Theses and Dissertations from UMD
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Item DISPARITIES IN ADOLESCENT MENTAL HEALTH SERVICES UTILIZATION AND HELP-SEEKING(2024) Truong, Michelle L; Sehgal, Neil J; Boudreaux, Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Inequities in access to and utilization of mental and behavioral health care for adolescents have persisted for numerous decades. Adolescents from racial and ethnic minority backgrounds, as well as those in underserved geographic regions, are disproportionately impacted. As the youth mental health crisis escalates, it is critical to study the mechanisms driving these disparities to inform effective and targeted interventions and policies. Divided into three studies, this dissertation explored the influence of individual, cultural, and contextual factors on adolescent help-seeking behaviors using data from the 2009 and 2011 to 2019 California Health Interview Survey (CHIS).The first study employed mediation analyses to assess the extent to which having a subjective or perceived need for mental health care, conditional on objective need, contributes to racial and ethnic disparities in mental health services utilization. I found significant racial and ethnic differences in subjective needs for mental health services and that these differences partially explain the racial and ethnic disparities in service utilization. The second study explored differences in mental health service utilization among subgroups of non-Hispanic (NH) Asian and Latino/Hispanic adolescents compared to NH white adolescents. I found that Vietnamese and Mexican adolescents were significantly less likely to utilize mental health services relative to their NH white counterparts. The third study merged the adolescent data with provider data from the National Plan and Provider Enumeration System (NPPES), facility data from the National Substance Use and Mental Health Services Survey (N-SUMHSS), and population data from the US Decennial Census Redistricting Data Summary Files to assess the moderating effects of distance to the nearest pediatric mental health facility and provider-to-population densities on the relationship between subjective mental health care needs and service utilization. I discovered that provider density and subjective needs interact, resulting in a diminished effect of subjective needs on service utilization among adolescents residing in areas with lower primary care provider density. I did not find that distance to the nearest pediatric mental health facility had a significant impact on service utilization. This dissertation examined racial, ethnic, and geographic mental health care disparities among a diverse adolescent population in California. Findings from this work contribute to the understanding of adolescent help-seeking behaviors and provide insights for targeted interventions and policies to advance mental health care equity.Item COLLABORATIVE CO-DESIGN OF PORTABLE WORK BENEFITS POLICY MODEL AND NON-POLICY PROTOTYPE BASED ON DIRECT CARE WORKERS' NEEDS, ATTITUDES, AND BELIEFS(2024) Kuo, Charlene C.; Aparicio, Elizabeth M.; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Direct care workers (DCWs) assist people with disabilities and frail elders with activities of daily living, thereby preventing institutionalization, hospitalization, and other costly medical services. From 2016 to 2060, the number of adults aged 65 and over is expected to increase from 49.2 million to 94.7 million. The number of adults 18 to 64 will remain the same, leading to a shortage of family caregivers. A shortage of family caregivers will require a robust direct care workforce. The direct care workforce is expected to grow by 1.3 million from 2019 to 2029 but this growth will not keep pace with the projected demand. The turnover rate among DCWs is high due to poor work conditions and inadequate compensation. Exploring ways to improve DCW working conditions and compensation is critical to prevent further shortages. DCWs' health is put at risk due to the nature of the work, low wages, and lack of worker protections and traditional work benefits. DCWs are vulnerable to injury, abuse, infectious diseases, and other poor health outcomes due to the previously listed disadvantages (Campbell, 2019c; Hughes, 2020; Jaffe, 2017; M. M. Quinn et al., 2016). DCWs in the United States are predominantly women, members of racial and ethnic minority groups, and one in four workers are immigrants.Work benefits improve health outcomes and protect clients of DCWs from healthcare-associated infections by allowing DCWs to take paid sick leave when ill. Portable benefits are benefits employees can take from job to job, prorated so that multiple employers can contribute, and accessible to all workers. Portable benefits are not widely available. I held 1)individual in-depth interviews and focus groups to explore the needs, attitudes, and beliefs of DCWs regarding work benefits, 2) two co-design sessions and a member checking session with DCWs to develop and refine policy recommendations for Maryland DCWs' portable work benefits, and 3) a co-design session and member checking sessions to develop usability recommendations for websites delivering portable benefits to DCWs. This study provides findings about direct care workers' experiences with inadequate or nonexistent work benefits, their recommendations for policy to support benefits that meet their needs and preferences, and their usability recommendations for portable benefits websites. This study provides information on how to design work benefits for DCWs that protect them, protect those around them, and improve work conditions in hopes of improving work conditions and compensation.Item CHARACTERISTICS AND HEALTH INSURANCE COVERAGE AMONG ADOPTED CHILDREN IN THE UNITED STATES(2024) Fleishman, Jamie Lin; Yue, Dahai; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The practice of adopting a child is a common occurrence within the United States. Research on adoption, birth parents, and adoptive parents has traditionally focused on psychology and social work outcomes. This master’s thesis shifts the focus of adoption outcomes to a public health perspective, examining the demographics, socioeconomic conditions, and health insurance rates of domestic and international adoptees. To help determine the rates of any health insurance, public health insurance, and private health insurance, this thesis examined American Community Survey 2022 5-year data, a nationally representative study of adoptees and their counterparts—non-adoptees who are biologically related to their parents or head of household. It was determined that domestic adoptees and non-adoptees had similar demographic and socioeconomic statuses whereas international adoptees were predominantly non-Hispanic Asians, females, and have wealthier and White heads of households. After controlling for demographic and socioeconomic variables, it was discovered that international adoptees have higher uninsured rates compared to non-adoptees and domestic adoptees, which could be attributed to geographic differences in health insurance coverage. Further research is needed to examine health insurance coverage rates in the United States for adoptees.Item LEADERSHIP AS A CATALYST FOR HEALTH EQUITY: AN EXPLORATORY STUDY OF STRATEGIES AND INSIGHTS FOR QUALITY IMPROVEMENT IN HEALTHCARE ORGANIZATIONS(2024) Howard, Christopher Norman; Thomas, Stephen B; White-Whilby, Kellee W; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Health equity is a growing field of study and evidence-based practice among healthcare providers. Two essential influencers of this dynamic paradigm are equity-centered leadership and quality improvement strategies. The acclaimed Malcolm Baldrige Framework was selected as the impetus for exploring the conceptual relationship between health equity competence and leader driven quality improvement. Investigating the importance of integrating critical elements of theseinfluencers to achieve equitable outcomes in patient care, workforce diversity, and organizational culture is the focus of this research. A comprehensive review of the literature, supported by a thorough scoping review of eighteen established framework methodologies, developed for health equity aims and primary qualitative data gathered through survey and semi-structured interviews provided useful concepts to guide the process of examining the health equity knowledge base of senior healthcare leaders affiliated with acute care hospitals located in the Washington, D.C. area, and their perceptions of how equity, as a value, is actualized within their healthcare organizations. Study results revealed the lack of systemic integration in the practices of organizational leadership, quality improvement implementations and health equity measures. Also, the study results showed a need for increasing investments in health equity education and training at all levels and classifications of the healthcare professional workforce.Item MDPCP Primary Care Practice Capabilities and Care Management Delivery among Maryland Medicare Beneficiaries(2024) Ector, Kaitlynn Robinson; Sehgal, Neil J.; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Care management is one of the core components of comprehensive primary care, which represents the future direction of primary care in the United States. Nearly twenty percent of Medicare beneficiaries experience 30-day readmissions. While primary care is uniquely positioned to provide care management services associated with reducing readmissions, only 50 percent of older adults who have experienced 30-day hospital readmissions receive outpatient care. The goal of this dissertation was to identify structural and process components associated with the delivery of care management services to Maryland fee-for-service (FFS) Medicare beneficiaries, to examine geographic variation in the delivery of care management services, and to examine the association between the provision of care management services and patient health outcomes. This dissertation explores the relationship between structural and process components of care delivery and the delivery of care management services with three aims: (1) examine the association between primary care practice structural and process capabilities and the delivery of care management to Medicare beneficiaries and whether this association is altered by primary care practice medically underserved area (MUA) designation, (2) examine the association between Health Equity Advancement Resource and Transformation (HEART) payments and care management comprehensiveness and whether this association is altered by primary care practice care management delivery option, and (3) identify unique trajectories of comprehensive care management performance and examine the association between care management trajectories and readmission rates. Several key findings and implications are identified through the exploration of these aims. Increased primary care practice-level capabilities were associated with increased care management comprehensiveness. There was geographic variation in the provision of care management services among Maryland FFS Medicare beneficiaries. Next, prospective HEART payments were associated with increased care management comprehensiveness, and this association varied according to MUA designation and care management delivery options. Additionally, intensive partnerships between care transformation organizations (CTOs) and primary care practices improved access to comprehensive care management services. Finally, four unique classes of comprehensive care management performance were identified, and these care management performance classes had distinct patient characteristics and geographic locations. Among the low care management performance class, increased comprehensiveness among care management services was associated with decreased unplanned readmissions over time. This dissertation provides evidence that geographic variation in the provision of care management exists and includes guidance on how to assess geographic variation in care management services across the United States. These results also provide valuable evidence about how prospective equity-based payments can transform care delivery in primary care settings. Lastly, this dissertation presents a novel method of program performance evaluation that can be applied to all evaluations of Medicare demonstrations.Item The Role of Personal Integrity in Shaping Healthcare Worker Perceptions of Patient Safety Culture in US Hospitals During the Covid-19 Pandemic(2024) Edelstein, Lauren Michelle; Franzini, Luisa; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Abstract Overview: The COVID-19 pandemic strained hospitals in unprecedented ways that required healthcare workers to adapt to and endure challenges, testing their ability to do a good job with the human and technological resources available to them. Using a proxy variable for personal self-integrity (PSI), derived from questions on the Agency for Healthcare Research and Quality (AHRQ) Hospital Survey on Patient Safety Culture (HSOPS), this dissertation explores the way workers’ capacity to maintain alignment of their actions and morals shifted during the pandemic. Conceptual Framework: The investigations within this study can be understood through the Healthcare Workforce Integrity Model, an innovation based on the Job Demands and Resources Model that accounts for the deeply moral nature of healthcare work. The model holds that intensity of job demands and the strength of supportive job resources shape workers’ abilities to maintain PSI in their work. Over a sustained period, this impacts worker energy and motivation, and ultimately, organizational resilience. Methods: The study uses descriptive statistics and regression modeling based on data from the AHRQ’s HSOPS and data from the Hospital Cost and Utilization Project (HCUP), from timeframes before and during the COVID-19 pandemic, to analyze shifting perceptions about patient safety culture within the hospital workforce. Results: Workers’ capacity to maintain their PSI worsened steadily over the pandemic. When patient mortality was higher, workers’ PSI worsened, with particularly acute effects experienced in ICU settings. When hospital workers perceived teamwork and leadership support negatively, and when they perceived that staff were blamed for patient safety problems, their perceptions of their own personal integrity diminished by statistically significant margins. No significant associations indicate that hospital workers’ perceptions of teamwork, leadership support, or being blamed for safetyproblems were more closely tied with their ability to maintain positive PSI during the pandemic than they were before the pandemic. Conclusions: Organizational solutions are needed to support healthcare workers’ ability to thrive and maintain integrity in non-crisis moments just as much as they are needed during moments of crisis and uncertainty. Achieving this goal can better ensure that healthcare workers feel they can depend on their institutions and its people to do the right thing.Item Exploring remote service provision in adult day centers during the COVID-19 pandemic(2023) Marte, Crystal; Lazar, Amanda; Vanderheiden, Gregg; Library & Information Services; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The COVID-19 pandemic profoundly impacted the long-term services and supports (LTSS) sector, necessitating a rapid shift from in-person services to remote. Adult day service centers (ADSCs) – a type of LTSS – offer in-person community-based programs comprised of health and wellness services to historically underserved populations, such as communities of color, low-income, and older adults. Based on data collected from 23 semi-structured interviews with 22 providers from eight ADSCs across a Mid-Atlantic state, this thesis explores the experiences of ADSC providers – such as directors, activity staff, and nurses – as they navigated pandemic-related closures. To ensure uninterrupted services, centers leveraged their existing infrastructure and adapted to a remote service model. An intricate interplay of technical (e.g., access to devices, internet) to non-technical (e.g., digital literacy, sociocultural context, limited staff) variables affected the overall success of remote services. Simultaneously, ADSCs grappled with limited reimbursement for remote services – which directly impacted their operations and the sustainability of remote services. These findings offer insights into the challenges and adaptations providers experienced amidst an unprecedented crisis, shedding light on the systemic issues throughout this period. The study seeks to inform future interventions that promote the sustainability of remote services in ADSCs, with a specific focus on preventing service disruptions for historically underserved populations.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 PHYSICIAN PEER NETWORKS AND PATTERNS OF OPIOID-RELATED BEHAVIOR(2023) Pope, Elle; Sehgal, Neil J; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Physicians are known to learn prescribing behavior from peers, although the extent and magnitude of peer influence on opioid prescribing is not well understood. Identifying the role peer networks play on influencing opioid prescribing, or opioid-related behavior, could elicit new understandings on how information in healthcare is spread and, in turn, lead to policy solutions and interventions to modify physician behavior in the direction of evidence-based medicine. The goal of this dissertation was to evaluate physicians prescribing opioids to patients in Medicare, or physicians receiving opioid industry payments, in order to determine if network-level characteristics are associated with patterns in opioid prescribing. This dissertation has three aims: (1) to determine whether patterns in opioid prescribing exist across physician networks and association with specialties, (2) to empirically demonstrate influence industry can have on clinical decision-making via targeted marketing within provider networks, and (3) to attempt to parse whether certain physicians with greater peer influence result in similar opioid prescribing among network peers. There are several findings and important implications related to this work. First, I find that primary care physicians who have more peer connections and more peers within a pain management specialty or surgery are more likely to have a higher median opioid prescribing rate across patient-sharing, hospital, and shared group clinic networks. Second, I find physicians who have any opioid payments are associated with three times the likelihood of at least one peer also having an opioid payment compared to physicians who did not have a similar payment. These physicians are more likely to belong to smaller and more interconnected patient-sharing networks. Finally, I perform a novel identification analysis of potential peer influencers to find certain provider-level characteristics that may shape peer prescribing behavior. The implications of this dissertation reveal that peer influence may serve as a potential mechanism for altering prescribing behavior and may be a lower-cost and efficacious way to increase adherence to evidence-based medicine.Item ASSESSING HEALTH CARE USE, COSTS, AND QUALITY FOR CENTERS OF EXCELLENCE FOR PEDIATRIC CONGENITAL HEART DISEASE CARE FOR THE MILITARY BENEFICIARY POPULATION(2022) El-Amin, Amber Jovan; Franzini, Luisa; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Background: For the military beneficiary population with cardiac or congenital anomalies, the Fiscal Year 2019 health care costs were $83 million, including $55 million for newborns who were less than one year of age and $28 million for youth ages 1 to 17 (Kennell and Associates Inc., 2020). The 2019 Military Health System (MHS) costs were approximately $50 billion (Mendez, 2019) and are expected to increase significantly through 2028 (Congressional Budget Office, 2014). In an attempt to close the gap between cost and benefit for its 9.6 million beneficiaries, the MHS has considered targeted inclusion of Centers of Excellence (CoE) for purchased care within TRICARE insurance coverage and MHS policies. In general, a CoE produces consistent outstanding measurable outcomes for a specific medical condition. A Congenital Heart Defect (CHD) is the presence of abnormalities in the heart structure that develop in the uterus during pregnancy. CHDs are the most common types of birth defects and the principal cause of illness and death for birth defect conditions. CHDs are associated with comorbidities and repeat surgical interventions resulting in significant use of health care services during infancy, childhood, and adulthood, making CHDs a great candidate for CoE use.Objective: To compare health care use, costs, and quality of care for pediatric CHD care at CoEs and non-CoEs for the military beneficiary population. Data Sources: Retrospective claims data from the MHS Data Repository for MHS beneficiaries aged 0 to 17 years who received CHD care from 2016 to 2020. Study Design: Using an instrumental variable approach to estimate the impact of CoE use on clinical outcomes (annual admissions, annual emergency room use, and mortality) and health care costs (total costs and hospitalization costs) for pediatric CHD care within the military beneficiary population. Results: A total of 10,865 patients were included, of which 82.9% used a CoE at some point for CHD care. Results suggested that racial disparities in CoE use were not significant for CHD care for the military beneficiary population. There were disparities noted in CoE use by military rank, suggesting that Senior Enlisted and Other ranks were associated with lower odds of CoE use than Junior Enlisted ranks. Results of the IV approach proved that the causal effect of CoE use was a lower probability (-14.1) of emergency room use post one-year CHD diagnosis for the military beneficiary population (p<0.01). The causal effect of CoE use on annual admissions and mortality was insignificant at the .05 significance level but proved that CoE use did not increase annual admissions nor jeopardize patients’ survival post one-year CHD diagnosis for the military beneficiary population. The causal effect of CoE use on CHD related annual costs was a $40,898 decrease in annual costs (p=.059). Although the relationship was not significant at the .05 level, the magnitude of the reduction was approximately 53% of the mean annual cost. When stratified by complexity of CHD diagnosis, the causal effect of CoE use on CHD related annual costs was a statistically significant reduction of $84,852 in annual costs post one-year CHD diagnosis for patients diagnosed with a moderate-complex or single ventricle CHD diagnosis, equating to an approximate 76% reduction in mean annual costs. The causal effect of CoE use on CHD related hospitalization costs was a $33,170 decrease in hospitalization costs (p=.087). Although the relationship was not significant at the .05 level, the magnitude of the reduction was approximately 47% of the mean hospitalization costs. When stratified by CHD diagnosis complexity, the causal effect of CoE use on CHD related hospitalization costs was a statistically significant reduction of $73,084 in hospitalization costs post one-year CHD diagnosis for patients diagnosed with a moderate-complex or single ventricle CHD, equating to an approximate 76% reduction in the mean admission costs. Conclusions: Patients with more severe CHD diagnoses were more likely to use CoEs. After adjusting for selection bias due to disease severity, CoE use improved clinical outcomes, reduced health care resource utilization, and reduced costs for CHD care for the military beneficiary population.