Neural tube defects (NTD) are among the most common birth defects and the leading cause of infant mortality. NTDs occur when the neural tube fails to close during early fetal development. The two most common types of NTD are spina bifida and anencephaly. NTDs result in lifelong complications like musculoskeletal deformities and loss of strength. The etiology of NTDs is complex and involves still unclear environmental and genetic factors. However, one of the well-established risk factors of NTDs is folic acid deficiency. The prevalence of NTDs can be lowered by an adequate intake of folic acid in the periconceptual period. In 1996, the Food and Drug Administration mandated that 140 micrograms of folic acid be added to 100 grams of bleached grain products with the goal of reducing the prevalence of NTDs. In the years following this fortification mandate, studies have shown that blood folate levels have more than doubled on average, that there are demographic and socioeconomic disparities in blood folate gains and that NTD rates have declined. However, no studies after the mandate have examined changes in blood folate distribution and differences in NTD prevalence by a wide range of theoretically and biologically relevant risk factors after the mandate. Using a nationally representative sample of non-institutionalized women of reproductive age, I investigated the relationship between the fortification mandate and blood folate levels. I also examined changes in the range/spread of blood folate distribution after the mandate. Using data on US live births from 45 states and the District of Colombia, the second study examined whether (1) the disparities in blood folate changes translate into differences in NTD prevalence and (2) NTD risk factors moderate the association between the mandate and NTD prevalence,. The final study explored potential unintended impacts of the mandate on birth weight, low birth weight, very low birth weight, high birth weight, and physician-diagnosed developmental delay, asthma and allergies. For this study, I employed samples from the Natality files and the National Survey for Children's Health. The cumulative results of my research suggested that the mandate was associated with increases in blood folate concentration, with greater increases in higher quantiles of the blood folate distribution and that the spread of blood folate distribution after the mandate widened. Additionally, the mandate was associated with a decrease in the prevalence of NTDs in the entire US population although the impact of the mandate was moderated by race/ethnicity, maternal educational attainment, acute illness during pregnancy and infant region of birth. Furthermore, the mandate was associated with other unintended infant and child health outcomes such as average birth weight increases in the population and increased risks of developmental delay among six year olds. This research is the first of its kind to examine changes in the spread of blood folate distribution after the mandate and whether NTD risk factors moderate the association between the mandate and NTD prevalence. It is also the first study to explore potential impacts of the actual mandate (not prenatal folic acid supplementation) on other unintended infant and child health outcomes. The results add significantly to our understanding of the effects of the mandate and have important implications for health care providers, women of reproductive age and policy makers because of the potentially increased risk of developmental delay among children and the increasing disparity in blood folate concentrations after the mandate.

Many physical changes occur as one ages, including changes associated with the oral cavity. A review of the literature suggests that the provision of dental care to institutionalized elderly patients presents problems due to a variety of factors. The purpose of this study is to assess the level or dental care provided to residents of long-term care facilities located in Warren County, Kentucky. In addition, secondary objectives Include the ascertainment of who provides dental care to residents and the amount or in-service dental training made available to staff members of the facility. Each administrator of the long term care facilities located in Warren County participated in an *interview conducted by the author. During the interview, information was obtained for a 21 item questionnaire concerning the facility, the number and age range or the residents, and types of dental services provided within the facility. Results obtained from the questionnaire indicated that 77 percent or the residents in long-tern care facilities in Warren County are 70 years of age or older. No significant differences were noted in the types or dental services provided to residents. However, the dental services provided ranged from those that were obtained in a private dental office via transportation or the resident to outside dental facilities to routine oral hygiene measures carried out by staff members employed by the facility. The findings revealed significant differences in the dental status of the MRDD residents when compared to the nursing home residents. Other findings indicated that none of the long-term care facilities had dental operatories or dental radiographic equipment on the premises. Additional research would be required in order to address uncertainties discovered in the study. A followup to the questionnaire Interview with the consulting dentists may be included to determine to what capacity and to what extent they are utilized by the facilities. Other recommendations include the utilization of entrance dental examinations to determine if services offered do meet the needs of the residents and periodic dental examinations to aid in detection and thus reduce the prevalence of dental diseases in this population.

Opioid dependence and opioid related deaths are a public health problem which the United States Centers of Disease Control have declared an epidemic. While opioid agonist therapy for opioid addiction has been accepted as the most effective treatment for opioid dependence among academics, and office based buprenorphine treatment has been available in the Unites States for over 10 years, OB buprenorphine faces many barriers to widespread adoption. Empirical data on the geographic distribution of physicians able to prescribe buprenorphine and the prescribing patterns of those physicians show considerable unevenness in access and utilization of treatment services. Federal-level policies have recently been implemented to expand access to opioid agonist therapy, but the medium and long term impacts of these policy changes on individual outcomes, public health, and geographic access equity are not yet clear. This dissertation compares two recent federal level policies on expanding access to buprenorphine treatment: raising the regulatory limit on the number of patients a provider can treat (implemented July, 2016), and extending prescribing privileges to nurse practitioners and physician assistants (implemented February, 2017), using an empirically supported Agent Based Simulation model. Policies are assessed by a novel, at-a-glance, quantitative access equity metric: the Spatial Potential Access Gini Index, in addition to year-end treatment utilization, opioid overdose deaths, and the amount of illicit medication diversion. In the simulation, expanding access by increasing the patient limit did not result in more equitable spatial access, while extending prescribing to NPs and PAs increased both utilization and spatial access equity. This is likely due to empirically supported model assumptions that NPs and PAs providing primary care often serve in medically underserved areas including rural and remote regions. Extending prescribing to these practitioners opens up new treatment locations changing the spatial distribution of treatment opportunities. Changing patient limits does not change the overall spatial distribution of services, so spatial access equity does not change even if overall treatment supply gets better or worse. The primary contribution of this work is the Spatial Potential Access Lorenz Curve and the Spatial Potential Access Gini Index, measures that aggregate individual-level Spatial Potential Access Scores commonly used in health care geography to map and identify areas of access disparity within a region. The equitability of Spatial Potential Access is calculated by using the Lorenz Curve, which is commonly used to characterize the distribution of wealth or income in a society, from which a Gini Index is calculated. The Spatial Potential Access Gini Index allows for direct comparison of complex quantitative information about the geographic distribution of supply and demand in a region with other regions, or in response to policies that impact supply or demand within the region. The measure has potential applications in simulation studies on the spatial allocation of services, allowing equity assessment of policy alternatives, as well as in empirical work, allowing equity comparisons of different regions, or in hybrid studies in which policy experiments are conducted on data-rich maps.

Continuity of patient care is an essential element of primary care because it should result in better quality care and disease management, especially for older adults who often have multiple chronic illnesses. Even though continuity of care has been studied for decades, it remains difficult to define and quantify and, there is no consensus about best practices for assessing whether or not a patient experiences it or a practitioner provides it. Moreover, no theoretically-driven measures for the assessment of continuity of care exist, and there have been few rigorous evaluations of its association with subsequent health and health service utilization outcomes. The principal purpose of this dissertation research was to better understand continuity of care for older adults by identifying the components of the patient-provider relationship that are important from the patient perspective, understanding how commonly used provider-proxy continuity measures relate to the patient experience, and evaluating whether the patient experience or provider-proxy assessments are associated with improved health and health services utilization. I used survey data from the 2,997 Medicare beneficiaries who participated in the 2004 National Health and Health Services Use Questionnaire (NHHSUQ) linked to their Medicare claims for 2002-2009. The NHHSUQ contained patient-reported data on usual primary provider, usual place of care, and the quality and duration of the relationship with their provider. By linking this information to their Medicare claims, I was able to evaluate both patient-reported and provider-proxy (claims-based) measures of continuity of care from two years prior to the survey, and evaluate the impact of continuity on health and health service utilization for five years after the survey. Study results indicate that the older adult patient experience of continuity is reflective of both relationship duration and patient-provider interaction during the care visit, and that most provider-proxy continuity assessments did not relate to patient perceptions. And, the patient and provider-proxy experiences of continuity had different relationships with important health outcomes. These results enhance our understanding of continuity of care for older adults and inform policymakers and researchers about aspects of continuity that are important for the health of older adults and the appropriate use of health care resources.

The recent reports by Institute of Medicine, `To Err is Human' and `Crossing Quality Chasm', revealed a large prevalence of medical errors and substandard care in US hospitals. Since then there has been a substantial increase in the efforts to measure and improve quality of care. The objective of this study was to compare the quality of care across hospitals using available performance indicators and examine the association between organizational factors and hospital performance. The main focus of this study was on important structural attributes of hospitals, namely - teaching status, location and market competition. The Nationwide Inpatient Sample for years 2003 and 2005, and the State Inpatient Database for years 2004 to 2006 were used for analyses. Two types of hospital performance indicators were examined to compare quality of care - Patient safety indicators developed by Agency for Healthcare Research and Quality, and process of care indicators developed by Centers for Medicare and Medicaid services. Multivariable regression analyses were performed using generalized estimating equations and random effects regression models. Several organizational factors as well as patient characteristics were included in the multivariable models as control variables. Overall, the results from this study showed an inconsistent relationship between teaching status, location of hospitals or market competition and quality of care in hospitals. In addition, the results demonstrated that isolating potential effects of hospital structure on outcomes requires controlling for the variation in patient characteristics, such as age and comorbidities, which increase patients' risk for incurring patient safety events. The findings from this study provide useful insight into the areas where the patient safety and quality initiatives should be focused. Moreover, the results identified the organizational factors that are relevant to certain types of hospitals and which should be considered before evaluating quality of care and enacting any policies about publicly reporting of performance or payment initiatives that are relevant to these hospitals.

Older individuals overwhelmingly prefer to receive long-term services and supports (LTSS) in home and community-based settings. Medicaid elderly 1915(c) waivers have become the primary mechanism that states use to provide home and community-based services (HCBS) to older individuals. Given the positive effects elderly waivers have on the quality of life of older individuals, I examined why states adopt elderly waivers; the extent of the substantive differences in program quality across elderly waivers; and the factors associated with elderly waiver program quality, contrasted with the factors associated with elderly waiver program size (i.e., number of participants and expenditures). I examined how state contextual, institutional, and political factors, as well as factors external to the states, including neighboring state and federal policy activity, influenced state policy decisions pertaining to elderly waiver adoptions and program quality and size. First, I performed a retrospective analysis using state-level longitudinal data from 1992-2010 to conduct a discrete time-series repeated event history analysis (EHA) to identify the variables associated with state adoptions of elderly waivers. Second, I created a measure of elderly waiver program quality consisting of four equally weighted components of waivers thought to be associated with the provision of higher quality HCBS to older individuals, including: eligibility criteria, self-determination supports, range of services provided, and participant protections. Using correlational analyses, I examined the relationships between program quality and size. Third, I performed retrospective ordinary least squares (OLS) analyses using waiver program-level data from 2015 to examine elderly waiver program quality and size and fixed-effects OLS using data from 1993-2010 to examine elderly waiver program size. I identified 63 elderly waiver adoptions across 35 states between 1992 and 2010, which were significantly associated with state contextual and external factors. Consistent with previous research, I found that contextual factors, including the number of older individuals, the supply of long-term care facilities and whether the state already had an elderly waiver program, affected state decisions to adopt elderly waivers. There was significant variation in each of the four component and overall quality scores and weak associations between program quality and size. I found that state contextual factors, including market and Medicaid program characteristics, influenced elderly waiver program quality and size. In addition, program quality was shaped by the capacity of state policymaking institutions (e.g., governorships and legislatures), while program size was shaped by neighboring state and federal policy activity. The findings from this research suggest that elderly waiver adoptions and program quality and size are shaped through different policymaking pathways. Efforts to improve the quality of elderly waiver programs should consider the capacity of state executive officials in addition to contextual determinants and focus on improving existing elderly waiver programs. Given that most waivers scored well on eligibility and participant protections, efforts to improve the quality of elderly waiver programs should focus on expanding self-direction supports opportunities, the types of waiver services, and eliminating restrictions placed on service delivery (e.g., waiting lists).

Background: Many innovative ideas have been proposed to manage and improve the quality and cost of clinical care. For many innovations, like Total Quality Management (TQM), the &quotblack box&quot of implementation process is not well understood. Empirical work on the process of innovation implementation in health care is limited. Objective: This study was designed to explore how one organisation, Intermountain Health Care (IHC), an acute and primary health care provider in the USA, innovates in implementing TQM organisation-wide to improve and manage clinical quality. More broadly, the study aims to identify factors that contribute to innovation implementation in health care for clinical quality improvement, and to generate a model of innovation implementation in health care for clinical quality improvement. Method: This thesis takes a case study approach using multiple research methods. The main methods used comprise interviews with key personnel, assessment of organisational documents and a survey of clinicians' and managers' attitudes and beliefs. Findings: The main finding of the research is that innovation implementation at IHC was a journey, not a destination. Embedded in the journey were five periods and many actions and interactions, grouped into eleven elements. The five periods were: exposing to an innovative idea, embracing the idea, extending knowledge and experience on the idea, emerging of strategies to implement the idea organisation-wide, and enacting and adapting the strategies. The eleven elements were: gestation, shocks, plan, proliferation, fluid participation, setbacks, criteria shift, top executive involvement, relationships and infrastructure building, and adoption. To implement TQM organization-wide, integrated structures and systems were being instituted. The study found that resistance to change came from not only some physicians but also hospital administrators. The study also found that supportive environments played a critical role in the journey. While the TQM implementation at IHC resulted in some cost savings and some behavioural changes including clinical practice change, cultural change at the level of values and beliefs had yet to occur. Conclusion: A process-oriented integrative model of clinical service management is proposed. The elements of an innovation, the temporal change processes, lead to formation and changes of the ongoing organisational processes, which in turn evaluate and improve the important clinical processes. These processes integrate TQM with other quality improvement approaches; also ensure that quality is part of the dialogue between key stakeholders who are responsible for managing and improving clinical quality and costs. These processes also are capable of dealing with dilemmas faced in health care and the constantly created managerial ideas and clinical knowledge. Key Words: Innovation, Clinical Outcomes, Knowledge, Quality and Costs, TQM Management

This thesis concerns an investigation of the tripartite arrangements between the government, the nursing and the medical sectors in New Zealand over the period 1984 to 2001 with a particular focus on primary health care. The start point is the commencement of the health reforms instituted by the Fourth New Zealand Labour Government of 1984. The thesis falls within a framework of critical inquiry, specifically, the methodology of depth hermeneutics (Thompson, 1990), a development of critical theory. The effects of political and economic policies and the methodologies of neo-liberal market reform are examined together with the concept of collaboration as an ideological symbolic form, typical of enterprise culture. The limitations of economic models such as public choice theory, agency theory and managerialism are examined from the point of view of government strategies and their effects on the relationships between the nursing and medical professions. The influence of American health care policies and their partial introduction into primary health care in New Zealand is traversed in some detail, together with the experiences of health reform in several other countries. Post election 1999, the thesis considers the effect of change of political direction consequent upon the election of a Labour Coalition government and concludes that the removal of the neo-liberal ethic by Labour may terminate entrepreneurial opportunities in the nursing profession. The thesis considers the effects of a change to Third Way political direction on national health care policy and on the medical and nursing professions. The data is derived from various texts and transcripts of interviews with 12 health professionals and health commentators. The histories and current relationships between the nursing and medical professions are examined in relation to their claims to be scientific discourses and it is argued that the issue of lack of recognition as a scientific discourse is at the root of nursing�s perceived inferiority to medicine. This is further expanded in a discussion at the end of the thesis where the structure of the two professions is compared and critiqued. A conclusion is drawn that a potential for action exists to remedy the deficient structure of nursing. The thesis argues that this is the major issue which maintains nursing in the primary sector in a perceived position of inferiority to medicine. The thesis also concludes that the role of government in this triangular relationship is one of manipulation to bring about necessary fundamental change in the delivery of health services at the lowest possible cost without materially strengthening the autonomy of the nursing or the medical professions.

published_or_final_version / Public Administration / Master / Master of Public Administration

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