Indiana University-Purdue University Indianapolis (IUPUI) / The United States has invested over $40 billion in digitizing the health care system, yet the anticipated gains in improved care coordination, quality, and cost savings remain largely unrealized. This is due in part to limited interoperability and low rates of health information exchange (HIE) use, which can support care coordination and improve provider decision-making. Primary care providers are central to the US health care delivery system and frequently function as care coordinators, yet capability and HIE use gaps among these providers limit the potential of these digital systems to achieve their intended goals. I study HIE use in the context of primary care to examine 1) factors associated with provider HIE use, 2) the extent and nature of team-based HIE use, and 3) differences in HIE system use patterns across discrete groups of system users. First, I use a national sample of primary care providers to analyze market and practice factors related to HIE use for patient referrals. Overall, I find that only 43% of primary care provider referrals used HIE. Furthermore, I find substantial variation in HIE use rates across electronic health record (EHR) vendors. Second, I use HIE system log data to understand the breadth and depth of HIE use among teams, a care model underpinning primary care delivery reform efforts. I find that although use of HIE systems remains low, in primary care settings it overwhelmingly takes place in a manner consistent with team-based care workflows. Furthermore, team-based use does not differ in breadth from single provider HIE use, but illustrates less depth before and after visits. Third, I apply cluster analysis to 16 HIE use measures representing 7 use attributes, and identify 5 discrete user groups. I then compare two of these user groups and find user-level variation in volume and efficiency of use, both of which have implications for HIE system design and usability improvements. Ultimately, these findings help to inform how HIE use can be increased and improved in primary care, moving the US health care system closer to realizing the coordination, quality, and cost savings made possible by a digitized delivery system.

<p>Examen i vårdadministration, YH-utbildning: 20 Yh-poäng  </p>

Studies have shown that the rates of incarceration in the United States of America have skyrocketed over the course of the last several decades. Furthermore, the extremely high rate of incarceration in the United States has become a destructive force on children, families and entire communities and has disproportionately affected and targeted young men from low-income communities of color. Studies have also shown that mass incarceration is generally harmful to the health of the individuals that are imprisoned, the health of formerly incarcerated individuals, and harmful to the health of families and communities. The true cost of mass incarceration on society is estimated to be as high as over $1 trillion per year and studies indicates that more than half of those costs are ultimately levied upon families, children, and community members that are not incarcerated. This paper discusses policy reforms that have been implemented in recent years and that are currently being implemented to help mitigate the harmful impacts of mass incarceration, prevent recidivism, and reduce the population of incarcerated individuals. It also outlines higher education and positive development programs as effective strategies to further achieve these goals, lists current programs and interventions that have been effective, and discusses policies that would improve access to education for justice-involved populations as an effective tool to combat mass incarceration. / Urban Bioethics

The purpose of this thesis was to explore the literature regarding physicians’ prescriptions of opioid analgesics before and after The Joint Commission Pain Standards for 2001. Opioids are a last resort treatment for chronic pain due to their high potential for tolerance, dependency, and misuse. The establishment of The Joint Commission Pain Standards for 2001 was the culmination of several movements to address the underassessment and undertreatment of pain. The Joint Commission Pain Standards for 2001 focused on improving pain assessment, management, and treatment through a systematic approach. The Joint Commission (TJC), formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), is the largest accrediting body for healthcare organizations in the United States and affects thousands of medical care facilities and physicians. Although many physicians were hesitant to prescribe opioids due to addiction concerns, opioid prescriptions rose due to pressures to meet the TJC’s accreditation requirements and maintain patient satisfaction. Pain management seemed to improve for a short period before adverse reactions and unintended consequences emerged. Confusing language within the TJC Pain Standards for 2001 and its supplemental materials and misleading information from researchers and pharmaceutical companies led to unnecessary pain measurement, problematic pain treatment algorithms, and excessive opioid analgesic use. As patient safety concerns emerged, the TJC continuously amended the TJC Pain Standards for 2001. They were revised in 2017 as the opioid epidemic became a national public health emergency. The TJC has since called for better evaluation of research validity, more vigilant examination for conflicts of interest, and more detailed instructions on interpreting and implementing future standards. The medical community, pharmaceutical industry, government, and the public need to coordinate future strategies to combat the opioid epidemic.

No description available.

Background: The evidence-based approach to policymaking has greatly facilitated policymakers' capacity to make scientifically informed policy decisions, especially in the medical and public health contexts. However, this approach is most beneficial for policy development when trustworthy research is used. Predatory journals and publishers pose a potential threat to evidence-based policy making, since they are more likely than traditional academic journals to publish unreliable evidence. Research Objectives: The purpose of this thesis is to advance knowledge on what factors contribute to the citation of predatory journal articles in policy documents by answering the following research questions: 1) How do people preparing public health documents consider the trustworthiness of research evidence? 2) How do they source and evaluate the research evidence they cite? Methods: I identified a cross-sectional sample of public health policy documents from Overton - the world's largest policy document database - that cited articles published by the OMICS group. OMICS is a well-established predatory publisher. I extracted meta-data (e.g., document source) and document characteristics such as whether they described their method of selection or quality assessment for cited sources. Authors of these documents with contact information listed, as well as a convenience sample of people who have prepared public health documents, were invited for a semi-structured interview. I thematically analyzed these interviews by organizing the codes (both deductive and inductive) into key overarching themes. Results: Two hundred forty-two public health policy documents were included. The World Health Organization was the most common source accounting for 45 documents (19%). A total of 283 articles were cited from 126 OMICS journals. Only 54 (22%) of the policy documents described their source-selection methodology, and 22 (9%) assessed the quality of cited sources. Five key overarching themes were generated from the thematic analysis of the interview data, highlighting that information cited in policy documents is sourced and evaluated in several ways, many of which are related to a series of factors which could be contributing to the predatory journal citations. Conclusion: Public health policy documents are prepared using a variety of methods for information selection and evaluation, but the exact approach for doing so is rarely reported within the document itself. This may contribute to the reliance on untrustworthy research to inform policy; and thus, may help amplify misinformation entering policy globally. Certain steps can be taken to help minimize any potential negative impact of relying on such sources, but a better understanding of policymakers' perspectives may be required to ensure successful implementation.

No description available.

Food deserts are a growing problem in the United States, and occur in areas of low-income where people have limited access to healthy foods. In response, the presence of farmers’ markets has grown exponentially, and improved healthy food access. Additionally, the USDA has strived to connect families to healthy foods through food assistance programs such as the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and the Senior Farmers’ Market Nutrition Program (SFMNP). This study investigated the relationship between farmers’ markets, their acceptance of food assistance benefits, and their locations within Tennessee food deserts census tracts. Using the 2017 Farmers’ Market Directory, this study merged market data, including geocoded addresses, with the appropriate census tract data from the 2015 Food Access Research Atlas. Chi-square tests of independence and spatial visualizations were used to assess the relationship of census tracts, farmers markets, and food assistance benefits. Of the 1,497 Tennessee census tracts, 18.0% were food deserts. Of these food deserts, 9.3% had at least one market present. Of these food deserts, 92.0% were urban. Of 130 farmers’ markets in Tennessee, 34.6% accepted any food assistance benefits. Additionally, 56.9% of all markets were in areas of high socioeconomic status (SES). Results indicated that markets were clustered in urban areas, and few were identified as food deserts. Additionally, few markets were in food deserts and accepted any food assistance benefit. Due to these findings, the definition of food deserts should be expanded to include additional food retailers other than supermarkets. Also, additional policies and research is needed to reinforce farmers’ markets and food assistance programs as food access interventions.

Oregon’s Death with Dignity Act: An Evidenced-Based Approach to Improving End-of-Life Healthcare in Tennessee Erin E. Mauck, MA Community and Behavioral Health, College of Public Health East Tennessee State University Johnson City, TN The legalization of physician-assisted death has been shown to improve the quality of end-of-life healthcare in the states that have passed Death with Dignity or End-of-Life Care Acts. The state of Oregon passed its Death with Dignity Act in 1994, and it is a model that has been replicated in Washington, Vermont, California, Colorado, and Washington D.C. In a national ranking of states in the areas of long-term services and supports for end-of-life care, five of the top nine were states with either a Death with Dignity or End-of-Life Care Act. This is not merely a coincidence. This data is a clear reflection that having legislation which clarifies the rights of a dying individual, impacts end-of-life healthcare in a positive way. Tennessee is currently ranked 47th nationally based on the following criteria: affordability and access, choice of settings and provider, quality of life and quality of care, support for family caregivers, and effective transitions. There are three major determinants that impact Tennessee’s poorly rated end-of-life health care. The first determinant is the limited use of advanced directives, living wills and patient-physician discussions about death, dying, and end-of-life healthcare choices. The second determinant is lack of coverage for the uninsured and less affluent. End-of-life healthcare is not strictly for individuals over the age of 65, terminal illness can impact the life of someone, regardless of age, income, or health insurance status. The third major determinant that is negatively impacting Tennessee’s end-of-life health care, is the lack of a Death with Dignity or End-of-Life Care Act. Data has been collected over the past 36 months, including data from secondary sources and field research data collected in Oregon, including 14 in-depth interviews with volunteers, employees, and the directors of two advocacy organizations at the center of Oregon’s Death with Dignity Act. The analysis of this data shows that states which have enacted Death with Dignity Acts, have better end-of-life care than states that have not. This includes the use of hospice and palliative care at the end of life, and the percentage of people who die at home. When a law that legalizes physician-assisted death is being considered, everyone, including citizens of the state, state policy makers, and healthcare professionals take notice. This encourages the public education of end-of-life healthcare options, as well as promotes further education in end-of-life care for all health professionals. In Tennessee, efficient and regulated end-of-life care is becoming more essential as the population increases, and life expectancy is extended.

Examining the persistence of disparities over time is an important obligation in terms of rectifying, maintaining, and improving community health and social well-being for all. This study analyzed the individual factors of (a) race/ ethnicity and (b) dual eligibility, as a proxy measure of socioeconomic status, as well as the environmental factor of (c) place of residence, and the organizational factor of (d) Rural Health Clinic (RHC) type on emergency room (ER) utilization of older adult Medicare patients treated by RHCs within the Department of Health and Human Services' (DHHS) Region 4. A prospective, multi-level, longitudinal design was employed to analyze potential health disparities or gaps that may exist among RHC Medicare beneficiary patients (+65) using longitudinal, mixed multilevel modeling in SPSS. The years of investigation were 2010 through 2012. R4 has continually lagged behind other Regions in the Nation in having higher Health Disparities and ER Utilization rates related to Race, Poverty, and Rural Isolation. A key question is: Do these disparities persist? This study's findings support that dual eligible RHC patients utilized ER services at higher rates than non-dual eligible, Medicare only RHC patients at: 77%, 80%, and 66%, in 2010, 2011, and 2012, respectively; and above the White reference group, Black RHC Medicare patients utilized ER services at higher rates of: 18%, 20%, and 34%, in 2010, 2011, and 2012, respectively. These findings support that dual Medicare and Medicaid eligibility, as a proxy measure of socioeconomic status, and race continue to influence higher rates of ER utilization in Region 4. In terms of health and utilization disparities, strikingly and persistently, as recent as 2012, Black, dual eligible RHC Medicare beneficiary patients age 65 and over are twice as likely to utilize ER services for health care than their more advantaged counterparts. Health care leaders and policymakers are seeking evidence-based performance measures as tools for detecting gaps in health care and using those subsequent findings as leverage to implement policy change for the purpose of increasing health care delivery performance system-wide while lowering health disparities across various patient populations. Toward that goal, communicating and disseminating the findings of this study contributes to the body of knowledge and enables policy leaders to better make decisions based on empirical evidence in order to strengthen the health care delivery system for older adults in diverse rural contexts. From a health and public affairs policy perspective, crafting in tandem targeted, top-down, population health and bottom-up, community interventions to curb poor health outcomes and high health care utilization would be in the public interest at-large within this region of the Southeastern United States.