School of Public Health
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The collections in this community comprise faculty research works, as well as graduate theses and dissertations.
Note: Prior to July 1, 2007, the School of Public Health was named the College of Health & Human Performance.
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Item UNDERSTANDING THE IMPACT OF LONG-TERM CARE NEED AMONG MEDICARE-ONLY BENEFICIARIES(2024) Albaroudi, Asmaa; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The population of adults 65 years of age and older is growing tremendously, and the majority of this population will have some level of long-term services and supports (LTSS) needs. Most older adults will qualify for Medicare insurance, which does not provide coverage for LTSS. The high costs associated with receiving LTSS, which includes supports for activities of daily living, places a financial burden on Medicare-only beneficiaries with limited resources, increasing their likelihood of becoming eligible for Medicaid coverage (i.e., dual-eligible). Given that Medicaid is the primary payer for LTSS, much of the literature on long-term care (LTC) is focused on a Medicaid eligible population. This dissertation explores the experience of Medicare-only beneficiaries with an LTSS need, who are responsible for the costs of their LTSS and may ultimately qualify for Medicaid. The Health and Retirement Study data are used to explore my dissertation objectives. My dissertation examines three areas: (1) the financial burden of Medicare-only beneficiaries with high functional impairment by assessing out-of-pocket costs; (2) spend down to dual-eligible status for Medicare-only beneficiaries with and without a LTC need; and (3) spend down by race and ethnicity with and without a LTC need.Item THE LONG TAIL OF HISTORY: COMBINING THE 1940 CENSUS, REDLINING MAPS, AND HRS: METHODS FOR ANALYZING THE IMPACT OF REDLINING ON HEALTH, ECONOMIC, AND HEALTHCARE OUTCOMES IN OLDER ADULTS TODAY(2023) Huang, Shuo Jim; Sehgal, Neil J; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)ABSTRACTTitle of Dissertation: THE LONG TAIL OF HISTORY: COMBINING THE 1940 CENSUS, REDLINING MAPS, AND HRS: METHODS FOR ANALYZING THE IMPACT OF REDLINING ON HEALTH, ECONOMIC, AND HEALTHCARE OUTCOMES IN OLDER ADULTS TODAY Shuo Huang, Doctor of Philosophy, 2023 Dissertation directed by: Neil Jay Sehgal, PhD, MPH Department of Health Policy Management BackgroundAs part of the New Deal in the 1930s, the Federal government used the Home Owners’ Loan Corporation (HOLC) to draw real estate security maps that were color coded or redlined to discourage lending in majority Black neighborhoods. Redlined areas still have worse health and economic outcomes in the present day. Current literature is focused on present-day residents of redlined areas. Tracking exposures to redlining and conditions of redlining close to the 1930s with present-day health is an unexplored area. Methods We utilize geo-referenced 1930s HOLC maps to locate individuals and map demographic considerations. We use novel algorithmic solutions to geolocate unknown 1940 enumeration districts. Using a 1940 census-linked sample of the Health and Retirement Study to locate individuals in HOLC areas at the time, we conduct survival analysis on HOLC categories’ effect on age at death as well as other analysis on health, economic, and healthcare utilization in the near present. We test for a potential mediator. Results Population density is not associated with either HOLC category or present day life expectancy, and is unlikely to be a mediator. In uncontrolled models, for HRS individuals in the 1940 census HOLC category is associated with greater hazards, worse odds of self-rated health, and worse economic outcomes. With controls, HOLC category is only associated with worse odds of self-rated health. HOLC category is not associated with health insurance or healthcare utilization in this sample. Conclusion Redlining is associated with health and economic outcomes which are attenuated when controlling for likely pathways between redlining and health. Future research should focus on whether individuals stay in redlined areas, and on identifying policy and initial state matrix that can describe what redlining may be a proxy for.Item RACIAL AND ETHNIC DISPARITIES IN ADL LIMITATIONS AMONG MEDICARE BENEFICIARIES AND THE EXPERIENCE OF TRANSPORTATION BARRIERS IN THE ADL POPULATION(2022) Saint Dic , Venchele; Boudreaux, Dr. Michel; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The study’s aims were to first determine if racial/ethnic disparities in ADL limitations for low-income Medicare beneficiaries. The logistic regression results suggested there is a variance in ADL limitation among Medicare Beneficiaries across race. Then, it tested if low-income elderly Medicare enrollees aged 65 years and older were at a higher risk of experiencing transportation barriers to care. On account of covariates, persons with ADL limitations (OR: 2.47 p<0.001) had higher odds of having transportation barriers compared to those without ADL limitations. Non-Hispanic African Americans had a higher chance of experiencing transportation delays than non-Hispanic Whites (OR 1.76 p<0.001). Finally, the effect size for transportation access barriers did not have a dose-relationship with increasing ADL limitation severity. Though the point estimates suggested that barriers were greatest for those with moderate severity (3-4 ADLs), it failed to find evidence of a statistically significant dose-response relationship between ADL severity and transportation.Item Competition and Consolidation in Medicare Advantage(2020) Chao, Sandra; DuGoff, Eva H.; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Background: Medicare Advantage (MA) serves roughly one in three (24 out of 68 million) Medicare beneficiaries and this number is expected to grow to about half (40 out of 80 million) of Medicare beneficiaries by 2030. Given this expected increase in demand for MA health plans, it is important to assess the relationship between market structure and benefit generosity to ensure that beneficiaries have equal access to high quality plans at low prices.Purpose: The purpose of this research is to assess how policy changes and market structures influence Medicare Advantage plan benefit designs. Data and Methods: This study uses publicly available MA data from the Centers for Medicare & Medicaid Services and the Area Health Resources File. Retrospective cross-sectional analyses examine contract consolidation and reconsolidation from 2012–2020, market competition and supplemental benefits in 2013, and market competition and maximum out-of-pocket limits in 2018. Key Results: Contract consolidations have declined in recent years, likely as a result of a policy that changed the calculation method of the star ratings among consolidated contracts. During the years that contract consolidations peaked, market concentration also increased. We find that the odds of a plan in a nonconcentrated market offering a transportation supplemental benefit is 2.8 times higher than a plan operating in a highly concentrated market, when holding all other predictors constant (p < 0.001). Similarly, plans in nonconcentrated service areas are 2.4 times more likely to offer a hearing benefit (p < 0.001) and 2.3 times more likely to offer a dental benefit (p < 0.001) than plans in highly concentrated markets. Regarding maximum out-of-pocket limits, we find that the odds of a plan in a highly concentrated market having a higher maximum limit is 1.6 times higher than a plan with a nonconcentrated market, when holding all other predictors constant (p = 0.049). Conclusion: MA contract consolidations have declined since 2016 but market concentration continues to increase. Market structure is important because we find that MA market concentration is associated with the offering of supplemental benefits and the level of maximum out-of-pocket limits.Item EVALUATING THE QUALITY OF HOME HEALTH CARE FOR INDIVIDUALS WITH COMPLEX MEDICAL NEEDS RECEIVING PRIVATE DUTY NURSING SERVICES IN THE MARYLAND RARE AND EXPENSIVE CASE MANAGEMENT PROGRAM(2020) Minang, Dyllis Sefeh Mbah; Simon-Rusinowitz, Lori; Chen, Jie; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)OBJECTIVE: To use process and structural measures to evaluate the quality of Private Duty Nursing (PDN) services provided to individuals with complex medical needs in the Rare and Expensive Case Management (REM) program in the state of Maryland. The results will form the basis for recommendations for legislative changes regulating Private Duty Nursing provider agencies. BACKGROUND: Individuals with defined complex medical needs diagnosed before age 21, may receive skilled nursing level of care at home under the Maryland Medicaid REM program. The REM and similar programs have been shown to be cost effective, providing cost-savings to both state Medicaid programs and private insurance companies as the beneficiaries avoid long stays in short-term and/or long-term care facilities. Unfortunately, the quality of care in the REM program is not consistent. Thus, there is a need to evaluate REM program services to understand the reasons for these inconsistencies and make recommendations for fixes to the State and PDN provider agencies. TARGET POPULATION: Individuals with complex medical needs receiving REM program services and PDN provider agencies in the state of Maryland. DATA: Results of audits of client and personnel records of PDN provider agencies performed by the Division of Nursing Services (DONS) in the Maryland Department of Health were reviewed and analyzed. ANALYTICAL METHOD: This was a mixed-methods study, utilizing both qualitative and quantitative methods for data analyses. A descriptive study method with a retrospective analysis was also employed. Frequencies, percentage scores, and means with confidence intervals were generated in Google Sheets and Stata software. Finally, qualitative content analysis was used to analyze the DONS auditors’ comments, to find themes from key words or phrases. RESULTS: The study found major deficiencies in the client and employee records. Out of 99 employees and 30 client records from about 13 PDN provider agencies, 100 % of the records had deficiencies of one kind or the other, the most prevalent being discrepancies between the physician orders and the medication administration records. CONCLUSION: Study findings indicate that improvements to the quality of nursing services to REM program participants can be implemented at provider agencies as well as the executive and legislative levels of state government.Item Addressing refugee health through evidence-based policies: A case study(Elsevier, 2018-06) Thiel de Bocanegra, Heike; Carter-Pokras, Olivia; Ingleby, J. David; Pottie, Kevin; Tchangalova, Nedelina; Allen, Sophia I.; Smith-Gagen, Julie; Hidalgo, BerthaThe cumulative total of persons forced to leave their country for fear of persecution or organized violence reached an unprecedented 24.5 million by the end of 2015. Providing equitable access to appropriate health services for these highly diverse newcomers poses challenges for receiving countries. In this case study, we illustrate the importance of translating epidemiology into policy to address the health needs of refugees by highlighting examples of what works as well as identifying important policy-relevant gaps in knowledge. First, we formed an international working group of epidemiologists and health services researchers to identify available literature on the intersection of epidemiology, policy, and refugee health. Second, we created a synopsis of findings to inform a recommendation for integration of policy and epidemiology to support refugee health in the United States and other high-income receiving countries. Third, we identified eight key areas to guide the involvement of epidemiologists in addressing refugee health concerns. The complexity and uniqueness of refugee health issues, and the need to develop sustainable management information systems, require epidemiologists to expand their repertoire of skills to identify health patterns among arriving refugees, monitor access to appropriately designed health services, address inequities, and communicate with policy makers and multidisciplinary teams.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 Preventive Services Use - Disparities and Changes Following Health Care Reform(2015) Holden, Craig David; Dagher, Rada; Health Services Administration; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)The federal Patient Protection and Affordable Care Act (ACA), signed into law on March 23, 2010, changes the landscape of U.S. health care through expanded insurance access, enhanced consumer protections, emphasis on wellness and disease prevention, and cost control. This dissertation is composed of three papers that investigate aspects of preventive services. The studies use nationally representative data from the National Survey of Family Growth and the Medical Expenditure Panel Survey and employs Andersen's Behavioral Model of Health Services Use as a theoretical model. The first study explores the relationships between use of various preventive services and being uninsured. The study employs multivariate logistic regression analyses to estimate variation in receipt of eight preventive services by race/ethnicity among adults aged 18 years and older uninsured in the previous year. The second article focuses on expanded access to health insurance in young adults and how this relates to the use of contraception and unintended pregnancy. This study used a difference-in-differences approach in order to identify a causal relationship between the policy and outcome. The third article examines colorectal cancer screening practices in the Medicare population before and after Medicare rules changes stemming from the ACA regarding reimbursement of screening procedures. Multivariate and single difference multivariate logistic regression models were estimated to examine trends and racial/ethnic differences in colorectal cancer screening over the 2007 to 2012 period. The results show how important it is to understand the determinants of preventive service access among a variety of population subgroups. With the introduction of the Affordable Care Act, health systems require strategies to determine what policy, system, and administrative methods are most effective in improving the uptake of preventive services and reducing disparities. This dissertation addressed policy influences on screenings and provided information on the impact of policies on use of preventive services as well as on reducing the disparities among subpopulations. Improved access to health insurance and better coverage of preventive services are necessary mechanisms to increase service utilization in the United States, but these may not be sufficient to actually realize improved utilization.Item A DESCRIPTIVE STUDY OF PROGRAM IMPLEMENTATION AMONG A GROUP OF HIGH ACHIEVING COALITIONS IN THE DRUG-FREE COMMUNITIES SUPPORT PROGRAM(2015) Perper, Emily; Beck, Kenneth H; Public and Community Health; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Substance abuse is a pervasive public health problem that affects all people and communities, regardless of socioeconomic status, race and ethnicity. Substance abuse can particularly devastate youth, as it correlates with many negative health outcomes including damage to the developing brain, dependence, delinquency, decreased academic potential, DUIs, and death. A potential solution to address these problems is the development and implementation of community coalitions. At the federal level, The Office of National Drug Control Policy's (ONDCP) Drug-Free Communities (DFC) Support Program does this through distributing competitive grants to eligible community coalitions that organize to prevent youth substance abuse. This descriptive study examines the degree of agreement between activities of 12 high achieving DFC coalitions to determine best practices. The analysis of the similarities and differences between the program implementation activities determined that 6 activities were universally present among high achieving coalitions, 10 activities has high agreement, and 33 activities to have low agreement among the coalitions. This paper aims to increase the knowledge about high achieving DFCs to help inform policies and practices for communities to reduce youth substance use.Item 'Right to the Active City': Public Recreation and Urban Governance in Baltimore(2014) Bustad, Jacob; Andrews, David; Kinesiology; Digital Repository at the University of Maryland; University of Maryland (College Park, Md.)Since the inception of the Baltimore City Department of Recreation and Parks (BCRP) in 1940, public recreation in Baltimore has continued to be restructured in relation to changing modes of urban governance, in particular in regards to the city's network of recreation centers. More recently, the reorganization of recreation resulted in the 2011 Mayor's Recreation Center Task Force plan, which proposed the further reformation of the department and changes to the provision and distribution of recreation centers and recreational services. This dissertation - entitled Right to the Active City: Public Recreation and Urban Governance in Baltimore - draws from a diverse and reflexive theoretical and methodological approach in exploring the historical and contemporary forms, practices and experiences of public recreation in Baltimore, specifically focusing on the city's recreation centers as social and spatial manifestations of the processes of urban governance. In seeking to engage and analyze the individuals, institutions, spaces and practices of urban public recreation, the primary goals of this research are: 1) to examine the intersection of historical and current formations of recreation policy and broader processes of urban governance, including the implications of these changing arrangements for the localized experiences of public recreation; 2) to analyze the spaces of public recreation, in particular the changing forms and practices of planning and design that is embedded within a shift between different `recreation center' models; 3) to draw out and describe the often complex and contradictory inter-relationships between the City government, BCRP, community and non-profit groups and city residents, focusing on the associations that actively construct and constitute an emergent form of public recreation; and 4) to provide a nuanced research approach that both contributes to relevant scholarly fields, including public health, kinesiology, sociology, urban studies and physical cultural studies, and simultaneously seeks to promote the co-production of research that can be engaged by and with those involved in the processes of public recreation. In short, this research attempts to better grasp the lived experiences of the active urban body and urban physical cultures, through an analysis of the planning and provision of recreational sites, services and opportunities in a specific postindustrial metropolis.