A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / Previous studies have shown that Parkinson’s disease (PD) patients are at an increased risk for a variety of complications impacting health related quality of life (HRQoL). Additionally, these various complications often lead to increased healthcare utilization. Wellness intervention in PD has shown to be effective in improving HRQoL and objective measures of disease burden such as motor functioning. What has not been demonstrated to date is whether patients who are given the opportunity to participate in regularly administered classes in these modalities will continue to attend and whether benefits will continue to be realized outside the strict confines of a controlled trial. This study examined whether intervening early in PD with a comprehensive Wellness Program is feasible and promotes lasting habits that will continue to provide sustained benefit. It was hypothesized that intervening early in PD with an intensive program involving structured exercise, socialization and PD specific education would serve to maintain or improve subject’s quality of life while decreasing healthcare utilization. Twenty‐one consenting ambulatory adult subjects diagnosed with PD within the last five years completed various screenings at baseline and following a required 6‐month Wellness Program intervention. Subjects were assessed at 12 and 18 months if they continued to participate. Patient demographics, disease specific quality of life, objective mobility, healthcare utilization and falls were assessed. Data were collected at Banner Sun Health Research Institute, located in Sun City, Arizona. All p‐values were 2‐tailed and P<0.05 was considered statistically significant. All data analyses were conducted using STATA‐14. Twenty of twenty‐one subjects completed the required 6‐month intervention. Continued participation was 70% at 12 months and 60% at 18 months. Overall HRQoL was stable at 18 months. Significant improvement was seen in patient reported mobility and emotion sub‐areas at 12 months. Communication specific HRQoL was significantly worsened at 12 months. Subjects demonstrated a stable level of physical activity while fatigue was significantly decreased. All objective measures were significantly improved from baseline. Healthcare utilization was decreased by 18 months. A total of 5 falls were reported by 3 subjects during the 6‐month interventional period. This pilot study demonstrates that comprehensive wellness intervention in early PD is feasible, effective, safe and valuable in establishing long‐term beneficial habits while potentially reducing healthcare utilization. The significant long‐term subject participation observed in this study establishes that wellness intervention may be practical for large scale implementation. The results also highlight the importance of addressing communication specific symptoms early in the course of the disease. Ultimately, this study will aid the design and implementation of future PD wellness interventions.

Background: Diabetes is a common and serious chronic condition. If not well-managed, significant multi-system complications often arise, resulting in increased health care utilization and poor health outcomes. There is considerable evidence that people with diagnosed diabetes are not receiving recommended care. A comprehensive program aimed at improving adherence to recommended care can improve patient outcomes and result in cost-savings. The key aim of this study was to determine whether the long-term receipt of appropriate clinical procedures by patients with type 2 diabetes was associated with higher medical care costs. Methodology: A cohort of 20,288 diagnosed type 2 diabetes patients was identified using physician and hospital records. An analytic file was created by linking information on patient characteristics with utilization of physician and acute care services during a five-year period (1996 to 2001). Adherence to recommended clinical procedures for the assessment of blood glucose, blood pressure and cholesterol levels, as well as retinopathy and nephropathy, were measured during this same five-year period. Subjects were assigned to both a categorical (low, medium and high) and a binary (low and high) adherence group. Physician and acute care resource use was converted to constant 2000 Canadian dollars. Multivariate logistic regression was used to assess the relationship between patient characteristics, including adherence as a categorical variable, and utilization of physician and acute care services. Results: Long-term adherence was suboptimal, with patients receiving just 53% of recommended procedures. Adherence to recommended procedures, however, improved during the five year period. Patient characteristics associated with poor adherence include being male, younger, low socio-economic status, having no diabetes-specific complicating conditions and living in certain geographic areas. Patients with high long-term adherence (receiving 73% of recommended clinical procedures) were 59% more likely to use a high level of physician resources but 22% less likely to use a high level of acute care resources. On the other hand, patients with low adherence (receiving 31% of procedures) were 28% less likely to use a high level of physician resources but 17% more likely to use a high level of acute care resources. The utilization difference related to adherence was particularly noticeable in older adults with higher levels of morbidity. Elderly patients in this low adherence group were more likely to be hospitalized (64.3% vs. 55.8% over the five-year period) and, when they were hospitalized, tended to stay in hospital for longer periods of time (11.9 vs. 6.7 days) than patients in the high adherence group. Conclusion: Improving long-term adherence may result in the avoidance of $4 in acute care costs for every additional $1 in physician costs. If all patients moved into the high adherence category, as much as $3.1 million in annual costs might be avoided across the study sample. If this analysis is applied to all adults with diagnosed diabetes in the province of British Columbia, the annual costs avoided could reach the level of $34.4 million. Systemic changes are required in the provision of primary care to promote long-term adherence to recommended diabetes care.

Background: Diabetes is a common and serious chronic condition. If not well-managed, significant multi-system complications often arise, resulting in increased health care utilization and poor health outcomes. There is considerable evidence that people with diagnosed diabetes are not receiving recommended care. A comprehensive program aimed at improving adherence to recommended care can improve patient outcomes and result in cost-savings. The key aim of this study was to determine whether the long-term receipt of appropriate clinical procedures by patients with type 2 diabetes was associated with higher medical care costs. Methodology: A cohort of 20,288 diagnosed type 2 diabetes patients was identified using physician and hospital records. An analytic file was created by linking information on patient characteristics with utilization of physician and acute care services during a five-year period (1996 to 2001). Adherence to recommended clinical procedures for the assessment of blood glucose, blood pressure and cholesterol levels, as well as retinopathy and nephropathy, were measured during this same five-year period. Subjects were assigned to both a categorical (low, medium and high) and a binary (low and high) adherence group. Physician and acute care resource use was converted to constant 2000 Canadian dollars. Multivariate logistic regression was used to assess the relationship between patient characteristics, including adherence as a categorical variable, and utilization of physician and acute care services. Results: Long-term adherence was suboptimal, with patients receiving just 53% of recommended procedures. Adherence to recommended procedures, however, improved during the five year period. Patient characteristics associated with poor adherence include being male, younger, low socio-economic status, having no diabetes-specific complicating conditions and living in certain geographic areas. Patients with high long-term adherence (receiving 73% of recommended clinical procedures) were 59% more likely to use a high level of physician resources but 22% less likely to use a high level of acute care resources. On the other hand, patients with low adherence (receiving 31% of procedures) were 28% less likely to use a high level of physician resources but 17% more likely to use a high level of acute care resources. The utilization difference related to adherence was particularly noticeable in older adults with higher levels of morbidity. Elderly patients in this low adherence group were more likely to be hospitalized (64.3% vs. 55.8% over the five-year period) and, when they were hospitalized, tended to stay in hospital for longer periods of time (11.9 vs. 6.7 days) than patients in the high adherence group. Conclusion: Improving long-term adherence may result in the avoidance of $4 in acute care costs for every additional $1 in physician costs. If all patients moved into the high adherence category, as much as $3.1 million in annual costs might be avoided across the study sample. If this analysis is applied to all adults with diagnosed diabetes in the province of British Columbia, the annual costs avoided could reach the level of $34.4 million. Systemic changes are required in the provision of primary care to promote long-term adherence to recommended diabetes care.

No description available.

Transgender and gender-nonconforming (TGNC) individuals in the United States experience significant marginalization due to stigma enacted at the structural, interpersonal, and individual levels. As a result, this population has reported increased behavioral and physical health needs, as well as unique barriers to healthcare. Moreover, TGNC individuals have reported greater experiences of childhood abuse compared to cisgender individuals. The cumulative experiences of stigma-related stressors and adverse childhood experiences put this population at risk for the development of mental and physical health problems, increasing need for health services. However, TGNC individuals have reported being denied medical care and postponing seeking care due to fear of discrimination, which may increase complications and severity of illness, and result in increased hospitalizations and healthcare costs. Utilizing the Andersen Behavioral Model of Health Services Use and Theory of Planned Behavior, the current study examined robust associations among stigma-related stressors, adverse childhood experiences, personal and physician-related enabling factors, mental, behavioral, and physical health needs, and healthcare utilization, intention, and delay among an online convenience sample of 109 TGNC adults in the United States. A series of multivariate and mediational analyses were conducted to determine the connections among predisposing factors, enabling resources, needs, health beliefs, and healthcare intention, delay, and behavior. Although predisposing factors were not directly associated with healthcare behavior, they were directly associated with healthcare delay. Moreover, mediation analyses indicated an indirect effect of victimization and adverse childhood events to decreased healthcare utilization and increased delay through mental health needs, internalized stigma, negative personal beliefs, perceived TGNC-inclusivity of healthcare providers, and finally, behavioral intention. Thus, the present study illuminated a possible cascade of detrimental effects that are initiated by stigma-related stress and adverse childhood experiences through enabling resources, needs, and beliefs, that ultimately are associated with healthcare utilization intent, behavior, and delay. These findings highlight the need to address both TGNC individuals’ timely use of care, and the quality of care they receive. It is imperative that future research takes a multi-level approach by creating and testing evidence-based interventions to improve both healthcare providers’ competency, as well as for TGNC individuals’ ability to coping with stressors.

Chronic liver disease is an important disease which affects national healthy in Taiwan. Hepatitis B or C virus infection is strongly relative to chronic hepatitis, liver cirrhosis and hepatocellular carcinoma. However, the early effective treatment can decrease the progression of liver cirrhosis and hepatocellular carcinoma and increase the recovery rate. In order to promote the health care quality for the patients with hepatitis, Bureau of National Health Insurance (BNHI) implemented the ¡§Enhance Hepatitis B or C Health Care Program¡¨ in October of 2003. The new policy sets up the standard treatment models and pay medical costs to encourage the patients to participate this program and fit cost-effectiveness. Therefore, aims of the study are to estimate the effects of the new policy on health care utilization and expenditures for the patients with hepatitis B or C. The study used the database from Bureau of National Health Insurance (BNHI) in 2002 and 2004. The study sample is the patients with hepatitis B or C who enrolled the program from January to June in 2004. We compared the differences of health care utilization and expenditures with these statistics in 2002. Besides, we also analyzed the difference in the characteristics of the patients and hospitals. In health care utilization, we found that number of visits was increased but interval between visits was decreased. Total costs, costs of treatments, prescriptions, total claim amount, and averages of prescription costs in health care expenditures were all increased significantly after the new policy implemented. Otherwise, there were not different on health care utilization and expenditures between different gender and level of the hospitals. On the other hand, there were significantly correlation of ages and number of comorbility. It means that the patients¡¦ ages are older, and their number of visits and total costs are higher but interval between visits is shorter than younger. Furthermore, number of comorbility increases and then interval between visits become short. The new policy certainly affects the health care utilization and expenditures of patients with hepatitis B or C. Implementing the new program can encourage patients adopt treatment actively and physicians have standard treatment protocols to follow. Understanding the changes on health care utilization and expenditures can give a health care guideline of cost-effectiveness. In conclusion, the results can provide the information about payments on patients with hepatitis to BNHI and then use it to be a basis after the new program implemented. Moreover, other countries also can evaluate the implementation of the new policy based on our results.

Background: To curb the transmission of HIV/AIDS and other infectious diseases several studies indicate the need for improved access to medical care for injection drug users (IDUs) including those already linked to syringe exchange programs (SEPs). However, availability and access to services remains a problem for many IDUs. This study seeks to examine perceptions of medical care access among a pharmacy-based sample of IDUs, utilization of medical services among IDUs and, identify barriers to accessing health care services to help ensure that IDUs receive appropriate care when needed and reduce the transmission of diseases. Methods: Data was obtained from the Pharmacists As Resources Making Links to Community Services (PHARM-Link) study. Dependent variables: health care access to the same provider and receiving care a usual source, health care utilization of services including the emergency room, clinic, medical office, medical mobile unit and hospital; and health care barriers categorized as personal or structural. Independent variables were insurance status, homelessness in the prior six months, case management, drug treatment and socio-demographic characteristics such as age, sex, income, education and employment status. Descriptive statistics analysis and logistic regression were performed using SAS version 9.4 (2013) with significance set at p<0.05. Results: Our sample included 615 IDUs participating in the PHARM-Link study. Overall, IDUs accessed health services and having the same provider remained statistically higher among those with legal income above $5,000 OR: 1.60 (95% CI: 1.03- 2.48), the insured OR: 4.11 (95% CI: 2.48-6.79), and those with positive HIV status OR: 7.64 (95% CI: 3.18 – 18.36), while those who were homeless reported lower access to the same provider OR: 0.63 (95% CI: 0.43 – 0.92). Only the older age group OR: 2.85 (95% CI: 1.42-5.73) and the insured OR: 3.42 (95% CI: 1.81-6.46) remained significantly associated with more access to receiving health needs at the same location. Those with some college education had less frequent visits to the clinic OR: 0.59 (95% CI: 0.38-0.92) and medical office OR: 0.64 (95% CI: 0.41-0.99), while the homeless were more likely to visit the emergency room OR: 1.49 (95% CI: 1.06-2.11). Females were less likely to go to a mobile unit OR; 0.52 (95% CI: 0.33-0.83) and married people were more likely OR: 1.95 (95% CI: 0.28-0.91). Visit to the hospital were less likely among females OR: 0.54 (95% CI: 0.36-0.81) and among those with some college education OR: 0.63 (95% CI: 0.41-0.96). Those with legal income above $5,000 were less likely to have any personal barriers OR: 0.64 (95% CI: 0.45 – 0.92). Structural barriers remained more likely among those who were homeless OR: 1.62 (95% CI: 1.13-2.39), but less likely among those 44 years and older OR: 0.58 (95% CI: 0.40-0.85), the insured OR: 0.60 (95% CI: 0.38-0.94), those with positive HIV status OR: 0.53 (95% CI: 0.28-0.99), as well as Non-Hispanic Blacks OR: 0.47 (95% CI: 0.14-0.83) and Latinos OR: 0.47 (95% CI: 0.25-0.86). Conclusion: Our results suggest that most IDUs linked to care through pharmacy-based SEP programs established to expand health services and improve health, did access available health services. However, some continue to experience difficulties such as structural barriers among the homeless as well as few reported visits to the clinic, medical office and the hospital among the employed believed to have resources to pay for such services. These services may have been underutilized because the participants were unsatisfied with the services provided. Therefore, interventions should target structural barriers such as homelessness among IDUs as well as health insurance coverage to help increase access to and utilization of health services.

This study is an investigation of how experiences of discrimination, self-efficacy, and the associated outcome expectations influence health care utilization of young college students. The relationships tested were informed by Andersen’s Behavioral Model of Health Services Use (Andersen, 2008), the most widely used model to understand and predict health care utilization. Andersen proposed that health care utilization is influenced by predisposing (i.e., personal characteristics), enabling (i.e., income, insurance), and need (i.e., perception of illness) factors. However, his model has been criticized for not taking in consideration social factors and oversimplifying the role of ethnicity as a predictor (Bradley et al., 2002). The purpose of this study is to expand the explanatory power of Andersen’s model, by including psychosocial variables (e.g., discrimination, self-efficacy). One hundred and eighty-five students completed a 20 minute online survey, which included measures of experiences of discrimination, outcome expectations, self-efficacy, attitudes, and demographic variables. Results indicated that self-efficacy to communicate with physicians was a significant predictor of health care utilization, although experiences of discrimination were not. The effects of discrimination on health care utilization were further found to be mediated by self-efficacy to communicate with physicians. The present study's finding provided support for the inclusion of psychosocial variables (i.e., self-efficacy) in Andersen's model to increase its explanatory power.

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.

No description available.