Indiana University-Purdue University Indianapolis (IUPUI) / With an estimated 30.2 million diagnosed and undiagnosed cases among adults (and another 84 million at risk), diabetes mellitus is one of the most prevalent chronic conditions and a leading cause of mortality in the US. Diabetes self-management education and training (DSME/T) is a recognized standard of care and provides patients with the requisite knowledge and skills to properly manage the condition, improve long-term health outcomes, and reduce health care expenditures. Yet, DSME/T is greatly underutilized. Health insurance coverage that does not include benefits for DSME/T effectively imposes barriers to access for patients in need of the service. Many states have adopted laws and regulations requiring public and/or private insurers in their market to provide benefits for DSME/T; however, these requirements vary by state. It is unclear if these policies effectively improve access to DSME/T services. This dissertation seeks to rigorously assess the impact of state-mandated benefits and reimbursement provisions on access to DSME/T among adult patients with diabetes. The first analysis utilizes a unique combination of legal and programmatic data to quantify changes in the supply of DSME/T resources after the adoption of state-mandated benefits (potential access). The second analysis merges legal data with the Medical Expenditure Panel Survey (MEPS) from 2008 to 2016 to examine the impact of state mandates and reimbursement provisions on patient utilization of DSME/T (realized access). Lastly, the final analysis utilizes electronic health record data (2010-2016) from a safety net population to determine if patients’ evaluated need for DSME/T predicts the likelihood of receiving a DSME/T referral during a provider encounter (equitable access). Using novel data sources and a sophisticated policy analysis technique, this study provides a rigorous assessment of the impact of decades of state policies designed to improve access to care. / 2020-04-02

No description available.

The Canadian healthcare system, by design, has been historically oriented to delivering acute and symptom-driven care; however, the current cost of treating chronic disease has risen to an average of nearly 45% of direct costs of the national health budget. As a consequence more attention is being directed to the diagnosis and treatment of chronically ill patients who also may suffer from disabilities, illiteracy, impairment in judgment, depression, or multiple co-morbidities. This has also resulted in a new emphasis on health and disease self-management, to help patients to mitigate and manage the impacts of chronic diseases. This approach affects and involves the patient’s entire circle of care including the patient, healthcare providers, and the patient’s family and friends. This study discusses how support elements (i.e. decision support, education and training, family and community support) and sustainability elements (i.e. recreation and entertainment, rewards systems, online social networks) combined with online technological support can help to support and provide motivation for chronically ill patients to adopt self-management in a sustainable manner. The PLS (Partial Least Squares) statistical approach was used to validate a proposed SEM (Structural Equation Model) research model with data collected from 198 participants across North America without any prior exposure to our proposed system. The research model hypothesized that support and sustainability constructs have a strong positive influence on the willingness of users to adopt and use the proposed system. The model results in a very good fit for Behavioural Intention to Adopt for patients with no caregiver support (R2=0.71), and for patients with such support (R2=0.65). The results clearly validate our proposed model including a high predictive relevance for endogenous variables. This research provides useful theoretical and practical insights and understanding for design, development and promotion of chronic care self-management systems as well as the perceptions of users regarding the adoption and use of such systems. / Dissertation / Doctor of Philosophy (PhD)

Two endemic late-season grape rot diseases, ripe rot and sour rot continue to pose a significant challenge to grape growers in Virginia and similar climates. Managing these diseases in the vineyard is challenging due to concerns over the increased risk of resistance against traditional single-site mode of action pesticides. This study evaluated the efficacy of different biopesticides and novel chemical options with a series of field trials across four vineyards in northern Virginia in 2021 and 2022. Among the tested products, a potassium-based nutrient formulation resulted in consistent ripe rot suppression in two of the three trials, showing around 46% and 83% less mean disease severity at the AHS AREC trial in 2022 and 2021, respectively, and 63% and 19% less mean disease incidence at the South Loudoun trial in 2021 and AHS AREC trial in 2022. For sour rot, zeta-cypermethrin with cyprodinil + fludioxonil or hydrogen peroxide + peroxyacetic acid resulted in effective control in two of the five trials, with a high of 71% and 73% less mean disease incidence compared to the untreated check in the Frederick trial in 2021 and 2022, respectively. In general, treatments with spinosad were less effective and resulted in lower disease control compared to those with zeta-cypermethrin and its fungicides/antimicrobials counterpart. The results suggest that integrating these biopesticides and novel chemicals into a spray program could offer a more sustainable solution for sour rot and ripe rot disease management without compromising the level of disease control. / Master of Science in Life Sciences / Ripe rot and sour rot are two diseases of concern for growers in Virginia and many other grape-growing regions due to significant losses in fresh cluster yield and the risk of contamination during the winemaking process. Traditional pesticides are often used; however, the breakdown of the effectiveness of these pesticides after continuous application, i.e., pesticide resistance, has become a critical issue. The other issues include, but are not limited to, adverse effects on human health, nature, and winemaking. On the other hand, biopesticides derived from microorganisms, their products, plant extracts, etc., are considered relatively safer and more sustainable options. This study evaluated the efficacy of biopesticides and novel chemicals against ripe rot and sour rot through field trials over two years at four locations in northern Virginia. Although no clear-cut winners were among the tested treatments, one of the tested chemicals (a potassium-based plant nutrient formulation) provided consistent disease suppression (up to 83%) against ripe rot. In the case of sour rot, several treatments, including a biologically derived insecticide, produced comparable disease suppression (up to 73%) compared to the current standard application. These safer options can be included in the spray schedule without compromising the level of disease control, meanwhile aiding the sustainability of the spray program in the long run.

End-stage conditions such as chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) have shown some of the most dramatic increases in mortality in the developed world over the past 40 years. Both are therefore leading causes of morbidity and mortality worldwide and should be considered as a major economic and social burden that is both substantial and increasing. In these conditions, exercise therapy should play an integral part in maintaining the patient’s maximal level of independence and functioning, as well as slowing or possibly even stopping the progression of the condition. In this context the main objectives of these doctoral theses are: a. Proving the safety of different exercise modalities. b. Identifying the most effective exercise interventions in regards to clinical parameters. c. Proving the feasibility of outpatient rehabilitation programmes for these high risk populations. This work, therefore, combines three studies looking into the effects of non-pharmaceutical interventions – predominantly different exercise regimes in the two major conditions in the mortality statistics of CHF and COPD - both with a very poor prognosis. In conclusion it can be said that the results and experience of all three studies demonstrate the safe feasibility of different outpatient exercise interventions and suggest specific positive adaptations in patients with heart failure and COPD which also led to a lower hospitalisation rate. There are clear hints that the therapy spectrum could be supplemented significantly by specific training interventions. The financial implications for any health care system are also highly relevant.

No description available.

Diabetes mellitus is a group of metabolic disorders caused by a relative or absolute lack of insulin. Currently, 23.6 million Americans have diabetes. Diabetes can lead to serious microvascular and macrovascular complications, such as cardiovascular disease, blindness, kidney disease, lower-limb amputations, and premature death. Due to the potential cardiovascular complications and the high prevalence of co-morbid hypertension and/or hyperlipidemia in patients with diabetes, diabetes management should include close monitoring of blood glucose, blood pressure, and cholesterol levels. Medical management of diabetic patients is costly; approximately 1 in every 10 health care dollars is currently spent treating diabetes. Studies have shown that in chronic conditions such as diabetes, increased medication use results in demonstrable improvements in health outcomes, reduced hospitalization rates, and decreased direct health care costs. To date no studies have evaluated the impact of a pharmacist-led intervention on diabetic medication adherence. The purpose of this investigation was to analyze the impact of a pharmacist-led medication management program on medication adherence and pharmacy costs and to evaluate clinical measures of diabetes, hypertension, and hyperlipidemia. This study was a quasi-experimental, longitudinal, pre-post study, with a control group. Scott & White Health Plan (SWHP) patients with diabetes (type 1 or type 2), poor glycemic control (most recent A1C >7.5%), and living within 30 miles of participating pharmacies were invited to participate in the intervention which consisted of monthly appointments with a clinical pharmacist and a co-payment waiver for all diabetes medications and testing supplies. A total of 118 patients met study inclusion criteria and were enrolled in the intervention between August 2006 and July 2008. Intervention patients were matched on sex and age to SWHP patients with poor diabetes control living more than 30 miles from a participating pharmacy. To measure the impact of the intervention, medical and pharmacy data were evaluated for one year before and after the study enrollment date. A significant difference was seen in the percentage of patients with type 1 diabetes in the intervention group (14) and the control group (3). The medication management program significantly improved A1C levels in intervention patients relative to controls (-1.1% vs. 0.6%) and was more effective in lowering A1Cs in type 2 diabetics than type 1 patients. Although the generalized linear model did not show that the intervention significantly improved the percentage of patients achieving the ADA goal A1C of <7% compared to controls, the multivariate logistic regression, which controlled for factors such as diabetes type, showed that patients participating in the intervention were 8.7 times more likely to achieve the A1C goal. Persistence with diabetic medications and the number of medications taken significantly increased in the intervention group; however, adherence rates, as measured by medication possession ratio (MPR), did not significantly improve relative to controls. The expenditure on diabetic medications and testing supplies increased substantially more in the intervention group than in the control group. The percentage of patients adherent with antihypertensive medications (MPR ≥80%) increased from 76% to 91% in the intervention group and decreased from 68% to 63% in the control group (P<0.05); no significant difference in blood pressure control was observed. For hyperlipidemia medications, adherence and persistence increased and pharmacy costs decreased in both groups, likely due to the introduction of the first generic HMG-CoA reductase inhibitor into the market during the study period. Future research is needed on the impact of the intervention on medical resource utilization and costs. / text

Disease management in organic apple orchards in Vermont is focused on controlling diseases with sulfur fungicides. The objective of this two year study was to evaluate the target and non-target effects of an organic disease management system containing agricultural biostimulants compared to two sulfur-based systems on foliar and fruit diseases, pest and beneficial arthropods, tree growth, yield and fruit quality on four cultivars, `Ginger Gold', `Honeycrisp' and `Liberty' and `Zestar!'. Trees were arranged in a complete randomized design of five three-tree replications in a certified organic orchard. The two sulfur-based systems differed in the number of applications; in the third system, sulfur was replaced with biostimulants including pure neem oil, liquid fish, an activated microbial inoculant plus equisetum and stinging nettle teas. Each biostimulant application also included kelp meal, unsulfured organic molasses and yucca extract emulsifier. The biostimulant system did not successfully manage apple scab and rust diseases as well as the sulfur-based fungicide systems, and had variable results with other diseases. No differences were observed among the three systems in tree growth parameters; however, the length of the study may not have been sufficient to determine effects. Differences in the incidence of disease among the three systems were reflected in extrapolated figures for gross income per hectare which takes into account fruit yield and quality. In the higher fruit-bearing year of the study, it was estimated that the gross income per hectare of the biostimulant system would be significantly lower than the reduced-sulfur system and the full-sulfur system by at least $5,800 and $12,000, respectively. In that same year, it is estimated that the full-sulfur system would have generated approximately $6,500 more gross income per hectare than the reduced-sulfur system suggesting the number of sulfur sprays can influence fruit quality and income. The use of the agricultural biostimulants had very limited non-target effects and when present, they were beneficial in suppressing insect pest incidence and/or damage on foliage compared to one or both of the sulfur-based fungicide systems. However, many insect pests or their damage were not observed on the foliage or had incidence of less than 1% in any of the systems. The biostimulant system did appear to suppress European red mites in both years compared to both sulfur-based systems when data were averaged across cultivars. On fruit, no differences in non-target impacts on arthropod pests were observed among the three systems except for surface-feeding Lepidoptera and San Jose scale damage. In a separate phytophagous mite study on the cultivar `Zestar!' leaf samples were evaluated for the number of motile phytophagous mites every 14 days from 1 July through 26 August each year. When there were differences, the biostimulant system had less mite incidence per leaf than one or both of the sulfur-based systems in both years. The difference in the number of sulfur sprays did not have a major effect on the mite populations. In summary, the use of the biostimulant system resulted in insufficient disease management which led to lower estimated gross income compared to the sulfur-based systems. These results show more research and further evaluation of new organic disease management tools, including the use of agricultural biostimulants, are necessary before growers consider replacing the use of standard sulfur fungicides for disease management in Vermont orchards.

Although it is well known that self-care reduces the frequency of hospital admissions and exacerbations and enhances quality of life (QOL) in heart failure (HF) patients, little is known about self-care in this population. Therefore, the study purpose was to examine relationships among selected individual characteristics (demographics, severity of illness, comorbidities, and social support), self-care strategies, and QOL using Reigel's Model of Self Care in Patients with Heart Failure as the guiding framework. In this descriptive correlational study, self-care was measured using the Self-Care of Heart Failure Index (SCHFI), which measures self-care maintenance (SC-Mt), self-care management (SC-Mn), and self-care self-confidence (SC-Sc). QOL was measured using a disease-specific instrument, the Minnesota Living with Heart Failure Questionnaire (LHFQ), and a generic instrument, the Short-Form Health Survey (SF-12) characterizing physical and mental-emotional functioning. Multiple regression analysis was used to identify predictors of QOL.Data were collected using Dillman's tailored design method for surveys. One hundred and sixty-five patients with HF were invited through a mailed letter and a survey packet to participate in this study. Five potential participants requested not to take part in the study, seven were reported as being deceased, and 23 letters were returned as undeliverable. After the initial mailing, we discontinued mailings to them. Thus, out of a possible sample of 130 subjects, 98 participants completed and returned questionnaires for a response rate of 75.38%.The sample (mean age = 56.33 years, SD = 13.65) included 56.1% males and 43.9% females and consisted of 48% Caucasians and 52% non-Caucasians. Approximately 55.1% were married and 60.2% had an annual income less than $30,000. The majority of the sample (72.5%) had at least a high school education. Half of the sample were somewhat functionally impaired (NYHA Class 11) and had an ejection fraction less than 30%. Ninety-three percent of the sample had been diagnosed with HF less than 10 years (mean = 5.05, SD = 3.34). Seventy percent of the sample had 0 to 4 comorbidities, and 17.7% reported that they only had HF and no other diagnoses. In addition, the sample reported mean score of social support at 71.72 (SD = 17.30) indicating good social support. On average, participants reported that they frequently performed self-care in order to maintain a healthy lifestyle: SC-Mt (mean = 69.59, SD = 15.56). They responded quickly and were likely to manage signs and symptoms that occurred: SC-Mn (mean = 61.69, SD = 19.91). Sixty-two percent reported that they recognized signs and symptoms of HF that occurred in the last month. They were very confident they could perform self-care: SC-Sc (mean = 66.11, SD = 17.02). The results showed that the participants' perceived their QOL as good (mean = 49.44, SD = 27.82). On average, participants perceived their physical functioning as fair (mean = 45.38, SD = 22.47), as was their mental-emotional functioning (mean = 53.32, SD = 22.36).Multiple regression analyses demonstrated that better disease-specific QOL was predicted by being less likely to use SC-Mn strategies (β = .325; p = 0.003), better SC-Sc (β = -.251; p = 0.012), better NYHA functional class (β = .246; p = 0.008), and less comorbidity (β = .236; p = 0.014) (R 2 = .334; F = 7.269, p = 0.000). Better generic QOL (physical functioning) was predicted by better NYHA functional class (β = -.309; p = 0.001), better SC-Mt (β = .205; p = 0.037), better SC-Se (β = .296; p = 0.003), and being less likely to try SC-Mn strategies (β = -.165; p = 0.000) (R 2 = .361; F = 9.602, p = 0.000). Better generic QOL (mental-emotional functioning) was predicted by better NYHA functional class (β = -.229; p = 0.024) and being male (β = -.204; p = .047) (R 2 = .277; F = 4.548, p = 0.000).Findings suggest that better QOL is associated with being male displaying better NYHA functional class, less co-morbidity, and better performance of self-care activities in order to maintain health (SC-Mt), being less likely to identify and respond quickly to signs and symptoms of HF (SC-Mn), having and confidence in performing of self-care strategies (SC-Se). The findings add to the scientific body of knowledge in self-care.

Personal Health Records (PHRs) allow patients to access and in some cases manage their own health records. Their potential benefits include access to health information, enhanced asynchronous communication between patients and clinicians, and convenience of online appointment scheduling and prescription refills. Potential barriers to PHR use include lack of computer and internet access, poor computer or health literacy, security concerns, and provider disengagement. PHRs may help those living in rural areas and those with chronic conditions such as heart failure, monitor and manage their disease, communicate with their health care team and adhere to clinical recommendations. To provide some much needed actual research, a descriptive mixed methods study of the usability, usefulness, and disease management potential of PHRs for rural heart failure patients was conducted. Fifteen participants were enrolled. Usability issues fell into three categories: screen layout; applying consistent, standard formatting; and providing concise, clear instructions. Participants used PHR features that were more convenient than other methods or that had some additional benefit to them. There was no difference between rural and urban participants. A heart failure nurse promoted recording daily heart failure symptoms in the PHR. Most participants did so at least once, but many found it cumbersome. Reasons for recording included the comfort of having clinical staff monitor the data. Participants who were stable did not find recording as useful as did those who were newly diagnosed or unstable. Participants used asynchronous communication to send messages to the heart failure nurse that they would not otherwise have communicated. The study expands the knowledge of PHR use by addressing useful functionality and disease management tools among rural patients with heart failure. The patients were able to complete tasks they found useful. The increased communication and disease management tools were useful to some.