Longitudinal Patterns and Economic Consequences of Emergency Department Visits among Medicaid Enrollees

Objective.;The objective of the dissertation was to examine the patient- and county-level factors associated with the Emergency Department (ED) visits and economic consequences associated with persistent ED use among adult fee-for-service (FFS) Medicaid beneficiaries. The first study examined the patient- and county-level factors associated with the number of ED visits and the second study examined the longitudinal patterns of ED visits among FFS Medicaid beneficiaries. Further, in both the studies ED visits due to primary care sensitive conditions were also examined. The third study examined the patient- and county- level factors associated with persistent ED use followed by an estimation of the excess healthcare expenditures associated with persistent ED use.;Methods.;Both cross-sectional and longitudinal study designs were implemented using a retrospective observational claims data of Medicaid beneficiaries residing in Maryland, Ohio, and West Virginia. Study population included adult, alive, FFS, not dually enrolled in Medicare, non-pregnant and continuously enrolled Medicaid beneficiaries. Data on patient-level factors were obtained from the Medicaid Analytic eXtract (MAX) files for the years 2006-2010. MAX files consisted of personal summary, other therapy, inpatient and prescription drugs claims. The personal summary file included demographics, Medicaid eligibility, county federal information processing standard (FIPS) codes, Medicaid managed care enrollment, and Medicare eligibility status. The inpatient claims file included information related to hospital stays, dates of service, Medicaid payment, and the International Classification of Disease, Ninth Revision, Clinical Modification codes (ICD-9-CM) and ICD-9-CM procedure codes. The other therapy claims file included information on dates of service, types of service, Medicaid payment, ICD-9-CM, and Current Procedural Terminology (CPT) codes. The prescription drugs claims file included information on the date of prescription filled, days supplied, Medicaid payment and national drug code (NDC). All these files were linked using encrypted identification numbers. Data on county-level factors such as socio economic status, healthcare resources, and obesity rates were obtained from the Area health resource and county health ranking files. Frequencies, means, inter-quartile range, and 90th percentile were used to examine the characteristics of the study population and distribution of ED visits. In the first study, unadjusted and adjusted negative binomial regressions (NBR) were conducted to examine the patient- and county-level factors associated with the number of ED visits. In the second study, multivariable hurdle models with logistic and NBRs were used to analyze ED visits over time, after adjusting for all other independent variables. In the third study, chi-square tests and logistic regression was conducted to examine the patient- and county-level factors associated with persistent ED use. Further, adjusted generalized linear models with log link function and gamma distribution were conducted to examine the excess expenditures. All analyses were conducted using STATA version 14.0.;Findings.;In the first study, it was observed that more than half of the study population had one or more ED visit. Patient-level factors such as complex chronic illness, fragmented primary care use, poly-pharmacy, and tobacco use were associated with higher number of ED visits. Residents in counties with higher number of urgent care centers had lower number of ED visits. Almost, half of the ED visits were preventable. In the second study, the likelihood of ED use did not change from year to year. However, among ED users, the estimated number of ED visits increased over time with a small magnitude. More than half of the ED visits were primary care sensitive in each panel year. In the third study, one in ten Medicaid beneficiary had persistent ED use i.e. they had 4 or more ED visits in both index and follow-up years. There were significant differences between persistent ED users and non-users in patient- and county-level characteristics. Individuals with complex chronic illnesses, fragmented primary care use, poly-pharmacy and tobacco use were more likely to be persistent ED users. In multivariable regression, persistent ED users had significantly higher total healthcare expenditures as compared to non-users.;Conclusions.;Adult FFS Medicaid beneficiaries with complex healthcare needs had higher number of ED visits. The number of ED visits increased over time with a small magnitude. Almost, half of the ED visits are preventable with timely care. Medicaid beneficiaries also had persistent ED use and had higher excess healthcare expenditures associated with persistent ED use. Taken together, these findings suggest that only access to primary care may not reduce ED visits. There is a need to have targeted interventions focused on this particular subgroup of the population who is consuming higher healthcare resources as compared to others. Cost containment may be achieved by providing comprehensive care management to individuals with complex healthcare needs. Access to county-level resources such as urgent care centers may contribute in reducing the number of ED visits and cost containment as care provided in these settings is less expensive as compared to ED

Emergency Physicians\u27 Perspectives on the Usability of Health Information Exchange

Emergency physicians are key users of health information exchanges (HIE). Understanding their perspectives on the usability of HIE is important if the full potential of the HIE is to be achieved. The literature identified that emergency physician experiences with HIEs are unexplored areas requiring further studies. The purpose of this study using grounded theory methods was to understand the perspectives of emergency physicians concerning the usability of HIEs. The fundamental question was how do emergency physicians use the HIE in making clinical decisions? Rich and thick data were collected from 15 emergency physicians in four urban hospitals in the mid-south using theoretical sampling and unstructured face-to face interviews. Concepts from the coded segments were developed into categories and an overarching theoretical scheme visualized in a conceptual framework. A substantive theory emerged that using the HIE among emergency physicians is the process of rationalizing non-use and reconciling challenges and benefits. The antecedent of usability was a typical day in the emergency department and why participants accessed the HIE and under what conditions. Six major themes emerged: using the HIE, influencing clinical decisions, struggling with challenges and barriers, recognizing benefits, current views, and rationalizing not using or reduced use of the HIE. Emergency physicians gave good reasons why the HIE is not being used for the majority of patients while reconciling the challenges and benefits of using the HIE to explain the role of HIEs in making clinical decisions. There was a disconnect in the necessity of using the HIE to make clinical decisions and any negative outcomes that may occur in patients from not using the HIE. Generally, emergency physicians viewed the HIE as not being user-friendly and that they probably do not use the HIE as much as they could for making clinical decisions. The perspective of the emergency physicians was the emergency environment is too busy and because the HIE is less than user-friendly as needed by physicians to practice emergency medicine, the HIE disrupts workflow and is a deterrent to consistent usage in making clinical decisions. A better understanding of how emergency physicians decided to use the HIE in making clinical decisions gives insights about how to achieve HIE usability. Satisfied end-users who view the HIE as effective and efficient should use the HIE more. However, this requires removing challenges and barriers while recognizing more benefits to using the HIE, and addressing the underlying reasons for not using the HIE. Understanding the complexities of using the HIE and providing solutions to increase usability of the HIE is necessary to influence greater use of the HIE in clinical decisions with demonstrated positive outcomes for patients

Evaluating the Feasibility and Potential Impact of a Transitional Care Management Service in an Independent Community Pharmacy + Clinic

Introduction: Hospital readmissions are a significant and largely preventable burden on the healthcare system. They can often be prevented with diligent coordination of care and a smooth transition of patients from hospitalist back to primary care. Transitional care management is a billable service that is designed to reward providers for reducing readmissions. This study assessed the feasibility and potential impact of a transitional care management service in the setting of an independent community pharmacy and embedded clinic. Methods: This exploratory mixed-method quality improvement study pursued three aims: (1) describe the current landscape of transitional care services in the literature based on an informal environmental scan; (2) adapt and improve the baseline transitional care service in Hillsborough Pharmacy to align with billing requirements for billing as guided by the intervention mapping methodology; and (3) establish the feasibility of the transitional care service in the pharmacy setting by conducting interviews with pharmacists considering a partnership with the clinic franchise company (IndyCare). Results: The environmental scan found 26 transitional care studies in community pharmacy settings. Feedback on service implementation was abstracted from the studies and used to identify best practices, facilitators, and barriers to program implementation. Key insights included the need for buy-in from external stakeholders to enable patient data sharing, and careful planning to ensure satisfactory patient enrollment in the service. These insights were used to improve the transitional care service through iterative intervention mapping in order to identify desired outcomes and revise the clinic’s processes to achieve them in the context of anticipated facilitators and barriers. This process enabled the clinic to achieve full alignment with billing requirements. Interview feedback from future partners was generally positive, with interviewees expressing an intent to partner in providing transitional care management. Conclusions: The independent pharmacy + clinic is a viable practice setting for implementing a transitional care management program, provided careful planning and awareness of best practices. While having in-house providers allows for more autonomy, collaboration with external providers is still a vital component for numerous reasons, including notification of recent discharges and shared patient data. Given its collaborative nature, transitional care management is a good service for initiating collaborative partnerships with external healthcare professionals.Doctor of Pharmac

Delineation of the genetic causes of complex epilepsies in South African pediatric patients

Background Sub-Saharan Africa bears the highest burden of epilepsy worldwide. A proportion is presumed to be genetic, but this aetiology is buried under the burden of infections and perinatal insults, in a setting of limited awareness and few options for testing. Children with developmental and epileptic encephalopathies (DEEs), are most severely affected by this diagnostic gap, as the rate of actionable findings is highest in DEE-associated genes. This research study investigated the genetic architecture of epilepsy in South African (SA) children clinically diagnosed with DEE, highlighting the clinical utility of informative genetic findings and relevance to precision medicine for DEEs in a resource-constrained setting. Methods A group of 234 genetically naïve SA children with drug-resistant epilepsy and a diagnosis or suspicion of DEE, were recruited between 2016 and 2019. All probands were genetically tested using a DEE gene panel of 71 genes. Of the panel-negative probands, 78 were tested with chromosomal microarray and 20 proband/parent trios underwent exome sequencing. Statistical comparison of electroclinical features in children with and without candidate variants was performed to identify characteristics most likely predictive of a positive genetic finding. Results Pathogenic/likely pathogenic (P/LP) variants were identified in 41/234(17.5%) * probands. Of these, 29/234(12.4%) * were sequence variants in epilepsy-associated genes and 12/234(5.1%) * were genomic copy number variants (CNVs). Sixteen variants of uncertain significance (VUS) were detected in 12 patients. Of the 41 children with P/LP variants, 26/234(11%) had variants supporting precision therapy. Multivariate regression modelling highlighted neonatal or infantile-onset seizures with movement abnormalities and attention difficulties as predictive of a positive genetic finding. This, coupled with an emphasis on precision medicine outcomes, was used to propose the pragmatic “Think-Genetics” decision tree for early recognition of a possible genetic aetiology, pragmatic testing, and multidisciplinary consultation. Conclusion The findings presented here emphasise the relevance of an early genetic diagnosis in DEEs and highlight the importance of access to genetic testing. The “Think-Genetics” strategy was designed for early recognition, appropriate interim management, and genetic testing for DEEs in resource constrained settings. The outcomes of this study emphasise the pressing need for augmentation of the local genetic laboratory services, to incorporate gene panels and exome sequencing. *These percentages were rounded off to whole numbers in the published articles included in this thesis (i.e., rounded off to 18%, 12% and 5%, respectively)

The Second International Conference on Health Information Technology Advancement

TABLE OF CONTENTS I. Message from the Conference Co-Chairs B. Han and S. Falan …………………………....….……………. 5 II. Message from the Transactions Editor H. Lee …...………..………….......………….……….………….... 7 III. Referred Papers A. Emerging Health Information Technology and Applications The Role of Mobile Technology in Enhancing the Use of Personal Health Records Mohamed Abouzahra and Joseph Tan………………….……………. 9 Mobile Health Information Technology and Patient Care: Methods, Themes, and Research Gaps Bahae Samhan, Majid Dadgar, and K. D. Joshi…………..…. 18 A Balanced Perspective to Perioperative Process Management Jim Ryan, Barbara Doster, Sandra Daily, and Carmen Lewis…..….…………… 30 The Impact of Big Data on the Healthcare Information Systems Kuo Lane Chen and Huei Lee………….…………… 43 B. Health Care Communication, Literacy, and Patient Care Quality Digital Illness Narratives: A New Form of Health Communication Jofen Han and Jo Wiley…..….……..…. 47 Relationships, Caring, and Near Misses: Michael’s Story Sharie Falan and Bernard Han……………….…..…. 53 What is Your Informatics Skills Level? -- The Reliability of an Informatics Competency Measurement Tool Xiaomeng Sun and Sharie Falan.….….….….….….…. 61 C. Health Information Standardization and Interoperability Standardization Needs for Effective Interoperability Marilyn Skrocki…………………….…….………….… 76 Data Interoperability and Information Security in Healthcare Reid Berryman, Nathan Yost, Nicholas Dunn, and Christopher Edwards.…. 84 Michigan Health Information Network (MiHIN) Shared Services vs. the HIE Shared Services in Other States Devon O’Toole, Sean O’Toole, and Logan Steely…..……….…… 94 D. Health information Security and Regulation A Threat Table Based Approach to Telemedicine Security John C. Pendergrass, Karen Heart, C. Ranganathan, and V.N. Venkatakrishnan …. 104 Managing Government Regulatory Requirements for Security and Privacy Using Existing Standard Models Gregory Schymik and Dan Shoemaker…….…….….….… 112 Challenges of Mobile Healthcare Application Security Alan Rea………………………….……………. 118 E. Healthcare Management and Administration Analytical Methods for Planning and Scheduling Daily Work in Inpatient Care Settings: Opportunities for Research and Practice Laila Cure….….……………..….….….….… 121 Predictive Modeling in Post-reform Marketplace Wu-Chyuan Gau, Andrew France, Maria E. Moutinho, Carl D. Smith, and Morgan C. Wang…………...…. 131 A Study on Generic Prescription Substitution Policy as a Cost Containment Approach for Michigan’s Medicaid System Khandaker Nayeemul Islam…….…...……...………………….… 140 F. Health Information Technology Quality Assessment and Medical Service Delivery Theoretical, Methodological and Practical Challenges in Designing Formative Evaluations of Personal eHealth Tools Michael S. Dohan and Joseph Tan……………….……. 150 The Principles of Good Health Care in the U.S. in the 2010s Andrew Targowski…………………….……. 161 Health Information Technology in American Medicine: A Historical Perspective Kenneth A. Fisher………………….……. 171 G. Health Information Technology and Medical Practice Monitoring and Assisting Maternity-Infant Care in Rural Areas (MAMICare) Juan C. Lavariega, Gustavo Córdova, Lorena G Gómez, Alfonso Avila….… 175 An Empirical Study of Home Healthcare Robots Adoption Using the UTUAT Model Ahmad Alaiad, Lina Zhou, and Gunes Koru.…………………….….………. 185 HDQM2: Healthcare Data Quality Maturity Model Javier Mauricio Pinto-Valverde, Miguel Ángel Pérez-Guardado, Lorena Gomez-Martinez, Martha Corrales-Estrada, and Juan Carlos Lavariega-Jarquín.… 199 IV. A List of Reviewers …………………………..…….………………………208 V. WMU – IT Forum 2014 Call for Papers …..…….…………………20

A descriptive and comparative study of the school adjustment counsellor program in the commonwealth of Massachusetts and in the communities of Waltham, Malden, Brookline, and Northborough

Thesis (M.S.)--Boston Universit

Holland City News, Volume 81, Number 29: July 17, 1952

Newspaper published in Holland, Michigan, from 1872-1977, to serve the English-speaking people in Holland, Michigan. Purchased by local Dutch language newspaper, De Grondwet, owner in 1888.https://digitalcommons.hope.edu/hcn_1952/1028/thumbnail.jp

September 24, 2007

The Breeze is the student newspaper of James Madison University in Harrisonburg, Virginia