It has long been argued that the organization of the U.S. health care system is shaped by the struggles between capital and labor, and this relationship is of increasing significance today. Transformations from an industrial to a service economy, rising insurance costs, neoliberal social policies, and decreased labor union power have increased the number of Americans with reduced access to health care, especially for service workers and women. This dissertation is an ethnographic study of how workers in two leading unions in the “new” unionism movement, the Retail, Wholesale, and Distribution Service Union (RWDSU) and the United Steelworkers (USW) in urban Central Appalachia, characterize union membership and economic (and benefit) transformations that threaten security for working and middle class families. Using health care as a case study, this dissertation demonstrates the ways in which economic transformations are making health care less affordable for working and middle class families. Through a discussion of the importance of union membership that highlights job protection in the face of the expansion and increasing feminization of service work and the decline in work sponsored benefits, this dissertation details how these processes reduce access to and affordability of health care. In so doing, this research highlights individual pragmatic action and broader union activism in seeking economic and health security for their families. More broadly, new unionism tactics are described in the actions of a Central Labor Council as it seeks to renew community alliances and link rank-and-file concerns of job security to current labor issues, including the Employee Free Choice Act and Right-to-Work legislation, on local, state, and national levels. This dissertation links access to health care problems in this community to broader national issues (e.g. job protection, service work, and outsourcing) and highlights how union members, individually and collectively, are participating in “new” unionism tactics to maintain job security and secure resources, including health care, for their families.

In the U.S., the number of persons who cannot afford health care continues to rise. Providing a "safety net" for such persons is becoming increasingly important. Medical professional volunteerism provides access to health care for people who have little or no access to health care otherwise. At a not-for-profit free health clinic in Tampa, Florida, hundreds of physicians have volunteered their time in an attempt to reduce the health care gap in their community. The clinic sees thousands of persons who have very limited options in regards to their health care. This study investigates the reasons physicians volunteer and the barriers physicians face when providing free medical service. Through a survey, shadowing sessions, and focused in-depth videotaped interviews with volunteer physicians concerning the risks, rewards, experiences, and barriers of professional volunteering, a greater understanding of this important topic was obtained. This applied visual anthropological project was developed in collaboration with the free clinic in order to provide a product which would be of use to the organization at the end of the research process. This research led to an enhanced understanding of this population as well as recommendations in volunteer physician recruitment strategies.

This study evaluated the associations of individual and neighborhood level risk factors with physical health, mental health, and stress in a diverse urban county. Relatively little research has attempted to disentangle the interactive individual characteristics and neighborhood conditions underlying health outcomes and disparities. To address this, survey data were collected and analyzed from 1,107 residents living in one of the 114 census tracts in DeKalb County, GA. Using multilevel structural equation modeling techniques, this study found that neighborhood level measures of the social and built environment were not associated with the health outcomes under study after controlling for neighborhood level income and education. Alternatively, individual level perceptions of the social and built environment and measures of access to health care were significantly associated with physical health, mental health, and perceived stress. This study also found that the association between low individual income and poor physical health was more pronounced for participants who lived in low-income neighborhoods than participants who lived in high-income neighborhoods. Additionally, this study found that Black residents reported significantly better mental health compared to White residents when they lived in high-income neighborhoods, and Black participants reported significantly more stress compared to White participants when they lived in low-income neighborhoods. Results of this study further scientific understanding of the role of neighborhood processes in health disparities and potentially help inform the development of programs and policies related to neighborhood conditions and health disparities.

The purpose of this dissertation is to effectively understand, measure, and model the impact of Access to Care (AC) on Patient Safety (PS) through the creation of a model that evaluates their interdependence. Through the use of statistical tools and through the combination of variables that define patient access to health care and patient safety, a Patient Access and Safety (PACSA) index is developed. The calculated Patient Access and Safety index provides information to both providers and patients about the impact of access and safety on treatment outcomes. The input variables used to support this research are Patient Access Factors (PAF) (Age, Insurance Type, Visit Type, List Price, and Days To an Appointment) and Patient Safety Factors (PSF) (Severity of Diagnosis, Race, and Gender). In this model, 7,535 observations were used from a single organization based in South Florida, in order to develop the index. The PACSA index offers a tool that helps providers, healthcare staff and patients evaluate patient safety as it is impacted by access to healthcare through the calculated index. This index produces an equation that examines the relationship between access to care and patient safety using the following relationship: PACSA=∑_(i=0)〖(.645〖PSF〗_i- .645〖PAF〗_i )+0.399〗An extensive literature review identifies the connection between AC and PS and the relationships governing these two concepts. Although large organizations like the World Health Organization (WHO), Agency for Healthcare Research and Quality (AHRQ), and Institute of Healthcare Improvement (IHI) have studied these concepts independently, there has not been a study that used a factor or index to describe the relationship. As the healthcare delivery system becomes more complex, and consumers demand better treatment outcomes, there is a growing need to analyze these concepts jointly. This study focuses on diabetic retinopathy (DR). This is a condition experienced by chronic Diabetic patients, and it is one of the major causes of blindness (National Eye Institute, 2009). The increase in the occurrence of Diabetes worldwide has heightened the disease and inspired clinical research. In 2002, it was estimated that the disease stemming from Diabetes, namely DR, accounted for about 5% of world blindness, representing almost 5 million blind people. If left untreated or undetected, about 2% of people become blind, and about 10% develop severe visual impairment. By the year 2030, a possible 36 million people will have acute visual impairments and 7.2 million people will possibly be blind worldwide. In the United States, there are 18 million people with Diabetes, and 30% have Diabetic Retinopathy (5.3 million Americans over the age of 18) (ATA Report 2004; AHRQ, 2004; WHO, 2004). Although this study focused on DR, the model has been designed with the ability to be applied to other diseases and conditions. The goal of creating the PACSA index is to help healthcare workers understand when to schedule patients within the context of access and safety. Current appointment schedules, which are the tools used by healthcare workers, use a “New patient vs. Follow up patient” design. The PACSA challenges the current scheduling schema. No longer will patients be categorized into “New vs. Follow Up” visits. Instead, they will be evaluated for access to care requirements and patient safety needs from the initial point of entry into the health system. The recommendation is to start designing schedules based on PACSA (low PACSA, medium PACSA, and high PACSA). In this new paradigm, the low PACSA would describe patients that have low disease complexity, low number of risk factors, and can wait a little longer for their appointment without having complications of disease from lack of treatment. On the contrary, the high PACSA would include a subset of patients that have high disease complexity, high number of risk factors, and require immediate appointment and medical continuity of care to have the best treatments and outcomes. The PACSA index can serve as a visual guide for decisions regarding access and patient safety requirements. Two key components of quality within healthcare include access to care and patient safety. To create “congruent system integration” (Maier-Speredelozzi, 2007), there must exist synchronization of all healthcare delivery operations. The Patient Access and Safety Index (PACSA) provides a framework for integrating these two components. This research and the indices developed can offer benefits to health care organizations, patients, physicians, and government entities by providing a versatile tool to help improve access to health care and patient safety.

Access to bevacizumab, an important component of oncology treatment regimens, may be limited. This survey of oncologists in the US (n = 150), Europe (n = 230), and emerging markets (EM: Brazil, Mexico, and Turkey; n = 130) examined use of and barriers to accessing bevacizumab as treatment of advanced solid tumors. We also assessed the likelihood that physicians would prescribe a bevacizumab biosimilar, if available. Bevacizumab was frequently used as early-line therapy in metastatic colorectal cancer, metastatic non-squamous non-small-cell lung cancer, and metastatic ovarian cancer (all markets), and as a second-line therapy in glioblastoma multiforme (US, EM). A greater percentage of EM-based physicians cited access-related issues as a barrier to prescribing bevacizumab versus US and EU physicians. Lack of reimbursement and high out-of-pocket costs were cited as predominant barriers to prescribing and common reasons for reducing the number of planned cycles. Overall, similar to 50% of physicians reported they "definitely" or "probably" would prescribe a bevacizumab biosimilar, if available. Efficacy and safety data in specific tumor types and lower cost were factors cited that would increase likelihood to prescribe a bevacizumab biosimilar. A lower cost bevacizumab biosimilar could address the unmet needs of patients and physicians worldwide, and may have the greatest impact on patient outcomes in EM.

Research in Canada and abroad has shown that newcomers face multiple obstacles in their search for health care during their resettlement and integration to the host society. In Ontario, primary care services are organized in three main models based on the remuneration scheme to physicians: fee for service, capitation, and salaried. During the Primary Care reforms in early 2000s, the province introduced new models of primary care practices to enhance the quality of care through the expansion of comprehensive multidisciplinary care, applying more preventive measures and enhanced chronic disease management strategies. Along with these innovative reforms, the province promoted an enrollment system with a family doctor in the primary care practices. This research examined the access of immigrants to the enrollment system in Ontario. A review of the literature contrasting a PMC and PHC approaches showed that the latter has more potential to address social determinants of health of immigrant populations. Taking into account the organization of health services in the province, immigrants can receive primary care services mainly through PMC practices (FFS and capitation-based), but also through PHC-type of models, such as Community Health Centers. The analysis of enrollment in primary care was conducted using a secondary analysis of administrative data. The main findings have shown that immigrants’ enrollment in primary care services has increased over time, but the levels of enrollment remain lower compared to long-term residents. Moreover, compared to long-term residents, immigrants have less access to the most comprehensive models of care, which represents an important inequity. In exploring the perceptions of immigrants in two major cities of the province, most of the participants perceived that important factors, such as information, knowledge, language barriers, cultural issues; are affecting their capacity to understand and navigate the system. Hence, it takes a long time for them to make sense and learn how to connect and use the system.

Background: Rates of physical disability are higher in women than in men, and economically disadvantaged women are at greater risk for physical disability than women with higher incomes. Chronic diseases increase the risk of physical disability, and people with physical disability experience some added risks of secondary conditions including chronic disease. Yet, little is known about the prevalence of chronic disease among women living with a physical disability who use Medicaid, a particularly disadvantaged population. Objective: This study described the prevalence of chronic disease among adult (18-64 years), female, Florida Medicaid beneficiaries living with a physical disability between 2001 and 2005. Methods: Using Medicaid eligibility and claims files, we extracted ICD-9 codes for physically-disabling conditions and Current Procedure Terminology codes for mobility-assistive devices to define three levels of physical disability. Results: Participants appeared to be at high risk for both physical disability and chronic diseases. Close to half of the women had been diagnosed with one or more physically-disabling conditions, and 5.3% used mobility devices. One-third of the women had hypertension and sizeable proportions had other chronic diseases. Women with physical disability were more likely to have co-morbid chronic diseases than their able-bodied counterparts. Discussion: Our findings support the need for improved chronic disease prevention among female Medicaid beneficiaries, particularly those with physical disability. Strategies to improve prevention, screening and treatment in this population may mitigate the trends toward higher physical disability rates in the low-income, working-age population and may prevent high Medicare and Medicaid costs in the long-run.

Background: Rates of physical disability are higher in women than in men, and economically disadvantaged women are at greater risk for physical disability than women with higher incomes. Chronic diseases increase the risk of physical disability, and people with physical disability experience some added risks of secondary conditions including chronic disease. Yet, little is known about the prevalence of chronic disease among women living with a physical disability who use Medicaid, a particularly disadvantaged population. Objective: This study described the prevalence of chronic disease among adult (18-64 years), female, Florida Medicaid beneficiaries living with a physical disability between 2001 and 2005. Methods: Using Medicaid eligibility and claims files, we extracted ICD-9 codes for physically-disabling conditions and Current Procedure Terminology codes for mobility-assistive devices to define three levels of physical disability. Results: Participants appeared to be at high risk for both physical disability and chronic diseases. Close to half of the women had been diagnosed with one or more physically-disabling conditions, and 5.3% used mobility devices. One-third of the women had hypertension and sizeable proportions had other chronic diseases. Women with physical disability were more likely to have co-morbid chronic diseases than their able-bodied counterparts. Discussion: Our findings support the need for improved chronic disease prevention among female Medicaid beneficiaries, particularly those with physical disability. Strategies to improve prevention, screening and treatment in this population may mitigate the trends toward higher physical disability rates in the low-income, working-age population and may prevent high Medicare and Medicaid costs in the long-run.

Indiana University-Purdue University Indianapolis (IUPUI) / Advancement of preconception and interconception health is a key element to improve women’s health as well as pregnancy outcomes. Little is known about the preconception and interconception health status of rural Midwestern populations in the United States. The primary objective of this study was to determine the preconception and interconception health status as well as behaviors of reproductive age women living in a rural Midwestern area. Secondary objectives were to quantify process measures of health care access and barriers to care, as well as determine disparities in preconception and interconception health status among women in this rural area as compared to statewide estimates. As existing national or state secondary data sources often have limitations in data derived from areas with low population densities or insufficient sample sizes to generate reliable estimates, a cross-sectional study was performed using a 34- item survey. Data were collected from February to May 2019 from 315 non-pregnant women ages 18-45 years in a rural county in northwestern Ohio. Nearly all women surveyed had at least one risk factor associated with poor pregnancy outcomes, many of which were modifiable. Nearly half of all respondents reported at least one barrier to receipt of health care services. Women in this rural county fared worse for several preconception and interconception health measures when compared to statewide estimates derived from Behavioral Risk Factor Surveillance System and Ohio Pregnancy Assessment Survey data. These findings illustrate the need for continued development of interventions to improve preconception and interconception health for rural women as well as improved methods to capture and analyze data on important subpopulations at risk. / 2021-03-09

That nurse practitioners (NPs) delivery high-quality care, equivalent to that provided by physicians, is well documented. However, many states have laws that restrict NPs from full practice authority, limiting their ability to comprehensively meet patient needs. North Carolina is a state that has very restrictive laws, with NPs working under physician supervision. In this article we address the effect restricted practice has had in North Carolina and the introduction of Senate Bill 695 (the Modernize Nursing Practice Act) that, if passed, would legislate full practice authority for NPs in our state.