Undocumented immigrants represent 27 percent of the uninsured population in the U.S. This study involved conducting a literature search in scientific, social, and law databases to evaluate current policy on healthcare for undocumented immigrants. The analysis focused on coverage for preventive, dialysis, pediatric, obstetrics, and emergency services. 

Findings: 

• Most states only offer emergency Medicaid and free services.
• Some state policies focused on increasing access to preventive, pediatric, and obstetrics services. Some state policies extended coverage to scheduled dialysis. 
• Findings support expanding Medicaid coverage for scheduled dialysis, pediatric services, and obstetric services. Maintenance dialysis costs are estimated to be four times lower if some of these preventive services are implemented. 

Individuals diagnosed with a severe mental illness (SMI) such as schizophrenia, bipolar disorder, or major depressive disorder are two to three times more likely to develop diabetes. Research indicates that 60 percent of Medicare beneficiaries (over 65) have at least three physical and mental health diagnoses, and about half have one or more diagnosed mental health conditions. This project evaluated rates of comprehensive diabetes care quality measures for beneficiaries with and without a co-occurring SMI diagnosis to identify possible disparities in care between these groups throughout the United States. 

Findings:

• Rates in receipt of two major recommended tests for ongoing diabetes monitoring (A1c testing and lipids testing) are suboptimal across the U.S.
  • The average rate of annual A1c testing was 60 percent. 
  • The lipids testing was as low as 50 percent.
• Ratios suggest overall comparable performance between both groups.
  • Increased interaction with the healthcare system among those with a comorbid SMI may contribute largely to this finding.
  • However, maps show ratios as low as .58 suggesting 42 percent of SMI beneficiaries with Type II Diabetes Mellitus compared to those with Type II Diabetes Mellitus in the region who are not getting preventive screening.

Injuries to the upper part of the humerus bone in the shoulder are the third most common non-vertebral fragility fracture in patients over the age of 65. Referred to as proximal humerus fractures, surgery is often required to treat the injury, and opioid medication may be prescribed for pain management. However, there is minimal data on opioid use after geriatric fractures. The purpose of this study was to determine whether there were any differences in opioid use among Medicare beneficiaries who underwent one of the surgical procedures used to manage these fractures — open reduction and internal fixation (ORIF), hemiarthroplasty (HA), or reverse total shoulder arthroplasty (RTSA). 

Findings:

• Despite multiple studies showing that reverse total shoulder arthroplasty (RTSA) has superior pain control (improved pain scores) compared to hemiarthroplasty (HA) and open reduction and internal fixation (ORIF) for the treatment of geriatric proximal humerus fractures, this study demonstrated that patients who underwent RTSA had higher opioid use at both 0-6- and 0-12-month time periods. 
• Further studies are necessary to determine the underlying reason(s) for differences in opioid use among the various surgical options used to treat these fractures.  

The United States faces a severe shortage of primary care physicians in many rural and disadvantaged urban communities. Research has shown that one of the strongest predictors of where a physician chooses to practice is where they complete their training. The Teaching Health Center Graduate Medical Education (THCGME) program was established in 2010 to address this challenge. THCGME residents are trained at ambulatory sites often within medically underserved rural/urban communities (MUCs). Today, there are 57 Teaching Health Centers (THCs) across the country training over 700 residents in crucial primary care fields. This capstone project used a mixed-methods research approach to evaluate the effectiveness of the THCGME program. 

Findings:

• THC graduates are more than twice as likely to practice in MUCs than residents trained in traditional graduate medical education programs. 
• THC residents come from diverse, often disadvantaged backgrounds and are being trained to practice primary care within a 21st century context, with quality improvement, EMR use, community medicine, rural health training, and value-based care delivery models incorporated in their training. 
• However, much of the potential progress has been stifled due to underfunding since 2015. This funding reduction, along with continual uncertainty about renewal, has led to significant reductions in resident recruitment and even THC closures. In order for THCs to effectively meet primary care needs, a more permanent funding source is necessary. 

Tears in the rotator cuff, a group of tendons that assist with shoulder motion, are common. Approximately 20 percent of patients with tears ultimately undergo surgical repair. In the 1990s, a minimally invasive procedure called arthroscopic rotator cuff repair was developed to treat the injury. The procedure quickly became widespread, and the number of arthroscopic procedures increased dramatically in the past two decades.  The objective of this study was to map the spread of arthroscopic rotator cuff repair in the United States and to determine regional characteristics that were associated with adoption of this technology. The project adapted Dartmouth Atlas methodology to evaluate the spread of new technology. 

Findings:

• Regions that spent more on healthcare also demonstrated higher rates of adoption, consistent with previous research highlighting that technologic innovation is a driver of healthcare costs. While high regional healthcare spending is often regarded negatively, those areas that spend more may be prone to adopt new technology earlier. 
• Regions with academic medical centers were associated with a lower adoption rate in 2006, and suggests a possible outside-inside-outward model of diffusion of innovation within the field of orthopedic surgery.

The human papillomavirus (HPV) vaccine was approved in 2006 as a preventative measure against HPV infection and HPV attributable cancers. The vaccine is currently recommended for boys and girls aged 11-12. Despite the recommendation, HPV vaccination rates are far below the vaccination rates for other recommended vaccines for the same age group (HPV - 43 percent, Tdap - 88 percent, meningococcal - 82 percent). A commonly reported barrier to vaccination is the lack of a strong recommendation for the vaccine from healthcare providers. 

This intervention is designed for Nemours Pediatrics, a pediatric health system that has five pediatric outpatient clinics in Wilmington, Delaware. The intervention is designed to help improve Nemours’ vaccination rate of 34 percent.

This proposal has four major categories for implementation: 

• First, to prepare for the full intervention, standing orders for non-vaccinated eligible patients will be created, physicians will attend education and communication training sessions, and a text message reminder service will be purchased. 
• Physicians will utilize the communication strategies taught in the training session and encourage same-day vaccination. 
• Receptionists at the clinics will implement rigorous follow-up procedures including calls and text messages sent to patients reminding them of scheduled appointments for completing the series. 
• The HPV vaccination champion will track and report results using statistical process control charts.

Nearly 70 percent of Native Americans have moved off of tribal reservations, with the majority choosing to live in urban areas. However, government programs designed to supply healthcare to Native Americans remain tied to facilities physically located on reservations. At the same time, striking health disparities exist between the Native American and non-Native American population in the U.S. For example, it is estimated that Native Americans are 520 percent more likely to die from alcohol-related deaths, and are 177 percent more likely to die from diabetes complications. 

Limited research has been done to determine the most effective ways to run a clinic in an urban area serving Native Americans. Urban Indian Health Programs are a more recent (1976) extension of the Indian Health Service, designed to supply culturally competent care to Native Americans living in urban areas; however, these clinics are limited in funding and resources, resulting in varying strategies to meet operational margins. 

This research proposal is designed to utilize qualitative research techniques to explore the strategies employed by the 34 Urban Indian Health Programs to meet their financial obligations while providing culturally competent care. Results can then be used to help establish better policies to support Urban Indian Health Programs. Additionally, knowledge gained from understanding these clinics can be applied to clinics that support various underserved populations. 
 

Research has shown that implicit biases against race, age, sex or socioeconomic status contribute to some of the healthcare disparities we see in the United States. These disparities can manifest in treatment options, medication or admission decisions, or services provided. This research proposal is for a review of four urban hospitals in Massachusetts to uncover potential disparities in ethics consultations in the Intensive Care Unit (ICU).

Ethics consultations are an important service for conflict resolutions, especially for patients in critical need in the ICU. Research has shown that the patient for whom an ICU ethics consultation is most commonly requested is white, male, and between the ages of 50-69. There is currently no research that specifically and extensively explores whether there are disparities in the ICU that would account for this finding.

This research proposal has three specific aims:

1. To identify which patient characteristics, if any, are associated with disparities in ethics consultations requested for ICU patients.
2. To identify whether certain ethical conflicts occur more often among patients of a certain race or socioeconomic status.
3. To identify whether disparities based on race or socioeconomic status exist in the period of time taken to request an ethics consultation after identification of an ethical conflict.

Alameda County, California, is one of the most diverse regions in the United States. As of 2016, approximately half the population belonged to one or more minority groups. The overall teenage pregnancy rate in Alameda County is 21.6 per 1,000 females aged 15-19. Teenage birth rates for African-American and Hispanic adolescent mothers are six times those of their white counterparts.

This intervention is designed to help Federally Qualified Health Centers (FQHC) in the area increase same day contraceptive availability and consultation rates. A series of focus group sessions will be used to identify key community resources and institutions. These resources and institutions will then be utilized to determine the optimal locations and avenues to communicate educational and advertising messaging. Trained staff from the Alameda County Public Health Department will go into the community to both market FQHC services and introduce basic sexual health concepts to adolescents aged 15-19. An electronic health record (EHR) prompt will be developed and implemented to remind physicians to engage in a contraceptive consultation with eligible clients.