archives@tulane.edu / Research has shown that populations with mental illness tend to have higher rates of obesity, diabetes, and other chronic conditions. This can be due in part to the medication treatment as anti-psychotic and anti-depressant medications have been shown to be major contributors to elevated rates of obesity, diabetes, dyslipidemia, and metabolic disorders that have the potential to lead to cardiovascular disease. Existing literature has identified many barriers that contribute to low preventive care utilization and screenings for metabolic risk factors. Consequently, national policy initiatives, such as the 2010 Affordable Care Act’s (ACA) Medicaid expansion, have aimed to improve access to care impacting adults with mental illness and expand coverage for more preventive and mental health services. Thus, this project: (1) examined longitudinal trends in diabetes preventive screenings and healthcare utilization associated with the 2016 Louisiana Medicaid expansion for a traditionally enrolled Severe Mentally Ill (SMI) Medicaid insured population, (2) assessed differences in racial and other socio-demographic characteristics associated with receiving diabetes preventive care and utilizing health care services amongst a traditionally enrolled SMI Medicaid insured population, and (3) assessed if Medicaid expansion was associated with better access to care and increased utilization of preventive care for diabetes-related complications in adults with diabetes and depression. To address these aims, adults ages 18 to 64 were analyzed through two data sources. The first is Louisiana Medicaid claims data; a longitudinal assessment of screening rates over a five-year period was used in an interrupted time series analysis to look at the change in screening rates for preventive care services and health care utilization before and after expansion for adults with SMI. Next, we used multivariable logit regression modeling, to examine the likelihood of receiving preventive care and utilizing health care services based on sociodemographic characteristics. Results from these analyses showed there was a total of 53,926 adults with a diagnosed SMI who had continuous enrollment in Medicaid between January 1st, 2014 – December 31st, 2018. Medicaid expansion was associated with significant increases in ED utilization and average inpatient length of stay for traditionally enrolled SMI adults. Racial differences in the likelihood of going to the ED were also apparent as blacks were more likely to go to the ED and for reasons that could have been prevented. For the third aim, data were extracted from the Behavioral Risk Factor Surveillance System survey for the years 2010 to 2017 for all adults with a self-reported diagnoses of depression and diabetes by a health professional. A retrospective cross-sectional study design using difference-in-differences analysis assessed relationship between Medicaid expansion and access to care and preventive care utilization for Medicaid eligible respondents in expansion states, compared to Medicaid eligible respondents in non-expansion states. Medicaid expansion significantly increased insurance coverage and the likelihood of having a personal doctor for eligible respondents in expansion states. / 1 / Alisha Monnette

Traditionally, the compliance rates with preventive care services for members in the Medicaid Program are significantly lower than their peers enrolled in a commercial health insurance plan even when there are no financial costs for those services to Medicaid members. Start of life services which include prenatal care for pregnant mothers and well-child visits for newborns and infants are used to focus the research. Non-compliance, defined as not receiving recommended preventive services within the timeframe expected, has large financial and societal costs. Women who receive only the minimal prenatal care are at high risk for developing pregnancy complications and having negative birth outcomes while those that failed to receive prenatal care were three times more likely to have a low-birth weight infant. Within the first 6 months of life, children with incomplete visits are 60 percent more likely to visit the emergency room. They may have untreated development delays and disabilities, which occur in approximately 13 percent of children and are estimated to cost $417,000 in direct medical costs and indirect lost productivity per child. This thesis looks at motivational theories and economic incentives in practice in the health care industry to address the lack of compliance of services. It will analyze the problem from the perspective of how does a business, the State Medicaid Program or Medicaid Managed Care Organization (MCO), get a customer, the Medicaid population, to perform a specific behavior, receive preventive care services using motivational theories. / text

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Among the minorities underserved by today׳s healthcare system, the lesbian, gay and bisexual (LGB) population may be the least studied, and the least understood by healthcare providers. High-quality evidence is often lacking regarding optimal preventive care measures, both in medical areas that (to date) fail to identify differences in need between LGB and heterosexual patients, and in those more prevalent in or more specific (or both) to sexual minorities. Issues of substance abuse, sexual health and sexually transmitted diseases, obesity and other eating disorders, cardiovascular prevention, cancer prevention and screening, depression and other psychological disorders, social isolation and personal and intimate partner violence are all as or more important to address in LGB patients as they are in the general American population. Although many barriers to the delivery of quality healthcare to these patients exist, support from governmental, professional and private organizations can assist both patients and providers in overcoming these barriers.

Purpose/hypothesis: The purpose of this study was to use the National Survey of Children's Health 2011/2012 (NSCH 2011/12) data set to determine if children with diagnosed mental health disorders (MHD) (depression and/or anxiety) have delayed or missed preventative healthcare services (medical, dental, vision care), and if their parents reported difficulty getting them the care they need at a different rate than children without MHD. Population of interest: Children (0-18 years of age) and their guardians who completed the survey were included in the analyses. Methods: For both hypotheses, we defined subject’s exposure (having MHD) and outcome (missed or delayed care/problem getting care) based on parental response to interview questions (N = 73,632,881). Covariates adjusted for in our models included child/parent demographics, insurance status, household employment, and DHHS poverty level. Both research questions were evaluated using multi-variable logistic regression (adjusted as necessary using the correct sampling methods as suggested by the NSCH). Results: The odds of having missing or delayed care for a child with MHD were 2.24 times higher (95% CI: 1.82-2.77) than a child without MHD. The odds of the parent reporting problems getting care for a child with MHD were 2.11 times higher (95% CI: 1.74-2.60) than a child without MHD. Clinical Relevance: These findings highlight a need to focus on finding ways to promote and provide all of the healthcare that a child needs. Children with MHD have many healthcare needs that other children may not, but they still need adequate preventative care. This may bring the specific needs of a population needing extra help to the attention of healthcare providers and outreach programs. / Epidemiology

Introduktion: Patientens upplevelser från intensivvårdsavdelningen kan ge upphov till stress som orsakas av flera faktorer. Detta kan påverka patienten lång tid efter utskrivningen. Det är därför viktigt att veta vilka omvårdnadsåtgärder på intensivvårdsavdelningen som stödjer patientens återhämtning. Syfte: Studiens syfte var att beskriva intensivvårdssjuksköterskors uppfattningar av preventiva omvårdnadsåtgärder på intensivvårdsavdelningen som kan vara stödjande för patientens återhämtning. Metod: En kvalitativ metod valdes och datainsamling skedde i form av nio intervjuer med intensivvårdssjuksköterskor, med erfarenhet av uppföljningsarbete, på tre olika sjukhus. Analys av insamlat material, skedde med hjälp av kvalitativ innehållsanalys enligt Graneheim och Lundman. Huvudresultat: I resultatet framkom fyra huvudkategorier som beskriver områden för preventiva omvårdnadsåtgärder: Skapa meningsfullhet, Förklara omvärlden, Skapa trygghet och Förbered framtiden. Konklusion: Studiens resultat visar att kunskap om patientens historia kan användas som grund för att knyta an till patientens vardagsliv. Struktur, förklaringar och råd från personalen har uppfattats stödja patientens omvärldsuppfattning på IVA. Trygghet och närhet från personal och anhöriga anses viktigt för patienten. Framförallt har stöd till patientens inre resurser och anpassande av miljön genom nedtrappad övervakning, uppfattats kunna bidra till att patienten återfår sin självständighet och bättre kan hantera framtiden. / Introduction: A patient´s experiences during intensive care can lead to stress that is caused by several factors. This can affect the patient long after discharge. Therefore, it is essential to know which nursing interventions in the intensive care unit, that best support the patient's recovery. Aim: The aim of this study was to describe the intensive care nurses' perceptions of preventive care measures in the intensive care that can be supporting for the patient's recovery. Method: A qualitative method was chosen and the data collection was done by interviewing nine intensive care nurses with experience in monitoring work at three different hospitals. The collected material was analyzed in accordance with Graneheim and Lundman´s qualitative content analysis. Main Results: The results revealed four main categories in which preventive care measures are especially useful: Creating meaning, Explaining the environment, Creating safety and Preparing for the Future. Conclusion: By gaining knowledge about what is relevant to each particular patient it is possible to adapt care measures based on this. It seems that structure, detailed explanations and advice provided by the staff will help the patient to better assess his/her situation. Being close to staff and family is comforting for the patient. It is a great importance to help the patient regain independence in order to manage the future. It was perceived that this can be done by gradually decreasing the use of technology and supporting the patient´s inner strengths.

Diet related factors are associated with the 2 most prevalent oral diseases- caries and periodontal disease. Furthermore, there is growing evidence of a synergistic link between nutrition, systemic health, and oral health. Regardless of this evidence and in spite of recommendations by dental associations, researchers have shown the majority of dental professionals are consistently excluding nutritional screenings and dietary counseling in their dental services. The purpose of this study was to examine the nutritional screening and dietary counseling practices of Utah dental hygienists and to evaluate possible associations between various factors influencing the implementation of nutritional services. Surveys were collected from members of the Utah Dental Hygienists’ Association. Mean scores showed low frequency and low confidence levels in performing nutritional services and high perceptions of barriers to care. Little to no difference in mean scores occurred when differentiating between degree achievements, years in dental hygiene practice, or component affiliation.

The Anderson and Aday access framework (1974) is utilized to investigate the association of individual and community level, predisposing, socio-demographic, and enabling factors, on potential and realized access to coronary heart disease (CHD) preventive care. The cross-sectional study is based on a sample of adults age 18-85 from the Medical Expenditure Panel Survey (MEPS) who were identified with CHD risk or who had a CHD diagnosis.Variables from the MEPS and the Area Resource File (ARF) are used to test logistic regression models for dependent variables measuring primary and secondary CHD preventive care services. The primary preventive care measures include blood cholesterol testing, blood pressure checks, and, diet, exercise and smoking cessation counseling. The secondary preventive measures include beta-blocker reciept after myocardial infarction (MI) and statin drug use for the treatment of high blood cholesterol.Being uninsured is associated with a reduced likelihood of receiving primary CHD preventive care. Overall study results indicated gender and race are more consistent predictors of the receipt of CHD preventive care services than individual enabling or community characteristics. Women had a greater likelihood of receiving primaryCHD preventive care services than men. Hispanics are less likely than Caucasians to receive primary CHD preventive care services, except for blood cholesterol testing for which they are more likely to receive. Blacks are more likely than Caucasians to have blood cholesterol testing, but are no less likely to receive the other primary CHD preventive care measures. Blacks demonstrate a lower likelihood of receiving secondary CHD preventive care than Caucasians, specifically beta-blocker post myocardial infarction indicating that disparities in secondary CHD preventive care persist for segments of the study population. Persons over 75 years of age are less likely to receive primary CHD preventive care services as well as the secondary preventive measure ofstatin use for high blood cholesterol.Community level factors did not improve the logistic regression model for the receipt of CHD preventive care, yet, when predicting potential access for preventive services, persons from a higher percent Hispanic or black community were less likely to have a usual source of care.

The roles of immigration status in preventive health care services among Nigerian immigrants in the United States were investigated in this quantitative, cross-sectional survey study. About 260,724 Nigerian immigrants reside in the Unites States, but many do not complete lifesaving preventive health services such as immunization and screening, a major factor contributing to the rise in the cost of healthcare resultant from their use of emergency room services. This study investigated the extent to which immigration status independently explains the relationship between health disparities and risks in non-completion of preventive health care among Nigerian immigrants in the United States by comparing data from Nigerian immigrant adults residing in the United States to data from the African American adults in the United States. Socio-cognitive theory and the social behavioral model served as the conceptual framework for this study. There were 291 adult Nigerian immigrants in the cross-sectional survey using a purposive sampling technique. The data were analyzed using the Levene's test for homogeneity of variances, the Pearson's Chi- Square test and the Kruskal-Wallis non-parametric test. The Kruskal-Wallis results showed that there was a significant difference in screening for preventive care services among the 4 immigrant status categories (p = .000) based on length of residency in the United States. Understanding the health disparities of this population according to their country of origin and immigration status will assist health providers with awareness of population-specific health needs, and may be beneficial in designing public health programs for this population group.

This dissertation examines the determinants of competition and consumer access in the health care market, and supply- and demand-side determinants of health care use under the Affordable Care Act (ACA). The first essay studies insurer entry into the federally-facilitated health insurance market under the ACA. Motivated by the fact that insurers’ service areas can be subsets of rating areas, and the substantial variation in plan composition within a rating area, I explore variations in the type of plans offered and insurers’ decisions to enter a rating area. I find that availability of medical providers, population size, and metropolitan status are important in insurers’ decisions to enter a rating area. Medical cost affects the entry of restricted network plans. The second essay examines how supply-side incentives affect treatment choice for depression. Using claims data from Florida’s Medicaid program, I find large variations in initiating antidepressant treatment among newly diagnosed patients with three plan types: Fee-for-Service (FFS), Primary Care Case Management (PCCMs) and Accountable Care Organizations (ACOs). Compared to FFS, PCCMs and ACOs are more likely to provide antidepressant but no office-based care. I use the control function approach to mitigate the self-selection bias and find that ACOs tend to use lower cost medication options. Despite the use of low-cost alternatives for ACOs, no differences are found in subsequent psychiatric hospitalization or emergency room visits among plans. Different provider contractual relationships may partially explain treatment choice differences. The third essay investigates whether the ACA policy of free preventive services affects utilization of preventive care. I use variation in commercially-insured enrollees to examine the demand and supply prices of four preventive services. Despite an average 53 percentage point decrease in demand prices for these services, the actual service use only increased by 17 percent from 2007 to 2011, possibly due to little or no change in prices paid to providers. Using risk adjustment tools to predict and control for patient underlying health status, I find similar changes in demand prices and rates of service use across six health plan types, consistent with preventive visits being provider rather than consumer choices.