Background: Understanding concentrated areas with high rates of opioid use disorder (OUD) allows for improved placement of Narcan access points through syringe services programs (SSPs). People Who Inject Drugs (PWID) have lower risk of contracting infectious diseases the closer they are to SSPs. Tennessee law prohibits SSPs within 2000ft of a school or park, impacting the placement of SSPs in non-urban areas. Testing factors related to SSP siting placement within a system dynamic model can better determine the relationship between PWID risk environment and SSP access and utility. Methods: We identified areas of greatest need for harm reduction interventions within a non-urban Tennessee county with Emergency Medical Services (EMS) Narcan administrations data (Aim 1). We then created a Google map to determine a theoretical ideal location for an SSP. We then applied the current legal restrictions to SSP placement to find the next-closest legal location (Aim 2). We then developed a theoretical system dynamic model of SSP access and utility and Risk Environment (Aim 3). Results: We determined “EMS Zone 1” has a higher rate of EMS Narcan administrations than most EMS zones in the county and a higher rate compared to the whole county (Aim 1). We located a theoretical SSP location with shorter walk, drive, and public transportation times compared to the existing location. The closest legal SPP location still had an improvement in travel times but lacked other utility factors (Aim 2). Our theoretical model indicates that laws limiting SSP placement increase the distance PWID travel to SSPs. The distance of support services to SSP sites has a negative relationship with risk environment and to accessibility and utility of SSPs (Aim 3). Conclusion: County-level geographic data is too crude to determine true “hot spots” of OUD. This new method using EMS data can provide entities a process for determining the best location for SSPs. Identifying measures of utility/accessibility for PWID can identify improved locations for SSPs but legal restrictions may lower utility/accessibility of SSPs especially for non-urban PWID. Current “Policy” or “Structural” level factors as described by the Social Ecological Model negatively impact PWID risk environment. Structural” or “Policy” and “Community” level interventions among state, city, and county governments have the highest potential to positively impact PWID risk environment.

Purpose Physical activity is recognized as a complementary therapy to improve physical and physiological functions among prostate cancer survivors. Little is known about communication between health providers and African-American prostate cancer patients, a high risk population, regarding the health benefits of regular physical activity on their prognosis and recovery. This study explores African-American prostate cancer survivors’ experiences with physical activity prescription from their physicians. Methods Three focus group interviews were conducted with 12 African-American prostate cancer survivors in May 2014 in St. Louis, MO. Participants’ ages ranged from 49 to 79 years, had completed radical prostatectomy, and their time out of surgery varied from 7 to 31 months. Results Emerged themes included physician role on prescribing physical activity, patients’ perceived barriers to engaging in physical activity, perception of normalcy following surgery, and specific resources survivors’ sought during treatment. Of the 12 men who participated, 8 men (67%) expressed that their physicians did not recommend physical activity for them. Although some participants revealed they were aware of the importance of sustained physical activity on their prognosis and recovery, some expressed concerns that urinary dysfunction, incontinence, and family commitments prevented them from engaging in active lifestyles. Conclusions Transitioning from post radical prostatectomy treatment to normal life was an important concern to survivors. These findings highlight the importance of physical activity communication and prescription for prostate cancer patients.

Opioid Use Disorder is defined by the NIH as “the chronic use of opioids that causes clinically significant distress or impairment.”1 Due to a number of factors, the overuse of opioids has become an epidemic in the United States. In recent years there have been a number of lawsuits against pharmaceutical companies and other parties who have benefitted from the proliferation of this issue. In most cases, it is up to the states or local governments who receive these funds to determine their best use. The purpose of this Thesis is to analyze the resources recommended by Ballad Health’s Community Health Needs Assessments, and five additional panels of experts in this field, and to compare these recommendations with available resources, along with making recommendations for the distribution and use of funds coming from a number of lawsuits and settlements.

Background: The mood stabilizer lithium has long been reported to be associated with reduced suicide risks, but many studies reporting associations between lithium and reduced suicide risks also have been nonrandomized and lacked adjustment for many potential confounders, active controls, uniform follow-up, or intent-to-treat samples. Concerns also have been raised that medications being considered as potential suicide preventative might increase risks of nonsuicide mortality while reducing risks of suicide. Methods: Three studies of Veterans Health Administration (VHA) patients were conducted combining high-dimensional propensity score matching with intent-to-treat analyses to examine the associations between lithium and valproate and one-year suicide and nonsuicide mortality outcomes. Results: In intention-to-treat analyses, initiation of lithium, compared to valproate, was associated with increased suicide mortality over 0-365 days among patients with bipolar disorder (Hazard Ratio (HR) 1.50 [95% Confidence Interval 1.05, 2.15]) Nonsuicide mortality among VHA patients with or without bipolar disorder was not significantly associated with the initiation of lithium compared to valproate ( HR 0.92 [0.82-1.04]). Rates of treatment discontinuation, however, were very high (≈ 92%). Longitudinal analyses revealed that the increased suicide risks associated with initiating lithium among patients with bipolar disorder occurred exclusively after discontinuation of lithium vii treatment. In secondary analyses restricted to patients still receiving their initial treatment, there was no difference in suicide risk between the initiation of lithium or valproate. Conclusions: Significantly increased risks of suicide were observed at one year among VHA patients with bipolar disorder initiating lithium compared to valproate, related to risks observed after the discontinuation of lithium treatment Since these studies are nonrandomized, confounding may account for some or all of our findings, including the risks observed after lithium discontinuation. Nevertheless, these results suggest that health systems and providers consider steps to minimize any potential lithium discontinuation-associated risk. Approaches might include educating patients about possible risks associated with discontinuation and closely monitoring patients after discontinuation if feasible. Given the obvious importance of any substantive difference between lithium and valproate in suicide or nonsuicide mortality risk, our studies also suggest that further research is needed, especially research that can further minimize the potential for confounding.

Background: Recent national trends and distribution of ileal pouch-anal anastomosis (IPAA) procedures for patients with ulcerative colitis (UC) are unknown. We examined the frequency of use of elective IPAA procedures among patients with UC and the distribution of IPAA procedures across more than 140 U.S. academic medical centers and their affiliates. Methods: Data were obtained from the University HealthSystem Consortium for patients with a primary diagnosis of UC admitted electively between 2012 and 2015. Results: The mean age of the study population (n=6,875) was 43 years and 57% were men. Among these, one-third (n=2,307) underwent an IPAA, while two-thirds (n=4,568) underwent colectomy, proctectomy, proctocolectomy or other procedures. The proportion of IPAA cases among all elective admissions was relatively stable at 33-35% during the years under study. A total of 131 hospitals, out of 279 hospitals participating in the UHC, performed IPAA. The median number of IPAA cases performed annually was 1.9 [IQR 0.8 – 4.3]. Nearly one half (48%) of these cases were performed by the top ten hospitals. Overall, only a total of 30 centers performed ³ five elective IPAA cases annually. Conclusions: Although the frequency of elective IPAA surgery in recent years has been stable, nearly one half of all IPAA cases was performed at ten hospitals. The concentration of IPAA cases at high-volume centers, and the steady number of cases performed annually, have potential implications for fellowship training, patient clinical outcomes and access to care.

Background. AHA guidelines have been established to reduce Acute Coronary Syndrome (ACS)-related morbidity, mortality and recurrent events post-discharge. These recommendations emphasize the patient as an engaged member of the health care team in secondary prevention efforts. Patients with high levels of activation are more likely to perform activities that will promote their own health and are more likely to have their health care needs met. Despite evidence and strong expert consensus supporting patients as active collaborators in their own ACS care, the complexity and unexpected realities of self-managing one’s care at home are often underestimated. This study seeks to examine the correlates of patient activation at hospital discharge and then identifies activation trajectories in this same cohort in subsequent months. Lastly, this study examines the association between patient activation and health care utilization in the year subsequent to an ACS event. Methods. This study incorporates three aims: Aim 1, identification of the correlates of low patient activation post-discharge; Aim 2, identification of patient activation trajectories among this same cohort in the months following hospitalization; and Aim 3, examination of the association between patient activation and health utilization, post-discharge. Results. Fifty-nine percent of ACS patients identified as being at the lowest two activation stages at the time of hospital discharge. Perceived stress (pidentified post-discharge: low, stable (T1), high, sharp decline (T2), and sharp improvement (T3). The majority of patients (67%) identified as being in T1. Those patients of older age (OR: 2.22; CI 1.4- 3.5), identifying as Black in race (OR: 2.14: CI 1.1- 4.3), and reporting moderate/high perceived stress (OR: 2.54: CI 1.4- 4.5) had increased odds of being in the low, stable trajectory. The bivariate analysis indicated a significant association (P=0.008) between low patient activation and self-reported hospital readmissions in the months following discharge. In the final model, moderate to severe depression (OR: 1.60; CI 1.1- 2.3) was the strongest predictor of readmissions in the 12 months subsequent to discharge. Conclusions: Patients reported low activation at hospital discharge after an ACS event indicated that these patients were not prepared to take an active role in their own care. Correlates of low activation at discharge include moderate to high perceived stress, depression, and low social support. Furthermore, in the months following hospital discharge, the majority of these patients followed either a low/stable or a sharp decline activation trajectory. Hence, these results suggest that over time patients feel less and less confident to take an active role in self-management. Lastly, we found that patient activation may impact healthcare utilization in the year subsequent to hospital discharge, although patient self-reported depression appears to be the strongest predictor of utilization in the subsequent year. Future research is needed to better understand the relationship(s) among patient activation, depression, and health care utilization.

Background: Cardiovascular disease (CVD) remains the leading cause of morbidity and mortality in the U.S. Acute myocardial infarction (AMI), with or without ST-segment elevation, is a common presentation of coronary heart disease and affected more than 800,000 American adults in 2010. The overall goal of this dissertation was to examine decade-long trends in the extent of delay in the receipt of a primary percutaneous coronary intervention (PCI) among patients hospitalized with ST-segment elevation myocardial infarction (STEMI), 30-day hospital readmission rates in patients having survived an AMI, and multiple decade long trends in 1-year post-hospital all-cause mortality, as well as factors associated with these outcomes, among patients hospitalized with AMI. Methods: Data from the Worcester Heart Attack Study, a population-based chronic disease surveillance project that has been carried out among adult residents of the Worcester, MA, metropolitan area, hospitalized with AMI on a biennial basis from 1975 through 2009 at all medical centers in central MA, were used for this dissertation. Results: Between 1999 and 2009, among patients hospitalized with STEMI, the likelihood of receiving a primary PCI within 90 minutes after emergency department arrival increased dramatically from 1999/2001 (11.6%) to 2007/2009 (70.5%). Between 1999 and 2009, among hospital survivors of an AMI, the 30-day all-cause rehospitalization rates decreased from 1999/2001 (20.3%) to 2007/2009 (16.7%). The overall cause-specific 30-day rehospitalization rates due to CVD, non-CVD, and AMI were 10.1%, 7.1%, and 1.8%, respectively, during the years under study. Between 1975 and 2009, among hospital survivors for a first AMI, the 1-year post-discharge mortality rates remained relatively stable from 1975-1984 (12.9%) to 1986-1997 (12.5%), but increased during 1999-2009 (15.8%). We identified several demographic, clinical and in-hospital treatment factors associated with an increased risk of failing to receive a primary PCI within 90 minutes after emergency department arrival, 30-day readmissions, and 1-year post-discharge mortality. Conclusions: Our findings can hopefully lead to the enhanced development of innovative, patient-centered, intervention strategies which can further improve the treatment and transitions of care, as well as short and long-term prognosis, of men and women hospitalized with AMI.

Background: Following passage of the Affordable Care Act in 2010, 30-day hospital readmissions have come under greater scrutiny. Excess readmissions for certain medical conditions and procedures now result in penalizations on all Medicare reimbursements. We examined the risk factors, outcomes, and costs of 30-day readmissions after colorectal surgery (CRS). Methods: The University HealthSystem Consortium database was queried for adults (≥ 18 years) who underwent colorectal resection for cancer, diverticular disease, inflammatory bowel disease, or benign tumors between January 2008 and December 2011. Our outcomes of interest were readmission within 30-days of the patient’s index discharge, hospital readmission outcomes, and total direct hospital costs. Results: A total of 70,484 patients survived the index hospitalization after CRS during the years under study, 13.7% (9,632) of which were readmitted within 30 days of discharge. The strongest independent predictors of readmission were: LOS ≥4 days (OR 1.44; 95% CI 1.32-1.57), stoma (OR 1.53; 95% CI 1.45-1.61), and discharge to skilled nursing (OR 1.63; 95% CI 1.49-1.76) or rehabilitation facility (OR 2.93; 95% CI 2.54-3.40). Of those readmitted, half occurred within 7 days of the index admission, 13% required ICU care, 6% had a reoperation, and 2% died during the readmission stay. The median combined total direct hospital cost was over twice as high ($26,917 v. $13,817) for readmitted than for nonreadmitted patients. Conclusions: Readmissions following colorectal resection occur frequently and incur a significant financial burden on the healthcare system. Future studies aimed at targeted interventions for high-risk patients may reduce readmissions and curb escalating healthcare costs. Categorization: Outcomes research; Cost analysis; Colon and Rectal Surgery

Objective: Chronic obstructive pulmonary disease (COPD) is a common comorbidity in patients with heart failure, yet little is known about the impact of this condition in patients with acute decompensated heart failure (ADHF), especially from a more generalizable, community-based perspective. The primary objective of this study was to describe the in-hospital and post discharge mortality and treatment of patients hospitalized with ADHF according to COPD status. Methods: The study population consisted of patients hospitalized with ADHF at all 11 medical centers in central Massachusetts during 4 study years: 1995, 2000, 2002, and 2004. Results: Of the 9,748 patients hospitalized with ADHF during the years under study, 35.9% had a history of COPD. The average age of this population was 76.1 years, 43.9% were men, and 93.3% were white. At the time of hospital discharge, patients with COPD were less likely to have received evidence-based heart failure medications, including beta-blockers and ACE inhibitors/angiotensin receptor blockers, than patients without COPD. Multivariable adjusted in-hospital death rates were similar for patients with and without COPD. However, among patients who survived to hospital discharge, patients with COPD had a significantly higher risk of dying at 1 (adjusted RR 1.10; 95% CI 1.06, 1.14) and 5-years (adjusted RR 1.40; 95% CI 1.28, 1.42) after hospital discharge than patients who were not previously diagnosed with COPD. Conclusions: COPD is a common co-morbidity in patients hospitalized with ADHF and is associated with a worse long-term prognosis. Further research is required to understand the complex interactions of these diseases and to ensure that patients with ADHF and COPD receive optimal treatment modalities.

The overarching goal of this dissertation was to elucidate the psychosocial and behavioral determinants of medication nonadherence among African Americans with hypertension. One in three Americans in the United States has hypertension, and the prevalence of hypertension among African Americans is among the highest in the world. In addition to healthy behaviors such as following a low-salt and low-fat diet, getting regular exercise, and reducing stress, patients with hypertension must also adhere to antihypertensive medications. Poor medication adherence may be driven by psychosocial and behavioral factors; however, the impact of these factors on medication adherence is unclear especially within the African American community. To date, a paucity of research has examined the relationship between psychosocial and behavioral factors such as reported racial discrimination, John Henryism (a measure of active coping and an unhealthy response to stress) and home remedies with medication nonadherence. However, each of these factors has individually been linked with poorer health outcomes among African Americans. Using data from the TRUST study (2006-2008) the association between these constructs and medication adherence was assessed within our sample of 788 African Americans and a comparison group of 137 White participants with hypertension. Ordinal logistic regression was used to assess the association between racial discrimination, John Henryism, home remedies, and medication adherence. The findings from this research indicated more reported racial discrimination, higher John Henryism scores, and greater use of home remedies were associated with lower medication adherence. These findings yield new knowledge about medication adherence and provide practical insights about the psychosocial and behavioral determinants of medication adherence.