Thesis (Ph. D.)--Brandeis University, 2008. / "UMI:3320136." Includes bibliographical references.

Thesis (Ph. D.)--University of Chicago, Dept. of Economics, August 2002 / Includes bibliographical references. Also available on the Internet.

Thesis (Ph.D)--Brandeis University, 2010. / "UMI:3391164." Includes bibliographical references

Class of 2014 Abstract / Specific Aims: To identify reasons that an angiotensin converting enzyme inhibitor (ACEi) would not be indicated in diabetic patients with repeated clinical alerts to add ACEi therapy for preservation of renal function and/or hypertension. In addition, to identify if these repeated clinical alerts to add ACEi therapy are appropriate. Methods: Eligible patient charts were reviewed by researchers using a data dictionary to complete a standardized spreadsheet with patient demographic information (age, gender, and location), type of diabetes mellitus, evidence indicative of comorbid hypertension, action taken by pharmacist in response to clinical alert (letter sent to patient and letter sent to prescriber), and rationale of that action. This data, along with SOAP notes of patient interactions, was used by researchers to classify the repeated clinical alert as appropriate or inappropriate. Main Results: There were a total of 200 charts reviewed (male n = 61 (30.5%), female n = 139 (69.5%), mean age = 70 ± 11 years). Reasons for not contacting patients again include previous failure or adverse drug reaction (n = 62, 31.0%), patient did not meet call script requirements (n = 55, 27.5%), patient did not have diabetes or hypertension (n = 20, 10.0%), potential drug-disease interaction (n = 17, 8.5%), overlapping or previously addressed alerts (1.9%), or documentation was provided for “other” reasons (n = 43, 21.5%). The previous failure or adverse drug reaction rationale was appropriate in 32 of 62 repeated clinical alerts (52%; χ2= 10.15). The patient did not have diabetes or hypertension rationale was appropriate in 11 of 20 repeated clinical alerts (55%, χ2= 2.72). The potential drug-disease interaction rationale was appropriate in 3 of 17 repeated clinical alerts (8%, χ2= 9.89). The patient did not meet call script requirements rationale was appropriate in 31 of 55 repeated clinical alerts (56%, χ2= 6.91). The overlapping or previous alerts rationale was appropriate in 2 of 3 repeated clinical alerts (67%, χ2= 0.18). The “other” rationale were appropriate in 22 of 43 repeated clinical alerts (51%, χ2= 7.21) Overall, retrigger alerts were considered appropriate 50.5% of the time compared to the predicted value of 90% (χ2= 347 > critical value = 3.84 for p = 0.05 Conclusion: There are multiple reasons pharmacists do not recommend initiating ACEi therapy in patients with diabetes. Although the Medication Management Center (MMC) has rationale of these reasons documented after individual patient interactions, there are still several reasons why a retrigger alert would be appropriate despite that rationale. In addition, retrigger alerts were not considered appropriate as frequently as expected.

This doctoral dissertation proposal is comprised of three separate chapters, all of which uses the nationally representative uniform survey Health and Retirement Survey (HRS) to examine the relationship between health, insurance, health care and health outcomes. Below, the brief introduction for each section is provided:  Chapter I: Medicare Part D and Patients' Well-being  Chapter II: Parent's Health Insurance and Informal Care  Chapter III: Job Insecurity and Health (with Dr. Ayyagari) In chapter I, I explore how Medicare Part D (MD) affects the well-being of the severely sick patients both in the short- and in the long- term. I employ difference-in-difference (DD) alongside the instrumental variable (IV) model. The estimated results imply MD significantly improves mental health and increases regular drug utilization for the elderly. However, it neither systematically improves out-of-pocket payment (OOP) nor improves mortality across all waves. This suggests that MD provides an efficient mechanism to improve mental health and drug utilization, but might not necessarily enhance survival rate and financial burden for vulnerable patients. Chapter II investigates the relationship between informal care provided by the children and the take-up of health insurance by the near-elderly and elderly parents, and how the correlation is influenced by parent’s Activities of Daily Living (ADLs) and Instrumental Activities of vii Daily Living (IADLs). The results indicate that when the endogeneity is controlled for, in-formal care systematically crowds out the take-up of private long-term care (LTC) insurance whereas “crowds in” the take-up of the total plan including supplement insurance plans (TSP). Nevertheless, the degree of both crowding-out and “crowding-in” effect is reduced when the severity of ADLs/IADLs disability level grows. Our study reflects (a) the strong demand for TSP and more additional health coverage within household budget line (b) and the potential gap between healthcare demands by the parents and the informal care provided by the children and the potential gap between the healthcare demands by the parents and the formal care covered by the insurance. Our estimates are robust to alternative measures of informal care. The final chapter III examines the causal effect of subjective job insecurity on health, using pooled ordinary least squares (OLS), fixed-effects (FE) and instrumental variable (IV) specifications. The estimate implies that the negative impact of job insecurity is more pronounced for certain outcomes such as mental health and the emergence of new health conditions. Job insecurity provides a powerful prediction on subsequent job displacement and real income loss. Sub-population such as low-employability/better-educated individuals or males responds more to job insecurity than their counterparts.

Approximately 49 million Americans are 65 years and older, 80% of whom have ≥1 chronic condition, while nearly 70% of Medicare beneficiaries have ≥2 such conditions. Moreover, avoidance of medical care is frequently seen among older adults; a national survey reported that over 33% of participants avoided seeking care even when they suspected that they should go to the doctor. Healthcare avoidance, especially by older adults, can result in adverse health and economic outcomes including higher use of emergency department (ED), longer inpatient stays, and poorer health status, alongside emotional burden. Studies have shown that perceived satisfaction of care and the need to seek care as a result of presence of illness are associated with care seeking behaviors. Thus, this study aimed to examine the extent to which these enabling and need factors translate to care seeking behaviors among Medicare beneficiaries. This is a cross-sectional study that includes 13,441 Medicare beneficiaries who responded to the 2018 Medicare Current Beneficiary Survey (MCBS). MCBS provides information on the beneficiaries’ medical conditions including healthcare utilization, healthcare access, and satisfaction with care. Multivariate logistic regression analyses were conducted to test the association between satisfaction of available care by specialists; satisfaction with the quality of medical care received the year before; presence of chronic illness like cardiovascular diseases (CVD), diabetes, arthritis, lung disease (chronic obstructive pulmonary disease (COPD), asthma, etc.) and depression, with care seeking behavior among Medicare beneficiaries. Care seeking behavior, which is the outcome of interest, was defined using three measures: not doing anything to avoid going to the doctor, not keeping sickness to self, and going to the doctor as soon as one feels sick. Of the total respondents, only about 29% showed care seeking behavior. Being male, being Hispanic, and having more than high school education were significantly associated with higher care seeking behavior. Lower likelihood of care seeking behavior was seen among beneficiaries who were dissatisfied with ease getting to doctor from home [adjusted odd’s ratio (aOR)=0.635; p

Introduction: The US Health Care and Social Services sector (North American Industrial Classification System 'sector 62') has become an extremely important component of the nation's economy, employing approximately 18 million workers and generating almost $753 billion in annual payrolls. At the county level, the health care and social services sector is typically the largest or second largest employer. Hospital employment is often the largest component of the sector's total employment. Hospital employment is particularly important to non-metropolitan or rural communities. A high quality healthcare sector serves to promote economic development and attract new businesses and to provide stability in economic downturns. The purpose of this study was to examine the intensity of hospital employment in rural counties relative to the nation as a whole using location quotients and to draw conclusions regarding how potential changes in Medicare and Medicaid might affect rural populations. Methods: Estimates for county-level hospital employment are not commonly available. Estimates of county-level hospital employment were therefore generated for all counties in the USA the Census Bureau's County Business Pattern Data for 2010. These estimates were used to generate location quotients for each county which were combined with demographic data to generate a profile of factors that are related to the magnitude of location quotients. The results were then used to draw inferences regarding the possible impact of the Patient Protection and Affordable Care Act 2010 (ACA) and the possible imposition of aspects of the Budget Control Act 2011 (BCA). Results: Although a very high percentage of rural counties contain medically underserved areas, an examination of location quotients indicates that the percentage of the county workforce employed by hospitals in the most rural counties tends to be higher than for the nation as a whole, a counterintuitive finding. Further, when location quotients are regressed upon data related to poverty, county demographics, and the percentage of the population insured, a relationship between the proportion of the population over 65 years, the percentage of the population living in poverty, the percentage of the population without insurance and county density was found. Conclusion: The results of the analysis suggest that hospital employment in rural communities is higher than would be expected in the absence of programs that provide external funding to support hospital hiring. The most important public programs providing this support are Medicare and Medicaid. Social Security is another source of federal funding important for rural populations. Sequestration and other cuts in funding could impact rural communities significantly. This can be even worse in states that fail to expand Medicaid and in states that fail to increase Medicaid reimbursements for services important in rural communities.

Introduction: The US Health Care and Social Services sector (North American Industrial Classification System 'sector 62') has become an extremely important component of the nation's economy, employing approximately 18 million workers and generating almost $753 billion in annual payrolls. At the county level, the health care and social services sector is typically the largest or second largest employer. Hospital employment is often the largest component of the sector's total employment. Hospital employment is particularly important to non-metropolitan or rural communities. A high quality healthcare sector serves to promote economic development and attract new businesses and to provide stability in economic downturns. The purpose of this study was to examine the intensity of hospital employment in rural counties relative to the nation as a whole using location quotients and to draw conclusions regarding how potential changes in Medicare and Medicaid might affect rural populations. Methods: Estimates for county-level hospital employment are not commonly available. Estimates of county-level hospital employment were therefore generated for all counties in the USA the Census Bureau's County Business Pattern Data for 2010. These estimates were used to generate location quotients for each county which were combined with demographic data to generate a profile of factors that are related to the magnitude of location quotients. The results were then used to draw inferences regarding the possible impact of the Patient Protection and Affordable Care Act 2010 (ACA) and the possible imposition of aspects of the Budget Control Act 2011 (BCA). Results: Although a very high percentage of rural counties contain medically underserved areas, an examination of location quotients indicates that the percentage of the county workforce employed by hospitals in the most rural counties tends to be higher than for the nation as a whole, a counterintuitive finding. Further, when location quotients are regressed upon data related to poverty, county demographics, and the percentage of the population insured, a relationship between the proportion of the population over 65 years, the percentage of the population living in poverty, the percentage of the population without insurance and county density was found. Conclusion: The results of the analysis suggest that hospital employment in rural communities is higher than would be expected in the absence of programs that provide external funding to support hospital hiring. The most important public programs providing this support are Medicare and Medicaid. Social Security is another source of federal funding important for rural populations. Sequestration and other cuts in funding could impact rural communities significantly. This can be even worse in states that fail to expand Medicaid and in states that fail to increase Medicaid reimbursements for services important in rural communities.

Dialysis patients are often denied hospice benefits unless they forego dialysis treatments. However, many of those patients might benefit from as-needed dialysis treatments to palliate symptoms of uremia, fluid overload, etc. The current Medicare payment system precludes this "palliative dialysis" except in those few cases where the terminal diagnosis is unrelated to renal failure. As approximately three quarters of all US patients on dialysis have Medicare as their primary insurance, a of review of Medicare policy is suggested, with a goal of creating a new "palliative dialysis" category that would allow patients to receive treatments on a less regular schedule without affecting the quality statistics of the dialysis center.

Anticoagulation risks in older adult, long-term care patients are known to be high, especially in those with frequent transitions between care environments. Introduction of collaborative practice agreements (CPA) in specific settings is encouraged in the United States and has provided an additional option for the care of medically challenging patients. The aim of this study was to investigate the time in therapeutic range (TTR) in a Medicare Part A sponsored long-term care environment managed by pharmacists through a collaborative practice agreement in South-Central Appalachia. A retrospective review of all warfarin patient admissions from a large long-term care pharmacy’s anticoagulant clinic was conducted for residents over an 18-month period. For all patients (n = 104), the overall TTR was 46.7% (INR 43% in range). Average management duration was 19.5 days per patient. Further studies are required to optimize CPA and transition strategies for complex, advanced age warfarin patients.