An estimated 15 million individuals in the United States have been formally diagnosed with dysphagia, defined as swallowing dysfunction -- the fifth leading cause of death in Americans over the age of 65. Statistical findings indicate that at least 50% of these individuals have limited access to treatment. However, despite the rapid expansion of telepractice (defined as the use of telecommunications technology to provide services at a distance) as a statistically valid online method for the provision of medical and clinical intervention to those without access, telepractice has yet to consistently incorporate online dysphagia service delivery (referred to as tele-dysphagia) into its clinical scope. This investigation compared the outcomes of traditional face-to-face intervention to online tele-dysphagia intervention by measuring the correct and incorrect responses to visual and auditory cues presented by a clinician during dysphagia intervention sessions. Data analysis conducted via t-test indicated that there was no significant difference in the mean scores from tele-dysphagia method (M = 9.67, SD = 3.74) as compared to face-to-face method (M = 9.00, SD = 2.70), t (28) = - 0.56, p = 0.580. Additionally, inter-rater reliability scores were obtained by determining a Cohen’s kappa coefficient in order to measure the degree of agreement between the two raters. Findings indicated a kappa statistic of k=1 for all items, given a 100% agreement for all trials. Additionally, results of a mixed-design analysis of variance suggested a significant within-subject effect with the use of cues, but there were no significant main effects of between-subject factors (gender, delivery type, etiology, or age) on the patients’ responses. Given that there was no significant statistical difference between the two delivery methods and inter-rater reliability scores demonstrated perfect agreement, we can suggest that the online tele-dysphagia method can potentially yield clinical outcomes similar to a traditional face-to-face method. Results from a mixed-design analysis of variance additionally suggested that there is a significant within-subject effect given the use of cues (F (1, 29)=14.99, p = .001) on patients’ responses. However, there were no significant main effects of between-subject factors (gender, delivery type, etiology, or age) on the patients’ responses. It is hoped that the results of this study will lend validity and direction to future attempts to provide much-needed dysphagia intervention via online service methods. Such attempts, in turn, would have the potential to promote increased longevity and quality of life in those populations currently unable to access such services.

Patient engagement has become a widely used term, but remains a poorly understood concept in healthcare. Citations for the term during the past two decades have increased markedly throughout the healthcare-related disciplines without a common definition. Patient engagement has been credited for contributing to improved outcomes and experiences of care. Means of identifying and evaluating practices that facilitate patient engagement in care have become an ethical imperative for patient-centered care. This process begins with a definition of the concept. Concept analysis is a means of establishing a common definition of a concept through identification of its attributes, antecedents and consequences within the context of its use. Concept analysis is a methodology that has been used in social science and nursing as a means to resolve conceptual barriers to theory development in an evolving field. The methodological theory was based in the analytic philosophical tradition and sustained during the 20th century by the strength of philosophical positivism in the health sciences. This concept analysis is guided procedurally by Rogers’ evolutionary approach that incorporates postmodern philosophical principles and well-defined techniques. This dissertation is informed by the expanded and updated perspective of the neomodern era in nursing research, which advances the concept analysis methodology further. An analysis of the concept underlying the term patient engagement in the scientific literature revealed four defining attributes: personalization, access, commitment and therapeutic alliance. These defining attributes were derived through thematic analysis of over 100 individual attributes shared among six categories and three domains. The resultant definition revealed that patient engagement is both process and behavior shaped by the relationship between patient and provider and the environment where healthcare delivery takes place. Patient engagement is defined as the desire and capability to actively choose to participate in care in a way uniquely appropriate to the individual, in cooperation with a healthcare provider or institution, for the purposes of maximizing outcomes or improving experiences of care. In addition to the attributes of the concept identified in the literature, themes relevant to patient engagement were identified through inputs from six focus groups of persons living with HIV in New York City. The focus group participants were convened to inform the development of a mobile application designed to support their healthcare needs. Their experiences, insights and expectations were valuable in ascertaining those actions or behaviors that may serve to assist the patient in obtaining and adhering to care. The focus group transcripts were coded twice. The first round occurred prior to the concept analysis of the literature and used emergent coding methodology to capture meanings independent of the findings of the concept analysis. The second round occurred after the concept analysis of the literature and used the resultant attributes to perform a directed concept analysis of the transcripts. The content analyses of the transcripts from the patient perspective supported and reinforced the attributes from the concept analysis. The focus groups also highlighted another important aspect of patient engagement, that of privacy/confidentiality, which had not been specifically addressed in the concept analysis of the literature. The definition and the identified attributes serve as a heuristic in designing patient engagement strategies and as a basis for future development of the engagement concept in healthcare. The supporting concepts for engagement, especially the role of empathy in the therapeutic alliance, require further clarification and debate. While patient engagement may be promoted through face-to-face interactions or through health information technology, the defining attributes are invariable and should guide the design of engagement processes and tools. Finally, the value of understanding and exploring the defining attributes of patient engagement in medical and nursing education becomes clear, as is the need for continuing clinical training to support and encourage patient engagement skills.

The service industry has become increasingly competitive. This dissertation addresses a number of outstanding and fundamental questions of competitions in service operations and supply chains. The challenges are characterization of the equilibrium behaviors, estimating the impact of firms' interactions, and designing of efficient market mechanisms. The first chapter of this dissertation considers price competition models for oligopolistic markets, in which the consumer reacts to relative rather than absolute prices, where the relative price is defined as the difference between the absolute price and a given reference value. Such settings arise, for example, when the full retail price earned by the ``retailer" is reduced by virtue of a third party offering a subsidy or a rebate or in prospect theoretical models in which customers establish a reference price and base their choices on the differentials with respect to the reference price. When choosing among the various competing options, the consumer trades off the net price paid with various other product or service attributes, as in standard price competition models. The reference price may be exogenously specified and pre-announced to the competing firms. Alternatively, it may be endogenously determined, as a function of the set of absolute prices selected by the competing firms, for example the lowest or the second lowest price. We characterize the equilibrium behavior under a general reference value scheme of the above type; this in a base model, where we assume that the consumer choice model is of the general MultiNomialLogit (MNL) type. We also derive comparison results for the price equilibria that arise under alternative subsidy schemes. These comparisons have important implications for the design of subsidy schemes. The second chapter applies the results of the first chapter to the Medicare insurance market, both in terms of its existing structure, as well as in terms of various proposals to redesign the program. Based on an oligopoly price competition model tailored towards this market, and actual county-by-county data for the year 2010, we estimate the impact such reforms would have on the plans' market shares, equilibrium premia, the government's cost, and the out-of-pocket expenses of the beneficiaries. We employ two different methodologies to derive the parameters in the county-by-county competition models: (i) a calibration model, and (ii) parameter distributions obtained from models estimated in Curto et al. (2015). The predicted impacts on the above performance measures are remarkably consistent across the two methodologies and reveal, for example, that the government cost would decrease by 8% if the traditional fee-for-service(FFS) plans are kept out of competitive bidding process and by 16.5%-21% if they are part of the process. The third chapter studies a class of buy procurement mechanisms, framework agreements (FAs), that are commonly used by buying agencies around the world to satisfy demand that arises over a certain time horizon. We are one of the first in the literature that provides a formal understanding of FAs, with a particular focus on the cost uncertainty faced by bidders over the FA time horizon. We introduce a model that generalizes standard auction models to include this salient feature of FAs; we analyze this model theoretically and numerically. First, we show that FAs are subject to a sort of winner's curse that in equilibrium induces higher expected buying prices relative to running first-price auctions as needs arise. Then, our results provide concrete design recommendations that alleviate this issue and decrease buying prices in FAs, highlighting the importance of (i) monitoring the price charged at the open market by the FA winner and using it to bound the buying price; (ii) investing in implementing price indexes for the random part of suppliers' costs; and (iii) allowing suppliers the flexibility to reduce their prices to compete with the open market throughout the selling period. These prescriptions are already being used by the Chilean government procurement agency that buys US$2 billion worth of contracts every year using FAs. The fourth chapter considers the preference of contractual forms in supply chains. The supply chain contracting literature has focused on incentive contracts designed to align supply chain members' individual interests. A key finding of this literature is that members' preferences for contractual forms are often at odds: the upstream supplier prefers more complex contracts that can coordinate the supply chain; however, the downstream retailer prefers the wholesale price--only contract because it leaves more surplus (than a coordinating contract) that the retailer can get. This chapter addresses the following question: under what circumstances do suppliers and retailers prefer the same contractual form? We study supply chain members' preference for contractual forms in three different competitive settings in which multiple supply chains compete to sell substitutable products to the same market. Our analysis suggests that both upstream and downstream sides of the supply chains may prefer the same ``quantity discount'' contract, thereby eliminating the conflicts of interest that otherwise typify contracting situations. More interesting still is that both sides may also prefer the wholesale price--only contract, which offers a theoretical explanation to why the simple inefficient contract is widely adopted in supply chain transactions.

Adults over the age of 65 are at increased risk for influenza and pneumococcal infections; particularly those residing in nursing homes (NHs). Despite the efficacy of influenza and pneumococcal vaccinations, vaccination receipt rates among NH residents remain well below federal recommendations and racial/ethnic disparities exist. Minority NH residents (non-Hispanic Blacks and Hispanics) are less likely to be offered either vaccination and are more likely to refuse them compared to their non-minority counterparts (non-Hispanic Whites). In the past decade, requirements have been implemented to increase vaccination coverage in NHs, but there is little documentation regarding current racial/ethnic disparities in vaccination receipt. Furthermore, activities important to resident care delivery and the prevention of care deficiencies such as infections are primarily dependent on the care provided by certified nursing assistants (CNAs). For these reasons, current research examining racial/ethnic disparities in vaccination receipt in NHs is needed and more attention directed towards CNAs is necessary to improve resident care delivery and outcomes related to infection prevention and control. This dissertation furthers our understanding of racial/ethnic disparities in influenza and pneumococcal vaccination coverage among minority NH residents and the role racial/ethnic diverse CNAs play in infection prevention and control. Chapter One introduces the problem of health disparities in nursing homes (NHs) related to differences in preventative vaccination receipt by racial/ethnic status and the role CNAs play in infection prevention and control. Chapter Two, an integrative literature review on racial/ethnic disparities in NHs, describes racial/ethnic disparities occurring in the NH setting in the context of infection prevention and control and influenza and pneumococcal vaccination receipt along with contributing factors and existing strategies related to policy that have been implemented to address poor care quality. In Chapter Three, facility-level factors related to the CNA’s role and the barriers and facilitators they experience that contribute to infection prevention and control are discussed. In Chapter Four, a systematic review of previous research on racial/ethnic disparities related to influenza and pneumococcal vaccination in NHs, individual, community, and facility-level factors that determine these disparities in influenza and pneumococcal vaccination receipt, along with associated strategies and practices are discussed. In Chapter Five, a national quantitative analysis of vaccination receipt practices (vaccination administered) and reasons for vaccination non-receipt (i.e., not offered versus refused) are presented. The results of this dissertation will inform clinicians and NH administrators as well as future policy and public health interventions and provide evidence needed to improve racial/ethnic minority health and eliminate health disparities.

The elderly population is growing in nursing homes (NHs), with an estimated 3 million seniors to be residing in NH facilities by year 2030. Many of these seniors are potentially at risk for falls or infections. NH residents with Alzheimer’s disease or other forms of dementia are also increasing, and they are vulnerable to the adverse effects of medications. Psychotropics are overused in NHs, with approximately half to two thirds of residents receiving one or more psychotropics. Many negative health outcomes, e.g. falls and infections, have been associated with their use. The usage of psychotropic medications among NH residents has been a concern and topic of scrutiny for nearly three decades. In 1986, the Institute of Medicine published a landmark report that identified the overuse of psychotropic medications in NHs. The following year, the federal government passed the Omnibus Budget Reconciliation Act that included reform legislation to address psychotropic drug overuse. Since then, additional policies and initiatives have endeavored to rectify the problem, and scientists have conducted research regarding psychotropics and negative health outcomes. However, newer research within the last decade and at a national level is lacking. Therefore, this dissertation explores the association of psychotropic medications with falls and infections among NH residents using a national dataset, and this document is organized into five chapters. The first chapter discusses the background, significance, and current challenges surrounding psychotropic medication use in NHs. The second chapter delineates the search of the literature and relevant findings. The third chapter describes the methodology upon which this analytics of this dissertation was conducted. The fourth chapter outlines the results from the analyses. Lastly, the fifth chapter provides a synthesis and discussion of the findings and recommendations for health policy, practice, and future research.

This dissertation examines the assessment and documentation of sexual orientation and gender identity in the home healthcare setting, specifically patient and nurse perceptions of such data collection, as well as what is documented in nurses’ narrative notes about patients’ sexual orientation and gender identity. Chapter One describes the problem of health disparities among lesbian, gay, bisexual and transgender (LGBT) patients and how lack of documentation contributes to this problem. In Chapter Two, an integrated review of the literature on patients’ attitudes and perceptions related to the collection of information about sexual orientation and gender identity in the healthcare setting is reported. In Chapter Three, a qualitative study to determine nurses’ experiences, attitudes, and perceptions related to collecting information about sexual orientation and gender identity in the home healthcare setting is reported, and emergent barriers and facilitators discussed. In Chapter Four, a data mining study to examine what is documented about sexual orientation and gender identity in narrative home care nurses’ notes in an electronic health record is described. Finally, in Chapter Five, the findings of the three studies are summarized, overarching conclusions reported and implications for policy, practice and research are discussed.

This dissertation focuses on utilizing data-driven approaches to objectively measure variation in the quality of care across different hospitals, understand how physicians make dynamic admission and routing decisions for patients, and propose potential changes in practice to improve the quality of care and patient flow management. This analysis was performed in the context of Intensive Care Units (ICUs) and the Emergency Department (ED). In the first part, we assess variation in the overall quality of care provided by both urban and rural hospitals under the same integrated healthcare delivery system when augmenting administrative data with detailed patient severity scores from the electronic medical records (EMRs). Using a new template matching methodology for more objective comparison, we found that the use of granular EMR data significantly reduces the variation across hospitals in common patient severity-of-illness levels. Further, we found that hospital rankings on 30-day mortality and estimates of length-of-stay (LOS) are statistically different from rankings based on administrative data. In the second part, we study ICU admission decision-making dynamically throughout a patient’s stay in the general ward/the Transitional Care Unit (TCU). We first used an instrumental variable approach and modern multivariate matching methods to rigorously estimate the potential benefits and costs of transferring patients to the ICU based on a real-time risk score for deterioration. We then used the quantified impact to calibrate a comprehensive simulation model to evaluate system performances under various new ICU transfer policies. We show that proactively transferring the most severe patients to the ICU could reduce mortality rates and LOS without increasing ICU congestion and causing other adverse effects. In the third part, we focus on understanding how physicians make ICU admission decisions for patients in the ED. We first used two sets of reduced-form regressions to understand 1) what and how patient risk factors and system controls impact the admission decision from the ED; and 2) what are the potential benefits of admitting patients from the ED to the ICU. We then proposed a dynamic discrete choice structural model to estimate to what extent physicians account for the inter-temporal externalities when deciding to admit a specific patient to the ICU, to the ward or let him/her wait in the ED. Note that the structural model estimation is still an ongoing process and more investigation is required to fine tune the details. Therefore, we will not discuss the structural model estimation results in this chapter, but only present the modeling framework and key estimation strategy.

The U.S. health care system of the 21st century is in desperate need of reform. Patients are being harmed in the hundreds of thousands attributable to medical errors, identified as the third leading cause of death in hospitals. The need for health care reform is further validated by the trillions of dollars that are infused into the U.S. health care system, where quality of care benchmarks are among the worst in the world. The historical evolution of the U.S. health care system was predicated on nurses who served as advocates and innovators of safe workplace and patient care practices. The Code of Ethics and Nurse Practice Act(s) for registered nurses and the requirements of registered nurse licensure in the 21st century, partnered with an ethical barometer in the delivery of quality patient care, command that registered nurses maintain their historical role as advocates and innovators to promote and maintain safe workplace and patient care practices. Registered nurses in the 21st century are being stifled in the fulfillment of what is commanded of them professionally. It is the quagmire of fulfilling their advocate, innovator role and being penalized with unjust discipline shortly thereafter that is stifling. This “coincidence” is silencing registered nurses across the United States. The aim of this study was to employ a hermeneutic phenomenological research design utilizing Max van Manen’s phenomenology of practice to explore the lived experience of unjust discipline among registered nurses. Audio-recorded interviews were conducted with the participants of the study. Vivid descriptions of the participants’ lived experiences of unjust discipline were communicated. Transcripts were generated from the audio recordings. An interpretive analysis utilizing the hermeneutic circle disclosed nine essential themes among the participants’ experiences of unjust discipline. Respondent feedback augmented validity in the interpretive processes during data collection and thematic analysis. In the context of the study, it was evident that unjust discipline is a disruptive workplace behavior that potentiated physical workplace violence. Further, authentic social support may have precluded many of the elements of unjust discipline experienced by the participants during the lived experience of unjust discipline.

Nonclinical frontline employees (FLE) work in a complex role that provides critical administrative support to healthcare organizations and they are extremely vulnerable to workplace stress. These employees frequently encounter challenging situations and routinely interact and serve many demanding customers. The purpose of this exploratory study was to understand how FLEs have learned the abilities they utilized to cope with workplace stress and how these relate to emotional intelligence. Utilizing a comprehensive survey; comprised of a demographic questionnaire, three assessment instruments (PSS, Brief COPE and SSEIT), a critical incident series and individual interviews, this study sought to understand the learned strategies acquired through personal and professional experiences and how those experiences impacted coping tendencies. FLEs were found to perceive high self efficacy and routinely regulated emotions in an effort to manage stress. Employees also adeptly managed routine conflict and impromptu difficult interactions. Formal, Nonformal and informal learning were pivotal to cultivating the strategies utilized in the workplace. Despite unpredictable stress levels, role ambiguity and the desire for stress management training, FLEs were optimistic, demonstrated the ability to use emotional intelligence and coped relatively well in the workplace.

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