Niiden avulla voidaan kehittää arvoa luovia tietoprosesseja ja tietojohtamista terveydenhuollossa
14
COMORETTO, ROSANNA IRENE. "Assessing healthcare pathways by means administrative data." Doctoral thesis, Università degli Studi di Milano-Bicocca, 2018. http://hdl.handle.net/10281/241293.
Анотація:
Il concetto di Burden of Disease è molto usato nella letteratura internazionale per indicare il peso, l’impatto che una condizione, una malattia o un fattore di rischio possono avere sulla popolazione. Misurare questo burden sembra essere necessario per migliorare i sistemi sanitari e per aiutare i decisori politici nell’allocare adeguatamente le risorse pubbliche. Una misura molto usata nella valutazione del Burden of Disease è la frazione attribuibile di popolazione, che misura il numero di casi di malattia che si potrebbero evitare o prevenire se il fattore di rischio venisse eliminato. I percorsi clinici, o PDTA (percorsi diagnostico-terapeutico-assistenziali), sono composti da un insieme di interventi clinici basati sulle evidenze e vengono considerati sia come uno strumento per una miglior cura del paziente sia come un modo per descrivere la struttura di un processo di cura, ed è uno strumento utilizzato in tutto il mondo per rendere trasparenti i processi stessi e per migliora l’efficacia e la qualità dell’assistenza. Tuttavia, il reale impatto di questi percorsi di cura sugli outcome clinici dei pazienti, soprattutto in ambino extra-ospedaliero, rappresentano un campo della ricerca ancora poco esplorato. Se consideriamo, inoltre, l’aderenza alle raccomandazioni contenute nei PDTA come un gold standard da perseguire per evitare diversi outcome clinici o complicanze, una condizione di non-aderenza rappresenta un fattore di rischio che può essere controllato e limitano, se non additìrittura eliminato.
L’obiettivo di questa tesi è quello di valutare l’impatto degli interventi sanitari per specifiche patologie dal punto di vista della salute pubblica, e cioè in termini di (i) dimensione del problema, (ii) processo di cura e (iii) associazione tra il processo stesso gli outcome in esame. Con queso fine, la tesi è formata da quattro parti che conducono ad esplorare il quesito principale di questi lavoro di ricerca e a capire come si possa misurare l’impatto di alcuni interventi sanitari su soggetti affetti da alcune patologie croniche.
Dopo un’inizale introduzione al concetto di Burden of Disease e alle sue possibili applicazioni nella valutazione degli interventi sanitari, vengono presentati i PDTA e il loro corrente utilizzo in ambito nazionale e internazionale. In questa parte della tesi viene descritto un progetto italiano che ha l’obiettivo di valutare l’impatto di diversi percorsi di cura sugli outcome clinici dei soggetti. In questo progetto, inoltre, i PDTA vengono anche descritti e utilizzati come uno strumento utile a comparare diversi Sistemi Sanitari Regionali (CCR) dal punto di vista dell’accountability: in questo modo ogni SSR è reso responsabile della qualità del servizio erogato (utilizzando gli indicatori che valutano il processo di cura) e dei risultati clinici che ottengono (utilizzando gli indicatori che valutano gli esiti).
Nella terza parte della tesi illustro alcuni aspetti metodologici imparati in questi anni di dottorato, a partire dalle fonti dei dati (i database sanitari amministrativi) fino ai diversi disegni dello studio implementati e alle diverse tipologie di analisi statistica utilizzate negli studi osservazionali, per poi approfondire la misura della frazione attribuibile di popolazione e le sue diverse applicazioni.
L’ultima parte riporta tre studi condotti durante il Corso di Dottorato e che, da diversi punti di vista, esplorano il concetto dell’impatto degli interventi sanitari in diversi contesti clinici. In particolare, nell’ultimo studio (work in progress) si applica la misura della frazione attribuibile di popolazione per quantificare l’impatto dell’aderenza a determinate raccomandazioni su definiti outcome clinici.The burden of a condition, illness or risk factor on the population is a fundamental issue in Public Health and evaluating this burden appears to be necessary to improve health systems and policies, and to help decision makers for a better allocation of public resources. The population attributable fraction, a measure used to assess the burden of disease, allows to determine the number of disease’s cases that would be avoided or prevented if a risk factor was eliminated. Clinical Pathways are composed by several evidence-based healthcare intervention and are considered both as tool for patients’ care and as a way to describe the structure of a care process that is worldwide used to make care processes transparent and to improve the efficiency and quality of health care. However, the real impact of these pathways on several clinical outcomes, in particular in outpatient settings, is a little explored field. If we consider the subject’s adherence to recommendations contained in Clinical Pathways as a ‘gold standard’ of healthcare to avoid adverse clinical events/complications, the condition of ‘non-adherence’ represents a risk factor that could be controlled and limited, if not even removed. The aim of this thesis is to assess the impact of healthcare interventions for specific health conditions, from the Public Health point of view, in terms of (i) size of the problem, (ii) process of care and (iii) association between process and outcomes. To this purpose, my thesis is composed of four parts that lead to explore the main issue of this work and to understand how we can measure the impact of some healthcare interventions on subjects affected by several chronic conditions. After an introduction to the concept of Burden of Disease and its possible application in the assessment of impact of healthcare interventions, Clinical Pathways and their current use are presented. In this part an Italian project aimed to assess the impact of several pathways on patients’ clinical outcomes is also described. In this project, outpatient Clinical Pathways are also used to compare different Regional Health Systems from the point of view of the accountability: in this way, each Regional System will be made responsible for the quality of healthcare deliver (with process-of-care indicators assessment) and for clinical results following the health services provided (with the outcome indicators evaluation). In the third part I explain some methodological aspects I learned about in this years, from data sources (large administrative databases) to study designs and statistical analysis used for retrospective observational studies, up to deepening the population attributable fraction measure and its different applications. The last part reports three studies conducted during my PhD course that, from different points of view, explore the concept of the impact of healthcare interventions in different clinical contexts. In particular, the third study (work in progress) applies the concept of population attributable fraction to quantify the impact of the adherence to recommendations on clinical outcomes.
15
Eliasson, Madeleine. "Recurrent macroscopic hematuria after anegative investigation – diagnostic yield ofrepeat investigation." Thesis, Örebro universitet, Institutionen för medicinska vetenskaper, 2021. http://urn.kb.se/resolve?urn=urn:nbn:se:oru:diva-93341.
Анотація:
Introduction: Macroscopic hematuria is an important alarm symptom of cancer in theurinary tract. One single episode in patients over the age of 50 fulfills the criteria for referralto the standardized care pathway. Several patients included in the pathway with a negativeresult of the investigation will return with recurrent macroscopic hematuria for repeatinvestigation. Aim: To evaluate the diagnostic yield of repeat investigation in patients presenting withrecurrent macroscopic hematuria after a previous negative investigation and to estimate theincidence of false negative investigations in the standardized care pathway for cancer in theurinary tract. Material and Methods: A retrospective review of medical records was performed at theDepartment of Urology in Örebro County, including all patients investigated in thestandardized care pathway for cancer in the urinary tract during 2016 with a negative result ofthe investigation. Individuals with repeat investigation were identified. Results of theseinvestigations and the time interval between investigations were documented. Results: Repeat investigation was performed in 96 out of 627 patients (15.3%). Two (2.1%)were diagnosed with cancer, at a time interval from initial investigation of 4 and 27 months,respectively. Other results were benign urological conditions (n = 62) and normalinvestigations (n = 30). Conclusions: It appears that few tumors are missed when macroscopic hematuria isinvestigated in the standardized care pathway. We observed a very low number of newlydiagnosed cancers after repeat investigation of recurrent macroscopic hematuria. A moreselective approach regarding repeat investigations should be considered.
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Hall, Julie. "Using integrated care pathways in mental health care : a case study." Thesis, University of Nottingham, 2010. http://eprints.nottingham.ac.uk/12749/.
Анотація:
Background: Integrated Care Pathways (ICPs) are prearranged processes of care which are being increasingly used to deliver mental health services. The literature reveals difficulties in their development and implementation, and a lack of empirical evidence to support their use. Aims: The aim of this research was to investigate how an ICP has been used to manage mental health care in one selected mental health Trust in England. Methods: A case study approach was adopted with several units of analysis. The views of healthcare professionals using semi structured interviews; the experiences of service users and carers using focus groups; contrasting hospital episode and performance statistics with a comparison Trust and documentary analysis of the ICP. Findings & Discussion: Of the healthcare professions, only nurses used the ICP. No professionals used the ICP to support clinical decision making and risk management. However, just over two-thirds (67.2%) of the interventions described in the pathway were delivered. There was no statistically significant difference when comparing performance indicators for an equivalent episode of care between the ICP Trust and non ICP Trust. Service user and carers' experiences revealed that peopled did not feel that their care was individualised to them, although amongst them they had different perceptions of the care process. Conclusions: Mental health ICPs need to reflect the relationships between stakeholders, variability of illness and individual ways of living if they are to provide a framework for managing care in the future that accords with the needs of people using mental health services.
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Smeds, Magdalena. "Managing care pathways for patients with complex care needs." Licentiate thesis, Linköpings universitet, Logistik- och kvalitetsutveckling, 2019. http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-156836.
Анотація:
One of the central challenges for the healthcare system today is how to manage care for patients with complex needs. This patient group is not well-defined but covers patients with serious diseases and comorbidities, or with a limited ability to perform basic daily functions due to physical, mental or psychosocial challenges. This group has a high service and resource utilisation resulting in high costs for the healthcare system and, typically, poor health outcomes. To improve care for these patients, it is necessary to implement strategies to manage the differentiated care needs, the additional support needs, the uncertainty in care delivery, and the coordination needs of the involved providers and the patient. Care pathways are increasingly used internationally to make care more patient-centred and to structure and design care processes for individual patient groups. Important elements in care pathways include structuring care activities, by defining their content and sequence; coordinating between providers and professionals; and involving patients in their care process. In this thesis, care pathways are proposed as the overall strategy for managing care for patients with complex care needs. The purpose of this thesis is thus to contribute with knowledge on how care pathways can be managed for patients with complex care needs. This is achieved by analysing how the practices coordination, standardisation, customisation and personalisation can support management of care pathways and by discussing how these practices influence quality of care. The quality of care dimensions discussed are accessible, timely, equitable, and patient-centred care. The empirical context in this thesis is the Standardised Cancer Care Pathways (CCPs) which were implemented in Sweden from 2015 to 2018. CCPs is the umbrella term for the national initiative to shorten waiting times, decrease regional differences and reduce fragmentation in care processes. CCPs include elements such as diagnosis-specific pathways and guidelines, introduction of CPP coordinators, and mandatory reporting of waiting times. Focus has been on implementing care pathways for 31 cancer diagnoses in all Swedish healthcare regions. Both qualitative and quantitative research methods have been used. A case study was conducted to examine standardised and customised care pathways, and coordination and multidisciplinary work in care pathways. A document study of regional reports on CCPs was analysed to study effects of care pathways on accessibility, timeliness and equitability. Finally, a national survey was conducted to deepen the understanding of the role of coordination, as performed by coordinators, in care pathways. This thesis argues that standardised and customised care pathways should be combined to manage care for patients with complex care needs. The customised pathway in particular benefits patients with serious unspecific symptoms, unknown primary tumour or more complex care needs, while patients with care needs that can be treated independently of the main diagnosis benefit from following a standardised care pathway. Coordinators are an important means to manage coordination, customisation and personalisation in the care pathway. The coordinators’ role is twofold: the first role is to manage care pathways by customising the care pathway and coordinating involved providers; the second role is to support and guide patients through the care pathway. This can be achieved by adapting interpersonal communication with patients through personalisation. This thesis further argues that care pathways have most potential to positively influence accessibility, timeliness, equitability, and patient-centredness. Accessibility has been positively influenced, especially for patients with ambiguous symptoms where symptoms indicating cancer have improved their chances of accessing cancer diagnostics. A negative aspect of prioritising patients who follow CCPs has been the potentially longer waiting times for other patient groups in equal need of urgent care. Notwithstanding, prioritised access to care is perceived to positively influence timeliness for patients following CCPs. Care pathways are perceived to have positively influenced patient-centredness by shifting the focus from what to deliver to how to deliver it.
18
Koch, Thomas. "Ein Beitrag zur Optimierung klinischer Patientenpfade und deren Anwendung auf komplexe Behandlungsfälle am Beispiel der Station Mund-, Kiefer- und Gesichtschirurgie am Universitätsklinikum Dresden." Bachelor's thesis, Dresden International University, 2014. http://nbn-resolving.de/urn:nbn:de:bsz:14-qucosa-147883.
Анотація:
Um den Kostendruck in medizinischen Versorgungseinrichtungen, getrieben von den Forderungen aus SGB V und DRG, bei gleichzeitiger Patientenzufriedenheit und Behandlungsqualität im komplexen Rahmen gerecht zu werden, ist die Identifizierung von Optimierungspotentialen und deren Realisierung ein wesentlicher Hebel für das Überleben von Krankenhäusern am medizinischen Markt. Der Patientenpfad, der den Kernprozess der Wertschöpfung der medizinischen Dienstleistung im Krankenhaus darstellt, bildet gleichzeitig die "Logistische Kette an medizinische und sozialen Dienstleistungen". Zur Darstellung der komplexen Struktur des Zusammenwirkens von Prozessen und Schnittstellen entwickelt der Autor das Phasenmodell "Gesundheitsversorgungsprozess" (GVP), bestehend aus seinen drei Hauptprozessen prästationärer-, stationärer- und poststationärer Prozess, die durch deren medizinische, logistische, ökonomische und humansoziale Interdisziplinarität charakterisiert werden. Dieses Modell erweist sich als ein tragfähiger Ansatz für die Analyse zur Optimierung von Behandlungspfaden im klinischen Bereich der Mund-, Kiefer- und Gesichtschirurgie (MKG). Im Ergebnis wird ein Vorschlag erarbeitet, der 7 elektive Krankheitsbilder und deren heterogene Prozessstrukturen in einen standardisierten Behandlungspfad MKG überführt. Ausgehend von der Herleitung standardisierter Behandlungspfade und der Definition sogenannter "Standard Operating Procedures" (SOP´s) wird ein Baukastensystem für die medizinische Behandlung bereitgestellt, welches eine konfigurierbare Individualisierung des Behandlungsprozesses für den Patienten garantiert. Mit der detaillierten Analyse und Ableitung der Sollstrukturen klinischer Behandlungspfade am Beispiel der MKG am Uniklinikum Dresden und dern Verknüpfung zu Interdisziplinaritäten unter dem prozessualen Aspekt liefert die Arbeit einen Beitrag zur Prozessoptimierung im Krankenhaus und bildet gleichzeitig einen Beitrag zur Modellierung für ein modellgestütztes, evidenzbasiertes ProzessmanagementTo meet the cost pressures in medical care facillities, driven by the demands of the volume V of the German Social Code and DRG, while patient satisfaction and quality of care in complex organizational requirements, the identification of optimization potentials and its realization is an essential lever for the survival of hospitals on the medical market. The patient pathway, which is the core process of the value added chain of medical services at the hospital, froms the "Logistical chain for medical and social services" at the same time. To illustrate the complexity of the interaction of processes and interfacesthe author develops the phase madel "Health Care Process" (HCP) consisting of its three madical and care main processes pre-clinical; clinical and post-clinical process, characterized by their medical, logistical, economic and human social interdisciplinary. This model proves to be a viable approach for the analysis for the optimization of tretment pathways in the clinical field of oral and maxillofacial surgery (OMS). As a result a proposal is being developed which converts 7 elective medical pattern and the heterogeneous processstructures in a standardized treatment pathway OMS. Based on the derivation of standardized treatment pathways and the definition of so-called "Standard Operating Procedures" (SOPs) a modular system for medical treatment is provided which guarantees a configurable individualization of the treatmet process for the patient. Based on the detailed analysis and derivation of target structures for clinical pathways on the example of OMS at the University Medical Center Dresden and their linkage to interdisciplinarities under the procedural aspect this bachelor graduation paper-work makes a contribution to process optimization in the hospital and at the same time forms a contribution to the modeling of a model-aided, evidence-based process management
19
Taylor, Clare Joanne. "The clinical pathway of patients with heart failure in primary care." Thesis, University of Birmingham, 2016. http://etheses.bham.ac.uk//id/eprint/6557/.
Анотація:
Background: Heart failure is a common clinical syndrome associated with major adverse symptoms and poor outlook for patients, and high costs for healthcare systems globally. This thesis examines four aspects of the clinical pathway of patients with heart failure in primary care. Methods: Routinely collected GP records are used to estimate the number of newly diagnosed heart failure cases by year. A qualitative interview study explores the patient experience of the diagnostic pathway. Survival analysis is used to determine prognosis of patients following a first diagnostic label. Finally, a screening study examines who develops heart failure over time. Results: The incidence of heart failure has been static at 2.3 cases per 1,000 person-years since 2006. Patients initially normalise their symptoms so delay seeking help, GP access is challenging and communication in secondary care, particularly delivery of diagnosis, could be improved. Survival rates are 81.5%, 51.6% and 29.5% at 1, 5 and 10 years, respectively, and have not changed over time. Screening provides an alternative pathway to identify patients with heart failure. Conclusions: Strategies to reduce the number of new cases of heart failure, enhance patient experience, improve survival and explore new diagnostic pathways should be important priorities for the NHS.
20
Horne, David. "Pathways into psychiatric care : user characteristics, settings and the referral process." Thesis, London South Bank University, 1990. http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.305150.
Анотація:
The thesis grew out of the recognition that there is a dearth of information on the users of mental health services. It set out to describe the characteristics of users across a range of health settings and to consider the role of such characteristics in the mental health referral process. The early phases of this research project were strongly influenced by a model of the referral process developed by Goldberg & Huxley (1980). They conceptualized users of health care existing on 5 levels ranging from people living in the community to users in hospital. Hypothetical filters are said to operate between each level to govern who is referred on to the next level of services. This research project borrowed the notion of filters and their arrangement of services in a referral sequence. However, the focus of this research is on the characteristics of users, and not the detail of the filters per se. What is described is the effect of the referral process not the mechanism. This thesis also moves substantially beyond the five settings in the Goldberg & Huxley model to produce a uniquely comprehensive analysis of the users of all the main mental health care providers in one health district. The research project uses a wholly quantitative methodology. The challenge has been to design a range of compatible survey forms to collect data in seven separate study settings, to collate information on over one thousand one hundred users, to describe the user profiles in each study and to develop a comparative analysis of users across a range of settings. The emphasis throughout has been to align the research with contemporary developments in health care policy, and as the project has progressed, to make a practical contribution to the important debate about information systems in mental health service planning. The thesis has been divided into four parts. Part I introduces and sets the context of the research, and describes the methodology. In seven chapters, Part II of the thesis reports the .findings of each of the seven study settings. Part III of the thesis reports the demographic and utilization characteristics comparatively across all the study settings. The conclusions of the thesis are reported in Part IV of the thesis, where the theoretical, research and policy implications are discussed.The research project makes a contribution to knowledge on 4levels. Firstly, it identifies and describes the characteristics and the typical profiles of mental health service users in a range of study settings, in one area. Secondly, it identifies the differences between users in each study setting. Thirdly, it identifies the overlap in use of one service and another. It is argued that the findings have profound implications for both developing a clearer picture of the referral processes and for highlighting for planners, producers, and providers possible complementary or inefficient service utilization patterns. On the fourth and macro level, this research project has developed a revised model of mental health service referral routes. This model provides a framework for further investigation, and has potential as a planning tool in and beyond the geographical boundaries of the current study area.
21
Hajdarevic, Senada. "Patient and health care delays in malignant melanoma." Doctoral thesis, Umeå universitet, Dermatologi och venereologi, 2012. http://urn.kb.se/resolve?urn=urn:nbn:se:umu:diva-54392.
Анотація:
Background: Unlike other cancers, malignant melanoma (MM) is generally visible and can be easily and effectively cured if treated in time. Optimal cure of MM requires early detection, diagnosis, and treatment, which improves prognosis. However, patients as well as the health care organization and its professionals contribute to delayed treatment in various ways. Aims and objectives: The general aim of this PhD thesis was to explore reasons for delay in care seeking, diagnosis, and treatment of malignant melanoma. The specific objectives to be addressed were To explore patients’ decision making about seeking care for malignant melanoma To identify specific patterns in the decision-making process to seek care for suspect melanoma, as narrated by women and men To compare self-reported decision making coping styles between men and women in various ages, who live with or without a partner and are diagnosed with various stages of malignant melanoma in northern Sweden. To describe and compare patients diagnosed with MM, depending on their initial contact with care, and with regard to age, sex, and MM type and thickness, and to explore pathways and time intervals between clinics from the initial contact to diagnosis and treatment. Methods: In studies I and II, 21 and 30 patients, respectively, were interviewed about their decision making to seek care for MM. Study II focused on gender patterns in this decision making. The interviews were analysed using Grounded Theory (I) and qualitative content analysis (II). Study III included 270 people with MM who completed a translated questionnaire (Melbourne Decision Making Questionnaire) about coping styles in decision making. In study IV the pathways and time delay in health care for 71 people with MM were explored. Studies I and II were qualitative, whereas studies III and IV were quantitative. Results: In study I, the insights into severity and feelings of fear and existential threat were identified as key motivators for patients to decide to seek care for a suspected melanoma. Results in study II showed that gender constructions influenced the care-seeking behaviour. Women acknowledged the skin changes and attempted self-care first. They delayed care seeking due to family responsibilities. Men seldom acknowledged the suspicious skin change, but sought care immediately after prompting, and most often complied with relatives’ advice to seek care. Study III showed that men generally scored higher in buck-passing, while women and those living without a partner scored higher in hypervigilance. Participants with nodular melanoma (NM), a rapid-growing form of MM, scored higher in vigilance than those diagnosed as in situ melanoma. No correlation was found between tumour thickness and coping styles. Some differences concerning treatment of MM were found in study IV between people who initially had sought care at primary health care centres (PHC) and those who had sought care at dermatological and specialist clinics (Derm). Thicker tumours as well as NM were more common in the PHC group. A larger proportion of patients from PHCs were primarily excided within the primary health care; however, almost all of them were later referred to surgical clinics for wide excision. Patients within the PHC group also had to wait longer for the registered results of histopathological assessments. In general, women waited a shorter time for primary excision, and older people waited longer for wide excision. Conclusions: Time delay of diagnosis and treatment of MM is still common, and crucial to decrease. Future interventions should include gender aspects to influence people to seek care earlier. In health care, time delay could be decreased by facilitating access for patients with suspected skin melanomas, but also by reducing unnecessary referrals. Moreover, organizational changes whereby general practitioners and primary health care nurses are supported in using new technology for faster diagnoses and management of MM in collaboration with specialist clinics should be considered. Easy access and frequently used guidelines for MM could further decrease delay. Lastly, more efficient transfer and registration of laboratory results and referrals could decrease delay and improve patient safety.Bakgrund: Malignt melanom (MM) är till skillnad från andra cancerformer ofta synlig och kan enkelt och kostnadseffektivt botas om det behandlas i tid. En optimal prognos av MM förutsätter tidig upptäckt, diagnos och behandling. Patienter, samt hälso- och sjukvården, dess organisation och dess personal kan på olika sätt bidra till fördröjning av behandlingen av MM. Syfte: Det övergripande syftet med denna avhandling var att undersöka orsaker till fördröjning att söka vård, diagnosticera och behandla malignt melanom. Specifika delsyften var: Att utforska patienternas beslutsfattande process att söka vård för MM Att identifiera specifika mönster i beslutsfattande-processen att söka vård för misstänkt MM utifrån kvinnors och mäns egna berättelser Att jämföra självrapporterade coping-stilar i den beslutsfattande processen mellan män och kvinnor i olika åldrar, boende med eller utan partner, och diagnosticerade med MM i olika stadier från norra Sverige Att beskriva och jämföra patienter med MM utifrån deras primära vårdkontakt samt utifrån ålder, kön, MM-typ och tjocklek. Ytterligare att utforska vård- och remissvägar samt tidsintervaller mellan olika kliniker från första kontakt till diagnos och behandling. Metod: I studie I och II, intervjuades 21 respektive 30 patienter om den beslutsfattande processen att söka vård för MM. Genuskonstruktioner i relation till den beslutsfattande processen var i fokus i studie II. Intervjuerna analyserades med hjälp av Grounded Theory (I) och kvalitativ innehållsanalys (II). I studie III inkluderades 270 patienter med MM som besvarade ett instrument (MDMQ) avseende coping-stilar i beslutsfattande processen. I studie IV undersöktes övergångar mellan olika kliniker och remissvägar för 71 patienter med MM samt eventuell tidsfördröjning inom hälso- och sjukvården. Resultat: I studie I, identifierades insikt i allvarlighetsgrad samt rädsla och existentiellt hot till följd av tillståndet vara nyckel-motivatorer för att bestämma sig för att söka vård för misstänkt hudmelanom. Resultat från studie II påvisade att genuskonstruktioner påverkar hur personer söker vård för MM. Kvinnor upptäckte själv sina melanom och försökte tillämpa egenvård i början. De kunde dröja att söka vård pga. ansvar för familjen. Män upptäckte sällan suspekta melanom själva men följde oftast anhörigas råd att söka vård och sökte vård omedelbart efter påstötning. Resultaten från studie III visade att män i högre grad använde en avvaktande startegi (buck-passing) medan kvinnor och de som bodde utan partner var överdrivet vaksamma (hypervigilance). Deltagare med nodulärt melanom (NM), en snabbt växande form av MM, var mer vaksamma (vigilance) jämfört med de med melanom in situ, en mycket tidig form av melanom. Några korrelationer mellan tumörtjocklek och coping-stilar hittades ej. Vissa skillnader avseende typer av MM samt vårdens handläggning beroende på var patienter initialt sökt vård identifierades i studie IV. Bland patienter som initialt sökt vård på hälsocentralerna var tjockare tumörer vanligare jämfört med dem som hade sökt vård på hud- och andra specialistklinker. Dessa patienter hade också som regel genomgått den primära excisionen på hälsocentralerna och en majoritet blev senare remitterade till kirurgisk klinik för utvidgad excision. Hälsocentralernas patienter fick vänta längre på att det histopatologiska svaret registrerades i journalen än sjukhusklinikernas patienter. Kvinnor fick generellt vänta kortare tid på primär excision och äldre patienter fick vänta längre för utvidgad excision. Slutsatser: Tidsfördröjning av diagnos och behandling av MM är fortfarande vanlig och därför viktig att minska. Framtida interventioner för att påverka människor att söka vård tidigare bör inkludera genusaspekter. Inom hälso- och sjukvården kan tidsfördröjning minskas genom förbättrad tillgänglighet för patienter med misstänkta hudmelanom, men också genom minskning av onödig remittering. En förändrad organisation där sjuksköterskor och primärvårdsläkare i samarbete med specialistkliniker stöttas att använda ny teknologi för snabbare diagnosticering och omhändertagande av MM bör övervägas. Ökad kännedom bland hälso- och sjukvårdspersonal om riktlinjer for MM-vård kan vidare minska fördröjning. Till sist, mer effektiva och förbättrade arbetssätt kring registrering och överföring av laboratoriska svar och remisser skulle kunna minska fördröjning och därmed öka patientsäkerheten.
22
Easton, Phyllis. "Exploring the pathways to poor health in the 'hidden population' with low literacy." Thesis, University of Dundee, 2011. https://discovery.dundee.ac.uk/en/studentTheses/b87ea302-9fdb-4cdf-9243-4d70b1991a4d.
Анотація:
Low literacy remains a problem across the developed world. Health literacy has emerged as a specialist literacy, although its conceptualisation and measurement overlap with those of functional literacy. The social practice view, which conceptualises literacy as an activity rather than a skill, is useful in examining literacy-related practices and demands in healthcare contexts. Associations between low functional or health literacy and poorer health outcomes have been established in the research literature but studies have included participants whose low literacy may be obvious to healthcare providers and others. This thesis presents first a systematic review that focuses on literacy and health outcomes in the ‘hidden population’ with low literacy, defined as those of working age whose first language is that of their resident country but who score low on literacy measures. The review concludes that there is a link between low literacy and poorer health in this ‘hidden population’ but that potential pathways have not been explored to any extent. The thesis then presents a primary research study which sought to explore links between low literacy and poor health from the perspectives of people with low literacy; and how the health service might respond to address the issues raised. The findings from 25 in-depth interviews and 2 focus groups with adult learners highlighted the various ways that people with low literacy struggle with written and spoken communication in clinical encounters and in self-care activities. They further revealed that stigma frequently plays a central role in the social practices of those with low literacy, affecting their mental wellbeing and social relationships, including those with healthcare staff. The potential solutions identified for service providers would benefit from piloting and evaluation to help create a literacy-sensitive health service, which could improve engagement; enable self-care and enhance capabilities for health in those with low literacy.
23
Souza, Fabiana Érica de. "O cuidado de usuários de álcool e outras drogas na APS: reflexões sobre as práticas e percepções de agentes comunitários na perspectiva da redução de danos." Universidade Federal de Juiz de Fora (UFJF), 2017. https://repositorio.ufjf.br/jspui/handle/ufjf/4225.
Анотація:
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Introdução: Além das implicações que o uso abusivo de substâncias psicoativas pode ocasionar para a vida das pessoas, há um conjunto de crenças e percepções dos profissionais de saúde que pode contribuir para o aumento das barreiras relacionadas ao acesso e vinculação dos usuários de álcool e outras drogas aos serviços de saúde existentes. Estudos apontam que a capacitação dos profissionais da atenção primária para a compreensão do contexto em que se situa o usuário e o uso de drogas é uma das necessidades para o alcance do cuidado integral a este público alvo. Objetivos: Este estudo visa analisar os saberes e práticas de agentes comunitários de saúde (ACS) capacitados pelo Projeto Caminhos do Cuidado, direcionados a usuários de álcool e outras drogas à luz da estratégia de redução de danos. Método: Esta pesquisa utilizou o método qualitativo, realizando entrevistas semi-estruturadas como fonte de coleta de dados e análise de conteúdo para a sistematização dos dados. Foram entrevistados seis ACS, atuantes em equipes da Estratégia Saúde da Família (ESF) do município de Ubá, MG. Resultados: Os dados demonstram que mesmo aqueles profissionais que conhecem o conceito de redução de danos e relatam a possibilidade de utilizar-se desta abordagem para o cuidado de usuários de álcool e outras drogas no contexto da atenção primária, não conseguem ofertar cuidados que se aproximam desta estratégia. Isto ocorre uma vez que os entrevistados não respeitam a liberdade de escolha, pautam-se pelo proibicionismo e pelo ideal de abstinência. Esta dificuldade prática em desenvolver o cuidado baseado nesta abordagem se relaciona com a percepção moralizante sobre o uso de drogas, sua associação ao crime e o foco na possibilidade de se extinguir o uso de drogas das sociedades. Considerações finais: A adesão às práticas pautadas na abordagem de redução de danos passa pela discussão do papel das drogas na sociedade, estando relacionada à percepção que os profissionais possuem do uso e do usuário de drogas. Para avançar em direção a este cuidado na atenção primária é necessário investir em práticas de matriciamento que podem e devem ser ofertadas pelos Núcleos de Apoio à Saúde da Família, pelos CAPS e demais equipes, de forma a redefinir as práticas dos profissionais de maneira permanente.
Introduction: Besides the implications that abusive use of psychoactive substances can cause on people's lives, there is a set of beliefs and perceptions of health professionals that can contribute to the increase of barriers related to access and attachment of alcohol and other drugs to existing health services. Studies point out that the training of primary care professionals to understand the context in which the user is located and the use of drugs is one of the necessities to reach the integral care of this target public. Objectives: This study aims to analyze the knowledge and practices of Community Health Agents trained by the Care Pathway Project, aimed at users of alcohol and other drugs from the perspective of the Harm Reduction (HR) strategy. Method: This research used the qualitative method, performing semistructured interviews as a source of data collection and analysis of content for data systematization. Six Community Health Agents were interviewed, working in teams of the Family Health Strategy of Ubá, MG. Results: The data show that even those professionals who know the concept of HR and report the possibility of using this approach to care for alcohol and other drug users in the context of Primary Health Care cannot provide care that is close to this strategy. This occurs because the interviewees do not respect freedom of choice, they are based on prohibitionism and the ideal of abstinence. This practical difficulty in developing care based on this approach is related to the moralizing perception about drug use, its association with crime and the focus on the possibility of extinguishing the use of drugs by societies. Final considerations: The adhesion to practices guided by the HR approach involves the discussion of the role of drugs in society and is related to the professionals' perception of the use of drugs and their users. In order to move towards this care in primary attention, it is necessary to invest in parenting practices that can and should be offered by the Primary Health Care Nucleus, the Psychosocial care center and other teams, in order to redefine the practices of professionals on a permanent basis.
24
Jamieson, Rachel. "Parent-mediated pathways to care for rural adolescents with depression." Thesis, University of Ballarat, 2008. http://researchonline.federation.edu.au/vital/access/HandleResolver/1959.17/54314.
25
Dunn, Paticia Laubach. "Steps to Reducing Heart Failure Hospital Readmissions Through Improvement in Outpatient Care." ScholarWorks, 2015. https://scholarworks.waldenu.edu/dissertations/234.
Анотація:
The outpatient care of the heart failure (HF) patient is fragmented due to the lack of evidence-based practice guidelines use. The primary goal of this project was to improve the care of the HF patient in the outpatient arena through use of clinical pathways using the logic model as the project framework. The intervention was carried out over a 4-week period on a convenience, random sample of patients (n = 80) attending a cardiology practice. The patients were recruited from 2 physicians' patient populations and were selected based on an adult diagnosis of HF, reduced ejection fraction of <40% at some point in time, and the New York Heart Association (NYHA) functional class II-V. Comparisons were made in the documentation of care between patients on or off the pathway. The intervention included documentation of patient education, care follow-up, medications, NYHA functional class, and symptom exacerbation, documented in the electronic medical record. The quality of care data were evaluated based on 3 of the Joint Commission core measures for outpatient care of the HF patient. Additional data were collected regarding use of the clinical pathway based on provider and week of implementation. Data were analyzed via a Chi-square test of independence comparing pathway use by provider and use of pathway as study progressed. The comparative results show statistically significant differences in use of the pathway by provider and a statistically significant increase in use during the project . The quality of care results varied in statistical significance. The pathway utilization increased over time and provided a method for standardizing documentation of care for the HF patient in this outpatient clinic, a benefit for HF patients and providers in this cardiology practice and beyond.
26
Cuevas, Penelope H. (Penelope Huggins). "Visualizing the conversation pathways of telephone linked care in a directed graph." Thesis, Massachusetts Institute of Technology, 2009. http://hdl.handle.net/1721.1/54458.
Анотація:
Thesis (S.M.)--Harvard-MIT Division of Health Sciences and Technology, 2009.Cataloged from PDF version of thesis.
Includes bibliographical references (p. 12).
Telephone linked care (TLC) is a telehealth intervention that has been shown to be effective in a variety of clinical settings. TLC is an interactive computerized telephone system. The system 'speaks' to patients, asking them questions and understanding their responses. There is logic built into the calls, so that a patient's response to a question will dictate the next question that is asked. This serves to personalize the call for each patient, and makes the conversation more realistic. All of the patients' responses are stored in a database. This database provides much opportunity for analysis because a single phone call contains many responses. Visualization is an important way of gaining insight into data. Visualization can make data easier to understand and process. Different aspects of data can be encoded in a visualization. The TLC data lends itself to visualization. By viewing each of the questions that the system asks as nodes, and connecting the nodes by the chronological order in which these questions are asked, a tree structure will reveal the conversational paths that are taken in the calls. By combining data from multiple calls and encoding them in this tree structure, new insights can be gained into the TLC data. For example, the frequency with which questions are answered in a particular way can be encoded to reveal the most common pathways through the tree. This paper describes a visualization application of TLC data which will allow researchers to gain new insights into the TLC conversations and into medical interviews in general.
by Penelope H. Cuevas.
S.M.
27
Bhattacharya, Abhik. "Development of a framework to identify patient pathways through a segment of the health care cycle." [Tampa, Fla] : University of South Florida, 2009. http://purl.fcla.edu/usf/dc/et/SFE0002866.
28
Pelletier, Lori Rebecca. "Information-Enabled Decision-Making in Health Care: EHR-Enabled Standardization, Physician Profiling and Medical Home." Digital WPI, 2010. https://digitalcommons.wpi.edu/etd-dissertations/166.
Анотація:
Health care today harms too frequently and routinely fails to deliver its potential benefits. Significant evidence suggests that high quality primary care can positively affect health outcomes. I explored three related topics mentioned frequently in current United States health reform €“ Electronic Health Records (EHR), physician profiling and Medical Home. An investment in these areas is expected to significantly improve quality of care and efficiency; however, there is only a patchwork of evidence supporting such claims. To achieve EHR promises, my research employed a standardization lens to study the dynamics between EHR embedded structures and primary care processes. Using grounded theory, a standardization dynamics model was created describing the influencers, conditions and consequences of the process state. A matrix of two conditions, information exchange and patient complexity, identified four distinct pathways that require a different balance between standardization and flexibility. The value of such pathways is that they frame choices about how to use embedded IT structures to support effective delivery processes. Physician profiling is an emerging methodology used in health care quality improvement programs. Efforts to measure performance at the individual physician level face a number of challenges, including the need for sufficient sample size to support reliable measurement. A process for creating a physician profiling model was developed, and a model designed for a case study site. Results indicate that reliable physician profiling is possible across care domains using a hierarchical composite model. Patient-Centered Medical Home (PCMH) is a new care delivery approach for providing comprehensive primary care that seeks to strengthen the physician-patient relationship. This exploratory study utilizes Pearson correlation coefficients to test four hypotheses about relationships between two sources of data: (1) PPC-PCMH Survey results that measure adoption of PCMH structures and (2) patient experience data from Massachusetts Health Quality Partners (MHQP). The results showed that the PPC-PCMH structures of access and communication were negatively correlated with the related patient experience measure. This study contributes to the literature by addressing deficiencies in how EHR-enabled processes, physician profiling models and Medical Home constructs are measured, to support improved outcomes.
29
Zulkepli, Jafri. "A theoretical framework for hybrid simulation in modelling complex patient pathways." Thesis, Brunel University, 2012. http://bura.brunel.ac.uk/handle/2438/6448.
Анотація:
Providing care services across several departments and care givers creates the complexity of the patient pathways, as it deals with different departments, policies, professionals, regulations and many more. One example of complex patient pathways (CPP) is one that exists in integrated care, which most literature relates to health and social care integration. The world population and demand for care services have increased. Therefore, necessary actions need to be taken in order to improve the services given to patients in maintaining their quality of life. As the complexity arises due to different needs of stakeholders, it creates many problems especially when it involves complex patient pathways (CPP). To reduce the problems, many researchers tried using several decision tools such as Discrete Event Simulation (DES), System Dynamic (SD), Markov Model and Tree Diagram. This also includes Direct Experimentation, one of techniques in Lean Thinking/Techniques, in their efforts to help simplify the system complexity and provide decision support tools. However, the CPP models were developed using a single tools which makes the models have some limitations and not capable in covering the entire needs and features of the CPP system. For example, lack of individual analysis, feedback loop as well as lack of experimentation prior to the real implementation. As a result, ineffective and inefficient decision making was made. The researcher also argues that by combining the DES and SD techniques, named the hybrid simulation, the CPP model would be enhanced and in turn will help to provide decision support tools and consequently, will reduce the problems in CPP to the minimum level. As there is no standard framework, a framework of a hybrid simulation for modelling the CPP system is proposed in this research. The researcher is much concerned with the framework development rather than the CPP model itself, as there is no standard model that can represent any type of CPP since it is different in term of its regulations, policies, governance and many more. The framework is developed based on several literatures, selected among developed framework/models that have used combinations of DES and SD techniques simultaneously, applied in a large system or in healthcare sectors. This is due to the condition of the CPP system which is a large healthcare system. The proposed framework is divided into three phases, which are Conceptual, Modelling and Models Communication Phase, and each phase is decomposed into several steps. To validate the suitability of the proposed framework that provides guidance in developing CPP models using hybrid simulation, the inductive research methodology will be used with the help of case studies as a research strategy. Two approaches are used to test the suitability of the framework – practical and theoretical. The practical approach involves developing a CPP model (within health and social care settings) assisted by the SD and DES simulation software which was based on several case studies in health and social care systems that used single modelling techniques. The theoretical approach involves applying several case studies within different care settings without developing the model. Four case studies with different areas and care settings have been selected and applied towards the framework. Based on suitability tests, the framework will be modified accordingly. As this framework provides guidance on how to develop CPP models using hybrid simulation, it is argued that it will be a benchmark to researchers and academicians, as well as decision and policy makers to develop a CPP model using hybrid simulation.
30
Darwin, Zoe. "Assessing and Responding to Maternal Stress (ARMS) : antenatal psychosocial assessment in research and practice." Thesis, University of Manchester, 2013. https://www.research.manchester.ac.uk/portal/en/theses/assessing-and-responding-to-maternal-stress-arms-antenatal-psychosocial-assessment-in-research-and-practice(f58f4ced-df4e-49d6-ba08-24f24fade0a5).html.
Анотація:
Background: Antenatal Psychosocial Assessment (APA) has recently been introduced into routine antenatal care, but the ways in which maternity service providers assess and respond to maternal stress are subject of debate. There is a lack of consensus on the instrument(s) of choice and lack of evidence regarding appropriate interventions. Further, national guidelines have not kept apace with the conceptual shift from ‘postnatal depression’ to ‘perinatal anxiety and depression’. Adopting the Medical Research Council Complex Interventions Framework, the ARMS research aimed to inform the development of interventions that support women who are experiencing, or at risk of, mild-moderate mental health disorder in pregnancy. Methods: A mixed methods approach was adopted. In the quantitative element (Study Part 1) participants (n=191) completed a questionnaire when attending for their first formal antenatal appointment, using a procedure and materials that had been previously tested in a pilot study. Details including mental health assessment and referrals were obtained from their health records, following delivery. In the qualitative element (Study Part 2) a sub-sample of women (n=22) experiencing high levels of maternal stress took part in up to three serial in-depth interviews during pregnancy and the early postnatal period.Findings: Maternal stress was found to be common. Using the Edinburgh Postnatal Depression Scale (EPDS) threshold of ≥10, approximately 1 in 4 women were classed as high depression (halving to 1 in 8 at the more conservative threshold of ≥13). Almost 1 in 3 women were classed as high anxiety, using the state scale of the State-Trait Anxiety Inventory (STAI-S, threshold ≥41), compared with 1 in 5 using the two-item GAD (threshold ≥3). Fewer than half of the women identified as high anxiety were identified by both measures. Factor analyses of the symptom measures were consistent with wider literature suggesting a three-item anxiety component of the EPDS; however, concurrent validation using regression analyses did not indicate that the EPDS could be used as an anxiety case finding instrument. Women reported that maternal stress had significant impact on their lives that may not be captured with existing clinical approaches. Women commonly found it difficult to self-assess severity of maternal stress and the assessment process could itself act as an intervention. The research provided the first validation of the depression case finding questions in UK clinical practice. The Whooley items completed in clinical practice identified only half of the possible cases identified by the EPDS, at both commonly adopted EPDS thresholds. Inclusion of the Arroll 'help' question as a criterion improved specificity of the assessment completed in clinical practice but substantially compromised sensitivity, missing 9 in 10 possible cases. Women’s mental health history and treatment history were similarly under-reported, particularly concerning anxiety. APA was introduced into routine clinical practice without attention to topics of relevance to women, context of disclosure or to provision of adequate resources for consistently responding to identified need. Women experiencing, or at risk of, mild-moderate disorder were thus usually ineligible for further support. Implications: Care pathways are needed that encompass both assessing and responding to maternal stress, where communication with health professionals, subsequent referral and management are addressed. The development, implementation and evaluation of low-cost resources embedded in such pathways are a priority and the research presented in the thesis offers a foundation on which to build.
31
Hutson, Malo. "Politics, jobs and workforce development : the role of workforce intermediaries in building career pathways within Boston's health care industry." Thesis, Massachusetts Institute of Technology, 2006. http://hdl.handle.net/1721.1/37874.
Анотація:
Thesis (Ph. D.)--Massachusetts Institute of Technology, Dept. of Urban Studies and Planning, 2006.Includes bibliographical references (leaves 201-204).
This research study examines the role that workforce intermediaries within Boston play in creating career pathways for economically disadvantaged, under-skilled residents in the local health care industry. Using a case study analysis, this study compares the outcomes of two workforce intermediaries-one which is employer-led and the other which is led by a community development corporation. Despite the proliferation of new workforce intermediaries around the country and the increased amount of funding to support them from the private and public sectors, these institutions are limited in their ability to increase the supply of a skilled workforce and to change the demand-side of the labor market. However, given the current structural holes in the publicly funded workforce development system, workforce intermediaries play a critical role in serving populations who otherwise would have a difficult time entering into the regional labor market.
by Malo André Hutson.
Ph.D.
32
Shai, Matlou Stephina. "An exploration of help-seeking pathways followed by patients seeking mental health care services in Polokwane-Mankweng Hospital Complex." Thesis, University of Limpopo (Turfloop Campus), 2012. http://hdl.handle.net/10386/891.
Анотація:
Thesis (M.A. (Clinical psychology)) --University of Limpopo, 2012A number of studies have indicated that help-seeking pathways followed by individuals suffering from mental disorders and other conditions of ill-health are not random, but are structured by a range of psychosocial and cultural factors. The quality and seriousness of the distress provide the impetus to the pathway, but its direction and duration is shaped by the convergence of psychosocial and cultural factors. This study explored the help-seeking pathways followed by patients receiving mental health care services in Polokwane-Mankweng Hospital Complex (PMHC) in Limpopo Province (South Africa). A qualitative approach was followed and participants were selected through purposive sampling. Ten participants (5 males and 5 females) who are receiving mental health care services at PMHC and were apsychotic at the time were recruited to the study. Data were collected using semi-structured interviews and analyzed using content analysis. The following psychological themes emerged from the study: participants’ subjective notions of the events or factors that could have led to their mental illness; their explanations of mental illness; the reasons for entering the mental health care system; the pathways they followed before receiving mental health services in the hospital; concurrent use of hospital mental health services and other services; their experiences of living with mental illness; and, the role of significant others in this regard. The study revealed that various agencies and providers of health care are visited by individuals suffering from mental illness and that there is also some evidence of concurrent use of these services, i.e., Western and African. The findings emphasize that help-seeking pathways are mainly determined by the perceived causes of the illness, which are derived from cultural ideologies.
33
Hussin, Duratul 'Ain. "Development and evaluation of optometrist-led referral pathways in Ampang, Malaysia." Thesis, Queensland University of Technology, 2016. https://eprints.qut.edu.au/98401/8/98401.pdf.
Анотація:
Screening for eye diseases is currently performed by ophthalmologists in most public hospitals in Malaysia, which increases workloads for ophthalmology eye-care personnel in hospitals. Optometrists also practise at hospital eye clinics in Malaysia; however, their main role currently focuses on refractive care. This study is the first in Malaysia and Asia to investigate, from a public health context, two optometry-led service pathways for triaging referrals to the hospitals and diabetic retinopathy screening in both hospital and community care. The thesis comprehensively evaluates the optometric pathways quantitatively and qualitatively considering clinical care outcomes, patient access, satisfaction and costs.
34
McKenzie, Elizabeth. "A qualitative study exploring the experiences of access and pathways to health care among BME community groups residing in Ayrshire." Thesis, Queen Margaret University, 2017. https://eresearch.qmu.ac.uk/handle/20.500.12289/7731.
Анотація:
A review of the literature showed that Black and minority ethnic (BME) communities carry a disproportionately higher burden of illness than the general population and experience greater inequalities in health and health care provision. A growing body of research confirms that BME groups are under-represented in research. The main objective of the present study was to gain insights into the perspectives of BME community groups' experiences of accessing general and sexual health care services in Ayrshire. Semi-structured interviews were conducted with 11 participants, n = 5 men (age range: 32-65; mean age = 52.4 years), and n = 6 women (age range: 27-60; mean age = 47.67 years). Data were analysed employing Interpretative Phenomenological Analysis (IPA). The analysis is illustrated through the use of four super-ordinate themes: ‘It’s a Trust Thing’, ‘Minding the Gap(s)’, ‘Sexual Health: a Culture of Silence’, and ‘Personal Perception of Risk’. The findings both support and add to the existing trust literature by presenting a heuristic model of trust, and by showing that participants trust is dynamic in character, has a role, and serves various roles and functions that impact decisions about accessing health services. Significant gaps in knowledge about available health services and unique communication challenges that prevent full access to health care and health promotion information were found, resulting in unmet needs. Analysis charted culturally driven factors that prohibit discussions about sexual health concerns and found complex cognitions involved in the personal perception of risk that was meaningfully understood by participants that direct towards understanding risk in terms of a heuristic model. The implications for clinical practice, health promotion, health service development, and the direction of future research will be discussed.
35
Chiyaka, Edward Tafumaneyi. "Effectiveness of the Pathways Community Hub Model in Reducing Low Birth Weight Among High-Risk Pregnant Women." Kent State University / OhioLINK, 2019. http://rave.ohiolink.edu/etdc/view?acc_num=kent1564765507539083.
36
Grubnic, Suzana. "The social construction of care pathways : a nursing management initiative towards operationalising continuous quality improvement in a children's hospital." Thesis, University of Derby, 2000. http://hdl.handle.net/10545/227118.
Анотація:
The literature is dominated by prescriptive accounts of the application of Continuous Quality Improvement and care pathways in the acute hospital services sector. The authors assume that the organisation is a designed artefact (Scapens, Otley and Lister, 1984): goals can be achieved. This thesisr eports on the nature, processa nd consequenceso f a Nurse Manager introducing care pathways in a Children's Hospital It believes, in opposition to the conventional view, that the organisation is a culture. The actions and interactions of individuals and groups shape initiatives. This is within context and within time. The research investigation was conducted over a twenty-five month period, from February 1996 to April 1998. It was ethnographic in nature. Interviews were conducted with managers, nurses and doctors, formal meetings and activity in the Children's Emergency Department observed, and documentation collected. The findings are, however, presented from the nurses' perspective using their words. Files for newspaper clippings were created and maintained. The thesis contributes to the literature in three ways. In the main, it represents the first contextual and critical account of the implementation of care pathways than that believed to be contained in the literature. Further, it purposefully utilises for the first time two conceptualf rameworks in order to explicate the changep rocessesin the Children's Hospital. These are Watson's (1994) Strategic Exchange Perspective and Dawson's (1994) Processual Framework. It presents the descriptive part of the findings in the form of a narrative. The Nurse Manager established a project to multiskill experienced nurses in the diagnosis and treatment of minor conditions using care pathways as the vehicle. Her role changed during the process of implementation, but the project had little, if no, impact on power structures between and decision making of doctors and nurses
37
Davis, Sarah Kate. "Multidimensional pathways to adolescent resilience : the case for emotional intelligence." Thesis, University of Manchester, 2012. https://www.research.manchester.ac.uk/portal/en/theses/multidimensional-pathways-to-adolescent-resilience-the-case-for-emotional-intelligence(80fa6787-a439-466b-8720-eadb8e2fd0e3).html.
Анотація:
Emotional intelligence (EI) has been reliably associated with better mental health (Martins, Ramalho, & Morin, 2010) however the nature of this relationship in adolescence remains largely unexplored. The small body of existing adolescent research is disproportionately focussed upon the ‘trait’ versus ‘ability’ EI perspective and the association with mood (versus behavioural) disorders in the form of simple, descriptive relationships that reveal little about the processes underpinning such adaptive outcomes. This research redresses this imbalance and advances the field by examining how (whether directly or indirectly linked to known stress-illness processes) and when (under which stress conditions) EI (in both ‘forms’) might be associated with better adolescent mental health, whilst simultaneously exploring the conceptualisation of EI within this developmental period. Adult literature is equivocal on both fronts. Firstly, evidence points to differential incremental contributions from ability and trait EI in the prediction of internalising versus externalising symptomatology beyond known correlates of performance, i.e., personality and cognitive ability (e.g., Gardner & Qualter, 2010; Peters, Kranzler, & Rossen, 2009). Secondly, whilst there is some evidence to suggest that trait EI may directly attenuate the effects of chronic and acute stressors to promote adaptation (e.g., Mikolajczak, Roy, Luminet, Fillée, & de Timary, 2007), the role of ability EI in this regard appears unclear (e.g., Matthews et al., 2006). Indirect links to adjustment are also hinted at; coping mediates trait EI-health outcomes in youth though not all EI-influenced ‘adaptive’ coping styles (e.g., problem-focussed) appear to contribute to this effect (e.g., Downey, Johnston, Hansen, Birney, & Stough, 2010). Using cross-sectional, self-reported data from 1,170 adolescents (mean age = 13.03 years; SD = 1.26) the present research aimed to address this lack of clarity. Preliminary regression analyses found that collectively, EI made a significant, incremental contribution to the prediction of depression and disruptive behaviour in youth beyond the influence of higher-order personality dimensions and general cognitive ability. However, of the two, trait EI appeared the stronger predictor. Structural equation modelling of conditional indirect effects found that whilst both forms of EI can buffer the effects of stressors (family dysfunction, negative life events, socio-economic adversity) on disorder, the mechanisms by which this beneficial effect operates differs substantially according to context - effects appear contingent on stressor, health outcome and level of EI. For depression, ability EI influences the selection of avoidant coping when facing family dysfunction and negative life events, whilst trait EI modifies the effectiveness of active coping under family dysfunction only. In contrast, EI directly attenuates the effects of stressors on disruptive behaviour. Nevertheless, the results of supplementary path analyses augur for the importance of both forms of EI in adaptational processes; actual emotional skill (as ability EI) appears dependent on perceived competency (trait EI) to realise advantageous outcomes. Implications for the EI construct and related intervention programmes are discussed together with recommendations for progression of the field.
38
Humphrys, Elka Suzanne. "Understanding the pathways to oesophageal and stomach cancer diagnosis : a multi-methods approach." Thesis, University of Cambridge, 2019. https://www.repository.cam.ac.uk/handle/1810/289397.
Анотація:
Increasing symptom awareness, encouraging help-seeking, and facilitating timely referral are key for improving cancer outcomes, particularly for cancers such as oesophageal and gastric (stomach), where five-year survival is less than 20%. In this research, I used multiple methods to explore factors that influence timely diagnosis of these cancers from a patient's perspective, with a particular focus on health literacy (accessing, understanding and using health information, and navigating healthcare systems). I started by exploring current knowledge in this field before conducting a systematic review investigating health literacy in the timely diagnosis of symptomatic cancer. Literature was searched from January 1990-May 2017 using six bibliographic databases. I screened 2304 titles/abstracts, assessed 26 full-text papers and included three, although they were methodologically weak, therefore limiting the conclusions. To examine pathways to diagnosis for oesophageal and gastric cancer, I conducted a questionnaire study of newly diagnosed patients across two hospitals in the East and North East of England. 127 participants were recruited (39.6% recruitment rate), aged 44-96 (median 71); 102 male (80%). Most had oesophageal cancer (n=102, 80%); 64 (50%) of the total cohort were late-stage at diagnosis. Common pre-diagnostic symptoms varied between cancers (oesophageal: difficulty swallowing (n=66, 65%), painful swallowing (n=55, 54%); gastric: fatigue/tiredness (n=20, 80%), weight loss (n=13, 52%)). The questionnaire included two domains (engagement, understanding) of the Health Literacy Questionnaire with participants demonstrating high health literacy (mean 4.18 and 4.28, score 1-5). The median time from noticing the trigger symptom (prompting help-seeking) to diagnosis was 81 days (IQR 45-137.5, n=107). Twenty-six participants were purposively sampled, from questionnaire respondents, for face-to-face interviews (aged 55-88, 18 male, 15 with oesophageal cancer). I undertook thematic analysis to explore participant accounts of their pathways to diagnosis, identifying that the symptom nature was important for appraisal, while health literacy ability influenced the health system interval. Descriptions of 'heartburn', 'reflux' and 'indigestion' differed between participants, suggesting these terms may introduce uncertainty in relation to symptom experience. This is the first study to explore the role of health literacy in the timely diagnosis of symptomatic cancer, and pathways to diagnosis for oesophageal and gastric cancers, from a patient's perspective. Findings provide important insights for the development of targeted awareness campaigns and strategies enhancing GP symptom exploration.
39
Petkova, Hristina. "How gene tests travel : bi-national comparison of the institutional pathways taken by diagnostic genetic testing for Maturity Onset Diabetes of the Young (MODY) through the British and the German health care system." Thesis, University of Exeter, 2008. http://hdl.handle.net/10036/47558.
Анотація:
Scientific developments in genetics receive great public and political attention. However, genetic tests as medical innovations need to travel from the laboratory to the individual patient in order to fulfil the goal that makes the science so attractive. A medical innovation has to pass through the institutions of diverse health care systems. This thesis compares how the structures of two very different health care systems in Europe (Germany and the UK) foster or hinder the diffusion of genetic technologies. It presents a detailed analysis of the institutional pathways involved in order to discuss whether and in which way the kind of medical innovation that genetic testing represents is accommodated. The case study used for analysing the passage of a genetic test in both countries is diagnostic testing for Maturity Onset Diabetes of the Young (MODY). This example has the idiosyncratic dimension that it had strong support by scientists and government when the UK Government prioritized genetics in health policy. However, MODY testing was chosen for this study because MODY is a ‘simple’ monogenetic test, and it is one of the few at present that are both reliable and lead to altered treatment with a better quality of life for the patient. MODY represents, according to the current state of genomic knowledge, a prime example of what genetics is likely to deliver at best over the coming decades. In brief, the comparison of the pathways MODY travelled and the degree to which it reached patients successfully shows that both systems are not optimally set up to exploit what MODY genetic testing has to offer, but that the vertical structure and centralization in the UK system fit the needs of genetic medical innovations better than the horizontal, diversified and market oriented structures dominating the German health care system.
40
Aicken, Catherine Rhiannon Helen. "Remote self-testing for sexually transmitted infections, within online care pathways : how could this intervention deliver public health benefit? : formative research using chlamydia as an exemplar." Thesis, University College London (University of London), 2018. http://discovery.ucl.ac.uk/10047215/.
Анотація:
Sexually transmitted infections (STIs) remain a public health challenge in England, despite free, confidential testing/treatment services. The eSTI2 Research Consortium is developing a diagnostic self-test for STIs, to be deployed within online care-pathways. Should this intervention lead to increased STI detection and prompt effective treatment, it could reduce transmission and morbidity. Through a scoping review and three studies I explored its potential to benefit public health, thus informing the intervention’s ongoing development. The review (2013) found diverse uses of internet/electronic communications in STI care-pathways, but little research was transferable to remote self-testing or management. Current internet-use for sexual health may predict use of the proposed intervention, so I estimated its prevalence, and identified associated factors, using British probability survey data (2010-12). Among sexually-experienced 16-44-year-olds (n=8926), internet-use for STI testing/treatment was rare (< 0.5%), but available services were limited. 4.5% women and 4.6% men reported internet-use for information/support with their sex-lives, elevated among the better-educated and some STI risk-groups including young people. In qualitative interviews, 25 young people at risk of STI expressed enthusiasm for a (hypothetical) STI self-test within online care-pathways. Findings informed colleagues’ development of eSTI2’s Online Chlamydia Pathway (OCP). For people requiring chlamydia treatment, this included: online automated medical assessment, a helpline, and community pharmacy treatment collection or facilitated clinic access. I undertook and thematically-analysed 40 qualitative interviews with OCP users, within pilot studies. Participants valued the rapid, convenient and discreet treatment access, increased control over their healthcare, and optional professional support by telephone, enabled by the OCP. Offline parts of the pathway (pharmacy/clinic attendance) risked compromising its perceived advantages, and require further development. Recommendations derived from an iteratively-developed understanding of this complex intervention’s use and appeal, can enhance its potential to enable STI detection and treatment, promptly, effectively and acceptably. Future evaluation must consider impacts on health inequalities.
41
Gatuguta, A. "Pathways of care for sexual violence survivors and the benefits and drawbacks of using community health workers to provide support health services to sexual violence survivors : a systematic review and case study in Kenya." Thesis, London School of Hygiene and Tropical Medicine (University of London), 2018. http://researchonline.lshtm.ac.uk/4646633/.
Анотація:
Background: Research shows that sexual violence is widespread and has multiple adverse health consequences. Globally, majority of sexual violence survivors either do not access care or access care late. Many of those who access care are lost to treatment follow-up before they can fully realise the benefits of medical care. Evidence suggests that community health workers (CHWs) have the potential to improve healthcare for survivors. There is limited data however, on how to deliver these services effectively. Aim: To explore sexual violence survivors’ experience of seeking healthcare and experiences through the continuum of care in Kenya; and, to understand the benefits and drawbacks of using CHWs to provide support health services to sexual violence survivors. Methods: A mixed methods approach was used: 1) a systematic literature review of CHWs services for sexual violence to explore the existing models of services as well as the benefits and drawbacks; 2) records for 543 survivors were reviewed and key informant interviews conducted with healthcare providers in two referral hospitals. These hospital data were compared with national-level data on survivors from the Kenya Demographic and Health Survey 2014, and the Violence Against Children Survey 2010; 3) survivors were interviewed on their care pathways, current experience of services, perceived health service’s needs and experience of CHWs services; 4) CHWs, healthcare workers and other stakeholder’s with expertise in providing care for sexual violence were interviewed on their experiences and views on CHWs services for sexual violence. Results: There are multiple barriers to healthcare and missed treatment opportunities for survivors, both at the community and hospital level. Children, men, partnered or ever-partnered survivors and survivors experiencing violence from intimate partners are more likely to miss treatment. CHWs are already involved in sexual violence healthcare pathways carrying out awareness creation, identifying survivors, linking survivors to care and providing psychosocial support. However, training, better definition of roles and support from the healthcare system is needed. Conclusions: This thesis has identified specific barriers to services for sexual violence survivors and specific groups at risk of missing treatment. CHWs can form a part of interventions aimed to address the current barriers to treatment; however, more research is required to inform designing the models of services.
42
Duflos, Claire. "Les parcours de soins des insuffisants cardiaques : de leur mesure à leur utilisation." Thesis, Montpellier, 2018. http://www.theses.fr/2018MONTT065/document.
Анотація:
L’insuffisance cardiaque est une pathologie chronique fréquente et grave, dont l’évolution est émaillée de décompensations qui nécessitent généralement une hospitalisation. Malgré des recommandations scientifiques claires (traitement de l’étiologie et des comorbidités, traitement symptomatique précoce des décompensations, traitement de fond pour les cas à fraction d’éjection diminuée), l’organisation du système de santé ne favorise pas la délivrance optimale des soins recommandés. On constate en effet dans la littérature que la délivrance des soins, ainsi que le contenu des soins délivrés, sont très variables d’un environnement à l’autre, avec un impact sur le risque de réhospitalisation. L’amélioration de la qualité des soins nécessite donc de pouvoir décrire les modalités de délivrance et le contenu des soins, c’est-à-dire le parcours de soins. Les méthodes de description de ces parcours sont rares et non consensuelles. L’objectif de cette thèse est de proposer des méthodes de description des parcours de soins, dans l’ambition de proposer des aides à la prise de décision en clinique et en santé publique. Deux études sont réalisées sur deux bases très différentes : une base de données médico-administrative ambulatoire et hospitalière à l’échelle d’une région, et une base de données clinique hospitalière monocentrique. Ces deux études mettent en évidence, à l’aide d’une classification ascendante hiérarchique sur composantes principales, des groupes de patients aisément interprétables. En particulier, elles montrent chacune deux groupes dont les caractéristiques cliniques sont proches, mais dont la prise en charge est très différente ; une prise en charge peu intense est associée à une évolution défavorable. La méthodologie utilisée dans ces études est discutée à la lumière de la littérature, et les opportunités offertes par les résultats en termes de recherche, de pratique clinique, et de santé publique, sont exploréesHeart failure is a frequent and serious chronic pathology, whose evolution is peppered with decompensations that usually require hospitalization. Despite clear scientific recommendations (treatment of etiology and co-morbidities, early symptomatic treatment of decompensations, specific treatment for cases with decreased ejection fraction), the organization of the health system does not promote optimal delivery of recommended care. The literature reports that the delivery of care, as well as the content of delivered care, vary widely from one environment to another, with an impact on the risk of rehospitalization. Therefore, improving the quality of care needs to describe the delivery modalities and the content of care, that is to say, the care pathway. The methods of describing these pathways are rare and non-consensual. The aim of this thesis is to propose methods for describing care pathways, with the aim of offering support for clinical and public health decision-making. Two studies are carried out on two very different bases: an ambulatory and hospital medico-administrative database on a regional scale, and a monocentric clinical hospital database. These two studies highlight, using a hierarchical ascending classification on principal components, easily interpretable groups of patients. In particular, they each show two groups whose clinical characteristics are similar, but whose management is very different; a low level of care is associated with an poor prognosis. The methodology used in these studies is discussed in light of the literature, and the opportunities offered by the findings in terms of research, clinical practice, and public health are explored
43
Ferreira, Paulo Ribeiro Matos. "Estudo das vias de acesso aos cuidados psiquiátricos na equipa de Sintra." Master's thesis, Faculdade de Ciências Médicas. Universidade Nova de Lisboa, 2012. http://hdl.handle.net/10362/8169.
Анотація:
Resumo: O estudo das vias de acesso à consulta de Psiquiatria permite identificar os parceiros mais importantes no acesso dos utentes aos serviços psiquiátricos. O modelo de Goldberg-Huxley considera que o acesso às
consultas de Psiquiatria se faz principalmente através dos cuidados de
saúde primários.
Material e Métodos: Para estudar as vias de acesso aos cuidados psiquiátricos utilizamos a Encounter Form, questionário desenvolvido por Gater. Foi também avaliada a classe social dos utentes utilizando a Escala
de Graffar.
Este inquérito foi passado na Consulta de Psiquiatria de Sintra a utentes de
primeira consulta. A amostra estudada foi de 93 utentes. O objectivo do estudo foi conhecer a trajectória do utente desde que teve necessidade de ser consultado até chegar à consulta de Psiquiatria, os sintomas que determinaram a decisão de procurar ajuda e a influência da classe social no tempo de percurso.
Resultados: Observa-se que os utentes passam pela Medicina Geral e Familiar em 71 % dos casos, pela Urgência Psiquiátrica em 16,1 % dos casos, pela Medicina Especializada Hospitalar em 10,7 % dos casos e pela
Urgência Geral em 1,1 % dos casos. Na escala de Graffar a classe social prevalente é a média (Classe III). O tempo de percurso foi maior que em estudo similar realizado em 1991. A classe Social III foi a que teve tempo de percurso maior.
Conclusões: O estudo conclui que o acesso a esta consulta de Psiquiatria se faz principalmente através da Medicina Geral e Familiar. O tempo de percurso é maior que o desejável por falta de recursos humanos.------- ABSTRACT: Introduction: The study of the Pathways to Psychiatric Care identifies the most important partners in accessing psychiatric services. The Goldberg-
Huxley model believes that access to Psychiatric consultation is done preferably through the primary health care.
Material and Methods: This survey included 93 first-time users of the Psychiatric Consultation of Sintra. The aim was to study the trajectory of the user since he had felt a need to be consulted until the consultation of Psychiatry, the symptoms that led to the decision to seek help and influence of social class in time spent in pathways. This study used the Encounter
Form, a questionnaire developed by Gater. Social class of users was also assessed using the Scale of Graffar.
Results: We observed that users have contact with General Practitionaires in 71% of cases, the Psychiatric Urgency in 16.1% of cases, the Hospital Medical Specialist in 10.7% of cases and the General Urgency in 1,1% of cases. On the Graffar scale middle class (Class III) was the most prevalent.
The travel time spend in pathways was reater than that obtained in a similar study carried out in 1991. Social Class III group had a greater time spent on pathways.
Conclusions: The study concludes that access to this Psychiatric consultation is principally through general practice. The time spent in pathways is greater than desirable due to lack of resources.
44
Bayen, Sabine. "Stratégies d'optimisation de la communication centrée sur la personne entre acteurs du parcours de santé et personnes ayant une maladie chronique et leurs proches aidants : l'exemple de la maladie de Parkinson." Electronic Thesis or Diss., Université de Lille (2022-....), 2022. http://www.theses.fr/2022ULILS028.
Анотація:
Contexte. Les personnes ayant la maladie de Parkinson (PcP) et leurs aidants changent pendant leur parcours de vie. Ces changements impliquent de nombreux acteurs professionnels de parcours (APP). Une communication optimale, entre PcP et APP et entre les différents APP est incontournable pour répondre aux nouveaux besoins des PcP et de leurs aidants. L'exploration de l'expérience vécue de la maladie au quotidien, via une communication centrée sur la personne, permet d'identifier ces besoins.Méthodes. Trois nouveaux outils d'aide à la communication ont été développés pour permettre une exploration et une évaluation multidimensionnelles de l'expérience vécue des PcP : le PARKINSUN (expérience rapportée par les PcP), les questionnaires Bela-A-P-k (exploration croisée de la perspective des PcP et des aidants), et le projet PROXIPARK (recherche action participative prospective avec les PcP, aidants, et APP).Résultats. Ces outils ont été expérimentés in vivo et analysés. Ils sont basés sur une approche introspective et réflexive qui permet aux PcP, aidants, et APP d'analyser et évaluer l'expérience vécue de la maladie au quotidien. Les outils invitent à ouvrir le dialogue entre PcP, APP et aidants et augmentent leur compréhension mutuelle à partir d'une augmentation de leur répertoire commun concernant l'expérience vécue au quotidien avec la maladie de Parkinson.Conclusions. L'évaluation multidimensionnelle via ces outils a lieu régulièrement au cours du suivi global, temporo-spatial, interdisciplinaire et interprofessionnel. Elle permet d'adapter les stratégies d'accompagnementBackground. People with Parkinson's disease (PcP) and their carers change during their life course. These changes involve many professional care providers (PCPs). Optimal communication between PcP and PPAs and between different PPAs is essential to meet the new needs of PcP and their carers. The exploration of the daily experience of the disease, through person-centred communication, helps to identify these needs.Methods. Three new communication tools were developed to allow a multidimensional exploration and evaluation of the lived experience of PCPs: PARKINSUN (PCP-reported experience), Bela-A-P-k questionnaires (cross-exploration of the perspective of PCPs and caregivers), and the PROXIPARK project (prospective participatory action research with PCPs, caregivers, and APPs).Results. These tools were tested in vivo and analysed. They are based on an introspective and reflexive approach that allows PCPs, carers and PPAs to analyse and evaluate their daily experience of the disease. The tools invite to open the dialogue between PcP, PPA and caregivers and increase their mutual understanding by increasing their common repertoire of the daily experience with Parkinson's disease.Conclusions. The multidimensional assessment using these tools takes place regularly during the global, temporo-spatial, interdisciplinary and interprofessional follow-up. It allows for the adaptation of support strategies
45
Jerndahl, Fineide Mona. "Controlled by Knowledge : A Study of two Clinical pathways in Mental Healthcare." Doctoral thesis, Karlstads universitet, Fakulteten för ekonomi, kommunikation och IT, 2012. http://urn.kb.se/resolve?urn=urn:nbn:se:kau:diva-12937.
Анотація:
Standardisation of professional work is a major policy concern to ensure quality and efficiency of services and a number of hospitals are now focusing on the use of clinical pathways as an important tool to standardise their work. This study sheds light on the processes set in motion when notions of standardisation meet local practice. In order to gain insight into what clinical pathways mean for professional work in mental health care, the focus of the study was to explore the contexts in which standardisation by “rule production” takes place. Two empirical cases from Norwegian mental health care show how dedicated professionals are in charge of carrying out the standardisation work, strongly influenced by a steering framework of defined governmental policies where employee involvement and responsibility ensured loyalty to the idea. Along with a “package” of ideas, new bodies and techniques, clinical pathways contribute to the institutionalisation of prima facie knowledge in demonstrating that evidence basing is linked to steering and control of employees. Thus, professional autonomy is threatened in an insidious way: through the institutionalisation of evidence-based knowledge as ‘prima facie’ knowledge in combination with professionals who standardise and control their own work. The thesis therefore concludes that the control of professional work has now become a complex and sophisticated process where professional work is “controlled by knowledge”.
46
Cohen, Sarah. "Apport et utilisation des bases de données médico-administratives dans l’étude des problématiques émergentes chez les patients adultes atteints de cardiopathie congénitale Administrative health databases for addressing emerging issues in adults with CHD: a systematic review Accuracy of claim data in the identification and classification of adults with congenital heart diseases in electronic medical records Exposure to low-dose ionizing radiation from cardiac procedures and malignancy risk in adults with congenital heart disease." Thesis, Sorbonne Paris Cité, 2018. http://www.theses.fr/2018USPCB228.
Анотація:
Les cardiopathies congénitales (CC) sont les plus fréquentes des malformations congénitales et concernent près de 1% des naissances. Grâce aux progrès considérables de la cardiologie pédiatrique et de la chirurgie cardiaque, 90% des enfants nés avec une CC atteignent désormais l'âge adulte. Mais ces « survivants » ne sont pas guéris. Un certain nombre de complications, cardiaques et extracardiaques, attendues ou non, et de problématiques spécifiques émergent, justifiant une consommation de soins grandissante. Le besoin d’études en population a motivé l’analyse secondaire de données médico-administratives dans diverses régions du globe. L’objectif de cette thèse était d’étudier les conditions d’utilisation des bases de données médico-administratives (BDMA) et leurs applications possibles pour mieux comprendre les enjeux émergents de cette population nouvelle d’adultes avec CC (ACC). La première partie de ce travail a été de décrire de manière systématique toutes les études ayant utilisé des BDMA pour explorer spécifiquement les problématiques des patients ACC. Cette revue a montré l’intérêt de ces bases de données dans le domaine des ACC, les effectifs importants permettant d’étudier des maladies relativement rares et la disponibilité de données exhaustives sur de longues périodes d’observation autorisant l’étude de certaines complications cardiaques ou extracardiaques de survenue parfois différée chez ces patients. En France, les bases de données administratives de remboursement utilisent la Classification internationale des Maladies, dixième révision (CIM-10) dont la fiabilité pour repérer les ACC et les pathologies qui leur sont associées est inconnue dans ce contexte. La deuxième partie de ce travail avait donc pour objectif d’étudier la performance de la CIM-10 pour identifier et classer des patients ACC au sein de l’entrepôt de données de l’hôpital Européen Georges Pompidou disposant d'une unité dédiée aux ACC. La troisième partie de cette thèse rapporte un exemple concret de l’utilisation des BDMA. A partir des données de la Québec Congenital Heart Disease Database issue des BDMA du Québec, notre objectif était d’évaluer l’association entre l’exposition aux rayonnements ionisants provenant de procédures cardiaques et la survenue de cancer chez les ACC. En effet, l’amélioration de l’espérance de vie des patients avec CC et l’augmentation du recours aux modalités d’imagerie cardiaque irradiante, font craindre un effet carcinogène potentiel à long terme. Bien qu’elles n’aient pas été conçues à des fins de recherche, ce travail de thèse montre que les BDMA sont un outil particulièrement pertinent pour générer de nouvelles connaissances sur les patients ACC de par l’exhaustivité des informations disponibles, la possibilité de produire de grands échantillons et de permettre un suivi longitudinal sur de longues périodes d'observation. L’exploitation des dossiers médicaux électroniques par des méthodes de fouilles de texte pourrait alors permettre de développer et valider des algorithmes pour identifier les cas de CC dans les BDMA. En France, bien que des efforts aient été déployés pour créer un programme de collaboration multicentrique efficace, il n’existe à l’heure actuelle aucune donnée épidémiologique d’envergure concernant l’ensemble des ACC. L’analyse secondaire de ressources existantes, telles que le Système National des Données de Santé, permettrait d’établir la cohorte nationale d’ACC et d’analyser leur parcours de soins afin d’orienter au mieux l’allocation des ressourcesCongenital heart diseases (CHD) are the most common types of birth defects and affect approximately 1% of births. Ninety percent of children born with CHD reach now adulthood thanks to improvements of pediatric cardiology and cardiac surgery. These "survivors" are not definitively cured. They are prone to cardiac or extra cardiac complications and specific issues that justify an increase in consumption of healthcare. The need for population-based studies worldwide has led to secondary analyses of administrative medical databases (AMD). The objective of this thesis was to study the conditions of use of the AMD and their possible applications, specifically to understand the emerging issues of this new adult population with CHD (ACHD). The first part of this work was to systematically describe all the studies that had used AMD to specifically explore the issues of ACHD patients. This review showed the value of these databases in the field of ACHD: the large numbers of patients allows studying relatively rare diseases and the availability of comprehensive data over long periods of follow-up enables to study cardiac and extra cardiac complications even when the occurrence is delayed. In France, claim databases use the International Classification of Diseases, 10th revision (ICD-10), the reliability of which is still largely unknown in this context. The second part of this work was therefore to study the performances of ICD-10 to identify and classify ACHD patients in the data warehouse of the Georges Pompidou European Hospital which has a dedicated specialized ACHD Unit. The third part of this thesis reported a concrete example of the use of AMD. Based on the Quebec Congenital Heart Disease Database derived from Quebec’s AMD, our goal was to evaluate the association between exposure to ionizing radiation from cardiac procedures and the risk of cancer in ACHD. Indeed, the improvement in the life expectancy of patients with CHD and the increasing use of cardiac imaging modalities using ionizing radiations may have a carcinogenic effect in the long term. Although not designed for research purposes, this thesis showed that AMD are a particularly relevant tool for generating new knowledge about ACHD patients through the comprehensiveness of information, the possibility of extracting large samples of patients with a longitudinal follow-up over long periods of observation. The exploitation of electronic medical records through text mining methods could then be used to develop and validate algorithms to identify CHD patients in AMD. In France, although efforts have been made to create an effective multi-center collaborative program, there is currently no significant epidemiological data for all ACHDs. Secondary analysis of existing resources, such as the National Health Data System, would establish the national ACHD cohort and analyze their care pathway in order to guide healthcare resources allocation
47
Roux, Jonathan. "Parcours de soins des patients atteints de sclérose en plaques à partir des données médico-administratives en France." Thesis, Rennes 1, 2018. http://www.theses.fr/2018REN1B042/document.
Анотація:
La sclérose en plaques (SEP) est une maladie neurologique chronique du jeune adulte affectant environ 100 000 personnes en France. Au cours des deux dernières décennies, les stratégies thérapeutiques ont fortement évolué avec l’apparition de nouvelles molécules dont les premières formes orales. Le parcours de soins dans la SEP implique plusieurs professionnels de santé médicaux (généralistes, neurologues) et paramédicaux (kinésithérapeutes, infirmiers). Actuellement, aucune recommandation sur ces parcours n’a été définie, et peu de données existent sur le recours aux soins des individus ayant une SEP et l’utilisation des traitements spécifiques à la SEP en France. L’utilisation des données du Système National des Données de Santé (SNDS), c’est-à-dire les bases de l'Assurance Maladie, couplée avec les méthodes d’analyse de séquences donne l’opportunité d’étudier ces parcours de soins. L’objectif principal de cette thèse était d’étudier les parcours de soins des personnes ayant une SEP en France, à partir du SNDS, afin de décrire les consommations de soins et de mettre en évidence une typologie de parcours. Les objectifs secondaires étaient d’étudier l’utilisation des traitements de fond de la SEP en France (fréquence et place dans la séquence thérapeutique), et d’étudier la faisabilité de mesurer le niveau de handicap moteur dans ces bases. Au total sur la période de suivi de 2010 à 2015, 112 745 patients ont été identifiés, dont 47,4% avaient reçu au moins une délivrance d’un traitement de fond spécifique à la SEP. Une typologie a été obtenue identifiant cinq groupes cliniquement distincts. En parallèle, un indicateur de quantification du niveau de handicap moteur, pouvant être répliqué dans d’autres études, a été proposé afin d’enrichir les données du SNDS. Au travers des différentes analyses réalisées et des questions méthodologiques soulevées, des éléments clés permettant l’utilisation des méthodes d’analyse de séquences en santé, notamment la multichannel sequence analysis, ont pu être mis en évidenceMultiple sclerosis (MS) is a chronic neurological disease starting in young adulthood and affecting about 100,000 persons in France. During the last two decades, therapeutic practices have evolved with the release of new substances, especially oral disease-modifying therapies (DMTs). Care pathways in MS involve both medical (general practitioners, neurologists) and paramedical (physiotherapists and nurses) health care professionals. However, no recommendation on care pathways in MS exists so far in France. Moreover, few data are available on care-seeking of persons with MS (PwMS) and the utilization of DMTs in France. The use of state sequence analysis (SSA) on data issued from the French National Health Data System (SNDS, i.e. databases from the French Health Insurance System) offers the opportunity to study care pathways. The main objective of this PhD thesis was to study the care pathways of PwMS in France using data from SNDS, in order to describe care-seeking and to create a typology of pathways. The secondary objectives were to study MS DMTs utilization in France (frequency and therapeutic sequences), and the feasibility to measure the level of motor disability in SNDS. Over the 2010-2015 study period, 112,745 PwMS were identified. Amongst them, 47.4% had at least one delivery of a MS-specific DMT. A typology was obtained allowing the identification of five clinically distinct groups of patients. In parallel, a parameter quantifying the level of motor disability in SNDS, which could be replicated in other studies, was defined. Thanks to the different analyses and raised methodological questions, key-elements allowing the use of SSA in health field, especially multichannel sequence analysis, were highlighted
48
Cantrelle, Christelle. "Le parcours de soin des greffés cardiaques en France : détermination des facteurs associés à leur accès à la greffe." Thesis, Université Paris-Saclay (ComUE), 2018. http://www.theses.fr/2018SACLS063/document.
Анотація:
Le stade terminal de l’insuffisance cardiaque peut nécessiter l’inscription en liste d’attente pour une greffe cardiaque. L’offre en greffon étant faible, l’accès à cette thérapeutique est priorisé pour les malades les plus graves dans le système d’allocation actuel, faisant de l’équité un enjeu éthique et sociétal important. L’objectif de cette thèse, grâce à des méthodes originales et de nouvelles sources de données, était d’analyser les déterminants d’accès à la greffe cardiaque liés aux candidats et aux équipes de greffe en France sur une période récente et d’apporter des éléments nouveaux sur le parcours de soin de ces malades. L’analyse du devenir des candidats à une greffe cardiaque inscrits entre 2010 et 2013 en intégrant la méthode de risques compétitifs a permis de dissocier le risque médical du risque induit par le système d’allocation actuel. Nous avons ainsi trouvé 7 facteurs relatifs au candidat associés à un risque de mortalité élevé dont 4 reliés à la sévérité de l’insuffisance cardiaque et 3 non spécifiques de l’insuffisance cardiaque mais associés à un faible accès à la greffe. La prise en compte de l’effet centre sur les inscrits entre 2010 et 2014 grâce à un modèle mixte de survie a permis de déterminer les facteurs équipe associés à l’accès à la greffe. Parmi les 23 équipes de greffe en France, l’ajustement sur les facteurs candidat et équipe, permettait d’observer que 5 équipes avaient des résultats différents des autres dont 3 avec un accès défavorisé. La mise en évidence de disparités médicales, géographiques et structurelles, révélatrices de failles dans le système actuel d’allocation des greffons cardiaques, nous a permis d’étayer la discussion sur la mise en place d’un nouveau système d’attribution en France. L’attribution au patient plutôt qu’à l’équipe de greffe devrait être plus pertinente. Les méthodologies utilisées permettront d’évaluer précisément ces répercussions. Enfin, l’étude du parcours hospitalier un an avant greffe (2010-2015) à l’aide des données du PMSI a permis de constater un nombre élevé d’hospitalisations pré-inscription majoritairement liées à leur défaillance cardiaque et de longue durée, confirmant le caractère réfractaire de ces insuffisants cardiaques. Ce travail sera poursuivi par une étude approfondie de la consommation de soins de ces malades grâce aux données du SNDS, indispensable étape pour évaluer la prise en charge et estimer les besoins en greffe cardiaqueHeart transplantation (HTx) is the preferred option for medically refractory advanced heart failure. Due to the small number of available grafts, current allocation policy in France, as in many other countries, is based on the severity of the candidate’s heart disease. This Ph. D thesis was designed to determine candidate and center factors associated with access to heart transplantation in France and in-hospital care pathways one year before heart transplantation using appropriate methodologies and the national hospital database. We first analyzed 1-year mortality in patients listed for HTx in France from 2010 to 2013 using competing risk models in order to distinguish patient-related predictors and the influence of allocation policy. We then distinguished the proportions explained by candidate characteristics and center factors with the persistent between-center variability on 1-year access to transplantation (2010-2014). These disparities are mediated by the severity of the candidate’s heart disease, the allocation system and listing practices rather than by transplant activity. These findings provide a new contribution to improve the heart transplant allocation scoring system in France. The study based on the nationwide administrative database overcomes a major limitation of the national transplantation registry by shedding light on the healthcare pathway of heart transplanted recipients (2010-2015) during the year prior to transplantation. These findings will be useful to assess the medical benefits and criteria for registration on the heart transplant waiting list. This study will be continued by a detailed analysis of the healthcare consumption of these patients based on French national health insurance (SNDS) data
49
Girard, Lucile. "La demande de soins des personnes transsexuelles en France : prise en charge médicale et respect de la dignité." Phd thesis, Université René Descartes - Paris V, 2013. http://tel.archives-ouvertes.fr/tel-00921071.
Анотація:
Le parcours de soins des personnes transsexuelles relève d'une prise en charge multidisciplinaire comportant des aspects médicaux, sociaux et juridiques. Ces trois pôles agissent en interaction et en complémentarité.En France, le protocole établi par la Sécurité sociale en 1989 impose un suivi psychiatrique des personnes d'au moins deux ans avant qu'elles puissent prétendre à une prise en charge de l'opération de réassignation sexuelle ; ceci dans le but, entre autres, d'évaluer la qualité de leur demande. Ces consultations sont souvent décriées par les personnes transsexuelles qui les trouvent stigmatisantes parce qu'elles associent ouvertement leur trouble à la maladie psychiatrique. Les personnes transsexuelles considèrent que le suivi psychiatrique imposé est une atteinte à leur dignité dans le sens où leur parole se trouve remise en question par des questionnaires et des évaluations, établis par un personnel médical qui ne peut ressentir ce qu'elles vivent. Actuellement, beaucoup de personnes transsexuelles ne suivent pas ce protocole médical recommandé par la Haute autorité de santé (HAS), qu'elles estiment trop rigide et éloigné de leurs besoins ; elles organisent elles-mêmes leur parcours ayant parfois recours à des actes chirurgicaux pratiqués à l'étranger. Pour finir, ce parcours de soins serait incomplet s'il n'était validé par une modification de l'état civil ; ainsi le parcours médical de transformation de la personne se trouve lié à un parcours juridique garant de l'intimité et des droits de la personne.Les origines psychologiques, psychiatriques, biologiques ou génétiques du transsexualisme sont encore discutées, sans qu'actuellement aucune réponse ne puisse être donnée de façon reproductible et fiable ; seules des interrogations sont posées. Dans ce contexte d'incertitudes, les paroles que nous avons recueillies font apparaître une réalité du terrain où la personne est, par la force des choses, au centre de l'acte de soins et heurte la conception scientifique de la médecine par ses choix et ses attitudes. Ces différents parcours de vie nous ont montré combien le respect de la personne dans sa différence, non quantifiable et inclassable, était important. Le respect de l'expertise acquise de la part du patient, le respect de sa vérité, de sa décision et de ses choix, sont des revendications qui sont apparues régulièrement. Par ailleurs, au-delà de l'aide médicale demandée, le besoin d'aide psychologique, de soutien moral et financier dessine le profil de personnes vulnérables qu'il convient de soigner et dont il convient de prendre soin. Toutefois il ne faut pas oublier la violence des actes demandés, les interrogations qu'ils suscitent chez les patients et les praticiens concernés. La décision d'entreprendre tous les traitements médicaux et chirurgicaux nécessaires au bien-être de la personne, si elle est présentée comme une décision personnelle, entraîne dans sa dynamique de nombreux acteurs. Certains choisissent d'adhérer à cette transformation, d'autres se trouvent parfois contraints de l'accepter
50
Duma, Davide. "Online optimization methods applied to the management of health services." Doctoral thesis, 2018. http://hdl.handle.net/2318/1678596.
Анотація:
The rising costs of health care due to new technologies and the aging population is a vitally important issue for health care policy makers. At the same time there is a paradigm shift in the service concept of health care: patients are no longer prepared to accept poor quality service, either in terms of long waiting times or inconvenient appointment systems, and expect that services are well organized from a ``customer'' perspective. In the modern health care delivery, the concept of health service needs to be focused on optimizing the use of resources finding a balance between service for patients and efficiency for providers.
Dealing at the same time with the uncertainty and the dynamics of health care delivery problems, the adoption of unconventional solution methodologies is necessary. In this thesis, we would propose an approach based on the online optimization methodology to manage the uncertainty and the dynamics of several health care delivery problems. Online optimization is characterized by the development of algorithms whose decisions are based only on past events without any solid information about future data. Starting from a given offline planning solution (when it exists), the basic idea is to fix such a solution in real time as soon as an unattended event will occur exploiting the available knowledge of the underlying Clinical Pathways (CPs).
We identified three health care delivery problems to illustrate and develop our approach. The three problems belong to two different CPs, which are the Surgical Pathway (SP) and the Emergency Care Pathway (ECP). The first problem arises in the context of Operating Room Planning (ORP), which is characterized by (i) a well-structured but complex pathway, and (ii) by several sources of uncertainty such as the arrival of unattended patients to be operated on, and the duration of a surgery and the length of stay. The second problem arises in the context of Emergency Medical Service (EMS) management, which is characterized by (i) a well-structured but simple pathway, and (ii) by several sources of uncertainty such as the arrival of unattended phone calls asking for an emergency requests to be served as soon as possible (depending on the level or urgency) by a not always available ambulance. Finally, the third problem arises in the context of Emergency Department (ED) management, which is characterized by (i) a non-structured but complex pathway, and (ii) by several sources of uncertainty such as the arrival of unattended patients to be served as soon as possible (depending on the level or urgency) by a possible overcrowded system, and the dynamic evolution of the patient path.
In the ORP and the EMS management we deal with lasagna processes: the sequence of activities to be performed is known a priori and the possible path evolutions are limited. For this reason, online optimization approaches have been used exploiting the solid knowledge of the CPs. On the contrary, the ED management is a spaghetti process: a large variety of path evolutions is possible and the sequence of activities to be performed is part itself of the lack of information taken into account by online optimization. To deal with this challenging aspect, we use an ad hoc process mining approach to extract information from historical data of a case study for predicting the possible path evolutions on the basis of the few information available, such as the past activities and the characteristics of the patient.
Since the competitive analysis, which is a typical evaluation approach of the online optimization algorithms, cannot be easily applied due to the complicated nature of the considered problems, an alternative evaluation framework to evaluate the proposed methods is required. Exploiting the discrete structure of the problems under considerations, we evaluate the quality of our online solutions within a Discrete Event Simulation (DES) framework. Basically, we adopt the DES to replicate the operative context in which the candidate algorithms operate using real world or realistic data, and allows us to evaluate their impact over time, that is how the previous decisions can impact on the current decisions. Further, we always consider a baseline configuration representing a basic organization equipped with some elementary decision making tools: it should provide a simple set of rules similar to those involved in delivering the health services in real case contexts, in such a way to have a comparison with the proposed methods.
There are several common lessons learned through the analysis and the comparison of the several policies proposed for the addressed problems. The same problems in different operative contexts usually obtain the best performance improvement using different method configurations, which is a further proof of the necessity of a decision support tool in health care. Standalone online optimization approaches seem to be effective in well-structured processes while they requires the support of process mining and predictive methods when the complex process is non-structured. Furthermore, the more flexible the operating context in which online optimization is applied (e.g. sharing resources among different patient classes) the greater the contribution of optimization in improving performance. Since sometimes a large flexibility is not possible because of the lack of adequate decision support tools, those proposed in the thesis can represent a solution for the management of the high complexity that derives from a flexible context.