Health Policy & Management Theses and Dissertations
Permanent URI for this collectionhttp://hdl.handle.net/1903/7127
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Item Adverse Childhood Experiences and Preterm Birth: A Systematic Review(2019) Wiggan, Morgan Lynn; Franzin, Luisa; Shenassa, Edmond; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Adverse childhood Experiences (ACEs) elevate one’s risk for poor health outcomes later in life such as psychiatric disorders, cardiovascular disease, depression, anxiety, obesity, diabetes, poor fetal health, and liver disease (Poulton et al., 2002, Anda et al., 2007, Jimenez et al., 2017, Talbot et al., 2009. While the association between ACEs and negative health outcomes is well established in the literature, only ten studies examine the effect of ACEs on one’s risk for preterm birth (Benedict et al. 1999; Bublitz et al., 2014; Cammack et al., 2019; Christiaens et al. 2015; Jacobs 1998; Gillespie et al. 2017; Grimstad et al. 1998; Leeners et al. 2010; Margerison-Zilko et al., 2016; Noll et al. 2007). Preterm birth accounts for 60% of neonatal deaths and elevates an infant’s risk for poor health outcomes later in life ranging from behavioral issues to heart disease (WHO, 2018) and the rate of preterm birth in the United States has steadily risen since 2015, reaching about 10% in 2018 (CDC, 2018). This systematic review seeks to critically assess and synthesize these ten studies and identify proposed mediators and identify gaps in the literature for future research.Item The Impact of International Accreditation on The Quality of Health Services at King Fahd University Hospital, Saudi Arabia: A Mixed Methods Approach(2019) AL Shawan, Deema Saad; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The Joint Commission International Accreditation (JCIA) is perceived worldwide as the symbol of exceptional quality of care. Despite the popularity of international accreditation, evidence of its effectiveness on improving health care quality is inconclusive. This dissertation research utilized a Convergent parallel mixed method framework to evaluate the impact of the JCIA process on quality and to identify the factors that influence the effectiveness of this process at King Fahd Hospital of the University in Khobar, Saudi Arabia. An interrupted time series analysis was conducted to assess the changes in a total of 12 quality outcomes pre and post accreditation. Furthermore, a qualitative approach was used to investigate the attitudes and perceptions of 31 health providers towards this process and the factors that influence its success. The quantitative results suggested that the JCIA had a positive impact on 9 out of 12 outcomes. The improved quality outcomes included: the average length of stay, the percentage of hand hygiene compliance, the rate of nosocomial infections, the percentage of radiology reporting outliers, the rate of pressure ulcers, the percentage of the correct identification of patients prior to medication administration, the percentage of critical lab reporting within 30 minutes, and the bed occupancy rate. The outcomes that did not improve were the rate of patients leaving the ER without being seen, the percentage of OR cancelations on the day of the or and the rate of patient falls. The qualitative analysis suggested that the JCIA was perceived positively by all participants. Some of the perceived advantages of international accreditation included the transformation of the organizational culture to a culture that promotes continuous quality improvement, standardization, and the reduced paperwork in some departments. The participants’ responses also indicated that there were many factors that influence the success of the process. Examples of the factors identified in the study include the increased workload and the providers’ resistance to participate in the JCIA process. In conclusion, international accreditation seemed to have a positive impact on quality outcomes and was received positively by providers. Nevertheless, the factors that hindered the JCIA process need to be addressed by the hospital’s leadership to ensure more efficient quality improvement efforts during future accreditation cycles.Item THE EXAMINATION OF NATIONAL-NUTRITION POLICIES ON NONCOMMUNICABLE DISEASE MORTALITY AT VARIOUS STAGES OF ECONOMIC DEVELOPMENT: A CROSS-COUNTRY PERSPECTIVE(2019) Gupta, Manisha; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The acceleration of economic growth over the past few decades introduces the need to reorient policy to address the needs and challenges for a healthier population. This paper will review the effectiveness of national nutrition policies targeting overweight, healthy diets during pregnancy, infancy and childhood, and noncommunicable diseases (NCDs) across advanced economies and transitional economies. The level of expansion and industrialization of food systems around the world have had a direct impact on nutritional status and health. Considering the magnitude of nationwide public health responses to shifts in mortality have varied over time, this introduces the need to assess the ability for dietary-related policies to successfully reduce NCDs. Results from this analysis can provide a strong rationale as to when interventions will be most effective as well as ways in which we can carry out a timely response in establishing effective policies for countries at different levels of economic development.Item THE EFFECT OF OWN RACE/ETHNICITY DENSITY ON INSURANCE TAKE-UP BY ASIAN AMERICANS(2019) Choi, Yoon Sun; Roby, Dylan H; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Asian Americans are the fastest growing minority population in the U.S. (Lopez et al., 2017). Since the implementation of the Patient Protection and Affordable Care Act (ACA), Asian Americans have benefitted from insurance coverage increases but continue to experience disparities at the subgroup level (Park et al., 2018). This study investigates the association of own race subgroup density on the take-up of insurance by examining the effect of Asian subgroup concentration that may provide social and knowledge support linkages to available insurance coverage options.Item Health Policy, Care Coordination, and Racial and Ethnic Disparities Among US Adults Aged 18-64 with Serious Psychological Distress(2019) Novak, Priscilla; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)About one in five Americans have a mental health condition, and in any given year, 3-5% of the population experiences serious psychological distress (SPD). The goal of this dissertation is to examine the impact of health policy on racial and ethnic disparities among people experiencing SPD. The literature review in my dissertation details evidence on systemic racial and ethnic differences in access, quality, and care coordination. I develop a causal theory examining the reasons why the problem of SPD and racial and ethnic health disparities exist and specific evidence that illuminates how the problems come into existence. Using National Health Interview Survey data from 2011-2016, access to care among Non-Hispanic (NH) Whites, NH Blacks and Hispanics with SPD is examined. Findings suggest that in comparison to NH Whites, NH Blacks and Hispanics experienced greater gains in health care access following the Affordable Care Act (ACA). Next, using data from the 2015 and 2016 Medical Expenditure Panel Survey, differences in racial and ethnic minorities being served by usual sources of care with care coordination services is examined. Findings suggest that in comparison with NH Whites with SPD, Hispanics with SPD had lower odds of being seen at a Patient Centered Medical Home (OR 0.55, (p <0.05)). Hispanics had higher odds (1.29 (p <0.03)) of being seen at a practice that used case managers; and Non-Hispanic Blacks with SPD had higher odds (3.25 (p< 0.001)) of being seen at a practice that used care managers. Given that people with diabetes experiences mental health conditions occur at about twice the rate of the general population, this dissertation examined the quality of care provided to people with doctor-diagnosed diabetes and SPD using data from the Medical Expenditure Panel Survey. Findings suggest that between 2012 and 2016, racial and ethnic disparities in the receipt of glycated hemoglobin (HbA1c) testing improved but were not eliminated. Results suggest that increased health insurance coverage alone does not eliminate health disparities, and work remains to be done to ensure that all Americans benefit from high-quality, evidence-based care.Item EFFECTS OF MEDICAID STATE PLAN DENTAL BENEFITS ON DENTAL VISITS AMONG NON-ELDERLY ADULTS(2018) Marthey, Daniel Joseph; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Using the Behavioral Risk Factor Surveillance Survey and optional Health Care Access module, I analyzed dental visits between insurance types and between three levels of Medicaid dental coverage for non-elderly adults in each state defined as no benefits or emergency-only, offering 1-4 services and offering 5 or more service types. I find Medicaid adults are less likely to experience a dental visit compared with adults covered by private insurance. I also find a statistically significant relationship between the level of benefits offered to beneficiaries and the odds of experiencing a dental visit in the previous year. Understanding factors associated with the use of dental services is necessary to adequately address health needs of the Medicaid population and unnecessary emergency room use for non-emergency dental services.Item Socioeconomic Position, Gender, and HPV Vaccine Utilization(2018) Rogers, Taylor; Boudreaux, Michel; Thomas, Stephen B; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)In 2011-2014, the prevalence of HPV was higher in adult males compared to adult females. HPV and its associated health outcomes can be prevented through the completion of the 3-dose HPV vaccine series. Using the 2010 - 2016 National Immunization Survey - Teen, I examined the association of family income and gender with three HPV vaccine utilization outcomes: (1) receipt of provider recommendation; (2) HPV vaccine initiation; and (3) HPV vaccine completion using logistic regressions. Results suggested that family income was negatively correlated with HPV vaccine outcomes regardless of gender and controlling for other covariates. I also found that males had lower vaccine use compared to females, regardless of income. In the second analysis I investigated if the 2011 ACIP guideline increased vaccine utilization outcomes using a difference-in-differences. This analysis suggested that the new guideline increased recommendations by 24 percentage points for males, relative to females (P<0.01), HPV vaccine initiation improved by 23 percentage points (P<0.01), and vaccine completion improved by 10 percentage points (P<0.01).Item PREVENTIVE CARE UTILIZATION AND ITS IMPACT ON POTENTIALLY PREVENTABLE HOSPITALIZATIONS: IMPLICATIONS OF MEDICAID COST-SHARING, MEDICAID EXPANSION, AND THE AFFORDABLE CARE ACT FOR VULNERABLE POPULATIONS(2017) Bloodworth, Robin; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)About half of Americans have at least one chronic disease, and chronic diseases account for nearly 90% of healthcare expenditures in the US. Primary care can reduce potentially preventable hospitalizations and overall costs of chronic diseases. However, only about 3% of US healthcare spending is on prevention. Racial/ethnic disparities and income disparities have been well documented in the use of primary care. The ACA expanded insurance coverage for millions of Americans and included a mandate that all insurance plans must cover recommended preventive services at no cost to the patient. Literature shows the ACA resulted in an increase in access to care, but results on utilization rates of primary care post-ACA are mixed. Using nationally representative data sets from 2009-2015, I examined the utilization rates of preventive services among vulnerable populations after the full implementation of the ACA, and how Medicaid state policy and expansion under the ACA affected the utilization of preventive services among vulnerable populations. Next, using the Maryland Medical Care Database from 2012-2014, I examined how continuity of primary care affects the odds of having any hospitalization as well as potentially preventable hospitalizations. I found that the ACA was associated with an increase in preventive services recommended yearly, and the ACA was not associated with disparities in preventive service utilization among vulnerable populations. Additionally, I found that state Medicaid policies on preventive services were associated with increased utilization of flu shot, but Medicaid expansion was not associated with increased utilization of preventive services or many changes in disparities in preventive service utilization among vulnerable populations. Finally, I found that primary care, especially ongoing primary care, was strongly associated with a decrease in the odds of having any hospitalization and potentially preventable hospitalizations. Results suggest that increased access alone will not increase utilization rates and reduce health disparities, but rather, a focus on education of what coverage options are available through the ACA, the importance of ongoing primary care, and how to navigate the healthcare system once insured could increase utilization of preventive care, especially in vulnerable populations.Item Community Living and Health Services Utilization among the Aging Services Network Population(2017) Gaeta, Raphael; Simon-Rusinowitz, Lori; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)By 2050, the number of older adults will increase from 67 million to 111 million, or roughly 28 percent of the total U.S. population. Age is a principal predictor of physical health status as well as functional and cognitive limitation. As the aging population grows, so too will the demand for long-term services and supports (LTSS) and healthcare services. Despite this intersection, LTSS and healthcare systems are highly disconnected. The Aging Services Network, authorized and partially financed by the Older Americans Act (OAA), may play an important role in an emerging trend toward integrating services. Yet, OAA research is lacking. Existing OAA research faces several obstacles, including handling program variation resulting from a decentralized Aging Services Network, identifying non-user comparison groups for OAA study samples, and limited utility of national datasets. Studies often rely on highly descriptive methods, indirect comparisons to the general population of older adults, or state-restricted analysis. This dissertation addresses several gaps in the research. The first study aims to identify factors associated with community tenure and participation among low-income elderly living in subsidized housing. The research is grounded in conceptual frameworks from the World Health Organization. In-depth interviews and focus groups are used to explore these associations among elderly HUD building residents in Prince George's County, Maryland. The second study aims to identify multilevel predictors of OAA Title III services participation. This study develops a conceptual framework based on the Andersen Behavioral Model of Health Services Use, and uses a merged data set from the nationally representative Health and Retirement Study with geographic data and relevant state policies. The third study further examines the relationship between OAA Title III services participation and patterns of healthcare utilization. This dissertation research provides evidence for the importance of OAA Title III services, including for elderly HUD beneficiaries. Findings from multivariate regression analyses provide evidence for (1) county level targeting criteria used to measure LTSS need and direct OAA Title III funding, (2) substantial influence of Medicaid on access to OAA Title III services, and (3) changes in mix of health care services use among OAA Title III services participants over time.Item ADVANCING THE HEALTH OF UNDERSERVED COMMUNITIES ACROSS THE UNITED STATES: OPPORTUNITIES TO IMPROVE HEALTH CENTER QUALITY OF CARE AND PATIENT EXPERIENCE(2017) Nair, Suma; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)1 in 13 people in the United States receives care at a community health center. As health center services become an increasing percentage of all primary care services delivered in the United States, their success is vital to national efforts to advance health and manage costs. This dissertation presents three studies, addressing critical gaps in our understanding of health center quality and quality improvement opportunities. The first study examined the association between ambulatory care accreditation and 14 clinical quality measures in 1,198 health centers. Results demonstrated that accredited centers achieved higher performance on adult weight screening and follow up, tobacco cessation intervention, and use of lipid-lowering therapy. Universal accreditation could lead to an additional 552,087 patients receiving weight screening and follow up, 157,434 receiving tobacco cessation interventions, and 25,289 receiving lipid-lowering therapy. Findings suggest universal accreditation could contribute to quality gains and facilitate health disparity reduction. The second study used the first nationally representative dataset of health center PEC, to investigate the association between five measures of PEC (access to care, provider communication, office staff interactions, follow up on results and overall provider rating) and patient and health center characteristics. Results demonstrated that PEC ratings varied significantly by race/ethnicity, health and mental health status, education and income levels, and language. Findings highlight PEC improvement opportunities as well as the importance of patient-mix adjustment of PEC ratings in value-based payment. The third study evaluated the association between PEC and health center quality of care. Quality of care metrics included receipt of care, health behaviors, patient activation, and clinical outcomes in health center patients. Results showed that PEC ratings were associated with receipt of care, as well as patient adherence and activation. The findings support the importance of measuring PEC as a key determinant of quality, as well improving PEC as a driver for improvement for other aspects of care quality. All three studies were the first to our knowledge to use nationally representative health center data to examine these dimensions of quality and provide significant contributions towards our understanding of health center quality and related quality improvement and policy implications.