Thesis (Ph.D.)--Lehigh University, 2009. / Adviser: Shin-Yi Chou.

Not much has changed for the migrant farmworker in the last thirty years. In one of the wealthiest countries on earth, migrant farmworker health status remains comparable to that found in Third World countries because of poor sanitation, poor nutrition and exposure. Current estimates show that migrant clinics are serving less than 20% of this population, leaving about 2,000,000 farmworkers without medical care. The barriers to health care for this population are numerous. This study will focus on the barrier to care resulting from lack of continuity in care due to poor inter-clinic communication. In this study it has been shown that computer disks and a standard word-processing program can be used to create a portable medical health history for the migrant to improve inter-clinic communication. In the process of carrying out this study, it was also shown how other barriers to care for this vulnerable population might be removed as well.

The Health Care Finance Administration is challenged with improving enrollment into the alternative managed health care system called Medicare+Choice. The current Medicare cohort is knowledgeable about where to obtain information about Medicare+Choice, but they cannot recall the terminology or comprehend the concepts of the program. This study attempts to improve older adult recall and comprehension of Medicare managed care written text, with the goal of improving their attitude toward Medicare managed care. Older adults (n = 49) from a community located in the Southwest were randomly assigned to one of three study conditions. Analysis of Variance, Tukey HSD, and correlation analysis were conducted on questionnaire responses measuring for recall, comprehension and attitude. An "Elderspeak Process" improved older adult recall of specific terms, words, and phrases about Medicare and Medicare managed care. Medicare managed care organizations can use the process to simplify information about their managed care programs to knowledgeable older adults.

The purpose of this study was to develop and validate a risk-adjustment index for one year healthcare resource use specific to diabetic patients, based on severity of illness measures; and to profile quality of diabetes care between outpatient clinics. The data for this study was collected from four outpatient clinics within the Southern Arizona Veterans Affairs Healthcare System, Tucson, AZ. The DRCI was developed using a sample size of 367 diabetic subjects that had complete information on diabetes-specific variables. Individual DRCI weights, based on the magnitude of one year healthcare resource use and socio-demographic characteristics, ranged from -471.5 to 3,081.2 for total healthcare costs, from -304.3 to 1,582.1 for outpatient costs, and -0.19 to 0.93 for risk of hospitalization. The DRCI was better than or equivalent to the Chronic Disease Score in predicting health care costs. Diabetics in the second cohort were predominantly elderly (mean = 66yrs ± 11.1), married (61%), white (73%), males (96%), had a high BMI (31 ± 6.3 kg/m²), and mean comorbidity score of 4.2 ± 1.8 conditions. Screening for HbA1c and microalbuminuria was frequently performed in all clinics. Overall, 61% and 36% of study patients did not have evidence of foot or eye examinations during the entire study period, respectively. Approximately, 27% (n = 408), 41% (n = 643), and 26% (n = 515) of the study patients had poor glycemic, renal function, and lipid control, respectively. Significant differences (p < .05) in HbA1c and creatinine clearance rates between the clinics were observed after adjusting for patient case-mix. However, differences between the clinics in cardiovascular outcome were not observed after adjusting for patient case-mix. This study demonstrated an association between diabetes severity with healthcare resource and costs. The DRCI, using laboratory data, is a diabetes-specific severity measure for prediction of one year healthcare resource use. Future studies are needed to validate this index in other settings. Finally, the results from this study emphasize the need to adjust for case-mix variable when comparing quality of diabetic care outcomes between outpatient clinics.

Two of the major infectious complications of cardiac surgery are pneumonia and surgical site infections of the sternum and graft harvest site. These postoperative adverse events significantly increase patient morbidity, mortality and cost associated with coronary artery bypass graft operations. Pre-existing diabetes mellitus is commonly considered one of the primary risk factors for development of these major infections. However, most of the previous cardiac surgery risk factor studies have not considered the role perioperative stress hyperglycemia may play in initiating these complications. The primary hypothesis of this retrospective descriptive cohort study was that perioperative stress hyperglycemia (defined as either perioperative serum glucose threshold ≥250 mg/dL or perioperative serum glucose change ≥50 mg/dL) is an independent risk factor for the composite outcome of postoperative infections, including pneumonia and surgical site infections of the sternum and harvest site. The relationship of stress hyperglycemia to the individual infection outcomes was also examined. The secondary study hypothesis was that stress hyperglycemia increases resource utilization as excess days of care. The setting was a tertiary care federal medical facility in the southwestern United States, and the study cohort involved 1285 male military veterans.

The healthcare marketplace is rapidly changing how we finance medical education, how we train physicians, and the interrelationships within an academic institution. This case study examined the historical development of the Department of Family and Community Medicine and the impact of growing financial constraints on the training of medical students and residents, the clinical practice, faculty workload, and departmental organization. The theoretical frameworks of resource dependence, culture, and professionalization theory were employed to understand how different groups within the context of an academic health center co-exist to meet the core missions of teaching, research, and service. Data collection was conducted over a two-year period and utilized the triangulation of interviews, document analysis, and participant observation methods. The study's findings indicated that the Department of Family and Community Medicine continually faced the challenge of being a primary care department in an academic medical culture that placed more emphasis on specialized care and specialty departments. Over a period of time, the Department went from a profit-center to a cost-center where faculty's ability to teach and conduct research revolved around the success or failure of the clinical care enterprise. Faculty productivity was increasingly emphasized and its definition was dependent on the healthcare marketplace and the availability of resources. The competitive health care market encroached on faculty workload and manifested itself in part through the loss of a major patient care contract, the receivership of the Department, and the splitting of the Department and its resources. During the period of time analyzed, the department was in a no-win situation because the success of the department was determined by more powerful coalitions that had decision making ability and controlled the necessary resources. The department's power lay in the provision of teaching resources and its alignment with the state's goal of training primary care physicians to work in rural and underserved communities. Conflict arose as departments tried to defend and protect their declining resources and jurisdictions. The study findings emphasized the importance of understanding departmental jurisdictions and how resource allocation decisions are made in the context of the academic setting and culture.

The Remote Consultation and Diagnosis (RCD) in Global Picture Archiving and Communication System (Global PACS) is a unique suite of multimedia telemedicine applications developed at the University of Arizona. The applications support real-time patients' data, image files, audio and video consultation and diagnosis annotation exchanges. The RCD enables joint collaboration between pathologists, radiologists, or physicians while they are at distant geographical locations. This project provides four RCD scenarios, i.e., Case Review, Case Acquire, Store and Forward Analysis, as well as Interactive Diagnosis and Consultation. The RCD Global PACS environment consists of heterogeneous, autonomous, and legacy resources. The Common Object Request Broker Architecture (CORBA), Java Database Connectivity (JDBC), and Java language provide the capability to combine the RCD Global PACS resources into an integrated, interoperable, and scalable system. The underneath technology, including IDL, ORB, Event Service, IIOP, JDBC/ODBC, legacy system wrapping and Java implementation are explored. This distributed collaborative CORBA/JDBC based framework will challenge the advanced, medical information management requirements. It also makes the RCD Global PACS both hardware and software technologically independent. As our research and development extend, we will continue to incorporate the latest advances in computer technology. RCD Global PACS is not another new tool in telemedicine, but rather a new paradigm for the delivery of health services that requires process reengineering, cultural changes, as well as organizational changes. It is a whole new way of practicing in telemedicine. We ensure that the RCD Global PACS project has long-term, comprehensive solutions for today and tomorrow's healthcare needs.

Formulary decision-makers must make choices based upon the safety, efficacy, and projected budgetary impact of medications. Models used to predict cost impacts are rarely assessed to determine how accurately they predict treatment cost changes. The purpose of this research was to assess the ability of a decision analytic based deterministic model and a regression analytic based stochastic model to predict the average diabetes-specific costs incurred by a managed care organization during the 12 month period following the addition of metformin to an HMO formulary. The ability of the stochastic model to predict the average diabetes-related costs and total health care costs was also assessed. The deterministic model, a decision tree, was constructed within an equilibrium framework using literature-based probabilities and internal costs to predict the expected diabetes-specific costs. The estimate of the total diabetes-specific cost impact came within 5% of the actual costs. The model underestimated the diabetes-specific medical costs (predicted was 73% of actual) and overestimated the diabetes-specific pharmacy costs (predicted was 258% of actual). A regression model was constructed using medical and pharmacy claims data to predict the expected diabetes-specific, diabetes-related and total health care costs. The average total cost estimates produced by the total health care cost model were within 7% of the actual average costs incurred. The diabetes-related and diabetes-specific cost models produced estimates that were within 12% and 18% of the actual costs incurred, respectively. The total, diabetes-related, and diabetes-specific average medical costs produced by the regression models were within 6%, 50%, and 46% of the actual costs respectively. The total, diabetes-related, and diabetes-specific average pharmacy costs were within 20%, 45%, and 49% of the actual costs respectively. Further research is needed to determine the best way to construct a model to estimate the economic impact of adding a medication to the formulary. A decision tree constructed with internal data should be used to predict the disease-specific economic impact of adding a medication to the formulary when only medical and pharmacy claims data from the previous year are available. A regression model should be used to predict the total health care cost impact.

This exploratory study utilized Donabedian's Quality model to develop a framework to study patients who must migrate for health care. One year of the Arizona Department of Health Services Discharge Database was used to analyze patient characteristics that influenced discharge travel and the impact of distance on risk adjusted patient outcomes. Geographic Interface software was used to identify rural patients, defined as those with zip codes farther than thirty miles from hospitals. Zip Code analysis was used to create distance variables between 31 and over 300 miles. The key findings for patients who traveled greater distances included larger hospitals, emergency admission type, private insurance, critical care services, and Neuro/Ortho/Trauma diagnosis group. Patients which traveled shorter distances included smaller hospitals, referral or transfer admit source, AHCCCS insurance (or Medicaid) and Women's Health diagnosis group. Outcomes were risk adjusted using age and distance was significant for both number of procedures and length of stay. Patients who traveled farther received fewer procedures and had a greater length of stay. A preliminary cost analysis of the length of stay outliers identified approximately four million dollars in potentially non-reimbursable charges.

The aims of this research were to determine the level of satisfaction with pharmacy services among enrollees of a managed care organization, compare the level of satisfaction between mail pharmacy and traditional pharmacy patrons, and evaluate the relationship between satisfaction with pharmacy services and health status. Data was collected via telephone interviews with 1,362 enrollees of the managed care organization. The overall response rate was 65%. Satisfaction was measured using previously developed items for traditional pharmacy services, and newly developed, parallel items for mail pharmacy services. Scores were calculated for hypothesized multi-item dimensions of satisfaction. Health status was measured using the physical and mental health composite scores of the SF-12 Health Survey. Satisfaction with pharmacy services was compared between patron groups using ANOVA and ANCOVA models. Confirmatory factor analysis and structural equation modeling (SEM) were used to evaluate the dimensional structure of satisfaction with pharmacy services and the relationship between satisfaction with pharmacy services and health status. The results indicated that mail pharmacy patrons were more satisfied than traditional pharmacy patrons with their pharmacy services in general, and specifically with the financial aspects and technical quality of those services. When the comparisons were adjusted for general satisfaction with medical care and mental health status, mail pharmacy patrons still had greater levels of general satisfaction with pharmacy services. However, when these covariates were included in the comparison of satisfaction with financial aspects and technical quality of pharmacy services, dimension scores between the two patron groups were not significantly different. Internal consistency reliability coefficients for the multi-item dimensions of satisfaction were in the range of 0.53 to 0.77, with the exception of the Written Information dimension for mail pharmacy service, where the alpha coefficient was 0.37. A positive correlation between the dimension scores for general satisfaction with pharmacy services and general satisfaction with medical care lends support to the construct validity of the measurements. Additionally, it was concluded that, as expected, general satisfaction with pharmacy services was positively correlated with mental health status, but there was no significant relationship between physical health and satisfaction with pharmacy services.