Rozprawy doktorskie na temat „Medical and Health Sciences”

Individuals enrolled in both the Medicare and Medicaid programs, the "dually eligible," are generally vulnerable and face a wide range of health care needs; numerous studies have found that their health care is beset with problems of cost and quality. Health policy researchers find that these problems are directly associated with the inadequate coordination of benefits and services, but studies about care coordination have largely used quantitative approaches and focused on providers—they have not explored the critical perspective of patients receiving the care. To improve the complex processes of care coordination, this hybrid case study examines the experience of a sample of dual eligible enrollees served in North Carolina's patient centered medical home, and care managers. The subjects were generally independently living, and at lower-risk that typical dual eligibles. Although some experienced some continuity of care issues within NC's PCMH, generally they described receiving the right care, at the right time, in the right care settings. However, some experienced barriers to accessing necessary care, especially in the areas of prescription drugs and navigating the health care delivery system. Some of these challenges could potentially be resolved by NC's PCMH, but many issues are outside the program's control. Care managers who were interviewed suggested modifications to the Agency for Healthcare Research and Quality's Care Coordination Ring, which represents care coordination for a more stable, middle-class population than the dual eligibles they serve.

This master's thesis will present a literature review and analysis ofthe implementation and use of Electronic Medical Records (EMR). The literature review will discuss reasons that support implementation of EMRs, factors that are necessary for successful implementation and barriers that impede implementation. Also, real-world examples of implementation for medical billing in healthcare organizations will be discussed, as well as the disparity in implementation rates between larger and smaller healthcare organizations.

The analysis portion of this thesis will include data from the 2009 National Ambulatory Medical Survey (NAMCS) EMR Supplement and, through the application of the Chi-Square statistical test using SPSS, will assess whether size of the medical practice in terms of number of physicians is significantly associated with EMR implementation and functionality, the latter of which includes clinical reminders and prescription ordering. It will be shown that physician size is indeed significantly associated with implementation and functionality.

Obesity has arisen as a major cause of morbidity and mortality in today' s society. The aim of this study was to assess potential barriers encountered by obese women seeking medical care. It was hypothesized that overweight or obese women will be likely to have a negative self-esteem and that a negative self-esteem associated with being overweight will decrease healthcare utilization. A convenience sample of 50 women over the age of 18 were surveyed upon entering a health care clinic. Self-report of height and weight was collected to calculate a body mass index (BMI) score. Furthermore, a self-report of healthcare utilization was obtained along with demographic data and a quantified self-esteem score. Results showed a significant Pearson's negative correlation between BMI and the self-esteem score (r = -0.395; p = 0.01) and a significant difference based on a t-test between self-esteem based on employment status ( p = 0.021). Other demographic variables (age, income, education, marital status, and race) had no significant impact on BMI, self-esteem or number of office visits. There was no significant difference between obese and non-obese women on the number or type of office visits, and no significant difference between average self-esteem score and number of medical office visits. Assessing self-esteem in those with higher BMIs may be a helpful tool in assisting providers to identify barriers of seeking healthcare in obese women.

The purpose of this study is to examine the role of physicians in the process of healing within the context of our current medical system. As an autoethnographic study, it explores the healing process from wounds the researcher experienced as a physician, teacher, student, and at times a sick patient. This study reflects on the experiences, insights, and observations that have molded the researcher’s spirit toward that of a healer not only of patients but also of the fragmented medical system. This study explores the early childhood experiences and wounds that were instrumental in the researcher’s initial pursuit of a medical career. In addition, this study explores how the researcher’s journey of over 40 years, dedicated to practicing high tech, high risk, intensive care medicine of critically ill patients has deeply shaped the researcher’s persona as a healer. Since the time of the researcher’s initial specialization in medicine, other areas of medicine as well as other disciplines relating to the humanities have been explored. This study incorporates the lessons, knowledge, experiences, and perspectives from those disciplines and thereby expands the scope of this research study. The autoethnographic approach is appropriate for gaining a greater understanding of self, others, and the culture. The essence of healing necessitates the integration of mind, body, spirit, and consciousness, which encompass multiple therapeutic approaches. In summary, the healing process incorporates aspects of both art and science that optimally benefit not only the patient, doctor, and healer, but also the medical system.

It has been estimated that by 2020 nearly one-third of all Americans (almost 160 million people) will have at least one chronic disease to manage and the cost of health care will consume over 20 percent of the GDP. The Obama Administration responded to this pending crisis by passing the Patient Protection and Affordable Care Act (PPACA) in 2010. This major legislation aims to instill patient-centered, accountable care into the health care delivery system. Specifically, the United States government is on a mission to reduce the utilization of expensive inpatient care, while increasing access to primary care for all Americans, thereby lowering the total cost of health care.

Primary care practices organized around the principles of the patient-centered medical home (PCMH) can better manage their patients, especially their patients with chronic conditions; and become accountable for their care. In 2008, the National Committee for Quality Assurance (NCQA) released practice-level recognition standards based on the seven Joint Principles of the PCMH, to aid doctors seeking to transform their practices into effective patient-centered delivery systems.

The results of several published studies have touted the successes (e.g., reduced emergency department visits, reduced hospitalizations) of the PCMH model at individual practice sites. These localized successes demonstrated that the principle tenets of the PCMH model—care coordination, team-based care, population management—helped lower utilization of more expensive health care services within the specific practice settings evaluated. However, there has been no study to determine if these core tenets are having a broader impact on the health care delivery system within a community.

One hypothesized outcome of a health care system centered on the PCMH care model is better care coordination and more effective, whole-person care management across the continuum of health care; resulting in a more efficient system that can prevent avoidable hospitalizations.

This dissertation proposal seeks to understand if the increasing numbers (density) of recognized PCMH practices in communities affect avoidable hospitalizations related to ambulatory care sensitive conditions (ACSC), as measured by the AHRQ Composite Prevention Quality Indicators (PQI). The research has two purposes:

1. Establish constructs and hypotheses to measure the effect of the increasing numbers of NCQA-Recognized PCMH practices in communities (counties).

2. Using an outcomes-based measurement approach, investigate the relationship between growing densities of NCQA-Recognized PCMH practice doctors among all primary care doctors (PCD) in a community and the associated impact on the utilization of inpatient care, specifically related to ACSCs, as measured by the AHRQ Composite PQIs.

The research is quasi-experimental in design and is based on a retrospective (2008–2011) analysis of existing data from the NCQA PCMH program, the AHRQ Composite PQI and the Centers for Medicare & Medicaid Services (CMS) National Provider Identification (NPI) databases. Analysis will link NCQA-Recognized PCMH practices (independent variable), AHRQ Risk Adjusted Composite PQIs (dependent variable), and the CMS NPI (total PCDs) on Federal Information Processing Standard (FIPS) identifiers across 114 state and county-level geographical areas in Vermont and North Carolina. The research will inform the following hypotheses:

1. Does the research literature support the measurement construct proposed in this study?

2. Communities with concentrations of recognized PCMH practices among primary care practices will have lower risk-adjusted avoidable hospital admission rates.

3. The use of technology and care coordination will have a greater predictive correlation on risk-adjusted avoidable hospital admission rates than other PCMH capabilities.

Childhood obesity is a disease that affects 17% of children aged 2-19. This disease, best described by a social ecological perspective, is multifactorial in nature and includes individual, familial, community, and societal contributors. As the causes are multifactorial, so too should be prevention and treatment. Healthcare providers, specifically physicians, can play an important role in the diagnosis, prevention, and treatment of childhood obesity, especially if they appropriately utilize nutrition behavior change counseling to facilitate lifestyle changes. Behavior change falls within the realm of the social and behavioral sciences, disciplines that will receive greater emphasis on the newly designed MCAT 2015^®; therefore, premedical and medical programs may need to alter their approaches to disseminating this discipline-specific knowledge. Nutrition education is currently limited in medical education; and thus, just as premedical programs seek to increase the social and behavioral sciences, so too should they increase nutrition education. In light of these recommended curricular changes, researchers sought to investigate the current state of premedical and medical students. views of childhood obesity. This dissertation describes three studies conducted for that purpose. In study 1, researchers investigated 30 pre-healthcare undergraduate seniors. views of childhood obesity and their sources of knowledge through in-depth qualitative interviews. Investigators found that students with specialized coursework and significant volunteer and/or internship experience had a deeper understanding of childhood obesity; however, as a whole, students failed to see the role of healthcare providers in prevention and treatment. These findings provide justification for premedical programs to guide students to see their role in prevention and treatment through educating them on the social ecological model and providing them with relevant service-learning opportunities and guided reflection. In study 2, researchers conducted a similar nationwide qualitative investigation in 78 third and fourth year medical students. These students described student-, patient- and healthcare system-centered barriers, including their lack of knowledge, patients. lack of access, and their lack of time in practice. Students also requested more applicable information and counseling training in order to equip them to prevent and treat childhood obesity. Much like the pre-healthcare seniors, these medical students failed to discuss their role in prevention and treatment. Therefore, medical schools need to help their students overcome barriers by providing them knowledge and skills and helping them understand their role in prevention and treatment. In study 3, researchers built on the knowledge gained from study 1 and study 2 and developed a valid and reliable computerized tool, the Childhood Obesity Prevention Self-efficacy (COP-SE) survey. Factor analysis of 444 completed surveys from students at 53 medical schools revealed a two factor structure with a correlation of 0.637 between factors. Factor 1 assesses self-efficacy in nutrition counseling while Factor 2 measures self-efficacy to assess readiness to change and initiate nutrition lifestyle changes. There was high reliability within factors (Factor 1 = 0.946; Factor 2 = 0.927), and the correlation (0.648) between the COP-SE survey and a general self-efficacy survey confirmed that the COP-SE measures domain-specific self-efficacy. This valid and reliable survey can be used by medical schools as a formative or summative assessment of students. self-efficacy in childhood obesity prevention and treatment. Further research should include confirming the factor structure and exploring the significance of response trends seen in this sample. The findings of all three studies can be used by premedical and medical programs to maximize the effectiveness of their preparatory programs to provide students with the necessary skills for prevention and treatment of childhood obesity. With the appropriate preparation, future healthcare providers can build their self-efficacy in disease prevention and treatment, hopefully resulting in improved patient outcomes.