College of Public Health

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Study of Predictive Analysis of Hospital Mortality Using ECG Signals from Heart
(2023-08-03) Jose, Roberto Siasoco; Wojtusiak, Janusz
The hearts electrical signals play an important role in its functioning to collect deoxygenated blood and pump oxygenated blood to the rest of the body. The abnormality in the hearts muscle can cause deficiencies in electrical signal generation or passage through heart valves which can lead to the imbalance of blood flow leading to a wide range of issues from a minor abnormality to a severe outcome such as death. Therefore, it is important to measure the strength of electrical signals on patients prone to heart diseases while admitted in a hospital or remotely using wearables. In this study, I experimented with different variations of ECG signals acquired on patients in a hospital setting to study the ability of advanced deep learning methodology vs. traditional signal processing to predict mortality of a patient in the hospital. The results are based on 198 patient cohort equally split between male and female. The results from deep learning are better than the traditional methods to predict patient mortality at hospital using ECG signals of heart.
Prescription Waste Among Hospice Patients
(2024) Irvin, Katherine Jean; Wojtusiak, Janusz JW
The purpose of this dissertation is to assess Part D prescription waste in hospice patients, in three related studies. This dissertation seeks to characterize Part D prescription waste among linked Surveillance, Epidemiology, and End Results (SEER) Medicare and a random 5% sample of Medicare fee-for-service hospice patients by examining policy intervention impacts, assess the quantity and type of prescription medication at time of death, use a novel methodologies such as random forests to identify factors that influence the likelihood of such prescriptions on hand at time of death, and assess life expectancy as a factor in determining prescription lengths that reduce prescriptions on hand at death. Overview of Hospice and Part D ProgramsHospice was created with the goal of providing medical care that focuses on optimizing quality of life and mitigating suffering among people with terminal illness. For eligible Medicare patients, hospice is covered under the Medicare Part A insurance benefits and includes care for an individual’s terminal illness and related conditions. Hospice uses teams to provide doctor services, nursing care, medical supplies, prescription drugs, therapy (physical, occupational, and speech-language), social worker support, dietary counseling, grief counseling, and short-term inpatient or respite care. Medicare Part D is a voluntary prescription drug benefit provided by private insurance sponsors for a monthly premium. The program aims to make prescription medications more affordable and accessible to Medicare recipients. The benefit covers patient’s prescription drugs in most cases, but there are circumstances where drugs are covered instead under either Medicare Part A or Part B. One exception is when a patient elects hospice, and the prescription drugs related to the care of the terminal illness and conditions are covered under the Medicare Part A benefit. Medications unrelated to the patient’s terminal illness may still be obtained through the Part D benefits. In the past decade, hospice care has prioritized quality while aiming to reduce unnecessary waste. The Center for Medicare and Medicaid Services (CMS) defines waste as practices leading to unnecessary costs for the Medicare program. Since October 2010, CMS has issued several communications to Part D Sponsors and Hospice Providers highlighting the problem of Medicare paying for drugs under Part D that should be covered by hospice Medicare Part A. This inappropriate billing has led to significant costs and waste for the Medicare program. The following reviews the laws, practices, and/or guidelines CMS has published from 2008 to present providing historical context for understanding Part D prescription waste among hospice patients. Years 2008-2013In June 2008, the CMS through the Federal Registrar released the first major revision of Medicare Hospice Conditions of Participation (CoPs) since the Medicare Hospice Benefit was established in 1983. The major revision related to hospice patient’s prescriptions (including Part D medications) included: CFR-Explanation of Revision§ 418.106(e) Added clarification that reiterates the requirement that hospices must provide all drugs and supplies related to a patient’s terminal illness and related conditions and not expect patients to obtain drugs related to the terminal illness and related conditions through Medicare Part D. And that longstanding, preexisting conditions and comorbidities are included in the hospice bundle of services as written in the original implementing regulations of the Medicare hospice benefit. However, if a patient necessitates drugs unrelated to the terminal illness, they may seek coverage through Medicare Part D. CFR-Explanation of Revision § 418.54(c) Clarified the term “unnecessary drugs” as part of the content of the comprehensive assessment and reiterated that all medications should be included in the review in order to develop a plan of care. The ruling went on to clarify that as part of the drug profile review, the assessment should include a patient’s prescription and over-the-counter drugs in use, drug effectiveness, side effects, drug interactions, duplicate therapies, and under or overdosing. Following these changes and clarifications it wasn’t until October 2010 that CMS released a Memorandum entitled Preventing Part D Payment for Hospice Drugs. The memorandum indicated there were concerns that Part D sponsors were paying for drugs that should be the responsibility of the Medicare hospice provider. Guidelines were released directing Part D sponsors to communicate with their network pharmacies to ensure Medicare hospice drugs were not billed to Part D. CMS indicated they would provide best practices for doing so by late 2011. However, following an initial proposal (in February 2011), by April 2011 CMS issued as part of the Announcement of CY 2012 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies a section detailing the best practices for “Preventing Part D Payment for Hospice Drugs”. The practices recommended Part D sponsors utilize patient-level transaction reply reports (TRR) they had previously been receiving from CMS. These reports contained patient enrollment information and hospice election information. The best practices detailed how to utilize the included hospice indicators and data to ensure the claims processor is notified of an enrollee’s hospice election and that processes are in place to prevent Part D payment for hospice drugs. Then in June 2012, the Department of Health and Human Service, Office of the Inspect General (DHHS OIG) released a report titled “Medicare Could Be Paying Twice for Prescription Drugs for Hospice Patients” (which examined data from 2009). CMS concurred with two recommendations DHHS OIG made with regard to preventing the Part D benefit paying for medications already covered under the hospice Part A per diem payments. The accepted recommendations included: 1) Educating Part D sponsors, hospices, and pharmacies that it is inappropriate for Medicare Part D to pay for drugs related to hospice patients’ terminal illnesses; and 2) Requiring Part D sponsors to develop controls that prevent Part D from paying for drugs that are already covered under the per diem payments. Following additional TRR report guidance was provided by CMS in April 2013, CMS released a final rule in August 2013 requiring all Part D sponsors to have in place “means” to prevent duplicate payment of hospice medications as well as provided additional clarifications and explanations to sponsors, hospices, and pharmacies. CMS strongly recommended the Part D sponsors use of the TRR reports and have in place controls to prevent the reimbursement for hospice medications. CMS indicated using prior authorizations (PA) for all hospice medications through Part D was best practice but wasn’t required. However, CMS gave specific instruction for sponsors to implement PAs (or other approaches) for four categories of prescription drugs in hospice patients: analgesics, antinauseants, laxatives, and antianxiety drugs. These were identified by the DHHS OIG as typically used to treat the symptoms generally experienced by hospice patients during the end of life. CMS also provided additional guidance and practices for Part D sponsors, hospices, and pharmacies detailing terminal diagnosis and interrelated conditions. CMS reiterated the original intent of the hospice benefit was to have a Medicare benefit available that provided virtually all-inclusive care for terminally ill individuals, provide pain relief and symptom management, and offered the opportunity to die with dignity and comfort in one’s own home rather than in an institutional setting. At the end of 2013 in December, CMS released a memorandum seeking comments on new expectation for stakeholders related to "Part D Payment for Drugs for Beneficiaries Enrolled in Hospice". The memorandum provided a condensed overview of prior regulatory directives pertaining to the eligibility criteria and extent of benefits applicable to Medicare hospice services under Part A. CMS reiterated that patients should only very rarely be taking drugs that are not covered under the hospice per diem. CMS further stated that for prescription drugs to be covered under Part D when the enrollee has elected hospice, the drug must be for treatment of a condition that is completely unrelated to the terminal condition(s) or related conditions. In other words, the drug is unrelated to the terminal prognosis of the individual. In addition, CMS communicated new expectations for Part D sponsors, aimed at preventing duplicate payments for medications covered within the hospice benefit or waived due to the beneficiary’s hospice election. CMS expected for drugs covered under Part D for hospice patients to be extremely rare, the Part D sponsors should place patient-level PA requirements on the following four categories of prescription drugs: analgesics, antinauseants, laxatives, and antianxiety drugs for hospice patients to determine whether the drugs are coverable under Part D. The memorandum also provided guidance to Part D sponsors on making retrospective determinations of payment responsibility for drugs within these categories during the hospice election. The guidance to sponsors was to conduct outreach to the hospice provider to determine whether the drug is for treatment of a completely unrelated condition. CMS stated they expected the hospice provider to coordinate with the plan sponsor regarding these claims and provide the necessary written information, as requested by the sponsor. Years 2014-PresentIn March 2014, CMS issued guidance and established a standard Part D PA form, required for use by Part D sponsors, hospices, and prescribers. The following July, CMS issued a final rule memorandum regarding the “Determination of Payment Responsibility for Drugs for Hospice Patients”. In this final memorandum, CMS provided updates to the March 2014 PA form and explanatory documentation and communicated their expectation for its universal implementation of their guidance by October 1, 2014. In June 2015, the DHHS OIG issued a report titled "Ensuring the Integrity of Medicare Part D", providing a synthesis of investigations, audits, evaluations, and legal guidance related to weaknesses in the Part D program. It again identified highlights the 2012 DHHS OIG report discussing the inappropriate billing of hospice patient’s drugs in 2009 to Part D that should be covered by hospice Medicare Part A. The DHHS OIG followed that report with a March 2016 report titled “Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care”. CMS responded by concurring with the recommendation to increase its oversight of Part D payments for drugs for hospice patients. CMS began the process to procure a Hospice Recovery Audit contractor to conduct claim reviews and recoup payments as necessary. That November, CMS issued a memorandum titled "Update on Part D Payment Responsibility for Drugs for Beneficiaries Enrolled in Medicare Hospice", acknowledging, and thanking stakeholders for improvements in billing practices and noting the implementation of their Hospice Recovery Audit contractor for claim reviews. Since 2013 stakeholders have raised concerns about the promptness of communications concerning the entitlement status of hospice patients. In response CMS, in August 2017, took additional action by outlining their strategy for introducing an electronic notice of election form for hospices to communication a patients election (OMB No. 0938-1269) as a component of the FY 2018 Hospice Wage Index and Payment Rate Update. The form went through updates before it was finalized in October 2018. In July 2018, the DHHS OIG recommended to CMS, via a report that assessed the vulnerabilities in the Medicare hospice program, the need to execute a strategy to intervene with hospices to ensure they are providing the drugs covered under the hospice benefits and not inappropriately billed to Part D. CMS did not concur with this recommendation, which was similar to a recommendation from the June 2012 “Medicare Could Be Paying Twice for Prescription Drugs for Hospice Patients” report that they didn’t concur with then either. Then the following year, in August 2019, the DHHS OIG conducted a follow-up audit to their 2012 findings. The DHHS OIG released their report titled “Medicare Part D Is Still Paying Millions for Drugs Already Paid for Under the Part A Hospice Benefit” [15]. The report, which examined data from 2016, detailed the ongoing inappropriate billing of prescriptions for hospice patients that the DHHS OIG found previously in its 2012 Report. In response, CMS commented that they would continue to engage in meaningful activities to reduce duplicate payment in this area, such as ensuring hospice providers are proactively educating patients on covered services and items (including drugs) and Part D drug plan sponsors are appropriately applying PA criteria and coordinating with hospice providers on drug coverage issues. To further address the ongoing problem of inappropriate billing documented in the 2012 and 2019 DHHS OIG reports, CMS through the Federal Registrar issued as part of the FY 2020 Hospice Wage Index and Payment Rate Update requires hospices disclose in an extensive written addendum to patients (and other health care providers) any care that would be deemed unrelated to hospice care as part of a Patient Notification of Hospice Non-Covered Items, Services, and Drugs (OMB 0938-1153). The following year in August 2020, CMS made form OMB 0938-1153 a condition for payment for hospices. Unfortunately, prescription waste can occur in many ways, not just through inappropriate billing. Estimates suggest up to $2 billion annually, in unused prescription medication, is being wasted in Medicare Part A long-term care facilities alone. A 2013 report by Visante found that around 14 million (approximately 1%) of all Part D prescriptions are wasted yearly. The study reported that most of this waste stems from therapy discontinuation, medication switching, dosage adjustments, and death. Regarding waste due to patient mortality, the study unearthed that, on average, patients had 50% of each prescription on hand at the time of their death. Goals of this DissertationThis dissertation seeks to characterize Part D prescription waste among SEER Medicare hospice patients by examining policy intervention impacts, assess the quantity and type of prescription medication at time of death, use a novel methodology such as random forests to identify factors that influence the likelihood of such prescriptions on hand at time of death, and assess life expectancy as a factor in determining prescription lengths that reduce prescriptions on hand at death compared to traditional prescribing methods. This will be accomplished through three related studies in hospice care and prescriptions. The first study will utilize generalized estimating equations (GEE) with negative binomial regression analysis to understand the effects of hospice patient Part D billing policy guidance on linked SEER Medicare data of male hospice patients with prostate cancer and their Part D prescriptions. The second study seeks to examine Part D prescriptions waste in linked SEER Medicare data of hospice patients, with breast; lung; pancreas; prostate; and stomach cancer and identify any predictive characteristics. The methodology for this study consists of calculating the type and amount of medication on hand at time of death and the associated costs by year and then conducting predictive analyses of characteristics that influence Part D prescriptions waste using machine learning techniques. The third study will develop and test rule-based prescription durations for Medicare patients in hospice, with a particular focus on those with a survival of 90 days or less. This work will inform the development of a decision support tool that will describe Part D prescription durations that reduce potential waste related to the amount of prescription medication on hand at death compared to traditional prescribing methods. The methodology will use Random Survival Forest (RSF) calibrated with median trapezoidal rule to develop survival estimates, to simulate clinician predicted survival, which the rule-based prescription durations were applied to. Medication on hand at time of death was calculated and the resulting waste was compared between the rule-based prescription lengths and provider durations. By employing generalized estimating equations, the first study was able to assess the (1) total monthly average prescriptions of all medications and (2) four categories of commonly prescribed hospice medications in pre-and-post policy guidance. This study investigated the effects of guidance issued by CMS on April 4, 2011, targeting providers to prevent the improper billing of prescription drugs for hospice patients’ terminal illness and related conditions to the Part D benefit. Using linked SEER Medicare data for male hospice patients between April 2009 and March 2013, the analysis found that hospice patients’ monthly average total Part D prescriptions decreased from 7.3 pre-policy guidance to 6.5 medications following the issuing of the guidance, while the four categories of hospice-specific medications decreased from 0.57 to 0.49. The findings of this study show that CMS’s guidance issued to providers to prevent the inappropriate billing of hospice patients’ prescriptions to the Part D benefit may lead to decreases in improper billing as observed in this sample. Summary statistics were applied in the second study to examine the type and quantity of Medicare Part D medications on hand at time of death in hospice patients. This analysis utilized a 5% subset of Medicare fee-for-service patient claims and linked SEER Medicare patient claims spanning from January 2015 to December 2019. Results indicated that cardiovascular medications accounted for 25% of prescriptions, followed by central nervous system medications at 20%. The mean prescription length was 36.65 days’ supply with a mean of 62.18 quantity dispensed. Prescriptions resulting in medication on hand at time of death on average were dispensed 72.69 days after a patient’s admission to hospice and resulted in a mean of 20.02 days’ supply and 34.18 quantity wasted. Additionally, the study evaluated the predictive accuracy of four classifiers in forecasting prescription waste at time of death, with Random Forest achieving the highest performance, boasting an area under the curve (AUC) exceeding 93%. Feature importance analysis revealed prescription days’ supply and quantity dispensed as the most influential factors. Even after removing these predictive features, Random Forest still demonstrated a respectable AUC of 73.5%. The study demonstrates that medication on hand at time of death in hospice patients can be predicted and supports additional research should be done to identify ways to reduce the waste. In the final study, rule-based prescription durations were developed and applied to each patient based on their simulated survival days. RSF calibrated with median trapezoidal rule was used to simulate clinician estimated patient survival days. Medication on hand at time of death was then calculated for the rule-based prescriptions and compared to the amount caused by the traditional clinician prescription durations. Two scenarios were conducted that compared the overage for (1) all prescriptions regardless of when the clinician determined prescription ended and (2) prescriptions where a threshold excluded prescriptions where either the clinician or rule-based prescriptions ended more than 3 days before the death date. In the initial scenario, the rule-based prescriptions reduced overage in 28% of cases, leading to a decrease of 29.1% to 36.1% in the amount of prescription medication on hand at the time of death. The second scenario saw similar success with the rule-based prescriptions reducing overage in 32% of cases, leading to a decrease of 32% to 45.5% in the amount of prescription waste. Overall, in this sample the rule-based initial and refill prescription durations were effective in reducing waste. The occurrence of Part D prescription waste in hospice has been well documented by CMS in memorandums and reports. However, few studies exist examining CMS implemented policy impacts to reduce waste, characteristics identification of Part D hospice prescription waste for predicting medication on hand at death, or novel methods to reduce medication waste at the source, i.e., the prescription. Each of these three related studies is significant in that it addresses a gap in hospice care and prescription waste using novel machine learning approaches. The first study is significant in it addresses how government policy guidance has impacted the inappropriate billing of Part D prescriptions in hospice patients. While CMS has documented decreases in billing of Part D prescriptions in hospice patients, no study or analysis exists that definitively ties the decrease and policy together. This study addresses this gap using a GEE with negative binomial regression will address this gap and has the potential to bolster the findings of CMS. The significance of the second study is twofold, as like the first paper, this study also addresses two gaps: 1) the review of Part D prescription waste patterns in hospice patients using individual hospice patient claim records, and 2) in its identification of characteristics that influence the likelihood of Part D prescription waste. Limited research exists in exploring the type, quantity, and costs of medications on hand at time of death in hospice patients and no research exists that examines characteristics that influence the likelihood of prescription waste. Currently this gap in research exists as prior studies have only assessed the amount of hospice Medicare Part A prescription waste at individual hospice organizations. Using novel methods, such as K Nearest Neighbor, the study will assess the effects of hospice patient’s characteristic on the likelihood of Part D medications on hand at time of death. This study is crucial as a first step to bring about further understanding and awareness of potential waste patterns in hospice patients’ Part D prescriptions in order to better the prescribing patterns of physicians and improved care coordination between teams. The use of average life expectancy to influence prescription lengths in hospice patients is a significant gap in the literature. While studies have explored the clinical and cost-effectiveness of longer and shorter (3-month vs 28 days) duration prescriptions to reduce waste, studies identifying prescription durations for reducing medication on hand at time of death in hospice patients do not. The use of machine learning methods in this study, e.g. RSF, to develop a rule-based decision support tool to assess prescription lengths that reduce waste in real time is novel. This study has the potential to influence how Part D prescriptions are prescribed to hospice patients in order to address ongoing issues of medical waste in terms of money and resources. This work provides critical evidence on the scope of problematic medication waste at the end of life. The research should ideally be used to promote increased efforts around appropriate billing of prescription drugs in conjunction with identifying predictors of medication on hand at time of death to developed tailored medication prescription duration strategies that minimize burden without impacting quality of life during the patient’s final weeks and months. Additionally, this work’s implementation of novel machine learning approaches, using individual patient data, provides further evidence of need for these advanced models to be incorporated into provider’s medical software to aide in decision making as well as providing personalized medicine to the patient. Until then, a more careful review of patients’ prescription prescribed through Part D and the prescription duration at the time of hospice enrollment is warranted.
SCHOOL NURSES MOVING THE NEEDLE ON HPV CANCER DISPARITIES: INTEGRATING QUALITATIVE & QUANTITATIVE METHODS TO IMPROVE ON-TIME HPV VACCINE COMPLIANCE
(2024) McNally, Kimberly A; Roess, Amira
The human papillomavirus (HPV) vaccine has the potential to prevent cancer. Unfortunately, many people remain unprotected against the common viral infection that can lead to several types of cancer. The HPV vaccine is most effective when given before exposure and is recommended for adolescents between the ages of 11 and 12. Uptake has been sub-optimal, when compared to other recommended adolescent vaccines like tetanus, diphtheria, pertussis, and meningitis. School nurses are involved in immunization compliance activities and play a pivotal role in preventative care for adolescents, including improving HPV vaccination. The primary objective of this dissertation is to mitigate HPV-related cancers by examining the socioecological factors influencing school nursing practices concerning vaccine compliance. To meet this goal 3 related studies were conducted. First, a systematic literature review (SLR) was conducted to thematically analyze all relevant findings reported in scholarly publications that include school nurses 'experiences and roles in promoting and administering the HPV vaccine in school settings guided by the socioecological framework. Second, a quantitative analysis identified social determinants of school-level HPV vaccination rates in Virginia including county-level factors like urbanicity, majority racial/ethnic group, and political leaning and school-level factors like percentage of students that are economically disadvantaged, majority racial/ethnic group, and percentage of children with disabilities. Finally, semi-structured interviews were conducted with school nurses in Virginia to understand their experiences with HPV vaccine promotion. The socioecological model was used to frame the studies and to guide the analysis of the data. This 5-level model included intrapersonal, interpersonal, organizational, community, and societal/policy was used. Factors that impact school nursing practice related to HPV vaccine promotion are present at each level of the socioecological model. At the intrapersonal level school nurses had good vaccine knowledge and positive attitudes towards vaccines, however, there were concerns related to vaccine safety and necessity. At the interpersonal level, school nurses sought to balance HPV vaccine promotion while maintaining positive relationships with students and families. Organizational factors like poor workflow processes and competing demands negatively impacted nursing practice. At the community level, school nurses relied on community partners to facilitate vaccination for families. Health departments and medical clinics were the most cited community partners, and school nurses relied on the partners to educate families and bundle vaccines. At the societal level, stigma was found to impact HPV vaccine uptake. Policies that normalize the vaccine as part of the general childhood vaccine schedule and large-scale education campaigns were noted. Interventions to improve nursing practice at the intrapersonal level should focus on the safety and efficacy of the HPV vaccine. Improvement in interpersonal communication skills will empower school nurses to positively engage with students and families. Schools can facilitate nursing vaccine practice with workflow improvements like adopting integrative vaccine reporting systems and supporting school-based vaccine champions. Accessible family-centered vaccine events and strong community partnerships allow school nurses to connect families with vaccines. Policy advocacy should continue to normalize the HPV vaccine as part of routine childhood vaccination.
Assessing Dental Care Utilization and Health Outcomes among Homeless Women of Reproductive Age
(2023) Abdo, Dina; Kitsantas, Panagiota
The purpose of this dissertation was to explore dental care utilization and oral health among women of reproductive age in the United States (U.S.) as well as examine adverse pregnancy and postpartum health outcomes in women who experienced homelessness before or around pregnancy. Study 1 examined associations between dental healthcare utilization, adverse dental health outcomes (e.g., tooth loss) and mental health conditions, sociodemographic characteristics, and health-related and behavioral factors among non-pregnant women of reproductive age (18-44 years) using parametric and machine learning methodologies based on data from the 2016, 2018 Behavioral Risk Factor Surveillance System (BRFSS). Study 2 used data from the 2012-2018 Pregnancy Risk Assessment Monitoring System (PRAMS) to examine associations between dental care utilization during pregnancy and social and behavioral determinants of health, along with dental health factors among homeless and non-homeless pregnant women in the U.S. Study 3 was a systematic review that examined pregnancy and postpartum outcomes among women who experienced homelessness before or around pregnancy.
One Health Approach to Zoonotic Disease Surveillance Utilizing Watering Hole Samples in Laikipia County, Kenya
(2023-07-26) Lilak, Abigail; von Fricken, Michael
Emerging and re-emerging pathogens and more specifically, water-borne pathogens continue to be a burden globally. In East Africa, water-borne infectious diseases include cholera, cryptosporidiosis, giardia, hepatitis A and E, leptospirosis, schistosomiasis, and typhoid. Watering holes are an understudied environment for surveillance, in Laikipia County, Kenya. These locations provide a unique perspective as it is a shared environment between animals, livestock, and humans and allow the ability to conduct pathogen surveillance under a One Health framework. Throughout Laikipia County, 10 watering holes were sampled. Within Kenya, there have been outbreaks of cholera, schistosomiasis is considered endemic, and leptospirosis has a high global burden (Chadeka et al., 2019). To our knowledge, there has not been a study in Laikipia County studying water samples from watering holes for zoonotic infectious diseases. Of increasing concern, due to climate change, there has been a scarcity of resources, and certain watering holes are now almost or completely empty during portions of the year. In addition, there has been an ongoing drought which has led to an increase in the shared usage of watering holes and made water a valuable resource amongst humans and animals. From May 2020 until March 2022, 122 pooled water samples were collected from 10 watering holes within Laikipia County. The samples were processed and sequenced using a Mk1C MinION, with output sequences analyzed through a data pipeline. Partial reads from the following microorganisms were detected: Acanthamoeba castellanii, Aeromonas veronii, Brevibacillus brevis, Gardnerella vaginalis, Legionella pneumophila, Orientia tsutsugamushi, Plesiomonas shigelloides, Staphylococcus aureus, Staphylococcus capitis, Staphylococcus epidermidis, Staphylococcus haemolyticus and Vibrio cholerae. Samples were further examined for potential contigs, many of the samples had limited mapping to the reference genome, often with no coverage overlapping. These findings highlight the potential uses of metagenomics for environmental surveillance and the need for more studies conducting work with environmental DNA and metagenomics. Additionally, this thesis starts to contribute towards a larger conversation within science about the reliability and confidence or working with and analyzing genetic data.
The Relationship between Dietary Intakes of Magnesium, Copper, Iron, Omega-3, and Selenium and Depression among College Students Aged 18-24 Years at George Mason University
Ren, Xinye; Basiri, Raedeh
Background: Depression is a common illness that leads to serious outcomes ranging from poor functional performance at work, school, and in family roles, to suicide. Young adult (18-29 years old) depression is a serious health problem. Over twenty percent of young adults have reported depression symptoms in the United States1. Around seventeen percent of American college students are depressed2. For college students, mental health is important for their education and quality of life. About sixty percent of people who have committed suicide previously reported mood disorders such as major depression, bipolar disorder, and dysthymia3. According to WHO (2020)1, suicide is the second leading cause of death among the individuals aged 15-29 years, which is the age when people typically attend college. Nutrition is a modifiable factor that plays an essential role in human psychological health4. It could be a sustainable treatment method for depression with low cost and minimal side effects. Nutrients, such as selenium, copper, iron, magnesium, and omega-3, are reported to have an association with depression. However, studies regarding the intakes of these nutrients and depression are inconclusive. Few studies focused on college students. Thus, the overall purpose of this study is to investigate the relationship between dietary nutrient intakes and depression level among college students at George Mason University by 1) evaluating the dietary intakes of selenium, magnesium, copper, iron, and omega-3 among George Mason University college students with different depression levels; and 2) examining whether the extent of dietary intake of these nutrients is related to the severity of depression. Method: This is a cross-sectional study. In total, 205 participants were eligible to be included in this study from the 2019 population of the Mason: Health Starts Here cohort study. The participants were first-year college students aged 18-24 years at George Mason University. Demographic information such as gender, race, BMI, and financial support were collected, and dietary nutrient intake was measured using Dietary History Questionnaire (DHQ-III). Depression level was evaluated by utilizing Patient-Reported Outcomes Measurement Information System (PROMIS). Physical activity level was assessed using International Physical Activity Questionnaire (IPAQ) - short version. SPSS version 28.0 was used to do the statistical analysis. ANOVA was used to compare the differences between the average nutrient intakes and depression levels. Linear regression was to analyze the relationship between dietary nutrient intakes and depression levels. Results: There were no significant differences between depression levels in race, gender, body mass index, physical activity level, and financial support. Compared to the mild and the moderate/severe groups, the none to slight depression group had the highest percentage of the participants (68.1%) with normal BMI. The moderate/severe depression group had the highest percentage of underweight (11.9%) and obese (11.9%) participants. Finally, the mild depression group had the highest percentage of participants being overweight (25%). A greater proportion of participants had low physical activity level as the depression level increased, from 17.6% in the none to slight group to 31.0% in the moderate/severe group. The percentage of participants with high physical activity was higher in the none to slight depressed group (56.3%) compared to the other two groups (mild 40.9% and moderate/severe 50%). Dietary intakes of magnesium, iron, copper, selenium, and omega-3 were not significantly related to depression level. The average intakes of examined nutrients were not significantly different between depression groups. Conclusion: The present study did not find significant between-group differences of the average dietary intakes of magnesium, copper, iron, omega-3, and selenium; nor a significant relationship between dietary intakes of selenium, iron, copper, magnesium, and omega-3 and depression level among freshmen college students aged 18-24 years at George Mason University.
Patient-Centered Communication and Provider Interacting eHealth Behaviors: Trends and Associations with Cancer Screening
(2022) McKeown, Lisa M; Hong, Y. Alicia
Patient-centered communication (PCC) is a key indicator of healthcare quality and is critical to patient-centered care. Provider interacting eHealth behaviors (PIEB) help facilitate patient-centered care. This dissertation is comprised of three papers centered around PCC and PIEB. The three papers examined PCC and PIEB from three perspectives: (1) trends in PCC, (2) trends in PIEB and the association of PCC with PIEB, and (3) the association of PCC and PIEB with cancer screening. The three studies used nationally representative survey data from the Health Information National Trends Study (HINTS) administered by the National Cancer Institute (NCI). Findings from the three papers indicate PCC has increased over the past decade, is associated with PIEB, higher PCC is associated with increased odds of breast and colon cancer screening adherence, and higher PIEB is associated with increased odds of breast, cervical, and colon cancer screening adherence when controlling for PCC. In addition, disparities in PCC and PIEB continue to exist. PCC is differentially associated with breast and colon cancer screening based on race and ethnicity. PIEB is differentially associated with breast, cervical, and colon cancer screening by race and ethnicity. This research helps to inform the continued need for progress in PCC and PIEB including culturally and linguistically appropriate communication and eHealth tools in healthcare.
Examining the Role of Social Isolation on Hospitalizations, Nursing Home Entry, and Mortality among Older Adults
(2022) Pomeroy, Julia Mary Louise; Gimm, Gilbert
Social isolation affects a quarter of older adults in the United States, complicating efforts for Americans who wish to age at home or in the community. Social isolation is a key risk factor for adverse health outcomes and high health care costs, and is expected to have increased during COVID-19 due to social distancing efforts. However, little research has examined the impact of social isolation on health care utilization. Literature in this area tends to be conducted internationally, uses short follow-up times, measures social isolation through single-item variables, and usually does not control for both social isolation and loneliness in the same sample. No prior studies have examined the association between social isolation and nursing home entry in a United States-based sample. This dissertation includes three studies that expand knowledge on the associations between social isolation and hospitalization, nursing home entry, and mortality in a nationally-representative sample of community-dwelling Americans ages 65 and older. Data from the Health and Retirement Study were used to construct a multi-domain measure of social isolation while controlling for loneliness. The first study uses a panel data analysis to examine whether social isolation was associated with overnight hospital stays, nursing home entry, and mortality among older adults tracked between 2006 and 2018. The second study uses a time-to-event analysis to examine whether social isolation is associated with earlier time to long-term nursing home placement (residency of 100+ days) and mortality over ten years. The third study provides an exploratory, cross-sectional analysis to examine whether use of senior services moderates the association between social isolation and nursing home entry among respondents interviewed between 2010 and 2012. Results demonstrate that social isolation is significantly associated with increased nursing home entry and early mortality. Research examining the association between social isolation and health care utilization has important implications for the expansion of home and community-based services under Medicaid and billing codes to cover screening, referral, and treatment under Medicare. Future research should evaluate whether initiatives that enhance social connections in home or community-based settings are effective in offsetting nursing home entry, reducing premature mortality, and curbing health care costs for patients and payers.
Understanding the Dynamics of Social Determinants in Health Disparity, and Their Impact on Cardiovascular Diseases
(2022) Parekh, Tarang; Cuellar, Alison E
Traditional efforts to improve health in the United States have been driven by focusing on the health care system. However, these efforts require broader approaches that also address social, economic, and environmental factors that influence health. Cardiovascular diseases remain the leading cause of death in the United States. Although CVD disparities are shaped by differences in risk factors across racial and ethnic groups, non-traditional risk factors such as housing and food insecurities remain important social determinants of health (SDOH). While the recent trend in CVD mortality has declined, the prevalence of CVD is expected to rise by 10% in 2030. With this current trajectory, chapter 1 of this dissertation is focused on identifying predictors of SDOH by reviewing and summarizing literature that examined the association of housing and food insecurity with cardiovascular disease. Chapter 2 builds on the findings from study-1 through identified literature gap in potential predictors of housing and food insecurities, retrospectively examining how demographics, socioeconomic, and healthcare characteristics differ by available food environment and the likelihood of CVD mortality with poor food environment. Chapter 3 focuses on addressing this unique challenge of capturing SDOH by conducting a natural experiment using the Difference-in-Difference methodology and examining whether the broad-based health delivery system and payment reforms can incentivize social risk factor diagnosis in hospital settings among adults hospitalized with CVD.
Effects of State Scope of Practice Laws on Supply of Nurse Practitioners in Rural Communities
(2022) Jones, Tammie Michele; Maddox, Peggy J
In 1965, the nurse practitioner profession began in response to a shortage of primary care providers in urban and rural areas. States began recognizing advanced practice nurse providers who completed certificate or post graduate training programs for advanced practice to diagnose and treat health conditions under various levels of physician supervision. Today, over 25 million people live in areas designated as rural primary care health professional shortage areas where it is still difficult to get timely access to health services. The National Governor’s Association, advocates for nurse practitioners, and researchers have suggested that more effective incorporation of nurse practitioner services and easing restrictions to practice could mitigate the growing shortage and/or maldistribution of primary care physicians, reduce geographic disparities, and improve access to primary care services. Over time, some states have amended their nurse practice acts to allow nurse practitioners more independent practice with the intent to increase the supply of primary care providers and improve access to care (especially in rural and underserved areas). Research studies conducted to date provide limited understanding about the relationship between state nurse practice act changes on the growth and distribution in the supply of nurse practitioners as primary care providers. This dissertation employed a difference-in-differences design to exploit variation in timing of changes in state scope of practice laws (from more restrictive to less restrictive) to study the causal effects on the supply of nurse practitioners at the county level. The results of this study found states that authorized nurse practitioners to practice independently saw a 17.5 percent decrease in the number of nurse practitioners at the county level and a 12.5 percent decrease in rural counties. We found the supply of nurse practitioners continued to decline 7 years after adoption of full scope of practice regulation in two states.
Disability, Depression, Opioids, and Suicide among Women of Reproductive Age: Four Different Studies of Nationally Representative Samples
(2022) Booth, Edward J; Kitsantas, Panagiota
Disability adversely affects a substantial proportion of the United States (US) population and is a recognized major public health challenge. Despite established associations between disability and adverse health conditions, limited information exists regarding its effects among women of reproductive age. This dissertation consists of four different studies that examine depression, opioids, and suicide among US women of reproductive age with disabilities. Using data from the Pregnancy Risk Assessment Monitoring System, the first study in Chapter One examined disability, stressful life events, and postpartum depressive symptoms among women. Descriptive statistics, bivariate, and binary logistic regression analyses were conducted to estimate the effect of stressful life events on postpartum depressive symptoms among women with and without disabilities. Compared to their peers without disabilities, women with disabilities reported a higher number of stressful life events (87% to 67%) and post depressive symptoms (37% to 9%). Women with disabilities experiencing six or more stressful life events were more likely (odds ratio = 3.78, 95% confidence interval = [1.57-9.10]) to report postpartum depressive symptoms, compared to those with no stressful life events. Data from the National Survey on Drug Use and Health (NSDUH) were used in the second, third, and fourth studies. The analyses included descriptive statistics, bivariate analyses, and logistic regression to measure associations. All of the analyses were weighted to account for the complex survey design of NSDUH. The second study in Chapter Two examined disability and prescription opioids among pregnant women. Pregnant women with any type of disability had higher adjusted odds of using (adjusted odds ratio = 1.71, 95% confidence interval = [1.27-2.29]) and misusing (adjusted odds ratio = 2.00, 95% confidence interval = [1.22-3.28]) opioids within the past year compared to their peers without disabilities. The third study in Chapter Three assessed disability and prescription opioids among non-pregnant women of reproductive age. The findings of this study indicate that similarly to the pregnant population, non-pregnant women with disabilities had higher adjusted odds of opioid use (adjusted odds ratio = 1.59, 95% confidence interval = [1.50-1.67]) and misuse (adjusted odds ratio = 2.01, 95% confidence interval = [1.82-2.21]) than their peers without disabilities. The fourth study in Chapter Four examined disability and suicidal behaviors among non-pregnant women of reproductive age. Women with disabilities had greater adjusted odds of past-year suicidal behaviors (adjusted odds ratio = 1.73, 95% confidence interval = [1.60-1.87]) than women without disabilities. Disability adversely affects women of reproductive age in multiple facets of life. Compared to their peers without disabilities, women with disabilities are at an amplified risk for stressful life events, opioid use and misuse, and postpartum depressive symptoms. Early prenatal screenings for disabilities, life stressors, and opioid use or misuse is critical for timely awareness and appropriate treatment to prevent associated adverse health conditions. Further postnatal screening for postpartum depressive symptoms and opioid use or misuse is vital to optimize favorable health outcomes for mothers and their children. Both pregnant and non-pregnant women with disabilities are at increased risk for prescription opioid use and misuse relative to their peers without disabilities. Furthermore, non-pregnant women of reproductive age with disabilities are at increased risk for suicidal behaviors, particularly suicide attempts, compared to their counterparts without disabilities. Effectively mitigating the effects of opioids prior to reproduction will prevent associated adverse consequences for prospective mothers, children, and families. Furthermore, this study’s findings elucidate the complexity of suicidal behaviors among women with disabilities and the influence of specific health determinants on such behaviors. Enhancing our knowledge of suicidal behaviors and associated health determinants among women with disabilities can preserve the wellbeing of future generations via enhanced prevention, detection, and intervention enterprises.
The Impact of an Online Movement Training Program for Community-Based Adults and Older Adults on Balance, Physical Activity, Self-Efficacy and Resilience
(2022) Kestle, Emily; Guccione, Andrew A; Higgins, Rosemary D
Objective: To examine the effects of a 30-minute, 3 times per week, 24-session at home online movement exercise program on balance, physical activity, self-efficacy, and resilience in community-based adults and older adults. Background: Balance impairment is a commonly reported consequence of the aging process. It may lead to falls, serious injuries, and physical activity avoidance. Moreover, these sequelae may worsen when balance impairments work in concert with the psychological factors of decreased self-efficacy and resilience. Fortunately, existing evidence supports the use of movement training programs to improve balance in older adults. However, there are no known studies that examine the impact of a dual-task online movement training program on balance, physical activity, self-efficacy, and resilience and associations among these factors in community-based independent living older adults. Several critical relationships have been identified among balance, physical activity, self-efficacy, and resilience, which affect balance and physical activity after motor training that warrant further exploration. Methods: Participants between the ages of 55-80 years of age were recruited from the Washington, D.C. metro area, including senior independent living facilities. Eligible participants were asked to complete a total of 24 30-minute training sessions, 2-3 times per week. Outcome Measures: Participants completed pre- and post-test measures of static balance using the 4-stage balance test, physical activity using the International Physical Activity Questionnaire (IPAQ), self-efficacy using the confidence scale of the OPTIMAL instrument (OPTIMAL) and Activities-Specific Balance Confidence Scale (ABC), and resilience using the Connor-Davidson Resilience Scale (CD-RISC). Data Analysis: Statistical analysis was completed using STATA/BE version 17.0 and Microsoft Excel. Comparison of means pre- and post-training was performed using a paired t-test with a significance level of p≤0.05 to determine if there was significant improvement in balance, physical activity, self-efficacy, and resilience. Wilcoxon signedrank tests were used for comparisons of non-parametric data. Effect sizes were also calculated. Additionally, Pearson’s correlations were used to determine the extent to which self-efficacy and resilience were associated with balance and physical activity before and after training. Results: Significant differences between baseline and final measures were found for tandem stance, single leg stance (SLS), and CD-RISC. Moderate effect sizes were found for both tandem and single leg stance measures. Additionally, moderate correlations were found between baseline SLS and IPAQ measures, final ABC and SLS measures, final OPTIMAL and SLS measures, final CD-RISC and IPAQ measures, and final SLS and IPAQ measures. Strength of correlations increased between baseline and final measures for ABC and SLS, OPTIMAL and tandem stance, OPTIMAL and SLS, OPTIMAL and IPAQ, CD-RISC and tandem, CD-RISC and SLS, and CD-RISC and IPAQ. Conclusion: Based on effect sizes, this study provides preliminary support for the efficacy of an at home online movement training program to make modest improvements in balance and physical activity, and small improvements in self-efficacy and resilience. Correlations among some aspects of balance, physical activity, self-efficacy, and resilience before and after training were also evident.
The Effects of an Online Movement and Cognitive Dual Task Training Program for Community-Based Adults and Older Adults on Executive Function: A Pilot Study
(2022) Elsarafy, Lobna; Guccione, Andrew A
Objective: To examine the effects of a 30-minute, 3x/week, 24-session at home online movement and cognitive exercise program on executive function in community-based adults and older adults. Background: Cognitive performance is known to decline over time. Essential for functional independence through the aging process, cognitive performance can determine whether an individual has the ability to live independently, drive safely, and manage medications and finances. There is a growing body of evidence supporting the use of dual movement and cognitive interventions to improve executive function in the aging population. No known studies have examined the impact of an online dual movement and cognitive training program on attention, visual and auditory spatial working memory and processing speed; three essential contributors to executive function. Methods: This was a prospective pre-experimental pilot study. Participants were recruited from the greater Washington, D.C area, including those who reside in independent living facilities. Twenty-two individuals consented (age: 75.95±3.55; gender: 17F/5M) and completed the Brain and Balance (BAB) program which consisted of 24-online training sessions, spanning approximates 30 minutes each, 2-3 times per week. Outcome Measures: Administered via videoconference, baseline and post intervention measures of cognitive performance included the Deary-Liewald simple (RTS) and choice (RTC) reaction time task, the forward (DS-f) and backwards Digit Span (DS-bk), Letter Number Sequencing (LNS) and the spatial addition (SA) subset of the Wechsler Memory Scale-IV. Data Analysis: Statistical analysis was completed using STATA IC version 16 and Microsoft Excel. Normality was visually confirmed with histogram graphs. A comparison of means pre and post training was completed using a paired t-test with a significance set at level of p≤0.05. Scatter plots were used to depict individual baseline and post treatment scores for each outcome measure, the difference in scores and mean difference (meandiff). Cohen’s d unbiased was used to calculate effect size. Results: Following BAB, improvements in RTS (meandiff = -10.95ms), RTC (meandiff= -37.50ms), DS-f (meandiff = 0.54), DS-bk (meandiff = 0.57), LNS (meandiff = 0.62) were observed. Small effects were observed for DS-f (Cohen’s d (unbiased) = 0.201), DS-bk (Cohen’s d (unbiased)= 0.236), LNS (Cohen’s d (unbiased)= 0.206). RTS and RTC were treated as non-parametric data, there was a small effect for RTC with r=0.210, however RTS effect was unremarkable at r= 0.053. SA data were grouped by baseline performance (low performers ≤ 10, high performers >10). Following BAB, improvements in low performers (meandiff = 0.60) and small effect (Cohen’s d (unbiased) = 0.27) were observed. However, baseline high performers in SA task showed a moderate decline post treatment, likely attributed to a possible regression towards the mean. Conclusion: Participants trended towards improvement in cognitive performance following an online simultaneous movement and cognitive training program. Further research is necessary to determine magnitude of change and functional implications associated with dual movement and cognitive training in this population.
Substance Use Disorders and Mental Health Illnesses Among U.S. Veterans: A Multi-Method Study Using Quantitative and Qualitative Research Methods
(2022) Betancourt, Christian; Kitsantas, Panagiota
This manuscript-style dissertation presents three studies highlighting some of the biggest challenges that U.S. veterans face after leaving the military, and explores trends related to their challenges. The most pervasive types of veteran’s health care treatment needs are for substance use disorders (SUD), suicidal behaviors (ideation, plan, attempt), and depression. Research evidence shows that among veterans who used the Veterans Health Administration (VHA) health care system, nearly half were diagnosed with at least one SUD. A study on military personnel found that approximately 30% of suicide attempts that resulted in death were preceded by substance use. Veterans who have experienced SUDs and homelessness also have a greater likelihood of struggling with depression and suicidal behaviors. The purpose of the first two studies were (1) to examine risk factors that contribute to SUD relapse upon completion of SUD treatment, (2) to estimate the prevalence of suicidal behaviors and prescription opioid misuse among veterans, and (3) to identify associations between suicidal behaviors and misuse of prescription opioids as well as other sociodemographic and behavioral determinants of health using data from large nationally representative datasets that are not affiliated with the VHA system. The third study used semi-structured interviews to conduct a phenomenological study in exploring the perspectives of homeless veterans living with SUDs and assess how social ecological factors impact their recovery. This multi-method study provides a robust analysis of the veteran population using nationally representative data and veterans’lived experiences through collection of data from semi-structured interviews. All three studies used non-VHA data, thus, producing an alternate assessment of all veterans, not just those who receive care from the VHA. The first study found that approximately 94% of veterans relapsed upon discharge from outpatient or residential SUD treatment. It also showed that veterans with homelessness, unemployment, or arrests upon discharge had a higher likelihood of relapse after SUD treatment completion. The second study revealed that approximately 3.7% of veterans experienced suicidal behaviors and nearly 3.0% reported prescription opioid misuse. This study also determined that 16.3% of veterans who misused prescription opioids also demonstrated suicidal behaviors; these results showed a much higher prevalence of suicidal behaviors than those with prescription opioid use without misuse (4.8%) and those with no prescription opioid use (2.5%) in the last year. The third study established that veteran homelessness and substance use are strongly associated with trauma suffered while on active duty and personal adverse life events. These experiences varied from grieving the death of a family member to being the victims of physical and sexual assault. Our findings suggest that a more focused approach to address substance use and mental health illness, along with permanent housing must be placed on veterans who recently separate from the military.
Three Essays on Antipoverty Programs and Reductions in Child Maltreatment
(2022) McCray, Neil; Anand, Priyanka
Millions of children are reported maltreated in the United States each year. In addition to the costs imposed on victims, maltreatment also imposes costs on society at large, including short and long-term medical care, reductions in education and workforce productivity, and increased criminality, among other costs. Finding ways to reduce maltreatment risk is a critical concern of public policy. Because poverty is a primary risk factor for child maltreatment risk, researchers have considered whether antipoverty programs might reduce child maltreatment. This dissertation consists of three papers discussing and assessing the effects of antipoverty programs on child maltreatment. The first paper discusses theories that explain the relationship between poverty and child maltreatment generally – primarily family stress and family investment models – and then considers literature on the relationship between child maltreatment and several antipoverty programs and policies including the Earned Income Tax Credit, the Supplemental Nutrition Assistance Program (SNAP), Medicaid, Temporary Assistance for Needy Families (and its predecessor, Aid to Families with Dependent Children), and the minimum wage. Findings from the literature suggest strong theoretical reasons to expect that antipoverty programs should reduce maltreatment risk, that there are correlations between antipoverty program increases and reductions in child maltreatment, and some more recent causal studies demonstrate policies can reduce maltreatment risk. The second and third papers each consider a different antipoverty program (Medicaid and SNAP, respectively) and use variation in policy decisions at the state-level to assess effects on child maltreatment outcomes. Paper two considers Medicaid’s effects on child maltreatment. First, the paper discusses why Medicaid might reduce maltreatment risk, both via the proposed theoretical models relating to socioeconomic status and via changes in health care utilization for both adults and children. Because the Patient Protection and Affordable Care Act’s (ACA) Medicaid expansions, which were originally mandatory, were rendered optional by the U.S. Supreme Court’s decision in National Federation of Independent Business v. Sebelius, state selection to expand or not expand Medicaid functions as a sort of natural quasi-experiment. This paper exploits variations in state selections to expand or not expand Medicaid to identify the causal effect of Medicaid expansion on child maltreatment outcomes. Prior to the ACA, a number of states had state-funded programs expanding Medicaid similar to ACA Medicaid expansions. Some states also chose to expand Medicaid early or to partially expand their programs. Due to these and other variations, precisely defining which policy changes constitute “Medicaid expansion” can be complicated; this paper considers several different definitions of expansion to examine whether inclusion or exclusion of some states affects results. The paper finds that January 2014 Medicaid expansions led to reductions in child neglect, but the robustness of that result is sensitive to which states are included in the sample in terms of when they expanded and the generosity of their prior Medicaid coverage. The third paper considers the relationship between SNAP and child maltreatment. The paper first considers theoretical reasons why SNAP might affect child maltreatment risk, including family stress and family investment models, and then considers additional factors relating specifically to food insecurity. Then the paper turns to empirically assessing whether SNAP leads to reductions in child maltreatment. It exploits variation in state decisions regarding broad-based categorical eligibility (BBCE) in SNAP, a policy which increases the number of people eligible for SNAP and can also simplify application processes. State selection of BBCE leads to reductions in neglect and sexual abuse, and some findings indicate BBCE may also reduce physical abuse and medical neglect, though those findings are sensitive to model specification. This dissertation discusses several theoretical reasons why antipoverty programs should reduce maltreatment risk, assesses literature on several programs, and empirically assesses the causal effect of two programs – Medicaid and SNAP – on child maltreatment outcomes. Findings suggest Medicaid expansions may reduce neglect, though the results are sensitive to how Medicaid expansion is defined, and that SNAP broad-based categorical eligibility reduces neglect and sexual abuse. Results support the proposed theoretical models and more generally support the idea that antipoverty policies and programs may reduce child maltreatment.
Investigation of the Correlation between Screen Time, Social Media Status, and BMI Status among Mason College Students
Alsayegh, Abdulrahman; Alsayegh, Abdulrahman; Batheja, Sapna
People's lives have become increasingly reliant on technology, especially with the emergence of social media. Research has shown that high technology usage has a detrimental impact on health and is linked to rising rates of overweight individuals and obesity worldwide (Chau et al., 2014; Liu et al., 2021; Melton et al., 2014). There is a surge in the number of college students who use technology. Previous research examined the effect of technology on BMI in children and adolescents (Alotaibi et al., 2020; Rosen et al., 2014; Shen et al., 2021), but to date, there has been limited research conducted on young adults ages between 18 -24. Increased technology usage is one of the main culprits that lead to poor dietary choices and sedentary lifestyles, both of which have been linked to an increase in BMI (Chau et al., 2014; Liu et al., 2021; Melton et al., 2014). This study aims to examine the relationship between screen time usage and an increase in body mass index (BMI) among George Mason University college students. The data was abstracted from the Health Starts Here Study and included 131 first year students from George Mason University. Technology usage, BMI, diet, physical activity, and sleep were obtained through various questionnaires and anthropometric measurements. These variables were analyzed using different statistical tests: Person's correlation, independent t-tests, and stepwise regression analysis. The results showed that there is a non-significant correlation between using social media, BMI, and dietary choices. Person's correlation result revealed that the correlation between social media and BMI was r (129) =.072 p=.416 while the correlation between BMI and diet was r (129) =.09 p=.30. T-test result showed on average low-tech usages (M#.24, SD=5.09) had lower BMI scores than high-tech usage (M$.71, SD=6.81). This study concludes that the amount of time of using social media has no impact on increasing BMI.
Measuring Food Preparation Equipment in the Home: Developing and Field Testing an Instrument for Use in a Pediatric Obesity Intervention
Kogan, Kelly; Kogan, Kelly; LaCharite, Kerri
Background: Hispanic children are disproportionately affected by obesity in the United States. Interventions targeting the home food environment of obese Hispanic children may contribute to reductions in obesity in both the short term and the long term. One component of the home food environment that has not been studied is food preparation equipment present in the homes of obese Hispanic children. Objectives: To develop and field test an instrument for the collection of data about food preparation equipment present in the homes of obese children of Spanish-speaking Central American immigrants living in the Woodbridge area of Northern Virginia. Method: A multi-stage process was used to develop and field test the instrument: A literature review was conducted to identify any existing instruments that could be used to collect data on the home food preparation equipment of the target population. Since no appropriate instrument was identified from this review, an instrument in the form of a checklist was developed. Face validity of the checklist was assessed using a review by a native Spanish speaker with experience working with the target population. Content validity of the checklist was assessed through its use in field tests that occurred in the homes of two members of the target population. Both quantitative and qualitative data were collected from these reviews and analyzed using descriptive statistics and NVivo software. Results: Face validity assessment revealed the need to include a photographic image of each item next to it on the checklist. With two limited exceptions, the checklist demonstrated good content validity. Descriptive analysis of the data collected with the checklist showed that the homes of both persons participating in the field testing were adequately stocked with the minimum number of items needed to store and prepare foods for home consumption. Qualitative analysis showed that both of these individuals regularly prepared balanced, healthy meals for their families. Both also showed interest in food and the process of cooking, although convenience was an important consideration. The reliance by one individual on the use of social media to obtain information about food and cooking skills suggests that efforts to promote home cooking as part of a family- and home-based obesity intervention must take these new ways of transmitting information into account. Overall, the checklist achieved the purpose for which it was developed. Field testing also suggested that the checklist was adaptable and could be used other populations of interest with some modification as appropriate to reflect their unique foodways.
The Influence of an Overground Locomotor Training Program on Walking Gait Propulsive Force in Ambulatory Patients with Parkinson’s Disease
(2022) Corfman, Thomas A; Corfman, Thomas A; Guccione, Andrew
OBJECTIVE: To determine the effect of a 12-week overground locomotor training (OLT) program on the anterior-posterior (A-P) ground reaction force in ambulatory subjects with mild to moderate Parkinson’s disease (PD).DESIGN: This is a pre- and post-test design interventional study. SETTING: The study was conducted at the university gait analysis laboratory. METHODS: Participants performed a propulsive force testing procedure before and after the OLT program. PARTICIPANTS: Eleven adults with mild to moderate PD (Hoehn & Yahr stage 1-3, ambulatory). INTERVENTIONS: The intervention was a 12-week OLT program. MAIN OUTCOME MEASURES: Gait parameters: peak anterior ground reaction force (AGRF), rate of rise (ROR) of AGRF, push-off impulse, push-off duration, peak posterior ground reaction force (PGRF), single stance duration, center of mass (COM) to center of pressure (COP) distance at push-off, and walking speed. RESULTS: Paired t-tests indicated significant differences in the ROR between pre and post OLT, the push-off impulse pre OLT and post OLT, and the preferred walking speed pre and post OLT. In addition, a Wilcoxon signed-rank test indicated significant differences in the push-off duration between pre and post OLT, and the single stance duration pre and post OLT. No significant differences were observed in peak AGRF and PGRF between pre and post OLT, and in the COM-COP distance between pre and post OLT. DISCUSSION: Taken together, our results suggest the OLT program was able to improve walking postural and dynamic stability in patients with PD. PD patients were able to spend less time in stance phase, less time in push-off duration, and decrease the rise time of the AGRF (push-off rate increased). This appears to have led to a quicker, more powerful AGRF without changes in peak PGRF, peak AGRF, or push-off posture, and an increase in walking speed in our patients with PD.
A Study of Administrative Data Representation for Machine Learning
(2022) Asadzadehzanjani, Negin; Asadzadehzanjani, Negin; Wojtusiak, Janusz
Administrative data, including medical claims, are frequently used to train machine learning-based models used for predicting patient outcomes. Despite many efforts in using administrative codes (medical codes) in claims data, little systematic work has been done in understanding how the codes in such data should be represented before model construction. Traditionally, the presence/absence of these codes representing diagnoses or procedures (Binary Representation) over a fixed period (typically one year) is used. More recently, some studies included temporal information into data representation, such as counting, calculating time from diagnosis, and using multiple time windows. However, these methods were not able to comprehensively capture temporal information in data and much of temporal information such as the exact time of the occurrence of an event, and the exact sequence of an event are missed. This dissertation presents the results of development and investigation of two additional methods of administrative data representation (Temporal Min-Max and Trajectory Representation) specific to diagnoses extracted from claims data before applying machine learning algorithms. It then presents a large-scale experimental evaluation of these methods by comparing them with traditional Binary Representation using four classification problems: one-year mortality prediction and high utilization of medical services prediction, prediction of chronic kidney disease and prediction of congestive heart failure. It was shown that the optimal way of representing the data is problem-dependent, thus optimization of representation parameters is required as part of the modeling.
The Effects of Performance-Based Overground Locomotor Training on Walking Turns Among Individuals with Parkinson’s Disease
(2022) Pugh, Randy Jamil; Pugh, Randy Jamil; Guccione, Andrew A; Higgins, Rosemary D
PURPOSE: Individuals with Parkinson's disease (PD), a progressive neurodegenerative disorder, exhibit compromised postural stability along with impaired gait and balance, contributing to walking limitations, including difficulty performing turns while walking. Previous studies demonstrated that individuals with neurological impairment improve walking capacity following performance-based overground locomotor training (OLT), but the effect of OLT on turning remains unknown. This study aimed to understand the effect of twenty-four sessions of OLT on walking turns among individuals with mild- PD.METHODS: Twelve participants with PD (7 Male / 5 Female; Age: 68.5±6.4 years; H&Y: 1-3) completed twenty-four 60-minute sessions of OLT, twice-weekly. Pre- and Post-assessments included the ten-minute walk test (10MWT) with the primary outcome measures including thoracolumbar rotation change in the vertical axis and peak turn velocity change in frontal (PTVF) and transverse (PTVT) planes. xii RESULTS: Mean thoracolumbar rotation change was not significant following OLT (+0.23 ± 4.24°;95% CI: -4.30, 3.84; p= 0.454;Cohen’s d = 0.05). Mean normalized thoracolumbar rotation change was also not significant (- 0.59 ± 5.52 (unitless);CI:[-12.05, 10.73]; Cohen’s d = 0.10)p = 0.45; Cohen’s d = 0.05). Mean PTVF showed a moderate and significant increase following OLT (1.59 ± 2.18 °/s; 95%CI: 0.20, 2.98; p = 0.014; Cohen’s d = 0.43). The effect of OLT on mean PTVT was small and not significant (0.88 ± 3.18 °/s; 95%CI: -2.90, 1.14; p = 0.179; Cohen’s d = 0.25). CONCLUSION: This study provides preliminary evidence suggesting individuals with mild-PD moderately improved frontal plane dynamic postural stability during walking turns following performance-based overground locomotor training.

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