<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>

No description available.

<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>

It is acknowledged that part of the failure to improve Indigenous health is due to the lack of participation of Indigenous people in national policy and decision making processes. In this three part study I investigated the nature of Indigenous people’s participation in national Indigenous health policy processes. I combined quantitative and qualitative methods through the perspective of policy networks. / The first part of the study was directed at the prominence of informal networks in the evolution of Indigenous affairs policy. I aimed to determine and describe the structural location of Indigenous people in an informal network of influential people. I administered a network survey questionnaire during the period 2003/04. In a snowball nomination process influential people nominated a total of 227 influential people. Of these, 173 people received surveys of which 44 people returned surveys, a return rate of 25 per cent. I analysed the data to detect the existence of network groups; measure the degree of group interconnectivity; measure the characteristics of bonds between influential people; and I used demographic information to characterise the network and its groups. I found a stable pattern of relationships in the three features of the informal network: the whole network was diverse, and the Indigenous people were integrated and embedded in the network. It would not have existed without Indigenous people due to a combination of their greater number, their distribution throughout the network groups, and the interconnections between the groups. I argued that the findings showed that Indigenous people were fundamental in this informal network of influential people. / The second part of the study was directed at the role of national health committees in engaging with advice about Indigenous health. I aimed to describe the structural location of Indigenous people in national health committees. Using internet sites I identified 121 national health committees at the end of 2003, and obtained information from 77 committees or 64 per cent of all committees. I calculated the proportion of members who were Indigenous within each committee; the proportion of committees which were Indigenous health committees; and constructed a visual representation of the formal reporting relationship between all the committees and Cabinet. I then determined the importance of each committee in terms of a committee network using eigenvector centrality scores. Finally, I identified the linking people between the informal network and the national health committees. I found that in a traditional hierarchical view that Indigenous people and Indigenous health committees were small in number and distant from Cabinet. In contrast a network view assumes that the importance of a committee depends on the combination of the number of interlocks, comembership, and betweenness with other committees. In this network view, Indigenous health committees were similarly located to other committees. A small number of elite knowledge brokers linked the informal networks and the national health committees. I argued that the findings showed a formal systemic deficiency in the strategic location of Indigenous people. / The third part of the study was directed at the significance of inter-personal bonds between influential people in influencing policy processes. I aimed to describe the interpersonal relationships between influential people through a semi-structured interview. The interview questions were designed to elicit responses in the broad context of knowledge and influence in national Indigenous health policy processes. From a list of 47 potential interviewees I obtained 34 interviews (a response rate of 72 per cent), transcribed 32 interviews and coded them thematically. I found that underlying the episodic meetings of national health committees was the constant activities of informal networking. The influential non-Indigenous people had to pass some rules of entry in order to engage in and utilise informal processes. The interviewees demonstrated a value of connectedness in interpersonal relationships through agreement with principles such as social models of health. However, advice about Indigenous health issues may need to be continually rediscovered as it remains anchored to local contexts in a macro context where advice faces pathways that are confusing and convoluted. I argued that the findings indicated a meta-level vacuum in conceptualising the relationship between the concepts of participation and advice in national Indigenous health policy processes. / The findings from the three parts indicated three characteristics of an ongoing meta-process (informal network), absence of a meta-perspective (national health committees), and a meta-concept of participation (interviews). I suggest that they form a meta-frame of participation. In this frame the energy dispersed in the many efforts at improving Indigenous peoples‟ participation are unfocussed because of multiple and uncoordinated policy origins. Therefore I concluded that the nature of participation of Indigenous people in national Indigenous health policy processes is one of unfocussed energy.

Thesis (Ph. D.)--University of Washington, 2003. / Vita. Includes bibliographical references (leaves 189-202).

Thesis (Ph.D.)--Australian National University, 2003.