UMD Theses and Dissertations
Permanent URI for this collectionhttp://hdl.handle.net/1903/3
New submissions to the thesis/dissertation collections are added automatically as they are received from the Graduate School. Currently, the Graduate School deposits all theses and dissertations from a given semester after the official graduation date. This means that there may be up to a 4 month delay in the appearance of a given thesis/dissertation in DRUM.
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Item CONTRADICTIONS AND OPPORTUNITIES IN MOBILE CARE MANAGEMENT (“mCare”): AN OBSERVATIONAL ANALYTIC COHORT STUDY(2019) Crowley, Patrick Kenyon; St. Jean, Beth; Butler, Brian; Library & Information Services; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Chronic diseases such as diabetes are among the most widespread, expensive, and preventable of all health problems, accounting for approximately 86 percent of the United States’ $2.7 trillion annual health care expenditures. In the face of such staggering numbers, it is surprising that our current approach to chronic disease care management has remained largely unchanged for decades, where the care team evaluates the patient and related data infrequently and episodically. However, mobile care management (mCare) information system use is growing, whereby individuals with chronic medical conditions such as diabetes are taught to monitor and manage their disease through the use of a mobile application for tracking, education and feedback, along with monitoring of vital signs with “connected” medical devices, and the support of a remote health coach. These mCare systems offer promise, but many unanswered questions exist surrounding their effects on the health and healthcare of the users, and how user individual differences may influence these effects. Informed primarily by the mobile health systems and health behavior literatures, this study provided a deeper understanding of the effects of an mCare platform on health outcomes and health services utilization of chronic disease patients, principally those with diabetes mellitus, and the effects of a user’s social support on these outcomes. This study analyzed administrative claims, device readings, app usage, demographic and social determinant data of 163 diabetic mCare users from a 21-week observation period from mCare initiation, along with a well-matched control group of diabetic non-users, and a supplemental cohort of 127 non-diabetic mCare users with other chronic medical conditions. mCare had a significant positive effect on users’ adherence to physician’s office visits, suggesting greater continuity of care, chronic care management, and a possible reduction in inpatient use (1.2 fewer encounters over 5 months, on average). The findings show that mCare had a significant beneficial effect, on average, towards the cardiovascular health of the users as measured by the change in their diastolic blood pressure (- 2.8 mmHg, - 3.3%) and systolic blood pressure (- 6.7 mmHg, - 4.9%) in the five-month observational period, which is a primary therapeutic target for diabetes care and clinically important. Furthermore, linear mixed models of cardiovascular outcomes uncovered how those mCare users with a moderate degree of social support are likely to achieve greater benefit in from mCare on average relative to those with very high or very low social support in their lives. This additional impact equated to on average a 2.4 mmHg drop (2.9%) in diastolic blood pressure and a 3.9 mmHg (3.1%) drop in systolic blood pressure over the five-month observational period, which is clinically significant. These results provide evidence to support a more precisely tailored future healthcare paradigm beyond the current one-size-fits-all archetype. A primary goal of mCare is triaging emergency department use where appropriate; however, this study found that this did not happen in a significant manner in the treatment group compared to the control group. Furthermore, the study identified specific medical problems where improved mCare design is needed, including processes to prevent hyperglycemia, hypoglycemia and exacerbations of hypertension and pulmonary issues (such as asthma and chronic obstructive pulmonary disease), and a need to assess pain more effectively to foster more appropriate healthcare utilization. Additional training for health coaches, as well as training and development of machine intelligence algorithms to better triage patient problems to appropriate sites of care, are productive directions for future research. mCare designers should seek to better gauge the severity of pain, and develop new sensor technologies to assess emergent issues, especially abdominal pain. mCare vendors should also seek to refine their processes to better manage glucose and respiratory issues to avoid exacerbations, and predict exacerbations earlier to intervene.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 The Relationship of Low Birth Weight and Current Obesity to Diabetes in African-American Women(2007-04-26) Harris, B. Michelle; Lei, David K. Y.; Nutrition; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Aims: (1) To test the fetal origins of chronic disease by examining birth weight, current obesity, and odds of developing type 2 diabetes (T2DM) in African-American women 38-57 years. (2) To assess birth weight and obesity in relation to fasting plasma glucose (FPG). Background: African-American women suffer disproportionately in prevalence and complications of T2DM. According to the fetal origins of chronic disease, T2DM is related to low birth weight with subsequent adult obesity. Several studies have substantiated this hypothesis; none have focused on African-American women. Outcome Measure: Self-reported physician diagnosis of T2DM. Exposure Measures: Birth weight, an indicator for fetal growth; waist-to-hip ratio, a marker for abdominal obesity. Other factors: physical activity, body mass index (BMI), history of gestational diabetes, blood pressure. Design: Retrospective, case-control observational study. Method: Convenience sample of urban African-American women. Cases (n=95) reported a physician diagnosis of T2DM. Controls (n=186), matched on race and age, reported no T2DM diagnosis. To verify control status, participants were screened for elevated FPG (cut-point, <126>mg/dL, as defined by the American Diabetes Association). Vital and family records were sources for birth weight. Current weight, height, and waist and hip circumferences were measured; BMI and waist-to-hip ratio were calculated. Confounding factors were collected on a 68-item questionnaire. Logistic regression analysis tested the proposed model for the odds of having T2DM. Multiple linear regression analysis was employed to assess FPG. Sample size was estimated. Results: The odds ratio for T2DM increased as waist-to-hip ratio increased (OR=1.13, 95% CI=1.08, 1.19, p<.0001). Birth weight did not contribute independently to the model's ability to examine T2DM (OR=0.92, 95% CI=0.74, 1.14, p=.4409). Birth weight and waist-to-hip ratio each contributed independently to assessing FPG. Conclusions: This study found an interaction between birth weight and abdominal obesity when examining T2DM in African-American women: those born small and who subsequently developed abdominal obesity had a greater odds for T2DM. Abdominal obesity, but not birth weight, was independently associated with T2DM. FPG significantly increased with increasing abdominal obesity and decreasing birth weight. African-American women are cautioned to maintain healthy body measures (waist-to-hip ratio <0.80 and BMI <25) to address T2DM.Item Relationship between disinhibition and metabolic control in adolescents with type 1 diabetes(2006-12-05) Sanchez, Lisa; Lejuez, Carl; Psychology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Given that adolescence poses a high-risk period for diabetes mismanagement, and consequently, threats to long-term health status, it is important to examine factors that contribute to individual differences in the propensity to exhibit poor management and engage in health incompatible behaviors. Importantly, researchers have identified personality constructs related to disinhibition, including impulsivity, sensation seeking, and risk-taking propensity, to be prospectively linked to engagement in real-world risk behaviors such as use of alcohol, nicotine, illegal drugs, and risky sexual behavior (Lejuez et al., 2002, 2003). However, this relationship has yet to be explored in adolescents with diabetes. Thus, the purpose of the current study was to examine whether disinhibition was related to metabolic control, and the extent to which self-management behavior and drug/alcohol use mediated this potential relationship. The sample consisted of 43 subjects with Type 1 diabetes aged 13-18 years who were recruited from diabetes clinics at Children's National Medical Center. Teens were assessed with self-report and behavioral measures of risk-taking and participated in an interview regarding self-management behaviors. Substance use and diabetes knowledge were measured by self report, and the glycosylated hemoglobin (HbA1c) test was used as a proxy for metabolic control. Results of partial correlational analyses indicated that disinhibition was not directly related to behavioral adherence, engagement in health incompatible behaviors, or glycemic control after controlling for race, gender, and insulin regimen type. Rather, results of regressional analyses suggested that sample characteristics, particularly race and insulin regimen, are the key variables in assessing overall management in adolescence. Results may have important implications for the prevention and treatment of morbidity associated with diabetes.