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Veteran enrollment in Medicare Advantage: analyses of favorable selection, plan marketing, and utilization
No full text2026Dual enrollment between the Veterans Health Administration (VHA) and Medicare Advantage (MA), the private alternative to Traditional Medicare (TM), poses a unique budgetary issue for the federal government. While the VHA operates under a global budgeting system, the Centers for Medicare and Medicaid Services (CMS) prospectively pays MA plans a risk adjusted capitation rate that does not account for enrollees' VHA utilization. Consequently, MA plans are still paid for enrollees who use VHA care, even if they use no MA services. This effectively creates a duplicate spending problem for the federal government and a financial incentive for plans to enroll VHA-reliant Veterans. Over the last decade, the VHA has spent over $78 billion for dual MA-VHA enrollees. With 1.3 million dual MA-VHA enrollees, there are concerns that duplicate federal spending has increased alongside the growth of MA and with the emergence of novel Veteran Medicare Advantage Affinity Plans (VMAPs) marketing to the Veteran population. However, this topic has been underexplored in recent years. In this dissertation, I use CMS MA plan directory files, VHA administrative claims and encounters, and MA encounter data to examine dual MA-VHA enrollment, plans' benefit design, and enrollees' VHA utilization between 2016 and 2022. Aim 1 examines who MA enrolls from VHA population compared to TM, identifying potential factors for favorable selection that are unobservable in the CMS risk adjustment model from 2016-2019. Aim 2 examines what benefits MA plans offer to Veteran enrollees, focusing on the novel VMAPs marketing to Veterans in 2022. Finally, Aim 3 leverages changes in MA plans' marketing and benefit design to analyze the effect of VMAP rebranding on VHA reliance (use of VHA care), compared to other MA plans, using a difference-in-difference design between 2019-2022. Collectively, this dissertation highlights the mechanisms for selection of VHA-reliant enrollees into MA. These results can provide CMS and VHA leadership with a deeper understanding of MA-VHA enrollment and can be used to help support legislative changes and payment reform options that address this duplicate spending problem.2028-01-16T00:00:00
Mental health and resilience following violent incidents in Nigeria (MaRVIN)
No full text2026BACKGROUND: Nigeria's protracted conflicts—including Boko Haram insurgency, farmer-herder violence, banditry, separatist conflicts, and resource-related violence—have exposed millions of persons to trauma, displacement, and economic devastation. Despite evidence suggesting extremely high mental health burden in conflict-affected populations globally, no validated mental health screening instruments existed for Nigerian conflict contexts, and no nationally representative data documented PTSD, depression, and anxiety prevalence or access to mental health services across Nigeria's diverse conflict zones. This critical gap in both measurement tools and epidemiological evidence prevented evidence-based mental health policy development and humanitarian program planning. OBJECTIVES: This three-manuscript dissertation aimed to: (1) culturally adapt and validate the PCL-5, PHQ-9, and GAD-7 for use in violence-affected Nigerian populations; (2) estimate weighted prevalence of probable PTSD, depression, and anxiety and identify key predictors across five conflict-affected states; and (3) examine the interaction between cumulative trauma exposure and daily stressors in predicting mental health outcomes, testing whether traditional cumulative stress models remain valid at extreme trauma exposure levels. Methods: The MaRVIN project employed a two-phase design. Phase 1 (validation study) enrolled 205 adults from Abuja IDP camps for psychometric evaluation including expert review (n=3 psychiatrists), cognitive interviewing (n=30), reliability analysis, factor analysis, and criterion validity assessment against CAPS-5 and MINI clinical interviews. Phase 2 (population survey) implemented multistage cluster sampling across five states representing five of Nigeria's six geopolitical zones (Benue, Borno, Enugu, Rivers, Sokoto), enrolling 1,371 adults. Data collection employed 60 trained field epidemiologists using ODK mobile data capture. Analysis used survey-weighted methods accounting for complex sampling design, with modified Poisson regression estimating prevalence ratios for predictors. RESULTS: In Phase 1, internal consistency coefficients were PCL-5 α=0.915, PHQ-9 α=0.906, and GAD-7 α=0.864. ROC analyses identified cut-points PCL-5≥38 (AUC=0.706), PHQ-9≥10 (AUC=0.697), and GAD-7≥8 (AUC=0.576). Exploratory factor analysis of the PCL-5 yielded four factors explaining 57.1% of variance: intrusion, a novel behavioral-cognitive cluster, avoidance, and hyperarousal. In Phase 2, weighted prevalence estimates were PTSD 20.8% (95% CI: 18.4–23.2), depression 23.2% (20.6–25.7), and anxiety 24.3% (21.6–26.9); 40% met criteria for two or more conditions. Persons in the poorest wealth quintile had PTSD prevalence ratio 2.08 (95% CI: 1.26–3.42) versus the wealthiest quintile. Widowed persons had depression prevalence ratio 2.00 (95% CI: 1.16–3.40) versus never-married persons. Each additional daily socioeconomic stressor was associated with a 3–4% increase in prevalence of all three conditions. Interaction models indicated variation in the association between daily stressors and mental health outcomes across trauma strata, with weaker marginal effects of additional stressors among respondents with the highest trauma exposure. SIGNIFICANCE: This dissertation provides validated mental health screening instruments for conflict-affected Nigerian populations and multi-state mental health prevalence estimates across diverse conflict zones. It also contributes to global PTSD research by identifying a unique symptom dimension that may reflect culturally specific trauma responses. Findings from Study 2 indicate that about one in four conflict-affected Nigerian adults meets criteria for clinically significant symptoms, with high comorbidity and clear socioeconomic gradients. The work shows that poverty and ongoing daily stressors function as key determinants of mental health outcomes, suggesting that livelihood and social protection programs can be conceptualized as mental health interventions. High comorbidity (40% with ≥2 conditions) supports integrated, transdiagnostic mental health services rather than disorder-specific vertical programs. Geographic heterogeneity in prevalence (PTSD ranging 7.7% to 29.2% across states) indicates that conflict-related mental health burden cannot be inferred from national averages and that state-level data should guide resource allocation. The validated instruments enable systematic mental health monitoring in humanitarian programs and primary care and address a measurement gap for evidence-based mental health system development in Nigerian conflict settings. Interaction analyses indicate a saturation effect at higher trauma levels, with smaller marginal effects of additional daily stressors among respondents with the highest trauma exposure. This pattern suggests that interventions targeting daily stressors may have larger marginal impact among persons with low to moderate trauma exposure, whereas persons with very high trauma exposure may require strategies that more directly address trauma-related mechanisms.This applied public health research directly informs: (1) Nigeria's National Mental Health Act 2021 and the National Mental Health Policy 2023 and their implementation by providing evidence population needs; (2) humanitarian mental health program design through validated screening tools and prevalence benchmarks; (3) task-sharing intervention development by establishing that non-specialist health workers can implement validated screening; and (4) mental health policy advocacy through robust population-based evidence demonstrating that mental health burden in Nigerian communities affected by conflict is comparable to that documented in other humanitarian emergencies globally. The research exemplifies DrPH training's emphasis on translational science—producing not only publications but actionable tools and evidence that strengthen health systems and inform policy decisions for vulnerable populations.2028-01-20T00:00:00
Optical voltage imaging and nonviral gene delivery for mechanistic investigation of Parkinson’s disease
Full text link2026Parkinson’s disease (PD) is the most prevalent neurodegenerative movement disorder characterized by the loss of midbrain dopaminergic neurons that project to the striatum. The striatum, a key basal ganglia region associated with movement, has been broadly implicated in PD. However, it remains unclear how striatal neural dynamics regulate voluntary movement and how their disruption contributes to motor pathology in PD. In this dissertation, we performed cell type–specific voltage imaging to investigate circuit-level neural dysfunction in PD and develop a nonviral gene delivery platform that expands the capacity for long-lasting transgene expression in the mammalian brain.In Chapter 2, we selectively expressed the genetically encoded voltage indicator SomArchon in cholinergic interneurons (ChIs) using ChAT-Cre mice to probe the impact of dopamine (DA) loss on ChI cellular dynamics in vivo. Leveraging our lab’s expertise as a leader in voltage imaging, we were able to perform high-resolution recordings of ChI neural activity. We also infused 6-hydroxydopamine (6-OHDA) unilaterally into the mouse striatum to induce DA loss. Although comprising only ~1-2% of striatal neurons, ChIs play a critical role in modulating both the direct and indirect pathways. Using optical voltage imaging, we identified that dopamine depletion exaggerates ChI burst firing, which is crucial for shaping striatal excitability. Additionally, dopamine loss impaired ChI encoding of locomotion, indicating that aberrant patterning of ChI firing contributes to degraded movement signaling in PD. Together, these results provide new mechanistic insight into how striatal interneuron function is altered in dopamine-depleted states and enhance our understanding of striatal circuit-level pathology in PD.
In Chapter 3, we developed a nonviral gene delivery method that targets brain cells, providing a novel tool to modulate the circuits we studied in Chapter 1. We screened lipid nanoparticle (LNP) formulations loaded with modified self-amplifying RNA (saRNA) containing cytidine substitution 5-hydroxymethylcytidine (hm5C), known to reduce innate immune responses. When injected into the striatum of mice, modified saRNA encapsulated in an LNP formulation comprising ALC-0315 (present in Comirnaty®; COVID-19 vaccine by BioNtech/Pfizer) efficiently mediates robust and long-lasting protein expression in brain cells beyond five weeks, with detectable expression in some neurons at three months. hm5C saRNA substantially outperforms N1-methyl-pseudouridine (N1mΨ) mRNA, a modified mRNA used in some COVID-19 vaccines. Intriguingly, in addition to transfecting astrocytes and neurons at the injection site, saRNA-LNPs labels neurons retrogradely. Thus, saRNA-LNPs are a promising nonviral gene transduction method that effectively transduces brain cells with excellent potency and mediates prolonged gene expression.
Together, this dissertation combines mechanistic investigation of striatal circuit dysfunction with the development of a molecular tool towards studying this circuitry. Chapter 2 establishes a powerful optical platform for precision analysis of ChI neural dynamics in motor impairment in PD, while Chapter 3 introduces a gene delivery platform that demonstrates capabilities for long-term gene expression and neuromodulation of striatal circuits in PD. This conceptual framework advances our understanding of PD and provides a foundation for future mechanistic and translational studies
Mechanisms of innate immune activation by human immunodeficiency virus type 1
Full text link2026Human immunodeficiency virus type 1 (HIV-1), the causative agent of acquired immunodeficiency syndrome (AIDS), has claimed tens of millions of lives since the emergence of the global HIV-1 pandemic in the 1980s. Chronic HIV-1 infection leads to gradual loss of CD4+ T cells in most people with HIV (PWH), ultimately leading to profound immune collapse known as AIDS and fatal opportunistic infections. Combined antiretroviral therapy (ART) involves treating PWH with a cocktail of antiretroviral inhibitors that target multiple stages of the viral replication cycle. In most individuals, this treatment achieves durable remission of viral replication and results in an undetectable viral load in peripheral blood. Although ART arrests progression to AIDS and onward viral transmission, a large reservoir of latently- and chronically-infected cells remains in essentially all tissue sites, and viral rebound usually occurs upon cessation of ART. As intracellular parasites, viruses must use sophisticated mechanisms to produce and assemble viral components while suppressing activation of cell-intrinsic innate immune effectors. In Chapter One, I report that coordination of HIV-1 assembly by the viral polyprotein Gag suppresses inappropriately-timed protease (PR) activity to avoid inflammasome activation. Employing mutants of Gag, I show that disruption of domains controlling the viral assembly site (matrix, MA) or virus particle release (nucleocapsid, NC and p6) lead to premature activation of PR, which is recognized by the inflammasome sensor caspase recruitment domain family member 8 (CARD8), resulting in interleukin 1β (IL-1β) secretion and pyroptotic cell death. The generation of active PR required myristoylation of Gag and capsid-capsid interactions which drive Gag aggregation, though Gag myristoylation was not necessary if PR activation was induced pharmacologically. Together, these data support a model where dysregulated viral assembly generates active soluble PR which can be sensed at a membrane-proximal or membrane-distal cytoplasmic site. Further, I demonstrate that previously observed host-adaptive mutations in HIV-1 MA (M30K) and p6 (PTAP motif duplication) associated with greater fitness in humans improve infected CD4+ T cell survival in a PR-dependent manner. Altogether, the work described in Chapter One reveals virus-encoded mechanistic control over PR activation and CARD8 sensing during assembly by HIV-1 Gag and suggests that assembly-regulated CARD8 activation may influence the trajectory of HIV-1 evolution and fitness in humans.
Heterogenous transcription start site (TSS) usage by the integrated HIV-1 provirus dictates the structure and function of unspliced HIV-1 RNA (usRNA). Previous reports indicate that the expression and Rev/CRM1-mediated nuclear export of HIV-1 usRNA in macrophages activate melanoma differentiation-associated protein 5 (MDA5), mitochondrial antiviral-signaling protein (MAVS), and innate immune signaling cascades. In Chapter Two, I report that MDA5 sensing of viral usRNA is strictly determined by TSS, 5’ leader structure, and RNA function. I show that cap-sequestered HIV-1 usRNA (cap1G) destined for packaging is specifically targeted by MDA5, while translation-destined (cap3G) usRNA is remarkably immunologically silent. Using mutant viruses which express usRNA with altered 5’ cap structural conformations, or inclusion of a retroviral constitutive transport element which drives messenger RNA (mRNA)-like nuclear RNA export factor 1 (NXF1)-dependent nuclear export of viral usRNA, I show that cap exposure and nuclear export pathway choice are major determinants of both lentiviral RNA immunogenicity and function. In total, I identify innate immune evasion as a possible rationale for the universal conservation of heterogenous TSS usage among ancestral and extant HIV-1 isolates and shed light on how MDA5 fundamentally discriminates between self and non-self RNAs.
Chronic innate immune activation is a hallmark of disease progression to AIDS, and occurs during infection even with successful ART treatment, which leads to a greater incidence of negative health outcomes for PWH relative to their age-matched counterparts without HIV. Separately, innate immune activation and viral subversion of these innate responses is also relevant to mucosal transmission, a low-efficiency event where the virus must traverse a complex tissue barrier prone to robust antiviral responses and establish efficient replication in a naïve host. Together, the findings described in Chapters One and Two deepen our understanding of the innate immunology of HIV-1. These results define innate immune sensing mechanisms which target late events in the viral lifecycle (viral genome packaging and assembly) and the viral immune evasion strategies which facilitate the establishment of chronic infection. Future studies should incorporate these findings to further investigate mechanisms of chronic inflammation in PWH and inform therapeutic strategies
Effect of antiretroviral treatment strategies on retention in care, viral suppression, and non-communicable diseases in a large South African cohort: an emulated trial framework approach
No full text2026As HIV is now a chronic disease due to improved access to treatment and improved antiretroviral therapies (ART), there is a growing need for evidence regarding the long-term impact of ART use on the health of people living with HIV (PLWH) on treatment and how the risk of weight gain, changes in blood pressure, and other chronic non-communicable diseases (NCDs) like hypertension are impacted by the specific ART regimens are on. This is particularly important as HIV-NCD comorbidity reduces engagement in care and decreases quality of life. With almost eight million PLWH, South Africa has the world’s largest HIV burden and HIV treatment program. In 2019, South Africa’s treatment guidelines were updated to replace efavirenz with dolutegravir, due to clinical trials demonstrating dolutegravir’s efficacy. However, clinical trial populations are often healthier with better retention than real-world populations, in part due to a trial’s intensive follow-up procedures and their selective inclusion/exclusion criteria. As dolutegravir use has expanded, there is growing concern that dolutegravir increases the risk of NCDs. However, the magnitude and severity of this risk remain unclear. While observational studies can offer important insights, they are often limited by bias. Robust causal inference methods can help reduce the risk of bias. In this dissertation, we aim to evaluate the impact of different HIV treatment strategies on long-term retention in care and viral suppression, as well as to assess the association between dolutegravir use and adverse health outcomes—including weight gain, elevated blood pressure, and the development of hypertension.In aim one, using the Target Trial Emulation Framework we estimated, among treatment-naïve PLWH initiating treatment from 2019–2022 in South Africa, the effect of initiating a dolutegravir-based regimen compared to an efavirenz-based regimen on 12- and 24-month retention and viral suppression using data from the Themba Lethu HIV Clinical Cohort (TLC), a prospective cohort of PLWH receiving care at a clinic in Johannesburg, South Africa. Linear regression was conducted to estimate the causal risk difference on 12- and 24-month retention and viral suppression. Baseline characteristics were balanced via inverse probability of treatment weighting. Initiation of dolutegravir was associated with a 5-percentage point increase (95% Confidence Interval (CI): -0.02, 0.11) in retention and 4-percentage point increase (95% CI: -0.06, 0.16) in viral suppression among those with a viral load at 12-months. At 24-months, dolutegravir was associated with a 10-percentage point (95% CI: 0.03, 0.16) increase in retention and a 14-percentage point (95% CI: -0.02, 0.30) increase in viral suppression. Initiation of dolutegravir led to an appreciable increase in retention over 24 months when compared to efavirenz. A moderate but imprecise increase in viral suppression was found among those who initiated dolutegravir compared to efavirenz over the 24-month period.
In aim two, utilizing the Target Trial Emulation Framework we evaluated, among ART-naïve individuals initiating treatment from 2019–2022, the impact of initiating a dolutegravir-based regimen versus initiating an efavirenz-based regimen on 12- and 24-month weight, body mass index (BMI), blood pressure, and incident hypertension, also using TLC data. Generalized linear models were used to estimate the mean difference in weight, BMI, blood pressure at 12- and 24-months and a log-binomial model was used to estimate the causal risk difference of 12- and 24-month incident hypertension were used. At 12-months, mean difference comparing dolutegravir to efavirenz in weight was 2.9 kilograms (95% Confidence Interval (CI): -0.3, 5.5), BMI was 0.8 kg/m2 (95% CI: -0.3, 1.9), diastolic BP was 1.6 mmHg (95% CI: -0.7, 3.9) and systolic BP was 3.9 mmHg (95% CI: 1.2, 6.6). Individuals who initiated a dolutegravir-based regimen had 1.35 times the risk (95% CI: 0.04, 0.5) of incident hypertension at 12 months compared individuals who initiated an efavirenz-based regimen. At 24-months, mean weight difference was 1.9 kilograms (95% CI: -1.3, 5.1), BMI was 0.6 kg/m2 (95% CI: -0.6, 1.9), diastolic BP was -0.4 mmHg (95% CI: -1.8, 5.1) and systolic BP was 1.7 mmHg (95% CI: -1.8, 5.1). Risk of incident hypertension was 22% higher among dolutegravir initiators compared to efavirenz initiators (95% CI: -0.1, 0.4). Dolutegravir was associated with greater increases in weight and systolic blood pressure over 24 months compared to efavirenz, with the greatest increase in the first 12 months. A moderate increase in incident hypertension was also observed.
In aim three, using data from TLC we emulated nine sequential target trials, among treatment-experienced PLWH, to estimate the effect of switching to a dolutegravir-based regimen versus remaining on an efavirenz-based regimen on 12- and 24-month retention and viral suppression from 2019–2022. At 12-months, switching to a dolutegravir-based regimen was associated with a 14-percentage point (95% CI: 0.10, 0.19) increase in retention and a 2-percentage point (95% CI: -0.04, 0.08) increase in viral suppression. By 24-months, we observed a 1-percentage point (95% CI: -0.05, 0.07) increase in retention and an 8-percentage point (95% CI: 0.02, 0.14) increase in viral suppression. Switching to dolutegravir led to an appreciable increase in retention at 12-months and a moderate but imprecise increase in viral suppression at 24-months. Findings suggest that switching to dolutegravir does not harm and might improve retention and viral suppression over a 24-month period.
Overall, we observed that initiating dolutegravir compared to initiating efavirenz led to improvements in retention and viral suppression at 12 and 24 months among PLWH who were treatment-naïve. However, initiating dolutegravir may also be associated with increased weight and systolic blood pressure, and subsequent increased risk of hypertension over the first 24 months of treatment initiation. Among treatment-experienced individuals while we found no appreciable difference in retention for those who switched to dolutegravir compared to not switching, our results suggest that it may potentially lead to improvements in viral suppression. Findings from this dissertation provide further evidence of the benefits of initiating treatment-naïve individuals onto dolutegravir but also highlights the importance of continuing to screen individuals for NCDs after ART initiation as dolutegravir may be associated with increased risk of weight gain and hypertension. Furthermore, our findings suggest switching individuals to dolutegravir does not adversely impact retention and may lead to improvements in viral suppression.2028-01-15T00:00:00
Scavenging behavior of vertebrates and invertebrates on rabbit (Oryctolagus cuniculus) carrion in a New England environment
Full text link2026Forensic entomology is the use of arthropods and their ecology to answer legal questions. Arthropods, along with vertebrate scavengers, temperature, and other abiotic conditions, play an important role in the rate of decomposition. It is important for forensic professionals to consider these factors when it comes to interpreting the evidence found on a scene. The present research objectives were to: (1) investigate the effects of Late Spring (April/May) and Early Autumn (September) on scavenging behaviors in an anthropogenic protected wooded/wetland ecosystems; (2) observe the influence of vertebrate scavenging on rabbit (Oryctolagus cuniculus) carrion; and (3) quantify the production of flies from rabbit carrion in anthropogenic protected wooded/wetland ecosystems. It was hypothesized that vertebrate scavengers will have a greater effect on the decomposition rate compared to invertebrate scavengers. The sample size for this study consisted of 14 rabbit carcasses. Rabbit carcasses were placed at the Outdoor Research Facility (ORF) at Holliston, MA and Curry College’s campus at Milton, MA. The rabbit carcasses were placed in eight different locations total from both sites. Vertebrate scavengers were recorded via Digital Trail Camera SL112 and GardePro Trail Camera A3S models. Invertebrate scavengers were collected from the carrion and quantified. The results for the study proved the hypothesis correctly. The results showed that vertebrate scavengers had a greater influence on the decomposition rate compared to invertebrate scavengers. The vertebrate scavengers that had a greater influence were probable Virginia opossums (Didelphis virginiana), Eastern phoebe (cf. Sayornis phoebe), and coyotes (Canis latrans). The invertebrate scavengers that were collected at both sites include Phormia regina (Meigen) (Diptera: Calliphoridae) and Lucilia sericata (Meigen) (Diptera: Calliphoridae). Curry College’s campus on average had more larvae present on the carrion (32,890) compared to the ORF (25,263). While the ORF had more adult flies present on the carrion (337) compared to Curry College’s campus (68). There is no significant difference in the number of larvae and adult flies from both sites (0.744)
Development and application of proteomics-based tools for ligand target identification
No full text2026Small molecules are the foundation of modern pharmacology, yet defining their direct protein targets in the complex environment of the cell continues to challenge chemical biology. This dissertation describes the development and application of proteomics-based tools that capture ligand-protein interactions through complementary readouts of stability, conformational change, and adsorption at material interfaces. Together, these approaches extend the scope of chemoproteomics beyond conventional formats and enable the discovery of targets and mechanisms that would otherwise remain hidden. Following a general introduction in Chapter 1, the dissertation is organized into three major research efforts presented in Chapters 2 through 4.Chapter 2 establishes an approach for the discovery of ribonucleoprotein-targeted interfacial ligands. Rocaglates, acting as proximity inducers, clamp RNA to DEAD-box helicases, a mode of inhibition that depends on multicomponent assembly rather than a single binary interaction. Using proteome-wide stability assays, I demonstrate how tailoring biochemical conditions with nucleotide analogs and RNA substrates can reveal substrate-dependent interactions otherwise inaccessible, expanding the known rocaglate clamping spectrum more than two-fold.
Chapter 3 explores bioactive scaffold tunability in a disease context. Through comprehensive chemoproteomic profiling of rocaglate acyl sulfamides, I show that subtle structural changes at chemically permissive sites shift rocaglate selectivity toward DDX3X, a helicase whose engagement correlates with selective cytotoxicity in glioblastoma stem cells. Comparative proteomic assays and structural modeling converge to explain this bias, establishing these compounds as context-specific chemical probes.
Chapter 4 introduces ILIAD (Identifying Ligand Interactions through Adsorption Differences), a new derivatization-free chemoproteomic platform that reframes protein adsorption to labware surfaces as a readout of target engagement. ILIAD detects both broad remodeling with nucleotide analogs and selective engagement by tool compounds and drugs, demonstrating that adsorption can serve as an orthogonal signature of ligand binding.
Building sequentially across the three research chapters, this dissertation demonstrates how chemical context, scaffold modification, and reframing can be leveraged to expand the chemoproteomic toolkit. The approaches developed here illustrate a path toward more complete mapping of drug-protein interactions and provide conceptual and methodological advances relevant to both probe discovery and therapeutic development.2028-01-22T00:00:00
Exploring patient activation among dual-eligible Medicare beneficiaries: studies on the impact of enrollment in dual-eligible special needs plans and care coordination on activation and self-managed care
No full text2026Individuals enrolled in both Medicare and Medicaid, or dual-eligible beneficiaries, face complex health and social challenges, including poverty, disability, and unmet social needs. Compared to Medicare-only beneficiaries, they report poorer health, lower educational attainment, greater functional limitations, and higher post-acute care. Although they represent only 19% of the Medicare population, they account for 34.5% of Medicare spending. Dual-Eligible Special Needs Plans (D-SNPs) were created to align Medicare and Medicaid benefits, improve care coordination, and reduce fragmentation. Within this context, patient activation—the knowledge, skills, and confidence to manage one’s health—is critical for promoting self-management, improving outcomes, and reducing costs. Yet little is known about how activation differs by dual-eligibility or plan type, or how care coordination shapes activation for this population. This dissertation used a sequential, multiphase mixed-methods design to examine relationships among dual-eligibility, D-SNP enrollment, care coordination, and patient activation. Quantitative analyses using Medicare survey data employed Fairlie decomposition, propensity scores, and inverse probability weighting to compare activation between dual-eligible and Medicare-only beneficiaries and assess whether D-SNP enrollment was associated with higher activation. Qualitative interviews with care coordinators explored how coordination practices foster activation within these contexts. Quantitative findings showed dual-eligible beneficiaries had significantly lower activation, largely explained by social risk such as low education attainment. Explanatory factors differed by subgroup: for older dual-eligibles, limited English proficiency, living alone, poor perceived health, depression, anxiety, vision impairment, and limitations in activities of daily living (ADLs); for disabled dual-eligibles, intellectual disability and limitations in instrumental ADLs. D-SNP enrollment was associated with lower activation compared to Medicare Advantage, though similar to traditional Medicare. Notably, D-SNP enrollment was associated with lower activation among disabled and historically marginalized dual-eligibles, particularly, non-Hispanic Black enrollees. Qualitative analyses of care coordinators working with dual-eligible beneficiaries identified themes aligned with the Information-Motivation-Behavioral Skills model: (1) relational trust as a catalyst for engagement; (2) seeing the whole person, not the diagnosis; (3) personalization and adaptation in communication; (4) active confirmation of patient comprehension; and (5) collaborative problem-solving and momentum building. Practice and policy implications for dual-eligible beneficiaries include tailoring outreach strategies to specific subgroups, integrating patient activation into the D-SNP Model of Care, and ensuring comprehensive teach-back techniques are embedded within provider practices to reinforce comprehension of self-management behaviors. Systematically addressing modifiable risk factors may enhance activation, equity, and quality of life for high-need Medicare populations.2028-01-15T00:00:00
Sacral preauricular extensions and notches and dorsal pubic pitting as indicators of parity
Full text link2026The use of pelvic changes to make inferences of parity has been long debated, and renewed interest highlights how sacral skeletal markers could provide information on life histories of unidentified remains. This research examines the presence of sacral preauricular extensions (SPE), sacral preauricular notches (SPN), and dorsal pubic pitting (DPP) on the sacra and pubic bones of modern assigned females at birth (AFAB; parous=150; non-parous=97) and assigned males at birth (AMAB; n=150) from the University of Tennessee, Knoxville’s Donated Skeletal Collection. SPE, SPN, and DPP were scored as present or absent on adults with self-reported parity data. Because the sacroiliac joints and pubic symphysis are affected by postural changes and the laxening of ligaments during pregnancy and birth, a correlation between pregnancy, childbirth, and the appearance of the SPE, SPN, and DPP was expected. Of parous AFABs, 27.3% exhibited SPE, 17.3% exhibited SPN, and 41.3% showed DPP. Of non-parous AFABs, 20.6% exhibited SPE, 9.27% exhibited SPN, and 17.5% showed DPP. There was no instance of an AMAB exhibiting DPP, but 11.3% showed SPE and 13.3% showed SPN. Based on chi-squared tests, all comparisons showed statistically significant differences. This demonstrates that the appearance of SPE, SPN, and DPP are not randomly occurring. SPE and DPP are particularly informative for predicting parity which could have useful implications for studies of biomechanics, bioarchaeology, and forensics. One limitation of this study is that the skeletal collection was self reported and could have lacked information regarding the number of full-term pregnancies for each individual
Establishing an occupational therapy program for acute and chronic care in Trinidad and Tobago: a practical roadmap for implementation
Full text link2026Non-communicable diseases (NCDs), including stroke, diabetes, and cancer, are the leading contributors to disability in Trinidad and Tobago. Although early and continuous rehabilitation improves recovery and reduces long-term functional decline, national rehabilitation services remain fragmented, with minimal occupational therapy (OT) presence in acute care and inconsistent support in community settings. The absence of structured pathways from hospital to home contributes to preventable dependence, poor functional outcomes, and increased burden on families and the health system. Sankofa Rehab T&T is a culturally responsive OT initiative designed to address these gaps by integrating rehabilitation across acute and chronic care pathways. The model combines early hospital-based OT, home and community rehabilitation, caregiver education, workforce training, and digital monitoring. It aims to restore functional independence for individuals with NCDs while strengthening national rehabilitation capacity and generating actionable data to inform policy.The project uses a mixed-methods, three-phase evaluation framework: Phase One focuses on tool validation and stakeholder alignment; Phase Two examines implementation processes; and Phase Three evaluates outcomes using pre- and post-intervention measures. Quantitative indicators include reach, fidelity, functional outcomes, readmission rates, and training outputs, while qualitative data explore cultural fit, relevance, and lived experience. Anticipated impacts include earlier OT involvement, improved daily living skills, increased caregiver confidence, and reductions in preventable disability. A two-year financial and dissemination plan supports implementation, scalability, and policy translation. The Sankofa model offers a feasible, culturally grounded, and sustainable approach to embedding OT within national NCD care for the first time, addressing longstanding service gaps and advancing equitable rehabilitation access in Trinidad and Tobago.