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Objective: Treatment compliance in children with Crohn’s disease is associated with higher levels of symptom remission. We hypothesized that the management, comorbidities, and complications for children with Crohn’s disease would differ based on a diagnosis of noncompliance. Methods: Using the Kids’ Inpatient Database for 2006-2012, we identified young patients (<21 >years) with a diagnosis of Crohn’s disease. Diagnoses and procedures were analyzed according to a recorded diagnosis of noncompliance. Multivariable logistic regression analysis was performed to examine the association between noncompliance and the outcomes of interest. Results: There were 28,337 pediatric Crohn’s disease hospitalizations identified with 1,028 (3.6%) hospitalizations having a diagnosis of both Crohn’s disease and noncompliance. The mean age of the study population was 15.9 years and 48.9% were girls. Black patients ( multivariable adjusted odds ratio, aOR,2.27; 95% CI:1.84-2.79) and those in the lowest income quartile (aOR 1.57; 95% CI:1.20-2.05) had an increased likelihood of a noncompliance diagnosis than respective comparison groups. Noncompliant patients had an increased likelihood of concurrent depression, nutritional deficiency, and anemia. Patients with a diagnosis of noncompliance had lower rates of intestinal obstruction (4.0% vs 6.3%), intraabdominal abscesses (2.0% vs 4.2%,), and underwent fewer major surgical procedures (aOR 0.40; 95% CI:0.31-0.53) and large bowel resections (aOR 0.44; 95% CI:0.31-0.64) than patients without this diagnosis. Conclusions: We found significant differences in socioeconomic status and race among hospitalized children with Crohn’s disease with, as compared to those without, a diagnosis of noncompliance. Children with noncompliance have different comorbidities, disease-related complications, and are managed differently. Possible explanations for observed treatment differences include a reluctance to offer surgery to those with a diagnosis of noncompliance, a refusal of intervention by noncompliant patients, or implicit bias. Further investigation is warranted to better define noncompliance in this population and to determine the implications of this diagnosis.

Background Fewer than one-third of nursing home residents with atrial fibrillation were treated with the only available oral anticoagulant, warfarin, historically. Management of atrial fibrillation has transformed in recent years with the approval of 4 direct-acting oral anticoagulants (DOACs) since 2010. Methods Using the national Minimum Data Set 3.0 linked to Medicare Part A and D claims, we first described contemporary (2011-2016) warfarin and DOAC utilization in the nursing home population (Aim 1). In Aim 2, we linked residents to nursing home and county level data to study associations between resident, facility, county, and state characteristics and anticoagulant treatment. Using a new-user active comparator design, we then compared the incidence of safety (i.e., bleeding), effectiveness (i.e., ischemic stroke), and mortality outcomes between residents initiating DOACs versus warfarin (Aim 3). Results The proportion of residents with atrial fibrillation receiving treatment increased from 42.3% in 2011 to 47.8% as of December 31, 2016, at which time 48.2% of treated residents received DOACs. Demographic and clinical characteristics of residents using DOACs and warfarin were similar in 2016. Half of the 8,734 DOAC users received standard dosages and most were treated with apixaban (54.4%) or rivaroxaban (35.8%) in 2016. Compared with warfarin, bleeding rates were lower and ischemic stroke rates were higher for apixaban users. Ischemic stroke and bleeding rates for dabigatran and rivaroxaban were comparable to warfarin. Mortality rates were lower versus warfarin for each DOAC. Conclusions In nursing homes, DOACs are being used commonly and with equal or greater benefit than warfarin.

Background Monoclonal Gammopathy of Undetermined Significance (MGUS) is an understudied precursor of multiple myeloma (MM), the second most prevalent hematologic malignancy in the United States. This dissertation was designed to: (1) Describe the trajectories of serum biomarkers over time in patients with an MGUS diagnosis, (2) Determine if an MGUS diagnosis is associated with changes in healthcare service utilization, and (3) explore the patient- and provider-level drivers of healthcare utilization in patients with MGUS. Methods Data sources include health claims and electronic health records from a community-based population of patients seeking care in central Massachusetts and primary qualitative data collected from providers and patients’ interviews. The analyses included descriptive statistics, group-based trajectory modeling, conditional Poisson regression, and qualitative data analyses. Results (1) Three distinct multi-trajectory groups of creatinine and hemoglobin were identified. (2) The rates of emergency room, hospital, and outpatient visits were higher for patients with MGUS than patients without MGUS. (3) Patients have a basic understanding of MGUS; however, some patients feel anxiety, which may affect other aspects of their lives. Patients primarily see hematologists for follow-up care; other providers have less knowledge about MGUS. Conclusions Biomarker trajectories characterize specific subpopulations of patients with MGUS over time. We found that an MGUS diagnosis is associated with higher healthcare utilization, especially during the months surrounding the diagnosis date. Finally, our study suggests that some patients with MGUS may need psychosocial support services and identifies a gap in knowledge around caring for MGUS patients among primary care providers.

Background: The United States Preventive Services Task Force guidelines support screening and provision of intensive multi-component behavioral counseling for adults who have obesity. One barrier to providing such counseling is lack of training in medical school. Not much is known about factors associated with medical students’ perceived weight management counseling (WMC) skills or whether preceptors model or teach WMC during primary care clerkships. Methods: A mixed methods approach addressed factors affecting WMC training during primary care clerkships. A secondary analysis of 3rd year medical students (n=730) described students’ perceived WMC skills, attitudes and frequency of engagement in 5As educational experiences. Linear mixed models were used to determine associations between educational experiences and perceived skills. Semi-structured interviews (n=12) and a survey were administered to primary care preceptors (n=77). Interviews described individual, inter-personal and institutional factors associated with preceptors’ WMC. The survey described preceptors’ frequency of modeling WMC behaviors, perceived WMC skills, and attitudes. Results: Students perceived themselves to be moderately skilled (M=2.6, SD=0.05, range 1-4). Direct patient experiences and specific instruction were associated with higher perceived skill. Preceptors support WMC curricula but do not perceive themselves to be experts in WMC. Preceptors perceive themselves to be moderately skilled (M=2.8, SD=0.06, range 1-4) but only sometimes model WMC (M=3.3, SD=0.05, range 1-5) to students during clerkships. Conclusion: Preceptor modeling WMC may not be feasible or necessary during primary care clerkships. Providing specific WMC instruction and working with patients may provide more benefit as they were more strongly associated with students’ perceived skills.

Purpose: The purpose of this study was to explore the way(s) in which family management of childhood asthma is affected by contextual influences as described in the Family Management Style Framework (FMSF) and to explore additional factors that affect family asthma management. Specific Aims: The specific aims of this study were 1) to describe the everyday experiences of childhood asthma management within families, 2) to explore the way(s) in which family management of childhood asthma is affected by contextual influences (social network, care providers & systems and resources) as described in the FMSF, and 3) to explore additional sociocultural factors (supported by the literature but not currently described in the FMSF) that affect asthma management in families. Framework: The Family Management Style Framework guided this study. Design: A qualitative descriptive design was used to gather data from a purposive sample of female primary caregivers. Demographic data were collected, and individual interviews were conducted using a flexible interview guide. Results: The findings support the contextual influences as described in the FMSF. An additional three contextual themes were identified: environment, emerging threats to health and work-life conditions. The themes are interrelated demonstrating the complexity of asthma management. Conclusion: Family management of asthma is challenging and complex. The findings move towards understanding the connection between family asthma management and the social determinants of health. Nurses can support families managing childhood asthma by considering each of the contextual influences when planning interventions and working on policy initiatives that support the health of children with asthma.

Thesis (Ph.D.)--University of the Witwatersrand, Faculty of Commerce, Law and Management, Wits School of Governance, 2016 / CEOs of public hospitals in South Africa are often held responsible when their institutions fail to deliver good quality care and are associated with poor health outcomes. Negative perceptions prevail and particularly in the National Department of Health it is held that the CEOs are generally not adequately qualified, inexperienced, incompetent and often inappropriately appointed. This study attempts to articulate the CEOs views (their side of the story) and in particular how they perceive the challenges that they face and what solutions they proffer in improving the running of their institutions. This research is viewed through the lens of the New Public Management paradigm (NPM), in terms of Public Sector Reform and in particular Health Sector Reform in South Africa. Thirty CEOs of public hospitals in South Africa responded to a survey of their opinions. The majority (86%) of them felt they were unable to manage their institutions effectively. A subsequent qualitative study of CEOs and experts in public management using in depth interviews and further focus group discussions with CEOs and senior hospital managers revealed that the major challenges that the CEOs faced were financial, human resources and operational management issues. Procurement and information challenges were linked to financial and human resources deficiencies, lack of accountability mechanisms and the presence of corruption. The Performance Management System currently in place did not work appropriately and was driven by perverse incentives. Political interference was also a pervasive problem. Their recommendations were that they needed clear and unambiguous delegations and the appropriate resources so that they can take full responsibility of their institutions. Clear accountability structures were paramount in achieving better health service management and care according to the advice of experts in public management as well as that of senior hospital managers. This requires the creation of enabling legislation and an appropriate accountability framework. The blanket application of NPM principles is also questioned. Selective application of the tools of NPM should be tested and consideration be given to the dimension of added public value in the South African public hospital context. / GR2018

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The purpose of this study is to report the current state of employer offering and employee participation in Long-Term Care Health Insurance within the Central Florida area. By distributing a voluntary survey to numerous businesses, information was collected from employers throughout the area regarding the plans and options available within their organizations. Through assessment and analysis of the information, a gauge of the present state of the workplace and Long-Term Care Insurance coverage in Central Florida has been established. What you will find within these pages is the availability and involvement of this insurance along with the options, awareness, advantages, and disadvantages it encompasses. I hope that you will in some way benefit from it.