<p> <b>Background:</b> Obesity has recently been classified by the American Medical Association (AMA) as a disease which, if unrecognized and unaddressed in childhood, causes multiple medical and psychological complications that can impact both personal and population health. Unprecedented funding is being invested in electronic health records to improve quality, safety, and delivery of healthcare and reduce healthcare costs. Scant literature has evaluated the use of aids in the electronic health record (EHR) to identify obesity. </p><p> <b>Objectives:</b> The purpose of this study was to determine to what extent the tools available in an EHR for automatic Body Mass Index (BMI) calculation based on height and weight documentation are used by pediatricians to correctly identify obesity in children. Secondary objectives were to evaluate quality of data input (discrete vs. free text) and see if there is any variation in rates of identification among patients of different socio-demographic characteristics and trainees of different levels. </p><p> <b>Methods:</b> We conducted a retrospective chart review for patients aged 2&ndash;18 years seen for a well-child visit at New York Presbyterian Hospital between January 2011 and January 2014, where it is standard practice at these visits to take height and weight measurements. The EHR automatically populates these values onto growth curves, converting them into BMI with percentiles. Standardized definitions from the Centers for Disease Control and Prevention (CDC) 2010 were used to qualify overweight and obese based on BMI. We determined the percentage of patients who were overweight or obese (based on CDC percentiles) that had the diagnosis identified by the pediatrician, and then assessed the quality of data input. We assessed laboratory follow up and referrals for all patients, and assessed for demographic differences among patients properly and not properly documented by providers as obese or overweight. </p><p> <b>Results:</b> We reviewed 700 charts in total. Inclusion criteria were all of the patients who had a BMI between 85&ndash;95% (these were grouped as overweight) and a BMI over 95% (obese). 209 patients were overweight or obese and therefore eligible for inclusion. Of the 209 clinically overweight/obese children, 72.2% had some form of documentation of this diagnosis, although the diagnosis was documented more often in the obese vs. overweight child. The diagnosis was most often captured electronically in the free text progress note. Over half of clinically overweight/obese children aged &ge;8 years did not receive follow-up standard laboratory testing, and only about one-quarter of clinically overweight/obese children had documented in-office nutrition guidance. Diagnosis of overweight was higher in females, but it was almost twice as likely that an obese male would be documented as such. Results showed no identification variation based on age or race/ethnicity. There was no difference in recognition of obesity/overweight based on postgraduate year (PGY) or nurse practitioner (NP) status. </p><p> <b>Conclusion:</b> Despite its importance as a public health priority for children, automatic calculation of BMI by use of an EHR led to documentation by a provider as a child being overweight/obese only three quarters of the time. This study suggests that despite increasing focus on using EHRs to improve individual and population health, including for obesity, clinical decision support remains underutilized.</p>

<p> Organizational work climates in healthcare organizations were described in the literature using a social framework of structured interactions, defined roles, and behavioral responses between team members of physicians and nurses. It was hypothesized that the characteristics of physician-nurse collaboration, physician dominance, and nurse autonomy in socially complex work settings have relationships to turnover intent in nurses who work in operating room settings. In an era of nursing shortages the challenge of nurse retention and the evidence of challenging work climate become even more critical for healthcare organizations. This research study examined a gap in knowledge regarding the extent to which aspects of organizational work climate predict nurse turnover in operating room work settings. A quantitative correlational study using three work climate characteristics of physician-nurse collaboration, physician dominance, and nurse autonomy was conducted using the Jefferson Scale of Attitudes Toward Physician-Nurse Collaboration (Hojat &amp; Herman, 1985, <i>Developing an Instrument to Measure Attitudes toward Nurses: Preliminary Psychometric Findings</i>) and the Anticipated Turnover Scale (Hinshaw &amp; Atwood, 1983, <i>Nursing Staff Turnover, Stress, and Satisfaction: Models, Measures, and Management</i>). Responses from 322 Operating Room staff nurses who were members of a national professional nursing organization were examined in the analyses. The study concluded that the independent variables of collaboration, dominance, and autonomy were not significant in predicting turnover among nurses in the operating room setting.</p>

<p> In today's modern world of medicine, most, if not all, physician employment contracts contain non-compete clauses. Non-competes, also known as restrictive covenants, essentially function as restraints on trade. Non-competes act as a restraint in the medical arena by preventing physicians from taking patients with them when physicians begin new employment or, alternatively, depart on a self-employment basis. They also restrain physicians from competitively practicing medicine in a predetermined geographic area for a specified period of time. </p><p> Restraints on trade have a long noteworthy history. One case that emphasized the importance of having checks and balances on such restraints is Lochner v. New York. While not relating to the practice of medicine and non-compete provisions, Lochner is nonetheless an important case to the analysis of non-compete provisions in physician employment contracts. Lochner is necessary to the discussion of non-competes because it emphasizes how the history of restrictions on restraints on trade have changed so that now private parties, and not just the government, are allowed to implement restrictions. Additionally, these restrictions vary depending on the profession and where professionals practice. </p><p> Non-compete provisions are found in contracts created by both small private medical practices, as well as bigger entities, such as hospitals and managed care organizations. Therefore, this is not an issue limited to the size of the practice. The physician-patient relationship has gradually become more and more of an impersonal one due to managed care organizations and legislation such as the Affordable Care Act (ACA). This does not, however, mean that physicians and patients approve of this interference and push towards an impersonal relationship. Thus, if patients are unhappy with the resulting impersonal relationship from managed care plans and legislation, patients may suffer further from these non-compete clauses interfering with the patients' utilization of physician services. </p><p> These clauses hurt not only the physicians trying to practice, but also have the capacity to conflict with patient choice in regard to selecting the physician they want for treatment purposes. More importantly, such non-competes negatively interfere with the continuity of patient care. It is for these aforementioned reasons that it would behoove the American Medical Association (AMA) to model its non-compete guidelines after those found in the American Bar Association (ABA), which strictly limit the use of such non-compete provisions in attorney employment contracts.</p>

The objective of this dissertation is to estimate the health and economic outcomes associated with two prominent child health conditions: autism spectrum disorder and influenza illness. Chapter 1 derives utility values associated with the health of children with autism spectrum disorder (ASD) and their parents. Our findings suggest that ASD has a large impact on the health-related quality of life of children and their caregivers, and that this impact is influenced by both the child’s specific diagnosis and the severity of their core social communication and repetitive behavior symptoms. Chapter 2 estimates the annual incremental costs associated with caring for a child with ASD from the societal perspective. Our findings suggest that there is a large economic burden both in terms of formal costs (healthcare, school and other direct costs of care) as well as the informal time costs of caregiving. Specifically, the societal costs of caring for this population amounted to $9.1 billion in 2011 alone, highlighting the tremendous financial challenges our society faces in meeting the needs of children with ASD. Chapter 3 uses a decision analytic model to evaluate 1-year clinical and economic outcomes associated with oseltamivir treatment for seasonal influenza in children, and considers the impact of oseltamivir resistance on these findings. Our results indicate that for unvaccinated children who present to their physician’s office with influenza-like symptoms, empiric antiviral treatment with oseltamivir appears to be a cost-effective treatment option. This is particularly true for ill children aged 1 to 12 years, but results are dependent on the prevalence of circulating seasonal influenza viruses that are resistant to oseltamivir.

In 1999 New York enacted Kendra's Law, in memory of Kendra Webdale, a young woman who was pushed to her death in front of an oncoming train by a man with untreated schizophrenia. Under Kendra's Law a court can order a person with a mental illness to participate in an "assisted outpatient treatment" (AOT) program. Kendra's Law includes a number of procedural due process protections including the right to a hearing and the right to counsel. Still critics argue that people with mental illnesses are routinely ordered to participate in the AOT program based on no more than "a bare recital of the statutory criteria." The first essay in this dissertation, Outpatient Commitment and Procedural Due Process, reports the findings from a study on procedural due process and assisted outpatient treatment hearings under Kendra's Law. Findings from this study suggest that despite the shift from a medical model of civil commitment to a judicial model in the late 1970s, by and large judges continue to accord great deference to clinical testimony. A second paper, Rethinking Kendra's Law, addresses the ethical dilemmas that arise when courts impose AOT over the patient's objection. The third paper of this dissertation, Public Assistance, Drug Testing and the Law, addresses the Fourth Amendment questions that arise when states condition public assistance benefits on passing a suspicionless drug test. To date eight states—including Florida, Georgia and Missouri—condition public assistance benefits on passing a drug test. Proposals to condition public assistance on passing a drug test have also appeared in Congress. However, without a genuine threat to public health or public safety, proposals to condition public assistance on passing a drug test without individualized suspicion of drug use are unreasonable under the Fourth Amendment. Even if the Supreme Court were to recognize special needs beyond a genuine threat to public health or public safety, policies that result in withholding public assistance benefits from people who abuse illegal drugs are likely to make many social problems much worse.

<p> The Kingdom of Swaziland is a small African nation with an HIV prevalence rate of 27.4% in adults and up to 39% in pregnant women (Global Health Observatory, 2014). In 2012, life expectancy for a woman in Swaziland was 55-years (World Health Organization, 2014). Health entails more than the absence of disease. Although considered a lower middle-income country, 69% of Swazi citizens live in poverty and nearly one-third live in extremely poor circumstances. The degree to which upstream factors such as social conditions and the cultural environment impact individuals tends to be minimized in Westernized models of health behavior. The purpose of this study was to examine the sociocultural factors that impact self-care and health maintenance of women in Swaziland. The goals related to this were to uncover the salient cultural values, beliefs and attitudes that affect the health of Swazi women, and to develop a deeper understanding of how strongly embedded cultural values are a determinant of health outcomes. Using Carspecken&rsquo;s methodology of critical ethnography, which incorporates both observational and narrative methods, this study focused intensively on the life stories of four rural African women. The findings richly illustrate how social issues such as poverty and food insecurity impact the health of women and their children; and how traditional customs and practices both support and threaten the health of women and families. Women in this study experienced a loss of husband or extended family due to death or abandonment that resulted in losses in supports and resources. Additionally, they worried about the health and education of their children before personal health needs. They also reported chronic employment problems and mistrust in existing governmental agencies including the healthcare system. Application of the culturally sensitive Person-Environment-Neighborhood (PEN-3) model highlights areas of resilience, strengths, and resource targets and identifies the community as an appropriate entry level for health interventions.</p>

<p> Contemporary commercial music (CCM) singers may be at a high risk for voice damage due to their increased vocal demands and the chronic exposure to chemical irritants associated with unhealthy lifestyle choices. Continuous mechanical damage, confounded with chemical trauma, has detrimental effects on the biomechanical properties of the vocal folds. Prior research on CCM singers has been limited, with efforts focused on physiologic aspects of voice production. The objective of the study was to report on the lifestyle choices of CCM singers and evaluate their vocal abilities according to healthy vs. unhealthy profile status via acoustic analyses as well as auditory perceptual assessments. The second objective was to evaluate if there were differences in lung volume associated with healthy vs. unhealthy lifestyle profiles. </p><p> Thirteen CCM singers participated in the study where they were assigned to either a healthy or unhealthy lifestyle vocal profile. Acoustic analyses of sound pressure level (SPL), signal-to-noise ratio (SNR), fundamental frequency (F0), and jitter/shimmer were collected during a prolonged singing /i/ in isolation as well as a singing /i/ in context of the &ldquo;Star Spangled Banner&rdquo; at three different vocal intensities <i>(low, comfortable, high)</i>. Lung volume was recorded via a vital capacity maneuver. Voice recordings were then rated via an auditory perceptual assessment (CAPE-V). Results were compared with a Wilcoxon rank-sum test. </p><p> Differences with regard to group trends were observed across all dependent measures. SNR median values for unhealthy singers were significantly lower in both singing tasks during <i>low</i> vocal intensity (p&lt;0.05), with differences approaching significance found during prolonged singing /i/ in isolation at <i>comfortable</i> vocal intensity (p&lt;0.10). F0 analysis noted significantly lower median values for unhealthy singers during isolated /i/ productions at <i>low</i> vocal intensity (p&lt;0.05). Jitter analysis among unhealthy singers showed significantly higher median values during isolated /i/ productions at <i>comfortable</i> vocal intensity (p&lt;0.05), with differences approaching significance found during singing /i/ in context at <i>low</i> vocal intensity (p&lt;0.10). Shimmer analysis among unhealthy singers showed significantly higher median values during isolated /i/ productions at low and comfortable vocal intensity (p&lt;0.05), with differences approaching significance found during singing /i/ in context at low vocal intensity (p&lt;0.10). Unhealthy singers showed lower vital capacity as compared to healthy singers, however results were nonsignificant (p>0.05). Auditory perceptual assessment of voice was perceived to be essentially normal for all participants regardless of healthy versus unhealthy profile status. </p><p> The findings provide a descriptive profile of contemporary commercial music singers and contribute to the existing literature on the harmful effects of exposure to cigarette smoke on voice production. Unhealthy singers displayed significant acoustic differences most often observed in <i>low</i> vocal intensity conditions, which suggest a decreased vocal ability. This may be explained by their repeated exposure to chemical irritants (i.e. cigarette smoke) and possible phonotrauma, causing changes in the biomechanical properties of the vocal folds. Given the disparity between acoustic measures and auditory perceptual assessment, it was concluded that the biomechanical changes might be in the early onset and suggest future voice difficulties.</p>

In this thesis we discuss three models that are used to estimate vehicle busy probabilities when call service time depends on call location and the serving vehicle. The first model requires an assumption that each vehicle operates independently of the other vehicles. The second model approximately corrects for the independence assumption. The third model also approximately corrects for the independence assumption, however it assumes that all vehicles have an equal busy probability. We evaluate model bias by comparing the estimates from each model with estimates from a simulation model. We use extremely long runs to ensure that the simulation is both accurate and precise. Our results suggest that the model using the independence assumption performs poorly as the system utilization increases. The correction models, however, perform well over a wide range of system sizes and utilizations. (Abstract shortened with permission of author.)

<p>An important factor in the rise of health care costs is the structure and performance of health care markets. This is an area in which policy can be particularly effective. Health care markets are characterized by complex interactions between consumers, physicians, insurers, facilities, and government agencies. Physicians, insurers, and facilities operate under a mix of objectives and governance structures. The many varieties of objectives, and governance structures can be broadly categorized as for-profit, not-for-profit, and governmental. </p><p> In the three chapters that follow I construct a theoretical framework to analyze hospital behavior and use a 30 year panel of data on Californian hospitals to assess the validity of the models and to identify the impact of governance structure on behavior. Chapter II addresses firm objectives. I find that firms have a continuum of weighting allocations, with for-profit firms placing greater weight on profit, government firms placing greater weight on social objectives, and not-for-profit firms locating in a middle ground. All three types of governance structures display overlap in their objectives. </p><p> In Chapter III, I identify patterns in hospital entry and exit. Like most manufacturing industries, entering hospitals are significantly smaller than incumbent hospitals and exiting hospitals are significantly smaller than surviving hospitals. The patterns of entry and exit for hospitals vary systematically with both governance structure and geographic diversification. </p><p> In Chapter IV, I develop a model of hospital entry that explains heterogeneous entry size and firm survival. I find entry size to be a relatively important factor in firm survival. In general entering on a larger scale increases the probability of survival. Despite this fact many firms enter relatively small. The model that I develop resolves small entry as a rational choice for uncertain firms. </p>

<p> <b>Introduction:</b> Human biospecimens such as surgical tissue and blood are essential for some types of biomedical research because they contain genetic material (genes contained in living organisms). Because of their genetic content, biospecimens are able to add great value to fields of study such as genomics, molecular biology and biological chemistry. Increasing knowledge in these fields holds promise for improving healthcare for individual patients (precision medicine), as well as the broader healthcare community. These genetic materials obtained from patient donors are procured, stored and dispersed through a complex operation called biobanking. Biobanking systems are involved with two primary functions, 1) procure sufficient quantities of human biospecimens allowing researchers the materials required to answer scientific questions, and 2) capture relevant corresponding clinical and phenotypic information for eventual correlation with scientific results. This capture and manipulation of corresponding information (e.g. clinical, pathological, and environmental) are where the value of the biospecimens are maximized for research purposes. The complexity of biobanking requires informatics to integrate the biospecimen-related information with corresponding clinical and phenotypic data. In designing biobanking systems, informatics must be considered as they play a vital role in managing the samples and data in a timely fashion as well as reducing the costs associated with biobanking. </p><p> <b>Background:</b> Biobanks are resources that play a key role in the procurement, processing, storage and dispersal of human biospecimens. Collections of human tissue have been a common place in hospitals and specialist clinics since the nineteenth century when preservation techniques were introduced. Governance concerning these human biobanks has evolved and is set by institutional, regional, national and international policy. They can be public (e.g. non-profit, academic, governmental), private (e.g. for-profit or pharmaceutical industry) or public-private partnerships. Regardless of the governance level or specific research focus of the biobank, the next generation of biobanking resources will require interdisciplinary collaborations and integrated informatics approaches to accelerate the procurement and use of the research biospecimens. </p><p> <b>Methods:</b> A literature search was conducted to explore biobanking informatics configurations and architecture to determine the context and extent of the software applications utilized in current biobanking systems. There were a substantial number of publications describing informatics architecture and their export of data to a Virtual Data Warehouse or Centralized Research Data Repository. However, there was a lack of published literature specifically describing use of an enterprise-wide electronic health record (EHR) in the initial three upstream workflows (i.e. clinical, pathology and biobank) involved with most institutional biobanking systems. Patient data generated/utilized in these three workflows are manually double-entered into separate information applications as there is no direct data exchange/export between EHR and the Laboratory Information System (LIS) or the Biorepository Information Management System (BIMS) specifically to assist with biobank procurement. Therefore, an EHR integrated-access informatics model was designed that would maximize benefits created by the EHRs capabilities in the upstream workflows of an institutional biobanking system. The approach described in the thesis was designed and documented using a model driven UML tool and incorporates an EHR integrated-access approach along with inter-departmental workflow processes. Interoperability gaps were identified that could take advantage of institutional EHR software existing at most large academic healthcare institutions or teaching hospitals. This model synergistically integrates the EHR, LIS and BIMS to maximize information exchange during the upstream biospecimen procurement workflow. This informatics model for institutional biobanking is based on the premise that commercial software applications are already implemented at most large academic healthcare facilities and they can be utilized within their biobanking systems. </p><p> <b>Conclusion:</b> This EHR integrated-access model would enhance sharing of key research data between three software applications (EHR, LIS, BIMS) that are available at most large academic medical centers that perform research biobanking. The informatics model would promote data exchange between processes of three primary biobanking steps in the clinic, pathology department and biobank improving efficiency and increasing biospecimen procurement. Large healthcare facilities who have EHR, LIS and BIMS applications available could utilize this EHR integrated-access model as a first-step in improving their biobanking informatics workflow to increase high-quality biospecimen collections. New methodologies that improve the success of biobanks can eventually lead to institutional biobanking systems playing a major role in a path to personalized medicine.</p>