Background: Patient reports of pain and function are used to inform the need for and timing of total knee replacement (TKR) and evaluate TKR outcomes. This dissertation compared measurement properties of commonly-used patient surveys in TKR and explored ways to develop more efficient knee-specific function measures. Methods: 1,179 FORCE-TJR patients (mean age=66.1, 61% female) completed questionnaires before and 6 months after TKR. Patient surveys included the knee-specific Knee injury and Osteoarthritis Outcome Score (KOOS) and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and generic SF-36 Health Survey. Tests of KOOS and WOMAC measurement properties included evaluations of scaling assumptions and reliability. Item response theory methods were used to calibrate 22 KOOS function items in one item bank; simulated computerized adaptive tests (CAT) then were used to evaluate shorter function scores customized for each patient. Validity and responsiveness of measures varying in attributes (knee-specific versus generic, longer versus shorter, CAT versus fixed-length) were compared. Results: KOOS and WOMAC scales generally met tests of scaling assumptions, although many pain items were equally strong measures of pain and physical function. Internal consistency reliability of KOOS and WOMAC scales exceeded minimum levels of 0.70 recommended for group-level comparisons across sociodemographic and clinical subgroups. Function items could be calibrated in one item bank. CAT simulations indicated that reliable knee-specific function scores could be estimated for most patients with a 55-86% reduction in respondent burden, but one-third could not achieve a reliable (≥ 0.95) CAT score post-TKR because the item bank did not include enough items vi measuring high function levels. KOOS and WOMAC scales were valid and responsive. Short function scales and CATs were as valid and responsive as longer KOOS and WOMAC function scales. The KOOS Quality of Life (QOL) scale and SF-36 Physical Component Summary discriminated best among groups evaluating themselves as improved, same or worse at 6 months. Conclusions: Results support use of the KOOS and WOMAC in TKR. Improved knee-specific function measures require new items that measure higher function levels. TKR outcomes should be evaluated with a knee-specific quality of life scale such as KOOS QOL, as well as knee-specific measures of pain and function and generic health measures.

Approximately half of all emergency department (ED) visits are primary-care sensitive (PCS) – meaning that they could potentially be avoided with timely, effective primary care. Reducing undesirable types of healthcare utilization (including PCS ED use) requires the ability to define, measure, and predict such use in a population. In this retrospective, observational study, we quantified ED use in 2 privately insured populations and developed ED risk prediction models. One dataset, obtained from a Massachusetts managed-care network (MCN), included data from 2009-11. The second was the MarketScan database, with data from 2007-08. The MCN study included 64,623 individuals enrolled for at least 1 base-year month and 1 prediction-year month in Massachusetts whose primary care provider (PCP) participated in the MCN. The MarketScan study included 15,136,261 individuals enrolled for at least 1 base-year month and 1 prediction-year month in the 50 US states plus DC, Puerto Rico, and the US Virgin Islands. We used medical claims to identify principal diagnosis codes for ED visits, and scored each according to the New York University Emergency Department algorithm. We defined primary-care sensitive (PCS) ED visits as those in 3 subcategories: nonemergent, emergent but primary-care treatable, and emergent but preventable/avoidable. We then: 1) defined and described the distributions of 3 ED outcomes: any ED use; number of ED visits; and a new outcome, based on the NYU algorithm, that we call PCS ED use; 2) built and validated predictive models for these outcomes using administrative claims data; 3) compared the performance of models predicting any ED use, number of ED visits, and PCS ED use; 4) enhanced these models by adding enrollee characteristics from electronic medical records, neighborhood characteristics, and payor/provider characteristics, and explored differences in performance between the original and enhanced models. In the MarketScan sample, 10.6% of enrollees had at least 1 ED visit, with about half of utilization scored as PCS. For the top risk group (those in the 99.5th percentile), the model’s sensitivity was 3.1%, specificity was 99.7%, and positive predictive value (PPV) was 49.7%. The model predicting PCS visits yielded sensitivity of 3.8%, specificity of 99.7%, and PPV of 40.5% for the top risk group. In the MCN sample, 14.6% (±0.1%) had at least 1 ED visit during the prediction period, with an overall rate of 18.8 (±0.2) visits per 100 persons and 7.6 (±0.1) PCS ED visits per 100 persons. Measuring PCS ED use with a threshold-based approach resulted in many fewer visits counted as PCS, discarding information unnecessarily. Out of 45 practices, 5 to 11 (11-24%) had observed values that were statistically significantly different from their expected values. Models predicting ED utilization using age, sex, race, morbidity, and prior use only (claims-based models) had lower R2 (ranging from 2.9% to 3.7%) and poorer predictive ability than the enhanced models that also included payor, PCP type and quality, problem list conditions, and covariates from the EMR, Census tract, and MCN provider data (enhanced model R2 ranged from 4.17% to 5.14%). In adjusted analyses, age, claims-based morbidity score, any ED visit in the base year, asthma, congestive heart failure, depression, tobacco use, and neighborhood poverty were strongly associated with increased risk for all 3 measures (all P<.001).

BACKGROUND: The barriers in accessing healthcare for gay, lesbian and bisexuals individuals are not well explored. These challenges as well as a lack of knowledge concerning this understudied group has prompted the Institute of Medicine to create a research agenda to build a foundational understanding of gay, lesbian and bisexual health and the barriers they encounter.1 the primary aim of this study will be to compare the differences in health care access and utilization between gay/lesbian, bisexual and heterosexual individuals using a large, nationally representative dataset of the U.S. population. METHODS: Data from 2001 to 2012 from the National Health and Nutrition Examination Survey was pooled. Using logistic regression, we calculated the unadjusted and adjusted odds ratios of having health insurance, having a routine place and seeing a provider at least one in the past year. RESULTS: We found that gay men were more likely to have health insurance coverage (ORadj:2.13 95%CI: 1.15,3.92), while bisexual men were at a small disadvantage in having health insurance coverage (ORadj:0.82 95%CI: 0.46,1.46). Bisexual men were more likely to have received health care in the past 12 months (ORadj:3.11 95%CI: 1.74,5.55). Lesbian women were less likely to have health insurance coverage (ORadj-lesbian:0.58 95%CI: 0.34,0.97). CONCLUSION: This study contributed to the limited knowledge on understanding the health care access and utilization among gay, lesbian and bisexual individuals, which was classified as a high priority by the Institute of Medicine. Expanding health insurance coverage through the Affordable Care Act and Universal Partnership Coverage may reduce the disparities among gay, lesbian and bisexual individuals.

Background: Major depression is one of the most prevalent, disabling, and costly illnesses worldwide. Despite a 400% increase in antidepressant medication use since 1988, fewer than half of treated depression patients experience a clinically meaningful reduction in symptoms and uncertainty exists regarding how to successfully obtain symptom remission. Identifying homogenous subgroups based on clinically observable characteristics could improve the ability to efficiently predict who will benefit from which treatments. Methods: Latent class analysis and latent transition analysis (LTA) were applied to data from the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study to explore how to efficiently identify subgroups comprised of the multiple dimensions of depression and examine changes in subgroup membership during treatment. The specific aims of this dissertation were to: 1) evaluate latent depression subgroups for men and women prior to antidepressant treatment; 2) examine transitions in these subgroups over 12 weeks of citalopram treatment; and 3) examine differences in functional impairment between women’s depression subgroups throughout treatment. Results: Four subgroups of depression were identified for men and women throughout this work. Men’s subgroups were distinguished by depression severity and psychomotor agitation and retardation. Severity, appetite changes, insomnia, and psychomotor disturbances characterized women’s subgroups. Psychiatric comorbidities, especially anxiety disorders, were related to increased odds of membership in baseline moderate and severe depression subgroups for men and women. After 12 weeks of citalopram treatment, depression severity and psychomotor agitation were related to men’s chances of improving. Severity and appetite changes were related to women’s likelihood of improving during treatment. When functional impairment was incorporated in LTA models for women, baseline functional impairment levels were related to both depression subgroups at baseline and chances of moving to a different depression subgroup after treatment. Conclusion: Depression severity, psychomotor disturbances, appetite changes, and insomnia distinguished depression subgroups in STAR*D. Gender, functional impairment, comorbid psychiatric disorders, and likelihood of transitioning to subgroups characterized by symptom improvement differed between these subgroups. The results of this work highlight how relying solely on summary symptom rating scale scores during treatment obscures changes in depression that might be informative for improving treatment response.

Deaf individuals experience significant obstacles to participating in behavioral health research when careful consideration is not given to accessibility in the design of study methodology. To inform such considerations, we conducted a secondary analysis of a mixed-methods study that explored 16 Deaf trauma survivors’ help-seeking experiences. Our objective was to identify key findings and qualitative themes from consumers' own words that can be applied to the design of behavioral clinical trials methodology. In many ways, the themes that emerged are what we would expect of any research participant, Deaf or hearing – a need for communication access, empathy, respect, strict confidentiality procedures, trust, and transparency of the research process. However, additional considerations must be made to better recruit, retain, and engage Deaf trauma survivors. We summarize our findings in a “Checklist for Designing Deaf Behavioral Clinical Trials” to operationalize the steps researchers should take to apply Deaf-friendly approaches in their empirical work.

Background: Migraine headache is a chronic pain condition that affects 20% of women of reproductive age, and is often treated with triptans. Triptans are serotonin 1B, 1D, and 1F receptor agonists that act as vasoconstrictors and inhibitors of the trigeminal cervical complex as well as peripheral neurons; they cross the blood brain barrier and placenta, and as such are plausible neurodevelopmental teratogens. No studies have examined risk of neurodevelopmental problems in children with prenatal triptan exposure. This dissertation had three aims: (1) to examine risk of behavioral problems in children using in the presence of time-varying confounding by concomitant medication use; (2) to examine risk of temperamental, motor, and communication disturbances associated with prenatal triptans exposure, adjusting for unmeasured confounding by migraine type and severity; and (3) to examine changes in neurodevelopment over time associated with prenatal triptan exposure. Methods: This dissertation used data from the Norwegian Mother and Child Cohort Study, a prospective birth cohort including more than 100,000 women recruited during their first prenatal ultrasound visit. Aims 1 and 3 used marginal structural models to assess the risk of (1) neurodevelopmental problems at age 36 months (Aim 1), or (2) change in risk of neurodevelopmental problems from 18 to 36 months (Aim 3) associated with prenatal triptan exposure. Aim 2 used propensity matching and calibration to adjust for unmeasured confounding by migraine type, severity, and attitudes towards medication use in pregnancy. Neurodevelopmental outcome measures included the Child Behavior Checklist (CBCL), the Emotionality, Activity, and Temperament Scale (EAS), and the Ages and Stages Questionnaire (ASQ). Exposure to triptans was ascertained by self-report. Results: Prenatal triptan exposure was associated with greater externalizing behavior problems at 18 and 36 months, as well as greater increases in emotionality and activity from 18 to 36 months. We observed no association between triptan exposure and motor skills or communication problems; triptan use during pregnancy was associated with migraine severity but not migraine type, and adjustment for unmeasured migraine characteristics moved effect estimates towards the null. Conclusions: Prenatal triptan exposure is associated with externalizing-type behaviors and temperament in children, while migraine itself is associated with internalizing-type behaviors and temperament. The use of concomitant medications and the severity of the underlying condition both exerted substantial influence on observed effect estimates, and should be considered in any future studies of triptan medication use in pregnancy.

Background: Venous thromboembolism (VTE), comprising the conditions of deep vein thrombosis (DVT) and pulmonary embolism (PE), is a common acute cardiovascular event associated with increased long-term morbidity, functional disability, all-cause mortality, and high rates of recurrence. Major advances in identification, prophylaxis, and treatment over the past 3-decades have likely changed its clinical epidemiology. However, there are little published data describing contemporary, population-based, trends in VTE prevention and management. Objectives: To examine recent trends in the epidemiology of clinically recognized VTE and assess the risk of recurrence after a first acute episode of VTE. Methods: We used population-based surveillance to monitor trends in acute VTE among residents of the Worcester, Massachusetts, metropolitan statistical area (WMSA) from 1985 through 2009, including in-hospital and ambulatory settings. Results: Among 5,025 WMSA residents diagnosed with acute PE and/or lower-extremity DVT between 1985 and 2009 (mean age = 65 years), 46% were men and 95% were white. Age- and sex-adjusted annual event rates (per 100, 000) of clinically recognized acute first-time and recurrent VTE was 142 overall, increasing from 112 in 1985/86 to 168 in 2009, due primarily to increases in PE occurrence. During this period, non-invasive diagnostic VTE testing increased, vi while treatment shifted from the in-hospital (chiefly with warfarin and unfractionated heparin) to out-patient setting (chiefly with low-molecular-weight heparins and newer anticoagulants). Among those with community-presenting first-time VTE, subsequent 3-year cumulative event rates of key outcomes decreased from 1999 to 2009, including all-cause mortality (41% to 26%), major bleeding episodes (12% to 6%), and recurrent VTE (17% to 9%). Active-cancer (with or without chemotherapy), a hypercoagulable state, varicose vein stripping, and Inferior vena cava filter placement were independent predictors of recurrence during short- (3-month) and long-term (3-year) follow-up after a first acute episode of VTE. We developed risk score calculators for VTE recurrence based on a 3-month prognostic model for all patients and separately for patients without active cancer. Conclusions: Despite advances in identification, prophylaxis, and treatment between 1985 and 2009, the disease burden from VTE in residents of central Massachusetts remains high, with increasing annual events. Declines in the frequency of major adverse outcomes between 1999 and 2009 were reassuring. Still, mortality, major bleeding, and recurrence rates remained high, suggesting opportunities for improved prevention and treatment. Clinicians may be able to use the identified predictors of recurrence and risk score calculators to estimate the risk of VTE recurrence and tailor outpatient treatments to individual patients.

Objectives: The objectives of this research were to describe the interactions (formal and informal) in which macrocognitive functions occur and their location on a pediatric intensive care unit (PICU); describe challenges and facilitators of macrocognition using three constructs of space syntax (openness, connectivity, and visibility); and analyze the health care built environment (HCBE) using those constructs to explicate influences on macrocognition. Background: In high reliability, complex industries, macrocognition is an approach to develop new knowledge among interprofessional team members. Although macrocognitive functions have been analyzed in multiple health care settings, the effect of the HCBE on those functions has not been directly studied. The theoretical framework, “Macrocognition in the Health Care Built Environment” (m-HCBE) addresses this relationship. Methods: A focused ethnographic study was conducted, including observation and focus groups. Architectural drawing files used to create distance matrices and isovist field view analyses were compared to panoramic photographs and ethnographic data. Results: Neighborhoods comprised of corner configurations with maximized visibility enhanced team interactions as well as observation of patients, offering the greatest opportunity for informal situated macrocognitive interactions (SMIs). Conclusions: Results from this study support the intricate link between macrocognitive interactions and space syntax constructs within the HCBE. These findings help to advance the m-HCBE theory for improving physical space by designing new spaces or refining existing spaces, or for adapting IPT practices to maximize formal and informal SMI opportunities; this lays the groundwork for future research to improve safety and quality for patient and family care.

For many health conditions, African Americans bear a disproportionate burden of disease, injury, death, and disability compared to European Americans. African Americans also use health services less frequently than do European Americans and this underuse of services contributes to health disparities in the United States. Studies have shown that some disparities are present not as a result of poor access to care, but, to a certain extent, as a result of the experiences patients have at their doctors' offices. It is, therefore, essential to understand African American patients' perspectives and experiences with healthcare providers. Past studies have shown that four barriers affect the quality of patient-provider relationships for African Americans: perceived discrimination, medical mistrust, race discordance, and poor communication. The studies, however, have not looked at how these barriers manifest when African Americans speak about their perspectives and experiences with health care providers. This project was a secondary data analysis of qualitative data provided by adult African American community members from Portland, Oregon with diabetes or hypertension or both, each of whom participated in one of 10 focus groups. The focus groups were conducted as part of a study that applied community based participatory research (CBPR) principles to understand patients' experiences with their doctors. Using a deductive approach, this analysis enhanced the understanding of how the barriers play a role in patient-provider relationships. Further, the analysis showed how the barriers are interrelated. In learning African American patients' experiences and perspectives on these four key barriers, the investigator proposes recommendations for healthcare providers as to how they can best deliver quality care for African Americans.

This study examines two groups -international and domestic students at Portland State University (PSU) - in terms of their motivations to seek university-health services, and their satisfaction with university-health services. The Theory of Motivated Information Management (W. A. Afifi & Weiner, 2004) served as the foundation for this study to examine the preferences of students in terms of the ways they seek information about their health concerns. Differences in international and domestic students' anxiety, efficacy, and satisfaction with physicians were supported. International students reported more anxiety than domestic students. Domestic students reported being more efficacious than international students when talking to a medical provider about a current medical issue. Also, international students reported higher satisfaction with a medical provider at their last university health services visit. First, subjects were asked if they currently have a medical concern for which they might consider consulting a physician at PSU health services. If this scenario applied, subjects were asked to rate a variety of possible, theoretically informed motivations for seeking medical information by consulting a physician, to test the Theory of Motivated Information Management. Second, subjects were asked if they have previously consulted a physician at PSU health services. If this scenario applied, subjects were asked to provide satisfaction ratings of the physician and staff. The results contribute to the understanding of information-seeking processes and support the theory's effectiveness in this situation, explaining where international and domestic students are significantly different in regard to their responses.