1,721,037 research outputs found
Equitable access and reimbursement for pharmacy-based services: A case study of adult vaccinations
No full textThesis (Ph.D.)--University of Washington, 2024Community pharmacies are vital access points for healthcare in the United States. The COVID-19 pandemic highlighted the indispensable role of community pharmacists for patients and the healthcare system. However, not every neighborhood has good access to pharmacies, and pharmacies are facing increased financial and operational pressures which threaten their widespread availability. Despite the importance of community pharmacies, robust evidence at a national level is lacking on 1) the populations and locations which have low access to pharmacies, 2) whether this lack of access affects utilization of pharmacist-provided health services, and 3) whether any of the proposed policy solutions, such as provider status recognition for pharmacists at the federal level, provide a plausible path forward to bolster access to pharmacist-provided health services. This investigation is structured as three aims. First, I defined, mapped, and characterized the locations of all “pharmacy deserts” in the U.S. at the census tract level. Pharmacy deserts are defined as areas that are both low-income (>20% of people living below the federal poverty line or median income 1/3 of people living outside a 1, 5, or 10-mile radius of any pharmacy, depending on urbanicity). I found that 15.8 million (or 4.7% of) people in the U.S. live in neighborhoods classified as pharmacy deserts. Further, the populations living in these neighborhoods were associated with a higher proportion of many known social determinants of health such as lower educational attainment, racial/ethnic minority status, and lower health insurance coverage. These patterns were generally consistent across urban and rural areas and across all 50 states in the country.
Second, I evaluated whether these pharmacy desert neighborhoods were associated with lower utilization of a key pharmacy-based health service: shingles vaccination. I acquired census-tract-level vaccination data from seven different state Departments of Health and used propensity score matching to efficiently account for a variety of known confounding factors in the evaluation. The results from our primary analysis showed that pharmacy desert status was not associated with lower vaccination completion rates (0.4 fewer shingles vaccinations per 1000 population, p = 0.83). However, the results of our secondary analysis found that census tracts with low pharmacy access (as opposed to the two-part pharmacy desert definition that includes low-income levels) were associated with reduced shingles vaccination completion rates (2.4 fewer vaccinations per 1000 population, p = 0.004). This pattern indicates that lack of community pharmacy access may have direct health consequences for people living in these neighborhoods.
Lastly, I used a national claims database to explore the effects of state-level provider status legislation on reimbursements for shingles and seasonal influenza vaccination visits at pharmacies. We found that despite having the legal authority to do so, there are very few pharmacy claims being submitted to health insurance plans for vaccination services. Our dataset contained 2.3 million vaccination visits between 2021-2022, of which only 0.4% had any outpatient services claims billed during the visit, even in provider status states. This inhibits more robust evaluation of these policies' effects and may indicate important implementation barriers to address alongside these new authorities for pharmacists. In sum, this body of work provides evidence on the current state of access to pharmacies in the U.S., the negative effect of poor pharmacy access on shingles vaccination, and the potential utility of state-level provider status legislation in improving the financial profitability of vaccination services in community pharmacies
Assessing the Association between Receipt of Antimalarial Drugs and Adverse Pregnancy Outcomes using Pooled Data
No full textThesis (Ph.D.)--University of Washington, 2016-08Malaria is a major cause of maternal morbidity and mortality and neonatal death in areas of malaria transmission. Worldwide, it is responsible for up to 100,000 neonatal deaths and 10,000 maternal deaths annually. There is a need for better information on the safety of antimalarial drugs for women and their fetuses. Artemisinin-based combination therapies (ACT) are the most effective antimalarials, but are associated with teratogenic and embryotoxic effects in animal models when administered in early pregnancy. The limited observational studies in humans reported to-date have been reassuring. We conducted a systematic review and meta-analysis of the occurrence of adverse pregnancy outcomes among women treated with artemisinin monotherapy or artemisinin-based combination therapy during the 2nd or 3rd trimester relative to pregnant women who received non-artemisinin antimalarials or no antimalarial treatments in pregnancy. Pooled odds ratios (POR) were calculated using Mantel-Haenszel fixed effects models with a 0.5 continuity correction for zero events. To assess the risk of congenital malformations after receipt of an ACT during pregnancy, we pooled data from five recently completed randomized-controlled trials (RCT) and one multi-site, observational cohort study from the Malaria in Pregnancy Consortium (MIPc). We calculated prevalence risk ratios (PRR) comparing ACT exposed infants to ACT unexposed infants. From the meta-analysis, the pooled odds ratios (POR) (95% confidence interval (CI)) for stillbirth, fetal loss, and congenital anomalies when comparing artemisinin versus quinine were 0.49 (95% CI 0.24-0.97, I2=0%, 3 studies); 0.58 (95% CI 0.31-1.16, I2=0%, 6 studies); and 1.00 (95% CI 0.27-3.75, I2=0%, 3 studies), respectively. From the pooled analysis, there was no increased risk of congenital anomalies associated with receipt of an ACT during pregnancy compared to no such use (PRR 0.91, 95%CI 0.52-1.58). The PRR for congenital anomalies among the infants of women who received an ACT in the 1st, 2nd, and 3rd trimester compared to infants with no exposure to an ACT were 1.54 (95% CI 0.55-4.34), 0.79 (95%CI 0.47-1.34) and 1.08 (95%CI 0.57-2.07), respectively. Evidence from these studies supports the current WHO guidelines that call for the use of ACTs in 2nd and 3rd trimester to treat malaria. The findings from the analysis of the first trimester exposures and the risk of congenital anomalies are inconclusive due to the small number of malformations observed. Additional pharmacovigilance is recommended to obtain more reassurance of safety
Evaluation and Potential Cost-Effectiveness of Active Surveillance Pharmacovigilance for First-Line HAART in Namibia
Full text linkThesis (Ph.D.)--University of Washington, 2016-02Background. Active surveillance pharmacovigilance (PV) is a systematic approach to medicine safety assessment and health systems strengthening. These systems can better estimate the burden of adverse events (AEs) and can generate useful information on risk factors of AEs for more effective medicine use, especially in conjunction with introduction of new medicines and/or treatment guidelines. Active surveillance has yet to be implemented on a large scale in low- and-middle income countries. This project aimed to evaluate an active surveillance pilot program for first-line antiretroviral therapy (ART) at sentinel sites in Namibia, project findings to the national level to evaluate potential cost-effectiveness, and demonstrate use of active surveillance data. Methods. Sentinel sites were outpatient ART clinics at the Windhoek Central Hospital and Katutura Intermediate Hospital. An active surveillance data collection form was developed and placed into patient charts. Adults naïve to ART were enrolled from August 2012-April 2013. Physicians recorded ART and health information during each follow-up visit, including presence or absence of AEs. Following evaluation of this data, a cost-utility analysis from a governmental perspective compared active surveillance PV to spontaneous reporting PV for highly active antiretroviral therapy (HAART) in Namibia. Programmatic data from a sentinel site active surveillance program in Namibia conducted from August 2012-April 2013 was projected to all HIV-infected adults initiating HAART in Namibia. Costs (PV program, HAART, adverse event [AE] treatment), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs, 2015 U.S. dollars/QALY) were evaluated. Analysis was completed for (1) a cohort analysis in which a single cohort beginning HAART in 1-year in Namibia were followed over their remaining lifetime and (2) a population analysis in which patients continued to enter and leave care and treatment over 10 years. Finally, we examined a potential use of active surveillance data by examining incidence of an AE. Data from the active surveillance forms was used to evaluate the incidence nephrotoxicity in those exposed to the HAART drug tenofovir . Results. A total of 413 patients were included from August 2012 to April 2013. Average age was 37 years; 51% of patients were at WHO Clinical Stage 1; and mean baseline CD4 count was 216. The most common ART regimen was tenofovir/lamivudine/nevirapine. Presence or absence of AEs was recorded in active surveillance forms for 94\% of first follow-up visits. In total, 66 patients experienced 119 AEs of any severity. Incidence of experiencing at least one AE was 33 per 100 person-years. Most common AEs were rash and abdominal pain. On active surveillance forms, demographic variables were missing in 14% of patients and follow-up visits were recorded for 82% of patients. For the cost-effectiveness cohort analysis totals were 23,922,400 and 182,292 QALYs for care and treatment under spontaneous reporting PV, resulting in an ICER of $3,949 for active surveillance compared to spontaneous reporting PV. In the population analysis active surveillance was cost saving. Results were sensitive to quality-of-life associated with AEs. In this study population, incidence of nephrotoxicity was 15 per 100 person-years. However, after adjustment for demographics and comorbidities, nephrotoxicity was not statistically significantly associated with tenofovir exposure. Conclusions. Completeness of AE recording on active surveillance forms was high. With improved logistical considerations, such as incorporation of active surveillance forms into medical records, long-term active surveillance programs could be successful. Active surveillance pharmacovigilance was projected to be a highly cost-effective system to improve treatment for HIV in Namibia. Active surveillance PV may be valuable to improve the lives of HIV patients and more efficiently allocate health resources in Namibia. Tenofovir was found to be a generally safe medicine, though results were limited by a small sample size
Optimizing the Immunization Supply Chain in Sudan
No full textThesis (Master's)--University of Washington, 2019Abstract This study is looking to overcome traditional problems facing immunization supply chain system in Sudan for decades, such as weak dry supply chain capacity, inadequate warehousing and storage level, un-effective distribution at lower level, weak maintenance of the cold chain equipment, and weak logistics information system and data collection. Despite, the huge efforts exerted by concern partners to overcome those problems but still the outcome is far beyond the expectation of clients and patients. This thesis report is based on that situation analysis where by bottlenecks and gaps were been identified and their magnitude quantified. The problems have been analyzed and the part which can be solved through modeling and redesigning approach have been selected. Additionally, different models are presented to allow transformation and changes in the traditional model that the EPI supply used since its establishment
First Trimester Use of Artemisinin-Based Combination Therapy and Risk of Low Birth Weight
No full textThesis (Master's)--University of Washington, 2017-02Introduction: There is a lack of sufficient evidence on the safety of use of artemisinin-based combination therapies (ACT) among pregnant women, especially during early pregnancy. We determined the association between exposure to ACT during the first trimester of pregnancy and occurrence of low birth weight (LBW), and small for gestational age (SGA) among the offspring of pregnant women. Methods: We performed a secondary analysis of data from a prospective cohort study of pregnant women recruited at three health and demographic surveillance system (HDSS) sites in the sub-Saharan African countries of Mozambique, Burkina Faso and Kenya. Data from the HDSS allowed earlier pregnancy identification and linkage and tracking of pregnancy outcomes to determine birth weight and gestational age at delivery. Exposure to any antimalarials was ascertained through a combination of data collected from clinic registers, prescription records and self-reported usage by the women. Results: There was no difference in the pooled prevalence of LBW among children born to pregnant women who were exposed to quinine, ACT and had no exposure to antimalarials, 21.0%, 11.3% and 10.2%, respectively. Children whose mothers had exposure to ACTs during the first trimester had 21% lower occurrence of LBW when compared to children born to mothers exposed to ACTs in second or third trimester, this difference was not statistical significant (95%CI: -7-49%). Conclusion: ACT exposure during the first trimester was not associated with an increased risk of LBW. Our findings support the use of ACT for treatment of malaria during the first trimester of pregnancy
Surgical Outcomes in Children According to Hospital Location and Designation: A National Study
No full textThesis (Master's)--University of Washington, 2013Introduction: The effects of hospital location and specialty designation on post-operative outcomes in children have not been extensively evaluated. We hypothesized that outcomes would be improved at urban centers, and that outcomes would differ at urban centers for children from rural versus urban counties. Methods: We conducted a retrospective cohort study of children undergoing non-incidental appendectomy (n=129,507) and pyloromyotomy (n=17,109) using the 2006 and 2009 Kid's Inpatient Database and 2007, 2008 and 2010 Nationwide Inpatient Sample. Hospitals were defined as non-children's, children's unit in a general hospital, or freestanding children's hospitals, and were classified as urban or rural based on census data. Patient County of residence was classified as urban or rural based on census data. Outcomes included post-operative complications defined by ICD-9 codes and total hospital length of stay. Multivariate logistic and linear regression models were used to adjust for confounding. Results: Among appendectomy patients, 12.1% were treated at rural hospitals, while 3.4% of pyloromyotomy patients received their operation at a rural hospital. For appendectomy patients, treatment at urban relative to rural hospitals was associated with a reduced odds of any post-operative complication (OR=0.82, 95% C.I. 0.73 - 0.92) and anesthesia-related complications (OR=0.75, 95% C.I. 0.59 - 0.96). This association was strongest in the youngest children (<5 years) and at freestanding children's hospitals, specifically. Among children receiving appendectomy at urban centers, adjusted length of stay was half a day shorter for urban children than for rural children (p<0.001). For pyloromyotomy patients, urban hospitals were associated with a reduced odds of any complication (OR=0.33, 95% C.I. 0.20 - 0.55), anesthesia-related complications (OR=0.12, 95% C.I. 0.05 - 0.29), and duodenal perforation (OR=0.36, 95% C.I. 0.16 - 0.82). These associations were strongest at freestanding children's hospitals. Conclusion: Post-operative outcomes are improved at urban specialty hospitals for certain common procedures in children, and this effect seems to be most important in younger children. The specific factors responsible for these improved outcomes must be identified in order to improve care for children treated in all practice settings
Barriers to and strategies for early implementation of pharmacy-delivered PrEP services in Kenya: An analysis from routine data
No full textThesis (Master's)--University of Washington, 2022Background: In settings where populations at high risk of HIV acquisition face challenges using clinic-based pre-exposure prophylaxis (PrEP) for HIV prevention, differentiated PrEP delivery models are needed to expand access and reach. During a pilot study testing a novel pharmacy-delivered PrEP model in Kenya, we identified early implementation barriers and actions that providers and study staff took in response. Methods: We trained pharmacy providers at four private pharmacies in Kisumu and Thika, Kenya to initiate and continue clients at risk of HIV acquisition on PrEP using a prescribing checklist with oversight from remote clinicians. Research assistants stationed at the pharmacies completed weekly observation reports. Using content analysis, we analyzed reports from the first six months of implementation and notes from a subsequent member-checking meeting with pharmacy providers and research staff near the study endline to identify multi-level barriers to implementation and actions taken in response. We organized identified barriers and actions by domains of the Consolidated Framework for Implementation Research (CFIR).
Results: From November 2020 to May 2021, pharmacy providers screened 472 potential PrEP clients and initiated 211 (45%) on PrEP. Research assistants stationed at the pharmacies completed 74 weekly observation reports (~18 reports/pharmacy). We identified barriers to pharmacy-delivered PrEP across CFIR domains: high costs to clients (intervention characteristics), client discomfort discussing sexual behaviors and HIV testing with providers (outer setting), and provider frustrations that PrEP delivery was time-consuming and disruptive to their workflow (inner setting), high provider turnover (inner setting), and provider hesitancy to deliver PrEP due to concerns about encouraging promiscuity (characteristics of individuals). To help address these, pharmacy providers implemented an HIV risk self-screening option for prospective PrEP clients, allowed flexible appointment scheduling, and conducted pharmacy PrEP training for newly hired providers.
Conclusions: Our study provides insight into early barriers to implementing pharmacy-delivered PrEP in Kenya and potential actions to mitigate these barriers. Future research is needed to understand client perspectives on this delivery model, to evaluate the feasibility and effectiveness of this model, and assess late-stage implementation outcomes
Going Beyond Counting First Authors in Author Co-citation Analysis
Full text linkThe present study examines one of the fundamental aspects of author co-citation analysis (ACA) - the way co-citation
counts are defined. Co-citation counting provides the data on which all subsequent statistical analyses and mappings
are based, and we compare ACA results based on two different types of co-citation counting - the traditional type that
only counts the first one among a cited work's authors on the one hand and a non-traditional type that takes into
account the first 5 authors of a cited work on the other hand. Results indicate that the picture produced through this non-traditional author co-citation counting contains more coherent author groups and is therefore considerably clearer. However, this picture represents fewer specialties in the research field being studied than that produced through the traditional first-author co-citation counting when the same number of top-ranked authors is selected and analyzed. Reasons for these effects are discussed
Variations on the Author
Full text link“Variations on the Author” discusses two of Eduardo Coutinho’s recent films (Um Dia na Vida, from 2010, and Últimas Conversas, posthumously released in 2015) and their contribution to the general question of documentary authorship. The director’s filmography is characterized by a consistent yet self-effacing form of authorial self-inscription: Coutinho often features as an interviewer that rather than express opinions propels discourses; an interviewer that is good at listening. This mode of self-inscription characterizes him as an author who is not expressive but who is nonetheless markedly present on the screen. In Um Dia na Vida, however, Coutinho is completely absent form the image, while Últimas Conversas, on the contrary, includes a confessional prologue that moves the director from the margins to the center of his films. This article examines the ways in which these works stand out in the filmography of a director who offers new insights into the notion of cinematic authorship
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