Thesis (Ph.D.). / Written for the Dept. of Epidemiology, Biostatistics, and Occupational Health. Title from title page of PDF (viewed 2008/07/23). Includes bibliographical references.

Title: The path(way) to a clean colon: Improving the management of functional constipation Authors: Sarah Nichols, D.O. Pediatrics Resident, Nathan Justice, M.D. Pediatrics Hospital Medicine, Anjali Malkani, M.D. Pediatric Gastroenterology, David Wood, M.D., MPH General Pediatrics and Adolescent Medicine Purpose / Objectives: Hospitalization for the treatment of functional constipation is a leading cause among encounters that incur a financial loss at our institution. There are few resources that describe best practices or quality improvement efforts in the management of children who are hospitalized with functional constipation. A clinical pathway was implemented to promote interventions that improve hospital resource utilization for this group of children. Design / Methods: A clinical pathway was developed by a multidisciplinary team of stakeholders. The pathway emphasized interventions known to improve resource utilization and believed to facilitate a more effective and efficient cleanout. The inpatient arm of the pathway was implemented on a 24-bed medical/surgical unit; members of the medical and clinical staff of this unit received education with dissemination of the pathway. An electronic order set was implemented concurrently to facilitate practitioners’ application of pathway recommendations. Plan-Do-Study-Act (PDSA) cycles were used to monitor process measures and outcomes. Inpatient utilization was selected as the primary outcome for this effort’s first iteration; length of stay and frequency of readmissions were monitored as a secondary outcome and balancing measure, respectively. Results: Pathway utilization reached 65% within two periods of implementation. Adherence to selected process measures exceeded 80% within two periods. Inpatient utilization demonstrated initial improvement, increasing from 20% at baseline to 50% post-implementation; however, it subsequently fell below baseline performance after third-party payers revised admission criteria during period 6. Length of stay and frequency of readmissions remained unchanged post-intervention. Conclusion / Discussion: A clinical pathway for the treatment of functional constipation was quickly adopted by clinicians within two periods of implementation (spanning two months). The pathway was effective at promoting interventions that improved inpatient utilization; however, these improvements could not be sustained in the face of an unanticipated, external force. Future improvement cycles will be directed at reducing the length of stay to improve hospital resource utilization.

For aging populations age 65 years and older, lack of social engagement, or social isolation, is a public health issue that can have serious health implications. The ability to engage socially can decrease with aging populations due to many factors, such as health status and mobility. As social engagement decreases, the potential for serious diseases, such as dementia, increases. Limited social connections and engagement can be linked to healthcare utilization through increased rates of re-hospitalization as well as potentially decreased ability to and increased need to regularly access physician services. The aim of this research is to expand on the existing body of work in the area of care access and social isolation among aging populations, to examine the relationship between physician office visits and social activity and what differences may exist between those who live in urban and non-urban settings. A cross-sectional analysis was conducted using data from the Fall 2019 Medicare Current Beneficiary Survey (MCBS). The number of physician office visits participants have annually was the variable of primary interest. Physician visits were categorized dichotomously into moderate or no use and high use. Individuals with 11 or more visits were considered to be high utilizers within this data set and those with 10 visits or less as low. The key independent variables in this analysis are social activities and geography of the respondent. Social activities are defined has having social limitations, from respondents indicating limited activities most or all of the time in the past month, or low limitations, indication of some or no limitation of activities within the past month. Metropolitan Statistical Area (MSA) was used to categorize respondents as residing in an urban or rural community. The study population included 11,670 individuals over the age of 65. Approximately 15% of respondents were categorized as high health service utilizers and 85% were low or average. Only 7% of respondents were noted as having high levels of restrictions on social activities. The majority (81%) of respondents were classified as residing in a metro area compared to 19% residing in non-metro areas. High restrictions on social activities were associated with higher numbers of physician visits Approximately 10.6% of individuals with high social restrictions were also categorized as having higher numbers of physician visits compared to 6.6% among those with low social restrictions (OR=1.667; 95%CI: 1.47-1.89). No associations between geography and physician visits were noted. This study found a relationship between restricted social engagement and higher utilization of physician services. These findings were not consistent when adjusting for additional covariates of interest. Because poor general health can play a large part in both the ability to engage socially and high utilization of physician visits in aging populations, these findings underscore the importance of enhancing community services and opportunities for social engagement as health policy tools for improving health and quality of life for aging individuals.

Thesis (Ph. D.)--University of Alabama at Birmingham, 2006. / Title from first page of PDF file (viewed Feb. 14, 2008). Includes bibliographical references (p. 97-100).

Thesis (M.A. (Population and Reproductive Health Research))--Mahidol University, 2006. / LICL has E-Thesis 0016 ; please contact computer services.

Thesis (Ph. D.)--University of Missouri--Columbia, 1998. / Typescript. Vita. Includes bibliographical references (leaves : 67-70). Also available on the Internet.

High blood pressure (BP) is the most significant risk factor for cardiovascular disease and a major contributor to chronic disease burden in the United States. Chronic conditions are the most common reason for office-based physician visits among adults, accounting for 37% of all visits. Home BP monitoring when combined with clinical support may help engagement with care and improve condition control. This study examines the extent to which home BP measurement is associated with total office visits among Medicare beneficiaries with self-reported high BP and the influence by other related factors. The 2018 Medicare Current Beneficiary Survey (MCBS) was used in the study. The study population consists of Medicare beneficiaries (n=4,456) with self-reported high BP who had at least one total office visit in the year. Total office visits served as the outcome and were dichotomized to low (1-5 visits) and high (greater than 5 visits), while self-reported home BP measurement was the primary independent variable. Andersen’s conceptual framework was used to establish the co-variates [Predisposing factors: age, gender, race, education; Enabling factors: insurance plan (Medicare Advantage, MA), income, patients’ satisfaction (a. quality, b. information); Individual needs: smoking, BMI; Environment: region]. Bivariate analysis using a chi-square test for independence, unadjusted and adjusted logistic regression was conducted using SAS v 9.4. Of the study population, 57.9% reported measuring blood pressure at home. Approximately 95.6% and 94.2% of beneficiaries were satisfied with the quality of care received and information about their symptoms respectively. Bivariate analysis showed a significant relationship between total office visits and home BP measurement (p<0.05). Unadjusted logistic regression results noted that those who reported home BP measurement had increased odds of high total office visits [uOR: 1.17 (1.02-1.33)]. This relationship was slightly increased in the adjusted analysis when accounting for other factors of interest [aOR:1.22 (1.06- 1.40)]. Those aged 65-74 years had reduced odds [aOR: 0.77 (0.61 -0.98)], females had increased odds [aOR: 1.38 (1.19 – 1.61)], and those with higher education had increased odds [aOR: 1.41 (1.14 -1.75)] of high total office visits. Those not enrolled in MA [aOR: 3.37 (2.31- 4.90)] and those who earn $25,000 or more [aOR: 1.23 (1.04 -1.45)] had increased odds of high total office visits. Those who have never smoked [aOR: 0.81 (0.69-0.94)] and those from the non-metro region [aOR: 0.65 (0.56-0.76)] had reduced odds of high total office visits. We conclude that those who engage in home BP monitoring are more likely to have a high number of total office visits. The use of home BP monitoring could reflect the severity of high BP suggesting the need for regular follow-up and frequent use of services. Further studies that explore this association are recommended.

Universal Newborn Hearing Screenings have largely been successful since the National Institute if Health Consensus Development recommended, in 1996, that all infants should receive a newborn hearing screening prior to hospital discharge. Currently, the implementation of newborn hearing screening programs is varied across states and hospitals in the U.S. Due to this high variability, it is the responsibility of each individual hospital to formulate and consistently maintain a protocol for their newborn hearing screening program. This can create a great burden among hospitals as they must obtain the appropriate equipment, as well as employ and train screeners. However, national medical groups may be utilized to alleviate this burden. These medical groups supply the equipment, and more importantly, employ and train the screeners. This not only alleviates the burden on hospitals, but also provides a degree of standardization across newborn hearing screening programs which may reduce lost-to-follow-up statistics. Hospitals who do not utilize a national medical group may not have the expertise to formulate a comprehensive newborn hearing screening protocol. Our study is interested in examining if birthing hospitals that utilize a national medical group have more standardized medical protocols and have better (lower) lost-to-follow-up statistics. A survey was administered to current universal newborn hearing screeners employed at five hospitals across the eastern region of Tennessee. The survey examined various aspects of a typical newborn hearing screening program including training protocols and requirements, screening equipment, data recording and tracking, and methods of delivery of test results. In our presentation, we will be sharing the results of this study and interpret the data in light of determining best practices for newborn hearing screenings.

Both audiologists and hearing instrument specialists (HIS) can assess hearing loss and fit hearing aids; consumers interested in purchasing hearing aids can choose the type of hearing professional they see. However, there are vast differences in required training and scope of practice for each professional and advanced test batteries, such as those associated with vestibular assessment and tinnitus management, may distinguish the two professional groups more thoroughly than standard hearing testing and hearing aid fitting. This study aimed to determine the knowledge and opinions the average individual possesses regarding differences between these two types of hearing professionals in order to identify areas in which audiologists can more effectively differentiate themselves from hearing instrument specialists. A one-time survey was administered at 3 locations to a total of 47 English-speaking participants over the age of 18. Locations included the 2018 Remote Area Medical event in Gray, TN; the Johnson City Senior Center, and the Bristol Public Library. The survey consisted of 8 demographic questions with 3 additional questions if the participant wore hearing aids, followed by 18 questions that covered “Diagnostics,” “Intervention,” and “Interpersonal Patient Interactions.” Responses were analyzed for trends in overall data as well as in sub-categories for gender, household income, education level, age, and hearing aid use. Overall, participants tended to believe audiologists were most likely to perform tasks in the “Diagnostic” category, while a majority of participants believed both professionals could perform tasks in the “Intervention” category. There was no clear trend within the “Interpersonal Patient Interactions” category. Most participants believed that either both professional groups, or only audiologists, could perform most tasks adequately, indicating subjects likely do understand differences between the two professionals. In analyzing results, two issues emerged. The first was that the majority of participants believed that they would not be likely to pay a reasonable price for hearing aids when visiting either professional. One reason may be that only a few hearing aid companies produce most of the world’s hearing aids, leaving little room for low-cost competition. The “bundled” method which most hearing healthcare providers use for selling hearing aids along with services might also exert an influence on the perception of hearing aid pricing and may not be clear to patients who try to understand the actual cost of devices and services. Another issue identified in this survey was access. A significant number of respondents believed it was difficult to make and attend appointments with either professional, signifying a possible deficit in this area in access to hearing healthcare. The barriers to access included income, availability of transportation, inconvenient provider hours, and lack of insurance coverage. The results suggested that audiologists and HISs face challenges when recommending personal hearing devices to support rehabilitative efforts. Additionally, the provision of services that utilize advanced diagnostic batteries, such as balance assessment and tinnitus services, may offer audiologists an opportunity to distinguish their practices from those managed by HISs.

Introduction: Cardiovascular diseases (CVD) remain the leading cause of death in the United States (U.S.), accounting for one in three deaths annually. Within the U.S., disparities in CVD outcomes and risk factors exist across demographic groups and geographic areas, such as the Central Appalachian region where the burden is higher than state and national rates. Patient-centered care (PCC), is a model of health care delivery that has been shown to improves disease outcomes and quality of life, and is critical in addressing disparities in health care. However, little is known about how high-risk Central Appalachian populations understand or perceive such a model. As such, the objective of this study was to examine the perceptions of PCC among community-dwelling CVD patients/caregivers in the region. Methods: A qualitative study design applying thematic analysis was utilized for data collection and analysis. Seven focus group discussions across six states in Central Appalachia were conducted, and comprised of 78 middle-aged participants selected through purposive sampling. Sessions were guided by standardized instrument regarding current efforts in their communities concerning CVD; challenges and needs; appropriate approaches to their cardiovascular issues; understanding and views about patient-centeredness; and related priorities. The discussions were audio-recorded, transcribed, and then coded for thematic analysis using NVivo qualitative data analysis software. Dependability of data analysis was achieved through an audit trail tracking the NVivo process. Results: Data analysis identified interpersonal relationships with health care providers (HCPs) as the most important aspect of PCC among participants. When asked what PCC meant to them, each group discussed the interpersonal relationship they wanted from HCPs, barriers that kept them from achieving this relationship, and how it impacted their care. Within this theme, two overarching subthemes emerged: (1) developing long-term relationships with HCPs, and (2) developing partnerships with HCPs. The first theme had subthemes that included: turnover of HCPs in their geographical location, the disappearance of family physicians, and preferences related to seeing a physician versus a physician’s assistant or nurse practitioner. The second theme’s subthemes included: communication, feeling cared for as an individual, and input into care. Conclusion: Patients/caregivers stressed the importance of interpersonal relationships with providers in the delivery of PCC. However, patients recognized when PCC was not being provided, provided examples of interactions that were not conducive to providing PCC, and reported feeling disempowered as a person and a patient. The results of this research can be utilized to understand patient/caregiver perceptions of PCC, and indicates the need for further research to reconcile these viewpoints with those of providers to improve the delivery of care, and health outcomes.