The purpose of this dissertation is to effectively understand, measure, and model the impact of Access to Care (AC) on Patient Safety (PS) through the creation of a model that evaluates their interdependence. Through the use of statistical tools and through the combination of variables that define patient access to health care and patient safety, a Patient Access and Safety (PACSA) index is developed. The calculated Patient Access and Safety index provides information to both providers and patients about the impact of access and safety on treatment outcomes. The input variables used to support this research are Patient Access Factors (PAF) (Age, Insurance Type, Visit Type, List Price, and Days To an Appointment) and Patient Safety Factors (PSF) (Severity of Diagnosis, Race, and Gender). In this model, 7,535 observations were used from a single organization based in South Florida, in order to develop the index. The PACSA index offers a tool that helps providers, healthcare staff and patients evaluate patient safety as it is impacted by access to healthcare through the calculated index. This index produces an equation that examines the relationship between access to care and patient safety using the following relationship: PACSA=∑_(i=0)〖(.645〖PSF〗_i- .645〖PAF〗_i )+0.399〗An extensive literature review identifies the connection between AC and PS and the relationships governing these two concepts. Although large organizations like the World Health Organization (WHO), Agency for Healthcare Research and Quality (AHRQ), and Institute of Healthcare Improvement (IHI) have studied these concepts independently, there has not been a study that used a factor or index to describe the relationship. As the healthcare delivery system becomes more complex, and consumers demand better treatment outcomes, there is a growing need to analyze these concepts jointly. This study focuses on diabetic retinopathy (DR). This is a condition experienced by chronic Diabetic patients, and it is one of the major causes of blindness (National Eye Institute, 2009). The increase in the occurrence of Diabetes worldwide has heightened the disease and inspired clinical research. In 2002, it was estimated that the disease stemming from Diabetes, namely DR, accounted for about 5% of world blindness, representing almost 5 million blind people. If left untreated or undetected, about 2% of people become blind, and about 10% develop severe visual impairment. By the year 2030, a possible 36 million people will have acute visual impairments and 7.2 million people will possibly be blind worldwide. In the United States, there are 18 million people with Diabetes, and 30% have Diabetic Retinopathy (5.3 million Americans over the age of 18) (ATA Report 2004; AHRQ, 2004; WHO, 2004). Although this study focused on DR, the model has been designed with the ability to be applied to other diseases and conditions. The goal of creating the PACSA index is to help healthcare workers understand when to schedule patients within the context of access and safety. Current appointment schedules, which are the tools used by healthcare workers, use a “New patient vs. Follow up patient” design. The PACSA challenges the current scheduling schema. No longer will patients be categorized into “New vs. Follow Up” visits. Instead, they will be evaluated for access to care requirements and patient safety needs from the initial point of entry into the health system. The recommendation is to start designing schedules based on PACSA (low PACSA, medium PACSA, and high PACSA). In this new paradigm, the low PACSA would describe patients that have low disease complexity, low number of risk factors, and can wait a little longer for their appointment without having complications of disease from lack of treatment. On the contrary, the high PACSA would include a subset of patients that have high disease complexity, high number of risk factors, and require immediate appointment and medical continuity of care to have the best treatments and outcomes. The PACSA index can serve as a visual guide for decisions regarding access and patient safety requirements. Two key components of quality within healthcare include access to care and patient safety. To create “congruent system integration” (Maier-Speredelozzi, 2007), there must exist synchronization of all healthcare delivery operations. The Patient Access and Safety Index (PACSA) provides a framework for integrating these two components. This research and the indices developed can offer benefits to health care organizations, patients, physicians, and government entities by providing a versatile tool to help improve access to health care and patient safety.

Irregular pagination - jumps from p. 168 to p. 170. / Untreated Obstructive Sleep Apnoea Syndrome (OSAS) increases the risk of motor vehicle accidents and morbidity. Its prevalence among taxi drivers is unknown. The goals of this thesis were to: (1) estimate the prevalence of OSAS symptoms and risk factors among taxi drivers; and (2) identify the barriers to accessing health care services for the diagnosis and treatment of OSAS. Between June and July 2004 questionnaires were mailed to 651 taxi drivers from two Wellington taxi companies (response rate 41.3%, n=241). Excessive daytime sleepiness (ESS>10) was reported by 18% of drivers. The estimated proportion with a pre-test risk of OSA (RDI≥ 15/hour) was 15%, according to a questionnaire-based screening tool. Pacific drivers were more likely to report OSAS symptoms than people of "other" (non-Māori) ethnicities. Logistic regression analyses identified the following independent risk factors for OSAS symptoms: increasing neck size, age groups: 46-53 years and 61-76 years, and self-reported snoring 'always'. Three focus groups were conducted in November 2004. Thematic analyses identified the following barriers to accessing health care: (1) sleepiness was not a perceived health problem; (2) personal demands; (3) industry demands; and (4) driver avoidance and dissatisfaction with general practitioner's services. Detailed examination of these themes indicated that drivers were deterred from seeking care by limited knowledge and awareness of OSAS, confusion about responsibility for health and safety, medical costs, and the risk of finding out about other health conditions. General practitioners reportedly failed to screen for OSAS symptoms and demonstrated little knowledge about sleep health. These barriers are a major cause for concern, and they are used to support the belief that earning a living is more important than personal health and safety. The key finding is that improving drivers' knowledge is unlikely to change their behaviour, without concurrent measures to address systemic issues in the taxi industry and in the health care system.

While individuals of Mexican origin are the largest immigrant group living in the U.S., this population is also the highest uninsured. Health disparities related to access to health care, among other social determinants, continue to be a challenge for this population. The government of Mexico, in an effort to address these disparities and improve the quality of life of citizens living abroad, has partnered with governmental and non-governmental health-care organizations in the U.S. by developing and implementing an initiative known as Ventanillas de Salud-Health Windows-(VDS). The VDS is located throughout the Mexican Consular network and aim to increase access to health care and health literacy, provide health screenings, and promote healthy lifestyle choices among low-income and immigrant Mexican populations in the U.S.

The present study aimed at analysing the role of socioeconomic factors in the unequal access to health care among Kenyans. Content analysis was utilised as the principal data analysis methodology, while systems theory guided the process of addressing the research question. Relevant data was obtained from scholarly sources published in credible databases. The findings identified several socioeconomic factors accounting for unequal access to health care in Kenya. Large household size, female-headed households, and lower social class were identified as the chief social factors contributing to this problem. Poverty, low family income, low level of education, and living in informal settlements were revealed as the main economic contributors of unequal health care access. Overall, the current study affirmed that health care disparities have become a substantial human right issue in Kenya due to a combination of socioeconomic variables, such as household size, household head, social class, living conditions, education level, and place of residence.

PURPOSE: Sickle cell disease (SCD) is an inherited blood disorder that affects the hemoglobin protein of red blood cells and has a significant impact on morbidity, mortality, and quality of life. Hydroxyurea has been FDA approved since 1998 as a disease-modifying therapy for SCD. However, hydroxyurea has not been optimally utilized for those with SCD. The purpose of this study was to evaluate reasons for hydroxyurea use, from the perspectives of providers, adults with SCD, and parents/caregivers of children with SCD, as well as perceived barriers to its use. We examined indications and reasons for being “on hydroxyurea,” defined by patients as currently taking hydroxyurea, and reported on pain frequency, perceptions of barriers, hydroxyurea adherence, and health care access for patients with SCD who were either on and not on hydroxyurea. METHODS: We conducted a cross sectional analysis of data collected within the Pacific Sickle Cell Regional Collaborative (PSCRC), a consortium of nine western U.S. states. Individuals were eligible for this study if they 1) had a confirmed diagnosis of SCD, 2) were followed at one of the PSCRC sites, and 3) were eligible for hydroxyurea therapy. Parents/caregivers of children with SCD less than 18 years and adults with SCD 18 years and older completed a brief survey about hydroxyurea use, indications, side effects, pain frequency, number of hospital and emergency department (ED) admissions per year, and individual and family perceptions of barriers to hydroxyurea use. Participants completed a follow-up survey annually, but we reported only on baseline data. Data collection occurred between February 2016 and May 2018. RESULTS: Individuals with SCD (n = 413) included 1) children (n=178; 6.7 ± 3.4 years), 2) adolescents (n=66; 15.0 ± 1.4 years), 3) young adults (n=57; 21.4 ± 2.6 years), and 4) adults (n=112; 39.2 ± 10.6 years). The majority were predominantly female (51.6%), African American (93.2%), and had HgbSS (74.1%) genotype. The majority of children (65.2%), adolescents (62.1%), and young adults (54.4%) were on hydroxyurea; fewer adults (39.3%) were on hydroxyurea. The majority with HgbSS (65.5%) were adherent to hydroxyurea. There was no significant difference in hospitalizations for pain, ED visits, and pain severity in the previous 12 months between individuals who were and were not on hydroxyurea, and between individuals who were and were not adherent to hydroxyurea. For those with a current prescription for hydroxyurea, the majority (66.5%) were receiving hydroxyurea for recurrent pain episodes or acute chest syndrome (19.9%). Hydroxyurea was discontinued because of patient/family preference (34.5%), chronic transfusions (31.1%), and side effects (24.1%). Patients prescribed hydroxyurea for empiric use (n=21) had fewer hospitalizations for pain, ED visits, and severe pain interfering with daily activities. The major barriers to hydroxyurea use, from the perspective of individuals with SCD or their caregivers, were 1) forgetting to take the medicine (19.4%), 2) worried about side effects (16.4%), and 3) lack of knowledge about hydroxyurea (13.6%). Fewer young adults (49.1%) and adults (50.0%) had primary care providers than children (78.1%) and adolescents (65.2%). CONCLUSIONS: Barriers to hydroxyurea use persist with emerging solutions to alleviate these barriers. For this sample, while hydroxyurea prescription rates by sickle cell specialists were similar to what has been seen in some other studies, neither hydroxyurea use nor adherence were associated with decreased frequency of hospitalizations for pain, ED visits, and severe acute pain episodes in the previous 12 months. Future studies need to evaluate hydroxyurea prescription patterns, duration on hydroxyurea, and adherence to hydroxyurea. Healthcare providers are recommended to prescribe hydroxyurea for eligible individuals who may benefit from it, such as those HgbSS or HgbS-β0 thalassemia genotype, and prescribe for empiric use to minimize complications. Provider and patient education about hydroxyurea could reduce common barriers experienced by individuals with SCD. It is important to customize educational resources to specific concerns for different age groups. Individuals 18 years and older with SCD have been documented with more ED visits and hospitalizations due to pain, most likely because they did not have a primary care provider and an adult hematologist with expertise in SCD. Future studies need to evaluate whether primary care providers who receive SCD education may promote hydroxyurea use and adherence. Dedicating time and resources for shared decision making between providers and patients/families can address concerns about hydroxyurea and increase patient/family confidence when deciding about hydroxyurea. As more disease-modifying therapies become available for individuals with SCD, strategies for shared decision making facilitate standardization and optimize the use of hydroxyurea and emerging therapies.

Abortion, the termination of pregnancy, is safe when provided as a surgical procedure by a trained provider or when the correct dosage of the drugs mifepristone and/or misoprostol are used. Despite this, many barriers to abortion care exist. In the United States (US), targeted state-level abortion restrictions create barriers to care, which make it so that people who wish to utilize abortion care face difficulty or are unable to do so. Such barriers to care have important public health implications, as studies have shown that individuals who cannot access wanted abortion care have poorer psychological, physical, social, and economic outcomes than those who obtained care. This dissertation aims to examine one component of abortion access, accessibility, operationalized as the drive time from a woman’s home to the nearest abortion-providing facility. We employ a novel measure of abortion accessibility constructed from three data sources: (1) the Advancing New Standards in Reproductive Health facility database; (2) US Census estimates and shapefiles; and (3) OpenStreetMap data. In the first study, we used geographic information systems (GIS) to explore the effect of programmatic and policy changes related to telemedicine for medication abortion services (TMAB) on population-level measures of abortion accessibility, or drive time to the nearest abortion-providing facility. We found that either expansions in TMAB services or removal of TMAB bans could improve abortion accessibility in the US. For these two exposure scenarios, compared to the current abortion provision scenario, increases in the proportion of women within a 30-, 60-, and 90-minute drive time of an abortion-providing facility ranged from 1.25 percentage points, or an additional 781,556 US women aged 15-44 years with accessibility, to 5.66 percentage points, or an additional 3,530,423 US women aged 15-44 years with accessibility. In the second study, we used GIS to assess the potential effect of the geographic unit of analysis (i.e., block group, ZIP code tabulation area [ZCTA], or county) on misclassification of the proportion of US women of reproductive age within a 30-minute drive time of an abortion-providing facility relative to a measure calculated using Census blocks. We found that block group- or ZCTA-based estimates of abortion accessibility were an underestimate, but resulted in little misclassification relative to measures constructed using Census blocks at the national level; however, county-based measures substantially underestimated abortion accessibility compared with Census block-based measures. Nationwide, the Census block-based abortion accessibility estimate was 0.35 percentage points greater than the block group-based estimate, 2.72 percentage points greater than the ZCTA-based estimate, and 24.21 percentage points greater than the county-based estimate. By state, the Census block-based abortion accessibility estimate ranged from 0 to 8.51 percentage points greater than the block group-based estimate, from 0 to 27.86 percentage points greater than the ZCTA-based estimate, and from 0 to 79.49 percentage points greater than the county-based estimate. Given that state-level ZCTA-based estimates could be substantially different from the Census block-based estimate, ZCTA-based estimates are likely not appropriate for state-level analyses or US analyses stratified by state. Finally, in the third study, we assessed the relationship between level of accessibility in an abortion client’s home ZCTA and the gestational age at which the client obtained abortion care, using fine stratification by propensity score to control confounding. We found that compared with living in a ZCTA with >0% accessibility, living in a ZCTA with 0% accessibility was associated with a decreased risk of being at or beyond 14 weeks’ gestation at abortion visit. These unexpected findings could be due to a selection bias induced by limiting the sample to those who obtained abortion care, uncontrolled or poorly controlled confounding, misclassification of exposure and/or outcome, and/or unidentified effect measure modification by state abortion provision landscape. Through these three dissertation studies, we highlighted the potential impact on abortion accessibility in the US with different changes in programming and policy, quantified misclassification of abortion accessibility, and examined how misclassification varied by geographic measure and location. The third study in this dissertation suggests a need for more research to identify how selection bias may affect studies of abortion access in the US that rely on data only from those who are able to access care.

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Little research has addressed the needs of Native American veterans. This study aims to provide a better understanding of Native American women veterans’ experiences using data from the Veteran Administration and Indian Health Services. Fifteen interviews were conducted with special attention to quality and quantity of health and mental health care services available to veterans, the barriers and local contextual factors in accessing and utilizing services, and potential solutions to service gaps for women veterans from two Montana reservations, the Northern Cheyenne and Flathead Confederated Salish and Kootenai Tribes. American Indians and Alaska Natives serve at a higher rate in the U.S military than any other population. Native American women veterans identified many barriers to accessing care, some of which include lack of information regarding eligibility and the type of services available. Many found the application process to be confusing and difficult. Other barriers included distance, cost of travel, and conflict with their work schedule. This research provides important data about Native American veterans who are often underrepresented in survey research and are a rapidly growing segment of the United States military and veteran population.