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Racial and Ethnic Disparities Among Minority Geriatric Trauma Patients in the United States: An Analysis of Data From a National Sample Using the Trauma Quality Improvement Program Database
For this dissertation, I completed three manuscripts with the common overall aim of assessing health disparities among geriatric trauma patients in the U.S. The first manuscript reports on a structured narrative review of the literature comprised of three approaches that ensure comprehensive and targeted research: a scoping review, an exploratory search, and a citation review. The second manuscript is a descriptive analysis of one-year (2016) of data from the American College of Surgeon’s Trauma Quality Improvement Program (ACS-TQIP) with a focus on older adults aged 65 and older who have had an injury. The population was stratified into four groups: Non-Hispanic Whites (NHWs), African Americans, Hispanics, and Other races. For each group, I conducted a simple univariate tabulation for key demographic characteristics and injury-related variables. I also assessed comorbidities, insurance type, and regional differences. Finally, in manuscript three, I performed a one-year analysis of the ACS-TQIP dataset and included all adult trauma patients aged 65 and older who were admitted in 2016. My primary aim was to understand health disparities regarding in-hospital health measures, such as in-hospital mortality, length of stay (LOS), and in-hospital complications. I conducted multivariable regression analysis controlling for age, gender, injury severity, comorbidities, insurance status, calendar year, and type of trauma center. I argue that racial/ethnic disparity exists for GTPs in terms of in-hospital mortality, in-hospital complications, and LOS. Type of injury, severity of injury, and age group are critical predictors of different health outcomes among minority GTPs. Minimizing disparities in GTPs care is crucial to reducing morbidity and mortality. More focused primary research is needed to expand our knowledge of racial/ethnic disparities among GTPs. It is critical that future research stratify each minority group by differences in injury type, injury severity, and age group.Release after 07/16/202
Factors influencing performance by contracted non-state providers implementing a basic package of health services in Afghanistan
Abstract Background In 2002 Afghanistan’s Ministry of Public Health (MoPH) and its development partners initiated a new paradigm for the health sector by electing to Contract-Out (CO) the Basic Package of Health Services (BPHS) to non-state providers (NSPs). This model is generally regarded as successful, but literature is scarce that examines the motivations underlying implementation and factors influencing program success. This paper uses relevant theories and qualitative data to describe how and why contracting out delivery of primary health care services to NSPs has been effective. The main aim of this study was to assess the contextual, institutional, and contractual factors that influenced the performance of NSPs delivering the BPHS in Afghanistan. Methods The qualitative study design involved individual in-depth interviews and focus group discussions conducted in six provinces of Afghanistan, as well as a desk review. The framework for assessing key factors of the contracting mechanism proposed by Liu et al. was utilized in the design, data collection and data analysis. Results While some contextual factors facilitated the CO (e.g. MoPH leadership, NSP innovation and community participation), harsh geography, political interference and insecurity in some provinces had negative effects. Contractual factors, such as effective input and output management, guided health service delivery. Institutional factors were important; management capacity of contracted NSPs affects their ability to deliver outcomes. Effective human resources and pharmaceutical management were notable elements that contributed to the successful delivery of the BPHS. The contextual, contractual and institutional factors interacted with each other. Conclusion Three sets of factors influenced the implementation of the BPHS: contextual, contractual and institutional. The MoPH should consider all of these factors when contracting out the BPHS and other functions to NSPs. Other fragile states and countries emerging from a period of conflict could learn from Afghanistan’s example in contracting out primary health care services, keeping in mind that generic or universal contracting policies might not work in all geographical areas within a country or between countries