Indiana University-Purdue University Indianapolis (IUPUI) / Technology dependent children such as those who require a feeding tube, tracheotomy or ventilator are a special group of chronically ill children who require complex care on a daily basis. When these children are hospitalized, the accompanying parent and the nurse caring for the child on the inpatient unit must communicate together about the care of the child. Care for the technology dependent child is optimized when parents and nurses both understand the plan of care for the child. To discover the process of parent-nurse communication that results in mutual understanding of the child’s plan of care, a grounded theory study to explore the perspectives of the parents of previously hospitalized technology dependent children was undertaken. The Theory of Shared Communication emerged from the data and illuminates the parent-nurse communication process. The antecedents of the process are respect for own and others expertise. The communication process consists of six communication behaviors; ask, listen, explain, advocate, verify understanding and negotiate roles. The behaviors are nested within each other and all are not necessarily required for the non-linear process to result in the relational outcome of mutual understanding of the child’s plan of care. An integrative review of the literature regarding the process of communication between parents of hospitalized chronically ill children and their nurses shed light on the components of the process, but no study was found that explicated the entire communication process. A subsequent grounded theory study added the perspectives of the nurses to the original theory. No new components of the process were uncovered, but the nurse’s narratives added significantly to our understanding of the communication process. Additionally, parents of currently hospitalized technology dependent children confirmed the propositions of the Theory of Shared Communication.

Managed care plans purport to improve the health of their members with chronic diseases. How has the growing adoption of Medicare Advantage (MA), the managed care program for Medicare beneficiaries, affected the progression of chronic disease? The literature is rich with articles focusing on managed care organizations' impacts on quality of care, access, patient satisfaction, and costs. However, few studies have analyzed these impacts with respect to market penetration of Medicare managed care. The objective of this research has been to analyze the relationships between the market penetration of MA plans and the progression of chronic diseases among Medicare beneficiaries. The Chronic Disease Severity Index scale (CDSI) was constructed to represent beneficiaries' overall chronic disease states for survey or claims-based data, when more direct clinical measures of disease progression are not available. Using the CDSI on the MEPS survey dataset from AHRQ, we sought to assess the impacts of MA market penetration and other covariates on the overall chronic disease state of Medicare beneficiaries from 2004 through 2008. Though the model explains much of the variation in CDSI change, the author expected the multilevel model would show that MA penetration explains a significant level of variation in CDSI change. However, this hypothesis was not substantiated, and the findings suggest that unmeasured factors may be contributing to additional unexplained heterogeneity. Policymakers should explore opportunities to refine the current MA program. The MA program costs the federal government more than the Traditional Fee-for-Service Medicare program, and there is no definitive evidence that outcomes differ. Within both programs, there is opportunity to experiment with different models of payment, healthcare service delivery and care coordination. The Patient Protection and Affordable Care Act (ACA) contains provisions for innovative demonstration projects in delivery and payment. The effectiveness of these ACA initiatives must be monitored, both for impacts on health outcomes and for economic effects. This research can inform future approaches to outcomes assessment using the CDSI, and multilevel modeling methodologies similar to those employed here. Firms offering MA health plans would be prudent to proactively demonstrate their value to beneficiaries and taxpayers. They should explore means of better monitoring and reporting the longitudinal outcomes of their enrolled beneficiaries. Demonstrating that they can bring value in terms of improved health outcomes will help insure their long-term survival, both in the marketplace and in the political arena. / Graduation date: 2012

Indiana University-Purdue University Indianapolis (IUPUI) / Symptoms of post-traumatic stress disorder (PTSD) are a common comorbidity in veterans seeking treatment of chronic musculoskeletal pain (CMP). However, little is known regarding the mutual influence of PTSD and CMP in this population. Using cross-sectional and longitudinal data from a randomized clinical trial evaluating a stepped care intervention for CMP in Iraq/Afghanistan veterans (ESCAPE), this dissertation examined the relationships between PTSD and CMP along with other factors including depression, anxiety, catastrophizing and health-related quality of life. The Classification and Regression Tree (CART) analysis was conducted to identify key factors associated with baseline PTSD besides CMP severity. A series of statistical analyses including logistical regression analysis, mixed model repeated measure analysis, confirmatory factor analysis and cross-lagged panel analysis via structural equation modeling were conducted to test five competing models of PTSD symptom clusters, and to examine the mutual influences of PTSD symptom clusters and CMP outcomes. Results showed baseline pain intensity and pain disability predicted PTSD at 9 months. And baseline PTSD predicted improvement of pain disability at 9 months. Moreover, direct relationships were found between PTSD and the disability component of CMP, and indirect relationships were found between PTSD, CMP and CMP components (intensity and disability) mediated by depression, anxiety and pain catastrophizing. Finally, the coexistence of PTSD and more severe pain was associated with worse SF-36 Physical Component Summary (PCS) and Mental Component Summary (MCS) scores. Together these findings provided empirical support for the mutual maintenance theory.