Health Services Research Commons^™

High-Deductible Health Plans In Rural And Urban Populations: Outpatient Utilization And Out-Of-Pocket Costs, Aaron P. Smith, Jefferey Talbert

Rural & Underserved Health Research Center Publications

Overview of Key Findings This policy brief explores rural-urban differences in High-Deductible Health Plan (HDHP) enrollment, subsequent healthcare utilization, and out-of-pocket (OOP) costs. ▪ HDHP enrollment was uncommon. Rural residents were slightly less likely to enroll than urban residents across all demographic groups. ▪ Switching plans influenced utilization. Compared to those who did not change healthcare plans, switching from a Traditional plan to a HDHP was associated with a larger reduction in 2022 outpatient visits for both rural and urban residents. Moving from a HDHP to a Traditional plan was associated with a smaller reduction in 2022 outpatient visits for …

Attrition Of The Midwifery Workforce: Understanding Factors Associated With Leaving The Profession, E. Brie Thumm, Amy H. Goh, Elizabeth G. Phillips, Zachary Giano

College of Health Professions Faculty Papers

OBJECTIVE: To understand why advanced practice midwives (certified nurse-midwives and certified midwives) leave the workforce.

STUDY SETTING AND DESIGN: A multi-method, multi-source investigation included secondary analysis of certification data of advanced practice midwives and a cross-sectional online survey with closed- and open-ended items. Advanced practice midwives' active certification data were used to compare self-reported demographic characteristics of advanced practice midwives who reported working in the discipline of midwifery to those who did not (n = 9704). A survey was conducted in 2022 with individuals who allowed their certification to lapse between 2017 and 2021 (n = 303) and individuals who …

Cost-Effectiveness Evaluation Of Artificial Intelligence-Assisted Chest Radiograph Interpretation For Tuberculosis Screening In Rural Health Units In The Philippines, Harold Henrison C. Chiu, Bryan Christopher C. Lao, Gloanne C. Adolor

Graduate School of Business Publications

Background: Tuberculosis remains a major public health burden in the Philippines, where diagnostic delays are amplified by limited radiology capacity in rural health units (RHUs) and geographically isolated and disadvantaged areas (GIDAs). Computer-aided diagnosis (CAD) using artificial intelligence (AI)-assisted chest radiograph interpretation may shorten the screening pathway and reduce reliance on scarce specialist readers. However, its economic value for RHUbased tuberculosis screening has not been fully evaluated.
Methods: We developed a decision-tree cost-effectiveness model in Microsoft Excel 365 to compare AI-assisted chest radiograph interpretation with conventional manual radiologist or teleradiology interpretation among a theoretical annual cohort of 1,000 presumptive tuberculosis …

A Longitudinal Analysis Of Hospital Consumer Evaluation In Virginia, Tulay Akmandor Inac

Health Services Research Dissertations

Suboptimal patient experience signals a need to improve clinical efficacy, patient safety, and healthcare quality. The COVID-19 pandemic intensified hospital resource and staffing demands, reducing hospitals’ capacity to invest in patient experience improvement. Prior studies remain limited because many lack longitudinal structure and organized theoretical models, making temporal inference difficult and weakening analyses of patient experience disparities. To address these limitations, this dissertation incorporates three studies examining patient experience and pandemic-related effects.

In state-level markets comparable to Virginia, limited research has examined longitudinal patient experience trends across regional hospital systems using HCAHPS scores. The first study uses descriptive trend analysis …

Rural And Urban Availability Of Substance Use Treatment Facilities, Aaron P. Smith, Tyrone F. Borders

Rural & Underserved Health Research Center Publications

Overview of Key Findings

• Rural counties have higher per capita numbers of substance use disorder treatment facilities than urban counties on average, but also greater variability and large pockets of unmet need.

• The highest proportions of residents living in counties without any treatment facilities are concentrated in rural areas within the Midwestern and Southern United States.

• Rural and urban treatment facilities offer medications for opioid use disorder (MOUD) at similar rates, with inpatient facilities most likely to provide MOUD, followed by residential and outpatient settings.

Bridging Models And Real-World Performance: Capturing Represented, Hidden, And Unrepresented Dynamics In Complex Systems, Dixizi Liu

All Dissertations

Complex systems often depend on adaptive performance that is difficult to capture using structured data or formal models alone. This dissertation asks how predictive modeling, coordination-cost measurement, and simulation can be integrated to better represent the visible, hidden, and unrepresented dynamics that shape real-world system performance.

Sterile Processing Departments (SPDs) provide the empirical context for this work because they support safe and timely surgical care while operating under high workload variability, time pressure, and tight coordination with operating rooms. Hospitals rely on SPDs to clean, assemble, sterilize, and deliver surgical instrument trays so surgeries can start on time and proceed …

Essays On Opioid Prescription Limit Policy Diffusion, Evaluation, And Opioid Use Disorder Treatment Utilization, Md Ashiqur Rab

All Dissertations

The drivers of the opioid epidemic in the United States include the oversupply of prescription opioids, the availability of illicit drugs, under-resourced healthcare settings, and several socio-economic factors. Federal and state-level initiatives, including policy interventions to curb the oversupply of prescription opioids, providing access to healthcare, prevention and recovery support services, and community-level engagement, have been adopted to combat the opioid epidemic. Motivated by the need to better understand the policy and recovery efforts to address the epidemic, this dissertation examines opioid prescription limit policy diffusion, evaluation, and treatment utilization patterns. This dissertation comprises three manuscripts that offer a comprehensive …

Uncovering The Path To Diagnosis Among Adults With Attention-Deficit/Hyperactivity Disorder: A Constructivist Grounded Theory Mini-Study, Jeffrey D. Whitaker, Rick Zoucha, Melissa Kalarchian

Graduate Student Research Symposium

Abstract

Background: Attention-deficit/hyperactivity disorder (ADHD) often persists into adulthood, yet many adults are first diagnosed only after years of functional strain, compensation, and alternative explanations for their difficulties. Purpose: This study explored how adults first diagnosed with ADHD in adulthood described navigating the process of obtaining a formal diagnosis. Methods: A constructivist grounded theory mini-study was conducted with seven adults, ages 27 to 43, who reported receiving their first formal ADHD diagnosis at age 18 or later. Participants completed semi-structured Zoom interviews focused on early experiences, symptom interpretation, help-seeking, and formal assessment. Data were analyzed using initial, focused, and theoretical …

Comments Re: Regulation For Federal Financial Assistance, Fred D. Ledley, Edward Zhou, Brian C. Fox

CISI Publication

This comment focuses on the proposed modifications to §200.205 “Federal Agency Merit Review of Proposals” and §200.340 “Termination and suspension” of Title 2 of the Code of Federal Regulations. We argue that the pre-issuance review, discretionary termination provisions, and other constraints of federal research support that would be established under this proposal create impediments to the scientifically-driven process of discovery and innovation that has long provided the foundation for advances in American prosperity, influence, health, and wellbeing. Our comments focus specifically on federal support for biomedical research by the National Institutes of Health (NIH) for the purpose of advancing healthcare …

Identification Of Prognostic Factors For Disease Recurrence-Free Survival (Drfs) In Breast Cancer Patients Using The Cox Proportional Hazards Model, Dwi Cahyaning Putri, Veny Prabaningrum, Samsul Arifin

Jurnal Biostatistik, Kependudukan, dan Informatika Kesehatan

Breast cancer remains one of the most common malignancies among women worldwide, with recurrence remaining a major clinical challenge. Despite various treatment efforts, the mortality rate from breast cancer remains high, particularly among patients with worse clinical and molecular conditions. This study aims to identify factors influencing the survival of breast cancer patients using the Cox proportional hazards model. The study analyzes clinical and molecular data of breast cancer patients to identify key risk factors affecting Disease Recurrence-Free Survival (DRFS). Analysis was conducted using Kaplan-Meier, the Log Rank test, and the Cox proportional hazards model. The results showed that nodal …

The Role Of Social Determinants Of Health In Hydroxyurea Adherence Among Persons With Sickle Cell Disease: A Systematic Review, Doreen O. Ugwu, Lori L. Vick, Terika Williams, Aurela Nikaj, Seyi Omeh, Benjamin Becerra Dr., Tilicia Mayo-Gamble

Journal of the Georgia Public Health Association

Objective: Georgia has one of the highest prevalences of sickle cell disease (SCD). For Georgians living with SCD, inadequate medication adherence is associated with important clinical outcomes. One important area that is understudied in SCD is the impact of social determinants of health (SDoH) on medication adherence. A foundational understanding of SDoH is needed to introduce, inform and carry out programs and interventions designed to facilitate hydroxyurea adherence through the state of Georgia.

Method: We conducted a systematic literature review to synthesize the literature on SDoH addressed in studies to improve hydroxyurea adherence in persons with SCD. SDoH were based …

Respectful Maternity Care: A Narrative Review Of Current Evidence And Clinical Implications, Hadeel Rasheed Seger, Nada Abd Ali Mohammed, Khalid Alyodawi

Preventia: The Indonesian Journal of Public Health

Respectful Maternity Care (RMC) is key to improving quality maternity care and has also been recognized as a foundational approach to quality maternity services. The framework has been developed around respect and promotion of dignified care, confidentiality and privacy, and autonomy of a woman, along with her right to freedom from neglect, discrimination, physical and verbal abuse, during pregnancy and childbirth. Despite worldwide acknowledgment and promotion of RMC, disrespect and abuse during childbirth have been observed among women in maternity settings, especially in low- and middle-income countries. This narrative review summarizes the current evidence and clinical implications of RMC. The …

Using United States Medicare Program Claims To Identify Reliable Measures Of Low Value Services Influenced By Primary Care Physician Decisions, Chris Fleming, Dmitriy Poznyak, Rhea E. Powell, Claire Erba, Eunhae Shin, Rui Wang, Claire Burkhart, Arkadipta Ghosh, Eugene C. Rich

Division of Internal Medicine Faculty Papers & Presentations

BACKGROUND: Low-value services (LVS) are those that “… provide little to no benefit to patients….”¹ Among an existing set of 31 LVS are invasive procedures not typically performed by primary care physicians (PCPs), and other LVS that may be commonly provided by specialists. To facilitate research on the role of primary care physicians in low-value care, we sought to identify the reliability of two subsets of LVS measures that are more directly subject to PCPs’ decisions. We refer to these as primary care adjacent (“PCA”) LVS measures.

METHODS: Retrospective observational cohort study to identify which of a 31-item LVS …

If Pets Are Family: Pet Loss And The Need For Grief Equity In One Health, Michele L. Whitney

Journal of One Health Systems

One Health frameworks increasingly recognize pets as integral to human health and well-being. However, these models often overlook the health and equity implications of pet loss. Culturally mediated grief experiences following pet bereavement represent a critical grief equity gap in One Health systems. Drawing on findings from a qualitative study of African American adults who experienced pet loss, along with existing literature, this Viewpoint highlights how pet loss is not only an emotional experience but also a socially structured one shaped by cultural norms, social recognition, and access to support. These dynamics contribute to inequities in how grief is experienced …

Impact Of Insurance On In-Hospital Mortality And Other Outcomes Among Patients With Acs And Cardiogenic Shock: A Nationwide Analysis From 2022., Renzo Aller, Aura Calderon

Research Symposium

Introduction: Insurance coverage may significantly affect access to timely and advanced cardiovascular therapeutic interventions within the United States. Among individuals experiencing acute myocardial infarction (AMI) accompanied by cardiogenic shock (CS), variations based on the primary payer may play a role in subsequent in-hospital outcomes. We conducted a retrospective analysis to determine whether insurance status correlates with in-hospital mortality and other outcomes among patients with AMI and CS, utilizing the NIS database.

Methods: ACS patients in the 2022 NIS were categorized as STEMI or NSTE-ACS using appropriate ICD‐10 codes. Patients with both types of ACS and cardiogenic shock were included in …

Healthcare Access Challenges Among Asian Americans, Phyo Theingi

University Honors Theses

Asian Americans are the fastest growing racial ethnic group in the U.S. According to the 2023 U.S. Census Bureau population estimate, Asian Americans account for 25.2 million (or 7.4%) of the nation's population. Asian Americans are not a monolith and represent a diversity of rich histories, cultures, languages and ethnicities. According to research conducted by the Pew Research Center, most Asian Americans face discrimination of some kind, including being treated as a foreigner in the U.S and being stereotyped as a model minority. They also experience health care access barriers. Research found that Asian Americans face barriers related to language …

Understanding Moral Injury In Emergency Department Clinicians: Predictors, Outcomes, And Evidence Gaps, Rose Doering Lightspeed

University Honors Theses

Moral injury (MI) is an emerging construct for understanding clinician distress in high-acuity healthcare settings, yet its application to Emergency Department (ED) clinicians remains limited. MI refers to psychological distress resulting from exposure to, or participation in, situations that conflict with deeply held moral or ethical standards, often due to systemic or organizational constraints. Although prior research has examined MI in heterogeneous healthcare samples, the ED remains underexamined despite its unique combination of high patient acuity, throughput pressure, and resource limitations.

This review synthesizes literature on MI among healthcare workers with a focus on ED clinicians, drawing on Industrial-Organizational psychology …

Determinants Of Corporal Punishment And Severe Physical Punishment In Egypt: A Mixed-Methods Analysis For Child Protection Policy, Marwa Moustafa Nassef

Theses and Dissertations

Corporal punishment (CP) and severe physical punishment (SPP) remain a major public health, child rights, and child protection policy concern. In Egypt, despite legislative reforms, survey-weighted analysis of the 2021 Egypt Family Health Survey (EFHS) 2021 (CAPMAS, 2022) reveals prevalence rates of 60.5% for CP and 27.4% for SPP among children aged 1–14 (author’s calculations using EFHS-2021, n=7623), yet evidence distinguishing the determinants of routine corporal punishment from escalation to severe physical punishment remains limited in low- and middle-income contexts. Guided by Bronfenbrenner’s ecological framework, this mixed-methods study identifies key drivers of CP and its escalation to SPP among Egyptian …

Cross-Cultural Differences Among Children And Youth With Special Health Care Needs: A Mixed-Methods Analysis Of Chinese, Spanish, And English-Speaking Families, Kathleen Mcgrath, Miriam Franco, Amy Morales-Lara, Karen Bonuck Phd, Joanne Siegel

Developmental Disabilities Network Journal

One in five U.S. children has a special health care need, with prevalence rates rising each year. Children and youth with special health care needs (CYSHCN) from immigrant and/or non-English speaking families face heightened barriers to care, unmet health needs, and worsened health outcomes. This mixed-methods study explores cross-cultural similarities and differences among English-, Spanish-, and Chinese-speaking families of CYSHCN across four key domains – (1) the diagnostic process, (2) access to essential services, (3) community integration, and (4) social supports. As part of a statewide, New York State Department of Health funded initiative implemented across three University Centers for …

Paidar: Private Sector Allied For Inclusive Delivery Of Accessible Reproductive Health, Population Council Pakistan

Sexual and Reproductive Health, Rights, and Choices

Pakistan continues to face critical challenges in increasing contraceptive use and reducing the unmet need for family planning (FP). While public-sector facilities remain key providers, a substantial proportion of healthcare seekers rely on private family physicians as their initial point of contact.

Recognizing this strategic opportunity, the PAIDAR study was designed to strengthen the role of private- sector male family physicians in FP service delivery. Implemented across six diverse districts of Punjab, supported by Health Care Commission Punjab and Department of Health and Population Punjab, the intervention enhanced providers' capacity to deliver quality FP counselling, contraceptive services, structured referrals, and …