<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>

<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> 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>

<p> Since 2014, voters in four California cities approved ballot measures seeking to levy a penny-per-ounce tax on sugar-sweetened beverages (SSBs). Prior to these instances of success, over 128 local and state SSB tax proposals in the U.S. failed passage since 2009. The recent success of SSB tax passage in California presented an opportunity to explore factors associated with SSB tax passage, and to explore if John Kingdon&rsquo;s Multiple Streams Approach (MSA) applied in cases where the tax passed. The study also identified how Kingdon&rsquo;s theory may be modified in cases involving local governments. </p><p> I conducted a retrospective qualitative analysis using primary and secondary data collection to compare the outcome of SSB tax proposals across California cities. I interviewed 22 individuals using semi-structured telephone interviews to learn about each city&rsquo;s SSB tax proposal and process. Successful and unsuccessful SSB tax proposals were compared to learn from both passage and failure. </p><p> Five key themes or patterns were associated with cases of success including: (1) advanced planning, (2) building support, (3) voter engagement, (4) messaging, and (5) media. Cities that failed to pass the tax did not achieve consensus about the problem, or the proposed solution. A policy that is perceived as technically unfeasible has reduced chances of survival. The MSA provided a useful framework for analyzing factors associated with SSB tax success, however it remains unclear how much independence there is between the three streams at the local policymaking level. Based on the results from this study, I proposed a modification to the <i>problem stream</i> by adding a typology of events to further analyze factors associated with why a policy alternative may rise or fall on an agenda. </p><p> The results from this project have the potential to broaden the application of the MSA theory. The findings from this study will be useful to policymakers and advocates in cities that utilize direct or representative democracy, and may lead to other local level SSB tax adoption in the future. Policy entrepreneurs play an important role in shaping the course of how a problem is perceived. Problems and solutions that resonate with voters are more likely to rise on an agenda. This project also demonstrates the value of learning from policy failures. In some cases, iterating a strategy after a failure may be the only way to innovate towards a successful outcome over time.</p><p>

<p> The United States is experiencing an unprecedented crisis of prescription and illicit opioid misuse, addiction and overdose. Coincident with the increase in opioid misuse and addiction in the U.S. over the past decade are rising rates of prescription opioid injection and transmission of infectious diseases such as hepatitis C virus (HCV) and endocarditis. </p><p> Following the 2015 HIV outbreak in Scott County, Indiana associated with injection of the prescription opioid oxymorphone, and a decade-long increase in viral hepatitis infection rates, especially in areas of the U.S. with long-standing prescription opioid misuse and addiction, policymakers, public health practitioners, and other stakeholders have become increasingly concerned about prescription opioid injection misuse and related harms. </p><p> Syringe Services Programs (SSPs)&mdash;evidence-based programs that provide sterile injection equipment and comprehensive infectious disease, substance use, and overdose prevention and treatment services&mdash;have been identified as a potential key intervention in response to the opioid crisis and increasing opioid injection. However, there is limited recent research characterizing the population of people injecting prescription opioids and other drugs that can help guide how to best position SSPs to reach and impact this population. Further, the policy environment for SSPs is rapidly evolving, with multiple states enacting laws, regulations, and policies in recent years to enable the establishment of SSPs. Collectively, the research gaps around prescription opioid injection and the changing policy environment for SSPs has created a critical need to better define the characteristics of people who inject prescription opioids, to identify the services and resources needed by this population, and to understand how SSPs are navigating the evolving policy environment in order to maximize their role in response to the opioid crisis. </p><p> This dissertation research aims, through the use of mixed methods, to address these knowledge and policy gaps through: 1) systematically reviewing the literature to synthesize what is known about the population of individuals who inject prescription opioids in the U.S.; 2) estimating the magnitude of prescription opioid injection in the United States; 3) examining overall, sociodemographic, and substance use trends and correlates of prescription opioid injection among a nationally representative sample to identify populations at-risk for prescription opioid injection and related harms; and 4) using these quantitative findings to inform a qualitative exploration of SSPs&rsquo; responses to the rapidly changing policy environment in the midst of the evolving opioid epidemic and how they can be further leveraged to reduce the harms associated with opioid injection. This dissertation accomplishes these aims through three separate, but related studies. Taken together, the new knowledge produced from this dissertation can be used to inform the development, prioritization, and implementation of policies, programs, and practices that aim to reduce prescription opioid injection and its related harms and expand the role of SSPs in response to the U.S. opioid crisis.</p><p>

<p> In response to the increased demand for primary care in the United States&mdash;a byproduct of a growing elderly population and insurance expansion under the Affordable Care Act (ACA)&mdash;the total number and capacities of community health centers (HCs) is expected to grow. While HCs have historically depended on physicians to deliver the majority of their care, more and more, they are shifting to non-physician clinicians, especially nurse practitioners (NPs); yet, little is known about the quality of care delivered by NPs in HCs or about the role state occupational restrictions have on these practitioners or their patients. </p><p> Using quasi-experimental methods and data from the community health center subsample of the National Ambulatory Medical Care Survey (NAMCS), this dissertation explores three distinct, but related, research questions regarding NP-delivered care in HCs&mdash;its effectiveness and comparability to physician care, the extent that tradeoffs in the quantity and quality of care are made, and the real-world risks and benefits of states easing their scope of practice restrictions. Findings, which suggest that NP care is comparable to physician care in most ways and that the quality of NP-delivered care does not significantly vary irrespective of states&rsquo; NP independence status, have important implications for policy and practice.</p>

<p> <b>Objectives:</b> Mothers of low socioeconomic status (SES) and of non-Hispanic black race deliver prematurely more often. The goal of my dissertation was to improve understanding of the mechanism of disproportionate premature birth in low SES women. I tested a psychological and physiological stress explanation of prematurity risk, estimated the effect of the Affordable Care Act (ACA) Medicaid expansion on gestational age (GA), and estimated how the ACA Medicaid expansion effect was influenced by race. <i><b>Data and Methods:</b></i> I developed a conceptual framework of how psychological and physiological stress increase premature birth risk utilizing Appraisal and pathophysiology theory. I generated hypotheses about how financial risk removal would impact GA and tested them utilizing variation in expansions in Medicaid eligibility for pregnant women in three matched state pairs and distribution of the Earned Income Tax Credit (EITC). I utilized data from the Pregnancy Risk Assessment Monitoring System and performed multivariate ordinal regressions. I also used national birth record data and exploited state variation in ACA Medicaid expansion status to estimate the impact on GA in non-Hispanic black and all other mothers using multivariate linear regressions and linear probability models. </p><p> <b>Results:</b> Hypothesis testing based on two of the three Medicaid expansion for pregnant women state pairs and the EITC analyses resulted in significant evidence (one-sided p-values &lt; 0.05) for a direct pathway between psychological stress concerning financial risk, physiological stress, and GA. The ACA Medicaid expansion was associated with an increase in GA for non-Hispanic black mothers (+34 hours), a decrease for all other mothers (&ndash;6 hours), and a 3% decrease (95% CI = &ndash;5% to &ndash;2%) in the incidence of early term or shorter gestation births for non-Hispanic black mothers. </p><p> <b>Conclusions:</b> Decreasing financial risk for low SES women with Medicaid or the EITC is associated with increased GA. The higher premature birth risk in this population is likely the result of a direct pathway involving psychological and physiological stress. Other financial risk removal strategies should be investigated. The ACA Medicaid expansion did not meaningfully influence GA on a weekly scale but did moderately decrease overall preterm birth risk in non-Hispanic black mothers.</p><p>

<p> A review of literature suggests that train derailments are a statistically relevant concern. While not all train derailments involve hazardous materials, those that do release chemicals pose a public health threat. This study challenges the decision-making mainstay tool of the hazardous materials response community &ndash; the <i>Emergency Response Guidebook</i> (ERG) &ndash; and its default strategy of evacuation through quantitative research that evaluates data from train derailments involving the release of hazardous materials. It explores whether there are correlations between a derailment&rsquo;s variables and evacuation, as well as correlations between the number evacuated and the number of those injured or killed. Secondary data on train derailments from the Pipeline Hazardous Material Safety Administration revealed 358 incidents involving the release of 876 substances between October 12, 1989 through August 10, 2016. The resulting data analysis confirms a certain level of predictability between causal factors and worsening outcomes supporting expansion of decision-making tools in the ERG.</p><p>

<p> Waiters who serve alcoholic beverages at the majority of bars and restaurants in the United States are apt to serve alcohol to patrons who are visually intoxicated, notwithstanding laws prohibiting such service. Adverse effects of this practice include patron injuries, deaths, and law violations resulting in fines, incarceration, and lawsuits. Waiters not effectively trained to practice responsible alcohol retailing practices put patrons and others at risk of harm from alcohol related injuries or death. The problem is that the perceptions and attitudes of waiters who serve alcohol regarding self-learning as a strategy to prevent patron intoxication are not known; the purpose of this qualitative case study was to explore these perceptions. The study utilized in-depth semi-structured interviews with 23 waiters who utilized a self-learning tool about preventing patron intoxication. The waiters perceived that this self-learning tool was a good training solution, that it would be beneficial if implemented, that the tool could be used to improve public safety, and that its specific data on patron behavior and BAC levels were helpful. The participants also indicated that there would be challenges to implementing such a tool, including the waiters&rsquo; assertiveness and social aptness. As a whole, the researcher recommended that this tool be implemented across the country to improve waiter knowledge and patron safety. For future research, the researcher recommended that the study be expanded to include the perceptions of waiters across the country, the perceptions of those who underwent this training more than a year ago, and that the learning tool be adapted for different learning styles.</p>