Health Policy & Management Theses and Dissertations
Permanent URI for this collectionhttp://hdl.handle.net/1903/7127
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Item Home Hemodialysis Utilization and Health Outcomes among Racial and Ethnic Minority Populations(2023) Zhu, Ying; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Background: Home hemodialysis (HHD) offers end-stage renal disease (ESRD) patients greater flexibility and advantages in terms of health outcomes over in-center hemodialysis. There is limited research on the differences between home and center hemodialysis (CHD) and preferences among racial/ethnic minorities, despite ESRD disproportionately affecting these groups. Methods: This project aims to explore the usage and health outcomes of HHD vs. CHD with a focus on racial/ethnic differences using a systematic review of the global main academic database from 2004 to 2022 (study 1), logistic regression and negative binomial analysis of the U.S. Renal Disease System (USRDS) cumulative core data since 2010 merged with 2016-2019 Medicare clinical claims (study 2), and qualitative research using semi-structured interviews with 18 nephrologists and 5 other hemodialysis providers in 8 states of the U.S. (study 3). Results: Study 1: from 3,114 unique studies, six studies met the inclusion criteria and all of them were comparative cohort studies; five out of six studies with a total of 3,172 White patients (68%) and 1,477 minority patients (32%) reported the utilization of HHD; in four of the six studies, the adjusted odds ratio for HHD treatment was shown to be significantly lower for patients of racial or ethnic minorities than for White patients; three out of six studies examined racial/ethnic differences in mortality and other outcomes indicating a lower risk of death for minorities in home hemodialysis. Study 2: minorities were significantly less likely to use HHD than Whites; most minority patients were younger and had fewer comorbidities than Whites, and all minority groups displayed significantly lower mortality and hospitalization incidences than the White group with adjustment on multiple covariates; in the overall and main racial/ethnic cohorts, HHD showed a significantly lower risk of death than CHD after confounding for major risk factors. Study 3: the majority of the interviewees felt that HHD was a viable, safe, and most cost-effective treatment for those with kidney failure, it offered many advantages over traditional CHD but there is a need for additional training and support for the patient, family, provider; minorities and White patients differed in their attitude toward dialysis care, social norms on HHD, and perceived control of personal health. Conclusion: There were major obstacles and considerable racial/ethnic variations in HHD utilization and health outcomes in the US. This study showed that the promotion of HHD will probably require a systematic overhaul in kidney disease management and education.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 Perceived Discrimination and Multimorbidity Among Middle-Aged and Older Adults(2020) Howard, Jianna; White, Kellee; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Multimorbidity, the presence of multiple chronic conditions, is increasingly recognized by researchers as a major health priority. Relative to younger adults, the burden is much higher among middle-aged and older adults with prevalence estimates ranging from 25-98%. Variations in the burden of multimorbidity within the aging population exist with a growing body of research showing racial/ethnic differences in the incidence, prevalence, and severity of multimorbidity. This study analyzed the association between perceived racial discrimination and multimorbidity among middle-aged and older adults and whether or not existing associations vary by race/ethnicity. Findings show that individuals reporting perceived discrimination are more likely to have multimorbidity. While racial/ethnic differences in the association between perceived discrimination and multimorbidity were not observed, Black respondents displayed the greatest risk for multimorbidity. Perceived discrimination may provide insight into why multimorbidity varies by race/ethnicity through the mechanisms of stress responses and health behaviors.Item Inpatient Mortality in Emergency Care: Is Competition Always Good?(2014) Kwok, Veronica; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The objective of this study was to measure the association between regional competition and emergency care outcomes. Competition was measured using the Herfindahl-Hirschman Index for three hospital referral regions in Maryland. Preliminary regression analysis using a logistic binary model showed that higher competition was associated with lower odds of mortality. Further investigation suggested that competition could be endogenous. Further regression analysis using an instrumental variable of hospital system affiliation and two-stage least squares estimation showed that lower competition was associated with lower odds of mortality for sepsis and trauma (OR = 0.7, p-value <0.001, OR = 0.5, p-value <0.001, respectively). Future investigation perhaps on a national level could help identify a stronger, more uniform association between competition and emergency care outcomes including large scale events, and as such provide policy guidance for quality of emergency care.