published_or_final_version / Community Medicine / Master / Master of Research in Medicine

This dissertation considers some challenges to delivering effective and equitable health care to disadvantaged children and families in the United States. Chapter one examines whether expanded access to health insurance following the enactment of the Children’s Health Insurance Program (CHIP) in 1997 reduced the prevalence of economic hardships (food insecurity, problems affording housing) and postponed medical care. In difference-in-differences analysis, I find that relative to a comparison group of families that missed the eligibility cutoffs, families that gained eligibility under CHIP did not experience changes in food or housing problems, but were significantly less likely to postpone medical care. These findings suggest that while public insurance for families with children likely improves access to care, it does not significantly reduce other forms of hardship. Chapter two provides an ethical argument for subsidizing health insurance for low income families – a central component of the 2010 Affordable Care Act (ACA). I argue subsidies are a vehicle for promoting equality of opportunity: specifically, subsidies ensure access to specific “basic opportunities” (such as the ability to attend college) when out-of-pocket spending on insurance would have otherwise crowded out those opportunities. Subsidies thus make a modest, but important, contribution to mitigating the negative effect of health spending on social mobility and financial security, even if they fall short of comprehensive income protection. I raise and respond to some potential concerns about inequities created by this system, and conclude with implications for evaluating the subsidies under the ACA. Chapter three investigates whether diffusion of long-acting stimulants, a medication for Attention-Deficit/Hyperactivity Disorder (ADHD), narrowed racial/ethnic disparities among diagnosed children in the Florida Medicaid program. In longitudinal analysis, we found that minorities were substantially less likely than whites to use medications overall, but minority medication users were equally likely to switch to long-acting medications after market introduction. The increase in prescribed days was comparable for white and black medication users, but lower for Hispanics. Geography and provider setting helped explain overall medication utilization disparities, but adherence disparities were not explained by any of the covariates. We recommend targeting interventions to increase medication adherence to high-volume, minorityserving providers.

The existence of unfair differences or disparities in access to and quality of health care is well known. However, the nature of disparities at different stages of the health seeking pathway and interventions to reduce them are less clear. Applying the tools of statistics and quasi experimental design-- interrupted time series, propensity score matching, hierarchical models---we can analyze how care is accessed in low, middle and high income countries and assess for disparities. The results are sometimes surprising and underscore the need to generate context specific evidence to ensure targeting of programs. My first paper evaluates the impact of a controversial policy, mandating of health insurance, on reducing disparities in health care access and affordability. Using longitudinal survey data from five states in USA (2002-2009), I show that living in MA, where health insurance is mandated, results in a higher probability of being insured and having a personal doctor and lower probability in forgoing care due to costs as compared to similar border states. The beneficial effect of the mandate is greatest in traditionally "disadvantaged" groups defined by race, income, education or employment status. My second paper examines gender disparities in access to medicines in sub Saharan Africa--Uganda, Kenya, Nigeria, Ghana, Gambia. Using medicines specific survey data, I construct a novel seven stage access to medicines pathway and assess gender disparities along it applying the Institute of Medicine framework. Contrary to prevailing belief, I find few gender differences in unadjusted outcomes which cease to be significant on controlling for health status and country characteristics. My third paper assesses disparities by educational attainment in process and outcomes of care. I use unique data extracted from an electronic medical record of diabetic patients in Mexico City. Using a matching algorithm, I control for only differences in health need and find few significant differences in processes and outcomes of care. The unmatched traditional regression based risk adjustments tend to overestimate the significance and magnitude of the association. The three papers demonstrate the need to use more sophisticated statistical tools to appropriately measure disparities and ensure the effectiveness of health programs.

Introduction: New treatments for stage IV (adv) NSCLC have emerged this past decade. Recent pharmacoeconomic research has focused on cost of treatment, comparative costs of therapies, and cost/cost effectiveness of adding a biologic to traditional therapy. Drug cost is thought to be a primary driver of cost change in NSCLC, yet to our knowledge, characterization of the direct cost of NSCLC has not been published since the new treatments have emerged in the guidelines. Our primary objective was to characterize the direct and segmented cost of adv NSCLC from 2000-9. We also want to determine cost impact of new therapies, and cost trend from 2000-9. Methods: This PharMetrics claims database study includes diagnosed NSCLC patients [greater than or equal to] 20 yo. Small cell lung cancer was excluded. Claims were divided into disease segments and time periods representative of changes in therapy ("pre" (2000-2), "transition" (2003-5), and "current" (2006-9) periods). Descriptive statistics (median, interquartile range (IQR)), chi-square test (nominal data), and Wilcoxan rank sum tests were performed on the data. To adjust for baseline confounders, multivariate least squares regression models were created. Results: Costs are reported as medians in terms of per patient per month (pppm). Overall monthly cost (n=969) was $10,281 pppm. Diagnosis cost $6,601 pppm, active treatment cost $9,287 pppm, and end-of life cost $12,215 pppm. There was no difference in cost between the “transition” (n=439) and “current” (n=503) periods overall or for any segment of disease. Comorbidities had no effect on cost. For patients receiving at least 5 months of active treatment medication (n=316) total median cost was $144,147 per patient ($9,371 pppm). Discussion: There was no difference in cost between the transition and current periods, in regards to either overall cost or segmented cost. The most expensive segment was end-of-life, with a median cost exceeding $12,000 pppm. Surprisingly, comorbidities had no effect on cost. Newer agents (biologics, TKIs, and pemetrexed) represent only a modest portion of cost, with a majority of cost for stage IV NSCLC comprised of non-drug costs. / text

Survivors of childhood cancer are a relatively new phenomenon in the medical world. The introduction of treatment protocols in the 1970s started a trend in curing children of cancer that historically had been a death sentence. Under these treatment protocols children were given different treatment regimens based on past research that helped remove cancerous cells from their bodies, but were later found to be the cause of treatment related morbidities years into the future; for most survivors roughly ten to 20 years post treatment. These morbidities, commonly called late-effects, are the prime reason that survivors of childhood cancer need to participate in survivorship care. Survivors of childhood cancer are particularly vulnerable to late-effects because the majority of them receive their treatment at a time when their bodies are still growing and developing. Survivorship care services vary by site, but all maintain the common goals of providing long-term follow up for the survivor and education about the ways in which treatments may affect a survivors’ health as they age. Similar to many other facets of healthcare and medicine, there are many populations who do not participate in survivorship care. The purpose of this research is to identify possible barriers to care, assess the level of impact these barriers have upon the survivor’s potential for participation and provide suggestions as to how these barriers can be mitigated. Additionally, this research highlights areas that need further research and analysis.

The Department of Health (DOH) has embarked on a noble initiative to address the disproportionate distribution of resources and spending within the public and private healthcare sectors. Social Health Insurance (SHI) has thus been mooted as the vehicle to obtain a more equitable healthcare dispensation. This thesis explores the state of preparedness of the DOH, for the implementation of SHI. Ten aspects of health have been identified which will assist in determining if sufficient reforms have been implemented to facilitate the successful implementation of SHI. The prospective mechanism of financing of SHI is compared to the highly acclaimed model employed by the Australian Department of Health. Two research methodologies have been utilized viz. the case study approach and semi structured interviews, to provide comprehensive data. This enabled the researcher to adequately answer the research question. The responses from the respondents on the 10 aspects of healthcare have been arranged into themes to facilitate a greater understanding of the issues being highlighted. Established strategic management instruments have been utilized to analyze the data obtained and evaluate the preparedness of the DOH for the implementation of SHI. Following the data analysis, recommendations are proposed that would facilitate the successful implementation of SHI, thereby promoting its viability and sustainability in providing quality healthcare to all who call South Africa home. / Thesis (MBA)--University of KwaZulu-Natal, 2006.

This dissertation focuses on the relationship between the education-based fertility gap and economic growth and on policy as a determinant of fertility. In the first essay I evaluate the impact of differential fertility (the difference between fertility rates of women with high educational attainment and women with low educational attainment) on economic growth by accounting for critical marginal effects and the general level of educational attainment in a given country. I also examine the possibility that this effect varies based on level of inequality and income levels. I find that for a less developed country with high income inequality, higher fertility rates of women with lower education has a favorable impact on economic development. In the second essay I examine the transmission and magnitude of the effect of differential fertility on economic growth at the subnational level. I explore the relationship between differential fertility and economic growth in a cross-U.S. state context. I find that a larger gap in fertility rates between highly-educated and less-educated women is strongly associated with a decrease in the rate of long-run economic growth across U.S. states, even after accounting for the levels of inequality and overall fertility. In the third essay I explore policy as a determinant of the education-based fertility gap. I use the 2007 Massachusetts healthcare reform which provides a good setting for evaluating the effect of an exogenous policy on the fertility. I find that fertility increases among young married women and decreases among young unmarried women but that there is no asymmetrical fertility response based on the education level of the mother.

A large body of research, typically nationally focused, has examined the relationship between family structure, educational attainment, and healthcare access. Within this field of study, there is limited availability of regionally based studies, specifically the Lower Mississippi Delta (LMD) region. This exploratory study examines the effects of family structure on high school graduation rates and health insurance coverage within the LMD region. The objective is to determine if family structure has a direct impact on the educational attainment and health outcomes of a child within the region using concepts from nationally focused literature. Through the use of an OLS regression, we find that family structure does not have a strong impact on the educational attainment of children within the region. However, we did find that family structure had a strong impact on the health insurance coverage of youth within the region. Additionally, we examine the impact that spatial location and race has on these variables. These results can encourage the development of potential intervention programs, outreach initiatives, and other programs geared toward helping youth within the region. The study's conclusions provide insight on the impact of family structure on health and education thus encouraging further research within the LDM region.

The purpose of this study was to examine three state-sponsored health insurance programs targeted at small businesses and identify the political and economic factors that contributed to their success. I evaluated the success of each states program using three criteria: reducing the number of uninsured, program participation, and providing portability. In my analysis, I examined factors which may have played a role in the varying levels of success that were observed. I found that the success of a program depended largely on two factors: economic conditions within the state and the quality of the program. / Department of Political Science

Health and safety is of the utmost importance for any company or institution to be successful. There is quite a negative perception regarding the health and safety of rural hospitals and clinics. Rural hospitals are most of the time overcrowded due the large amount of patients that has no medical aid, thus increases the risk for health and safety issues. Patients sit in long queues for hours to receive medical attention and their medication and are therefore exposed to all kinds of diseases, which is a high risk for these patients’s health. The employees working in these rural areas are also exposed to life-threatening diseases on a daily basis and have a good chance of being infected. Employees leave the public sector because of these unsafe working conditions and find themselves either working in the private sector or may even immigrate to foreign countries for better and safer working conditions. During this research done, there were a few shortcomings identified for the management to improvement on and to ensure a safe working environment. There are quite a lot of negativities surrounding the patients and employees in these rural hospitals, because patients get raped by nurses, babies get stolen from maternity wards, doctors are attacked by patients and much more horrific incidents happening in these hospitals. Cultural differences are also a main concern for management, because there are a lot of different races working together in the same department and not everyone has the same beliefs and ways in doing tasks. These cultural differences may lead to clashes amongst employees and result in a negative working environment. This quantitative research was done in selected rural hospitals, due to cost and time consumption. Only 80 employees (doctors, nurses and pharmacists) participated in the research done and the research was not an in-depth research, but enough evidence was compiled to make the necessary assumptions that all is not well in the public sector. With the new National Health Insurance (NHI) to be implemented from 2012, there may a lot of changes in the rural hospitals for the better. Hospitals all over the country are being upgraded and the working conditions are being attended to by the government which may attract more health professional to rural hospitals and clinics. / Thesis (MBA)--North-West University, Potchefstroom Campus, 2012