Tesis sobre el tema "Utilization of public assets"

Healthcare utilization is a factor that directs quality and cost of health services. The cost of healthcare, income level, and demographics affect the frequency and circumstances, in which patients seek medical attention. One of the main goals of public assistance programs in this study is to facilitate the access to medical services for vulnerable groups of children. This study analyzes the impact of enrollment in various different public assistance programs and the access patterns to healthcare services. The study found that children who are enrolled in public assistance programs are more likely to visit an emergency room but less likely to visit a doctor at least 7 times a year (high utilization) compared to children who are also eligible for public programs but are not enrolled. This difference in patterns has a significant impact on cost of health services for public assistance programs' beneficiaries. A causal multifactorial link is observed, and therefore further research is needed.

This research examines three factors – macroeconomic conditions, the Deficit Reduction Act of 2005, and inter-vivos transfers – that influence both the availability of long-term care services and the use of these services. The first essay explores how changes in the macroeconomy, specifically the 2007-2009 “Great Recession,” affect the utilization of paid and unpaid long-term care services. It is theoretically unclear how long-term care use should be affected by such downturns, as an individual’s health status, wealth, insurance coverage and access to care are all likely to change during a significant downturn such as the “Great Recession.” Using data from the 1998-2012 waves of the Health and Retirement Study, a survey that follows Americans over the age of 50 as they begin to transition into retirement, we estimate the effects of changes in the unemployment rate at both the national and county levels on long-term care use. We find consistent evidence that overall care use declines significantly during downturns, with additional results suggesting that these results may be driven by reductions in individual wealth and improvements in individual health status. The second essay examines how the implementation of the Deficit Reduction Act of 2005, a policy that imposed stricter regulations about how individuals could “spend down” their assets to become Medicaid eligible, impacts both asset transfers and long-term care use among the elderly. Using data from the 1998-2010 waves of the Health and Retirement Study, I estimate the effects of this policy using a difference-in-difference framework. Overall, individuals seem to substitute from making inter-vivos transfers to holding assets in trusts in response to the enactment of the Deficit Reduction Act. With regard to care use, individuals seem to substitute from in-home long-term care to more visits to both doctors and adult day care facilities following the DRA, an effect primarily driven by the wealthiest and youngest individuals. The third essay investigates the relationship between parent-to-child inter-vivos asset transfers and future informal care provision by that child. Using data from the 1998 – 2010 waves of the Health and Retirement Study, I am able to use the timing of the transfers and the care use to describe this relationship. The results suggest that the receipt of an inter-vivos transfer during the previous two years is strongly positively correlated with that child’s likelihood of providing care during the previous month. In addition, I confirm a previous finding in the literature that child’s gender, relationship to the parent and geographical proximity to the parent all significantly influence the child’s decision to provide care.

Alzheimer’s disease (AD) is associated with substantial healthcare utilization costs, resulting in a public health priority. In this study, the relationship between the demographic characteristics of age, gender, and type of health insurance; the presence of comorbidities of older Puerto Rican residents diagnosed with AD; and their healthcare utilization patterns (i.e., medical office and emergency room visits and hospital admissions) was examined using Andersen’s behavioral model. Data from the 2013 Puerto Rico Health Study was used in this retrospective cohort design study. All AD cases aged ≥ 60 years were extracted using systematic random sampling. One-way ANOVA-WELCH, Mann-Whitney U test, and negative binomial regressions determined if there was a relationship between independent and dependent variables. Results indicated a statistically significant relationship between age, gender, health insurance type, and presence of comorbidities factors and healthcare utilization patterns among older Puerto Ricans with AD. From the results, opportunities were identified for further research and changes in professional practices in order to initiate discussions and action plans to improve services coordination for older Puerto Ricans with AD. Findings might impact social change by inspiring modifications to the public health infrastructure. These modifications may lead to enhanced disease management support, promoted social justice, and increased resources to improve healthcare access and quality of care, and overall enhancement of health outcomes, for Puerto Ricans living with AD.

Voluntary HIV/AIDS testing and counselling (VHTC) is one of the preventive measures used in many countries to decrease the spread of HIV/AIDS. Archived data from National HIV/AIDS Response Program’s (NHARP) raw 2016 dataset were used to identify relationships and to assess significant differences between sociodemographic factors and selected sexual risk behaviours versus VHTC practices among adults 18 years and older who resided in Dominica. The health belief model was used as the framework for this cross-sectional study. The sample comprised 982 participants (40% [394] men and 60% [588] women). Logistic regression analysis was used to assess associations between sociodemographic and sexual risk exposure factors versus VHTC. Findings revealed that, as compared to age group > 65 years, participants in age groups 25–44 years were 5 times more likely—and 45-64 years were 2 times more likely—to have engaged in VHTC (OR = 5.11, 95% CI = 2.03, 12.8 and OR = 2.63, 95% CI = 1.07, 6.49, respectively). The odds not to engage in VHTC were 48% higher for participants from Grand Bay district (rural area) compared to Roseau health district (capital) (OR = .52, 95% CI = .29, .94). The odds of nonengagement in VHTC were 51% higher for participants not having vaginal sex, compared to those who reported having vaginal sex ( OR = .49, 95% CI = .26, .92). The implications for positive social change include providing public health practitioners with data to plan and implement educational programs specific to the demographic characteristics in Dominica. This will enhance current efforts to raise awareness regarding HIV/AIDS and may increase VHTC practice among the population that may reduce the incidence of HIV/AIDS.

Diabetes is one of the most prevalent diseases in America, and the associated costs place a heavy burden on our health care system. This study was undertaken to provide information on emergency service utilization and hospitalization among people with diabetes in the United States. The hypotheses were that adults with diabetes visit the emergency department (ED) more than those without diabetes, that persons with diabetes who present in the ED are hospitalized more than those without diabetes and that more patients with diabetes present in the ED within 1 week of hospital discharge than those without diabetes. To test these hypotheses, secondary data from the 2010 National Hospital Ambulatory Medical Care Survey was analyzed. The results indicate that adults with diabetes did utilize the ED more than those without diabetes, and that patients with diabetes were admitted to the hospital through the ED more than those without diabetes. Furthermore, persons with diabetes presented within 1 week of hospital discharge more than those without diabetes.

This qualitative study explores the utilization of mental health services among Latinos in the United States. The sample included 15 Latino participants of various age groups who completed an 11-question questionnaire that provided data regarding demographics, perceptions about mental illness, consequences and improvements regarding mental illness, and known resources concerning mental health. Findings revealed that older generational Latinos were less receptive to utilizing mental health services than younger Latino generations. Majority of participants (54.5%) identified alcoholism as one of the most common family dysfunctions in their households while growing up. Participants indicated that although family members would benefit from mental health services their lack of awareness and education prevented family members from utilizing mental health services. Majority of participants, (66.7%) held a college degree and belonged to a younger Latino generation and were more receptive, educated, aware and open to accept mental health services.

Expansion of Medicaid and private health insurance coverage through passage of the Affordable Care Act of 2010 was expected to increase primary care access and reduce emergency department (ED) use by reducing financial burden and improving affordability of care. The aim of this study was to examine the differences in utilization patterns that exist among the Medicaid population that participated in an optimal level of care (OLC) intervention inclusive of appointments scheduled to primary care providers. Using the integrated behavior model as a theoretical framework, the key research question focused on determining if there was a difference in ED use among Medicaid individuals who scheduled follow-up appointments compared to those that did not schedule follow-up appointments. The sample population consisted of 176 Medicaid enrollees who presented to the ED for treatment of nonurgent conditions and participated in an OLC intervention from June 2016 to July 2017. The results showed that there were no differences in ED utilization between the population that had scheduled appointments compared to the population that did not have scheduled appointments. A bivariate analysis on demographic variables also showed no differences in ED utilization among the variables. The social change implications of this study are that the practice of scheduling appointments with primary care providers does not reduce or affect ED utilization in the Medicaid population. This study contributes to positive social change through the findings that reducing ED utilization requires more than follow-up appointment scheduling with primary care providers. Further studies are warranted to understand the potential barriers and factors that affect ED utilization.

Background: Throughout the twentieth century, Brazil developed a Social Health Insurance, providing coverage to formal workers and their dependents. In 1988, the country implemented a health reform adopting a National Health Service model, based on three core principles, universal coverage, open-ended benefit package and striving for health equity. During this transition, formal workers recomposed their privileged access to healthcare through private health insurance, resulting in a two-tier system represented by those with dual coverage—public and private—and those who must rely exclusively on the public insurance. Private health insurance coverage has a positive correlation with income, however, between 1998 and 2008 private coverage expanded vigorously among the poor, while remained stable among the rich. The health equity literature in Brazil consistently reports the presence of relevant inequalities in utilization of health services favoring privately insured individuals. A gap in this literature, however, is to determine whether inequalities in utilization of health services remain among insured individuals, i.e., does private insurance improve access regardless of individuals’ income?

Methods: The study relies on Andersen’s behavioral model as a theoretical framework to analyze data from two rounds (1998 & 2008) of a national household survey, assessing levels of utilization of fourteen dependent variables across income quintiles and calculating concentration indexes as summary measures of inequality. Dependent variable distributions across income are standardized by need using the indirect method. Concentration curves compare the evolution of inequality during that time. Curve dominance is formally tested between survey years. Decomposition analysis identifies the most relevant contributors to inequality. Physician services are analyzed as the probability of having a physician visit and the number of physician visits. Hospital services are analyzed as the number of hospital admissions, the probability of having a hospitalization, and the number of hospital days during the last hospitalization. The latter two variables are broken down according to their financing source, either public (SUS) or private insurance.

Results: Physician services present very low inequalities, although a statistically significant positive gradient persists in both survey rounds. Poor PHI beneficiaries have an advantage compared to national levels. SUS financed hospitalizations are a rare phenomenon among privately insured individual but strongly concentrated on the poor. Poor PHI beneficiaries utilize private hospital at lower levels than the rich. Compared at a national level, they are at a disadvantage. In 1998, this was not the case, suggesting that insurers may be developing mechanisms to deter hospital utilization among the poor. Premium value and income are the most relevant contributors to inequality in physician and hospital services.

Conclusions: The Brazilian government (ANS) needs to monitor utilization levels across income and develop policies to increase accountability of PHI products particularly preventing insurers from purposefully pushing their beneficiaries to use SUS hospitals. Greater availability on insurance policies segmented as ambulatory care only and inpatient services only would increase the range of options for consumers that could sort more adequate coverage according to their capacity to pay and healthcare needs.

Objective: To identify genomic variance of C. difficile strains to determine diversity and transmission potential which can guide future directions in clinical care and hospital policy. Study Design: We analyzed epidemiological and genomic data from 35 patients with laboratory confirmed C. difficile infection (CDI) in two three-month periods in 2011 and 2014 at a large urban hospital. Whole genome sequencing was conducted on all isolates; further analysis was conducted for 13 cases of CDI with the highly virulent NAP1 strain. Results: Overall strain diversity within the hospital was analyzed. Stable prevalence among the NAP1 strain indicated an endemic status; no other strain exhibited a specific pattern. Genomic analysis identified at least 4 distinct subgroups in the NAP1 strain specific to the hospital. Conclusion: Genomic analysis is necessary to unequivocally identify C. difficile transmission and can provide both clinical and procedural benefit.