Health Policy & Management Theses and Dissertations
Permanent URI for this collectionhttp://hdl.handle.net/1903/7127
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Item Novel Immunotherapy Agents in Oncology: Generalizability of Trial Results and Drivers of Clinical Utilization(2021) Mishkin, Grace; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Cancer is the second most common cause of death in the United States after heart disease. Novel immunotherapy agents such as nivolumab and pembrolizumab have become an essential, albeit extremely expensive, component of oncology care since their first approvals in melanoma in 2014 and lung cancer in 2015. However, little is known about differences between immunotherapy clinical trial participants and the real-world patient population, or about the drivers of provider utilization of these agents. The first objective of this dissertation used the SEER-Medicare linked database with claims data from 2014-2016 to conduct two aims analyzing potential disparities between Medicare beneficiaries on active treatment for melanoma and lung cancer and Medicare clinical trial participants. Aim one compared the characteristics of Medicare patients on active cancer treatment to Medicare patients on active cancer treatment clinical trials. Aim two compared Medicare patients receiving the novel immunotherapy agents nivolumab or pembrolizumab to Medicare patients participating in trials of these two immunotherapy agents. Because of the demographic differences in the melanoma and lung cancer patient populations, these aims were analyzed separately in melanoma and lung cancer. As hypothesized, patients in clinical trials were significantly younger and had fewer comorbid conditions than patients undergoing active cancer treatment not in clinical trials. Underrepresentation of non-White and female patients in clinical trials was hypothesized, but these results were less consistent. The second objective used Medicare Open Payments data from 2016 and Medicare provider utilization data from 2017 to analyze 1) if industry payments promoting nivolumab or pembrolizumab were positively associated with whether a provider was a high utilizer of the agent, and 2) among these high utilizers, if industry payments were positively associated with greater utilization amounts. The hypothesized results, that industry payments were associated with greater likelihood of high utilization and more utilization among high utilizers, were seen in some of the analyses but not consistently throughout the study. Through unique analyses of recent datasets, this dissertation advances our understanding of potential disparities in clinical trial representativeness and the generally positive relationship between promotional payments and provider utilization of immunotherapy agents in the Medicare cancer patient population.Item Racial/Ethnic Disparities in Amputation and Revascularization: The Roles of Socioexonomic Reighborhood Stress and Allostatic Load(2020) Hughes, Kakra; Sehgal, Neil J; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Blacks are several times more likely to undergo a leg amputation as compared to Whites. This is because while peripheral artery disease (PAD), the most common cause of amputation, is more likely to be treated by revascularization (restoration of blood flow) in Whites, PAD is more likely to be treated by amputation in Blacks. Whereas an ongoing debate argues as to whether this disparity is primarily a sociologic versus a biologic phenomenon, I proposed that there are socioeconomic neighborhood stressors that create more severe PAD and renders individuals less likely to undergo successful revascularization and more likely to undergo amputation. Three specific aims are addressed in this dissertation resulting in three manuscripts. In Study 1, utilizing the Nationwide Inpatient Sample Database (NIS) in a retrospective study design, I determined that among patients admitted to the hospital for severe PAD, low socioeconomic status (SES) correlates positively with the likelihood of amputation, but paradoxically correlates negatively with the severity of PAD. In Study 2, I used the National Health and Nutrition Examination Survey, in a cross-sectional study design, to evaluate if there was a relationship between PAD severity, as determined by the ankle-brachial index (ABI) and the level of allostatic load. I did not identify an association. In Study 3, I employed the Nationwide Readmission Databases to show that low SES positively correlates with readmission for amputation following surgical revascularization. Findings from these three papers indicate that there is a positive correlation between low SES and the likelihood of amputation both upon initial admission as well as during subsequent follow up after surgical revascularization. I was unable to establish a clear relationship between PAD severity and allostatic load. The paradoxical finding that low SES individuals present with less severe manifestation of PAD signifies that there are yet-to-be-established factors involved in this complex disparity. This dissertation underscores the dominant role of social determinants of health and submits that in order to adequately address this amputation-revascularization disparity and avoid unnecessary amputations, major investments need to be made not only in healthcare, but also in America’s social infrastructure.Item SOCIAL AND ENVIRONMENTAL BARRIERS TO HEALTHCARE ACCESS AND UTILIZATION FOR LESBIAN, GAY, AND BISEXUAL PEOPLE IN CALIFORNIA.(2020) Akre, Ellesse-Roselee; Roby, Dylan H; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Sexual minorities, lesbian, gay and bisexual people, are exposed to chronic stigmatization and heteronormativity in their daily lives and when they access health care. There are no genetic differences between sexual minorities and their heterosexual counterparts; the literature demonstrates that chronic stress related to being a minority, experiences associated with accessing care in a system that assumes one is heterosexual, exposure to negative attitudes from others, and internalized negative attitudes regarding one’s sexuality impact health outcomes and healthcare access and utilization. While there are known barriers to healthcare access the literature does not examine how multiple social identities influence healthcare access in sexual minorities. Intersectionality posits that the interconnected nature of social identities creates an overlapping and interdependent system of disadvantage. This study had three aims: 1) To examine differences in healthcare access at the intersections of urbanicity, race/ethnicity, and sexual identity; 2) examine differences in healthcare access at the intersections of sexual identity, gender, and income; and 3) determine whether non-identifying sexual minorities have disparate access to healthcare compared to identifying sexual minorities. Using 2014-2017 California Health Interview Survey data combined with the supplemental sexual orientation special use research file, I examined the relationship between healthcare access and utilization outcomes and the intersections between sexual identity, urbanicity, gender, income, and sexual identity disclosures. Using known evidence of barriers to healthcare access as dependent variables I used predictive modeling to estimate odds ratios of experiencing barriers to healthcare access using adjusted logistic regressions. The results of my dissertation produced evidence that for sexual minorities in California, sexual identity is associated with varying levels of healthcare access when examined within the context of other social identities. That is, there are differences in access and utilization amongst sexual minorities based on income and gender, and within subgroups of sexual minorities, especially in female and bisexual subgroups. Urban and rural environment did not determine healthcare access in sexual minorities and there was not enough data to confidently estimate differences in access between urban and rural sexual minorities of color. Study findings demonstrate that the female gender has more disadvantages to healthcare access that advantages regardless of income and sexual identity. They also demonstrated that income does not fully mitigate access barriers in sexual minority women. Lastly, findings from the study demonstrate that the non-identifying sexual minority identity is associated with less access to healthcare, specifically in men. Findings from this dissertation contributes to the knowledge of how disparities in healthcare access and utilization continue to persist in the sexual minority population despite increased access to healthcare coverage. This dissertation suggests that other factors uniquely related to being female and bisexual are salient for accessing healthcare for sexual minorities. It is essential that researchers, policy makers, and healthcare providers and staff provide more data on sexual minorities, create curated policy to support the most vulnerable sexual minorities, and engage in culturally sensitive training to eliminate barriers to healthcare access for sexual minorities to eliminate healthcare access disparities.