Thesis (M. Phil.)--University of Hong Kong, 2005. / Title proper from title frame. Also available in printed format.

<p> Adequate access to primary care is an integral part of any health care system. One indicator for access outcomes is potentially preventable hospitalizations (PPH), i.e., a hospitalization that occurs when a patient is hospitalized for an ambulatory care sensitive condition (ACSC). PPHs are of interest because the additional costs of caring for a patient in a hospital with an ACSC, as opposed to in a primary care setting, are substantial, for patients, payers, and hospitals. Identifying the factors associated with PPH will aid in policymaking, improve access to care, and reduce the burden on the health care system. To address the gaps in the literature, I analyze how community-level access to care resources and state policies are associated with PPH using nationally representative data, while controlling for individual patient characteristics and community-level demographics. Multiple publicly available and restricted use data sources are linked to create a comprehensive data set that is used to investigate the relationship between PPH rates and community access to care factors. The dissertation addresses the following three objectives: (1) To determine the association between state Medicaid policies and the odds of a potentially preventable hospitalization; (2) To assess how primary care capacity and the odds of a potentially preventable hospitalization varies across the urbanization spectrum; and (3) To assess how primary care capacity and the odds of PPH varies for chronic and acute ACSCs. The findings are summarized below: - An analysis of state Medicaid policies does not find any significant associations between the odds of PPH and Medicaid generosity index and managed care penetration. - Primary care physician supply and the presence of a federally qualified health center are associated with a lower odds of PPH across the urbanization spectrum. - Physician supply, primary care and specialist, is associated with a lower odds of PPH for chronic ACSCs, while nurse practitioner and physician assistant supply is associated with a lower odds of PPH for acute ACSCs. The presence of a federally qualified health center is associated with lower odds of PPH for both chronic and acute ACSCs.</p>

<p> Over 59 million US residents live in rural areas where they cannot easily access healthcare services. Well-documented disparities between rural and urban healthcare access led the federal government to certify and financially support Critical Access Hospitals (CAHs), which offer rural healthcare services and 24/7 emergency care. Many CAHs are in dire financial distress, and some are looking to increase their patient population volume to improve financial health and ensure continued operations. It is a well-known business truism that satisfied customers are return customers. Today many patients' first encounter with a hospital is with the emergency department (ED). Thus, it is likely that increasing patient satisfaction with their ED visits in a CAH can be expected to increase the chance that they will return for additional care. </p><p> All hospitals engage in quality improvement (QI) activities. Many papers outline efforts by QI teams to implement one or a few predetermined interventions with mixed results. Because patients in an ED are subject to a variety of processes in the ED and other hospital departments, improving patient satisfaction in the ED demands a comprehensive approach. This paper focuses on the QI processes and tools used by the QI team in a CAH that developed a comprehensive list of (56) short- and long-term interventions to take place over five years to improve patient satisfaction in the ED. For this hospital, two aspects of the project deserve mention: </p><p> 1. The use of Failure Mode and Effects Analysis (FMEA): The FMEA is a QI tool developed by the military to address complex problems. Although it has been adapted for use in healthcare QI, in the author's experience, it has not always been fully implemented. The QI team completed a traditional, full, two-part FMEA. In completing both parts of a traditional FMEA, the team first identified and individually analyzed each known or potential failure in the care of an ED patient and potential interventions that could prevent each failure. Then, after careful analysis of all potential interventions, the QI team chose those most likely to succeed and began implementing a sequenced schedule of interrelated interventions deemed most likely to improve care and patient satisfaction. </p><p> 2. Learner-Centered Teaching: QI projects typically use learner-centered teaching methods that, according to Social Cognitive Theory, improve participants' general self-efficacy, which is the likelihood of choosing difficult problems to solve and persisting when faced with challenges. The hospital's project team members' self-efficacy scores increased after participating on the team. Post-project interviews with team members indicate they feel better equipped to solve other problems and have begun to plan other QI projects because they understand other areas' processes, they know who should participate on projects, and they better understand QI processes and tools.</p><p>

Thesis (M.P.H.)--University of Michigan, 1947.

Thesis (P.H.D.)--Columbia University, 1927. Without thesis note. / Vita. "Notes": p. 585-626; Bibliography: p. 627-668.

Thesis (M.P.H.)--University of Michigan, 1947.

<p> The purpose of this study was to characterize sexual harassment in public, or &lsquo;eve teasing&rsquo;, in rural India, develop a measurement tool, and to estimate its prevalence and association with common mental disorders (CMD) and suicide ideation (SI) among young women. Mixed methods included focus group discussions, direct observation of questionnaire administration, and both qualitative and quantitative data gathering with a novel questionnaire. Females ages 14&ndash;26 were recruited through purposive sampling in nine villages for the initial pretest (N=89). Using the finalized questionnaire, we conducted a cross-sectional survey using a randomized cluster sample of 19 villages and recruited 198 women ages 15-24 using house-to-house probability sampling. Eve teasing was described as staring, stalking, passing comments, or inappropriate physical touch. Most participants perceived significant negative consequences, including tight restrictions on girls&rsquo; mobility, inability to attend school or work, girl&rsquo;s being blamed, and causing family problems. Among those who reported eve teasing victimization, psycho-social responses included feelings of fear (88%), anger (78%), and shame (68%) (N=59). The internal reliability of the questionnaire was high for key measures (Cronbach&rsquo;s alpha: .65 to .84) and principal components analysis suggested two underlying constructs in the eve teasing instrument. Nearly 30% of participants reported ever having been eve teased, 21% screened positive for a CMD, and 27% reported recent suicide ideation (N=198). In multivariate analyses, spending more than 1 hour in public daily was associated with reported eve teasing (OR: 3.1 (CI: 1.26-7.49) p=0.016). The odds of screening positive for CMD were significantly higher if eve teased, but only among participants who reported adverse childhood events (ACEs) (OR: 4.5 (CI: 1.18-11.43) p=0.003). Eve teasing was significantly associated with SI among participants who reported ACEs when CMD were included in the model (OR: 3.1 (CI: 1.119-8.472) p=0.032). This is the first study, to our knowledge, to assess the association between eve teasing victimization and mental health outcomes in a community setting. We found that eve teasing may negatively impact the mental health of young women, especially victims of child abuse, and offer a reliable and valid questionnaire for future research.</p>

<p> Opioid Substitution Therapy (OST) attempts to curb opioid addiction by substituting a treatment opioid (i.e. methadone, buprenorphine, naltrexone, etc.) for an addict&rsquo;s primary drug of abuse (i.e. heroin, oxycodone, etc.). However, insofar as patients continue abusing their preferred drug during treatment, OST programs may be increasing the absolute number of drugs patients are abusing. To the extent that some OST patients &ldquo;divert&rdquo; their treatment drugs into illicit markets, OST programs may also be increasing the absolute number of opioids abused by the surrounding population, as well. If corroborated, these trends would indicate a connection between OST treatments and the phenomenon most correlated with drug overdoses&mdash; &ldquo;polydrug use&rdquo;, or the concurrent use multiple drugs by one person. </p><p> To ascertain whether and to what extent OST treatment provisioning may be affecting regional polydrug use, this study models the annual number polydrug treatment episodes reported in a state as a function of that state&rsquo;s OST patient population. The study relies primarily on two administrative datasets&mdash;the National Survey of Substance Abuse Treatment Services (N-SSATS) and the Treatment Episode Data Set-Admissions (TEDS-A)&mdash;collected between 2002 and 2006. </p><p> Using a two-way fixed-effects model that controlled for both state and annual fixed-effects, as well as for state populations and population densities, this study discovered a statistically significant positive correlation (p&lt;.002) between a state&rsquo;s OST patient population and the number of polydrug treatment episodes reported in the state. The model predicts that a doubling of a state&rsquo;s OST patient population will be correlated with a 6.16-percent increase in polydrug episodes. These results suggest that OST treatment may be producing a dangerous side effect. At the very least, they suggest that, when considering potential expansions to OST programs, circumspect policymakers should also consider simultaneous expansions to services that address the predicted increase in polydrug use.</p>

<p> Vibrio bacteria are emerging pathogens responsible for 80,000 illnesses and 100 deaths in the United States each year. Infections are directly linked to the marine environment and are acquired by consuming contaminated seafood or exposing wounds during aquatic activities. Florida has the highest national incidence of vibriosis, with 20% of its cases reported from the Indian River Lagoon region, a popular recreation destination. This study utilized a combination of cultivation and molecular techniques to investigate the local distribution of V. vulnificus, V. parahaemolyticus and V. cholerae in this local waterway. </p><p> The targeted species were found in an array of samples which may facilitate their transmission to humans. Overall, these bacteria were abundant in estuarine sediments (Vp: 2,439 CFU/g, Vv: 303 CFU/g, Vc: 176 CFU/g), on the sharp edges of oyster shells (Vp: 82 CFU/cm, Vv: 102 CFU/cm, Vc: 41 CFU/cm), and in the water column (Vp: 3.78 CFU/ml, Vv: 5.51 CFU/ml, Vc: 2.46 CFU/ml). Vibrio also pose a hazard to recreational anglers as they were recovered from fish (Vp: 61%, Vv: 55%, Vc: 30%), live bait shrimp (Vp: 80%, Vv: 37%, Vc: 0%) and hooks (Vp: 32%, Vv: 18%, Vc: 0%). Additionally, a molecular analysis of the V. vulnificus virulence revealed that the local population was dominated by disease-causing (vcgC) strains, which may explain why wound-related infections are common in this region. </p><p> Vibrio occurrence varied both spatially and temporally due to their relationship with salinity and temperature. These bacteria exhibited a strong negative correlation with salinity, being particularly abundant near freshwater discharge locations. Due to Florida&rsquo;s year-round warm climate, these species were found to be permanent members of the local microbial community. Seasonal peaks in abundance occurred between August and October, a period which corresponds with the warmest water temperatures as well as frequent rainfall. Predictive models were constructed based on these parameters to provide a better understanding of how, when and where Vibrio spp. may be encountered by humans. This information is important for both water management and healthcare initiatives, with an overall goal of improving local recreational safety.</p>

<p> The forces driving the prescription opioid epidemic currently raging across the United States include aggressive marketing, weak regulation, addiction, freely prescribing doctors, a glut of pills available for sharing, and easy access to illicit drugs like heroin. This thesis aims to quantitatively analyze the interactions between these drivers through construction of a System Dynamics model, in order to determine the efficacy of policy intervention through Prescription Drug Monitoring Programs. The System Dynamics model simulates the flow of doctors&rsquo; prescriptions to the two very different classes of prescription opioid patients. One class is the long-term pain patients whose tolerance and appetite for opioids grows over time, leading them to higher doses, often dangerously high, and yet also frequently to feeling under-medicated; the other is those patients prescribed opioids for short-term pain, who typically find that they have been given more pills than they need.</p><p> These &ldquo;extra&rdquo; pills find their way into the hands of friends and family who, in common with the patients who received prescriptions, are in jeopardy of addiction to the opioids. Those addicted repeatedly visit doctors, shopping for more. Sensitivity analysis results reveal that drug diversion is a major contributor to the opioid death rate; that mandatory PDMP use will slow but not stop opioid proliferation, and will cause long term pain patients to be under-treated in larger numbers; that a significant number of people addicted to prescription opioids will transition to heroin use for reasons of price and availability; and that the rate of opioid overdose deaths will remain high until and unless society is better educated about the risks of addiction. Overall, the study helps conclude that the efforts of state governments and the FDA will be insufficient to stem the flow of opioids, and that there is no simple intervention to thwart drug diversion and sharing of pills.</p>