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Business and Health Administration Association

Division of MBAA International 2013 Meeting Chicago, Illinois

ABSTRACT AND PAPER PROCEEDINGS

BHAA President – Avinandan Mukherjee Program Chair – Deborah Gritzmacher Proceedings Editor – Zach Frank

PROCEEDINGS
of the

BUSINESS AND HEALTH ADMINISTRATION ASSOCIATION
CHICAGO, IL February 27 – March 1, 2013
Copyright 2009 Business and Health Administration Association

All rights reserved. No part of these Proceedings may be reproduced, stored in a retrival system, or transmitted in any form or by any means electronic, mechanical, photocopying, recording, or otherwise, without prior permission of the BHAA organization. The BHAA does encourage the author(s) of the enclosed articles to seek publication of their efforts in appropriate journals. All correspondence concerning purchase of these Proceedings or copyright release should be addressed to the Proceedings Editor.

2013 PROCEEDINGS EDITOR Dr. Zach Frank Washburn University Topeka, KS

Sample Footnote: Please use the following style when referring articles from the Proceedings: Zakari, Nazik M.A. (2009), “The Influence of Academic Organizational Climate on Nursing Faculties Commitment in Saudi Arabia,” in Business & Health Administration Proceedings, Avinandan Mukherjee, Editor, p. 244.

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Letter from the BHAA 2013 President

Avinandan Mukherjee
Montclair State University

Dear Colleagues and Friends, I take great pleasure in extending greetings to all attending the 2013 Business and Health Administration Association (BHAA) Conference. As the President of Business and Healthcare Administration Association, I am delighted to welcome you to Chicago. The BHAA Conference brings together scholars, teachers, students, practitioners, regulators and planners from a variety of business and health related disciplines, such as healthcare administration, pharmaceutical and healthcare marketing, pharmacy, healthcare management, health economics, health policy, medicine, public health, nursing, health informatics, global health, etc. The BHAA is a growing and vibrant organization, under the umbrella of the MBAA International. The 2013 conference has a high quality program and is divided into distinct specialty tracks chaired by highly qualified and well-known individuals. Several outstanding papers have been submitted by individuals from world-renowned educational institutions and healthcare organizations. I am confident you will find research presentations in this conference useful that will stimulate your thoughts and initiate dialogues and conversations on the state-of-the-art in theory and practice of business and health administration. I hope that your academic and professional pursuits will be enriched by networking and sharing your thoughts and expertise while reflecting on those of others, thus building a BHAA professional community that you will cherish to be a member of. Wish you an enjoyable and productive experience at the conference and have a great time in Chicago! Sincerely Dr. Avinandan Mukherjee President – BHAA 2012/13

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Letter from the BHAA 2013 Program Chair

Deborah Gritzmacher
Clayton State University

I am so fortunate to have the opportunity to greet you for the 2013 Business and Health Administration Association (BHAA) Conference. I welcome you to a participant group that is diverse in specialty, nationality, cultural, and ethnic origin. We merge offerings from “scholars, teachers, students, practitioners, regulators and planners from a variety of business and health related disciplines, such as healthcare administration, pharmaceutical and healthcare marketing, pharmacy, healthcare management, health economics, health policy, medicine, public health, nursing, health informatics, and global health” (Avinandan Mukherjee, 2012). We as members of the planning committee are so grateful for this richness. MBAA and BHAA have a long history of quality, collegiality, and respect among and between disciplines. I trust that you will find presentations that relate and enrich your specific interest, and you will benefit from ideas that expand your vision. I hope that you will take advantage of the opportunity to engage others in conversation about the presented subjects, different approaches to similar issues, and that you will take advantage of the available entertainment. Thank you all for your submissions and we look forward to you joining us next year. Sincerely, Deborah Gritzmacher Chair – BHAA 2012/13

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Letter from the BHAA 2013 Proceedings Editor

Zach Frank
Washburn University
Dear BHAA Colleagues: I would like to take this time to welcome you to the BHHA conference. I have thoroughly enjoyed this conference each year I have been able to attend and look forward to attending and participating due to not only the intellectually stimulating presentations but also the camaraderie that is present within this group. BHAA offers everyone an opportunity to meet and work with colleagues from around the globe. It was my pleasure and to serve as your Proceedings Editor for this year’s meeting. Healthcare across the world is in a constant state of change. The depth and variety of papers for this year’s conference indicate the enormity of theses changes. This group continues to expand and reach out to new colleagues every year. We have 77 authors this year that did not submit to last year’s conference. That is quite a significant increase and can be contributed in large part to the quality of information packed into this conference. I would like to express my gratitude to Deborah Gritzmacher and Avinandan Mukherjee whose help in compiling the proceedings was invaluable and greatly appreciated. In addition, I would like to thank all of the delegates who submitted papers for this outstanding conference.

Dr. Zach Frank Proceedings Editor - BHAA 2012/13

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Best Paper Awards
BHAA OVERALL BEST PAPER AWARD Developing Effective Preceptors for Future Health and Aging Service Administrators Jennifer Johs-Artisensi, Lanette Flunker, Douglas Olson

TRACK: HEALTH PROMOTION AND DISEASE PREVENTION Social Development for Women and its Role in Environmental Health: A Cross-Country Study Avinandan Mukherjee and Naz Onel TRACK: PHARMACOECONOMICS AND PHARMACEUTICAL INDUSTRY The Role of Nutritional Supplements in Primary Care Darrell McCall and Steven Szydlowski TRACK: ETHICAL ISSUES IN HEALTHCARE Muslim Women Wearing Hajib in the Workplace: Facing Possible Religious Stigma Terrie C. Reeves, Arlise P. McKinney, and Laila Azam TRACK: FINANCE ISSUES IN HEALTHCARE ICD-10 in the United States: Better Late Than Never Holly Johns, Cara Havens, Danielle Robinson, Bala S. Pothakamuri, David P. Paul III, and Alberto Coustasse TRACK: CHANGES IN HEALTHCARE SETTINGS Hospital at Home: What Are They and How Well Do They Work? David P. Paul, III TRACK: HEALTHCARE MARKETING Effective Mechanism of Disruptive Innovation’s Diffusion in Medical Markets Mohammad Hajhashem .

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TRACK: HEALTHCARE EDUCATION Developing Effective Preceptors for Future Health and Aging Service Administrators Jennifer Johs-Artisensi, Lanette Flunker, and Douglas Olson TRACK: CHANGES IN HEALTHCARE PROVIDERS AND ACCESS Expanding the Career Pathways of Dental Hygienists: Adding the Healthcare Management Susan I. Duley and Peter Fitzpatrick TRACK: HEALTH INFORMATICS AND TECHNOLOGY Importance of New Technologies for Diabetes Monitoring David P. Paul III, Joey Priest, Zach Garrett, and Alberto Coustasse TRACK: INTERNATIONAL HEALTHCARE Medical Tourism and International Healthcare Options David Conley, Andrew Sikula, William Willis, and Alberto Coustasse

TRACK: CULTURAL DIFFERENCES EFFECTING HEALTHCARE OUTCOMES Arabic translation and adaptation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Patient Satisfaction Survey Instrument James Dockins, Ramizi Abuzahrieh, and Martin Stack TRACK: STUDENT LED PAPERS The Interconnection of Registered Nurs’es Motivation and Hospital Acquired Infection Chester H. Doering III and Ken Gambrell

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BUSINESS AND HEALTH ADMINISTRATION ASSOCIATION ABSTRACT AND PAPER PROCEEDINGS
- TABLE OF CONTENTS HEALTH PROMOTION AND DISEASE PREVENTION Vaccination Trends for Public and Private Sectors Suzette Hershman and William Stroube .................................................................................... 15 Employers Wellness Programs in the Greater Aurora Area Ileana Brooks ............................................................................................................................. 19 Social Development for Women and its Role in Environmental Health: A Cross-Country Study Avinandan Mukherjee and Naz Onel ......................................................................................... 20 The Effect of Health Orientation on Patient Compliance: What Role Does Social Media Play in this Equation? Avinandan Mukherjee and Archana Kumar .............................................................................. 36 Obesity in the Workplace: An International Out-look Bharate Mishra and Jitendra Mishra .......................................................................................... 43 The Impacts of Evolution’s MPowerement Project in the CDC’s Backyard Barbara Lacy Wilson and Arletha Williams .............................................................................. 58 A Wellness Model That Improves Financial Performance in University Settings Riddhima Palta, Allen C. Minor, and Daniel J. West, Jr. .......................................................... 59 Nursing Education in Saudi Arabia: Challenges and Future Implementation Adel S. Bashtash and Osama Samarkandiy ............................................................................... 60 A Global Perspective on Health and Wellness Programs in the Workplace: United States vs Central Europe (Czech Republic) Jessica Haynos and Robert Spinelli ........................................................................................... 61 Understanding the Determinants of Lifestyle Diseases: A Segmentation Approach Vivek S. Natarajan, Kabir Chandra Sen, and Avinandan Mukherjee ....................................... 62 Monetary Value of Food Desert and Policies Crystal Weeks, Antoinette Paragon-Singh, and Michael Dalmat .............................................. 63 Waistlines Will Continue to Rob Bottom Lines Until Physicians Lead by Example with Their Own Employee Wellness Programs Barbara Lacy Wilson, Suvidha Khatri, and Michael Dalmat..................................................... 64

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An Examination of Risk Factors for Obese Adults: Prevention as Policy Robin Hyson and David P. Paul III............................................................................................ 65 The Diabetes Pandemic: The Promise of Combining Multiple Treatments and Prevention Modalities Scott Yeager, David P. Paul III, and Michaeline Skiba ............................................................. 75 PHARMACOECONOMICS AND PHARMACEUTICAL INDUSTRY Safety of the United StatesPharmaceutical Supply Increasingly in Question Gene C. Wunder ........................................................................................................................ 82 The Role of Nutritional Supplements in Primary Care Darrell McCall and Steven Szydlowski ..................................................................................... 83 Problems with Alternative Medicines in the Health Care Setting: From Nurse’s Experience Dennis Emmett .......................................................................................................................... 84 Clinical Evaluation of Genetic Drug Sensitivity for Patients Using Codeine-Related Drugs in chronic Pain Management Setting Ahmet “Ozzie” Ozturk ............................................................................................................... 92 ETHICAL ISSUES IN HEALTHCARE Ethical and Legal Issues in Exhibiting Human Bodies Eva Grey and Jane Trizuljakova ................................................................................................ 94 Understanding the Family Member’s Lived Experience Transitioning from Active Care to End-of-Life Care – It’s Not Just One Decision Frances Gomes Marthone and Ptlene Minick. ........................................................................... 97 Organisation and Management of Antimalnutrition Programmes in Kenya Vladimir Krcmery Dadline Kisundi, Jaroslava Sokolová, Victor Namulanda, Ann Nageudo, Nada Kulková, Daria Pecháčová, Mario Jančovič, Alexandra Mamová, Petra Stulerova, Anna Porazikova, Sona Revicka, Steve Szydlowsky, Daniel West, Petra Mikolasova ............................................................................................................. 99 Muslim Women Wearing Hijab in the Workplace: Facing Possible Religious Stigma Terrie C. Reeves, Arlise P. McKinney, and Laila Azam ......................................................... 101 CHANGES IN PROVIDERS OF HEALTH CARE: A PANEL DISCUSSION Supply of Physicians and Nurses in the United States and Worldwide: Issues, Trends, and Effects on Healthcare Management Maysoun Dimachkie Masri, Lynn Unruh, Bernardo Ramirez, Cristina Popescu, and Ibrahim Zeini .................................................................................................................... 114

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FINANCE ISSUES IN HEALTHCARE Massachusetts Health Care Reform: A Look at Its Cost-Effectiveness and Sustainability Joshua McAdoo, Julian Irving, Chales Braun, and Alberto Coustasse .................................... 120 Changing the Reimbursement Environment: Impact on Group Practices Cristinel Miinea and Robert Spinelli ....................................................................................... 121 Using Communication Theory to Analyze Corporate Reporting Strategies: A Study of the Health Care Industry Zachery Lukes, Sheri L. Erickson, and Marsh Weber ............................................................. 122 A Wellness Model That Improves Financial Performance in University Settings Riddhima Palta, Allen C. Minor, and Daniel J. West, Jr. ......................................................... 133 ICD-10 in the United States: Better Late Than Never Holly Johns, Cara Havens, Danielle Robinson, Bala S. Pothakamuri, David P. Paul III, and Alberto Coustasse ............................................................................................... 134 CHANGES IN THE HEALTHCARE SETTINGS Hospital at Home: What Are They and How Well Do They Work? David P. Paul III ...................................................................................................................... 145 Understanding Emergency Nurse’s Experiences in Caring for People During Mental Health Crisis Ginger Taylor Truitt and Ptlene Minick .................................................................................. 152 The Paradox of Parity: Limitations in the Breakthrough Law for Mental Health Equity Jessica dowches and Daniel J. West Jr. ................................................................................... 153 HEALTHCARE MARKETING Relative Importance of Extrinsic and Intrinsic Product Attributes: A Conjoint Analysis of Consumer Preferences for OTC Analgesics Abhishek Sahu and Rajesh Nayak ........................................................................................... 155 Effective Mechanism of Disruptive Innovation’s Diffusion in Medical Markets Mohammad Hajhashem ........................................................................................................... 156 The New Era of Healthcare: Consumer-Driven Marketing Robert Spinelli ......................................................................................................................... 170 Pharmacy-Based Cost Groups and Its Current Utilization Within Insurance systems in Europe Robert Babela and Vladimir Krcmery ..................................................................................... 171

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HEALTHCARE EDUCATION Developing Effective Preceptors for Future Health and Aging Service Administrators Jennifer Johs-Artisensi, Lanette Flunker, and Douglas Olson ................................................. 173 Social Service Management Career Primer: What Graduate School Won’t Teach You Kevin C. Flynn and Daniel J. West Jr. ..................................................................................... 186 Reformation of Higher Education System in Countries from Central and Eastern Europe: Structural Impacts of the Bologna Process Cristinel Miinea and Daniel J. West Jr. ................................................................................... 187 Developing a Successful MHA Student Mentor-Mentee Program Aliya Shaikh and Daniel J. West Jr.......................................................................................... 188 Nursing Education IN Saudia Arabia: Challenges and Future Implementation AdelS. Bashatah and Osama Samarkandiy .............................................................................. 189 CHANGES IN HEALTHCARE PROVIDERS AND ACCESS Expanding the Career Pathways of Dental Hygienists: Adding the Healthcare Management Susan I. Duley and Peter Fitzpatrick........................................................................................ 191 Primary Care in the U.S.: A Preliminary Report of the Differential Impact of State Specific Scope of Practice Regulations to Access Nurse Practitioners Scott Stegall, Thhomas McIlwain, Qiu Fang, Deborah Gritzmacher, and Peter Fitzpatrick ................................................................................................................................ 201 Qualities of Workplace Environments Associated with Nurses’ Decisions to Remain Employed in Their Current Work Settings Larecia Gil and Ptlene Minick ................................................................................................. 208 Some Options to Stem the Negative Effects of the Health Care “Brain Drain” Charles Braun, Ivan Muslin, and Marge McInerney................................................................ 210 Access to Care Improvement Plan Robert D. Fenstermacher and Robert Spinelli ......................................................................... 211 HEALTHCARE INFORMATICS AND TECHNOLOGY Technology: Driving Dentistry for the 21st Century David P. Paul III ...................................................................................................................... 219 Importance of New Technologies for Diabetes Monitoring David P. Paul III, Joey Priest, Zach Garrett, and Alberto Coustasse ....................................... 229 Potential Benefits of Using Facebook in the Healthcare Industry: A Literature Review Chelsea Slack, William Willis, and Alberto Coustasse ........................................................... 241 Business and Health Administration Association Annual Conference 2013 Page 10

Virtual Information Systems Teams in the Healthcare Industry Nadene A Chambers and Linda V. Knight .............................................................................. 248 INTERNATIONAL HEALTHCARE Global Healthcare Management Education: Research Findings and Future Implications Daniel J. West Jr. ..................................................................................................................... 255 European Economic Crisis: Effects in Romania, Czech Republic, and Hungary Stephanie Hill .......................................................................................................................... 256 Analysis of the Integrated Medical Information System Implementation: The Case of Healthcare Organizations in the Republic of Kazakhstan Aisulu Zholdybayeva, S.D. Asfendiyarov, Zhansulu Baikenova, Dilbar Gimranova, and Alma Alpeissova ........................................................................................... 257 Understanding the Drivers of Medical Tourism: An Exploratory Empirical Study Vivek S. Natarajan and Avinandan Mukherjee ....................................................................... 258 Medical Tourism and International Healthcare Options David Conley, Andrew Sikula, William Willis, and Alberto Coustasse ................................. 259 Pain Assessment in the Critically Ill, Intubated Patient Colleen Meade and Matthew Ripper ....................................................................................... 269 Management of Social Services in the Post Communist Country-Slovakia Libusa Radkova and Anna Pavlovicova .................................................................................. 270 The Transitions from Adolescence to Adulthood of Young People with Disabilities in Slovakia Josef Matulnik, Maria Orgonasova, and Jana Adamcova ........................................................ 271 Leisure Time and Health of Young People in Slovakia Roman Kollar and Margita Minichova .................................................................................... 272 A Global Perspective on Health and Wellness Programs in the Workplace: United States vs Central Europe (Czech Republic) Jessica Haynos and Robert Spinelli ......................................................................................... 273 Why Eastern Europe Lags Behind Western Europe? Julius Horvath .......................................................................................................................... 274 Is the Euro Really Irreversible? The Puzzles of the European Monetary Integration Julius Horvath .......................................................................................................................... 275 Chronic Diseases as Key Challenge of Public Health Administration in Europe and in U.S.A. Robert Babela, Steven Szydlowski, Vladimir Krmery, and Daniel J. West Jr. ....................... 276

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Innovations as Key Strategy for Sustainable Healthcare in CEE Region Robert Babela, Vladimir Krmery, Mariana Mrazova, Jane Hruskova, and Marvin Fasko ........................................................................................................................................ 277 Health Economics: A New Tool for Reimbursement Process in Slovakia Robert Babela and Tomas Tesar .............................................................................................. 278 CULTURAL DIFFERENCES EFFECTING HEALTHCARE OUTCOMES Breast Feeding Experiences among African-American and Carribean-American Women Joanne Carrega and Ptlene Minick .......................................................................................... 280 HIV-Infected African Americans: Barriers to Quality Care and Strategies to Improve Health Outcomes Caryn Ewbank and Steven Szydlowski ................................................................................... 281 A Comparative Study of Long Term Care in U.S. and China: The Government’s Role Qiu Fang, Deborak Gritzmacher, and Scott Stegall ................................................................. 282 European Economic Crisi: Effects in Romania Czech Republic, and Hungary Stephanie Hill .......................................................................................................................... 283 Arabic translation and adaptation of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) Patient Satisfaction Survey Instrument James Dockins, Ramizi Abuzahrieh, and Martin Stack ........................................................... 284 Reformation of Higher Education System in Countries from Central and Eastern Europe: Structural Impacts of the Bologna Process Cristinel Miinea and Daniel J. West Jr. ................................................................................... 294 Mirro Mirror: A Comparative Study of Malfeasance Among the Health Care Professions Vivek V. Pande and Steven W. Thornburg.............................................................................. 295 Global Healthcare Management Education: Research Findings and Future Implications Daniel J. West Jr. ..................................................................................................................... 296 STUDENT LED PAPERS Single Parenthood: Exploring Positive Child Upbringing Strategies Brittany LeCleir and Ken Gambrell ......................................................................................... 298 The Interconnection of Registered Nurs’es Motivation and Hospital Acquired Infection Chester H. Doering III and Ken Gambrell ............................................................................... 302 The Impact of Emotional Intelligence on Employee Engagement Tracy B. Hart and Ken Gambrell ............................................................................................. 307 Barriers to Telemedicine for Rural Healthcare Clinics Cynthia M. Delphey and Ken Gambrell .................................................................................. 313 Business and Health Administration Association Annual Conference 2013 Page 12

Self-Efficacy and Body Image in Post Breast Cancer Patients Lauriann S. Grosskopf and Ken Gambrell ............................................................................... 318

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TRACK HEALTH PROMOTION AND DISEASE PREVENTION

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VACCINATION TRENDS FOR PUBLIC AND PRIVATE SECTORS
Suzette Hershman, University of Evansville William B. Stroube, University of Evansville

ABSTRACT A new federal mandate will soon go into effect banning any child with insurance from receiving free immunization shots from the health department. This paper uses the state of Indiana as an example for examining issues related to this mandate. The impact upon health care organizations and consumers is discussed.

INTRODUCTION The state of Indiana is pursing fundamental changes in the delivery and administration of children and adolescent vaccines in the state. A new federal mandate will soon go into effect banning any child with insurance from receiving free immunization shots from the health department. Many parents and private sector physician practices tend to use their county’s clinic as a means to escape the high costs of the shots, (Gardner, 2011). These costs may be defined as out-of-pocket expense from the patient perspective or the actual costs to purchase the vaccine from the physician perspective. Indiana counties began to implement this change with notice effective July 1, 2011. However, due to great concerns from providers across the state this date was quickly moved to January 1, 2012 to allow a smooth transition for back to school vaccine requirements. The topic brings to the forefront financial challenges for both the insured family and the private sector physician practice. While providers feel the best medical home for administration and tracking of the childhood vaccination record is the physician practice, they often times refer their patients to local health departments. Physicians may refer patients to receive vaccines when the patient has coverage yet a significant self-pay portion of the bill will remain or when insurance reimbursement doesn’t cover the manufacturer’s cost of the vaccine. The state change for the provider is a growing concern as vaccine costs continue to rise and the insurance companies and employers are passing on more shared costs to the insured. This pass back is done through the employee benefit coverage via co-pays, higher deductibles and co-insurance all leaving the private practice physician to subsidize the lack of state and federal funding and payer coverage to collect the patient due portion of the non-covered costs. This issue may result in financial negative variances for the provider while the practice is purchasing the inventory of the vaccines and paying the overhead to store and administer; however, patients cannot afford to pay the balance due even though they have coverage. Some required vaccinations can cost up to $600.00, a cost that can add up very fast for families with multiple children, “the insurance companies used to do a good job of paying for immunizations but that’s changing now, or if they do pay it’s a small portion so parents have been turning to the health department to cut down costs”. “The main issue is the Vaccination for Children (VFC) was never designed to provide vaccine for children with full insurance coverage”, (Gardner, 2011). The goals of physicians, the National Vaccine Advisory Committee (NVAC), and state and federal stakeholders is to create optimal approaches to vaccine financing in both the public and private sectors (NVAC, 2009). Business and Health Administration Association Annual Conference 2012 188

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CURRENT STATUS STATE OF INDIANA Earlier this year, the Indiana State Department of Health Commissioner provided local health departments with guidelines for the use of publicly funded vaccines, advising them to provide those vaccines only to underinsured and uninsured individuals beginning July 1, 2011. The intent of the policy was to help assure that publicly funded vaccines remained available for the underinsured population throughout the year and to comply with the strict guidelines set forth by the Centers for Disease Control and Prevention (CDC). The ISDH then delayed the policy change to January 1, 2012 for the back to school immunization push, (Larkin, 2011). Some recent articles and news reports throughout the state include: -cost vaccines to children with medical insurance in July. Indiana will no longer be offering free vaccines for children that are currently covered through some form of medical insurance. State officials say that the move will relieve some of the financial burden weighing on families. The costs of providing free vaccines for children have been trickling down to families for several years. Now parents will have to rely on their insurance companies and local pediatricians to obtain the necessary immunizations for their children, (Vagus, 2011). As indicated in the above article, parents will have to rely on their insurance companies and pediatricians to obtain the necessary immunizations, is stating the issue of conflict. As a public health provider does the (ISDH) have responsibility to our community to assure all children are vaccinated without putting the financial burden on the provider? How will parents rely on their insurance companies? ceived harsh criticism from both medical professionals and parents. Several insurance companies have voiced their concerns regarding the issue, saying the new law may mean a significant number of children may not get immunized, which puts them at risk of serious illnesses, (Vagus, 2011). The same article also indicates how insurance companies do not see this as their issue to resolve. Health care professionals have suggested the state legislators consider a new law that would require all insurance companies in Indiana to cover immunizations. If legislation would take place, does coverage for the patient mean costs are covered for the provider? As we so often avoid in debate in our political system, access to coverage doesn’t mean access to care. Often times, access doesn’t mean the physician can provide the service because the “coverage” may still not cover their costs as learned from the funded Medicaid system of coverage. children, we will run out early and those who truly need the coverage, those who are uninsured and underinsured, will not be able to get vaccinations”, (Indychannel, 2011). VFC program is now being affected by these changes. The new requirements closely examine Health Insurance Programs that cover vaccines. The intention is to not leave children without vaccine protection, but distribute vaccine costs to insurance policies that include Coverage of Vaccines. -pays such as 80/20 will need to go to their own physician/health care provider, GCBH (2011). RELATED ISSUES AND IMPACT ON PROVIDERS Physicians who provide vaccines to children and adolescents report dissatisfaction with the reimbursement levels and increasing financial strain from immunizations. Although large-scale withdrawal of immunization providers does not seem to be imminent, efforts to address root causes of financial pressures should be undertaken. (Business and Health Administration Association Annual Conference 2012 189) Cost shifting from the public sector to the private sector for vaccine services continues to cause concern because government programs generally pay less, both for the vaccine itself and for administrative costs. It is not unreasonable to anticipate some variation in a free market; however, it remains essential that the United States maintains its great public health success in childhood immunization through a delivery network that is financially stable and efficient, (Rosenberg, 2009).

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In a survey conducted to assess the Net financial Gain or Loss from Vaccination in Pediatric Practices found more than one half of the respondents broke even or suffered financial losses from vaccinating patients. The greater proportions of Medicaid enrolled patients served, the greater the financial loss was noted. On average, private insurance vaccine administration reimbursements did not cover administration costs unless a child received greater than three at one visit, (Coleman, et al., 2009). FUTURE ISSUES AND CONCLUSIONS Many community physicians are referring patients with adequate health insurance to local health departments for vaccinations that are intended only for residents who are without insurance or who are under –insured and unable to pay for the immunizations. Misapplications of these state and federally funded vaccinations will lead to premature depletion of vaccination supplies in the local health departments, (ISMA, 2011). It’s understood why local health departments are advocating that community physicians provide vaccinations to their insured patients. Dr. Larkin, states appropriately using both private and public resources will best assure broader community immunizations and therefore a safer and better-protected environment, (Larkin, 2011). The future issue to be understood is the correlation between insured patients with coverage and the costs of the vaccines for the private sector. The NVAC (2009) recommendations include some future considerations of: or VFC eligible underinsured children and adolescents receiving immunizations in the public health department clinics and thus should not limit access only at federally qualified health centers. ing business practices in the provider office. The AMA relative value scale update committee should review its relative value unit coding to ensure it reflects accurately the non-vaccine costs of vaccination. icaid administration reimbursement amounts for each state and should include all appropriate non-vaccine related costs and determined in current studies. The efforts should be coordinated with AMA review of relative value unit coding. th care purchasers should develop reimbursement policies for vaccinations that are based on methodologically sound cost studies of efficient practices. These costs studies should factor in all costs associated with vaccine administration, purchasing, handling, storage, labor, and patient and parent education. While the state and federal goal is to ensure immunizations for pediatric patient population and to maintain public health, the financial trend and cost shifting is in the hands of the physician to provide the majority of their young patients with vaccinations. A survey of research by Berman (2008) reveals that payments throughout the country for immunizing children do not fully cover the associated costs. Secondly, the survey suggests access in rural areas is already eroding as increasing numbers of family physicians decide not to provide vaccines. Also, findings showed one in five family physicians were seriously considering whether to stop providing all recommended vaccines to privately insured children. The trend to keep the insured patient in the physician practice in place of the health department may be sustained financially if the overhead of the vaccine administration and costs can be reimbursed at 17 % to 28% above the purchase price of the vaccine, (Berman, 2008). Immunization reimbursement is a complex issue involving multiple stakeholders. Resolution of these issues is critical in maintaining the health of individuals and society as a whole. REFERENCES Berman, S. (2008). Is Our Vaccine System at Risk for a Future "Meltdown? Pediatrics, 122 (6), 1372 -1373. Coleman, M.S., Megan, C.L., John, E., & Lance R. (2009). Net Financial Gain or Loss From Vaccination in Pediatric Medical Practices. Retrieved 13 August 2011 from http://pediatrics.aappublications.org/content/124/Supplement_5/S472.full. Freed, G. L., Cowan, A. E., & Clark, S. J. (2008). Primary Care Physicians Perspectives on Reimbursement for

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Childhood Immunizations. American Academy of Pediatrics. Retrieved 13 August 2011 from http://pediatrics.aappublications.org/content/122/6/1319.abstract. Gardner, D. (2011). Some Children Will Be Banned from Health Dept. Shots. Retrieved 13 August 2011 from http://tristatehomepage.com. GCBH (2011), Greene County Board of Health. Retrieved 13 August 2011 from http://www.wrv.k12.in.us/index.php?option=com_docman&task=cat_view&gid=57&Itemid=48. Indychannel (2011). State Health Dept. to Cut Low-Cost Vaccines. The Indychannel.com. Chanel 6 News, 8 June 2011. Accessed, 13 Aug. 2011. <http://www.theindychannel.com/news/28174139/detail.html. Larkin, G. (2011). ASDH Issues New Vaccine Policy. News & Publications. ISMA, 13 June 2011. Retrieved 12 August 2011 from http://www.ismanet.org/news/RRSArticle336.aspx. NVAC (2009). Financing Vaccination of Children and Adolescents: National Vaccine Advisory Committee Recommendations (2009). Journal of the American Academy of Pediatrics, S558, 558-559. Rosenberg, A. B. (2009). Vaccination in the United States: Payer Perspective on the Working Group and Its Recommendations. Pediatrics.aappublications.org. WellPoint, Medical Policy, Technology Assessment and Credentialing Programs, 25 Aug. 2009. Retrieved 13 August 2011 from http://pediatrics.aappublications.org/content/124/Supplement_5/S472.full. Vagus, S. (2011). Indiana to Stop Providing Low-cost Vaccines to Children with Medical Insurance in July. Liveinsurancenews.com. Live Insurance News, 28 June 2011. Retrieved 13 August 2011 from http://www.liveinsurancenews.com.

Suzette Hershman University of Evansville Health Services Administration Program 1800 Lincoln Avenue Evansville, IN 47722

William B. Stroube University of Evansville Health Services Administration Program 1800 Lincoln Avenue Evansville, IN 47722 E-mail:bs52@evansville.edu

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EMPLOYERS WELLNESS PROGRAMS IN THE GREATER AURORA AREA
Ileana Brooks, Aurora University

ABSTRACT This paper is based on an on-going interdisciplinary and community collaborative research and planning effort to focus on the problem of obesity and wellness that is being conducted in Aurora, Illinois. The project grew out of a collaboration of community health, education, and recreation organizations, and Aurora University that formed an entity known as the Healthy Living Council. This past year, the Healthy Living Council received a grant from the Kane County Health Department under its "Fit for Kids" initiative. The grant funding enabled the Council to focus on strategy #1 in the Economic Strength section of the Fit Kids 20/20 Plan – Improve the economic strength of employers by encouraging the implementation of wellness plans for employees. The HLCGA recognizes that healthy children depend on healthy families, and that both will not occur, other than in isolated instances, without institutional change. Employers are a central economic institution that can have substantial impact on families’ and their children’s motivation and ability to develop healthier lifestyles. In recent times, employers have begun to understand the relationship between health expenditures and healthy families, and to take positive action to improve the health and well-being of employees in order to reduce their organization’s potent ial and actual exposure to increased health care costs. The 2012 Kaiser Family Foundation and Health Research and Educational Trust annual survey of employer health benefits found 63 percent of companies with three or more employees that offered health benefits also offered at least one wellness program. The HLC is committed to establish, through survey research, a baseline of employer wellness practices that enable tracking of health improvement in the Aurora community. In this session we will present and discuss the creation of a survey for employers to measure the quantity and quality of wellness plans. Areas of discussion will focus on the survey design, the findings as compared to the other nationwide benchmarks, and most importantly, how the information will be utilized in both the Aurora and county-wide health and wellness project concentrating initially on childhood obesity.

Ileana Brooks Aurora University Dunham School of Business Aurora, IL 60506 630-844-4892 (Phone) 630-844-7830 (Fax) ibrooks@aurora.edu

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SOCIAL DEVELOPMENT FOR WOMEN AND ITS ROLE IN ENVIRONMENTAL HEALTH: A CROSSCOUNTRY STUDY
Avinandan Mukherjee, Montclair State University Naz Onel, Montclair State University

ABSTRACT Women’s less privileged status in society, fewer benefits granted, and limited access to resources provided by governmental agencies can impair well-being of the environment and public health. There is a considerable scarcity in the literature on environmental performance of the countries that would affect the human health directly and the mechanism between women’s social development and environmental health. This study aims at executing a cross-country study and examines the effects of social development for women on environmental health by incorporating different variables from World Bank and Environmental Performance Index. The main objective of the study is to empirically test the effects of different components of women social development practices on environmental health performance of countries and examine if different country clusters, i.e., high income, upper middle income, lower middle income, and low income, reveal different results in terms of determining environmental health. Multiple linear regression models were employed to test the hypotheses on a sample of 163 countries. Empirical results show that women social development dimensions of unemployment rate-female in high income countries, vulnerable employment-female in upper middle income and low income countries, HIV prevalence-female in upper and lower middle income countries, as well as progression to secondary school-female in low income countries significantly influence environmental health performance when we execute separate models using four cluster of countries. Combined country analysis of the effects of women social development on environmental health, however, shows significant effects of female’s primary school completion, HIV prevalence, vulnerable employment, and contraceptive prevalence. These findings provide theoretical and policy implications of women’s empowerment and social development initiatives.

INTRODUCTION The rapid increase in problems arising from destruction of natural resources, rapid industrialization, urbanization, and pollution caused by humans need immediate solutions and social empowerment of women may be the key. Sustainable growth at country specific and global levels highly depends on women’s social development such as getting education, joining the labor force, and receiving the necessary health treatments. Women population, however, is one of the most underutilized sources in the world (OECD, 2008) that needs instant attention of the researchers and policy makers. In fact, according to the Organisation for Economic Co-operation and Development’s (OECD) publication Gender and sustainable development: Maximising the economic, social and environmental role of women, currently, “the female half of the world’s human capital is undervalued and underutilized the world over… Better use of the world’s female population could increase economic growth, reduce poverty, enhance societal well-being, and help ensure sustainable development in all countries”(p.32)(OECD, 2008). With this study, we aim to understand better social opportunities and development for women population of the nations could in fact impact sustainable development, more specifically, social development for women could have an effect on well-being of the countries’ environmental conditions. Sustainable development requries healthy development of the countries that will not impact well-being of the environment and human health. Human health is determined by a broad variety of external and internal factors. These factors include individual behaviors, genetic inheritance, quality and accessibility of healthcare, and the wideranging external environment such as the quality of water, air and living conditions (Hernandez and Blazer, 2006). Today, the significant and detrimental effects of environmental factors on human health are accepted by many (e.g., Iles, 1997). In fact, in many parts of the world, it is easy to see environmental factors, such as pollution and degradation, are being increasingly responsible for ill-health of the world population (WHO, 1997; UNDP, 1998). Rapidly industrialized societies generate wide variety of pollutants and wastes that affect human health adversely,

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and cause decline or loss of biological diversity. In many cases, destroyed habitats negatively affect the quality of living conditions of human communities. For instance, millions of people are exposed to unnecessary physical and chemical hazards in their living environment and work place constantly. According to WHO (2012), more than one billion people are lacking access to safe drin king water, and more than three billion people’s accessed water lacks minimally acceptable sanitation requirements. Tuberculosis causes deaths of three million people every year, and any given time 20 million are affected by it. Hundreds of millions suffer from sicknesses caused by poor nutrition (Yassi et al., 2001; Moeller, 2005). All these and many more negative impacts of deteriorated environmental goods on people’s lives help us to infer that the health of millions of people around the world highly dep ends on their access to unaltered environmental goods such as clean air and uncontaminated water. In fact today, a wide range of domestic as well as international bodies, such as the World Bank, World Health Organization (WHO), and United Nations (UN), recognizes the associations between environmental conditions and human health (Iles, 1997). According to World Health Organization, environmental health means “those aspects of the human health and disease that are determined by factors in the environment”. It addresses all the external factors (e.g. physical, chemical, and biological) to an individual and all the related factors impacting behaviors of this individual. Environmental health includes the evaluation and control of these external factors that can potentially affect the human’s health (WHO, 2011). Over the last four decades, the scope of environmental health issues has expanded significantly, from a narrow focus which simply takes in to account refuse and sewage, to consideration of increasingly widespread and multifaceted phenomena that involves many connections between different social, economic, ecological, and political factors. Given the greater visibility of impacts, the kinds of environmental problems that cause direct effects on human health, such as air, water pollution or waste disposal, are more readily recognized as environmental health problems. Additionally, basic environmental goods ( e.g. water, soil), quality and accessibility have been recognized as the main sources of environmental health problems (Iles, 1997). Even though all of these aforementioned problems can be seen as infrastructure development issues, which are solvable through scientific and technological advancements, nowadays there is ever increasing concern about environmental health issues and acknowledgement that they cause broader public health problems that need immediate solutions. Certainly, coming up with a solution could be possible with finding the potential contributors of environmental health. This way, it can be possible to understand how the environmental health of a country or a region changes over time, and how can the communities adapt to these changes, or with the help of governments, alter or fix them. Previous studies related to environmental conditions in the literature generally focused on the environment in general. Most of these studies have showed that economic development and environmental degradation of a country are connected closely (e.g., Husted, 2005; Mendelsohn, 1994). Although scholars have argued and proved that social and economic development are important factors of determining the level of the environmental performance (e.g., Grafton and Knowles, 2004; Husted, 2005, Park et al., 2007; Peng and Lin, 2009), none of these studies in the literature has tried to compare and evaluate the relationship of women social development on environmental health. Herein lays the importance of empirically determining the significance of social development for women on environmental health conditions. The purpose of the present paper is to provide some modest first steps in the search for greater understanding of the statistical relationship between elements of women’s social development and environmental health. A quantitative analysis of women’s social de velopment is not an easy task, mainly because social development is itself a complex concept. In this paper, we take World Bank’s social development indicators as a base to capture women’s social development and employ eleven parameters. In addition, we include country clusters from World Bank to control for economic development, as well as environmental health variables to complete the statistical analyses. Given its theoretical significance and practical relevance, the mechanism linking women’s social development, such as educational attainment and labor participation, and environmental health ( i.e. impacts on human health) deserves systematic and in depth analysis. Specifically, this study attempts to answer the following research questions: (1) does social development of female population of the countries affect environmental health of a country? (2) does certain level of economic development of the countries have an impact on changes in the effects of women’s social development on environmental health? In the following section, we first develop a set of hypotheses, and then test the hypotheses on a sample of 163 countries.

LITERATURE REVIEW AND HYPOTHESIS CONSTRUCTION

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Over the past few decades, there have been growing concerns for environmental degradation in the process of globalization and growth, and this damage to the environment is attributed by some to increased economic activity. The possible relationship between environmental degradation and economic development has been the research focus of numerous studies in the literature (e.g. Xing and Kolstad, 2002; Tonelson, 2000, Grossman and Krueger, 1995; Antoci, 2009; Tamazian et al., 2009). However, these studies have failed to account for the effect of social development of women. If we consider the influence of women capital on increasing economic growth, reducing poverty, enhancing societal welfare, and most importantly, ensuring sustainable development (OECD, 2008), it can be inferred that the will and ability to protect the environment and environmental health are influenced by the factors related to women’s social development. In this research study, we are interested in exploring the relationships between women’s social development and environmental health. The World Bank provides social development and gender indicators that delineate women’s social development (WorldBank, 2012). Some of them we chose for the purpose of our study are: female population’s primary school completion rate, progression to secondary school, share of women employed in the nonagricultural sector, vulnerable employment, labor participation, unemployment, proportion of seats held by women in national parliaments, prevalence of HIV, births attended by skilled health staff, and contraceptive prevalence. All these should lead to a better environmental health condition for the society that has higher social development for women. For instance, lower educational attainment for women can cause a lack of understanding of the importance that environmental protection could have. Since the population cannot pay the necessary attention to the environment (prime education provided by mothers would get affected), environmental health can become deteriorated. However, if the community knowledgeable enough to see the connection between the harmful practices they adopt and detrimental health outcomes, they can alter their actions towards conserving the limited resources. So, in addition to acquisition of knowledge and skills that promote health, such as the implementation of healthier behaviors (Cutler & Lleras-Muney, 2006), higher level of schooling can affect the prospects towards the environmental health. Similarly, women’s individual health condition is an important determinant of the living standards and human development. Usually, if they have a higher life expectancy, they would feel more sympathetic to coming generations -their kidsas well as their own future. Therefore, Mariani et al. (2009) conclude that if someone expects to live longer, that person would be keen to invest more in environmental quality and future generations. Also, healthy person can focus more on her surroundings, including environmental conditions. In fact, it is reasonable to invest in environmental quality, depending on how much a person expect to live a healthy life; because every individual would want to have a better quality life and higher standards. Increased investment in environmental quality eventually will lead to better living conditions and improvement in environmental health. Thus, we expect the followings: Hypothesis 1. The higher the level of female school enrollment of a country, the higher is the environmental health of the country. Hypothesis 2. The higher the level of female primary school completion a country, the higher is the environmental health of the country. Hypothesis 3. The higher the level of female’s progression to secondary school of a country, the higher the environmental health of the country. Hypothesis 4. The higher the share of women employed in the nonagricultural sector of a country, the higher is the environmental health of the country. Hypothesis 5. The higher the female’s vulnerable employment level, lower the environmental health of the country. Hypothesis 6. The higher the female labor participation rate of a country, higher the environmental health of the country. Hypothesis 7. The higher the rate of female unemployment of a country, the lower the environmental health of a country. Hypothesis 8. The higher the level proportion of seats held by women in national parliament of a country, the higher is the environmental health of the country. Hypothesis 9. The higher the prevalence of HIV for women in a country, the lower is the environmental health of the country. Hypothesis 10. The higher the level of births attended by skilled health staff of a country, the higher the environmental health of the country. Hypothesis 11. The higher the level of contraceptive prevalence of a country, the higher is the environmental health of the country.

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METHODOLOGY Conceptual model On the basis of the section of literature review and hypothesis construction, the framework of this research is illustrated in Figure 1. In this study, we attempt to explore the relationships among women social development variables and environmental health using economic development as a control variable. We investigate the relationship between women social development variables and environmental health for high income, upper middle income, lower middle income, and low income countries separately, and lastly, we investigate the effects of women social development on environmental health for all countries combined.
Economic Development Social Development for Women
Female Unemployment

Labor participation rate Vulnerable employment Women employed in nonagricultural sector Ratio of educational enrollment (Prim., sec., tert.)

Environmental Health

Env. Burden of Disease Air Pollution (effects on humans) Water (effects on humans)

Women in national parliaments Prevalence of HIV in female Births attended by skilled health staff

Contraceptive prevalence Primary school completion rate

Progression to secondary school

Figure 1: Model: Effects of Social Development for Women on Environmental Health of the Countries.

Sample The research sources were from two international databases: the World Bank and World Economic Forum. The data of environmental performance was taken from the Yale Center for Environmental Law and Policy/Global Leaders of Tomorrow Environmental Task Force of the World Economic Forum. The data of social development for women variables of school enrollment (female-primary, secondary, tertiary), primary school completion rate

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(female), progression to secondary school (female), share of women employed in the nonagricultural sector, vulnerable employment (female), labor participation rate (female), unemployment (female), proportion of seats held by women in national parliaments, prevalence of HIV (female), births attended by skilled health staff, contraceptive prevalence were collected from the World Bank (2010). All the data used for the study was from year 2010. We first obtained country clusters from World Bank (see Table 1) and excluded those countries without social development predictors’ data. Finally, we collected the country’s Environmental Health index data from World Economic Forum. High Income Countries
Australia Austria Bahamas, The Barbados Belgium Canada Croatia Cyprus Czech Republic Denmark Equatorial Guinea Estonia Finland France Germany Greece Hong Kong SAR, China Hungary Iceland Ireland Israel Italy Japan Korea, Rep. Liechtenstein Luxembourg Malta Netherlands New Zealand Norway Poland Portugal Qatar San Marino Saudi Arabia Slovak Republic Slovenia Spain Sweden Switzerland United Kingdom United States

Upper Middle Income Countries
Algeria Argentina Azerbaijan Belarus Bosnia and Herzegovina Botswana Bulgaria Chile China Colombia Costa Rica Cuba Dominica Dominican Republic Ecuador Grenada Iran, Islamic Rep. Jamaica Jordan Kazakhstan Latvia Lebanon Lithuania Macedonia, FYR Malaysia Maldives Mauritius Mexico Montenegro Namibia Panama Peru Romania Russian Federation Serbia Seychelles South Africa St. Lucia Suriname Thailand Tunisia Turkey Uruguay Venezuela, RB

Lower Middle Income Countries
Albania Armenia Belize Bhutan Bolivia Cameroon Cape Verde Congo, Rep. Djibouti Egypt, Arab Rep. El Salvador Fiji Georgia Ghana Guatemala Guyana Honduras India Indonesia Lao PDR Lesotho Marshall Islands Moldova Mongolia Morocco Nicaragua Nigeria Pakistan Paraguay Philippines Samoa Sao Tome and Principe Senegal Solomon Islands Sri Lanka Sudan Swaziland Syrian Arab Republic Timor-Leste Ukraine Uzbekistan Vanuatu Vietnam West Bank and Gaza Zambia

Low Income Countries
Afghanistan Bangladesh Benin Burkina Faso Burundi Cambodia Central African Republic Chad Comoros Congo, Dem. Rep. Eritrea Ethiopia Gambia, The Guinea Guinea-Bissau Kenya Kyrgyz Republic Liberia Madagascar Malawi Mali Mauritania Mozambique Myanmar Niger Rwanda Sierra Leone Tajikistan Tanzania Togo Uganda Zimbabwe

Table 1: Four country clusters developed from World Bank’s (2012) country groupings.

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In social development for women dataset, missing values were replaced with closest years’ averages. If there was no data available for that specific variable, missing value was replaced with the mean value of that variable for all countries in the model that executed. Measures Dependent variable Environmental Health: Environmental health, as a dependent variable, was measured by the Environmental Health Performance provided by the Environmental Performance Index (EPI). The EPI was developed by the Yale Center for Environmental Law and Policy (YCELP) and the Center for International Earth Science Information Network (CIESIN) of Columbia University, in collaboration with the World Economic Forum and the Joint Research Centre of the European Commission. The index gives each country scores on two key objectives; (1) Environmental Health and (2) Ecosystem Vitality (EPI, 2010). Environmental Health refers to the extent to which deficiencies in water quality, air pollution, and other factors cause health issues and reductions in quality of life. Ecosystem Vitality measures the health of a country’s ecosystem by evaluating such factors as agriculture, biodiversity and habitat, climate change, fisheries, and forestry. The fact that we are interested in the human health consequences related to the environmental conditions, from these two key objectives of the index, we used Environmental Health measures for the purpose of this study. When measuring the variables, the EPI utilizes a proximity-to-target methodology focused on a core set of environmental outcomes linked to policy goals. The Environmental Performance Index (EPI) in its 2010 report ranked 163 countries on 25 performance indicators that are tracked across ten policy categories covering both environmental public health and ecosystem vitality. Performance indicators used by EPI provide a general picture in terms of how close countries are implement environmental policy goals. In the index, "environmental health" determined by the human health related variables, such as child mortality, indoor air pollution, drinking water, adequate sanitation and urban particulates. Sub-categories of the environmental health are given as: (1) Environmental burden of disease (with 25% weight assigned to it), (2) Air pollution effects on human (12.5%), and (3) Water effects on human (12.5%). Both air and water indicators are also divided into two different groups, for air, they are indoor and outdoor pollutions (each has 6.25% weight), and for water, they are access to water and sanitation (also each has 6.25% weight) (EPI, 2010). Independent variables Social Development for Women: The social development for women variables of school enrollment (femaleprimary, secondary, tertiary), primary school completion rate (female), progression to secondary school (female), share of women employed in the nonagricultural sector, vulnerable employment (female), labor participation rate (female), unemployment (female), proportion of seats held by women in national parliaments, prevalence of HIV (female), births attended by skilled health staff, contraceptive prevalence were measured using data published by World Bank (2010) for 163 countries. World Bank provides 331 indicators from the World Development Indicators (WDI) covering 214 countries from 1960 to 2011 that are widely used by researchers from all disciplines. School enrollment (female-primary, secondary, tertiary): This variable calculated by averaging three indicators; ratio of female to male primary enrollment, ratio of female to male secondary enrollment, and ratio of female to male tertiary enrollment.  Ratio of female to male primary enrollment (%): This is the gender parity index for gross enrolment ratio. According to the World Bank (2010), “Primary is the ratio of female gross enrolment ratio for primary to male gross enrolment ratio for primary. It is calculated by dividing the female value for the indicator by the male value for the indicator.” Ratio of female to male secondary enrollment (%): This is the gender parity index for gross enrolment ratio. “It is calculated by dividing the female value for the indicator by the male value for the indicator. A GPI [Gender Parity Index] equal to 1 indicates parity between females and males. In general, a value less than 1 indicates disparity in favor of males and a value greater than 1 indicates disparity in favor of females” (WorldBabk, 2010).

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Ratio of female to male tertiary enrollment (%): This is gross enrolment ratio for female population. “Tertiary is the ratio of female gross enrolment ratio for tertiary to male gross enrolment ratio for tertiary. It is calculated by dividing the female value for the indicator by the male value for the indicator. A GPI equal to 1 indicates parity between females and males. In general, a value less than 1 indicates disparity in favor of males and a value greater than 1 indicates disparity in favor of females” (WorldBank, 2010).

Primary completion rate, female (% of relevant age group): The WorldBank (2010) provides the definition of this variable as “Female is the total number of new female entrants in the last grade of primary education, regardless of age, expressed as percentage of the total female population of the theoretical entrance age to the last grade of primary. This indicator is also known as gross intake rate to the last grade of primary. The ratio can exceed 100% due to over-aged and under-aged children who enter primary school late/early and/or repeat grades.” Progression to secondary school, female (%): This is the transition from primary to secondary school in percentage. “Female is the number of new female entrants to the first grade of secondary education (general programs only) in a given year, expressed as a percentage of the number of female pupils enrolled in the final grade of primary education in the previous year” (WorldBank, 2010). Share of women employed in the nonagricultural sector (% of total nonagricultural employment): “Share of women employed in the nonagricultural sector is the share of female workers in the nonagricultural sector (industry and services), expressed as a percentage of total employment in the nonagricultural sector. Industry includes mining and quarrying, manufacturing, construction, electricity, gas, and water. Services include wholesale and retail trade and restaurants and hotels; transport, storage, and communications; financing, insurance, real estate, and business services; and community, social, and personal services” (WorldBank, 2010). Vulnerable employment, female (% of female employment): This variable defined as “unpaid family workers and own-account workers as a percentage of total employment” by WorldBank (2010). Labor participation rate, female (% of female population ages 15+): “Labor force participatio n rate is the proportion of the population ages 15 and older that is economically active: all people who supply labor for the production of goods and services during a specified period.” Unemployment, female (% of female labor force): “Unemployment refers to the share of the labor force that is without work but available for and seeking employment.” Proportion of seats held by women in national parliaments (%): “Women in parliaments are the percentage of parliamentary seats in a single or lower chamber held by women.” Prevalence of HIV, female (% ages 15-24): “Prevalence of HIV is the percentage of people who are infected with HIV. Youth rates are as a percentage of the relevant age group.” Births attended by skilled health staff (% of total): “Births attended by skilled health staff are the percentage of deliveries attended by personnel trained to give the necessary supervision, care, and advice to women during pregnancy, labor, and the postpartum period; to conduct deliveries on their own; and to care for newborns.” Contraceptive prevalence (% of women ages 15-49): “Contraceptive prevalence rate is the percentage of women who are practicing, or whose sexual partners are practicing, any form of contraception. It is usually measured for married women ages 15-49 only” (WorldBabk, 2010). DATA ANALYSES Data analysis A summary of descriptive statistics and correlation matrix for the variables of pooled cross-national data are provided in Table 2. There are significant correlations among dependent variable –ENV. HEALTH – and independent variables including primary school completion rate (female), progression to secondary school (female), share of women employed in the nonagricultural sector, vulnerable employment (female), labor participation rate

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(female), proportion of seats held by women in national parliaments, prevalence of HIV (female), births attended by skilled health staff, and contraceptive prevalence. Only unemployment (female) rate did not show a significant correlation with environmental health. Statistical results Table 3, 4, 5, 6 and 7 show the statistical results of the study. Total environmental health data used as a dependent variable for all models. The regression analysis of the effects of women social development on environmental health in high income countries is considered as the first step of the data analysis (Table 3). For this first step, we run a regression analysis using high income countries’ women social development variables of primary school completion rate (female), progression to secondary school (female), share of women employed in the nonagricultural sector, vulnerable employment (female), labor participation rate (female), unemployment (female), proportion of seats held by women in national parliaments, prevalence of HIV (female), births attended by skilled health staff, and contraceptive prevalence as independent variables and Environmental Health as dependent variable . To examine the Model 2, we took upper middle income countries’ variables of women social development as independent variables and run a regression analysis between them and Environmental Health (Table 4). The next tests were on the effects of women social development variables on Environmental Health for lower high income and low income countries which were also the assessments of Models 3 and 4 (Tables 5&6). Finally, the last test was on the effects of women social development on Environmental Health for all countries combined, which was also the assessment of Model 5 (Table 7). In Model 1, we examined high income country cluster implemented from World Bank and found that unemployment rate for women showed a correlation with aggregated environmental health measure (Table 3). The overall significance of the Model 1 was 0.000 with an R2 of 0.833. The significance level for unemployment rate for women was 0.031. For regression analysis of Model 2, we took upper middle income countries’ social development for women data as independent variables. From these variables, our regression analysis showed a strong correlation between vulnerable employment and HIV prevalence in women, and environmental health total with statistically significant p values of 0.020 and 0.009 for each variable, respectively. The overall model gave us an R 2 of 0.608 with 0.000 significance (Table 4). The third regression analysis was for Model 3. We looked at lower middle income countries’ social development for women data as independent variables. Our regression analysis showed a strong correlation between HIV prevalence in women and environmental health total with statistically significant p value of 0.017. The overall model gave us an R2 of 0.693 with 0.000 significance (Table 5). Next, we looked at low income countries with a regression analysis which was examined with Model 4. We looked at low income countries’ social development for women data as independent variables. The regression analysis showed a strong correlation between progression to secondary school, vulnerable employment in women population of the countries, and environmental health total with statistically significant p values of 0.030 and 0.014 for each variable, respectively. The overall model gave us an R2 of 0.815 with 0.000 significance (Table 6). The last regression analyses was on the all countries’ social development for women combined effects on Environmental Health which also the assessment of Model 5 (Table 7). When we added all countries’ eleven variables into the model, it gave us slightly different results. The model gave an R 2 value of 0.876 with 0.000 significance. From each independent variable, women’s primary school completion, HIV prevalence, vulnerable employment, and contraceptive prevalence rates showed a significant effect on environmental health with significance levels of 0.032 for women’s primary school completion, and 0.000 for all other three variables. Thus, Hypotheses 2, 5, 9, and 11 were supported in Model 5. However, Hypotheses 1, 3, 4, 6, 7, 8, and 10 were not supported in the all countries model (Model 5), which was analyzed excluding economic development control variable. The aforementioned regression analyses in this study gave the following results for each variable:

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School enrollment for women (primary, secondary, tertiary): The effect of women’s primary, secondary, tertiary school enrollment on environmental health was not significant in any model we examined. Hence, H1 was not supported. Primary school completion for women: The results of the study did not show any significant effect of primary school completion rate of women on environmental health except in the model that we did not control for economic development. Therefore, we can state that the H2 was only supported in the Model 5. Progression to secondary school: The statistical analyses showed that when the level of women’s progression to secondary school of a country was high, the environmental health of that country was high in particularly low income countries. This result supported the H3. Share of women employed in the nonagricultural sector: The results of the study showed that the environmental health of a country was not affected by the share of women employed in the nonagricultural sector of the country. So, the hypothesis H4 was not supported. Vulnerable employment of women: The fifth variable of social development of women, vulnerable employment, had a significant effect on the environmental health in upper middle and low income countries. In addition, this variable showed a significant effect on environmental health when we combined all countries. Thus, H5 was supported. Labor participation rate: The effect of women labor participation on environmental health was not significant in any model. Hence, H6 was not supported. Unemployment rate for women: As an indicator of women’s social development, unemployment for women showed a significant effect on environmental health of high income countries we examined in Model 1. Thus, H7 was supported. Proportion of seats held by women in national parliaments: The effect of women participation in national parliaments on environmental health was not significant in any of the models. Hence, H8 was not supported. Prevalence of HIV in women: The effect of prevalence of HIV in women on environmental health was significant in three models; upper middle, lower middle income countries, and all countries combined models. Hence, H9 was supported. Births attended by skilled health staff: The effect of number of births attended by skilled health staff on environmental health was not significant in any of the models. H10 was not supported. Contraceptive prevalence: The last indicator of women’s social development, contraceptive prevalence , showed a significant effect on environmental health in all countries combined model that we did not control for economic development. Thus, H11 was supported.

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Descriptive statistics and correlation matrix
ENV. HEAL TH

Variable

SCHE

PRIM COMP

PROG SEC

NOAG EMPL

VULN EMP

LABR PART

UNEMP

PARL SEAT

HIV

BRTH HLTHS

CONT PRV

Mean

SD

SCHE

1.000

.568**

.514**

.355**

-.626**

-.141

.066

.014

-.098

.270**

.486**

.575**

103.164

21.636

PRIM COMP PROG SEC NOAG EMPL VULN EMP LABR PART UNEM P PARL SEAT HIV BRTH HLTH S CONT PRV ENV. HEAL TH

1.000

.598**

.484**

-.600**

-.195*

.011

.036

-.202**

.285**

.683**

.662**

88.100

19.952

1.000

.483**

-.680**

-.285**

-.059

.041

-.297**

.192*

.618**

.703**

87.556

14.925

1.000

-.571**

.172*

-.016

.308**

-.150

.220**

.524**

.582**

37.393

12.227

1.000

.355**

-.135

-.157*

.217**

-.289**

-.650**

-.885**

43.808

31.785

1.000

-.356**

.218**

.224**

-.075

-.181*

-.261**

52.947

15.941

1.000

-.128

.184*

.039

-.156*

-.034

11.319

9.514

1.000

.048

-.005

.241**

.214**

18.294

10.672

1.000

-.103

-.210**

-.383**

1.062

2.382

1.000

.298**

.299**

87.982

75.250

1.000

.742**

52.980

22.417

1.000

60.1948

27.156

TABLE 2. Descriptive statistics and correlation matrix *p < 0.05, **p < 0.01, 2-tailed test. N=163

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Model 1: Regression analysis of the effects of Women Social Development on Environmental Health for High Income Countries, R2 = 0.833, F Sig. = 0.000

Hypotheses

Standardized Beta
0.114 0.229 -0.150 0.176 0.005 -0.080 - 0.249 0.186 -1.030 -0.440 0.048

p-Value
0.378 0.145 0.475 0.364 0.949 0.644 0.031 0.090 0.070 0.399 0.746

Results
Not Supported Not Supported Not Supported Not Supported Not Supported Not Supported Supported Not Supported Not Supported Not Supported Not Supported

H1. School Enrollment Environmental Health H2. Primary Completion  Environmental Health H3. Progression Second Sch  Environmental Health H4. Nonagri Employment  Environmental Health H5. Vulnerable Employment  Environmental Health H6. Labor Participation  Environmental Health H7. Unemployment  Environmental Health H8.Parliement Seats  Environmental Health H9. HIV Prevalence  Environmental Health H10. Births w/ Health Staff Environmental Health H11.Contrecept Prevalence  Environmental Health

Table 3. Summary of results Model 2: Regression analysis of the effects of Women Social Development on Environmental Health for Upper Middle Income Countries, R2 = 0.608, F Sig. = 0.000

Hypotheses

Standardized Beta
0.013 0.090 0.001 0.276 -0.366 0.415 - 0.223 0.020 -0.381 0.142 -0.156

p-Value
0.929 0.478 0.995 0.251 0.020 0.086 0.192 0.883 0.009 0.237 0.328

Results
Not Supported Not Supported Not Supported Not Supported Supported Not Supported Not Supported Not Supported Supported Not Supported Not Supported

H1. School Enrollment Environmental Health H2. Primary Completion  Environmental Health H3. Progression Second Sch  Environmental Health H4. Nonagri Employment  Environmental Health H5. Vulnerable Employment  Environmental Health H6. Labor Participation  Environmental Health H7. Unemployment  Environmental Health H8.Parliement Seats  Environmental Health H9. HIV Prevalence  Environmental Health H10. Births w/ Health Staff Environmental Health H11.Contrecept Prevalence  Environmental Health

Table 4. Summary of results

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Model 3: Regression analysis of the effects of Women Social Development on Environmental Health for Lower Middle Income Countries, R2 = 0.693, F Sig. = 0.000

Hypotheses

Standardized Beta
0.012 0.195 0.153 0.122 -0.124 -0.172 0.159 0.047 -0.272 0.119 0.282

p-Value
0.934 0.222 0.257 0.428 0.468 0.261 0.284 0.704 0.017 0.502 0.061

Results
Not Supported Not Supported Not Supported Not Supported Not Supported Not Supported Not Supported Not Supported Supported Not Supported Not Supported

H1. School Enrollment Environmental Health H2. Primary Completion  Environmental Health H3. Progression Second Sch  Environmental Health H4. Nonagri Employment  Environmental Health H5. Vulnerable Employment  Environmental Health H6. Labor Participation  Environmental Health H7. Unemployment  Environmental Health H8.Parliement Seats  Environmental Health H9. HIV Prevalence  Environmental Health H10. Births w/ Health Staff Environmental Health H11.Contrecept Prevalence  Environmental Health

Table 5. Summary of results Model 4: Regression analysis of the effects of Women Social Development on Environmental Health for Low Income Countries, R2 = 0.815, F Sig. = 0.000

Hypotheses

Standardized Beta
-0.034 0.253 0.284 -0.073 -0.388 0.275 0.151 0.166 -0.139 0.088 0.243

p-Value
0.826 0.156 0.030 0.574 0.014 0.080 0.256 0.145 0.286 0.525 0.097

Results
Not Supported Not Supported Supported Not Supported Supported Not Supported Not Supported Not Supported Not Supported Not Supported Not Supported

H1. School Enrollment Environmental Health H2. Primary Completion  Environmental Health H3. Progression Second Sch  Environmental Health H4. Nonagri Employment  Environmental Health H5. Vulnerable Employment  Environmental Health H6. Labor Participation  Environmental Health H7. Unemployment  Environmental Health H8.Parliement Seats  Environmental Health H9. HIV Prevalence  Environmental Health H10. Births w/ Health Staff Environmental Health H11.Contrecept Prevalence  Environmental Health

Table 6. Summary of results

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Model 5: Regression analysis of the effects of Women Social Development on Environmental Health for All Countries, R2 = 0.876, F Sig. = 0.000

Hypotheses

Standardized Beta
-0.019 0.096 0.057 -0.020 -0.673 0.062 -0.033 0.058 -0.178 0.012 0.174

p-Value
0.645 0.032 0.204 0.647 0.000 0.137 0.349 0.074 0.000 0.709 0.000

Results
Not Supported Supported Not Supported Not Supported Supported Not Supported Not Supported Not Supported Supported Not Supported Supported

H1. School Enrollment Environmental Health H2. Primary Completion  Environmental Health H3. Progression Second Sch  Environmental Health H4. Nonagri Employment  Environmental Health H5. Vulnerable Employment  Environmental Health H6. Labor Participation  Environmental Health H7. Unemployment  Environmental Health H8.Parliement Seats  Environmental Health H9. HIV Prevalence  Environmental Health H10. Births w/ Health Staff Environmental Health H11.Contrecept Prevalence  Environmental Health

Table 7. Summary of results

DISCUSSION AND CONCLUSION In this study, we examined the impact of women’s social development on national environmental health performance. With an empirical application to the year 2010 pooled cross-national data of 163 countries, results indicated that from women’s social development variables, unemployment rate has possible effects on environmental health of countries with high income, vulnerable employment and HIV prevalence of women has effects in upper middle income, HIV prevalence in lower middle income, and progression to secondary school and vulnerable employment have effects on environmental health of low income countries. However, without taking into account the effects of economic development, we found women’s primary school completion, vulnerable employment, HIV prevalence, and contraceptive prevalence to be the important factors in effecting environmental health of the countries. Our assumption that there is an association between women’s primary school completion, progression to secondary school, HIV prevalence, vulnerable employment, and contraceptive prevalence, and environmental health was supported by the results of this study. However, the effects of women’s primary, secondary, tertiary school enrollment, share of women employed in the nonagricultural sector, labor participation, women participation in national parliaments, and births attended by skilled health staff on environmental health was not significant in any of the models we examined. These results have a variety of policy and managerial implications. For the high income countries, our results showed only one of the women social development indicators, female unemployment rate, showed a direct effect on environmental health. The beta value of - 0.249 explains the negative correlation between these two variables. So, we can state when unemployment rate of women in a country is high, one can expect environmental health conditions of that country to be low. Income is associated with exposure to a wide variety of environmental quality indicators in the ambient environment, at home, in school, on the job, and in one’s neighborhood (Evans and Kantrowitz, 2002), and women’s empowerment i n terms of labor participation can be important factor to increase earnings. So as proved by some studies (e.g., Kawachi and Berkman, 2003; Kling et al., 2004) each incremental rise in income help individuals to improve their surrounding health related conditions. This result related to high income countries helps us conclude in these countries, policy

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makers should pay more attention to increasing employment opportunities for women in order to improve environmental health. The results of this study also showed that in upper middle income countries, vulnerable employment and HIV prevalence in women affect environmental health significantly. Negative beta values of the relationships for both determinants surfaced an inverse correlation with environmental health. Thus, we can infer that when an upper middle income country has high vulnerable employment rate as well as HIV prevalence rate in women, those countries would be more susceptible to environmental health damages. Consequently, improving employment conditions and combating HIV and its detrimental effects on women can be an alternative approach to improve environmental health. For lower middle income countries, the results confirmed that HIV prevalence in women is the most important determinant of environmental health. HIV prevalence and the potential impacts of the epidemic on environmental health in three of the five regression analyses -upper middle and lower middle income country groups, and all countries combined- highlight the significance of efforts to be undertaken to prevent the disease. Formulating national policies and strategies, and providing high-level advocacy for HIV prevention and control in women can be important in the countries that are facing environmental health deterioration. Last country group, low income country cluster, results illuminated a slightly different picture compared to the other regression analyses. The analyses showed that when the level of women’s progression to secondary school was high, the environmental health of that country was also high in low income countries. This result supported our hypothesis on the effect of women’s educational attainment of progressing towards secondary school on environmental health. Environmental scholars supported the idea that higher education institutions occupy a unique position in that they educate and mold the next generation of society’s decision-makers (Walton et al., 2000); therefore, formal education considered critical for achieving environmental and ethical awareness, values, attitudes, skills and behavior (Peng and Lin, 2009). This approach becomes more significant for female population when we consider the nurturing role played by women in societies. National planning of programs on encouraging women to progress towards secondary school can be an important policy support to increase, expand and coordinate the women empowerment in educational attainment, which can be crucial strategy to improve the environmental health of a nation. While there is rapidly increasing interest in researching and explaining the linkages between economic and social development variables and environmental health, many obstacles remain. For instance, some environmental degradation has a long latency period, and other degradation occurs on such a scale that it defies foresight and data gathering. Additionally, many risk factors may interact synergistically, making it extremely difficult to predict their effects. Also, many of the data sources in this area of study are incomplete and require improvements. All these need careful consideration when focusing on potential predictors related to environmental health outcomes. Furthermore, it is possible that the future research considering different time periods and over time changes can help identify the potential relationship between social development for women and environmental health differently . The future data may show different results regarding this relationship. REFERENCES Antoci, A. (2009). Environmental degradation as engine of undesirable economic growth via self-protection consumption choices. Ecological Economics. 68 (5): 1385-1397. Cutler D, Lleras-Muney A. (2006). Education and Health: Evaluating Theories and Evidence. Ann Arbor, MI: National Poverty Center. EPI (2010). Environmental Performance Index. Yale Center for Environmental Law & Policy, Yale University. Retrieved from <http://epi.yale.edu/> on September 19, 2011. Evans, G.W., & Kantrowitz, E. (2002). Socioeconomic status and health: The potential role of environmental risk exposure. Annual Review of Public Health, 23, 202-231. Grafton, R.Q. and Knowles, S. (2004). Social capital and national environmental performance: a crosssectional analysis, Journal of Environment and Development, 13(4), 336-370.

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Hernandez, L. M. & Blazer, D. G. (2006). Genes, Behavior, and the Social Environment Moving Beyond the Nature/Nurture Debate. Edited by Lyla M Hernandez and Dan G Blazer. Institute of Medicine (US) Committee on Assessing Interactions Among Social, Behavioral, and Genetic Factors in Health. Washington (DC): National Academies Press (US); 2006. Mendelsohn, R. (1994). Property rights and tropical deforestation. Oxford Economic Papers, New Series , 46, Special Issue on Environmental Economics (Oct. 1994), 750-756. Husted, B. W. (2005). Culture and Ecology: A Cross- National Study of the Determinants of Environmental Performance, Management International Review, 45(3), 349–371. Iles, A. T. (1997). Health and the Environment: A Human Rights Agenda for the Future. Health and Human Rights, 2(2), 46-61. Kawachi I, Berkman LF. (2003). Neighborhoods and Health. New York: Oxford University Press; 2003. Kling J.R., Liebman J.B., Katz L.F., Sanbonmatsu L. (2004) Moving to opportunity and tranquility: Neighborhood effects on adult economic self-sufficiency and health from a randomized housing voucher experiment. [accessed June 14, 2004]. KSG Working Paper No. RWP04-035. [Online]. Retrieved from http://ssrn.com/abstract=588942 on November 10, 2012. Mariani, Fabio, Perez Barahona, Agustin and Raffin, Natacha (2009). Life Expectancy and the Environment. IZA Discussion Paper No. 4564. Available at SSRN: http://ssrn.com/abstract=1506316. Moeller, D.W. (2005). Environmental Health (3rd ed.). Cambridge, MA: Harvard University Press. Retrieved from http://books.google.com/books?hl=en&lr=&id=A4DSAonzJN4C&oi=fnd&pg=PR7&dq=education+%22e nvironmental+health%22+relationship&ots=qm82Z7__Mh&sig=GVhm6yQLSZ8hEsJoAre9J7dJ0wA#v=o nepage&q&f=false on November 12, 2011. OECD (2008). Retrieved from http://www.oecd.org/social/40881538.pdf on January 24, 2013. Park, H. , Russel, C., & Lee, J. (2007). National culture and environmental sustainability: A cross-national analyses. Journal of Economics and Finance, 31(1), 104-121. Peng, Y. S., & Lin, S. S. (2009). National Culture, Economic Development, Population Growth and Environmental Performance: The Mediating Role of Education. Journal of Business Ethics, 90(2), 203-219. Tamazian, A.; Chousa, J. P.: Vadlamannati, K. J. (2009). Does higher economic and financial development lead to environmental degradation: Evidence from BRIC countries. Energy Policy, 37(1): 246-253. doi:10.1016/j.enpol.2008.08.025. Tonelson, A. (2000). The race to the bottom. Boulder, CO: Westview Press. UNDP (1998). World Resources Institute, United Nations Environment Programme, United Nations Development Programme, World Bank. A guide to the global environment: environmental change and human health. New York: Oxford University Press; 1998. Walton, J., T. Alabaster and K. Jones (2000). Environmental Accountability: Who’s Kidding Whom?, Environmental Management, 26(5): 515-526. doi: 10.1007/s002670010109. WorldBank (2010). WorldBank indicators. Retrieved from http://data.worldbank.org/indicator on January 26, 2013. WorldBank (2012). WorldBank countries and economies, Retrieved from http://data.worldbank.org/country on January 24, 2013. WHO (1997). Health and environment in sustainable development: five years after the Earth Summit. Geneva: World Health Organization;1997. WHO document WHO/EHG/97.12.

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WHO (2011). World Health Organization, Health Topics. Environmental health. Retrieved from http://www.who.int/topics/environmental_health/en/ on September 12, 2012. WHO (2012). World Health Organization. Health through safe drinking water and basic sanitation. Retrieved from http://www.who.int/water_sanitation_health/mdg1/en/index.html on May 14, 2012. Yassi, A., Kjellström, T., de Kok, T., & Guidotti, T. (2001). Basic Environmental Health. New York: Oxford University Press. Xing, Y. and C. Kolstad (2002). Do lax environmental regulations attract foreign investment? Environmental and Resource Economics, 21: 1-22.

Avinandan Mukherjee Professor and Chair, Department of Marketing Editor – International Journal of Pharmaceutical and Healthcare Marketing School of Business Montclair State University Montclair, NJ 07043, USA Phone: (973) 655-5126; Fax: (973) 655-7673 Email: mukherjeeav@mail.montclair.edu Naz Onel Ph.D. Candidate, Environmental Management Earth and Environmental Studies College of Science and Mathematics Doctoral Research Scholar, Department of Marketing School of Business Montclair State University Montclair, NJ 07043, USA Ph: (973) 655-7037; Fax: (973) 655-7673 Email: onelgarmkhb1@mail.montclair.edu

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THE EFFECT OF HEALTH ORIENTATION ON PATIENT COMPLIANCE: WHAT ROLE DOES SOCIAL MEDIA PLAY IN THIS EQUATION?
Avinandan Mukherjee, Montclair State University Archana Kumar, Montclair State University

ABSTRACT Patient compliance is considered to be a critical issue that healthcare managers need to address. While the healthcare management literature has identified several antecedents to patient compliance, the role of health orientation of patients remains relatively unexplored. Further, as social media gains prominence in healthcare behavior, this paper explores how social media attitudes differ for patients with high and low levels of health orientation. We offer eleven propositions based on theoretical and conceptual foundation to examine these linkages. Healthcare managers can use this idea to better understand how health orientation, social media and patient compliance come together in influencing improved patient outcomes.

INTRODUCTION Monikered as the ‘holy grail’ of healthcare marketing, patient non -compliance or non-adherence to instructions given by healthcare personnel is one of the major issues faced by the healthcare industry today. Noncompliance results in not only financial losses but also poses a danger to the patient’s well -being. The estimated annual financial losses because of patients who do not take their prescriptions as described have reached a staggering $300 billion (Ringler, 2011). In addition to financial losses, non-adherence is the cause of approximately 10% of all hospitalizations, 23% of all nursing home admissions and leads to over 125,000 deaths per year (Berg et al., 2003). Hospitals also need to pay serious heed about compliance because of a new law in place which will fine hospitals that have too many patients readmitted within 30 days of discharge due to complications (Hospitals to be Fined, 2012). With over half of the 1.8 billion prescriptions written annually taken incorrectly by patients, patient compliance is a serious issue which needs to be better understood by healthcare managers. Social media in healthcare and compliance Though healthcare in the U.S. is one of the leading industries in terms of size and scope, it is also the slowest to adopt advances in communications using new media. Networking through social media has become an integral part of life and its influence has extended to healthcare. A recent study indicates that nearly 59% of adults in the U.S. seek health information on the Internet with 25% of U.S. adults reading someone else’s commentary or experience about medical issues on social media (Social Media in Healthcare, 2012). Social media is a form of electronic communication through which users create online communities to share information, ideas, personal messages, and other content. Acknowledging the growing influence of social media on the patient’s lives, the healthcare industry has begun to tackle the problem of non-compliance through this medium. Utilizing social media sites to advertise, incentivize and teach patients about the importance of compliance is becoming the next step in the fight to increase compliance. Educational and reminder materials informing patients about the benefits of the regimen are increasingly made available through traditional means (print, and oral explanation), new media (email newsletters, websites, text messages, and social media sites), and through interactive elements (patient quizzes, and

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mobile widgets). However, the effect of social media on patient compliance remains unexplored. There are no empirical understanding of the motivators of social media use by patients and its influence on compliance. The objective of this study is to empirically test a conceptual framework that aims to understand the role of social media on health orientation of patients and to further understand the relationship between health orientation and compliance. LITERATURE REVIEW General information about compliance Compliance is defined as the degree to which a patient correctly follows the instructions that are given to them by a healthcare professional and written on the medication label (e.g., prescribed dose and time schedule) (Kermani and Davies, 2006). Though it is difficult to pinpoint on one particular reason for patients being noncompliant, it could result from patient-centric unintentional factors (e.g., forgetfulness, cost of the treatment, and regimen complexity), and patient-centric intentional factors (e.g., personal health beliefs, health motivations, and the perceived value of the medication) (Loden and Schooler, 2000). As a result of non-compliance, patients may not fill the initial or subsequent prescriptions, take incorrect dosage of a prescription or stop the use of prescription altogether, and not follow the treatment regimen correctly. In some instances people start to gain a misconception about a particular drug’s ability to perform when in reality the drug may be being misused or abused. A patient’s inability to stick with their prescription or treatment regimen can also lead to lower retention rates, a higher level of brand switching, and potentially negative word of mouth if the patients are not satisfied with the drug or a bad experience occurs. Pharmacies see less traffic when prescriptions are not refilled which produces less revenue for both those stores as well as the pharmaceutical brands. All of these consequences can also lead to an impact on the overall economy by adding healthcare costs. Some of the direct costs that can attribute to non-compliance are additional physician visits, diagnostic testing, and hospital admissions. Nearly 25% of all malpractice suits are related to a non-compliance situation. With several serious financial and life-threatening repercussions, empirical understanding of what leads to patient non-compliance is essential. Technology and compliance The healthcare industry has been taking several steps to decrease the ramifications of non-compliance such as enhancing patient understanding or knowledge of the regimen, modifying treatments to reflect patient preferences, reducing regimen complexity or duration, and even offering financial incentives to patients (Becker and Maiman, 1989). Doctors have long been playing a role in patient compliance by incorporating traditional means such as reminder conversations during an appointment or instructing the patient to maintain a journal about the patient’s health behavior. Apart from the interaction between doctors and pat ients, the healthcare industry uses several other external tools to help compliance such as reminder devices, computer aids, and direct to consumer advertising. Reminder devices such as counter cups and electronic pill boxes with built-in reminder alarm are simple, non-expensive tools to enhance patient compliance. The use of computer aid devices as also become a practice as a means for ensuring adherence. All of these reminder assistance options are beginning to become dated because of the new technology and media outlets that patients are able to access today. Although these reminder devices and computer aids may still appeal to the the Baby Boomers or the Generation X, the Millennials and the Internet generation will benefit by a technologically savvy way to track their treatments. One way to accomplish patient compliance while using current technology trends is the use of social media to steer patients towards compliance.

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Social Media and Patient Compliance Social media is defined as “a group of Internet-based applications that build on the ideological and technological foundations of Web 2.0, and that allow the creation and exchange of User Generated Content” (Kaplan and Haenlein, 2010, p. 61). The different types of social media include blogs, social news, networking websites, microblogging, social bookmarking, discussion boards, online communities, professional networks, photo and video sharing, and review/recommendation websites which promote participation, openness, conversation, community, and connectedness. With hundreds of social media websites abounding, more and more users are utilizing social media productively in their day-to-day life. A recent study indicates that over 80% of all Americans use a social network website with one in every six minutes spent online is on social media websites (Kruse, 2010). Because of its widespread usage, social media is becoming vital in health management among patients. Patients use several social media websites such as online forums, video-sharing websites, and blogs not only to search for information about their health but also to interact with other people with similar health conditions. The healthcare industry has been generally lagging behind in social media presence compared to other industries. Healthcare industries need to jump start their social media presence because studies indicate that nearly 80% of Internet users looked up health information online (Schoen, 2011). Patients and consumers are increasing their involvement with online peer to peer communications by interacting with other consumers and participating in online communities (Misra, Mukherjee, and Peterson, 2008). Further, in survey conducted by Wego Health, it was found that nearly 63% concurred that social media dialogue between healthcare companies and online communities is valuable, and 60% of respondents said companies should get involved in monitoring and correcting any misconceptions about their products online (Arnold, 2011). Social media initiatives such as these by healthcare and pharmaceutical companies can provide a large return on investment by building relationships with their consumers, improving outcomes such as adherence and making their brand visible on the web. Innovative campaigns, games, apps, articles, videos, etc., will help to connect and motivate users. The challenges to get patients to stay complaint with their treatments cost the healthcare industry billions of dollars each year. Social media can be a low cost effort to try and reach the goal of a decline in non-compliance. It also allows companies to appeal to all patient types by using the variety of features the platforms have to offer. However, there is no empirical evidence to understand the users of social media towards healthcare. Having presented the importance of social media initiatives by the healthcare companies in order to improve patient compliance, this study aims to identify the role played by social media towards healthcare and its influence on health orientation which in turn has an impact on patient compliance. PROPOSITIONS Health Orientation  Patient Compliance Health orientation is one of the emerging approaches to segment healthcare consumers and is defined as “a goal-directed arousal to engage in preventive health behaviors” (Moorman a nd Matulich, 1993, p. 210) and is an important variable that explains the difference in health behaviors in individuals (Burns, 1992; Dutta-Bergman, 2004). Health orientation is measured by three indicators namely health consciousness, health beliefs, and health information orientation (Dutta-Bergman, 2004). Health consciousness indicates the degree to which an individual integrates health concerns into his or her day to day activities (Jayanti and Burns, 1998). These people try to stay healthy not only when they need medical assistance but also they are in favor of taking preventive steps such as exercising and eating right in order to keep their body healthy. The second indicator of health orientation is health beliefs which refer to “specific cognitions held by individuals about health behaviors such as eating healthy, exercising, and so forth”. The third indicator of health orientation is health information orientation which refers to the extent to which an individual is willing to search for information relating to health and wellness. Individuals with

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high health information orientation are self-motivated to read and watch stories about their health and eagerly look for various ways to gather information either on remaining healthy or their treatment in case of a medical assistance. (Dutta-Bergman, 2004). Health orientation is a motivational variable that taps into consumer interest in maintaining a healthy life and propels the enactment of health behaviors (Dutta-Bergman, 2004). Their motivation to be and stay healthy shows to what extent they are willing to take some certain actions for the sake of their health. The level of motivation is directly proportional to the attention and the comprehension of the person towards that specific topic. The patients who have are positively oriented toward health would be willing to keep themselves healthy and try to comply with healthcare regimen as well as take preventive steps if necessary. Hence, we propose that health oriented patients will have a greater interest in being compliant to health treatments. P1: Positive health consciousness of patients will lead to greater degree of compliance P2: Positive health belief of patients will lead to greater degree of compliance P3: Positive health information orientation of patients will lead to greater degree of compliance In order to propose the relationship between individual characteristics pertaining to health and social media for healthcare, we borrow from the literature pertaining to direct-to-consumer advertising (DTCA) of pharmaceutical products. Research indicates that those with higher health knowledge and health belief tend to trust DTCA to a lesser extent (Hoek and Maubach, 2007). However, trust is an important determinant in many social interactions concerning important decisions and new technology (Fukuyama, 1995). Researchers have concluded that trust in a system does not occur overnight but in a gradual manner through enduring interactions with the system (Gefen, 2000). Trust is based on imperfect knowledge as it is a belief that one forms from various cues. Social media provides various cues for an individual to assess the credibility of the information source. For example, the social media website by itself might represent a certain level of credibility in the consumers’ eyes. Another cue could be the background of the information provider within the social media. The consumer may be familiar with the information provider on a personal level that they might trust the information provided by them. However, trust in information generated from social media is a novel concept which is still under scrutiny and is unclear whether healthcare consumers have a complete trust in that medium or not. Hence, we suggest the following propositions, P3: Individuals with higher health consciousness will trust social media for healthcare more than those with lower health consciousness P4: Individuals with higher health beliefs will trust social media for healthcare more than those with lower health beliefs P5: Individuals with higher health information orientation will trust social media for healthcare more than those with lower health information orientation Similarly, patients who have a higher orientation toward health and well-being may find themselves drawn towards social media for healthcare (Idriss, Kvedar, and Watson, 2009). Such individuals will also seek healthrelated information from social media websites that are geared towards healthcare. Hence, we propose the following relationships, P6: Individuals with higher health consciousness will have an affinity towards social media for healthcare more than those with lower health consciousness

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P7: Individuals with higher health beliefs will have an affinity towards social media for healthcare more than those with lower health beliefs P8: Individuals with higher health information orientation will have an affinity towards social media for healthcare more than those with lower health information orientation P9: Individuals with higher health consciousness will use social media for health-related information than those with lower health consciousness P10: Individuals with higher health beliefs will use social media for health-related information than those with lower health beliefs P11: Individuals with higher health information orientation will use social media for health-related information than those with lower health information orientation CONCLUSION Patient non-compliance is a major issue in healthcare and is responsible for a number of avoidable deaths and unnecessary healthcare expenses. It is imperative that healthcare managers address the issue of noncompliance. Academic studies are essential to understand the underlying reasons for non-compliance and implications from these studies could aid managers to develop effective strategies to counter the issue of noncompliance. The issue of non-compliance should be viewed from an empirical standpoint and studies should focus on understand the inherent reason for patients’ being non -compliant. To this end, future studies should examine the characteristics of patients that lead to compliant behavior. This paper proposes to consider the health orientation of patients as precursor to compliant behavior as it will aid in understand the issue better. Since the healthcare industry is moving into the era of electronic commerce, examining the role of social media in healthcare is timely and relevant. In order to further understand patient compliance, it is essential to consider how social media could be effectively used to remedy the issue of non-compliance. This study proposes to investigate the relationship between health orientation of patients and their attitude towards social media. Several real-life examples suggest that social media could play a significant role in compliance. In that regard, it is crucial to ask the question ‘Who are the users of social media for healthcare?’ and ‘How do they use social media for healthcare’? We hope that our paper will lead to greater inquiry in this nascent but an important area of research. REFERENCES Arnold, M. (2011). Merck Web Widget Points to Future Adherence Fix. Medical Marketing & Media. Retrieved September 10, 2012 from http://www.mmm-online.com/merck-web-widget-points-to-future-adherence-fix/article/213574/ Becker, M.H. and Maiman, L. A. (1980). Strategies for Enhancing Patient Compliance. Journal of Community Health, 6(2), 113-135. Berg, J. S., Dischler, J., Wagner, D. J., Raia, J. J., & Palmer-Shevlin, N. (1993). Medication compliance: a healthcare problem. Harvey Whitney Books Company. Dutta-Bergman, M. (2004).Primary Sources of Health Information: Comparisons in the Domain of Health Attitudes, Health Cognitions, and Health Behaviors. Health Communication, 16(3), 273-288. Fukuyama, F. (1995). Trust: The social virtues and the creation of prosperity. New York: Free Press.

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Gefen, D. (2000). E-commerce: the role of familiarity and trust. Omega, 28(6), 725-737. Hoek, J. and Maubach, N. (2007). Consumers’ Knowledge, Perceptions, and Responsiveness to Direct -to-Consumer Advertising of Prescription Medicines. NZ Medical Journal, 120-128. Hospitals to be Fined (2012). Retrieved on December 5, 2012 from http://www.usatoday.com/story/money/business/2012/09/30/medicare-fines-over-hospitals-readmittedpatients/1603827/ Idriss, S. Z., Kvedar, J. C. and Watson, A. J. (2009). The role of Online Support Communities: Benefits of Expanded Social Networks to Patients with Psoriasis. Archives of Dermatology, 145(1), 46. Jayanti, R. K. and Burns, A. C. (1998). The Antecedents of Preventive Health Care Behavior: An Empirical Study. Journal of the Academy of Marketing Science, 26(1), 6-15. Kaplan, A. M. and Haenlein, M. (2011). The Early Bird Catches the News: Nine Things you Should Know About Micro-blogging. Business Horizons, 54(2), 105-113. Kermani, F. and Davies, M. (2006). Patient Compliance: Setting the Scene. Patient Compliance: Sweetening the Pill, 3, 4-8. Kruse, K. (2010). New Facebook Game from Boehringer Ingelheim and Diabetes Hands Foundation. Research - The Patient Will See You Now, Doctor…. Retrieved December 4, 2011, from http://blog.kruresearch.com/2010/06/new-facebook-game-from-boehringer-ingelheim-anddiabetes-hands-foundation/ Loden, J. and Schooler, C. (2000). Patient Compliance. Pharmaceutical Executive, 20 (July), 88–94. Misra, R., Mukherjee,A. and Peterson, R. (2008). Value Creation in the Virtual Communities: The case of a Healthcare Web Site. International Journal of Pharmaceutical Healthcare. 2, 321-337. Moorman, C. and Matulich, E. (1993). A Model of Consumers' Preventive Health Behaviors: The Role of Health Motivation and Health ability. Journal of Consumer Research, 208-228. Ringler, J. (2011). The Adherence Fight: A TKO? Pharmaexec. Retrieved September 10, 2011 from http://pharmexec.findpharma.com/pharmexec/Partnerships/The-Adherence-Fight-ATKO/ArticleStandard/Article/detail/734674 Schoen, L. (2011). Social Health Revolution. Medical Marketing and Media. Retrieved December 2, 2011, from http://www.mmm-online.com/social-health- revolution/article/208644/ Social Media in Healthcare (2012). Retrieved on December 5, 2012 from http://www3.aaos.org/member/prac_manag/Social_Media_Healthcare_Primer.pdf Smith, M. (2009). Achieving Social Media Marketing Success: Secrets from Three Successful Marketers. WhitePaperSource Publishing. 1-33.

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Avinandan Mukherjee Professor and Chair, Department of Marketing Editor – International Journal of Pharmaceutical and Healthcare Marketing School of Business Montclair State University Montclair, NJ 07043, USA Phone: (973) 655-5126; Fax: (973) 655-7673 Email: mukherjeeav@mail.montclair.edu

Archana Kumar Assistant Professor, Department of Marketing School of Business Montclair State University E- mail: kumara@mail.montclair.edu

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Obesity in the Workplace- An International Out-look
Bharate Mishra, Grand Valley State University Jitendra Mishra, Grand Valley State University

ABSTRACT Over 64% of America is overweight and the number is increasing every year by a staggering amount. According to the Center for Disease Control (CDC) 44 million Americans are obese. That is one in five people that are obese. The scariest part about that statistic is that the number of people who are obese skyrocketed at a rate of 7% every year since 1991. The amount of medical care costs for an obese person is around $ 620 compared to nonobese persons (Obesity in America, 2004). According to CDC cost of treating soared to around 150 billion in 2008 and the cost doubled over a decade (WSJ, July 28, 2009). The cost was 74 billion in 1998. Obesity is a big problem because of injury claims, healthcare costs and absenteeism of obese workers. This can lead to discrimination of overweight workers. Obese people are stereotyped and often discriminated against in the workplace, although antidiscrimination laws for obese people are beginning to come into existence. Current research has shown that obese employees tend to result in higher costs for employers because of higher absenteeism rates, more medical claims, and lower productivity rates. Obesity has become a global problem. According to the WHO (World Health Organization, October 2009), more people worldwide now die from being overweight and obese than from being underweight. The WHO report states that 1.6 billion overweight or obese people in the world and 2.5million deaths are attributable to obesity.The United States has higher obesity rates than other countries, including the U.K. and France, although the prevalence of obesity worldwide is increasing. Some major cases involving overweight workers are cited: Cook Vs Rhode Island Department of Mental Health, Butterfield Vs New York State, Pan Am Flight Attendants Vs Delta Air Lines, and European Program-EPODE etc. The obesity epidemic, as it is called, has resulted in companies such as Microsoft and UniLever implementing wellness programs that have shown positive returns on investment. GlaxoSmithKline is another case that successfully promotes health lifestyles for its employees. HR(Human Resource) Manager faces a major challenge of controlling costs, endorsing healthy life styles and working to counter the dysfunctional and harmful effects of stereotypes about weight and appearance, and try to implement wellness programs that can ultimately benefit the company with improved productivity and decreased health costs. _____________________________________________________________________________________________ Introduction “To say that obesity is caused by merely consuming too many calories is like saying that the only cause of the American Revolution was the Boston Tea Party. “ Wolfdyke Adelle Davis According to the CDC(Center for Disease Control), obesity is considered to be just as debilitating as adding 20 years of agedness to your life. If you are 30 year old and are considered to be obese, you actually have the same mobility and health problems as a 50 year old should. The surgeon general has stated that over 9% of the nation’s health care spending is directly correlated to people who are obese. The government assumes that it costs almost $117 billion dollars a year in health costs and obesity leads to about 300,000 deaths a year. Obesity costs over 39 million lost workdays as well as 63 million trips to the doctors. Obesity costs U.S businesses around 13 million dollars (Obesity in America, 2004). Obese people who had BMI’s of over 4 0 had the highest number of lost work days (USA Today, 2007). John Hopkins study had results similar to the Duke study. According to the John Hopkins study 29% (percent) of the 7690 workers included in the study were injured at least once and 85% (percent) of the injured workers were classified as obese (Obese Workers, Associated Content, 2007). Every year, more and more

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people are considered overweight. The number of Americans considered obese by the CDC (Center for Disease Control) in 2001 was 44 million approximately one in five. This is 74% (percent) increase since 1991. The CDC (Center for Disease Control) calculated the cost as about $117 billion annually and 300,000 deaths per year (Obesity-Braun Consulting, 2004). According to CDC (Center for Disease Control) cost of treating soared to around 150 billion in 2008 (WSJ, July 28, 2009). Society accepts the underweight than the overweight much more readily, and shuns the obese even more. Obesity is growing at two three times GDP. As the number of obese employees is on the rise, so are the complaints of discrimination. Adding fuel to the fire studies show that obese employees are actually earning less to their counterparts. A study by TSU (Tennessee State University) shows that obese men and women can expect to earn on average anywhere from1 to 6 percent (%) less than normal weight employees. Obese people are constantly dealing with ridicule, and the workplace is not a safe haven for the stereotypes associated with obese people either. Obesity is a multi-factorial condition that results in a person being overweight to the point that it begins to cause serious health problems. As described by Wolfdyke Adelle Davis, obesity is not caused by simply eating too much, as many people perceive it to be. Obesity is a complicated condition that is the result of a multitude of factors, many that are still being discovered. Van Itallie describes obesity by saying it’s “an individual’s degree of fattiness has exceed some arbitrary limit (Van Itallie, 1979).” There is no universally accepted measure of Obesity, but the most common measure is an individual’s Body Mass Index (BMI). BMI is measured by taking weight/height 2 (kg/m2). The following chart is the most commonly accepted BMI equivalencies:

(Boston Medical Center 2007) How to Calculate Body Mass Index (BMI)? To calculate BMI, one must divide one’s weight in pounds by height in inches squared. The n multiple that answers by 703. Multiple your height in inches by itself(68 times 68, if you are 5’8”(68 inches) give s you 4,624, yields.04 The next step is to multiply that number by 703 to arrive at a BMI of 28. For people at home with metric measures, the BMI is weight in kilograms divided by height ibn meters squared. One can also get one’s BMI calculated at nhlbisuoort.com/bmi. BMI provides an estimate of how much of your weight is muscle and bone and how much is fat. A normal BMI is 18.5 to 24.9; 25 to 29.9 is overweight; 30 and above is obese.BMI is a better health gauge than weight alone. But BMI is far from perfect. Heavily muscled individuals end up classified as obese. BMI is not reliable for people than 75. At that age much muscle tissue has shriveled and these people are classified as normal when their body fat is higher than it should be. Waist measurement, taken with a cloth tape measure, is another way to ascertain health risk. A man’s waist should be equal to or less than 40 inches (102cm); a woman’s 35 inches or less (88cm).

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The current research on obesity fails to provide a single collective definition of the condition. Since the research on the subject has only recently begun to expand as the obesity rates increase, there is still much debate about the negative effects of obesity, and if obesity should be considered a disease, but one thing is for sure: Obesity is a major problem. Some even say it is becoming an epidemic and more research is being done to better understand the consequences of obesity. The prevalence of obesity in the United States has been on the rise for many years, and the same trend is beginning to prevail in other countries as well. Our paper investigates the differences in prevalence of obesity between the United States and select countries, including France and the U.K. We also examine the different tactics being employed internationally to help prevent and decrease the prevalence of obesity in the workplace. In the field of human resource management obesity of a company’s employees is cited as one of the biggest concerns for many organizations for numerous reasons. Obese employees are associated with higher costs, as they tend to have higher absentee rates and require more medical attention. Morals can also be an issue as historically obese people have been ridiculed for their appearance, resulting in lower self-esteem and motivation levels which in turn results in a decreased output. The negative factors associated with obese employees create a dilemma for many human resource managers: do they hire the obese employees and incur the extra costs, or overlook the qualified obese employee and become entangled in a potential discrimination lawsuit? In recent years, more case studies have begun to emerge that centered on the implications for companies that hire obese employees. The Fat Chance case study examines this dilemma and its implications in a real world situation. A case study performed by PricewatersCoopers L.L.P. that included many companies, such as Microsoft, also examined numerous companies and their new obesity programs as the latest wellness focus of many of the companies. The final two case studies included in our paper concern GlaxoSmithKline and Du Pont. These two studies touch on the future outlook for many companies in the war against obesity by highlighting the successful implementation of programs promoting healthy lifestyles for their respective employees. Combining information from the medical and business fields of study from the United State and other countries with recent real world case studies all support the notion that an obese worker is more costly to the company and programs that promote health and wellness in the workplace must be implemented to help combat the fight against obesity. Obesity is a rising concern Obesity is a rising concern within the workplace. It has been proven to affect fifty-nine percent of employees in their twenties, sixty-eight percent who are middle-aged, and seventy-seven percent of older workers (2006). Since the late nineties to now, the percentage of working Americans has doubled from fifteen percent to thirty-four percent of the entire adult population (Gabel). According to a recent study done by Pfizer many working Americans who are obese have trouble keeping up pace in a steady work environment. A sample size of 140 million people over the age of twenty years old was subject to this study. The findings show that obese employees are less productive and cost employers a larger sum of money to keep them employed. It is reported that 86.3% of American Adults will be overweight or obese in 2030.Obesity is defined as having a body-mass index-a calculation based on height and weight-above 30 or about 180 or more pounds for a 5-foot 5 inches person. People with a BMI of 18.5 to 24.9 are considered of healthy weight and a BMI of 25 to 29.9 is considered overweight. Overweight is defined as having BMI of 27 or higher and obese means a value of 30 or higher. Colorado has the highest rate of obese adults and Mississippi has the highest, according to a CDC(Center for Disease Control and Prevention). The CDC(Center for Disease Control and Prevention) report found that 18.6%

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of adults age 18 and over in Colorado were obese in 2009 while 34.4% of adults in Mississippi were obese. Overall the CDC(Center for Disease Control and Prevention) report found that 26.7 % of adults nationwide are obese. This is up from 25.6% in 2007 survey. Americans are fetter than ever. Obesity related illnesses and complications are now responsible for nearly one-tenth of the nation’s annual health-care costs. It is vital to understand what is behind America’s “obesity plague”. Productivity gains at work, brought about by automation have raised incomes and increased the cost of burning calories. When the labor is sedentary because of automation, weight can increase even though calorie intake falls. Stereotypes According to a majority of studies, stereotypes pinned to obese individuals are nothing more than myths and biases. While correlations can be made to health risks and costs, personality traits are harder to rationalize due to inconsistencies and vicious-cycle situations between personality and obesity (Roehling, Roehling, and Odland, 2008). In analyzing previous studies, the authors found that there was little to no rationale for the relationship between stereotype and weight, and that possibly the treatment by coworkers who hold these biases cause the negative traits to become more developed. It is common for obese individuals to be judged on their internal dispositions, as obesity is looked at as a self-afflicted malady (Townsend and Paul, 1998). Instead, it is based on interactions between biological, environmental, and personality factors (Roehling, Roehling, Odland, 2008). This is reiterated in Weight Discrimination in the Workplace, where Roehling discusses a study that also attributes obesity to complex networking between “psychological, environmental, and physiological or genetic factors,” Figures of Stereotypes of Overweight Employees shows a linkage of factors contributing to (causing and reinforcing) negative stereotypes about overweight employees. Overweight individuals get ridiculed by teachers, physicians, and complete strangers in public settings, such as supermarkets, restaurants and shopping areas. Overweight people tell stories of receiving poor grades in school, being denied jobs and promotions, losing opportunities to find good life-partners or soul-mates. Employers discriminate against the obese persons-call them ‘unfit’ for many positions like sales and more appropriate for telephone sales or positions involving little face-to-face contacts. Overweight employees are assumed to lack self-discipline, be lazy, less conscientious, less competent, sloppy, disagreeable, and emotionallyunstable. Obese employees are also believed to think slower, have poorer attendance records and be poor role – models (Paul RJ, TownsedJB, Employee Responsibilities, Rights J, 1995). There is evidence of significant wage penalty for obese employees. A study of over 2000 women and men (18 years of age and older) reported that obesity lowered wage growth rates by nearly 6% in 1982 to 1985 (Lob ES, Soc Sc Quart, 1993). An analysis from the National Longitudinal Survey Youth Cohort examined earnings in over 8000 men and women (18 to 25 years old) and reported that obese women earned 12% less than non-obese women (Register CA, Williams Soc Sci Quart, 1990). It appears that economic penalty of obesity seems to be specific to women. Hesitations in Hiring There are many reasons why employers are hesitant to higher overweight workers. The first of these hesitations is a decrease in worker productivity. Many studies have concluded that companies who employ overweight workers lose money due to a decrease in production. This is because “overweight workers are slower and less efficient than their slimmer counter parts-costing their employers and average of $1800/- a year (Harper, 2008) Companies that employ overweight workers risk the increasing cost of insurance. In 2004 health care cost was around 12 percent of the budget and now it has risen to more than 18 percent. A New York-based Insurance Information Institute reported that because of obesity, rate for health insurance, life insurance, disability insurance, workers compensation liability insurance and excess casualty insurance are all on the rise (Merx, 2004). Joyce reported that in 2004 total costs of obesity to U.S companies was around $13 billion annually and there was also 13 percent increase in health care premiums (Joyce, 2004). And according to CDC (Center for Disease Control) cost of

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treating soared to around 150 billion in 2008 and the cost doubled over a decade. The cost was 74 billion in 1998(WSJ, July 28, 2009). Wages can be affected by weight discrimination. A study showed that overweight women make 24 percent less than normal size women and moderately obese make 6 percent less (Kirstein, 2002). Airline Industry weight regulations for flight attendants have posed problems for employees above average weight. In Tudyman v. Southwest Airlines, a flight attendant was terminated and his reinstatement was denied because weight exceeded airline requirements (Garcia J, Hofstra Labor Law J. 1995). Courts have accepted airline weight restrictions. Legal Environment With the increase in obesity in the workforce, many employers have begun to face discrimination charges. Without obesity-specific laws, they are pioneering new directions in the litigious world, following previous discrimination cases as guidelines. The linkages here are with an increase in age, compensation laws, disabilities acts, and privacy issues. Constraints also arise in termination laws, negligent hiring liabilities, and promotion/benefit discrimination (Townsend and Paul, 1998). In most cases, the proof is on the employer to provide evidence that the employee is deserving of their received actions, and although these legalities require no additional employment practices, but deserves attentiveness and continuous evaluation. Although obesity is not currently covered by federal or state law, it can be covered by other laws depending on the interpretation of that law. For a business to avoid allegations of these discrimination claims they should maintain awareness of laws and trends, establish antidiscrimination policies, and train employees on proper hiring and compensation practices. Further, they should attempt to look forward to and create an environment conducive to healthy and employee wellness (Townsend and Paul, 1998). Obesity is an issue not only once an employee enters the workforce, but potentially before they are even hired. According to a study comparing body weight and four relative personality traits (conscientiousness, agreeableness, emotional stability, and extraversion), obese applicants tend to hold the characteristics identified with overweight employees (Roehling, Roehling, Odland, 2008). This validity may prevent an individual from being hired based solely off these preconceived stigmas. Selection is only the first phase of overweight bias during employment- it exists in nearly every stage through counseling, compensation, training, and discharge. Individuals who are overweight tend to be rated as less desirable for all positions within an organization as well, and that women are critiqued more harshly than men in all areas (Roehling, Roehling, Odland, 2008). Unfortunately, in many cases where discrimination laws do not cover obesity, especially in equal opportunity, justice and ethical standards are at conflict. Whether the personal trait is unrelated to job performance or legal and ethical standards overlap, it is a difficult decision that may have worse consequences than anticipated (Roehling, Roehling, Odland, 2008). When people are faced with obesity issues it affects both the individual’s performance and the organization’s profits. To explain, when an individual is overweight they are restrained to the amount of work they can perform due to the physical, emotional, and mental stress. In fact, it has been proven by Robin Hertz, PhD, senior director at Pfizer, that obese employees are seven percent more likely to report limitations in their job description compared to an average weight employees at only three percent (Obesity, 2005). From the employer’s view it also costs mo ney for obesity. A cost for an employer to have an obese employee deals with the direct cost of increasing insurance premiums. For each person who is at risk of obesity the firm needs to increase the medical insurance coverage. Another factor that costs the firm money is the decrease in the firm’s productivity. Since the firm has to be more focused on the health and well being of their employees, they are less focused on increasing their market share. Granted, this helps companies save time and money on training and rehiring, but it is also a catch twenty-two because they are spending their money elsewhere instead of focusing more on their profits, therefore, ending with less output.

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Furthermore, a study conducted in 2005 by the National Health Survey database and the Medical Expenditure Panel Survey database have shown that obesity rates for each employee range from $450 to $2,500. In fact it has been recognized that the combined annual per capita cost of being obese for men costs an employer anywhere from $460 to $2,030 and for women anywhere from $1,370 to $2,485 (obesity costs). Granted, these costs are a greater risk for those between the ages of fifty-four to sixty-four years old but, these costs includes the medical expenses as well as their absenteeism (Long, 2007). The frequency of absenteeism for an illness or an injury of average weight people usually consist of three days, whereas an obese employee averages eight days per year (obesity costs). Employers are still trying to find ways to fight obesity. A report from the Centers for Disease Control and Prevention show that thirty-three percent of all American working women are obese while thirty-one percent of all American working men struggle with obesity as well (Long, 2007). To help prevent costs and benefit the working atmosphere, businesses are willing to incorporate weight management programs. From a recent survey conducted by Strategies to Overcome and Prevent Obesity Alliance (STOP) it showed that seventy-three percent of managers feel that offering obesity programs to their employees is both effective and appropriate. This survey also showed that eighty percent of American employees would be willing to participate in an obesity program (EHS News, 2008). In addition to this, Susan Randolph, president of the American Association of Occupational Health Nurses Inc., (AAOHN) performed a survey on wellness programs within the workplace. In 2004 only two percent of all business within the United States was actively participating. And although only two percent of American businesses were doing this, over half of them reached their weight loss goal with flying colors and were happy to have the program at a convenient spot where they work. International Four to seven point eight percent of total illnesses globally can be attributed to obesity or overweight tendencies. Similarly, obesity reports regarding several western countries, including Australia, US, Sweden, and the Netherlands, between two and five percent of healthcare costs in industrialized societies stem from obesity (Basdevant, 1995). Along with the United States, the United Kingdom is also facing obesity. In Great Britainwhere 60% of men and 50% of women are expected to be obese by mid-century-residents of some cities are being recruited to wear electronic tracking tags to calculate how much they move each day and how many calories they burn. Daily exercises will be rewarded with store coupons and even days off from work. The UK government is trying to help put a stop to obesity in the workplace and at home. With a combined effort from the media, retail, and health industries, the UK will be getting around 200 million Euros that will be put towards the awareness for obesity. In U.K most employers preferred to offer jobs to workers of a normal weight. And one in five adults is dangerously overweight (Thomas, 2007). The government hopes to create a “lifestyle revolution” and put a stop to obesity (Mayor, 2009). Most people in the UK feel that if the government does not help stop obesity in the workforce now then it will only get worse. The people of the UK feel that working parents will bring home their obesity problems and pass them to the children of the working future. In Australia, 10% of deaths in 1989 were attributed to obesity; following the same rate, this would allude to 55,000 deaths related to obesity. Obesity has become a global problem. According to the WHO (World Health Organization, October 2009), more people worldwide now die from being overweight and obese than from being underweight. The WHO report states that 1.6 billion overweight or obese people in the world and 2.5million deaths are attributable to obesity. The country most aware of the dangers of obesity is Finland(83%), followed by Netherlands(73%), Australia(72%), while Hungary (24%), India(21%) are the last(Readers Digest, Feb. 2010). The countries that feel the most pressure to be thin are Brazil(83%), India(68%), U.S.(62%) while Russia(36%) and Hungary(28%) are the last (Readers Digest, Feb. 2010). The Country where most wives want their husbands to lose weight is U.S.(51%) (Readers Digest, Feb. 2010). And the country where most husbands want their wives to lose weight is India(46%)(Readers Digest, Feb.

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2010). And the countries most likely to blame parents are Russia(70%),Germans(61%) and Indians(50%)(Readers Digest, Feb. 2010).. France also faces the issue of obesity as an economic impact, as it has risen from 8.2% in 1997 to 11.3% in 2003 (Avignon and Thuan, 2005). By studying the tangible costs incurred by obese employees for one year in France, reports were made stating representation of obesity in health care costs. These impairments could be either physical or psychological (Van Itallie, 1979). The study did not differentiate between grades of obesity or stages of health. Results implied that if obesity was classified as a BMI over twenty-seven percent, the direct cost of obesity in 1992 was two percent of the French Health Care system, equivalent to twelve billion French Francs, and indirect costs equating to 0.577FF. This compares to the U.S. cost of 5.5% ($39.3 billion), Netherlands 4%, and Australia 2% (from various other studies) (Van Itallie, 1979). Although French general practitioners seem less inclined to believe weight loss is the answer, they are more likely to be realistic about changes that should take place. They believe weight loss is possible, but that many individuals set unrealistic goals, along with the ideal that professional help is not mandatory in succeeding with weight management. The problem the role of health advisors in France currently have is not a naïveté to the epidemic, but a lack of knowledge and skill to handle the situation. They do not currently all view obesity as a chronic disease, and therefore do not typically treat it properly or completely, using long-term commitment and multi-pronged approach to reducing obesity (Avignon and Thuan, 2005). The European Program, which is known as EPODE- a French acronym for Together Let’s Prevent Childhood O besity-began in France based on the experience of two towns in the north of the country Fleurbals and Laventie that instituted a community based obesity-prevention-program aimed at children between 1992 and 2004. The results, the percentage of over-weight and obese children in two towns fell to 8.8% in 2004 from 11.2% in 1992. And the rates of overweight and obese children in two nearby towns that didn’t adopt the strategy rose to 17.8% from 12.6%. Germany plans to spend $47 million on healthy eating and sports program and to set tougher nutritional standards for school lunches. The government is asking candy makers to stop targeting young children and encouraging soft-ware companies to develop programs that force players to move. Kuwait Oil Company faced overweight worker injury problems. In Kuwait Oil Company 63percent of the workforce spent most of the time walking, climbing ladders, opening heavy valves and attending oil gathering centers and booster stations on the rig. Obese field workers had more injuries. Kuwait Oil Company has encouraged active life style, healthy eating habits, weight control programs to reduce the frequency of injuries (Al-Asi, 2003). In Japan, the health officials check the waistlines of citizens over 40 and those considered too fat and failure to slim down can lead to new fines. New Zealand has rules barring people it deem too fat from immigrating to the country. Obesity in the Workplace Obesity in the workplace is still increasing at a fast pace. In fact , it’s predicted that by 2015 obesity will account for forty percent of the American working population (Gabel, 2009). A study done from 1990 that dealt with the BMI (Body Mass Index) and the body fat percentage had smaller numbers than the same study performed in 2000. Professor G. Harbin from the University of Kansas, along with his former colleagues, found that the increase in the percent of body fat with employees was due to the lack of fitness within the workforce. If employers were more willing to reward employees for healthy behavior the obesity rate would not be as high (obesity measurements). It is becoming obvious that employers are going to have to start being proactive in their approach with their hiring practices on this subject or implement more weight management programs. Business management should become aware of the population trends of obesity and provide a better work atmosphere to their employees that feel stressed from obesity. They should also provide the training and education regarding discrimination and obesity to

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employees, especially in the hiring department. It is important interviewers do not fall into the habit of the Halo Error, which would impart negative characteristics to obese applicants, deserving or not (Townsend and Paul, 1998). The heart of the issue of obesity discrimination is that the stereotypes held are potentially just beliefs; in many cases, the stereotypes do not hold true, and create a negative environment that is not contributing to assisting or encouraging the obese employee. It is not just the responsibility of the individual, but also of the community and the private and public sectors (Strumpf, 2004). Studies that have been conducted point out that age, race, and lack of rationale in links found within studies all can have a significant effect on the correlation between body weight and personality traits (Roebling Roebling Odland). There is little justification in discriminating against an obese individual before their abilities have been proven; even if a prejudice is held, there are inadequate circumstances where an individual’s weight is correlated to job performance, with very little support sustaining the notion that obese employees are poorer performers (Roehling, Roehling, Odland, 2008). In order for changes to be made in the workplace, thereby passing on positive effects to the bottom line of the company, upper level management should encourage a positive and healthy atmosphere in the workplace (Sullivan, 2008). By establishing supportive management of health, absenteeism, and mental health, the organizations can play a significant role in the prevention of work-related stress and health issues. This can lead to significant benefits for the company; both fiscally and environmentally seeing as this epidemic is growing globally as well as domestically, it might be wise for industries and corporations as a whole to work towards making these changes that will benefit everyone in the long run. It will be imperative to reducing the levels of discrimination against obese employees, as well as hopefully reducing the numbers regarding obesity. It will be in the hands of the upper management and powerful roles to instigate this process, but once the benefits can be tangibly experienced, it is more likely to pick up speed and for progress to be made. We cite following cases to support our thesis. McDuffy Vs Interstate Distributor Company(2004), Cook Vs Rhode Island Department of Mental Health(1993), Butterfield Vs New York State, EEOC Vs Watkins Motor Case, Pan Am Flight Attendants Vs Delta Air Lines McDuffy Vs Interstate Distributor Company (2004) John McDuffy a truck driver for 18 years had worked the last 14 years with Interstate Distributor. McDuffy, at around 550 pounds was considered morbidly obese. McDuffy was suspended from his duties without pay. McDuffy was later told that the company had feared for his health. McDuffy filed a claim against Interstate Distributor for discrimination and won the case. During the trial a video was presented to the jury of McDuffy demonstrating performing various duties as a truck driver. A doctor confirmed that McDuffy was able to carry out his duties. McDuffy was awarded his lost wages of $9000/ and punitive damages of $100,000(Fox, 2006). Cook Vs Rhode Island Department of Mental Health (1993) In Cook Vs Rhode Island a “morbidly obese” plaintiff was denied reemployment because the state claimed her “obesity compromised her ability to evacuate patients in case of emergency”. Her employment into two periods between 1978 and 1986. At the time she was 5’2’ and 320 pounds. The state mental hospital turned her down because of her height and weight. They also expressed over increased risk of workers’ compensation claims and absenteeism because of her weight. The Court of Appeals found that the state’s concern over absenteeism and increased cost is not a valid basis for denying employment. And obesity caused by metabolic dysfunction qualified as disability under the Rehabilitation Act and awarded the plaintiff $100,000/ (National Education Association, 1994). Butterfield Vs New York State- The plaintiff was an overweight corrections officer, who was harassed by his coworkers in ways such as spraying his locker with cheese, cartoons posted of an overweight character which led to many jokes, harassing phone calls, and adding an unknown substance to his soda, resulting trips to emergency room.

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When the calls were traced, he discovered they were from his work. He finally decided to file a discrimination complaint. He found his mail/time cards were altered and he received a dead “rat” in an envelo pe (Kristen, 2002) EEOC Vs Watkins Motor Case (2006) Grindle weighed 450 pounds and worked for Watkins Motor Line. When at work while climbing a ladder, the ladder broke and Grindle fell and hurt his knee. Shortly after he was terminated after a company doctor determined Grindle could not safely perform his job. Grindle filed a complaint with EEOC. The Court of Appeals ruled in favor of Grindle Pan Am Flight Attendants Vs Delta Air Lines Pan Am Flight attendants sued Delta Air Lines (Pan Am merged with Delta after Pan Am declared bankruptcy in 1991) for weight discrimination. Pan Am Flight attendants claimed they were not hired because of their disability including age, gender, marital status and national origin. An administrative law judge found they were discriminated against due to their gender and perceived disability. New York Supreme Court ruled that Delta’s decision on weight standards did not fall under age, gender, or disability discrimination Impact of Obesity The above cases indicate the impact of obesity on business. Many employers feel that obesity is becoming a serious problem. Obesity impacts productivity, which is measured by days, missed at work due to illness. Lost productivity may be several times greater than the medical costs associated with obesity. In addition, being present but working at a reduced rate may account for a larger portion of losses than being absent from work. Overweight workers cost more. Obese employees had twice the rate of workers’ compensation claims as their fit-coworkers. A Duke University study found that overweight workers were more likely to have claims involving injuries to the back, wrist, arm, neck, shoulder, hip, knee and foot compared to normal workers. Obese workers had 13 times more lost work days injuries. (Fox, 2008). The CDC (Center for Disease Control) found that obesity costs around 75(seventy five billion dollars annually in health care cost, disability, absenteeism and lost productivity. Businesses paid 8% more in health care claims due to overweight and obesity prior to 2007(National Business Group on Health, 2007). The government assumes that it costs almost $117 billion dollars a year in health costs and obesity leads to about 300,000 deaths a year. Obesity costs over 39 million lost workdays as well as 63 million trips to the doctors. Obesity costs U.S businesses around 13 million dollars (Obesity in America, 2004). Obese people who had BMI’s of over 40 had the highest number of lost work days (USA Today, 2007). John Hopkins study had results similar to the Duke study. According to the John Hopkins study 29% (percent) of the 7690 workers included in the study were injured at least once and 85% (percent) of the injured workers were classified as obese (Obese Workers, Associated Content, 2007). Every year, more and more people are considered overweight. The number of Americans considered obese by the CDC (Center for Disease Control) in 2001 was 44 million approximately one in five. This is 74% (percent) increase since 1991. The CDC (Center for Disease Control) calculated the cost as about $117 billion annually and 300,000 deaths per year (Obesity-Braun Consulting, 2004). According to CDC (Center for Disease Control) cost of treating soared to around 150 billion in 2008 (WSJ, July 28, 2009). We need intensive and ongoing efforts to address obesity. If we don’t more people will get sick and die from obesity -related conditions such as heart diseases, stroke, Type 2 diabetes and certain types of cancer. Case Study Fat Chance The case study “Fat Chance” highlights the effect that stereotypes towards obese workers can have on hiring or promotion decisions. It also looks at the possibility of being cited for discrimination that HR managers face if they don’t hire a qualified obese worker for reasons p urely related to vanity.

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Sid is an obese man working for NMO financial services. He has recently applied for a new position in the company that would be client-serving. “He’s got the skills and the knowledge-the problem is, he’s also obese. Can his weight be a factor in the decision?” (Obesity, 2005). Bill, the man making the promotion decision, consults his friend Chuck for his opinion. Consistent with much of the research on people’s perceptions to obese people, Chuck scoffs at the idea of placing Sid in a position that would put him in the public’s eye. “What kind of impression would he make for NMO?” While reviewing Sid’s files, Bill recalls his increase in sick days correlates with his weight gain over the years. Sid also suffers from diabetes. Sid is very qualified for the position, the only internal candidate that applied and his loyalty to the company has never faulted, but Bill find himself wondering if the company could be sued for discrimination is Sid is passed over for the job. The case is very consistent with much of the research findings on the perceptions of obese people. Sid is scrutinized by just about everyone he comes into contact with based solely on his physical appearance. From the manager’s side, Bill is also in a dilemma many managers face: will promoting an obese employee be detrimental to the company, or will not promoting him result in a lawsuit? Trying to balance what is best for the company and what is ethical is a challenge many HR managers face when it comes to obese employees. Currently in the United States laws that prevent discrimination towards obese employees are becoming more common. Many other countries have yet to follow in the footsteps of the U.S. with such laws. In fact, France recently focused on passing legislation that would ban the promotion of extreme thinness. This cultural difference can be attributed to the higher prevalence rate and costs of obesity in the U.S.: obesity accounted for , “as much as $92.6 billion in 2002 dollars—9.1 percent of U.S. health expenditures” (2007, U.S. department of health and human services). The stereotypes Sid faced were consistent with the findings of Roehling, Roehling and Odland, whose researched showed the existence of a “stereotypical belief that overweight people posses a number of undesirable personality traits” (Roehling, Roehling, Odland, 2008). What are lacking from most of the research are the HR managers having to balance the morally right thing with the perceived stereotypes of the obese employees. More research needs to be completed that delves into the battle between whether HR managers are more driven by societal pressure or internal morals when it comes to decisions regarding obese employees. The company itself could also take action into promoting healthier lifestyles for Sid and its other employees. One of the comments on the “Fat Chance” case supports this idea: “Too many companies implicitly enable the unhealthy lifestyles of the minority-and they do so to their detriment” (Roehling, Roehling, Odland, 2008). The following case looks at the success of corporate wellness programs currently being implemented in the U.S. and abroad. Case Study Corporate Wellness Programs PricewaterhouseCoopers L.L.P. reported on numerous multinational employers and “found that wellness programs can result in a 3-1 return on investment” (Kertesz, 2007). UniLever, a multinational company headquartered in London, England implemented a wellness program in 2004 and 2005. According to Dr. John Cooper, the head of cooperate occupational health for Unilever P.L.C in London the program, “to our astonishment produced a 3.7-1 return on investment” (Kertesz, 2007). This return on investment fully supports the research discussed earlier that focused on how increasing employee’s health will reduce health related costs. The success of the program for Unilever in London prompted them to implement a wellness program globally in late 2006. In line with what many researchers recommend for company wellness programs, Unilever’s corporate wellness programs includes, “a health risk assessment and a personal coaching program for exercise, nutrition and mental resilience” (Kertesz ,2007). UniLever’s subsequent success with its wellness programs not only show that they are valuable, but that they are transferable across cultures: a very valuable asset for many multinational companies.

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Microsoft was another company that was examined in terms of its wellness programs for employees. As the research suggests, Microsoft was spending a great deal mor e in medical claims for obese employees, “about 40% more” (Kertesz ,2007). The wellness program they implemented 5 years ago is now showing a full return on investment for the employees involved, and they are also seeing a significant decrease in medical claims. PricewaterhouseCoopers and Microsoft, both well known multinational companies, recognize the importance of not only implementing wellness programs but promoting wellness culture within the company. Their actions and subsequent results support the current research and provide examples for many other multinational companies to follow. Case Study Du Pont Company Experience Du Pont adopted a comprehensive workplace health promotion program in 1980 called PROCEED. The framework was developed by Lewis Green and his colleagues. He directs initial attention to the desired outcomes of integrating the framework. To find the areas that need the most improvement within Du Pont, the Du Pont Health Promotion Needs Survey was conducted in 1982. This survey was administered to medical staff and employee relations personnel. It provided a descriptive profile of Du Pont’s many locations based on the company’s existing health promotion resources, activities and expectations. The results showed that many locations already had health promotion and risk reduction activities in place; however most of these activities were one-time lectures or video presentations. Skill building and reinforcement were generally not available to employees. In 1984 another health survey was administered. This time, the respondents were employees within the company. Two areas were assessed: employee attitudes towards their own health and health knowledge. The data indicated that nearly all respondents (90%) thought it was important that a person exercise regularly each week, and 73% thought that Du Pont was a leading company in promoting employee health (Bertera, 1990). The health knowledge portion of the survey showed that respondents were knowledgeable in most areas of health because the majority of the answers were correct. Therefore, the barriers to health program success are not based on lack of knowledge, but in other aspects of behavior. Following these two surveys, the framework then ran a diagnosis on the strengths, limitations, and opportunities that would affect the development of a wellness program within Du Pont. After identifying these areas, a program for the company was created. The major components of the program included: public health approaches to program introduction and health risk assessment, group and self-directed choices for health information, recognition and awards for achieving health and fitness objectives, and workplace climate changes aimed at healthier eating choices. The cost per employee for implementation averages $56 for the first year of the program (Bertera, 1990). To motivate employees to participate in these programs, recognition awards were publicized in company newsletters and plaques and certificates are awarded to individuals or specific locations within the company. Since the implementation of the program, Du Pont has experienced a 12.5% decline in hourly employee absenteeism over six years. One location even experienced a 47.5% decline. However, the program still needs to improve in reaching employee spouses, sales personnel, shift workers, and employees at small sites. However, the initial success of the PROCEED framework could be replicated in other companies today. The framework allows each company to tailor wellness programs to their company’s culture and employees. By adopting this framework to companies around the world, the trickle-down effect of generally healthier individuals will be immense. Case Study GlaxoSmithKline Promotes Healthy Lifestyles In May of 2008, the National Business Group on Health (NBGH), named GlaxoSmithKline (GSK) a leader in providing a healthy workplace by promoting healthy lifestyles for its employees and their families. The National Business Group on Health honored GSK with their highest award, the Platinum Award, for their dedication to foster

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a business culture that includes programs to manage healthy lifestyles. The Platinum Award is awarded to companies that have integrated health programs with positive measurable outcomes. GSK’s Vice President of Employee Health Management in the U.S., Ann Kuhnen, states that their goal is to “design programs and communication plans that support [employees] in adopting healthy lifestyle practices and making informed healthcare decisions” (Business Week,2008). GSK launched a n innovative program called “Energy for Performance” which linked energy and resilience with their new leadership development framework. This framework focuses on four key domains of leadership: Expertise, Execution, Leadership Behavior, and Self. The domain of self is where much of health focused awareness and behaviors are focused. All development in the Self component is extremely important as growth here fuels and ignites the sustained ability to perform in all the other components of the framework. The “Energy for Performance” program gave employees long-term incentives to maintain healthy and energetic lifestyles both at home and at work. The program includes Total Reward benefits which includes programs to support nutrition and physical activity, as well as healthy food choices on site through food service providers. Within the United States, diseases such as asthma, diabetes, and heart disease are increasingly preventable and treatable, however they account for the majority of healthcare spending. The treatment and lost productivity as a result of these diseases in the U.S. total $1.3 trillion in 2003 (Business, 2008). The awards for Best Employers for Healthy Lifestyles have only been in practice for four years and its goal is to act as a catalyst to encourage all employers to take action. Hopefully with the National Business Group on Health continuing to reward employers for their proactive programs to prevent chronic diseases within the workplace, the United States as a whole will benefit from its effects. Conclusions/Recommendations Exercise more. Avoid junk food. Such common sense health advice has proved to be much against the temptations of modern life, which have sent obesity rates around the world soaring. Instead of hoping that individuals can muster the self-discipline on their own to avoid processed foods, fast food and days without physical exercise, the idea is that governments, organizations, companies must actively work to change environments and reduce the menu of harmful options available in everyday life. Now organizations, companies and government officials in a number of countries are pursuing new strategies; enlisting entire communities to insulate people from these temptations and make healthier choices easier. A primary benefit of reducing obesity in the workplace is having happier and healthier employees. A secondary side benefit is that happier and healthier employees are more productive and take less time off because of illness relating to problems caused by being overweight. It is evident that employers are recognizing the benefits to having healthier and fit employees, which is why so many companies have chosen to incorporate and offer employees healthier programs and options. New health programs have proven to be the best response by companies trying to deal with obesity in the workplace. Health promotion programs, including education and wellness programs, encourage employees to improve their life styles. They educate employees on healthy habits and help create healthy workplace environments. The first step to creating a healthier, and safer, work environment for everyone, including obese employees is to tackle the issue of discrimination. The “Fat Chance” case raised many ethical dilemmas related to obese employees. To help deal with stereotypes, diversity training could be implemented into companies facing problems like NMO faced. As more anti-discrimination laws focused on obesity come into effect, employees will need to be trained in diversity to understand what really constitutes discrimination.

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For many multinational companies wellness programs could be used to help with greater integration within the company. In the case with PriceWaterhouse-Cooper, Microsoft and General Mills Inc. the companies’ implemented very similar wellness programs at individual bases. One recommendation would be to allow for an online forum, a yearly conference or other interaction for employees from the different offices worldwide to interact through the program. Incorporating a company wide support structure into the wellness program would not only boost morale for the individual employees involved, but it would also create connections for employees from all different countries that could increase collaboration. Continuous support from organizations such as the National Business Group on Health would also encourage companies to integrate wellness programs in their business culture. By having a centralized organization with specialized interests in healthy lifestyles in the workplace, incentives for companies to adopt a wellness program would increase. Currently, the National Business Group on Health is only based in the United States; however an international organization would be even more beneficial because the flow of information and methods could be exchanged freely between companies in different countries. Also, more published case studies on successful company integration such as the case on GlaxoSmithKline would benefit companies worldwide. Companies looking to adopt a wellness program could research methods companies have used to integrate these programs and adopt them. Innovations have occurred in the form of bariatric surgery, such as gastric by pass and gastric binding for morbid obesity. New drugs may replace the $17billion annual market for high –cholesterol medicine Lipitor; Vivus’s new weight loss drug Onexa likely to be approved the FDA(Food and Drug Administration). Employers need to be sure that hiring decisions are based on the individual’s a bility to perform the job tasks, not their outer appearance. In the U.S. an increasing number of anti-discrimination laws for obese people are being passed, making it illegal to have weight be a factor in the hiring decision. What is more important is for companies to provide their employee’s with healthy lifestyles: introducing wellness programs, adding incentives for healthy choices and promoting healthy choices in vending machines and at corporate functions are all proactive ways for companies to improve the overall health of their employees, and in turn reduce their costs. About 32 %( percent) of American school children are overweight or obese-a shocking statistic by any standard. What should be done? Sugary drinks on school property and junk food on lunch menus need to be discouraged. Physical fitness classes ought to remain an integral part of the school day. Unhealthy weight gain is responsible for more than 100,000 deaths each year. Problems with obesity start early. By age 11, 30 %( percent) of American children are overweight. To help companies combat and prevent obesity, we recommend discouraging the consumption of sugar-sweetened beverages, instituting smaller portionsize options of cheeseburgers etc., requiring physical education and healthy diets in schools, posting calorie counts on menus, banning artificial trans-fat in some foods in certain chain restaurants etc., Companies that invest in health promotion programs see results in lower insurance costs, reduced absenteeism, increased productivity and employee job satisfaction. Solutions like these have proven to be most effective and successful for the human resource managers in combating issues brought on by obesity. REFERENCES Al-Asi, Overweight and Obesity among Kuwait Oil Company Employees; A Cross-sectional study. Occupational Medicine, 53(7) Avignon, A., and Thuan, J-F. (2005). Obesity management: attitudes and practices of French general practitioners in a region of France. International Journal of Obesity. 29, 1100-1106.

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Basdevant, A., Levy, E., Levy, P., and Le Pen, C. (1995). The economic cost of obesity: the French situation. International Journal of Obesity. 19, 788-792. Bertera, R (1990). Planning and implementing health promotion in the workplace: a case study of the Du Pont Company experience. Health Education Quarterly. 17, 307-327. Boston Medical Center. (2007). Retrieved March 17, 2009, from BMI Chart Web site: http://www.bmc.org/medicine/medicine/nutrition/images/BMI-Chart.png Chojnacki, A, Cruse, S, & Carr, R. sustaining healthy-high performance – Through a global resilience and energy portfolio. In Equilibrium, from http://www.in-equilibrium.co.uk/resources/articles/sustaining-healthy-highperformance-glaxosmithkline-article. Flight Attendants Sue Delta for Weight Discrimination, Court on TV Online (Dec.1996) Legal Documents www.courttv.com Fox, M, The Changing Face of Discrimination Law, Texas Bar Journal (2006) www.texasbar.com Gabel, Jon R., et al. (2009 February). Obesity and the workplace: Current Programs and attitudes among employers and employees. Health Affairs. 28 (1). Garcia J, Weight Based Discrimination and the Americans with Disabilities Act. Is there an end in sights? Hofstra Labor LawJ, 1995 GlaxoSmithKline named a top employer for promoting healthy lifestyles. Biotech Business Week. (2008, May 26). Greenwald, J Obese Workers not ADA protected, Business Insurance (2006) Harper Obese Workers Cost Employers, The Washington Times (2008) Joyce, Amy New Meaning Given to Trimming Fat, The Washington Post (March 27, 2004) Kertesz, L. (April 9, 2007). Corporate wellness programs help shape a better bottom line; Companies Benefit as healthier workers file fewer claims. (Benefits Management). Business Insurance, 41 (15) p.15. Retrieved March 19, 2009, from Academic One File via Gale: http://find.galegroup.com/itx/start.do?prodId=AONEEmployees and employers face obesity issue, seek solutions. EHS News. (2008 June). www.occupationalhazards.com

Kita, Joe, The Weight of the World, Readers Digest, Feb. 2010. Kristen, Elizabeth, Weight Discrimination in Employment, California Law Review (Jan. 2002) Laurier, D., Guiguet, M., Phong Chau, N., Wells, J. A., Valleron, A. (1992). Prevalence of obesity: a Comparative survey in France, the United Kingdom and the United States. International journal Of obesity, 16(8), 565-572. Loh ES, The Economic Effects of Physical Appearance, Soc Sci Quart 1993 Long, Adam. (2007, November 1). Obesity in the workplace: Employers search for answers. The Insider’s Business Briefing on Managed Healthcare. 20 (21). Mayor, Susan. (2009, January 10). Government launches initiative to cut obesity. UK News. http://www.bmj.com/cgi/section_pdf/338/jan05_3/b1.pdf.

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More employers battle bulge: Managers ready to lead weight management. (2008, September). http://content.ebscohost.com/pdf9/pdf/2008. Obesity costs; Study finds obesity increases costs for employees and employers. Obesity Fitness and Wellness Week. (2005, October 8). Retrieved from Lexis Nexis database. Obesity Measurements; Percent body fat seems to be a good indicator for evaluation of workplace obesity. Obesity Fitness and Wellness Week. (2006, June 6). Retrieved from Lexis Nexis database. Obesity; Study finds obesity rates of American workers grew 20-29% in the past decade. Obesity Fitness and Wellness Week. (2005, January 5). Retrieved from Lexis Nexis database. Overweight Workers Cost Employees More (Fox News) Retrieved Feb. 26, 2008http://www.foxnews.com Obesity in the Workplace, Braun Consulting (Nov. 2007) www.braunconsulting.com Paul RJ, Townsed JB, Shape up or Ship out? Employment Discrimination against the Overweight, Employee Responsibilities Rights J, 1995 Register CA, Williams DR, Wage Effects of Obesity Among Young Workers, Soc Sci Quart, 1990 Roehling, M. (2002). Weight discrimination in the American workplace: Ethical issues and analysis. Journal of Business Ethics. 40(2). 177-189. Roehling, M., Roehling, P., and Odland, L. (2008). Investigating the validity of stereotypes about overweight employees: the relationship between body weight and normal personality traits. Group Organization Management. Strumpf, E. (2004). The obesity epidemic in the United States: causes and extent, risks, and solutions. Issue Brief for Commonwealth Fund. Sullivan, N. (2008, November). Healthy people, healthy profits. Employee Benefits, Retrieved March 23, 2009, from Business Source Complete database. Thomas, Nathan, Weight in Workplace, Career & Hotelkeeper (2007) 197(4484) Townsend, J., and Paul, R. (1998). Shape up or ship out? Discrimination against the overweight. Employee Responsibilities and Rights Journal. 8(2) 133-145. U.S. department of health and human services. (2007).Retrieved March 17, 2009, from Weight Control information network: http://www.win.niddk.nih.gov/statistics/#econ USA ToDay, Overweight Workers Cost Employers More (Nov 2007) Van Itallie, TB (1979). Obesity: adverse effects on health and longevity. The American journal of clinical nutrition (0002-9165), 32 (12), p. 2723. World Health Organization, October 2009 Jitendra Mishra Management Department Grand Valley State University 469C DeVos 401 W.Fulton, Grand Rapids Michigan 49504-6431 Phone: 616-331-7465 Fax: 616-331-7445 Email: mishraj@gvsu.edu

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THE IMPACTS OF EVOLUTION’S MPOWERMENT PROJECT IN CDC’S BACKYARD
Barbara Lacy Wilson, AID Atlanta, Inc. Arletha Williams, AID Atlanta, Inc.

ABSTRACT The Evolution Project, an AID Atlanta, Inc.’s educational HIV prevention program, is a safe space conveniently located in CDC’s backyard impacting Atlanta. Often referred as a drop -in center for the community, Evolution has a conceptual framework of being peer-driven/inclusive of programmatic activities. The primary target population is young black gay/bisexual men and transgendered individuals between the ages of 18 and 28 years (Who We Are, 2012). Helping youth and young adult members professionally develop their skills and strengths, achieve reachable goals, connect with other young members alike while having fun and supporting one another is how Evolution’s Mpowerment Project constantly evolves. Keywords: Evolution Project, Aid Atlanta, CDC, Mpowerment, young black gay men, young black bisexual men, professional development, skill building, condom negotiation, support, drop-in center, empowerment.

Barbara Lacy Wilson 402 Winterwood Drive Stockbridge, Georgia 30281-1100 (678) 939-8551 wireless (404) 870-7752 office Lacy.Wilson@aidatlanta.org BarbaraWilson@clayton.edu Dr. Arletha Williams Evaluation Manager AID Atlanta, Inc. 1605 Peachtree Street, N.E. Education Building, First Floor Atlanta, Georgia 30309 (404) 368-9252 wireless (404) 870-7757 o

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A WELLNESS MODEL THAT IMPROVES FINANCIAL PERFORMANCE IN UNIVERSITY SETTINGS
Riddhima Palta, University of Scranton Allen C. Minor, University of Scranton Daniel J. West, University of Scranton

ABSTRACT Objective: This article presents information needed to develop a university-based wellness program. The framework provides a practical approach for smaller academic institutions to use, and identifies specific structural and design elements. Methods: Worksite wellness is not a new concept for business and industry. A survey of industrial models demonstrates the ability for wellness programs to control costs, reduce absenteeism, improve utilization of insurance, produce a return on investment, reduce medical claims filed, and reduce disability expenses. Results: An examination of business models, outcomes and design can be used to conceptualize and implement wellness programs in small universities. Universities have internal faculty and staff who can participate in designing wellness services. Conclusion: Universities can learn from business and industry to design wellness programs that improve employee morale, save money and create a positive work culture..

Riddhima Palta University of Scranton Dr. Allen C. Minor University of Scranton Dr. Daniel J. West, Jr. University of Scranton

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NURSING EDUCATION IN SAUDI ARABIA: CHALLENGES AND FUTURE IMPLEMENTATIONS
Adel S. Bashatah, College of Nursing, King Saud University, Saudi Arabia Osama Samarkandiy, Faculty of Applied Medical Science, Al Baha University, Saudi Arabia

ABSTRACT Nursing in Saudi Arabia has established in the begging of 1954 under the administration of the Ministry of Health (MOH). During the past 50 years, nursing has faced many obstacles and challenges to reform nursing among Saudi community. Now, according to the ministry of health, the number of the majority of nurses are holding a diploma degree exceeds 10,000 nurses with diploma degree. In response to the challenges, and in order to improve the quality of nursing education in the country, the Ministry of Health (MOH), in collaboration with Ministry of Higher Education (MOHE) have recommended that Baccalaureate of nursing is the minimum required degree for professionalism, and the entry level to the practice. Yet, with shortage of nurses, qualified preceptors, and difficulties of clinical settings, the poor outcome of nursing practice has affected nursing image. Moreover, the revolution of higher education in health specialties including nursing has been emerged to reach up to 25 nursing program with average of 1000 students per year. This paper will address the history of Saudi nursing education identifying the challenges of creating qualified new nurses to be ready in the field of care. Furthermore, it will explore the current nursing workforce and ways to improve nursing images at Saudi Arabia.

Adel S. Bashatah Assistant Professor Department of Nursing Administration & Education College of Nursing King Saud University Saudi Arabia Osama Samarkandiy Assistant Professor Department of Nursing Faculty of Applied Medical Science Al Baha University Saudi Arabia

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A GLOBAL PERSPECTIVE ON HEALTH AND WELLNESS PROGRAMS IN THE WORKPLACE: UNITED STATES VS. CENTRAL EUROPE (CZECH REPUBLIC)
Jessika Haynos, University of Scranton Robert Spinelli, University of Scranton

ABSTRACT As healthcare organizations in the U.S look for ways to control increasing healthcare expenditures, the country has begun to promote the wellness of individuals. By focusing on promoting healthy lifestyles, U.S healthcare organizations hope that they will be able to curb these increasing costs. One way to improve the health status of the population is through the use of wellness programs in the workplace. Research shows that U.S companies have been addressing employee wellness for many years, while European companies do not believe that they should be as deeply involved. This presentation will focus on the trend in workplace health promotion in the United States and in Central European countries to examine the importance these countries place on employee wellness, their effectiveness, and benefits of each system.

Jessica Haynos MHA Student University of Scranton Scranton, PA 18510 Robert Spinelli, D.B.A Assistant Professor University of Scranton Scranton, PA 18510

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UNDERSTANDING THE DETERMINATES OF LIFESTYLE DISEASES: A SEGMENTATION APPROACH
Vivek S. Natarajan, Lamar University Kabir Chandra Sen, Lamar University Avinandan Mukherjee, Montclair State University

ABSTRACT A major challenge for health care managers and policy makers alike has been the preponderance of lifestyle diseases such as obesity, diabetes, and hypertension. Consequences of these diseases include rise in health care costs, insurance premiums, additional burden on healthcare systems, and a reduction in the overall quality of life. Thus, an understanding of the key variables impacting these diseases is of paramount importance. This study employs macroeconomic data at the MSA level and employs a clustering approach to understanding groups of MSAs with similar disease profiles. We employed the three lifestyle diseases namely obesity, diabetes, and hypertension as the clustering variables. A three cluster solution was found to be optimal. We furthered employed discriminant analysis to determine the key demographic variables that predicted the cluster membership. The variables that emerged as significant include family income, educational variables, and lifestyle variables. Keywords Healthcare, obesity, diabetes, hypertension, macro issues, lifestyle variables, cluster analysis, discriminant analysis, segments.

Dr. Vivek S. Natarajan Associate Professor of Marketing Lamar University, Beaumont Tx-77710 US Phone: 409-880-8643 vivek.natarajan@lamar.edu Dr. Kabir Chandra Sen Chairman and Professor of Marketing Lamar University, Beaumont Tx-77710 USA Phone: 409-880-8929 kabir.sen@lamar.edu Dr. Avinandan Mukherjee Chairman and Professor of Marketing School of Business Montclair State University Montclair NJ 07043, USA Phone: 973-655-5126 mukherjeeav@mail.montclair.edu

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MONETARY VALUE OF FOOD DESERTS AND POLICIES
Crystal L. Weeks, Clayton State University Michael Dalmat, Clayton State University

ABSTRACT With limited access to healthy food choices, barriers exist to nutrition. Areas are designated as food deserts without meaningful understanding as to what accurately reflects a food desert. This study was designed to identify a small city food environment and allocation of funds to areas without access to healthy food alternatives. As an important part to community assessment, a windshield survey was utilized in support of findings of accumulated data within a identified area. An analysis of access to healthy foods spawns a more complex picture of precise fooddesert locations. Keywords: Food access, food deserts, supermarkets, grocery stores, food prices, low-income communities, small city, transportation, obesity, diet, poverty, policy decisions.

Crystal L. Weeks 335 Tonawanda Dr SE Atlanta, Ga. 30315 (719) 243-8001 Cweeks1@student.clayton.edu Dr. Michael Dalmat Assistant Professor Department of Health Care Management College of Business, Room T-264 Clayton State University 2000 Clayton State Boulevard, Morrow, GA 30260-0285 678-466-4938 office Michael.Dalmat@gmail.com

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WAISTLINES WILL CONTINUE TO ROB BOTTOM LINES UNTIL PHYSICIANS LEAD BY EXAMPLE WITH THEIR OWN EMPLOYEE WELLNESS PROGRAMS
Barbara Lacy Wilson, Clayton State University Michael E. Dalmat, Clayton State University

ABSTRACT The goal of any organization is to make a profit. With escalating costs of healthcare, health care organizations’ (HCOs) in particular are increasingly challenged by waist lines robbing them of their bottom line. The 2010 Georgia Data Summary concludes: “3 in 5 adults are physically inactive, 3 in 4 have poor dietary habits, and 2 in 3 are sedentary at work”.1 Clayton State University’s eight client organizations implemented Employee Wellness Programs (EWPs) to demonstrate that small medical practices can motivate employees through wellness programs and decrease absenteeism and turnover, and increase presenteeism/productivity and morale through behavior change and lifestyle choices. Keywords: Work place wellness, employee wellness, lifestyle changes, adult obesity, absenteeism, reduced turnover, physicians and tipping points, health care organization profitability, return on investment. 1 Georgia Department of Health (July 2011). 2010 Georgia Data Summary: Obesity in Adults. http://health.state.ga.us/pdfs/epi/cdiee/DPH.Epi.7-20-11.pdf _____________________________________________________________________________________________ Barbara Lacy Wilson 402 Winterwood Drive Stockbridge, Georgia 30281-1100 (678) 939-8551 wireless (404) 870-7752 office Lacy.Wilson@aidatlanta.org BarbaraWilson@clayton.edu Dr. Michael E. Dalmat Assistant Professor Department of Health Care Management College of Business, Room T-264 Clayton State University 2000 Clayton State Boulevard, Morrow, GA 30260-0285 (678) 923-9237 wireless (678) 466-4938 office MichaelDalmat@clayton.edu Michael.Dalmat@gmail.com

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AN EXAMINATION OF RISK FACTORS FOR OBESE ADULTS: PREVENTION AS POLICY
Robin Hyson, Monmouth University David P. Paul, III, Monmouth University

ABSTRACT The rise in incidence of obesity in the United States, and the multifactorial nature of the cause of this increase are examined. Psychological and social risk factors are discussed in detail, and potential public policy remedies are presented.

Introduction Obesity is a serious and increasing prevalent condition in the United States. The 2009 Gallup-Healthways Well-Being Index indicted that 63.1% of adults in the U.S. were either overweight or obese (Hendrick, 2010). This is up from 55% in 1994 (Flegal, et al., 1998). The incidence of obesity is on the rise in the United States and with this rise comes significant consequences: estimates indicate that the steady rise in longevity occurring for the past two centuries may soon come to an end, largely due to effects of obesity (Olshansky, et al. 2005). Obesity is associated with serious medical problems including high blood pressure, adverse lipoprotein profiles, diabetes mellitus, atherosclerotic cerebrovascular disease, coronary heart disease, colorectal cancer, as well as lower educational attainments and higher rates of poverty (Dietz, 1998). Obesity is not only related to disease morbidity, the condition is also related to mortality. Obesity is credited with 435,000 deaths annually in the United States (Mokdad, et al., 2004). The issue of obesity costs individuals and the general public as health care costs continue to rise in the United States. The Surgeon General estimates the annual direct and indirect cost of obesity at approximately $117 billion (Richards, Patterson, and Tegene, 2007). Obesity is associated with substantial direct health care costs (Allison, Zannolli, and Narayan, 1999-ok). Costs associated with a single obesity-related disease – diabetes – was estimated to be $147 billion in 2007, the last year for which such an estimate is available (American Diabetes Association, 2008). The cost of obesity and health issues associated with it is undoubtedly a huge expense in the US. There are multiple causes for obesity, including genetic and hormonal factors, but the basic cause is taking in more calories than burning through exercise and normal daily activities (Jeffrey and Utter, 2003). The excess calories are stored as fat. According to the Mayo Clinic, obesity usually results from a combination of causes and contributing factors, including inactivity, unhealthy diet and eating habits, pregnancy, lack of sleep, certain medications and some medical conditions (“Obesity Causes”, 2013 ). In addition, socioeconomic causes for obesity have been advanced. For example, Levine (1995) indicates that obesity is associated with reduced incomes. People who are obese have lower incomes compared to average weight individuals. Popular opinion points toward genetic influences as being responsible for obesity (Friedman, 2009). Certainly, genes influence obesity, as they influence all of human health. However, as far as genetics is currently understood, it plays only a very limited role in influencing human obesity and in any event, individuals who have the so-called “obesity genes” do not become overweight because, with few exceptions, healthy lifestyles can overcome genetic predisposition to weight gain (“Genes”, 2012). Several researchers (Wadden, Brownell, and Foster, 2002; “Toxic”, 2012) point to a “toxic” environment as the responsible party, especially the U.S. culture which encourages consumption of large portions of high-fat, high-sugar food while discouraging physical activity. Our culture and society contributes to the obesity epidemic more than our gene pool does (Price, 2002). The increase in the prevalence of obesity suggests that psychological and behavioral factors, rather than biological factors, are primarily responsible for this trend.

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Psychological Risk Factors Binge Eating A form of high calorie intake- binge eating- is receiving attention as a potential risk factor for obesity (McGuire, et al., 1999). Binge eating is a form of disordered eating in which an individual consumes a larger than normal amount of food in a short period of time (American Psychiatric Association, 2000). Research by Geliebter, et al. (1992) suggests that binge eating results in an enlarged stomach capacity. Having a larger stomach capacity could lead to the increased likelihood of future binge eating. An individual with a stomach capacity which has been enlarged through repeated binge eating will consume more calories before the body initiates satiety signals to terminate eating (Gibbs, Young, and Smoth, 1973). Binge eating is an eating disorder which has become problematic in the U. S. (Puhl, et al., 2011). There are both emotional factors and physical factors that result from binge eating. It is a serious risk which may lead to obesity. Emotional Eating Emotional eating has become a growing concern with the rising rates of obesity (Spoor, 2007). “Emotional eating” can be linked to an individual’s emotional state. It is characterized by overconsumption and weight gain. In addition, it can jeopardize an individual’s attempts to lose weight (Arnow, et al., 1995). Triggers or certain situations such as stress, frustration, and grief can motivate individuals to eat in order to alleviate feelings. This is influences by a desire for immediate gratification but this solution is only short-term. Emotional eating is also heavily influenced by advertising (Kemp, Bui and Grier, 2011). Emotional eating can lead an individual to utilize eating as a coping skill. Not only does using food to cope with emotional problems lead to weight-related issues, it may also prevent individuals from learning constructive coping skills for resolving negative emotion states. Behavioral Risk Factors Sedentary Behavior Low levels of exercise and sedentary behavior have predicted future weight gain among adults (Ching, et al., 1996). An individual who is not active in daily activity and does not incorporate exercise into their lifestyle is at higher risk for becoming obese. Some level of increased physical activity is almost certainly required in order to lose weight (Field et al. 2010; Jakicic, 2009), if only to “burn off” calories. Although increased exercise alone may have only a modest effect in promoting weight loss in overweight and obese individuals (Wing et al., 1988; Wood et al., 1988; Hagan et al., 1986), the effects of increase exercise have been shown to be “dosage dependent” - the initiation of vigorous exercise and its cessation has been shown to decrease and increase, respectively, body weight and these changes are proportional to the change in exercise dose (Williams and Thompson, 2006). Food Consumption Choice High calorie food is generally more palatable. It is metabolized quickly and converted to fat in the body. This is a powerful predictor of weight gain (Golay and Bobbioni, 1997). Furthermore, fat intake produces weak signals of fullness relative to other macronutrients, which results in overall greater intake (Rolls, 1995). Individuals who choose a high fat diet are likely to eat more than those who choose low fat diets. Adults who consume a diet high in fat and calorie are likely to gain weight over time which could lead to becoming overweight or obese. In addition to choosing the wrong mix of foods, the majority of Americans simply eat too much food. According to Economic Research (ERS) data on food consumption, the average daily calories available in the U.S. food supply increased by more than 500 calories per person between 1970 and 2004 (Just, Mancino, and Wansink, 2010). Individuals may not only be choosing high-fat food choices but they are likely consuming larger than recommended portion sizes. Dieting Although it seems reasonable that dieting would lead to weight loss, some dieting may actually lead to weight gain and obesity. French, et al., (1994) found that adults with elevated scores on dieting scales are at an

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increased risk for future onset of obesity and weight gain. Stice (2002) finds that extreme weight-control behaviors, such as vomiting and laxative abuse, also have predicted increases in weight gain over time. Individuals who score high on dieting scales appear to be more likely to diet. Kleges, Isbell, and Klesges (1992) indicate that these behaviors may also lead to changes in metabolic efficiency. In addition, these high risk behaviors could lead to eating disorders such as Binge Eating Disorder and Bulimia Nervosa which could lead to increased weight gain and obesity. Problems in self-control People may have problems in self-control when choosing food. This could be linked with immediate gratification and a fast-paced society. They may be under the influence of a visceral factor such as hunger (Just, Mancino, and Wansink, 2010). People tend to make less rational choices when making food choice compared to the consumption of other goods. Painter, Wansink, and Heiggelke, 2002) indicate that food choices are more often based on emotion than rational thought (Painter, Wansink, and Heiggelke, 2002). Market Data (2011) estimates the U.S market for weight loss products to be over $60 billion. Weight loss products include pills, lotions, written diets, at-home weight loss contraptions, and gym memberships. Despite the fact that there so much is spent on attempts to lose weight, obesity continues to be a major health concern. A successful characteristic necessary for weight loss is the ability to exercise self-control when making food choices. Family Obesity Genetic factors and psycho-social factors affect obesity. Obese parents have children who are at greater risk of becoming obese. This is partly due to within family environmental factors (Faith, et at., 1999). Parental obesity has generally been found to predict onset of obesity in adulthood (Settler, et al., 2000). Family predicts obesity due to genetic predisposition but also, and possible more importantly, due to environment. Research has shown that parents can model aversive eating behavior for their children (Elfhag and Linne, 2005), i.e., parents may effectively role model eating behaviors that lead to obesity. Psycho-social and environmental factors could include learned eating behaviors that lead to obesity. This could include the amount of food consumed and the frequency of meals and snacks. It could also include lessons that encourage children to utilize food as a coping tool such as emotional eating. Environment Bickel and Vuchinich (2000) state that in struggles between immediate gratification and long-term reward, immediate gratification, usually characterized as impulsive and irrational, often wins out. In the public health arena, immediate gratification translates into increased smoking, substance use, obesity, and other “failures of willpower”. Environmental effects have been shown to have a stronger impact on the amount that people eat than taste and food preference (Wansink and Kim, 2004). We live in a fast-paced culture that values immediate gratification and lacks consequential thinking. There are constant advertisements encouraging us to indulge in convenience. Fast food, fast shopping at the click of the mouse, fast pace, fast consumption, fast and immediate fulfillment of our needs and wants attempt to persuade our choices. Research has referred to these forces as “toxic” environments and refers to such environments as so due to the “unprecedented exposure to energy-dense, heavily advertised, inexpensive, and highly accessible foods” (Horgen and Brownell, 2002). Food is just part of the problem as today’s society encourages and enables an increasingly sedentary lifestyle. Gortmaker et al. (1996) found that children watch an average of 28 hours of television a week and that these children have a greater the likelihood of obesity, and Jeffrey and French (1998) demonstrated that fast food meals and hours of viewing television were positively associated with body mass index in women (but surprisingly, not in men). Wadden, Brownell, and Foster (2002) give additional examples of toxic environment, including the explosion of fast food restaurants, large and ever-growing portion size, all-you-can-eat buffet restaurants, gasoline stations with minimarkets, fast food franchises in school cafeterias, soda machines in schools, and powerful food advertising. Environment and environmental factors that affect obesity are worsening. These risk factors are becoming more influential on the prevalence of obesity (Foreyt and Goodrick, 1995). The environment for healthy food choices is degrading and the risk factors for obesity are becoming stronger. This is a high risk situation. The

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negative, “toxic” environment and increasing risk factors may continue to grow and with the obesity epidemic will worsen. Prevention and Policy There have been many advances in medical treatments for obesity. Pharmacologic and surgical interventions have played increasingly important roles in treatment of obese individuals (Bray and Greenway, 2000). However, behavioral change and addressing underlying psychological pathology must be addressed in order to address obesity. It is not likely that medical interventions alone will end the obesity epidemic. Environment plays a large role in the problem of obesity. Due to the contribution of environment, it makes sense to address environmental factors when addressing the obesity epidemic. There are many factors that contribute to obesity; therefore, it may be more reasonable to work toward prevention of obesity than remedies for the problem (Faith, et al., 2000; Muppala and Paul, 2006). Prevention may be a more successful way to battle obesity as it can teach individuals healthy behavior change before poor habits settle in. Waddne, Brownell, and Foster (2002) assert that management of the obesity epidemic will require better treatments for individuals who are already obese, but of more importance, it will require that greater resources and efforts be aimed at the prevention of the disorder. Interventions must target social and environmental factors that strongly contribute to obesity. Prevention may be an important factor in the efforts to reverse the prevalence and severity of the obesity epidemic. In addition to focusing efforts that encourage individual behavior change in the prevention of obesity, policy could be implemented. Interventions that target societal norms and regulations should be implemented to support prevention efforts. Government policy that addresses advertising, developing programs that educate the general public and parents in cultivating healthy relationships with food, self-regulation, and self-awareness, and taxing unhealthy foods and with food are 3 important areas. Obesity in children has been growing at alarming rates. Recently, nearly 9 million – or 15% of - school age children were found to be obese. The present obesity rates are thrice that of 1970s rates for children age 6 to 11 and double that for teenagers and preschoolers. The effect of obesity in childhood extends into adult life. Children with hypertension, which is linked to childhood obesity, are more likely to have heart disease and stroke in their adult life (Koplan, Liverman and Kraah, 2005). Advertising aimed at children is dominated by foods of poor nutritional quality. The average American child sees 10,000 food advertisements on television each year; 90-95% for sugared cereals, fast food, soft drinks, and candy (Horgan, Choate, and Brownell, 2001), which have been found to be associated with weight gain (Anonymous, 2012; Cannon, 1993; Woodward-Lopez, Kao and Ritchie, 2010). Policy could limit the number of poor nutrition quality foods to which children are exposed. This would be especially important for the future, as there is evidence that early intervention can increase preferences for healthy foods (Birch, 1999). Policy could require healthy food advertisements are targeted toward children to counterbalance unhealthy food advertisements. Just, Mancino, and Wansink (2010) find that, in the context of food, individuals are more likely to add utilitarian foods (likely to be healthier) to their diet than they are to eliminate a hedonic (typically less healthful) food; i.e., individuals are more likely to add a healthy food to their diet then they are to eliminate an unhealthy one. If these healthy food choices are introduced early on, and they become a preference, that preference will continue through life. It is important to develop healthy preferences in children for the prevention of both childhood and adult obesity. Parenting skills and psychoeducational classes in a variety of areas including relationships with food, selfregulation, and self-awareness could be important in prevention of obesity. Research on role modeling and relationships with food find that parents can model aversive eating behavior for their children (Elfhag and Linne, 2005). They may role model negative food consumption behaviors which could lead to obesity. Parenting skills programs could be used to help parents develop healthier relationships with food in their children. The Block, et al. (2009) study finds that initiatives to support healthy relationships with food appear to be important to overall well

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being. Programs that teach parents skills for cultivating healthy relationships with food for their children would also benefit the parent’s relationship with food. In addition to relating directly with food, the ability to self-regulate in general is an important factor in obesity. This area of interest is also one that could be addressed through parenting skills education and awareness. Graziano, Calkins, and Keane (2009) assert that early self-regulation difficulties represent significant individual risk factors for the development pediatric obesity (Graziano, Calkins, Keane, 2009). More specifically, Francis and Susman (2009) find that self-regulation failure in early childhood may predispose children to excessive weight gain though early adolescence. When adults lack self-regulation skills, they may turn to food to sooth themselves. This could lead to weight gain and, over time, obesity. Adults who are taught self-regulations skills could improve in this area and would be less likely to turn to external resources to self-regulate. In turn, if a parent could be taught to teach their child to self-regulate, they may be decreasing that child’s risk factors for obesity . Overweight children are more likely to become overweight adults. With this knowledge, policy could implement self-regulation training to teach children and adults alike, to become more aware of their thought processes that affect behavior and ultimately food choices. Self-awareness in general is an important education factor which policy could affect in regards to food choice. Shiv and Fedorikhin (1999) found that individuals who were given some cognitive task to perform while choosing between cake or fruit salad were much more likely to choose cake then those given only the food-choice task. This result held true even if the price of the cake was raised considerably higher than the price of the fruit salad. In our society of increasingly faster pace and unending multitasking, it may be important for public policy to increase self-awareness though training and education. The increased awareness of cognition and how multitasking can affect food choice could lead to prevention of poor food choices which lead to weight increase. There has been much controversy in the popular press regarding taxation of unhealthy foods. This is an area with much resistance from obese people and non-obese alike, raising questions of ethics and freedom of choice. Horgan and Brownell (2003) suggested that small taxes (a few cents) might achieve greater public support and therefore be more successful than larger taxes (5%-10%). As of 2000, 18 states and 1 major city imposed taxes on less nutritious foods (e.g., soft drinks, candy, gum, potato chips) (Jacobson and Brownell, 2000). Faith, et al. (2007) project that a sales tax of only 1 cent per pound of candy, chips, and other snack foods, fats, or oils would yield approximately 70, 54, and 190 million dollars annually, respectively. Taxation of particular foods may motivate individuals to make less expensive, healthier choices. Monies raised by such a program could be used to raise money to subsidize the sale of healthier foods. Policy should target both taxation of unhealthy food with the intent to subsidize healthier food. This may motivate individuals to make healthier food choices. Conclusions Himmelstein et al. (2009) assert that health promotion should be one of the highest priorities in the United States, given the skyrocketing costs of treating disease and disability. The prevalence of disease associated with obesity is alarming and costly in the United States. The need for treatment of medical issues in obese individuals is much higher than non-obese individuals. The treatment of obesity and related medical issues is costly and difficult. Intervention should start early with prevention strategies that are implemented by policy. Because the obesity epidemic appears to be out of control, public policies that promote prevention definitely appear to be required. It is necessary to identify the psychological and behavioral risk factors associated with obesity because without doing so behavioral change is unlikely. In their 2010 study, Kemp, Bui, and Grier indicated that past and current efforts to persuade consumers to eat healthier have focused a great deal on the provision of objective information (e.g., nutrient content). However, policy initiatives and social marketing programs must consider the role that psychological and social factors play in food related consumption. The traditional efforts to inform consumers about nutritional content have been insufficient to induce behavioral changes. Programs to prevent obesity must address the strong psychological, behavioral, social, and environmental factors that affect each individual’s risk of obesity.

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“Obesity Causes” (2013), “Obesity Causes” Mayo Clinic website, http://www.mayoclinic.com/ health/obesity/ds00314/dsection=causes. Retrieved June 5, 2013. Stansky, S. Jay, Douglas J. Pesaro, Ronald C. Hershow, Jennifer Leyden, Bruce A. Carnes, Jacob Brody, Leonard Hayflick, Robert N. Butler, David B. Allison and David S. Ludwig (2005), “A Potential Decline in Life Expectancy in the United States in the 21st Century,” New England Journal of Medicine, 352 (11), 1138-1145. Painter, James E., Brian Wansink and Julie B. Hieggelke (2002), “How Visibility and Convenience Influence Candy Consumption,” Appetite, 38 (3), 237-238. Price, R. Arlen (2002), “Genetics and Common Obesities: Background, Current Status, Strategies and Future Prospects,” in Handbook of Obesity Treatment, Thomas A. Wadden and Albert J. Stunkard (Eds.), New York: Guilford Press. Richards, Timothy J., Paul M. Patterson, and Abe Tegene (2007), “Obesity and Nutrient Consumption: A Rational Addiction?” Contemporary Economic Policy, 25 (3), 309-324. Rolls, Barbara J. (1995), “Carbohydrates, Fats, and Satiety,” American Journal of Clinical Nutrition, 61 (4 supplement), 960-967. Sallis, James F., Adrian Bauman and Michael Pratt (1998), “Environmental Policy Interventions to Promote Physical Activity,” American Journal of Preventive Medicine, 15(4), 379-397. Sallis, James F., Thomas L. McKenzie, John E. Alcaraz, Bohdan Kolody, Nell Faucette and Melbourne F. Hovell (1997), “The Effects of a 2 -Year Physical Education Program (SPARK) on Physical Activity and Fitness in Elementary School Students. Sports, Play, and Recreations for Kids,” American Journal of Pediatric Health, 87 (8), 1328-1334. Settler, Nicholas, Andrew M. Tershakovee, Baette S. Zemel, Mary B. Leonard, Raymond C. Boston, Solomon H. Katz, and Virginia A. Stallings, (2000), “Early Risk Factors for Increased Adiposity: A Cohort Study of African American Subjects Followed from Birth to Young Adulthood,” American Journal of Clinical Nutrition, 72 (2), 378383. Stice, Eric (2001), “A Prospective Test of the Dual Pathway Model of Bulimic Pathology: Mediating Effects of Dieting and Negative Affect,” Journal of Abnormal Psychology, 110 (1), 124-135. Stice, Eric (2002), “Risk and Maintenance Factors for Eating Pathology: A Meta -Analytic Review,” Psychological Bulletin, 128 (5), 825-848. Shiv, B., and A. Fedorikhin (1999), “Heart and Mind in Conflict: Interplay of Affect and Cognition in Consumer Decision Making,” Journal of Consumer Research, 26, 278-282. Spoor, S. T. (2007), “New Life Sciences Study Results from University of Texas Department of Psychology,” Women’s Health Weekly, 28, 149. “Toxic” (2012), “Toxic Food Environment,” Harvard School of Public Health, http://www.hsph.harvard.edu/obesity-prevention-source/obesity-causes/food-environment-and-obesity/index.html. Retrieved June 6, 2013.

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Wadden, Thomas A., Kelly D. Brownell and Gary D. Foster, (20 02), “Obesity: Responding to the Global Epidemic,” Journal of Consulting and Clinical Psychology, 70, 510-525. Wansink, Brian and Junyong Kim, (2004), “Bad Popcorn in Big Buckets: Portion Size Can Influence Intake as Much as Taste,” Journal of Nutrition Education Behavior, 37 (5), 242-245. Weil, Andrew (2004), “Fighting Fast Foods in Schools,” Andrew Weil, M.D. Website, http://www.drweil.com/drw/u/id/QAA331092. Retrieved on November 15, 2011. Williams, Paul T. and Paul D. Thompson, (2006), “Dose-Dependent Effects of Training and Detraining on Weight in 6406 Runners During 7.4 Years,” Obesity, 14 (11), 1975-1984. Wing, Rena R., Elizabeth Venditti, John M. Jakicic, Betsy A. Polley and Wei Lang, (1988), “Lifestyle Intervention in Overweight Individuals with a Family History of Diabetes,” Diabetes Care, 21 (3), 350–359. Wood Peter D., Marcia L. Stefanick, Darlene M. Dreon, Barbara Frey-Hewitt, Susan C. Garay, Paul T. Williams, H. Robert Superko, Stephen P. Fortmann, John J. Albers, Karen M. Vranizan, Nancy M. Ellsworth, Richard B. Terry, and William L. Haskell (1988) “Changes in Plasma Lipids and Lipoproteins in Overweight M en During Weight Loss Through Dieting as Compared with Exercise, New England Journal of Medicine, 319 (18):1173–1179. Woodward-Lopez, Gail, Janice Kao and Lorrene Ritchie (2010) “To What Extent Have Sweetened Beverages Contributed to the Obesity Epidemic?” Public Health Nutrition, 14 (3), 1-11. World Health Organization (WHO) (2000), “Global and Regional Burden of Disease Attribution to Selected Major Risk Factors.” http://www.who.int/healthinfo/global_burden_disease/cra/en/. Retrieved 9/18/2011. Zimmerman, Barry J. (2001), “Theories of Self -Regulated Learning and Academic Achievement: An Overview and Analysis,” in Self- Regulated Learning and Academic Achievement: Theoretical Perspectives, Barry J. Zimmerman, Dale H. Schunk, Mahwah, NJ: Lawrence Erlbaum Associates, Publishers.

Robin Hyson Monmouth University David P. Paul, III Monmouth University

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THE DIABETES PANDEMIC: THE PROMISE OF COMBINING MULTIPLE TREATMENT AND PREVENTION MODALITIES
Scott Yaeger, Monmouth University David P. Paul, III, Monmouth University Michaeline Skiba, Monmouth University

INTRODUCTION The current United States healthcare delivery system puts a greater emphasis on disease treatment rather than prevention. Two-thirds of U.S. healthcare expenditures are associated with preventable diseases, but we invest less than 5% of our more than $2 trillion annual health care spending in this area (Kovner and Knickman, 2008). Many healthcare experts (see, for example, “AACOM 2012 Annual Meeting”, 2012), would like to see a shift in our system to focus more on preventive health care in order to hopefully decrease incidence and/or severity of preventable diseases. Such a shift of emphasis will take a more collaborative effort from various health sectors such as public health, health policy, health education, community wellness programs, and help from the government on the state and federal level as well as health care professionals. On a more operational level, a shift to additional preventive programs will take time, enormous preparation, and funding in order to get them up and running. An important question here relates to the cost-effectiveness of such a shift: would additional funds spent on preventive health care be more efficiently spent on our current system of focusing on disease treatments? The hurdle is substantial, as many, if not most, studies focus on cost-effectiveness of specific disease treatments. Currently, 25.8 million children and adults in the U.S. (8.3% of the population) have diabetes. Another 7.9 million have undiagnosed diabetes, and 79 million have prediabetes (“Diabetes Statistics”, 2011). Five to 10% of individuals with prediabetes will develop the condition each year (Tabák, et al., 2012). Between 2007 and 2009, treatment for diabetes in the U.S. consisted of 12% insulin only, 14% both insulin and oral medication, 58% oral medication only, and 16% no medication whatsoever. The estimated costs due to diabetes in 2007 were $174 billion and the average medical expenditures among people with diagnosed diabetes were 2.3 times higher than if that population did not have diabetes (CDC, 2011a). These statistics were not broken down into each type of diabetes, so it is hard to analyze the effect of each one. DIABETES AND ITS TREATMENTS Diabetes is a group of diseases that result in high blood glucose levels. Type 1 Diabetes, formerly known as juvenile-onset diabetes, cannot be prevented and usually occurs in children or young adults, although onset can happen at any age. This form of diabetes occurs when the pancreatic beta cells that make the hormone insulin which regulates blood glucose are destroyed (Centers for Disease Control and Prevention [CDC], 2011b). Individuals with this disease must put insulin in their bodies in some manner in order to survive. Type 2 diabetes, or adult-onset diabetes, accounts for 90-95% of all diagnosed diabetes and occurs when the body’s cells do not use insulin properly and the pancreas gradually uses its ability to produce it (CDC, 2011b). Although this latter form of diabetes can have genetic component and is therefore more prevalent in some families and/or races more than others, obesity, poor diet, and physical inactivity are major risk factors in developing Type 2 diabetes. Gestational diabetes is another form of diabetes, but only occurs when a women develops a glucose intolerance during pregnancy. Through proper monitoring, high blood glucose levels often return to normal after delivery. However, this patient population should be watched closely both post-partum and at regular doctor’s appointments. Unfortunately and at this point in time, many women with gestational diabetes develop diabetes within five to 10 years after delivery (U.S. National Library of Medicine, 2011). There are different treatments available for diabetes, but most of them are used in conjunction rather than individually. Regardless of the treatment(s) employed, diabetes can be an inconvenient and costly disease.

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Monitoring blood glucose levels properly requires frequent checks of blood glucose and may also require keeping a log of the results. In addition, even with the proper medications, certain foods and drinks must not only be avoided but others also carried at all times when glucose levels drop too far. This can become a burden and costly to monitor. In 2007, total costs of diabetes in the U.S. were estimated to be $174 billion, of which $116 were costs directly attributable to medical treatment and $58 billion were indirect costs (disability, work loss, premature death, etc.) (CDC, 2011a). Although this is a lot of money for treatment of one disease, it is important to remember that diabetes not only requires treatment but also can lead to other conditions that require treatment (e.g., neuropathic and microvascular issues), and the treatment of these potential conditions incurs a cost. Another factor to keep in mind is that the CDC data is not broken down by type of diabetes, so it is impossible to estimate how much of these costs could have been prevented. However, as Type 2 diabetes is responsible for about 90-95% of all diagnosed cases, it is fair to assume that a large portion of these medical costs probably could have been prevented or minimized through better lifestyle choices and preventive measures. Dall et al. (2008) break down the costs of diabetes, attributing 50% to hospital inpatient care, 12% to medication and supplies, 11% to retail prescriptions to treat complications, and 9% for physician visits. It is shocking that half of the expenditure toward diabetes comes from hospital inpatient care and not from medication and supplies. It seems the best way to limit costs would be to minimize these hospital inpatient costs as much as possible as opposed to focusing efforts – at least, financial efforts –on inpatient treatment. Recent research and the advancement of technology have made treatments for diabetes more effective and convenient through the use of new medications, new insulin delivery devices, and new forms of insulin. Studies have shown that in people with Type 2 diabetes, a dual release medication containing both a rapid acting insulin to control blood glucose following meals and an intermediate acting insulin to control blood glucose between meals may be a better treatment option tha n the traditional use of a once a day insulin (“Recent Advances”, 2002). A potentially major technological ground-breaking advancement would be the development of inhaled insulin therapy that would take the place of insulin injections. Such a product was once FDA approved, but its use produced complications and it was withdrawn from the market. Currently, a different inhaled insulin product is in phase III clinical trials and looks promising (Sarala, Bengalorkar, and Bhuvana (2012). Such a product would be beneficial for individuals who are uncomfortable with taking insulin injections 3-4 times daily, which is often necessary to keep their diabetes well controlled (Eisner, 2012). The use of oral anti-diabetic drugs (OADs) can also serve this purpose, but this form is usually taken during the early stages of Type 2 diabetes and the patient eventually has to switch to insulin as the disease progresses. A regular exercise program and a good diet should be followed to increase the effectiveness of OADs and to minimize the risk of developing other health issues (e.g., heart disease, stroke, or hypertension). Heart disease death rates and the risk for stroke are both two to four times higher in adults with diabetes than adults without diabetes (CDC, 2011a). Not surprisingly, these potential complications contribute significantly to total health care expenditures associated with diabetes. PREVENTIVE CARE Preventive care refers to any measure taken to prevent the development of a disease. Preventive care measures include but are not limited to regular exercise, proper diet, examinations or screenings, vaccines and immunizations. One major issue in modifying our current health care delivery system which focuses on disease treatment rather than disease prevention is the creation of a program, or multiple integrated programs, which would be both effective and efficient. The adoption of such a system could take generations to be fully integrated and most efficient. However, the need for a change is obvious, since the U. S. spends more on health care than any other country in the world and doesn’t rank highly in overall health according to numerous measures (Kovner and Knickman, 2008). This poor standing vis-à-vis other developed (and even undeveloped) countries supports the contention that our health care system, despite delivering high quality treatment, is improperly focused. A major focus of such a change would be prevention. Chronic conditionssuch as diabetes are directly associated with obesity (Kenneth, 2008; Thorpe, 2006), and it is estimated that 80% of type 2 diabetes is preventable (“Diabetes Facts”, 2012). Thus, efforts to rein in rising health care costs associated with diabetes and other medical conditions should center on reducing obesity (Kenneth, 2008), a largely preventable condition. It is no secret that disease and illness result in a heavy financial burden on people and the nation. A great way to mitigate these financial burdens would be better screening for high risk individuals, which would allow early treatment before a condition becomes chronic. There are currently 133 million people in the U.S. with chronic conditions, most of which are preventable; these chronic conditions are responsible for 70% of all deaths and 75% of

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U.S. healthcare expenditures (Loeppke, 2008). Cutting down on chronic conditions can considerably decrease the health care expenditure. The use of screenings and routine primary care checkups would be helpful in detecting prediabetes before it becomes diabetes and creates the potential for subsequent complications. The Affordable Care Act (ACA) will play a major role in preventive care in the future. This Act eliminates any out of pocket payment for most preventive care services as long as they are provided within network. Covered preventive services include screening for Type 2 diabetes. This should be helpful in terms of providing more access to preventive care for most people as it removes the financial barriers to preventive care, which in turn gives health care providers to detect health issues before they become chronic conditions. Loeppke, Edington, and Beg (2010) developed a comprehensive prevention program which “identified an individual’s top health risks and designs a customized personal prevention plan to reduce those risks” (276). Participants were divided into high, moderate and low risk groups, and results showed a decrease in the percentage of individuals in the high risk group (p=0.000), a decrease in the percentage of individuals in the moderate risk group (p=0.0042), and a decrease in the percentage of individuals in the high risk group (p=0.000). More germaine to this discussion was a 31% decrease in fasting blood sugar in study participants in the high risk group (p=0.001). The underlying idea of preventive care is to reduce the risk of illness in order to lower expenses. The aforementioned results certainly demonstrated accomplishment of this goal by significantly lowering the risk of each group. This is evidence that the idea of preventive care is not only possible but also can be effective. The Prevention PlanTM is currently available from U.S. Prevention Medicine® (http://www.thepreventionplan.com/) for $229 annually (free to children under 18). The company claims that widespread adoption of Prevention Plan TM could save the U.S. a trillion dollars annually by 2020 (CBS Chicago, 2009). An integrated prevention plan can significantly help people either at high risk for or currently with diabetes. A study done with people who were at high risk confirmed that physical activity, a healthy diet, and lifestyle interventions reduced the development of Type 2 diabetes by 58% in the participating adults during a three year period and 71% for people sixty years or older (CDC, 2011b). Research has also found that lifestyle interventions and other preventive care actions are more cost-effective than medications. For instance, treatments with the drug metformin reduced the risk of diabetes by only 31% and were most effective in younger and heavier adults as opposed to the 58% reduction from preventive actions that were overall more effective, especially in older adults (CDC, 2011b). According to Teutsch (2003), lifestyle intervention is more cost-effective than the use of metformin and the long-term benefits should be much greater. Unfortunately, our health care reimbursement system is designed for clinical services instead of preventive and behavioral actions. This is a major flaw in our health care system since it will limit the use of these behavioral actions or preventive care measures and encourage the use of more clinical services as treatments for diabetes. DISCUSSION The effectiveness of preventive care to lower overall costs demonstrates that preventive measures offer a better healthcare delivery system than disease treatment. So what are the issues that are making this change in emphasis so difficult? A large investment in both time and effort would be required to get a preventive care system fully implemented and effectively working. Integration of preventive methods into our existing treatment system combined with simultaneous treatment of populations that are already diagnosed would not be easily accomplished. In terms of time, it may take several generations before the rate of chronic conditions decrease to a level with which we are comfortable and all of the necessary preventive programs are operationalized to be where we want our nation’s health to be. Another issue is implementing a prevention plan complex enough to withhold the complications of the country’s entire population. Studies to date have been done on a relatively small scale, and there is n o definitive assurance that similar results could be obtained if the same or similar protocols were applied nationwide. It is easy to assume that what worked in a small study would work for the entire country, but overhauling a vital part of our nation’s infrastructure based upon limited evidence is unlikely to occur. Many, if not most, aspects of health care would have to change in order to make this system work, including the availability of screenings and other preventive services, the structure of insurance coverage, government and private funding, a shift in the health care work force, better access to more nutritional foods, and more recreational and physical activity programs. Data and

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research have not been collected long enough to prove such measures will work and to justify a complete overhaul of our nation’s health care into this type of delivery system. However, there is hope. In an effort to quell the obesity epidemic – a strong risk factor for developing diabetes – the U.S. Preventive Services Task Force issued revised guidelines for clinicians whose patients exhibit a body mass index of 30 or higher. According to the guidelines, patients who meet or exceed that level should be offered or referred to intensive, multicomponent behavioral interventions aimed at helping them lose weight. At this juncture, it is unclear whether employers and insurers will embrace these guidelines because the task force has indicated that effective weight-loss programs should involve 12 to 26 sessions over the course of a year that cover multiple behavioral management techniques (Andrew, 2012). Finally and in terms of a cure, an article in Diabetes Forecast explained that over 90 years ago, insulin was heralded as the cure for diabetes. While insulin has saved and extended countless numbers of lives and made life manageable for diabetics, it is not a true cure. Recent and ongoing medical and technological breakthroughs, however, show great promise, and they include the following: - Matthias von Herrath, MD and professor at the La Jolla Institute for Allergy and Immunology in California, is developing a vaccine that targets specific components of the immune system to coax the body into tolerating beta cells. The aim of his research is to alter parts of the immune system that are detrimental to beta cells while preserving the parts that keep people healthy. - Other researchers are harvesting particular cells and reintroducing these cells to establish new immune systems. - To encourage beta cells to start producing insulin again, two strategies are being studied for regenerating these cells. According to Alexander Rabinovitch, MD and associate director of the Sanford Project, these methods include either growing beta cells outside the body or treating the diabetic with drugs that would stimulate the body to develop its own beta cells. - Some researchers are trying to make beta cells in laboratories from stem cells because stem cells potentially can provide a limitless source of insulin-producing beta cells. - Continued mapping of the genetic sequence may reveal the origins of insulin resistance and why beta cells fail in some people and not others (Gebel, 2011). In conclusion, the discovery of a cure may be many years ahead. However, serious attention must be paid to preventive measures (through ongoing monitoring of potential and existing cases of diabetes) and multidisciplinary case management teams that educate and encourage diagnosed diabetics to take an active role in their own care. In this way, preventive and therapeutic advancements used in tandem may, indeed, make a cure a reality. REFERENCES “AACOM 2012 Annual Meeting”, (2012) “Annual Meeting Draws High Marks from Attendees,” American Association of Colleges of Osteopathetic Medicine website. Retrieved August 22, 1012 from http://www.aacom.org/resources/e-news/ome/2012-4/Pages/2012AnnualMeeting.aspx. American Diabetes Association (2008), “Economic Costs of Diabetes in the U.S. in 2007,” Diabetes Care, 31 (3), 596-615. American Diabetes Association (2011), “Diabetes Statistics. Data from the 2011 National Diabetes Fact Sheet (released Jan. 26, 2011),” Retrieved November 17, 2011 from http://www.diabetes.org/diabetes-basics/diabetesstatistics/. Andrews, Michelle (2012), “New Guidelines On Obesity Treatment Herald Changes In Coverage,” Kaiser Health News website. Retrieved September 11, 2012 from http://www.kaiserhealthnews.org/Features/Insuring-YourHealth/2012/obesi... CBS Chicago (2009), “U.S. Preventive Medicine: The Pr evention Plan for Every American Could Create Billions in Health Care Savings,” UBMB Press Coverage. Retrieved June 10,

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2012 from http://www.uspreventivemedicine.com/News/Press-Room/USPM-Press-Coverage/ Billions-in-Health-Care-Savings.aspx. “CDC” (2011a), “2011 National Diabetes Fact Sheet. Diagnosed and Undiagnosed Diabetes in The United Sates, All Ages, 2010,” Centers for Disease Control and Prevention. Retrieved August 18, 2012 rom http://www.cdc.gov/ diabetes/pubs/estimates11.htm. CDC (2011b), “2011 National Diabetes Fact Sheet. General Information,” Centers for Disease Control and Prevention. Retrieved November 17, 2011 from http://www.cdc.gov/diabetes /pubs/general11.htm. Dall, Tim, Sarah Edge Mann, Yiduo, Zhang, Jaana Martin, Yaozhu Chen, and Paul Hogan (2008), “Economic Costs of Diabetes in the U.S. in 2007,” Diabetes Care, 31 (3), 596-615. “Diabetes Facts” (2012), “Diabetes Facts: The Prevalence of Diabetes Has Reached Epidemic Proportions,” World Diabetes Foundation. Retrieved August 22, 2012 from http://www.worlddiabetesfoundation.org/composite-35.htm “Diabetes Statistics” (2011), “Diabetes Statistics,” American Diabetes Asscoiation. Retrieved August 24, 2012 from http://www.diabetes.org/diabetes-basics/diabetes-statistics/. Eisner , Robin (2012), “Inhaled Insulin Study Results Promising,” ABC News (online). Retrieved August 20, 2012 from http://abcnews.go.com/Health/story?id=117655&page=1. Gebel, Erika (2011), “What Will It Really Take To End Diabetes?” Diabetes Forecast, 9, 39-43. Kenneth, T. (2008), Keynote Presentation at the American College of Preventive Medicine Prevention 2008 Conference, Austin, TX. Kovner, Anthony R. and James R. Knickman, Editors (2008) Jonas and Kovner’s Health Care Delivery in the United States, 10th Edition. New York: Springer Publishing Company. Loeppke, Ronald (2008), “The Value of Health and the Power of Prevention,” International Journal of Workplace Health Management, 1 (2), 95-108. Loeppke, Ronald, Dee W. Edington, and Sami Bég, (2010), “Impact of the Prevention Plan on Employee Health Risk Reduction,” Population Health Management, 13 (5), 275-284. “Recent Advances” (2002), “Recent Advances Make Diabetes Treatments More Effective and Convenient,” Novo Nordisk Press Release. Retrieved August 20, 2012 from http://www.evaluatepharma.com/Universal/ View.aspx?type=Story&id=27293. Sarala, N., G. Bengalorkar, and K. Bhuvana, (2012), “Technosphere Insulin: A New Inhaled Insulin,” Practical Diabetes, 29 (1), 23–25. Tabák, A. G, C. Herder, W. Rathmann, E. J. Brunner, and M. Kivimäki (2012), “Prediabetes: A High -Risk State for Diabetes Development, Lancet, 379 (9833): 2279-2290. Teutsch, Steven (2003), “The Cost-Effectiveness of Preventing Diabetes,” Diabetes Care, 26 (9), 2693 -2694. Thorpe, Kenneth E. (2006), “Factors Accounting for the Rise in Healt h-Care Spending in the United States: The

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Role of Rising Disease Prevalence and Treatment Intensity,” Public Health, 120 (11), 1002 -1007. U.S. National Library of Medicine, (2011), “Gestational Diabetes: Glucose Intolerance During Pregnancy.” Retrieved October 4, 2012 from http://www.nlm.nih.gov/medlineplus/ency/article/000896.htm Scott Yaeger Monmouth University David P. Paul, III Monmouth University Michaeline Skiba Monmouth University

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TRACK PHARMACOECONOMICS AND PHARMACEUTICAL INDUSTRY

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SAFETY OF THE UNITED STATES PHARMACEUTICAL SUPPLY INCREASINGLY IN QUESTION
Gene Wunder, Wunder Consulting Group

ABSTRACT The safety of pharmaceuticals continues to a serious issue in the United States. Problems remain despite numerous legislative and administrative attempts to resolve safety issues. Recent news articles continue to highlight concerns of the safety of pharmaceuticals manufactured or imported from outside of the United States. Canadian pharmacies previously thought to be a safe source of pharmaceuticals have recently come under investigation by the Federal Drug Administration (FDA). Canada Drug. Canada Drug, a well-known and trusted mail order pharmaceutical firm is currently being investigated concerning the origin and safety of pharmaceuticals they import to Canada and then export to patients in the United States . Recently at least two custom prescription formulating pharmacies in the Boston, Mass have come under scrutiny by the FDA. One has been the source of a serious fungal meningitis infection which has lead to the death of dozens of patients in many states . It appears that custom pharmaceutical drug-mixers fall between the cracks. The specialized pharmacies were licensed to make and distribute their products in Massachusetts. Instead, they were distributing their product in numerous states in the United States. This paper will investigate other questions relating to the safety of pharmaceuticals imported into the United States. The FDA is limited by its relatively small staff. Congress and administrative agencies have passed legislation and promulgate volumes of regulations. However, regulation fails to cover many often-overlooked sets of circumstances as illustrated by the recent outbreak of fungal Meningitis that was traced a drug-mixer in Massachusetts. Clearly more must be done in order to protect the consumer from harmful or ineffective pharmaceuticals. _____________________________________________________________________________________________ Gene C. Wunder* * Retired marketing professor, Washburn University, Topeka, KS 66614 Wunder Consulting Group 3611 SW Blue Inn Road Topeka, Kansas 66614-4677

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THE ROLE OF NUTRITIONAL SUPPLEMENTS IN PRIMARY CARE
Darrell McCall, University of Scranton Steven Szydlowski, University of Scranton

ABSTRACT Supplements for improving health status require an intake of nutrients that are not often met through an individual’s daily intake. The presenters define nutritional supplements, discuss common uses of supplements, and discuss the role supplements can have in primary care. There are multiple supplements that can be taken. The following are the most commonly used in healthcare:  Glucosomine  Melatonin  Seaweed  Potassium  Calcium Additionally, supplementation in primary care generally consists of Omega 3, Vitamin B, and Calcium. Our discussion and presentation will consist of supplementation in healthcare, specifically, in primary care. Furthermore, we will discuss the causes (need), side effects, and benefits.

Darrell McCall University of Scranton darrell.mccall@scranton.edu Steve Szydlowski University of Scranton

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PROBLEMS WITH ALTERNATIVE MEDICINE IN THE HEALTH CARE SETTING: FROM THE NURSES’ EXPERIENCE
Dennis Emmett, Marshall University

ABSTRACT This paper examines the problems with and advantages of alternative medicines from the experience of nurses. A survey was developed asking nurses concerning their experience with alternative medicines. Their experience shows that there are some problems areas; such as, increased bleeding associated with certain herbal medicine. Meanwhile, many of the respondents felt that certain herbal medicines were effective. The basic conclusion is that certain practices may be helpful, but more regulation and study are required.

INTRODUCTION Alternative medicines are becoming more common in today’s society. Approximately 38% of all adults in the United States use some type of complementary and alternative medicine (CAM) in 2007 according to a National Health Interview Survey (Barnes et al., 2008). The expenditures amounted to $33.9 billion in the previous twelve months (Nahin et al., 2009). CAM accounts for approximately 1.5% of the total health care expenditures ($.2.2 trillion) and 11.2% of total out-of-pocket expenditures (total $286.6 billion) (Office of the Actuary, 2007). The majority of the out-of-pocket costs went to the purchase of non-vitamin items, such as fish oil, glucosamine, and Enchinacea. Americans spent $$11.9 billion on acupuncturists, chiropractors, massage therapists, etc. (Office of the Actuary, 2007). People have questioned the effectiveness of alternative medicines. In fact, many argue that alternative medicines should be held to the same clinical effectiveness standards as conventional medicine (Arias, 2005). Adding herbal medicines to a multiple drug therapy has the risks of possible herb-drug interactions (Ernst, 2002). There are also side effects which may not be known to the user (Maranton et al., 2005). In addition, only 20% of health care providers consider herbal and alternative medicines to be safe (Maranton et al., 2005). Jibrin (2010) points out that there are no safety regulations for dietary supplements. His argument is that health care reform should address this issue. Consumer Reports (September, 2012) reported on the dangers of vitamins and supplements. They came up with a list of 10 dangers, as follows: 1. Supplements are not risk-free. The FDA reported from 2007 and 2012 more than 10.300 serious outcomes, including deaths, hospitalizations, serious injuries, emergency room visits, etc. Some supplements are really prescription drugs. Dietary supplements spiked with prescriptions drugs are the largest threat to safey. Many of the supplements contain same active ingredient as a prescription drug. For example, some supplements contain sildenafil which is basically Viagra. You can overdose on vitamins and mineral. Large dose of certain vitamins (e.g., A or D) can cause problems and interfere with prescription drugs.

2.

3.

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4.

You can’t depend on warning labels. FDA doesn’t require warning labels. Ginkgo biloba can interfere with blood thinners, but a warning is rarely issued. None are proven to cure major diseases. The Federal Trade Commission, which monitors advertising, has brought legal challenges to claims being made. Buy with caution from botanicas. Reports left the investigators concerned about product quality and identity. No evidence of providing warnings. Heart and cancer protection: not proven. Research is lacking on whether Omega-3 pills and antioxidants reduce the risk of heart disease or cancer. Betcha can’t guess this co mmonly reported problem. Choking is a serious problem. Some natural products are anything but. Vitamin pills are sometimes synthetically produced.

5.

6.

7.

8.

9.

10. You may not need supplements at all. You may be getting all of the requirements through correct diet, including nuts, fruits, vegetables, etc. People utilizing alternative medicines rarely tell their physicians, less than 40% (Arias, 2005). This is quite a low percentage given the possible side effects that exist. It is suggested that physicians need to ask about the use of alternative medicines, especially herbal and dietary supplements (Bressler, 2005). When asked, more than onehalf of physicians stated that they would encourage patients to discuss their use of alternative medicines (Arias, 2005). On the other hand, physicians know very little about herbal supplements and alternative medicines. Training on these matters should be incorporated into medical education programs (Maranton et al., 2005). In a survey of pharmacists, the results showed that most pharmacists did not have adequate training of alternative medicines and also did not regularly document the use of herbal medicine by their patients (Dolder et al., 2003). Herbal therapy has been promoted as a possible treatment for Attention deficit hyperactivity disorder (ADHD). A study was done which showed some improvement, but the study was not scientific (Reddy and Devi, 2007). Certain herbs are good sources of antioxidants without the side effects of other sources (Ali et al., 2008). The overall purpose of this paper is to determine the impact that alternative medicines have. Health care providers (in this case, nurses) were asked their opinions of the effectiveness of alternative medicines, along with any interactions or adverse effects. ANALYSIS OF DATA A survey was administered to 94 individuals in the United States. The nurses are students in an nurse anesthesia. All of these individuals were required to have prior nursing experience, including critical care nursing. There were 36 males and 58 females in the sample. The average number of years’ experience was 6.94. Table 1 provides data on the ages. The vast majority of the individuals were young.

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Table 1, Ages of Respondents Age Group 21-30 31-40 41-50 51-60 Total Number 55 28 9 2 94 Percent 58.5 29.8 9.6 2.1 100.0

Experience with Alternative Medicines The first questions were related to experience with various types of alternative medicines. The types were acupuncture, aroma therapy, herbal healing, Chinese or Ayurvedic, and others. The respondents were asked whether they had any experience with any of the above techniques. Table 2 provides the responses. Table 2, Experience with Alternative Medicines Type of Alternative Medicine Acupuncture Aroma Therapy Herbal Healing Chinese or Ayurvedic Other Yes 4 9 21 5 8 % Yes 4.3 9.6 22.3 5.3 8.9 No 90 85 73 89 82 % No 95.7 90.4 77.7 94.7 91.1

One can see that most of the individuals had little experience with alternative medicines. Herbal healing was the largest with 22.3% of the individuals having experience. The other experiences were chiropractic, massage, music, and religious. Next, the respondents were asked how effective they thought the different types of alternative medicine were. Table 3 provides the responses. Very effective was scored as a one and very ineffective was a five.

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Table 4, Effectiveness of Alternative Medicines Effectiveness Very Effective 3 11.1% Aroma Therapy 0 0.0% Herbal Healing 5 12.8% Chinese or Ayurvedic 1 3.7% Other 2 13.35 Somewhat Effective 10 37.0% 9 28.1% 17 43.6% 5 18.5% 4 26.7% Neutral Somewhat Ineffective 0 0.0% 5 15.6% 3 7.7% 1 3.7% 0 0.0% Very Ineffective 0 0.0% 1 3.1% 0 0.0% 0 0.0% 0 0.0% Mean Std. Dev. 2.41 0.69 2.94 0.76 2.38 0.82 2.78 0.58 2.47 .74

Acupuncture

14 51.9% 17 53.1% 14 35.9% 20 74.1% 9 60.0%

Of the people that had experience with the various alternative medicines, there were some differences in their perceptions of effectiveness. Most respondents felt that the alternative medicines were somewhat effective. The method perceived as the most effective was herbal healing. The least effective was aroma therapy. In each case, the type of alternative medicine was perceived as being somewhere from somewhat effective to neutral. Table 5, Adverse Impact on Conventional Treatments Adverse Impact on Conventional Treatment Yes % Yes Conventional (Western) Medicine Surgical Procedures Anesthesia Administration Other 16 12 9 4 17.6% 13.2% 9.9% 4.3% 75 79 82 87 No % No 82.4% 86.8% 90.1% 95.6%

There is some evidence to suggest an adverse impact on medical procedures. The highest percentage is with conventional treatment at 17.6%. The respondents saw 12 occasions where alternative medicines interfered with surgical procedures and 9 cases of adverse impact on anesthesia. This suggests that one should be careful, if involved in other types of treatment. Other adverse impacts were mostly with delaying conventional treatment, due to receiving alternative treatments. This resulted in death in one case.

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Next, the respondents were asked to rate the effectiveness of different types of herbal medicines. The results are given in Table 6. The results were scored from 1, very effective, to 5, very ineffective. Table 6, Effectiveness of Herbal Medicines Effectiveness Very Effective Basic Vitamins 25 28.7% Fish Oil 29 34.1% Eye Vitamins 6 7.1% Other Herbs (e.g., Ginseng, Gingko Biloba) 9 10.7% 47 54.0% 38 44.7% 19 22.6% 35 41.7% 14 16.1% 17 20.0% 57 67.9% 37 44.0% 1 1.1% 0 0.0% 1 1.2% 2 2.4% 0 0.0% 1 1.2% 1 1.2% 1 1.2% Somewhat Effective Neutral Somewhat Ineffective Very Ineffective Mean Std. Dev. 1.90 0.70 1.89 .80 2.67 0.68 2.42 0.76

The majority of the respondents felt that basic vitamins (82.7%), fish oil (78.8%), and other herbs (52.4%) were either very effective or somewhat effective. In contrast, only 29.8% of the respondents felt that eye vitamins were either very effective or somewhat effective. The adverse impacts of herbal medicines are given in Table 7. The adverse impact was asked with respect to conventional medicines, surgical procedures, anesthesia administration, and others. Table 7, Adverse Impact of Herbal Medicines Adverse Impact on Conventional Treatment Yes % Yes Conventional (Western) Medicine Surgical Procedures Anesthesia Administration Other 16 18 13 3 18.2% 20.5% 14.8% 3.4% 72 70 75 84 No % No 81.8% 79.5% 85.2% 96.6%

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Table 8, Types of Adverse Impacts Suggested Type of Adverse Impact Times Suggested 14 2 2 2 2 1 1 1 25 Percent of Total Responses

Bleeding Did Not Seek Treatment Until Late Interaction with other medications Interaction with Anesthesia Liver and kidney problems Increased heart rate and blood pressure Affected intubation Death Total

56% 8% 8% 8% 8% 4% 4% 4% 100%

Bleeding appears to be the most frequent adverse impact. This is consistent with other literature ; particularly, Consumers Reports which suggests that herbal medicines can interact with blood thinners. CONCLUSIONS The main purpose of this paper is to examine the opinions of a class of healthcare providers (nurses) in relation to the use of different types of alternative medicine. Many of the nurses had no experience with the different types of alternative medicine. Respondents had the most experience with herbal medicines. When asked about effectiveness, nurses listed herbal healing as the most effective, followed by acupuncture, aroma therapy, and Chinese or Ayurvedic. The use of herbal medicine is probably the most utilized by consumers. Nurses felt that there were adverse interactions with other types of treatment, including conventional medicine and surgical procedures. Most nurses felt that basic vitamins, fish oil, and other herbs were somewhat effective. These individuals were neutral to eye vitamins. They felt that these treatments did interfere with other treatments. The major side effect was bleeding, which has been previously reported (Stanger et al., 2012). A lot of money is spent on alternative medicine in the United States. The amount of money spent is growing. There are many doubts about the effectiveness of these treatments. Other healthcare providers have the same doubts as nurses. While the sample for this paper is relatively small, I would suggest that the same results would hold for a larger sample. I would also suggest that physicians would be less enthusiastic about the value of these treatments. One can do more training on herbal remedies and alternative medicines. Some medical education programs now include alternative medicine as part of the training. Pharmacists are beginning to receive education about the interactions of herbal medicines with traditional medications. This will be helpful, but not the panacea. The results of this study mirror the problems suggested by the literature. What can be done? There are several suggestions that need to be done. The ten items suggested as problems areas in Consumer Reports (2012) can be addressed as follows:

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1.

Alternative medicines should be tested for curing certain ailments, diseases, etc. These tests should be similar to tests for regular pharmaceuticals. These would list the possible side effects and the possible interactions.

2.

If the product contains the active ingredients of a prescription medicine, then this medicine should also require a prescription. In addition, the facilities that manufacture those drugs should be under the same restrictions as all medical manufacturing facilities. All vitamins, herbs, etc. should be manufactured in accordance with certain rules and regulations for quality. All claims of “natural” would have to be substantiated by proof. All alternative treatments (acupuncture, chiropractic treatments, etc.) would have to be able to prove their claims with scientific evidence.

3.

4.

If these items were implemented, then alternative medicine would be seen on a par with Western medicine. These medicines and practices would be justified as legitimate. This probably will not happen, since this would involve a lot of time and money. The alternative medicine industry would see this as an infringement on their livelihood. This would be seen as bending to the wishes of conventional medicine. Alternative medicine is here to stay. The best that can be hope for is that individuals will advise their physicians of their use of alternative medicines (herbs, treatments, etc.). Hopefully, this will alleviate any unwanted interactions that may be dangerous. In addition, medical and pharmacy schools should make sure that all doctors receive some level of education in the use of alternative medicines and possible side effects. REFERENCES _______. “Vitamins and Supplements: 10 Dangers That May Surprise You”. Consumer Reports. (September, 2012). Ali, Shahin, Naresh Kasoju, Abhinav Luthra, Angad Singh, Hallihosur Sharanabasava, Abhishek Sahu, and Utpal Bora (2008), “Indian Medicinal Herbs as Sources of Antioxidants”, Food Research International, 41,1, 115. Arias, Donya (2005), “Effectiveness Standards Urged for Alternative Health Treatments”, The Nation’s Health, March, 12. Barnes, P.M., B. Bloom, and Nahin, R. L. (2008) “Complementary and Alternative Medicine Use Among Adults and Children: United States 2007 (/news/2008/nhar12.pdf)”. National Health Statistics Reports, No. 12, Hyattsville, MD: National Center for Health Statistics. Bressler, Rubin (2005), “Interactions Between Ginkgo Biloba and Prescription Medications”, Geriatrics, 60 (4), 3033. Dolder, C., J. Lacro, N. Dolder, and P. Gregory (2003), “Pharmacists’ Use of and Attitudes and Beliefs About Alternative Medications”, American Journal of Health-System Pharmacy, Vol. 60 Issue 13, 1352-1358. Ernst, Edzard (2002), “The Risk-Benefit Profile of Commonly Used Herbal Therapies: Gingko, St. John’s Wort, Ginseng, Echinacea, Saw Palmetto, and Kava”, Annuals of Internal Medicine, 136 (1), 42 -53. Jibrin, Ismaila (2010). “Complementary and Alternative Medicine: The Other Healthcare Reform”, Southern Medical Journal, 103, 7, 605-606.

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Maranton, D. G., C. G. Dimopoulos and F. Thomson (2005), “How Much Do Health Care Professionals Know About Herbal and Alternative Medicines”, Age and Ageing, 34 (7), 119. Nahin, R.L., P.M. Barnes, B.J. Stussman, and B. Bloom, “Costs of Complementary and Alternative Medicine (CAM) and Frequency of Visits to CAM Practitioners: United States, 2007”, National Health Statistics Report, No. 18, Hyattsville, MD: National Center for Health Statistics, 2009. Office of the Actuary (2009). Centers for Medicare and Medicaid Services, “National Health Expenditure Data for 2007”, U.S. Department of Health and Human Services. Reddy, P. and G. Devi 2007). “Herbal Therapy: Children with ADHD (Attention Deficit Hyperactivity Disorder) and Depression”, Internet Journal of Alternative Medicine, 4,1, 3. Stanger, Michael, Lauren Thompson, Andrew J. Young, and Harris Lieberman (2012). “Anticoagulant Ac tivity of Select Dietary Supplements”, Nutrition Reviews, Vol 70, 2, 107-117.

Dennis Emmett Professor, Department of Management Marshall University School of Business Huntington, WV Phone: (304) 746-1961 Email:demmett@marshall.edu

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CLINICAL EVALUATION OF GENETIC DRUG SENSITIVITY TESTING FOR PATIENTS USING CODEINE RELATED DRUGS IN CHRONIC PAIN MANAGEMENT SETTING
Ahmet “Ozzie” Ozturk, Marshall University School of Medicine

ABSTRACT Genetic Drug Sensitivity testing (GDST) is a new way of assessing the appropriateness of a drug for a particular patient. We have tested the usefulness of GDST in a chronic pain clinic setting. We have limited the study to patients taking codeine or codeine derivative containing pain medications. Our preliminary study included 50 patients chosen by the clinician if their Urine Drug Testing suggested abnormal codeine metabolism as indicated by lack of or low level of metabolite, in which case a sample for GDST is sent for analysis. If the GDST result showed intermediate or poor codeine metabolism, patient’s drug is changed to a non codeine based pain medication. Our results indicate that GDST is a useful clinical tool in chronic pain management setting, by identifying patients who would not benefit from codeine related medications. In conclusion we have demonstrated that GDST can be used successfully for choosing appropriate pain medicine, whereby providing better pain relief for the patient, and for allowing cost saving by choosing the more effective medication early on.

Ahmet “Ozzie” Ozturk, M.D., M.S. Clinical Professor, Marshall University School of Medicine, Neuro Science Dept. Director Cabell Huntington Hospital Pain Management Center 1623 13th Avenue, Huntington, West Virginia 25701 Phone: 304-526-2243 Fax: 304-526-2220 E-mail: Ahmet.Ozturk@chhi.org

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TRACK ETHICAL ISSUES IN HEALTHCARE

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ETHICAL AND LEGAL ISSUES IN EXHIBITING HUMAN BODIES
Eva Grey, St Elisabeth University of Medical and Social Sciences, Bratislava Jana Trizuljakova, Medical Faculty of Comenius University, Bratislava

ABSTRACT Over centuries dead human bodies have been used as a valuable tool in education of medical profession. In the last decades, human bodies have been used as artifacts exhibited in public halls and exhibition rooms for public display. Organizers of these exhibitions declare them educational, but many other people, including medical professionals, consider them similar to freak shows, designed to shock and attract money from the viewers. This paper looks at several ethical and legal norms that are being neglected or violated by such displays.

Introduction Posters inviting the public to visit the Human Body Exhibition in Bratislava displayed a dead human body without skin. Extensive (expensive) media coverage claimed an educational purpose of the exhibition, but added that it is shocking and meant to startle viewers. Parents and school teachers organized visits of children as young as first graders in basic school expecting to boost their knowledge of the human body and its functions. Dead bodies of real humans are preserved by a complex process called plastination, in which water in the cells is replaced first by acetone and eventually by a liquid polymer. After achieving the preplanned position, the body is exposed to gas, heat or UV light to harden the plastic. (1) Education or shocking art The Czech Anatomical Societies proclamation states that the arranged positions of the bodies are not reflecting requiremets for systematic visual education. Therefore the educational aspects can only be secondary to the main goal which is to shock and raise curiosity. (2) The Dean of the Medical Faculty of Comenius University canceled a lecture about educational achievements of the exhibition and the faculty distanced itself from exhibitions that degrade the human body. There are better ways of teaching anatomy and understanding the complex functioning of the human body, including anatomical atlasses, educational movies, arteficial models of organs that can be touched, and so on. Several people who visited the site admitted that they were unlikely to attend an exhibition which would use detailed but arteficial models of human bodies and organs. It is no surprise that the first exhibitions of dead human bodies claimed to be avantgarede artistic displays. (3) After public disgust and disagreement, several original showpieces were not included in later exhibitions (sexual intercourse of two skinless corpses, corpse of dead pregnant women with dissected uterus) and organizers of these exhibits began promoting their educational character. Voluntary or involuntary donation of bodies Controversies have also been raised by human rights organisations concerning the origin of the human bodies. “Together against the death penalty” and “Solidarity China” both said they suspected the bodies came from the Chinese prison authorities. About 6000 death penalties are performed in China each year. (4) The bodies often belong to young people and show no visible cause of pathology or injury. Organizers of these exhibitions were unwilling or unable to show valid evidence that the bodies were donated voluntarily with written informed consent. According to a Report from investigation of allegations into organ harvesting in China, until July 1st, 2006, the practice of selling organs in China was legal. This report also states: “Deputy Health Minister Huang Jiefu, speaking at a conference of surgeons in the southern city of Guangzhou in mid November, 2006, acknowledged that executed prisoners sentenced to death are a source of organ transplants.” There are doubts about whether such prac tice has ended. (5) Respect or disrespect of dead human body

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Moral norms and state laws exist about the treatment of a dead human body and human remains. Slovak law on funerals No. 131/2010 Collection of Laws in § 4 par. (1) f) forbids such ways of handling of corpses and human remains, which would interfere with the dignity of the dead person, ethical feelings of survivors or the public. (6) Even if the dead people had agreed to donate their bodies, it is questionable that they wanted them to be skinned off , dissected, and put into a pose for public viewing. Bodies donated for research are usually seen by a small group of professionals or medical students and treated with due respect. Even if there was an agreement of donors on being exhibited, it would not justify violation of basic moral and legal norms. Parents and teachers misinformed by the advertising campaign bring school children to see this exhibition. Psychologists are worried that this can be a shock to small kids and a source of fears and nightmares. On the other hand, they can not exclude the development of a certain insensitivity to the human body. Grave robbing and desecration is one of the lesser potential consequences. Public service or commercial business Supporters of such exhibitions claim that there is no difference from anatomical sections. They even complain that medical professionals want to keep the privilige of seeing inside dead human bodies for themselves and away from the general public. Anatomical and pathological sections are performed for real educational purposes. They improve knowledge and skill of doctors and future doctors, so they can better treat and help their living patients. There are rules of ethical conduct to protect the dignity of those dead people. Importantly, no financial gain is involved in this activity. Donated bodies serve exclusively educational and scientific purposes. Public exhibitions of dead human bodies charge relatively high entrance fees and serve as a profitable business. They are violating international Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine. Article 21 of this Convention states: “The human body and its parts shall not, as such, give rise to financial gain.” (7) Conclusion Exhibiting dead human bodies is in violation of ethical and legal norms of individual states as well as the international community. Court decisions in France and Israel have already closed such exhibitions on legal grounds. (4, 8) In many countries there seems to be no interest to follow their example and ban imoral and illegal, yet financialy very profitable business. REFERENCES 1. Our body. The preservation process. http://www.ourbodytheuniversewithin.net/ 2. Prohlášení České anatomické společnosti. Aktuálne CZ. 04/05/2007. http://aktualne.centrum.cz/clanek.phtml?id=416325 3. Glasa J. Panoptikum hrôzy a nevkusu. In. Zdravotnícke noviny. Č.35/ S.12. 4/10/2012. ISSN 1335 -4477. http://www.kklz.sk/files/zdn35_12.pdf 4. The jury’s in: 'Our Body' exhibition banned in France. France 24 . 17/09/2010. http://www.france24.com/en/20100917-our-body-controversial-exhibition-france-appeal-court-ban-china-prisonsjustice-arts 5. Matas D., Kilgour D. An Independent Investigation Into Allegations of Organ Harvesting of Falun Gong Practitioners in China. 31/01/2007. .http://organharvestinvestigation.net/ 6. Zákon o pohrebníctve č. 131/2010 Z.z. http://www.zakonypreludi.sk/zz/2010-131 7. Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine. Oviedo, 04/04/1997. http://conventions.coe.int/Treaty/en/Treaties/Html/164.htm 8. Phillips J.: Israeli Supreme Court Closes Bodies Exhibition. Epoch Times. 02/10/2012. http://www.theepochtimes.com/n2/world/israeli-supreme-court-closes-bodies-exhibition-299249.html

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Prof. Eva Grey, MD, PhD St Elisabeth University of Medical and Social Sciences Nám.1. mája č.1 810 00 Bratislava +421 905 353 669 eva.grey@gmail.com Jana Trizuljakova, MD, PhD Medical Faculty of Comenius University Sasinkova 2 813 72 Bratislava +421 903 320 996 jana.trizuljakova@fmed.uniba.sk

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UNDERSTANDING THE FAMILYMEMBER’S LIVED EXPERIENCE TRANSITIONING FROM ACTIVE CARE TO END-OF-LIFE CARE. IT’S NOT JUST ONE DECISION.
Frances Gomes Marthone Georgia State University Ptlene Minick, Georgia State University ABSTRACT Introduction: The journey to end-of-life care is difficult and families report that they had to make decisions about end-of-life care for a loved one with little knowledge about the final wishes of the dying patient. The role of family members in the decision-making process about end-of-life remains under explored. Previous studies mention relatives with regard to decisions, but do not assess the family member’s ro le or participation in the decision-making process. When no advance directives exist or the final wishes and desires have not been verbalized by the patient, the journey to end-of-life care becomes challenging. The purpose of this study is to understand th e families’ perceptions of the decision making process when transitioning from active treatment to end-of-life care. If we know and understand the concerns that exist before and during this precarious transition time, then we can improve and enhance support for the families while they move to care for their loved one at the end-of-life. Method: Because the decision-making process about end of life issues is conceived as taken-for-granted, a qualitative methodology was chosen as the best approach for this study. Data are being gathered by face-to-face interviews, because the best way to gain an understanding of what transpired during the transition phase at the end of life is to interview the family who participated. A sample of twelve designated decision makers who have experienced the loss of a 65 -year -old (or older) person with a terminal illness is being recruited. A homogeneous sample will reveal what this particular experience means to this group. Participants will be between six months to one year post loss of their loved one and not receiving or have completed bereavement or support counseling for their loss. Results: To date three themes have been identified across seven interviews. First, participants report there are few conversations about death and dying between the primary support person and dying patient. The discussion about end of life care, options, and final wishes were not discussed at any point during the diagnosis, treatments, remission, or final days of the patient’s life. Second, the majority of participants explained that hospice is considered only after the families have reached physical and emotional exhaustion or when the medical team announces there is nothing more that can be done. And finally, there was little to no experience with death and dying with these participants. Participants were unfamiliar with the process, what to expect and how to navigate this strange but necessary final stage of life. The lack of experience left doubt and uncertainty of how to proceed. The lack of language and the words to ask the right questions stifles the conversations about choices and options which left the primary caregiver feeling lost and abandoned by the very team they relied on for guidance and direction. Recommendations/Implications: Nurses are a primary resource for education and information for patients and their families. We must begin by ensuring an understanding of all options available to the dying patient and their families including hospice and palliative care. Physicians and nurses should be competent in facilitating difficult conversations; they should be trained in delivering “bad” news and then providing support and guidance on next steps. As the healthcare team patients and families look to us for guidance, direction and support though these difficult times, we must be a resource for them as the experts in end-of-life care. We should make available social services, spiritual and grief counseling. As administrators we should work to improve resource and supports for these families, we should facilitate collaboration and inter-disciplinary conversations, we should encourage appropriate and timely referrals and provide end-of-life education and support for staff.

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Frances Gomes Marthone Georgia State University Ptlene Minick Georgia State University

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ORGANISATION AND MANAGEMENT OF ANTIMALNUTRITION PROGRAMMES IN KENYA
Vladimir Krcmery, St. Elisabeth University Dadline Kisundi, St. Elisabeth University Jaroslava Sokolová, St. Elisabeth University Victor Namulanda, St. Elisabeth University Ann Nageudo, St. Elisabeth University Nada Kulková, St. Elisabeth University Daria Pecháčová, St. Elisabeth University Mario Jančovič, St. Elisabeth University Alexandra Mamová, St. Elisabeth University Petra Stulerova, St. Elisabeth University Anna Porazikova, St. Elisabeth University Sona Revicka, St. Elisabeth University Steven J. Szydlowsky, University of Scranton Daniel J. West, University of Scranton Petra Mikolasova, St. Elisabeth University

ABSTRACT Malnutrition is emerging problem in tropic. In additional increasing number of tropical disease is related to undernutrition. Currently, about 2 billion population is suffering on food and water depression. Therefore we activate our ten years’ experience from our antimulnutrition program in Kenya*. INTRODUCTION One of millennium United Nations and World Health Organisation goals are to secure nutrition at least for children needs. Another development goal is to secure drinking water for about 2 mil children and women. About 100 million households have not asses to drinking water and about 500 million have access only to one meal per day. Millennium goals urge government on NGO´s to activate within 2015 and 2025 full nutrition for children, resulting to at least one warm meal for mothers and at least 2 meals per day for children needs. PATIENTS AND METHODS St. Elisabeth University since 2002 started in cooperation with existing first anti-malnutrition in Nairobi (since 1999) development of tree antimalnutrition clinics in Lunga Lunga slum (St. Charles Lwanga), second one in the third largest slum in the world – in Kibera (1.2 mil. inhabitants) and third Mary Immaculate clinic in Nairobi. Patients flow (mother and children) varied 20 – 60 per week. In addition, active surveillance and visits in those three slums has been organised on daily basis by PhD students and MSC students of social work on Mary Immaculata and St. Charles Lwanda and St. Vincent clinics in Nairobi. RESULTS Organisation and number of cases/malnutrition pairs is in the Table 1. While measuring the basic anthropometric parameters of children, we have observed about 85% response rates among starving children under 5 years of age.

Vladimir Krcmery, St. Elisabeth University Dadline Kisundi, St. Elisabeth University Jaroslava Sokolová, St. Elisabeth University Victor Namulanda, St. Elisabeth University Ann Nageudo, St. Elisabeth University Nada Kulková, St. Elisabeth University Daria Pecháčová, St. Elisabeth University Mario Jančovič, St. Elisabeth University Alexandra Mamová, St. Elisabeth University Petra Stulerova, St. Elisabeth University

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Anna Porazikova, St. Elisabeth University Sona Revicka, St. Elisabeth University Steven J. Szydlowsky, University of Scranton Daniel J. West, University of Scranton Petra Mikolasova, St. Elisabeth University

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MUSLIM WOMEN WEARING HIJAB IN THE WORKPLACE: FACING POSSIBLE RELIGIOUS STIGMA
Terrie C. Reeves University of North Carolina Greensboro, Associate Professor Arlise P. McKinney University of North Carolina Greensboro, Assistant Professor Laila Azam Froedtert Hospital, Admitting Manager

ABSTRACT This study examined Muslim women working in healthcare organizations and their choice to disclose their religious identity by wearing headscarve s known as hijab. We examined women’s experiences and decision-making processes, given that wearing hijab at work might result in stigmatization. About forty-five percent of the respondents chose to wear hijab. Many who chose not to wear hijab were fearful of prejudice or workplace discrimination, although their reasons varied widely. Experiences for women who did wear hijab in the workplace were both positive and negative. We discuss these findings in light of organizational diversity initiatives to address climate and inclusion. Keywords: religious tolerance, stigma, Muslim, discrimination _____________________________________________________________________________________________ INTRODUCTION As the workplace becomes increasingly global, there has been a heightened awareness of diversity management issues that extend beyond the demographic characteristics of race, gender, and age to include consideration of additional characteristics such as religion. In the U.S., religion is protected from workplace discrimination by Title VII of the Civil Rights Act of 1964. Religious discrimination involves treating a person (an applicant or employee) unfavorably because of his or her religious beliefs (U.S. Equal Employment Opportunity Commission, 2011). Moreover, the law requires employers to reasonably accommodate an employee’s religious beliefs and practices, unless there is a business necessity reason that such accommodation would otherwise interfere with business operations. Thus, an employer must not only prevent discrimination but must also reasonably accommodate an employee’s religious beliefs and practices. In addition to other practices, many religions include certain attire or adornment as an expression of faith. This paper specifically examined Muslim women and their decision to wear attire, known as the hijab, associated with their religion in the workplace. We sought to learn more about the decision processes and workplace outcomes in response to the religious expression. RELIGION IN THE WORKPLACE While religion is protected from employment discrimination in the United States, it is often quite unclear how the law is to be applied, or what inclusive workforce practices allow for religious expression. Cromwell (1997: 169) argued that religion can be problematic because unlike other characteristics (e.g., race, gender, national origin, disability, etc.), it is “an acquired property consisting of a set of beliefs that can be dynamic in nature.” Other than disability, it is the only protected basis that may require accommodations in workplace practice to avoid intentional or unintentional discrimination. In the current study, we focused on Muslim women because of the recent debate in Europe and the United States about the appropriateness of wearing the headscarf known as hijab in schools and at work (Giddens, 2004). As shown in Figure 1, the hijab covers the hair, neck, and shoulders and is traditionally an

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expression of Islamic modesty (Syed, 2010). In this paper, we examined Muslim women and their choice to wear the hijab as an expression of their religious persuasion, the associated stigma they might encounter as a result, and specifically whether they experienced discrimination in the workplace.

Figure 1. Hijab, the headscarf often worn by Muslim women. This photo belongs to Zharif the Future Surgeon's photostream, taken May 1, 2009. Source: http://www.flickr.com/photos/zharif/3504796495/ Permission: CC BY 2.0

Creative Commons is a freely licensed media file repository. There is an extensive literature about people who exhibit bias by stigmatizing others, but the stigmatized individuals’ perceptions, cognitive processes, and beliefs are less studied (Crocker & Major, 2003; Miller, Smith, & Mackie, 2004). We sought to examine these issues in the current study with Muslim women in the healthcare industry. We chose the healthcare industry for the following reasons: 1) women in this occupation had relatively high levels of educational attainment, and 2) this industry allowed us to examine diversity in position/rank for both physicians and other healthcare professionals. This study contributes to the literature of managing diversity and inclusive workplaces but is distinctly different from research that examines inclusion based on ethnic minority workplace experiences (Dawson, 2006; Van Laer & Janssens, 2011) and cultural discrimination (Cromwell, 1997). In contrast to those diversity aspects, religious persuasion is not a stable demographic categorization but, instead, is an aspect of diversity that can be malleable and expressive. Although prior research has examined the role of religion, spirituality, and faith in the psychological and physical health of patients in healthcare (King, 2008; King & Crowther, 2004; Liu & Robertson, 2011; Strauss & Sawyerr, 2009), we could find no studies that examined these practices for those who work in healthcare. One study examined discrimination in healthcare but it focused on age and gender, not on religion or

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religious expression (Ozcan, Ozkara, & Kizildag, 2011). Thus, this study is timely in examining the religious aspect of diversity and its impact on the perceived employment outcomes on Muslim women employed in healthcare settings. The stigma of religion Stigma is a phenomenon often studied in diversity contexts as an explanation for some of the experiences of women and ethnic minorities in social and employment contexts. Stigmas are personal characteristics labeled as flaws within a certain social contexts (Ragins, 2008), and a person with a stigmatizing characteristic is viewed as being in a separate, stereotypical group of lower status (Link & Phelan, 2001). According to Goffman(1963: 3), “stigma is an attribute that discredits an individual, reducing him or her from a whole and usu al person to a tainted, discounted one.” Stigmas may be linked to appearance, behavior, or group membership (Major, 2005), and in the U.S. and Europe, have been linked to religion, particularly Islam. The stigmas associated with being a Muslim and with the religion, Islam, were certainly heightened after the events of 9/11. As Khosravi(2012) noted, veils or headscarves associated with being Muslim are the most conspicuous signifiers of Muslims’ stigmatized identity. A substantial body of research has demonstrated the negative consequences accruing to a stigmatized individual (Beals, Peplau, & Gable, 2009; Clair, Beatty, & MacLean, 2005; Cottrell & Neuberg, 2005; Crocker, Voelkl, Testa, & Major, 1991; Goff, Steele, & Davies, 2008; Halperin, Pedahzur, & Canetti-Nisim, 2007) so many people try to avoid being stigmatized. Unlike race, gender, or certain disabilities, religion can be an invisible social identity. The invisibility allows an individual to control the likelihood of being stigmatized by his or her choice to disclose what would otherwise remain hidden. Major and O’Brien (2005) identified four mechanisms of stigmatization: (1) negative treatment and discrimination, (2) expectancy confirmation processes, (3) automatic stereotype activation, and (4) identity threat processes. Further, they classified negative treatment and discrimination as acts that directly affect the social status, psychological well-being, and physical health of the stigmatized individual. Here, we are interested in the process of negative treatment directed to stigmatized individuals and the consequence of exclusion from or disengagement in the workplace. Specifically, we were concerned with examining the experiences of and the associated consequences for those who chose to disclose their religious identity by wearing hijab in the workplace in the United States. Negative treatment and discrimination Prior research suggests that stigmatized individuals will likely experience negative treatment and discrimination. Interpersonal discrimination, one form of negative treatment, refers to discriminating interactions between individuals within a workgroup (Karlsen & Nazroo, 2002). Interpersonal discrimination can be overt (e.g., being treated rudely or threatened) and/or subtle (e.g., being ignored or watched closely) and both the frequency and severity of these incidents will likely shape negative perceptions of organizational climate. Prior research among diverse groups has shown that interpersonal discrimination affects women (Priola & Brannan, 2009) and ethnic minorities (Dawson, 2006), and results in a number of important psychological and employment outcomes (Krings & Olivares, 2007; Van Laer & Janssens, 2011), but little is known about discrimination experiences based on religious expression in the workplace. METHODS Participants Participants for this study were identified as females who were members of two U.S. healthcare professional organizations for Muslims. We solicited participants for the study with personal invitations at several meetings of the organizations and the women were contacted via email and/or phone to ask for their voluntary participation. Data were gathered on demographic and background characteristics and on hijab status followed by

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semi-structured interview questions, which were used to capture perceptions about hijab and the decision to wear it in the workplace. In addition to the semi-structured interview questions, participants were allowed to write and provide any comments they wished to share with the researchers. Procedure The questionnaire included both quantitative and qualitative approaches capturing the following information: (1) the choice of Muslim women to wear or not wear hijab in the workplace and (2) the associated work outcomes, both perceived and experienced. All participants were Muslim professional women already familiar with hijab, so each introduced to the study and informed of its purpose, which was to better understand perceived and/or experienced discrimination associated with wearing hijab in the workplace. Participants were also asked to provide demographic information including professional status, current position within the healthcare field, type of healthcare organization employer, highest education completed, region of the country in which organization was located, and hours worked each week. In the quantitative assessment, participants were first asked several direct questions beginning with the question of primary interest in this study, with the first being, “do you wear hijab?” This was dichotomo usly scored for yes/no responses. Two additional questions, also dichotomously scored for yes/no responses were, “I have witnessed discrimination” and “I have personally experienced discrimination.” In the qualitative assessment, participants were asked to respond to the following semi-structured interview questions and provide any additional feedback they would like to share with the researchers: 1. Tell us whether you wear hijab at work; please share your thoughts on why you do or do not wear hijab? 2. Can you tell me about any positive or negative experiences you have encountered based on being Muslim? Analysis Demographic characteristics of all participants were analyzed using counts and percentages as shown in Table 1. Following Dawson’s (2006) framework, which used interviews to examine partial inclusion and biculturalism experiences of African-Americans in the workplace, data from the semi-structured interview questions were grouped into recurring themes. The expressions of experience were evaluated to examine religious tolerance, perceived and experienced discrimination, and choice to engage in religious expression within the organizational environment.

Table 1. Demographic characteristics, (percentages may not total 100% due to rounding error) Variable Overall % Wears Hijab Number Yes All respondents Professional status Non-physician Physician 47.9 35.3 30 16 27 26 25.2 13.4 22.7 21.8 57 42 59 No 60 Percent of total Yes 49.6 No 50.4 119 N

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No response By region of US North east South east Midwest West No response By employing organization type Hospital or medical center Integrated system or HMO Military Research or educational Other No response By current position Management Clinical care LT, home, or mental health care Educational or residency training No response By highest education completed Baccalaureate or less Post Baccalaureate or Masters degree Professional degree Doctoral degree No response By hours worked (mean = 52 hours/week)

16.8

13

7

10.9

5.9

20

25.2 7.6 43.7 13.4 10.1

15 5 27 5 7

15 4 25 11 5

12.6 4.2 22.7 4.2 5.9

12.6 3.4 21.0 9.2 4.2

30 9 52 16 12

30.3 15.1 4.2 16.8 26.9 6.7

16 9 1 6 19 8

20 9 4 14 13 0

13.4 7.6 .8 5.0 16.0 6.7

16.8 7.6 3.4 11.8 10.9 .0

36 18 5 20 32 8

19.3 27.4 14.5 38.8 47.9

1 13 5 7 33

11 4 4 17 24

.8 10.9 4.2 5.9 27.7

9.2 3.2 3.4 14.3 20.2

12 17 9 24 57

16.8 24.1 35.3 5.9 16.8

13 14 16 3 13

7 16 26 4 7

10.9 11.7 13.4 2.5 10.9

5.8 13.3 21.8 3.4 5.9

20 30 42 7 20

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40 hours or less per week 41 – 60 hours per week 61 – 75 hours per week More than 75 hours per week No response

40.3 24.2 10.1 16.8 8.4

29 14 6 4 6

19 15 6 16 4

24.2 11.8 5.0 3.4 5.0

16.0 12.6 5.0 13.4 3.4

48 29 12 20 10

RESULTS One hundred nineteen women responded to the questionnaire to provide demographic information but only seventy-nine women participated in the qualitative assessment using semi-structured interviews as a means to capture their perceptions and experiences. Of the seventy-nine participants, about forty-five percent wear hijab in the workplace, compared to fifty percent in the total sample. The responses to the semi-structured interviews revealed several emerging themes which included: (1) perceptions of hijab in Islam, (2) perceived and experienced discrimination, and (3) overall experiences of Muslims wearing hijab in the workplace. Each of these themes reflected a need to better understand the exercise of religious freedom in the United States and the need to teach tolerance to address perceptions of Islam. Perceptions of hijab in Islam When participants discussed why they did not wear hijab, an unexpectedly large range of variability was revealed in regard to Muslim women’s beliefs about the relationship of hijab to Islamic percepts, scriptures, and/or practices. This wide variability was reflected in the following comments taken directly from the women’s written responses: I have my own personal expression of modesty and identify as a Muslimah. Hijab does not define my concept of Islam/practicing Muslim. It is not in my culture to do so (wear hijab) and also I don’t believe it’s the only route to modesty in Islam. I do not feel culturally tied to the tradition of wearing hijab in daily life. Hijab consists of modest behavior in lowering the gaze, guarding the private parts, and avoiding showing off by modest dress. I don’t completely believe in hijab. I believe in honesty, modesty, and humility but since I have been disillusioned by people in hijab I prefer not to wear one. Hijab is a grey area and I don’t believe such a burden should be placed on women. I think it is a personal choice after reviewing the Qur’an and Sunna to mentally accept to wear hijab, (there is) no mention of it (hijab) in the Qur’an, I do dress conservatively but I do not wear the headscarf. I do not believe the hijab is a requirement in Islam. Dressing modestly is mentioned, but not covering of the head.

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I don’t feel comfortable wearing it. I just feel uncomfortable in it. It is an illusion of modesty, sometimes falsely. The responses revealed a surprisingly wide variation among Muslim women in their beliefs about the meaning of hijab. Although the majority of these responses were based on the women’s personal religious or scriptural beliefs, several responses mention disillusion about Muslim women, themselves. This variation was not evident based on dichotomous questions or quantitative data and it would likely not have been discovered without the qualitative approach used in this study. Perceived or experienced discrimination? Even among women who believed that the hijab should be worn for Muslim modesty, many said that the consequences of wearing it may be negative. For these women, the decision not to wear hijab in the workplace was influenced much more by the consequences than by their interpretation of Islamic percepts. Often, workplace issues were specifically mentioned. For example, we found the following from those who choose not to wear hijab: It (wearing hijab) is a challenge in today’s society. It was very nerve-wracking as I knew many of my patients would not like a covered woman in their home. I finally decided to wear my scarf tied in the back rather than wearing it the correct way and since then, I have had no negative comments. I don’t wear hijab in my current job because after searching for a position for over a year, I found that as soon as I took off the hijab, I was hired! It would be hard for me to wear hijab and be able to concentrate at work…..I thi nk I am not ready for that kind of rejection. Afraid of judgment and hostility both from within Muslim community, employers/school, and family. I hate that it has become such a lightning rod as far as who people think you are or what you stand for. Personally, lack of courage. I may not be strong enough to take the risks of wearing hijab. I am a convert to Islam and do not yet feel ready to make a change in my external presentation since I began my professional relationship without wearing hijab. It takes t ime to change one’s identity and plan on wearing hijab when I feel psychologically and emotionally strong enough to handle situations and events that change brings about. It seemed to create a barrier….I was told that it was creating a barrier between othe r colleagues and patients. I don’t wear hijab because I feel that it just makes things harder in a society that may not always be understanding. It is an act that requires great courage and I applaud those who wear hijab.

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I am afraid of discrimination by my employer, co-workers, and patients. I don’t want to stand out or be singled out. I actually was afraid to wear hijab at a VA hospital in a suburban area. It was especially interesting to find that for Muslim women in this study, it was perceived intolerance or discrimination, and not experienced discrimination that affected their decision to wear hijab. Many of the participants acknowledged that disclosing religious identity would result in being a stigmatized target. Prior research has shown that stigmatized individuals reported mental health effects from both perceived and experienced discrimination (Gee, Ryan, Laflamme, & Holt, 2006). The responses from our sample should thus be of interest to organizations that seek to embrace all forms of diversity in that most of the respondents expressed some level of worry of fear about disclosing religious persuasion and the potential consequences in the workplace. Organizations may not be aware that suppression of desired religious expression in the workplace creates psychological stressors that may impact engagement within the workplace. Workplace experiences when wearing hijab As we wanted to learn more about discriminatory experiences associated with wearing hijab, we asked the participants to discuss positive or negative experiences they might have encountered as Muslims. This question elicited the women’s experiences, but in addition, some respondents began to talk about their perceptions of the reasons for their experiences as follows: Positive: Someone at work asked me about Islam and I was able to answer her questions and show her how I cover my hair. I am better able to communicate with patients from the same religion and ethnic background. I am able to provide better care to my Muslim patients. When I have needed to pray, others at the hospital have always been supportive. I think some patients take me more seriously because I look more “wholesome” After 9/11, people were concerned about me being harassed in general. Negative: A lot of recruiters require us to go out for drinks and sometimes it’s hard to be the only one around who does not drink alcohol. Patients, mostly the elderly, express disgust that I became a Muslim. Sometimes I have gotten distant feelings and actions when someone found out I was Muslim I was told by the manager that she hoped that I did not think I could work in her store with that “rag” on my head. After 9/11, all of sudden I found myself being reprimanded and written up for things I have been doing for years and as a result I watched a lot of people get fired.

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My former supervisor was Jewish and she joked about the tension that exists between Muslims and Jews. Some people react negatively when they find out that I am a Muslim and they are surprised because I am White. No one seems to have an open mind about White people and diversity. Socially, I feel stifled by the culture of drinking and each outing seems to focus on alcohol, which makes me less prone to participate. I was asked NOT to encourage fellow sisters to wear hijab. Most experiences are negative…people believe that all hijabis were from Afghanistan….I have drivers honk at me and yell out of their windows for no particular reason. People ask me if I feel subservient to my husband or men in general, which makes me wonder if they think I can’t handle a management position. After 9/11, I sometimes felt embarrassed to admit I was Muslim. The Muslim women in our study experienced more negative than positive interactions and consequences when wearing hijab in the workplace. Many participants felt the negative reactions were due to portrayals of Muslims in U.S. media in their references to 9/11 and the war against terrorists in Afghanistan. They felt that the media invoked more fear and false perceptions and only in rare cases did they fault the person making the negative comment. DISCUSSION We found that many women chose to disclose that they were Muslim and to experience any possible consequences of stigmatization, intolerance, or discrimination. Roughly thirty to forty percent of Muslim women in the United States wear hajib (Ahmed, 2011b), thus we found it surprising that a greater proportion of the study participants chose to subject themselves to possible stigmatization. This finding may be partially due to selfselection bias among women who wear hijab as participants in this study. However, there are at least two other reasons to explain why this group of highly educated women might choose to wear hijab. Ahmed (2011b) has suggested that wearing hijab does not represent a step toward repression for U.S. Muslim women, unlike the situation of women in predominately Muslim countries (Syed, 2010). Instead for U.S. women, wearing hijab represents a step toward a new Islamic activism focused on social justice of all sorts in all situations, not just equality for Muslim women (Ahmed, 2011b). Another possible reason is suggested by the literature. Perhaps wearing hijab represents greater freedom for these Muslim women: it demonstrates to parents and co-religious members that the woman wearing the hijab has conservative mores, which may, in turn, allow her more freedom of movement in public spaces (Ahmed, 2011a) while at the same time allowing her to express her complete autonomous identity (Williams & Vashi, 2007). Both of these reasons were supported by the participants’ comments and the underlying themes found in those comments. The first theme involved varying beliefs about requirements for wearing hij ab based on the Qur’an or other Islamic percepts or practices. 1 Although the variability in beliefs surprised us, it may demonstrate the general lack of knowledge among most U.S. citizens and organizations about Islamic beliefs and practices. It also illustrated the ease with which people can be categorized into stereotyped groups. Given the wide range of religious beliefs and expression among the many religions in the U.S., we should not have been surprised to find similar variation among Muslims. It is unlikely within any religious group for all members to have uniform beliefs, thus, organizations can learn that this also holds true for Muslim women. The second theme that emerged was about prejudice, discrimination, or barriers in the workplace due to

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wearing hijab. Respondents reflected about experiences with hiring difficulties, prejudice or discrimination, and fear. It was notable in the respondent’s comments that most experiences occurred in society at lar ge and were not exclusively associated with the workplace. Even without mentioning discrimination per se, many women reported they felt uncomfortable wearing hijab in the workplace, or they talked about lacking the courage, confidence, or strength required to wear hijab. This level of discomfort may be likely to carry over into negative workplace engagement. Especially in the life-or-death circumstances often encountered in healthcare organizations, negatively engaged workers may become liabilities to their employers when healthcare issues are overlooked or not fully explored. The third theme to emerge reflected both positive and negative experiences in the workplace attributed to being Muslim, and may provide further insight for organizations seeking to create and/or maintain a diverse and inclusive work climate. The positive experiences described by our participants also revealed that members of diverse groups may be best suited to enhancing cultural awareness among organizational members. Participants reported the pleasure involved in explaining Islamic beliefs and practices to co-workers while the co-workers enhanced their understandings of Islam. These conversations originated as co-workers inquired about wearing the hijab and what it means for the individual. Organizations may be able to increase inclusiveness by encouraging Muslim women to actively discuss their religion and to wear attire that makes them comfortable. The negative experiences described revealed the problems people experience when they believe they are or will be stigmatized. While very few participants reported actual instances of discrimination, many respondents believed that discriminatory consequences might result if they were to disclose that they were Muslim by wearing hijab. It seems likely that women who were afraid to wear hijab because they fear discrimination may be more likely to be more disengaged. The fact that many of the women’s employing organizations had hired women who wear hijab might represent highly beneficial change toward more inclusive workplaces in U.S. healthcare organizations. Healthcare organizations that pay particular attention to increasing possibilities for positive experiences among Islamic women may find that those experiences translated into positive experiences and better compliance among Islamic patients. The women’s positive comments support this suggestion. CONCLUSION For this study, we drew on the employment discrimination and stigma literature to examine the experiences of Muslim women in the U.S. workforce. Prior research has examined stigmas associated with race, gender, disability, and sexual preference but there is little research examining the issues of religion and specifically, Islam. The comments of women who choose not to wear hijab support the stigma literature and our expectation that wearing hijab exposed the women to more negative outcomes and impacted their decisions to disclose. At the least, our study suggests that organizations need to be cognizant of inadvertent stigmatization and discrimination due to religion. However, beyond this, the positive outcomes experienced by the women suggest that encouraging open workplace disclosure of hidden characteristics like religion may be highly beneficial for organizations. If women want to wear hijab in the workplace and if they suffer no negative consequences as a result, they may better serve clients, who are in turn happier clients, and they may be more engaged employees. REFERENCES Ahmed, L. 2011a. Reinventing the veil, Financial Times, on-line ed.: FT Magazine. London. Ahmed, L. 2011b. A quiet revolution: The veil's resurgence, from the Middle East to America. New Haven and London: Yale University Press. Beals, K. P., Peplau, L. A., & Gable, S. L. 2009. Stigma management and well-being: The role of perceived social support, emotional processing, and suppression. Personality and Social Psychology Bulletin, 35(7): 867-879. Clair, J. A., Beatty, J. E., & MacLean, T. L. 2005. Out of sight but not out of mind: Managing invisible social identites in the workplace. Academy of Management Review, 30(1): 78-95. Cottrell, C. A. & Neuberg, S. L. 2005. Different emotional reactions to different groups: A sociofunctional threat-based approach to "prejudice". Journal of Personality & Social Psychology, 88(5): 770-789.

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Crocker, J., Voelkl, K., Testa, M., & Major, B. 1991. Social stigma: The affective consequences of attributional ambiguity. Journal of Personality & Social Psychology, 60(2): 218-228. Crocker, J. & Major, B. 2003. The self-protective properties of stigma: Evolution of a modern classic. Psychological Inquiry, 14(3/4): 232-237. Cromwell, J. B. 1997. Cultural discrimination: The reasonable accommodation of religion in the workplace. Employee Responsibilities & Rights Journal, 10(2): 155-172. Dawson, G. 2006. Partial inclusion and biculturalism of African Americans. Equality, Diversity and Inclusion: An International Journal, 25(6): 433-449. Gee, G. C., Ryan, A., Laflamme, D. J., & Holt, J. 2006. Self-reported discrimination and mental health status among African descendants, Mexican Americans, and other Latinos in the New Hampshire reach 2010 initiative: The added dimension of immigration. American Journal of Public Health, 96: 1821-1827. Giddens, A. 2004. Beneath the hijab: A woman. NPQ: New Perspectives Quarterly, 21(2): 9-11. Goff, P. A., Steele, C. M., & Davies, P. G. 2008. The space between us: Stereotype threat and distance in interracial contexts. Journal of Personality & Social Psychology, 94(1): 91-107. Goffman, E. 1963. Stigma: Notes on the management of spoiled identity . New York: Simon & Schuster, Inc. Halperin, E., Pedahzur, A., & Canetti-Nisim, D. 2007. Psychoeconomic approaches to the study of hostile attitudes toward minority groups: A study among Israeli Jews. Social Science Quarterly, 88(1): 177-198. Karlsen, S. & Nazroo, J. Y. 2002. Relation between racial discrimination, social class, and health among ethnic minority groups. American Journal of Public Health, 92(4): 624-631. Khosravi, S. 2012. White masks/Muslim names: Immigrants and name-changing in Sweden. Race and Class, 53(3): 65-80. King, J., James E. 2008. (Dis)missing the obvious: Will mainstream management research ever take religion seriously? Journal of Management Inquiry, 17(3): 214-224. King, J. E. & Crowther, M. R. 2004. The measurement of religiosity and spirituality: Examples and issues from psychology. Journal of Organizational Change Management, 17(1): 83-101. Krings, F. & Olivares, J. 2007. At the doorstep to employment: Discrimination against immigrants as a function of applicant ethnicity, job type, and raters' prejudice. International Journal of Psychology, 42(6): 406-417. Link, B. G. & Phelan, J. C. 2001. Conceptualizing stigma. Annual Review of Sociology, 27(1): 363. Liu, C. H. & Robertson, P. J. 2011. Spirituality in the workplace: Theory and measurement. Journal of Management Inquiry, 20(1): 35-50. Major, B. & O'Brien, L. T. 2005. The social psychology of stigma. Annual Review of Psychology, 56(1): 393-421.

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Miller, D. A., Smith, E. R., & Mackie, D. M. 2004. Effects of intergroup contact and political predispositions on prejudice: Role of intergroup emotions. Group Processes & Intergroup Relations, 7(3): 221-237. Ozcan, K., Ozkara, B., & Kizildag, D. 2011. Discrimination in health care industry: A research on public hospitals. Equality, Diversity and Inclusion: An International Journal, 30(1 2040-7149): 22-40. Priola, V. & Brannan, M. J. 2009. Between a rock and a hard place: Exploring women's experience of participation and progress in managerial careers. Economic and Industrial Democracy, 28(5): 378-397. Ragins, B. R. 2008. Disclosure disconnects: Antecedents and consequences of disclosing invisible stigmas across life domains. Academy of Management Review, 33(1): 194-215. Strauss, J. P. & Sawyerr, O. O. 2009. Religiosity and attitudes toward diversity: A potential workplace conflict? Journal of Applied Social Psychology, 39(11): 2626-2650. Syed, J. 2010. An historical perspective on Islamic modesty and its implications for female employment. Equality, Diversity and Inclusion: An International Journal, 29(22040-7149): 150-166. U.S. Equal Employment Opportunity Commission. 2011. Laws and guidance, Vol. 2011. Washington, DC: USA.gov. Van Laer, K. & Janssens, M. 2011. Ethnic minority professionals' experiences with subtle discrimination in the workplace. Human Relations, 64(9): 1203-1227. Williams, R. H. & Vashi, G. 2007. Hijab and American Muslim women: Creating the space for autonomous selves. Sociology of Religion, 68(3): 269-287.

Terrie C. Reeves Associate Professor University of North Carolina Greensboro Arlise P. McKinney Assistant Professor University of North Carolina Greensboro Laila Azam Admitting Manager Froedtert Hospital

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TRACK CHANGES IN PROVIDERS OF HEALTHCARE

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SUPPLY OF PHYSICIANS AND NURSES IN THE UNITED STATES AND WORLDWIDE: ISSUES, TRENDS & EFFECTS ON HEALTHCARE MANAGEMENT
Maysoun Dimachkie Masri, Sc.D, MBA, MPH Lynn Unruh, PhD, RN, LHRM Bernardo Ramirez, M.D., M.B.A. Cristina Popescu, MA Ibrahim Zeini, MS-HAS _____________________________________________________________________________________________ ABSTRACT Fortifying the healthcare workforce is critical to successful implementation of the Affordable Care Act, which is intended to increase the quality, access, and safety of accountable care organizations (ACOs). This symposium addresses problems and potential solutions regarding supply, composition, distribution, retention and migration of physicians and nurses, who typically lead effective health teams. Exacerbated by ongoing globalization, competitive internal and external migration patterns contribute to imbalanced health outcomes that have their greatest impact on the neediest, most vulnerable and underserved populations. Symposium participants will be able to discuss and share their experiences and ideas for making progress on this pressing issue. Key words: Workforce supply, physician and nurse migration, healthcare outcomes, Accountable Care Organizations

PANEL OVERVIEW Background & Overview Access to good-quality health services is crucial for the improvement of health outcomes, as emphasized by the new Healthcare Reform legislation, the Patient Protection and Affordable Care Act. Excellence in healthcare is directly related to the quality and quantity of healthcare providers and, in particular, of the physicians and nurses who customarily lead the healthcare team. Improving the quality of care cannot be achieved if a number of geographical areas in the United States suffer from shortages of physicians, nurses, or lack the right type of physician specialties.1 Current projections indicate that the supply of physicians in the United States may be below current and future requirements. Although the existence and degree of the shortage is still under considerable debate, some experts estimate a shortfall of as many as 200,000 physicians by the year 2020. 2 Researchers argue that states that are largely rural will suffer the most.1 Today, the real problem facing the United States healthcare system is how to properly distribute the right number of physicians with the right specialties in the right locations. The relationship between the availability and supply of primary care and specialty care and health outcomes has been analyzed in a number of studies. Studies have shown that primary care physician density is related to the reduction of the overall mortality and total health expenditures. Starfield & Shi3 in the early 1990s showed that states with higher ratios of primary care physicians to population had better health outcomes (birth weight and self-reported health) and lower rates of all causes of mortality (mortality from heart disease, cancer, stroke, and infant mortality) after controlling for socio-demographic measures. On the other hand, greater supply of specialty physicians was associated with higher mortality. According to Baicker and Chandra 4, an increase in the number of specialists per 10,000 of population is associated with poor quality and higher costs. Another critical issue affecting both the quantity and quality of health care providers is the migration of the healthcare workforce, which is becoming a common trend as our world continues its globalization process. According to the World Health Organization (WHO), there is a shortage of doctors, nurses and support health personnel estimated at more than 4 million worldwide; this trend will continue since the growth of professional

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education graduates is smaller than the projected demand. The worldwide and regional migration patterns of key health professionals unbalance and exacerbate this workforce worldwide shortage trend. Several studies have documented the patterns and consequences for human resources policies affecting physicians’ and nurses’ migration. The consequences are equally important for the source developing countries, and for the hosts more developed countries, of which the U.S., the United Kingdom, Canada and Australia are the main recipients and beneficiaries. Today, the United States relies heavily on International Medical Graduates (IMGs) also known as Foreign Medical Graduates (FMGs). IMGs are physicians who have graduated from a medical school in a country different from the one where they intend to practice.5 According to the American Medical Association, about one in four physicians practicing in the U.S. is an IMG. The greatest concentration of IMG practitioners is in four states: New Jersey (45%), New York (42%), Florida (37%), and Illinois (34%). In addition, most IMGs come from India (about 21% in 2009).6 The most common way for these foreign-trained physicians to come to the U.S. and join the local workforce is by entering residency programs with U.S. hospitals. The U.S. has enabled immigration legislation that favors the migration of foreign physicians from other countries. This has led to discussions about the ethics of recruiting workforce from poorer countries, thus depleting local resources and negatively affecting the quality of those health systems. Given the shortage of health workers worldwide, particularly physicians and nurses, there is concern that migration from less advantaged areas to more resourceful areas contributes to widening the gap in the availability and quality of healthcare services. Existing research on this subject indicates several migration patterns:  Between employer types (e.g., from public sector to private sector)  Within regions (e.g., within U.S. or Canada, from rural areas to urban areas)  Within continents (e.g., within the European Union, from low-income Eastern Europe countries to higherincome Western Europe countries)  Between continents (e.g., from Africa, Asia, and South America to Europe, North America, and Australia) Generally, the causes of physician migration can be summed up into push and pull factors and fall in the following categories:  Remuneration and employment opportunities  Professional development and training  Working environment, including availability of resources and infrastructure  Quality of life, personal, and family-related motives  Political situation Physicians typically leave a particular environment because of deficiencies in the above mentioned categories and migrate to another environment that provides better conditions in those categories. In this symposium Dr. Unruh will present her study on the impact of work environment on the retention of newly licensed RNs, which is crucial to maintaining an adequate supply of RNs. Dr. Dimachkie Masri will present her findings on the determinants of geographical imbalances in the distribution of physicians, and the impact on mortality amenable to healthcare. The symposium will conclude with Dr. Ramirez, Cristina Popescu and Ibrahim Zeini who will consider international trends and effects of physician migration. RELEVANCE & IMPORTANCE The physicians’ and nurses’ workforces’ composition, the migration trends, and the different policies governing the supply of healthcare resources are very complex issues that have proven difficult to study given that information available from world databases and country-based resources are many times incomplete, imprecise or asymmetric. Studying the relationship between healthcare resources supply and outcomes requires the availability of process and outcome indicators at the patient and provider levels. Unfortunately, patient level data are not easily available because of privacy considerations and costs of collection. Furthermore, the number of confounding variables makes the interpretation of the findings and conclusions difficult and often debatable. At this symposium, participants will have the opportunity to share their experiences, obstacles, and findings of their current research studies related to the topic.

PANEL DISCUSSION SYNOPSIS

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The discussion will follow a specific outline, starting with Dr. Unruh discussing findings from her research. Topic 1: Title: Keeping Newly Licensed RNs in Nursing: the Role of Work Environment Discussant: Lynn Unruh, PhD Research Objective: Keeping newly licensed RNs (NLRNs) in nursing is crucial to maintaining an adequate supply of RNs. In prior studies, NLRNs describe stress, lack of preceptor and supervisory support, and disillusionment. Little is known about how these perceptions affect NLRNs' professional commitment. This study assesses the influence of hospital work environment upon NLRN’s intent to leave nursing and commitment to nursing. Study Design: A random sample of NLRNs in Florida was surveyed. The main part of the survey instrument was obtained from Kovner and Brewer, who developed it from a number of sources. Items and scales in the survey were validated in prior studies, and the survey was pilot tested. The survey asks questions regarding: demographics; perspectives on work difficulties due to inadequacy of supervisor or resource support and workload; perspectives on job pressures such as having enough time to get work done, and the pace of job; and items related to professional commitment and intent to leave the occupation. The survey was mailed to a random sample of 40% (n=3,027) of NLRNs, with follow-up to nonresponders. Due to a response rate of 18%, a bias analysis was done. The sample was demographically and geographically representative of the population. We used a subsample of 414 respondents who were currently working in hospitals. Both scaled dependent variables (intent to leave nursing, commitment to nursing) were separately regressed on two scaled work environment variables (job difficulty, job pressures) and each of their items (9 and 4 respectively) (total of 30 regressions). Other explanatory variables included age, gender, ethnicity, race, marital status, children in the home, educational level, hospital characteristics, type of shift, number of patients in recent shift, perception of orientation adequacy, and wage. Population Studied: NLRNs who were working in Florida hospitals at the time of the survey. Principal Findings: The job difficulty and job pressure scales and nearly all of their items were statistically related to a greater intent to leave nursing, and a lower commitment to nursing . Based on a ranking by standardized coefficient, the strongest ranked of the job difficulties items were those due to: incorrect instructions, organizational rules, lack of supervisor support, and inadequate help from others. Workload and other items were significant, but ranked lower. The strongest ranked of the job pressure items were: “having no time to get things done” and “having to do more than can be done well.” “Working very fast” was significant, but ranked lower. Several demographic characteristics that were related to professional commitment were race, ethnicity, and health status. Nurses working the day shift and with positive orientation experiences were less likely to intend to leave nursing and more likely to be committed to nursing. Conclusions: Negative perceptions of the work environment were strong predictors of intent to leave nursing and a lower commitment to nursing among NLRNs. Implications for Policy, Delivery or Practice: These results indicate that retention of NLRNs in nursing can be improved through changes in the work environment that include improving communication and supervisor support, increasing resources, and reducing workload and other job pressure factors. Topic 2: Title: The Distribution of Physicians Workforce in Louisiana: Results from a Cross-Sectional Study Discussant: Maysoun Dimachkie Masri, Sc.D

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Research Objective: to provide an accurate descriptive analysis of the physician workforce in Louisiana, during 2006-2008. For the past two decades, Louisiana’s population health rankings as reported by United Health Foundation have been among the lowest in the nation. In addition, the 2009 Commonwealth State Scorecards Report ranked the Louisiana health system performance, in terms of health outcomes, among the poorest in the nation. One reason for this disparity could be attributed to shortages of physicians and other healthcare resources in the state. These shortages were exacerbated by the damage done by the 2005 hurricanes Katrina and Rita to hospitals and physicians’ practices in New Orleans, and throughout the state. Study Design: data were obtained from the Louisiana State Board of Medical Examiners (LSBME). Louisiana physicians’ workforce was described by specialty, license status (active vs. non-active), graduation date, and parish. Frequency distribution of physicians by specialty (primary care physicians vs. specialists) and density were analyzed and tabulated for each parish. Principal Findings: No consensus has been reached on what is an adequate physician supply in the United States. However, when comparing Louisiana’s total physician ratio to the national average of physician density, Louisiana is experiencing a shortage. Furthermore, approximately 70% of physicians in Louisiana practice in Metropolitan areas. Metropolitan areas had the highest physician densities compared to non-Metropolitan and Micropolitan areas. On average per parish, the total physician supply was 111 physicians per 100,000 population with a maximum of approximately 924 in New Orleans. Louisiana appears to have a surplus of specialists, but not of primary care physicians Conclusions: future research should study the combined effect of the Rural Scholars Track program created by the School of Medicine at LSU, and the Tulane Rural Medical Education program (TRuMEd), in producing more primary care physicians for Louisiana in general and for rural areas in particular. Topic 3: Title: The Distribution of Physician Workforce in Louisiana: Implications on Outcomes of Care Presenter: Maysoun Dimachkie Masri, PhD Research Objective: To assess the effect of physician supply on mortality amenable to healthcare (MAHC) from all conditions amenable to healthcare, Diabetes Mellitus, and Ischemic Heart Disease, in Louisiana, for 2006-2007. Study Design: Using the framework of the Andersen Behavioral Model of health care utilization, this study (1) described the differences in age adjusted all cause MAHC and age adjusted MAHC for two specific conditions (Diabetes Mellitus and Ischemic Heart Diseases) by parish, in Louisiana for 2006; (2) estimated the correlation between parish level MAHC and socio-economic factors including race, income, gender, urban location, unemployment, and being uninsured that can alter appropriate utilization, and produce disparities in health outcomes; and (3) studied the association between physician supply and MAHC (measured by ASMRs) from all conditions amenable to healthcare, Diabetes Mellitus, and Ischemic Heart Diseases in Louisiana (2006-2007), while controlling for confounding variables (Ki). Principal Findings: the study did not demonstrate that higher physicians supply was associated with better health outcomes more specifically, ASMRs from all conditions amenable to healthcare, Diabetes Mellitus, or Ischemic Heart Diseases. On the other hand, socioeconomic factors like race composition, percentage of unemployed and the percentage of uninsured in a parish explained some of the variation. Conclusions: Where we live matters to our health. The health of the population in a parish depends on many different factors including socio-economic factors, access to healthcare providers (providers and facilities), financial barriers (such as insurance coverage), individual behavior toward health, and environmental conditions. In Louisiana, there are big differences in health status across parishes with some parishes having much healthier populations than others. For quality improvement efforts, it is important to measure factors affecting the health status in each individual parish. Worse MAHC disparities among disadvantaged population groups argue for policies prioritizing the health needs for those groups within the parishes.

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Topic 4: Title: Physician Migration Worldwide: Patterns, Trends, Causes, and Impacts Mentor: Maysoun Dimachkie Masri, Sc.D., Bernardo Ramirez, M.D, Lynn Unruh, PhD Presenter: Bernardo Ramirez, Ph.D Cristina Popescu, doctoral student Ibrahim Zeini, doctoral student Research Objectives: (1) To analyze empirical studies, key non-governmental reports, and commentaries to identify patterns and trends in physician migration; (2) To identify empirical data on the magnitude of physician migration worldwide; and (3) To identify empirical studies and evidence of the impact that physician migration is having on the workforce, on the availability of services, and on the quality of care provided to individuals. Study Design: Physician migration has long been the subject of debates and controversies. This study is a systematic review of the literature related to the measurement of physician migration and its effects in different countries and within the same country on healthcare outcomes. Methods: a systematic literature review was conducted in EBSCO host, MEDLINE, the CINAHL (Nursing and Health Services Administration), and the Econlit (Economics and Health Services Administration) data bases for studies on physician migration trends, impacts, and healthcare outcomes. Search years: 1995 – present Principal Findings: A brief look at the literature on the impacts of international physician migration showed that the literature could be divided into categories based on the impact on the healthcare workforce, patient care, and patient outcomes. The literature could also be categorized according to methodology. There are several articles that provided theoretical perspectives, editorials, policy, or commentaries, but there is very little empirical research conducted on this topic. Most empirical studies conducted on this topic were mainly qualitative in nature. Some studies examined only the impacts on one country, either donor or recipient. Conclusions: Without the full picture of the international impact of these trends, solutions cannot be developed. Extensive database searches have not produced articles that systematically and empirically analyze migration and its impacts.

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TRACK FINANCE ISSUES IN HEALTHCARE

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MASSACHUSETTS HEALTH CARE REFORM: A LOOK AT ITS COST-EFFECTIVENESS AND SUSTAINABILITY
Joshua McAdoo, Graduate School of Management -- Marshall University Julian Irving, Graduate School of Management -- Marshall University Charles Braun, Graduate School of Management -- Marshall University Alberto Coustasse, Graduate School of Management -- Marshall University

ABSTRACT In 2006, the Commonwealth of Massachusetts had over 500,000 residents who lacked health care insurance. In an attempt to cut overall costs and increase coverage levels, then Governor Mitt Romney advocated landmark health legislation that required all residents to obtain medical insurance. Ultimately, this legislation resulted in the addition of slightly over 400,000 individuals to the roster of covered lives at the same time increasing state spending for Medicaid coverage by 2.42 billion dollars (approximately one percent). While these early data suggest Romney’s legislation has generated positive outcomes, it remains to be seen whether this new system will be sustainable over the long run. The purpose of this paper is to investigate (1) the financial impact of the enacted changes and (2) whether these benefits are merely a short-term stopgap or evidence of a much more sustainable solution to this state’s uninsured conundrum.

Joshua McAdoo, MS. College of Business, Graduate School of Management Marshall University Tel: 304-746-1968 Fax: 304-746-2063 mcadoo@live.marshall.edu Julian Irving, MS. College of Business, Graduate School of Management Marshall University Tel: 304-746-1968 Fax: 304-746-2063 irving5@aol.com Charley Braun, PhD College of Business, Graduate School of Management Marshall University Tel: 304-696-2674 Fax: 304-696-6013 braun@marshall.edu Alberto Coustasse, Dr.PH. MD, MBA, MPH College of Business, Graduate School of Management Marshall University Tel: 304-746-1968 Fax: 304-746-2063 coustassehen@marshall.edu

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CHANGING THE REIMBURSEMENT ENVIRONMENT: IMPACT ON GROUP PRACTICES
Cristinel Mîinea, University of Scranton Robert Spinelli, University of Scranton

ABSTRACT Patient Protection and Affordable Care Act, as one of the most exhaustive piece of legislation affecting the healthcare sector is expected to have cascading repercussion on the reimbursement environment. Significant changes will affect the structure of premium rates set by insurance plans. The restructuring of Medicare and expansion of Medicaid programs are likely to alter patient enrollment, costs, and need for physicians. However, the extent of the actual expansion of these programs remains uncertain. In addition the introduction of value and episode of care as criteria redefining Medicare reimbursement are still in the conceptual phase and there is still little understanding on their impact on the overall reimbursement system. This presentation has the aim of examining the changing reimbursement environment as a result of healthcare reform and its impact on physician group practices.

Cristinel Mîinea, Ph.D. Department of Health Administration and Human Resources The University of Scranton 417 McGurrin Hall Scranton, PA 18510 Tele: 570 941-5872 Robert Spinelli, DBA Department of Health Administration and Human Resources The University of Scranton 417 McGurrin Hall Scranton, PA 18510 Tele: 570 941-5872

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USING COMMUNICATION THEORY TO ANALYZE CORPORATE REPORTING STRATEGIES: A STUDY OF THE HEALTH CARE INDUSTRY
Zachary Lukes, Bobcat and Doosan Co Sheri L. Erickson, Minnesota State University Moorhead Marsha Weber, Minnesota State University Moorhead

ABSTRACT This study examines the health care industry and its management responses to material weaknesses in internal control. Management is required to evaluate the effectiveness of company internal controls pursuant to Sarbanes-Oxley Section 404. Analysis of financial disclosures using communication theory can provide useful insight to company stakeholders. The results of our research show that a corrective action strategy was used 83% of the time, a positive correlation exists between firms reporting material weaknesses and the size of the firm, and that there is a positive relationship between the number of material weaknesses and the degree of leverage a firm employs.

INTRODUCTION Regulatory reforms in the U.S., such as Sarbanes-Oxley, emphasize the significance of timely and transparent corporate reporting and highlight the problems associated with inaccurate information disclosure. Sarbanes-Oxley (SOX) requires the implementation of Section 404 related to internal control over financial reporting and mandates management’s disclosure of its assessment of the firm’s internal controls as well as the corresponding opinion by the firm’s auditor. With the enactment of SOX, the U.S. Cong ress acknowledged major issues relating to the quality of earnings, transparency of financial reporting, and investor confidence in financial reporting. A major objective of SOX is to protect investors by improving the accuracy and the reliability of corporate disclosures that increase the transparency of reporting. SOX requirements relating to financial reporting and internal control analysis emphasize management responsibility for preparing financial reports. This has generated academic interest, resulting in several different research streams regarding firm reporting and compliance under Section 404, including the market reaction to internal control weakness disclosures and the characteristics of firms that have material weaknesses. Our study concentrates on how management addresses their material weaknesses by analyzing firms’ Section 404 disclosures within the health care industry. The health care industry was studied for a variety of reasons. First, papers by Rezaee and Jain (2005) and Beasley et. al. (2000) cite numerous studies that find that the health care industries have a prevalence of fraudulent financial statements. Among these, according to Beasley et. al., the most prevalent accounting fraud techniques used in the health care industries are improper revenue recognition (including recording fictitious revenues and recording revenues prematurely) and overstatement of assets (particularly overstating existing assets). Second, the KPMG Integrity Survey for 2008-2009 finds that 73% of employees in health care and 70% of employees in pharmaceuticals and life sciences reported/witnessed misconduct at the workplace. When asked to report on the seriousness of the misconduct, 57% in health care and 51% in pharmaceuticals and life sciences reported/witnessed instances of misconduct that would result in a loss of public trust (KPMG, 2009).

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BACKGROUND The goal of financial accounting The goal of financial accounting is to provide information to various stakeholders for their analysis of the firm’s financial condition. Users of financial statements assess the financial health of an organization, not only through its financial statements but also through the background information provided within Management’s Discussion and Analysis as well as the summary of significant accounting policies. The objectives of financial reporting are affected by various economic, legal, political, and social environment factors in which financial reporting takes place. When a company reports internal control weaknesses under SOX 404, management’s responses to the internal control weaknesses provide insight into how the company intends to change and improve internal controls. These responses also communicate the firm’s image. Material internal control weaknesses can provide information about a potential pre-crisis situation in that a failure of the firm to correct the weakness can result in a loss of investor and creditor confidence in the firm’s financial statements or even in business failure. Management must first acknowledge why material weaknesses exist before they can correct the weaknesses. By studying responses to material weaknesses, we gain insight into how serious management is about taking the necessary actions to eliminate these weaknesses. Communication theory and image restoration strategies One of the primary goals of corporate communication is to help the firm preserve a positive image (Benoit, 1995). This fact is evidenced by the existence of public relations departments or public relations firms hired for the purpose of making or re-making company images. A reputation may be damaged intentionally or unintentionally through words or actions. When this happens the communicator is faced with the problem of negative public image. Benoit creates his theory based on the assumption that, due to this negative image, the communicator will be motivated to attempt to restore its image as one of the central goals of its communication to the population. Stephens, et al. (2005) suggest that communication strategies are used to “manage meaning, represent the organization, build trust and credibility, and manage uncertainty.” Communication researchers have used Benoit’s (1995) typology to study organizational responses to crisis. These communication strategies provide a useful framework to understand and analyze how a company responds to stakeholders about issues that are indicators of a pre-crisis situation, which could lead to fraudulent activity or other severe business risks (Cowden & Sellnow, 2002). Seeger, et al. (2003) studied pre-crisis communication, and note that the pre-crisis period is characterized by “missed warnings, failed interpretatio ns, and/or failure to act on warnings.” Ineffective management of these warning signs can result in a movement from the pre -crisis to the crisis stage, resulting in losses for stakeholders. Research in the communications area has addressed attempts by an institution to restore legitimacy following crises that threaten that legitimacy (Erickson et al., 2010b). Image restoration in practice Accounting and finance researchers have used communication theory and image restoration research to analyze how managers and corporations communicate their financial and non-financial information to the public (Hildebrandt and Snyder, 1981; Thomas, 1997; Crombie and Samujh, 1999; Jameson, 2000; Rutherford, 2005; Deumes, 2008; and Geppert,and Lawrence, 2008). Researchers have also used communication theory models in the study of corporate disclosure of material weaknesses in internal control in Section 404 reports (Erickson et al., 2010a; 2010b). Erickson et al. (2010a) use Benoit’s image restoration typology to determin e what types of communication strategies firms use to disclose their material weaknesses in internal control and analyze what types of material weaknesses are associated with the use of non-corrective action strategies in the computer industry. Benoit’s typology Benoit’s (1995, 1997) typology is the one used most often by communication researchers to analyze strategic responses to legitimacy issues. The five categories of image restoration used are: (1) denial (2) evasion of responsibility (3) reducing the offensive act (4) taking corrective action and (5) mortification. The five categories are further divided into fourteen more highly focused strategies as shown in Table 1.

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Table 1. Benoit’s Typology Categories Denial Strategy 1. Simple denial 2. Shifting the blame Evasion of responsibility 3. Scapegoating 4. Defeasibility 5. Accident 6. Good intentions Reducing the offensive act 7. Image bolstering 8. Minimization 9. Differentiation 10. Transcendence 11. Reducing the credibility 12. Compensation Taking corrective action Mortification Source: Benoit (1995) Denial has two forms: simple denial and shifting the blame. Denial is the best strategy if the firm is truly blameless. If the firm uses a denial strategy and later is found to have blame in the event, its reputation can be irreparably damaged. If denial is not a feasible approach, the firm may choose to evade responsibility by using one or more of those strategies. The first strategy is scapegoating, which involves blaming the crisis on the provocation of another. Other evasion strategies occur when the organization: asserts that it did not know what to do or lacked the knowledge to act properly (defeasibility), claims the crisis was accidental, or states that it had good intentions and therefore should be vindicated. The next step may be to reduce the offensiveness of the act by image bolstering, minimization, differentiation, transcendence, reducing the credibility of the accuser, or victim compensation. In the case of internal control weaknesses, victim compensation is not possible because no known loss has yet occurred. A lack of internal control is a warning that possible losses can occur in the future if such weaknesses are not detected and corrected in a timely manner. The most responsible action for the company to take is corrective action. An organization that uses this strategy tries to make amends for the wrong that was committed and takes measures to prevent the event from reoccurring. More specifically, the firm addresses the source of the problem, explains how changes will eliminate future occurrences of the problem, and implements a remediation plan. When corrective action is used, management accepts its responsibility to maintain proper internal controls. The last strategy that could be implemented is mortification, which is admission of wrongdoing followed by an apology to the victims of this wrongdoing. 13. Corrective action 14. Mortification 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. Description/example Refuting outright that the organization had any part in the event Asserting that someone else is responsible Blaming the event on the provocation of another Not knowing what to do; lacking knowledge to act properly Claiming the event was “accidental” Claiming the company had good intentions Using puffery to build image Stating the crisis is not bad Indicating that this crisis is different from more offensive crises Asserting good acts far outweigh the damage of this one crisis Maintaining the accuser lacks credibility Paying the victim; making restitution to set things to where they were before the event Taking measures to prevent event from reoccurring

13.

14. Admitting guilt and apologizing

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RESPONSES TO MATERIAL WEAKNESSES IN INTERNAL CONTROL Companies reporting their financial results will strive to uphold a positive image. A significant material weakness may result in a company trying to minimize the reader’s reaction to negative results. Additionally, a company could also defend or restore its image to reduce the spotlight for misbehavior or wrongdoing. Thus, a company could “engage in recurrent patterns of communicative behavior designed to reduce, redress, or avoid damage to their reputation from perceived wrongdoing” (Benoit, 1995), a form of image restoration. Benoit’s (1995) image restoration typolog y will assist in the determination of the communication strategies management uses. For example, SOX requires that a company CEO and CFO certify their responsibility for implementing adequate internal control policies and procedures. Because management is responsible for its assessment and evaluation of internal controls, we would expect them to take corrective actions when internal control weaknesses exist. However, management may use other strategies to disclose the weakness, to evaluate the weakness, or to address its responsibility to correct the weakness. Firms can use different or multiple communication strategies in explaining these weaknesses to their stakeholders. Using Benoit’s typology, we are able to gain insight into how a company reports inte rnal control weaknesses under SOX 404 and to assess management’s responses to these weaknesses, which provides information on how the company intends to change and improve internal controls and whether it accepts responsibility for the weakness. The existence of internal control weaknesses can provide information about a potential pre-crisis situation. If the firm fails to correct the weakness, investor and creditor confidence in the firm’s financial statements may be shaken or, in the worst-case scenario, the firm may even fail. RESEARCH QUESTIONS Previous research has been completed regarding firms reporting material weaknesses in internal controls. Several studies document the characteristics of firms disclosing material weaknesses. Ashbaugh-Skaife et al. (2007); Doyle et al.(2007); Ge and McVay (2005); and Bryan and Lilien (2005) all find that firm size is a determinant of good internal control. They argue that large companies are more likely to have more reporting mechanisms in place and tend to have more employees and greater resources to spend on their internal control processes whereas small firms may lack sufficient resources to implement effective internal controls and may be more likely to use a type of non-corrective action strategy. Rapid-growth firms may outgrow their internal controls or they may dedicate a large portion of their resources to support growth rather than internal control processes (Doyle et al. 2007). Less profitable firms may not be able to invest in the proper internal control processes or they may be so concerned about improving their financial performance that they do not put sufficient resources and time into their internal controls (Ge and McVay, 2005 and Ashbaugh-Skaife et al., 2007). We also anticipate that leverage is related to the existence of material weaknesses. Firm debt levels and the existence of material weaknesses may be positively related because increased leverage may indicate that a firm is more focused on managing its debt levels than on maintaining effective internal controls. According to Lenard and Alam (2009) firms with high debt levels may be in violation of loan agreements and may have difficulty raising external capital, events which may lead to the existence of material weaknesses. Thus, we anticipate that firm size and profitability (ROA) will be negatively related to the probability of a firm experiencing material weaknesses. Growth (3 year growth rate in revenues) and leverage (debt/assets) are expected to be positively related to the existence of material weaknesses. We use these variables in the statistical analyses to respond to our research questions. Additional research by Ge and McVay (2005) focuses on types of material weaknesses firms disclose, but this prior research does not analyze how the firm communicates a material weaknesses and whether firms with different characteristics communicate the weaknesses differently. This notion shifts us to the first series of research questions: RQ1: Do health care firms respond to material weaknesses with a corrective action strategy, recognize their responsibility, and take or plan to take action to correct the weaknesses? RQ2: What firm characteristics (size, profitability, growth, and leverage) are associated with the existence of material weaknesses?

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RQ3: How do material weakness firms in the health care industry compare to the health care industry as a whole in terms of size, profitability, growth, and leverage? Since the use of corrective action strategies implies that management accepts that they are responsible and intends to make corrective amendments, we are most interested in management’s use of strategies other than corrective action. The use of these types of strategies could signal that management is less focused on transparent disclosure in financial reporting and their strategic communication with the public. Sarbanes-Oxley requires firms to address material weaknesses in internal control in a relatively new type of corporate communication. Firms were provided limited guidance on how to communicate this information. Firms may construct this communication in any way they choose, so it is helpful to look at specific examples of how these messages are put together. This discussion leads us to the second series of research questions: RQ4: Do health care firms use non-corrective action strategies in their SOX 404 reports to address material weakness deficiencies? If so, what are the most commonly used strategies? RQ5: If health care firms use non-corrective action strategies, what are specific examples of these strategies from the sample? DATA AND METHODOLOGICAL ANALYSIS This study uses a critical analysis method of studying communication strategies employed to mend tarnished images by carefully examining the language used by firms to communicate material weaknesses in internal controls and whether the company plans to correct the weakness in the future. An examination of the text of these communications provides insight into how companies use communication strategies to report these weaknesses. Critical analysis of strategic communication has been used by many scholars, including Benoit (1997); Benoit and Czerwinski (1997); Benoit and Henson (2009); Blaney et al. (2002); Coombs (1995); Hearit (1995); and Seeger et al. (2003). A variety of texts have been evaluated using critical analysis, including speeches, advertising, newspaper articles, and public relations announcements. The first step was to identify all firms in the health care industry that reported material weaknesses in internal control in their 200510-K and10-Q SEC filings from EDGAR by searching the keyword s “material weakness” and “internal control” and collected each firm’s Section 404 report. These material weakness disclosures are made in Item 9A: Controls and Procedures of the firm’s 10 -K and in Management’s Report on Internal Control over Financial Reporting and in Item 4: Controls and Procedures of the 10-Q. The Standard Industrial Classification (SIC) codes that were used in this analysis are: 2833-2836, 8000-8093. From here, all reports were read and independently classified by two researchers according to the material weakness responses using Benoit’s (1995) typology. Most firms’ reports numbered the material weaknesses, followed by a corresponding number that contained the particular action the firm would take to correct the weakness. RESULTS The resulting sample includes 61 companies in the health care industry that disclosed a total of 126 material weaknesses during the sample period. In 2005, 560 firms existed in the health care industry. The first set of research questions requires an analysi s of firms’ responses to material weaknesses using the communication strategies as defined by Benoit’s (1995) image restoration typology. Table 2 presents a summary of the strategies used by the firms in our sample.

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Table 2 Image Restoration Strategies by Typology Typology Denial: Denial Shifting the Blame Evasion of Responsibility Scapegoating Defeasibility Good Intentions Reducing the Offensiveness Bolstering Image Minimization Differentiation Taking Corrective Action TOTAL Number of Times Used 0 0 13 3 2 0 3 0 105 126 Total for Category

0

18

3 105 126

As anticipated, we find that management uses corrective action most frequently (83% of the time). However, one of the most interesting observations is that some health care firms use other image restoration communication strategies. This may indicate that reporting lacks transparency and that management may not take measures to prevent material weaknesses. To address research question two, we use the following logistic regression model to analyze the characteristics of firms using non-corrective action strategies. PROB(MW) = f(Β0 + Β1log(TA) + Β2ROA + Β3SG03 + B4 D/A) (1)

Where MW = 1 if the firm reports a material weakness and 0 if no material weakness exists. Table 3 contains the output of equation estimation. Results of the regression analysis indicate that firm size and leverage are positively related to the existence of material weaknesses for health care firms. The positive relationship between firm size and the reporting of internal control problems is not consistent with our expectations. However, it is possible that large firms are unable to devote the appropriate level of resources to effectively manage their internal controls. We also found that leverage is positively related to the existence of material weaknesses, which is as we expected. In order to address research question three, we conducted a univariate analysis to compare the characteristics of firms in our sample (firm size, profitability, growth, and leverage) with material weaknesses to all firms in the health care industry. Table 4 contains the results of the analysis. Material weakness firms are significantly larger (total assets) than firms in the health care industry. This is consistent with the results of the logistic regression estimation.

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Table 3. Logistic Regression Results Probability that Firm Characteristics are Related to the Existence of Material Weaknesses Dependent Variable MW Independent Variables Coefficients p-values Intercept -2.97276 0.0000*** Total Assets (Ln) 0.15091 0.0079*** Return on Assets -0.00008 0.9205 3-year Revenue Growth (Ln) 0.16795 0.3856 Total Debt/Total Assets 0.30327 0.031**    

*** Indicates significance at the 0.01 level ** Indicates significance at the 0.05 level Total Assets, Return on Assets, Revenue Growth, and Total Debt/Total Assets were obtained from Compustat. MW is an indicator variable that is equal to 1 if the firm reports a material weakness and 0 if no weaknesses are reported. Wilcoxon Test Statistic (two-tailed p value)

Table 4. Characteristics of Material Weakness Firms versus Health care Industry--2005 Material Weakness Health care Industry1 Firms N=560 N=61 Mean VARIABLE Size Total Assets Profitability ROA (%) Growth Sales growth (2002-2005) Leverage Total Debt/Total Assets
1

Median

Mean

Median

554.817 -54.817 25.7% 0.592

144.819 -5.981 6.40% 0.241

1775.039 -42.389 18.41% 0.344

73.708 -17.211 6.94% 0.127

0.0013*** 0.8046 0.5329 0.1294

SIC Codes 2830-2836 and 8000-8093 ***Indicates significance at the 0.01 level All variables obtained from Compustat. Total Assets are dollar amounts shown in millions. ROA (%) is return on assets, measured by dividing net income before extraordinary items by total assets and is used as a measure of firm profitability. Sales growth is calculated by finding the average annual growth rate in sales over a 3 year period. Debt to assets (%) is total firm debt to total assets. The second set of research questions (questions four and five) relate to the use of non-corrective action strategies by the health care firms in our sample. Table 2 indicates that evasion of responsibility strategies were used in 18 instances by these companies. Most of these responses (13) were examples of scapegoating, where the firm places responsibility for the weakness on an outside party. Firms also used defeasibility and good intentions evasion strategies. Firms that use these strategies indicate that management did not want to take all the responsibility for failure to implement effective internal controls. There were three instances where the firms used minimization strategies. Firms use these strategies when they cannot avoid taking responsibility for the weakness, but they attempt to diminish the importance of the problem.

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We selected excerpts that illustrate various communication strategies managers use to respond to material weaknesses in internal control over financial reporting based on Benoit’s (1995) image restoration typology. We chose these examples to illustrate each type of non-corrective action strategy used by firms in our sample. Table 5 contains these excerpts and an analysis of the strategies used to respond to material weaknesses in internal control. SciClone Pharmaceuticals and King Pharmaceuticals both used defeasibility strategies to respond to the material weaknesses by stating that they did not have sufficient personnel and knowledge to carry out appropriate internal control activities. Examples of scapegoating include Savient, which blamed some of its internal control problems on a subsidiary and Solexa, which placed responsibility for weak controls on the resignation of the controller. Alteon and Hermisperx Biopharma used minimization strategies to try to diminish the severity of their errors that resulted in financial restatements. Although reducing the offensiveness is less dangerous than trying to evade responsibility because management is clearly responsible for the company’s internal control structure, firms must still be cautious when using this type of strategy. An analysis of communication strategies used in SEC reports provides insight into management’s reactions to internal control weaknesses and its use of corrective action to avoid a potential crisis. If firms use communication strategies other than corrective action such as evasion of responsibility or reducing the problem through minimizing the weakness management reporting is potentially not transparent. If management uses similar strategies in other financial reporting disclosures, users may have concerns about whether management is fairly reporting the company’s economic reality.

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Table 5 Excerpts and Classification According to Benoit’s Typology Company SciClone Pharmaceuticals, Inc. Excerpt “This material weakness related to our failure, due to our lack of familiarity with certain technical stock option accounting matters, to evaluate the correct accounting effect of a stock price performance based option granted to our Chief Executive Officer on June 1, 2005, the date he commenced his employment.” Benoit’s Typology Evasion of ResponsibilityDefeasibility

King Pharmaceuticals, Inc.

“We did not maintain effective internal control over the period -end financial reporting process because we did not have a sufficient number of finance and accounting resources performing supervisory review and monitoring activities.”

Evasion of ResponsibilityDefeasibility

Savient Pharmaceuticals, Inc. Solexa, Inc.

“Our in-progress remediation steps related to controls over the Cash and Treasury process include: implemented improved check stock access controls and monitoring at Rosemont “We are recruiting additional personnel. However, in March 2006, our controller announced her decision to terminate her position with us effective April 30, 2006.” “While we believe that the remedial actions that have been or will be taken will result in correcting the conditions that are considered to be material weaknesses as soon as practicable, the exact timing when the conditions will be corrected is dependent upon future events which may or may not occur.” “In addition, the changes that would have resulted in the financial statements for the year ended December 31, 2005, as a consequence of the material weakness, were deemed to be immaterial but were nevertheless recorded by the Company.” “While the result of applying the proper accounting principles decreased our net loss per share by only $0.02 and $0.01 for the years ended December 31, 2003 and 2004, respectively we consider our accounting review process to be a material weakness that resulted in a material misstatement to our consolidated financial statements.”

Evasion of ResponsibilityScapegoating Evasion of ResponsibilityScapegoating Evasion of responsibilityGood Intentions

Ameripath, Inc.

Alteon, Inc.

Reducing the OffensivenessMinimization Reducing the OffensivenessMinimization

Hermisperx Biopharma, Inc.

Source: Company 10-K and 10-Q reports. SUMMARY Using Benoit’s (1995) typology, this study provides evidence that when management reports internal weaknesses, health care firms are most likely to communicate their intended corrective action to eliminate these weaknesses in the future. However, our examination reveals that, in some instances, management uses strategies other than corrective action including evasion of responsibility, and reducing the offensive act. These non-corrective communication strategies provide important insight to the users of financial statements. Strategies other than corrective action could signal to stakeholders that management may not be willing to take responsibility for correcting problems in internal control that created the material weaknesses or that management is unwilling to establish and maintain disclosure controls over financial reporting as mandated by

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Sarbanes-Oxley. These strategies could reflect the overall control environment of the organization and provide a signal of potential future internal control problems. The statistical analysis portion of our report reveals that firm size and financial leverage are positively correlated to the existence of material shortfalls for health care firms. Furthermore, material weakness firms are considerably larger by measure of total assets than the health care industry in its entirety.

REFERENCES Ashbaugh-Skaife, H., Collins, D. & Kinney, W. (2007). The discovery and reporting of internal control deficiencies prior to SOX-mandated audits. Journal of Accounting and Economics, 44 (1-2), 166-192. Doi:10.1016/j.jacceco.2006.10.001 Beasley, M., Carcello, J., Hermanson, D., & Lapides, P. (2000). Fraudulent financial reporting: Consideration of industry traits and corporate governance mechanisms. Accounting Horizons 14(4), 441-454. doi: 10.2308/acch.2000.14.4.441 Benoit, W. L. (1995). Accounts, excuses, and apologies: A theory of image restoration strategies . Albany: State University of New York Press. Benoit, W. L. (1997). Image repair discourse and crisis communication. Public Relations Review, 23(2), 177-186. doi:10.1016/SO363-8111(97)90023-0 Benoit, W. L. & Czerwinski, A. (1997). A critical analysis of USAir’s image repair discourse. Business Communication Quarterly, 60(3), 38-57. doi:10.1177/108056999706000304 Benoit, W.L. & Henson, J.R. (2009). President Bush’s image repair discourse on Hurricane Katrina. Public Relations Review, 35(1), 40-46. doi:10.1016/j.pubrev.2008.09.022 Blaney, J.R., Benoit, W.L., & Brazeal, L.M. (2002). Blowout!: Firestone’s image restor ation campaign. Public Relations Review, 28(4), 379-392. doi:10.1016/S0363-8111(02)00163-7 Bryan, S. & Lilien, S. (2005). Characteristics of firms with material weaknesses in internal control: an assessment of section 404 of Sarbanes-Oxley. Retrieved from SSRN: http://ssrn.com/abstract=682363. doi.org/10.2139/ssrn.682363 Coombs, W.T. (1995). Choosing the right words: The development of guidelines for the selection of the “appropriate” response strategies. Management Communication Quarterly, 8, 447-475. doi:10.1177/0893318995008004003 Cowden, K., & Sellnow, T.L. (2002). Issues advertising as crisis communication: Northwest Airlines’ use of image restoration strategies during the 1998 pilot’s strike. The Journal of Business Communication, 39(2), 194220. doi:10.1177/002194360203900203 Crombie, W. & Samujh, H. (1999). Negatice messages as strategic communication: A case study of a New Zealand company’s annual executive letter. Journal of Business Communication,36(3), 229-246. doi:10.1177/002194369903600301 Deumes, R. (2008). Corporate risk reporting: A content analysis of narrative risk disclosures in prospectuses. Journal of Business Communication, 45 (2), 120-57. doi:10.1177/0021943607313992 Doyle, J., Ge, W., & McVay, S. (2007). Determinants of weaknesses in internal control over financial reporting. Journal of Accounting and Economics, 44 (1-2), 166-192. doi:10.1016/j.jacceco.2006.10.003 Erickson, S. L., Weber, M., Segovia, J., & Dudney, D. (2010a). Management use of image restoration strategies to address SOX 404 material weaknesses. Academy of Accounting and Financial Studies Journal, 14(2), 5982. Erickson, S.L., Weber, M., Segovia, J., & Dudney, D. (2010b). Section 404 material weaknesses: Using communication strategies to predict bankruptcy, mergers, or SEC reporting problems within the computer industry. Journal of Forensic and Investigative Accounting , 2 (2). Retrieved from http://www.bus.lsu.edu/accounting/faculty/lcrumbley/jfia/Articles/v2n2.htm Ge, W. & McVay, S. (2005). The disclosure of material weaknesses in internal control after the Sarbanes-Oxley Act. Accounting Horizons, 19 (3), 137-158. doi:10.2308/acch.2005.19.3.137 Geppert, J., & Lawrence, J.E. (2008). Predicting firm reputation through content analysis of shareholders’ letter. Corporate Reputation Review, 11(4), p285-307. doi:10.1057/crr.2008.32

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Hearit, K.M. (1995). From “we didn’t do it” to “it’s not our fault”: The use of apologia in public crises. In W. N. Elwood (Ed.), Public Relations Inquiry as Rhetorical Criticism: Case Studies of Corporate Discourse and Social Influence, 117-131. Praeger Series in Political Communication. Westport, CT: Praeger. Hildebrandt, H. & Snyder, R. (1981). The Pollyanna hypothesis in business writing: Initial results, suggestions for research. Journal of Business Communication, 18(1), 5-15. doi:10.1177/002194368101800102 Jameson, D. (2000). Telling the investment story: A narrative analysis of shareholder reports. Journal of Business Communication, 37(1), 7-38. doi:10.1177/002194360003700101 KPMG (2009). KPMG Forensic Integrity Survey 2008-2009. Retrieved from http://www.kpmg.com/za/en/issuesandinsights/articlespublications/advisory-publications/pages/integritysurvey-2008.aspx Lenard, M. & Alam, P. (2009). An historical perspective on fraud detection: From bankruptcy models to most effective indicators of fraud in recent incidents. Journal of Forensic and Investigative Accounting, 1(1): 1-27. Available for download at: http://www.bus.lsu.edu/accounting/faculty/lcrumbley/jfia/articles.htm Rezaee, Z. & Jain, P.K. (2005). Industry-wide effects of the Sarbanes-Oxley Act of 2002. Journal of Forensic Accounting, (6), 147-162. Retrieved from http://maaw.info Rutherford, B. (2005). Genre analysis of corporate annual report narratives. Journal of Business Communication, 42(4), 349-378. doi:10.1177/0021943605279244 Seeger, M.W., Sellnow, T.L., & Ulmer, R.R. (2003). Communication and organizational crisis. Westport, CT: Praeger. Stephens, K., Malone, P., & Bailey, C. (2005). Communicating with stockholders during a crisis. Journal of Business Communication. 42(4), 390-419. doi:10.1177/0021943605279057 Thomas, J. (1997). Discourse in the marketplace: the making of meaning in annual reports. Journal of Business Communication, 34(1), 49-61. Doi:10.1177/002194369703400103 Zachary Lukes Bobcat and Doosan Co Sheri L. Erickson Minnesota State University Moorhead Marsha Weber Minnesota State University Moorhead

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A WELLNESS MODEL THAT IMPROVES FINANCIAL PERFORMANCE IN UNIVERSITY SETTINGS
Riddhima Palta, University of Scranton Allen C. Minor, University of Scranton Daniel J. West, University of Scranton

ABSTRACT Objective: This article presents information needed to develop a university-based wellness program. The framework provides a practical approach for smaller academic institutions to use, and identifies specific structural and design elements. Methods: Worksite wellness is not a new concept for business and industry. A survey of industrial models demonstrates the ability for wellness programs to control costs, reduce absenteeism, improve utilization of insurance, produce a return on investment, reduce medical claims filed, and reduce disability expenses. Results: An examination of business models, outcomes and design can be used to conceptualize and implement wellness programs in small universities. Universities have internal faculty and staff who can participate in designing wellness services. Conclusion: Universities can learn from business and industry to design wellness programs that improve employee morale, save money and create a positive work culture..

Riddhima Palta University of Scranton Dr. Allen C. Minor University of Scranton Dr. Daniel J. West, Jr. University of Scranton

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ICD-10 IN THE UNITED STATES: BETTER LATE THAN NEVER
Holly Johns, Marshall University Cara Havens, Marshall University Danielle Robinson, Marshall University Bala S. Pothakamuri, Monmouth University David P. Paul, III, Monmouth University Alberto Coustasse, Marshall University

ABSTRACT The United States faces a revolution in the healthcare system soon, when the present coding system (ICD9) will be replaced with what has for some years been the international standard: ICD-10. ICD-10 will provide a tremendous opportunity for better capturing the information in the increasingly complex delivery of healthcare. Although the transition to ICD-10 will undoubtedly result in substantial short-term costs, the long term benefits make the transition imperative.

Introduction International disease classification systems date back to 1763, when French physician Francois Bossier de Lacrois published a classification system listing ten major classes of diseases and 2400 individual diseases for helping his fellow doctors in making diagnoses (Knibbs 1929). In 1898, the American Public Health Association recommended that Canada, Mexico and the United States adopt the Bertillon Classification of Causes of Death, the international standard at the time. In 1946 at the International Health Conference, the World Health Organization (WHO) accepted the responsibility of the sixth revision of the International List of Causes of Death and included illness and injury classifications in the system (Schoenbach, 2000; ACEP, 2010). The resulting classifications accepted by the conference, as proposed by the WHO, were deemed as the International Classification of Diseases, Injuries, and Causes of Death which through later revisions came to be known as the International Classification of Diseases (ICD) (World Health Organization, 2010a). Through several decades of revision, ICD-9 was developed by the WHO in order to classify and globally compare statistical data related to mortality (Colorado Department of Public Health and Environment, 2001). In 1979, the Center for Medicaid and Medicare Services (CMS) modified the ninth revision to create the ICD-9-CM (Clinically Modified) for coding diagnoses and procedures in order to facilitate reimbursement and incorporate diagnosis and procedure codes as a means of statistically monitoring disease (American Academy of Professional Coders, 2010a; CDC, 2009). The U.S began using the ICD-9 system the same year and continues to utilize this system (AAPC, 2010a). Today these codes, which are annually updated, are used in the U.S. healthcare system as a means of billing and reimbursement (ACEP 2010). As technological advancements demanded a movement towards a universally compatible electronic health record system and advances were made in medical diagnosis and treatment, the current ICD codes have proven to be inadequate. The ICD-9 classification codes simply lack the detail needed to accurately reflect current medical terminology and procedures, and cannot be expanded to include new discoveries and procedures in medicine. Each year there are hundreds of new diagnoses submitted to CMS from medical research and technological advances of procedures that need greater specificity for adequate reimbursement and it cannot be requested due to the ICD-9 insufficiency of detailed coding (Haugh 2005). This inhibits the coding system’s ability to be utilized as a tool in the measurement of quality and outcomes (LeMier, Cummings and West, 2001).

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As of 1999, the WHO revised the ICD-9 to create ICD-10 (WHO 2010a). The ICD-10 has been modified into the ICD-10-CM and the ICD-10-PCS (Procedural Coding System). The ICD-10-CM, which is regulated by the National Centers for Health Statistics (NCHS) and the CMS, covers codes for reporting diagnoses and symptoms. The ICD-10-PCS, which is regulated by the CMS was created to code inpatient hospital procedures (American Medical Association, 2010). More accurate procedure descriptions with ICD-10 can facilitate better outcome measurement by discovering previously unknown correlations related to details such as laterality (Leon-Chisen, 2010). One-hundred fifty three countries have adopted an updated ICD-10 classification which is touted as allowing not only for increased specificity with diagnosis and coding but also for interoperability in global sharing of records and statistics (Schlom and Battani, 2009). Since 1999 the U.S. has only used this updated classification for tracking mortality (Dimick, 2009). The ICD-10 eventually will replace the International Classification of Diseases, 9th edition, Clinical Modifications (ICD-9-CM), which has codes dated from 1979-1998 (ACEP, 2011). The Center for Medicare and Medicaid Services (CMS) mandated the transition to ICD-10 codes throughout the U.S. healthcare industry by October 1, 2011 (CMS, 2010), but delayed the transition date until October 1, 2013, and more recently until October 1, 2014 (“Federal Register”, 2012). This transition will give the US the ability to track and respond to international health threats as well as better use the benefits associated with an Electronic Health Record (EHR), (International Healthlink Professionals, Inc., 2010). Any claims reported after the transition date using ICD-9 codes will be rejected and reimbursement will not be allocated (American Medical Association, 2010a. The necessity of this change has become overwhelmingly evident if the U.S. is to catch up with the technological advances in healthcare systems of other countries and to improve cost and quality of care. It is estimated that the conversion from ICD-9 to ICD-10 CM/PCS can cost as much as eight billion dollars in the US; most of these costs will be incurred by training staff, systems upgrades, and contract negotiations (American Academy of Professional Coders, 2009). ICD-10-CM/PCS implementation will be a costly conversion, but it will provide many advantages over the ICD-9 coding system. Two of the biggest and most important improvements seen in the ICD-10 code set will be the addition of sixth and seventh characters and the use of alphanumeric characters which will allow for more specific classification of various diseases and diagnoses. The new code set will allow for the inclusion of laterality, expanded injury codes, and information relevant to ambulatory and managed care encounters (Centers for Disease Control, 2001). Comparison of ICD-9 to ICD-10 One of the most noted differences between the two classifications is the enhanced specificity of ICD-10 codes (Quan et al., 2008), (Table 1). The improved level of detail provided in this revision is primarily due to the growth of diagnosis and procedure codes (AAPC 2010b). For example, it is possible to differentiate between an initial visit with diagnosis and subsequent follow up visits related to the same diagnosis while identifying any secondary complications. ICD-10 also allows for differentiation between right or left sided structures and procedures (AAPC, 2010c), (Table 1).

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Table 1: Comparison of Key Differences between ICD-9 and ICD-10 ICD-9  Lacks specificity  ICD-10 Highly specific

13,000 codes

68, 000 codes

Limited ability to expand and add new codes

Capable of expansion

Lacks identification of anatomical site laterality

Identifies anatomical site laterality

Lacks codes for ambulatory care, home health and skilled nursing

Creates new codes for ambulatory care, home health and skilled nursing

Procedure codes: 3 to 4 character numeric codes

Procedure codes: 7 character alpha numeric codes (each having a specific meaning)

Diagnosis codes: 3-5 characters in length. First digit may be alpha ( E or V) digits 2-5 are numeric

Diagnosis codes: 3-7 characters in length. Digit 1 alpha; digits 2 and 3 are numeric; digit 4-7 are alpha or numeric

Sources: Nagel 2004; Bowman 2008; DHHS 2008a; AAPC 2010b; Leon-Chisen 2010; TMA 2010 The ability to be more exact with classification has resulted in a three-fold increase in the number of codes (DHHS 2008a). In addition to combining diagnosis and symptom codes, ICD-10 has also been structured to include new coding for ambulatory care, home health care, and skilled nursing care facilities, as well as new technological advancements and procedures (Nagel, 2004). For example, the ICD-10 has around four categories and more than 46 codes related specifically to anesthesia, a significant increase, as currently ICD-9 contain less than 20 codes (WHO, 2006; Vlessides, 2009). The basic format of the revised coding structure is such that it can facilitate future expansion in addition to the already substantial increase in the number of codes (TMA, 2010), (see Table 2). Table 2: ICD-10-PCS Medical and Surgical Procedure Coding 1 2 3 4 Section Body system Root Operation Body Part

5 Approach

6 Device

7 Qualifier

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While the providers and payers eventually should see significant benefits, transitioning to ICD-10 will require big adjustments. Unlike ICD-9, ICD-10 differentiates its procedural codes into a distinct entity, called ICD10 –PCS. Apart from having more codes, ICD-10 codes are alphanumeric, containing letters and numbers. ICD-10 diagnosis codes have three to seven digits rather than three to four digits of ICD-9. In addition the ICD-9 and ICD10 code designations for similar diagnoses and procedures are entirely different. Normally there are not exact one to one matches between ICD-9 and ICD-10 diagnosis and procedural codes. As per CMS, about 76% of all ICD-9 codes map approximately to ICD-10 codes. But in reverse direction, 95% of all ICD-10 codes map approximately to ICD-9 codes. In addition many ICD-9 codes match more than one ICD-10 code and vice versa. In the procedural coding system, nearly 99% of all ICD-9 codes have only an approximate one to one match with an ICD-10 codes and some ICD-9 procedural codes map to several hundred ICD-10 codes. If providers aren’t watchful in their codes utilization, these differences could have serious reimbursement consequences; e.g., underpayments or overpayments. Substantially, ICD-10 codes capture far more useful detail. ICD-10-PCS differentiates body parts, surgical approaches, medical/surgical devices used, resource consumption and outcomes; e.g., under ICD-9; there is only one procedure code for angioplasty, but under ICD-10, 1,196 codes are available for that procedure. Under the ICD-9 code what blood vessel was involved in an angioplasty. But with ICD-10, the physician can describe the exact location of the blockage and the instruments used. It allows the provider to be reimbursed correctly for the true level of acuity. Under ICD-9 diagnostic coding for wrist fracture, if a patient has two doctor visits in a month, there is no option to determine if the second visit was related to a same fracture of a same wrist, a fracture of the other wrist, poor healing of the original fracture, or incorrect billing. But with the ICD10 diagnostic codes, it clearly specifies whether it is a left wrist or right wrist, is it an initial or subsequent encounter and also indicates whether there was routine healing or complications. With this specificity, physician and patient may know the side of the body, location, and condition, and helps them to identify the surgical errors. Under ICD10, gaming of the system is prevented which is lacked under ICD-9. The ICD-10 also varies most dramatically from ICD-9 in its Information Technology (IT) structure. ICD10-PCS (procedure codes) utilizes standardized terminology consisting of codes which are seven alpha-numeric characters in length, with each character having a specific meaning (TMA, 2010), (Table 2). The ICD-9 procedure classification system, in contrast, consists of 3-4 character numeric codes and just two letters, the E and V codes (Frieden, 2009). Similarly, the diagnosis codes for the ICD-10 system vary from ICD-9 as they are greater in length and have an increased use of both alpha and numeric characters (AHIMA, 2008). The ICD-10 codes are not case sensitive and this standardized format can help to facilitate interoperability and sharing of data internationally (Table 2). ICD-10 - A Costly Necessity? Despite an international transition to the revised ICD codes, the DHHS delayed mandatory participation in the U.S. based on public protest (Schneider, 2008; American Medical Association [AMA], 2010). One major concern voiced by the medical community was the cost of the transition (American Academy of Orthopedic Surgeons [AAOS], 2009). Many organizations have tried to estimate the cost for transitioning to ICD-10. Implementation costs estimates vary widely. The RAND Corporation estimates (for National Committee on Vital Health Statistics) initial costs between $475 million and $1.55 billion, plus additional long-term costs of between $20 million and $170 million (Libicki and Brahmakulam, 2004); the Robert E. Nolan Company estimates (for the Blue Cross Blue Shield Association) costs to be between $ 11.65 billion and $39.45 billion (“Nolan”, 2003); and The Hay Group’s estimates (for America’s health insurance plans) costs to range from $3.2 billion to $8.3 billion (Wildsmith, 2006). On a more micro level, costs for physician practices will also be high, averaging around $83,000 for a three-doctor practice, $285,000 for a ten-doctor practice, and $2.7 million for a 100-doctor practice, according to a study commissioned by the Medical Group Management Association . The American Hospital Association do esn’t appear to have done a cost estimate for hospitals, but one system, Christiana Care, a two- hospital, 1,100-bed system in Wilmington, Delaware, estimated the total implementation cost around $15 million to $20 million (Meyer, 2011). These costs include funds needed for training and education on the new system, fees related to contract changes in health plans and coverage determinations, expenses to upgrade computer and information systems to function with the new coding system, increase in billing and documentation charges, and a possible disruption in monetary transactions related to billing and reimbursement (AAOS 2009). The issues of substantial financial and

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time investment are reasons cited by the AMA as concerns with the transition to ICD-10, especially with the nearing 2013 implementation deadline and simultaneous switch to electronic medical records (AMA, 2010a). Proponents of the conversion to ICD-10, such as the American Hospital Association (AHA), have made valid arguments that the improved coding system can actually decrease healthcare costs in the long run and allow for increased reimbursement to providers (Bowman 2008; AMA 2010a). The increase specificity with diagnosis codes can reduce the need for additional documentation and be more efficient. This will help to ease processing and payment on claims and allow for reimbursement on newer procedures (DHHS, 2009). Overall, such a simple improvement as more uniform and accurate documentation can enhance monitoring of outcomes and lead to improved quality of care. As CMS moves towards to a Pay-for-Performance reimbursement, the lack of detail in the ICD-9 coding system is not supportive of such a reimbursement model (Bowman, 2008). The more precise data can not only improve the quality of care provided by an organization, but also allow for fiscal benchmarking (AMA, 2010a). There will be a greater capability for identification of risk and growth trends as well as enhanced marketing strategies and management of portfolios (Piselli, Wall, and Boucher, 2010). The RAND study concluded that benefits of the revised ICD system could easily outweigh concerns about the cost of transition (Libicki and Brahmakulam, 2004). Benefits of ICD-10 Utilization Despite the adding of new codes, the ICD-9 coding system has been utilized for almost 30 years and it was not designed with the intent to accommodate the level of detail needed in today’s age of electronic health records (DHHS, 2008b). ICD-9 consists of approximately 17,000 codes which have evolved since 1979 and reached a point in 2009 where many chapters were full and the possibility of further expansion had been exhausted (DHHS, 2008a). The U.S. is the only nation in the Group of Seven (which also includes Canada, France, Italy, Japan, Great Britain, and Germany) that continues to use ICD-9 classifications for morbidity. The other nations, which have converted to ICD-10 for morbidity classification and which also use a modification of ICD-10 for billing and reimbursement, are already reaping the benefits of the revised system (DHHS, 2008b). In fact, many countries are currently using trial versions of ICD-11 which is scheduled for final release in 2014. This version is intended to update ICD-10 and allow for further development of systems integration and the use of more uniform terminology (WHO, 2010b). The ICD-10 system consists of over 68,000 codes and offers the capability for further growth (AMA, 2010b). This coding system will allow for greater specificity with coding, fewer coding errors and less incidence of rejected medical claims (Libicki and Brahmakulam, 2004; American Health Information Management Association [AHIMA] 2010). This will also decrease the incidence of fraudulent claims. This reduction in inaccurate coding will increase efficiency in billing and reimbursement, thus lowering cost (AAPC, 2010b). The current movement towards electronic record keeping will also be facilitated with the transition to a more accurate and efficient coding system (AHIMA, 2010). An added advantage will also include improved patient safety as a more detailed coding system will allow for a universal assessment of medication side effects, treatment outcomes, and compliance of providers with quality of care protocols (Deloitte Center for Health Solutions [DCHS], 2008). An integrated coding system will create more ease in the sharing of medical data not only in the U.S. but internationally (DCHS, 2008). The use of a universal coding system combined with the ability to electronically transmit medical record data will align the U.S. globally and facilitate research related to disease etiology, progression, transmission, and management (CDC, 2001). This can provide improvement in identification and treatment of public health threats (AAPC, 2010b). The worldwide sharing of such data can provide universal treatment protocols, improved quality of care, and better outcomes globally (Bowman, 2008). In a time with fears of bioterrorism and epidemic outbreaks, the transmission of medical data which is internationally coded in a uniform manner creates the ability to have the greatest level of preparedness in the event of an anticipated disaster (AMA, 2010a). This conversion, despite its worthiness, is likely to be the most difficult feat for the U.S healthcare system in decades, being compared to sparking fears such as the Year 2000 phenomenon (Schneider, 2008).

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Discussion The U.S. healthcare system is currently undergoing major transformations. The transition to ICD-10 is one aspect of these changes which has sparked great debate, controversy and research. As ICD-10 is at the forefront of discussion in U.S. healthcare, there is a wealth of information about this topic. The transition to ICD-10 for procedural and diagnostic coding is long overdue. Historically, as new technologies and medical discoveries developed, the ICD system had been updated and revised to incorporate these changes approximately every ten years. Yet, despite great advances in medicine over the past 30 years, the U.S. has remained stagnant in its coding system. Fears of change coupled with substantial transitional cost, as acknowledged by the AMA (Carmel, 2011), are major barriers to implementing ICD-10 in the U.S. However, the benefits of ICD-10 adoption are huge, including advantages in format, potential for healthcare cost savings, and the overall benefits of utilization when compared to the ICD-9 system. WHO statistics which reports that 70% of worldwide healthcare payments are based on ICD-10 coding and 110 countries, which embody 60% of world’s populati on, currently use ICD-10 for cause of death monitoring and health planning (WHO, 2010b). Many countries are continuing to further develop a more integrated and uniform system as they trial ICD-11, the next ICD revision by the WHO. A simple increase in the number of characters and the use of an alpha-numeric system will greatly increase the number of codes from ICD-9. This created the capability for more specific and detailed coding, allowing for greater accuracy in coding diagnoses and procedures. It also allows the ICD-10 system to evolve along with future advances in medical technology. The accuracy of future medical research will be greatly enhanced by the capability with ICD-10 to identify laterality and to give greater detail about anatomical sites, diagnoses, and procedures. The benefits of being able to code greater detail and side of surgical site are facilitation of billing as well as greater specificity with future research studies (Zeisset, 2009). The revision of the ICD also allows for coding of home healthcare, outpatient, ambulatory care, skilled nursing and post-acute care services. This will allow for outcome based research to continue outside the acute care setting and on through these various phases of healthcare. Coding in the ambulatory, skilled nursing, and rehabilitative settings may also facilitate more accurate billing and could change the way providers of these post-acute care services are reimbursed. Although the initial cost may be substantial, the long term return on this investment makes it a worthy transition and is a major reason for its endorsement by the AHA (“Testimony”, 2011). The standardized codes will facilitate claims processing, decrease the number of errors and rejected claims, and also allow for billing and reimbursement on newer procedures. Providers will be able to utilize the data better for fiscal benchmarking. The more detailed diagnosis and procedure information will also make it easier for providers to plan future risk and growth management. Unfortunately, the fragmented U.S. healthcare system has failed to find any sense of urgency to adopt the more standardized ICD-10 coding, and HHS has even delayed its implementation again, to October 1, 2014 (Frieden, 2012). Adoption and implementation of ICD-10, as it has been by other countries globally, could offer a solution to this lack of cohesiveness in the U.S. and create a more efficient healthcare system. The passage of legislation in the U.S., such as the Health Information Technology for Economic and Clinical Health as part of the American Recovery and Reinvestment Act and the Affordable Healthcare Act, initiated a movement for the U.S. to become more globally aware and connected (DeVore and Figlioli, 2010; Steindel, 2010). The conversion to ICD-10 is one specific means of reaching goals set by these acts, such as a transition to a fully integrated and electronic medical records system. Such a transition could spark employment opportunities for IT professionals and coding specialists (DCHS 2008), but only if the mandated electronic medical record (EMR) is unable to code directly to ICD-10, which may be possible. The utilization of ICD-10 for mortality tracking in the U.S would resulted in consistency of these risk reports with other nations. A higher degree of detail in diagnosis and comorbidity coding would lead to greater validity due to increased accuracy, and therefore the improvement of the healthcare in the U.S. The advantages of ICD-10 are pretty clear, because of its well defined and commonly understood terminology codes. CMS and several other health care providers are currently in the process of adopting the newly created ICD-10-CM coding system. But most of the players in the health care system are comfortable with the current system and are in the learning process regarding ICD-10. The current economic downturn, coding inconsistencies, political and provider disputes, complicated health care regulations and reform, excessive costs, and other implementation issues are the main reasons for delay in adopting ICD-10-CM codes. The HHS mandated

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transition to ICD-10 does not provide any funds or incentives like for the EMR to cover the conversion costs to providers, payers and claims clearing houses. As per CMS it is giving the providers adequate time and flexibility for implementing it. The deadline for the switch to ICD-10 has been pushed back (again!), but the time to ensure the successful transition is quickly coming. The benefits of the new system are many, but the inertia associated with the present system (ICD-9) must be overcome

REFERENCES American Academy of Orthopaedic Surgeons [AAOS]. 2009. Switching to ICD-10: The impact on physicians. Retrieved January 21, 2012 from http://www.aaos.org/news/aaosnow/ feb09 /reimbursement1.asp. American Academy of Professional Coders [AAPC]. 2009. The cost ICD-10 implementation. Retrieved January 21, 2012 from http://news.aapc.com/index.php/2009/09/the-cost-of-icd-10-implementation. American Academy of Professional Coders [AAPC]. 2010a. What is ICD-9-CM? Retrieved February 3, 2012 from http://www.aapc.com/resources/medical-coding/icd9.aspx. American Academy of Professional Coders [AAPC]. 2010b. Benefits of implementation. Retrieved January 21, 2012 from http:/news.aapc.com/index.php/2010/01/benefits-of-implementation. American Academy of Professional Coders [AAPC]. 2010c. ICD-10 frequently asked questions. Retrieved January 21, 2012 from http://www.aapc.com/ICD-10/faq.aspx American College of Emergency Physicians [ACEP]. 2011. ICD-9 and ICD-10 frequently asked questions. Retrieved January 21, 2012 from: http://www.acep.org/ practres.aspx?id=30476. American Health Information Management Association [AHIMA], 2008. AHIMA Comments on the Nachimson Report “The Impact of Implementing ICD-10 on Physician Practices an Clinical Laboratories”. Retrieved on February 3, 2012 from: http://www.ahima.org/downloads/pdfs/resources/nachimson.pdf. American Health Information Management Association [AHIMA]. 2010. The value of ICD-10. Retrieved January 21, 2012 from http://www.ahima.org/icd10/value.aspx. American Medical Association [AMA]. 2010a. ICD-10 101: What it is and why it’s being implemented. Retrieved January 21, 2012 from www.ama-assn.org/go/ICD-10. American Medical Association [AMA] 2010b. ICD-10 deadline causing worry, even 3 years away. Retrieved on February 3, 2012 from http://www.ama-assn.org/amednews/2010/01/04/ gvsc0104.htm. Bowman, S., 2008. Why ICD-10 is worth the trouble? Journal of AHIMA / American Health Information Management, 79 (3), 22-29. Carmel, P. W. (2011), “AMA hoping to stop ICD-10 use in billing,” American Medical News, November 11. Retrieved May 3, 2012 from http://www.ama-assn.org/amednews/2011/ 11/28/ prsh1128.htm on May 3, 2012. Centers for Disease Control and Prevention [CDC]. 2001 International classification of diseases 10th revision (ICD-10). Retrieved January 21, 2012 from http://www.cdc.gov/nchs/data/dvs/

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icd10fct.pdf. Centers for Disease Control and Prevention [CDC]. 2009 International classification of diseases ninth revision (ICD-9-CM). Retrieved April 5, 2012 from http://www.cdc.gov/nchs/ icd/icd9cm.htm. Centers for Medicare and Medicaid Services [CMS]. 2010. ICD-10 overview. Retrieved January 21, 2012 from http://www.cms.gov/ICD10/01_Overview.asp. Colorado Department of Public Health and Environment. (2001). New international classification of disease (ICD-10): The history and impact. Retrieved April 5, 2012, from http://www.cdphe.state.co.us/hs/briefs/icd10brief.pdf. Deloitte Center for Health Solutions [DCHS]. 2008. ICD-10 turning regulatory compliance into strategic advantage. Retrieved January 21, 2012 from http://www.nahq.org/enews/pdfs/0510_leader.pdf Department of Health and Human Services [DHHS]. 2008a. HHS proposes adoption of ICD-10 code sets and updated electronic transaction standards. Retrieved January 21, 2012 from http://www.hhs.gov/news/press/2008pres/08/20080815a.html. Department of Health and Human Services [DHHS]. 2008b. HIPAA administration simplification modification to medical data code set standards to adopt ICD-10-CM and ICD-10PCS; Proposed rule. Federal Register part III, 73 (164). Retrieved January 21, 2012 from http://edocket.access.gpo.gov/2008/pdf/E8-19298.pdf. Department of Health and Human Services [DHHS]. 2009. HHS issues final ICD-10 code sets and updated electronic transaction standards rules. Retrieved January 21, 2012 from http://www.hhs.gov/news/press/2009pres/01/20090115f.html. DeVore, S. and Figlioli, K. 2010. Lessons premier hospitals learned about implementing electronic health records. Health Affairs, 29 (4), 664-667. Dimick, C. 2009. Mortality coding marks 10 years of ICD-10. Journal of AHIMA, 80 (70), 3033. “Federal Register” 2012. Federal Register, 77 (162), 54664 -54720. 45 CFR Part 162. Downloaded November 4, 2012 from http://www.gpo.gov/fdsys/pkg/FR-2012-09-05/pdf/201221238.pdf. Frieden, J. 2009. ICD-10 will be complicated but more useful. Retrieved January 21, 2012 from http://www.entrepreneur.com/tradejournals/article/202437878.html. Frieden, J. 2012. HHS announces ICD-10 delay. MedPage Today. Retrieved May 7, 2012 from http://www.medpagetoday.com/practicemanagement/informationtechnology/32095. Haugh, R. 2005. Will Codes Turn 10? Hospitals and Health Networks, 79 (6), 18-20. International Healthlink Professionals, Inc. (2010). Frequently asked questions. Retrieved January 21, 2012 from http://www.ihelpinc.net/FAQs/index.html.

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Knibbs, G.H. (1929), “The international classification of disease and causes of death and its revision,” Medical Journal of Australia, 1, 2-12. Leon-Chisen, N. 2010. Introducing a clinically richer coding system. National Association of Healthcare Quality. Retrieved April 5, 2012 from http://www.deloitte.com/assets/ DcomUnitedStates/Local%20Assets/Documents/us_lshc_ImpacOfICD10_081409.pdf. LeMier, M, Cummings, P and West, T.A. 2001. Accuracy of external cause of injury codes reported in Washington State hospital discharge records. Injury Prevention, 7 (4):334–338. Libicki, M. and Brahmakulam, I. 2004. The cost and benefit of moving to the ICD-10 code sets. (TR-132-DHHS) RAND Science and Technology. Retrieved January 21, 2012 from http://www.rand.org/pubs/technical_reports/2004/RAND_TR132.pdf. Meyer, H. (2011), “Coding complexity: US health care gets ready for the coming of ICD-10,” Health Affairs, 30 (5), 968-74. Nagel, S. 2004. The migration to the ICD-10-CM. Preparing for the inevitable. For the Record, 16 (12), 30. “Nolan” (2003), “Replacing ICD-9-CM with ICD-10-CM and ICD-10-PCS: Challenge, Estimated cost and potential benefits,” Robert E. Nolan Company. Retrieved April 30, 2012 from http://www.renolan.com/healthcare/icd10study_1003.pdf. Piselli, C., Wall, K., and Boucher, A. 2010. A new language for healthcare? Healthcare Financial Management, 64 (1), 94-100. Quan, H., Li, B., Duncan Saunders, L., Parsons, G., Nilsson, C., Alibhai, A., Ghali, W. A., and IMECCHI Investigators. 2008. Assessing Validity of ICD-9-CM and ICD-10 Administrative Data in Recording Clinical Conditions in a Unique Dually Coded Database. Health Services Research, 43 (4), 1424-1441. Schlom, A. and Battani, J. 2009. Responding to ICD-10: Healthcare payer strategy to achieve regulatory compliance and ROI. Retrieved January 21, 2012 from http://assets1.csc.com/health_services/downloads/CSC_Responding_to_ICD-10.pdf. Schneider, M. 2008. Physician groups protest timeline for ICD-10 switch. Clinical Psychiatry News. Retrieved February 3, 2012 from http://www.entrepreneur.com/tradejournals/ article/189668716.html. Schoenbach, V. 2000. Phenomenon of Disease. Retrieved January 21, 2012, from http://www.epidemiolog.net/evolving/PhenomenonofDisease.pdf. Steindel, S. J. 2010. International classification of diseases, 10 th edition, clinical modification and procedure coding system: descriptive overview of the next generation HIPAA code sets. Journal of the American Medical Informatics Association, 17 (3), 274-282. “Testimony”. 2011. Testimony of the American Hospital Association before the Standards

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TRACK CHANGES IN HEALTHCARE SETTINGS

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HOSPITAL AT HOME: WHAT ARE THEY AND HOW WELL DO THEY WORK?
David P. Paul, III, Leon Hess Business School, Monmouth University

Internationally, one of the fastest-growing approaches to what has been known for years as “inpatient” medical care is the provision of acute care to patients in their homes (Jacobs, 2001; Papazissis, 2004; Shepperd, 2009a). Home care medical models have been accepted in many countries, particularly in the United Kingdom, Europe, and the Middle East (Danzi, 2009; Kane, 2007), but only a few such programs currently exist in the U.S. (Graham, 2012a; Senior, 2012). However, the increasing pressure in the U.S. to lower health care costs and improve the quality of medical care could lead to the widespread acceptance of such programs in the U. S. as the model become better understood (Graham, 2012b; Klein, 2011). The most prevalent form of acute home medical care is “hospital at home” (HaH), the provision of medical services normally associated with acute inpatient hospital care, but provided instead in a patient’s home (Leff, 2009). Basically, HaH involve the provision of care in the patient's home which: (1) eliminates or reduces an inpatient hospital stay; (2) is similar to care normally provided in a hospital; (3) is clinically appropriate; and (4) is not provided by usual community-based services (Lemelin et al., 2007). Literature reviews and meta-analyses have categorized HaH programs as either admission avoidance or early discharge (Shepperd, 2009a, b). Briefly, admission avoidance HaH programs avoid hospital admission altogether (treating, for example infectious diseases and thromboembolic disorders). Early discharge HaH programs discharge the patient from the hospital directly to home to receive medical care that would be traditionally have been delivered in hospital following an initial surgical or acute medical treatment delivered in hospital. Another classification system for HaH is based on whether services are delevered predominately by specialists or subspecialists. Although this approach is sometimes useful for understanding the differences in case mix between these types of HaH programs, significant crossover exists between specialist and subspecialist HaH programs, as some types of clinical care may be provided by specialists in one HaH and by sub-specialists in others. The majority of HaH programs are the specialist type, providing care across a range of common conditions. In the specialist approach, a different group of staff usually provide in-home care compared with staff providing acute hospital care. In the subspecialist model, care is provided by a more narrow clinical team having knowledge and skills relating to a specific condition, with the same doctors, nurses and allied health professionals usually involved in providing care in both hospital and at-home settings (Shepperd, 2005). Subspecialty HaH care usually requires a sufficient caseload of patients being available for the HaH service to be feasible and efficient (Chevillotte, 2008). Basis of care Substantial variation exists between HaH programs with regard to the illnesses treated, the acuity of patients, the source of admission, the origin and composition of the treatment teams, whether the patient was at one time considered to be an inpatient before being treated in HaH, and the amount of physician and nursing care coverage provided. HaH utilizes substantial medical technology in provision of care, and requires substantial understanding of how pharmaceuticals are used at home. The most common conditions and treatments delivered by HaH include treatment of infections, particularly genitourinary tract, respiratory tract, skin, joint and soft tissue infections; anticoagulant therapy; post-surgical acute care; congestive heart failure treatment; treatment of COPD; and rehabilitation services (Shepperd, 2009a). Patients who receive HaH services can be classified into two main groups, admission avoidance and early discharge. Patients treated in admission avoidance HaH generally have these characteristics: - the condition occurs with some frequency and accounts for a significant portion of hospitalizations;

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- the diagnosis is relatively uncomplicated and can therefore be made rapidly without substantial consultation or invasive testing; and - the treatment is well defined and can be delivered in a feasible, safe, and efficient manner at home (Leff et al., 1997). This larger of these two groups – the early discharge group - includes chronically ill patients diagnosed with multiple illnesses and needing acute episodic care. The majority of these patients are elderly and disabled, although pediatric patients with chronic illnesses may also be recipients of ongoing acute episodic care from HaH services. These patients often have difficulties with mobility and other activities of daily living, and have difficulty in maintaining their households. Many have care givers who provide assistance, and patients’ use of existing community servic es is common. The second group of patients includes people of varying ages who, following an acute event, require short-term, intensive medical treatment such as intravenous antibiotics, intensive rehabilitation or post-surgical care, but do not need long-term nursing and maintenance care (Siu et al., 2009). Another component of this early discharge HaH group includes patients who may have less common diagnoses that are usually treated by sub-specialty inpatient units (Shepperd et al., 2009). Eligibility criteria for access to HaH services reflect the differences between patient groups. HaH programs usually only admit patients with a specific diagnosis, as outlined in the eligibility criteria set by each service. These criteria encompass the health care needs of patient groups, and reflect patient characteristics, patterns of care, case-mix, and staff composition (Leff and Montalto, 2004). The majority of programs operate as hospital outreach programs, although they may also be operated by community health services, or hospital-based teams working in conjunction with community-based services (Shepperd et al., 2009). Staffing The composition of staff providing HaH services differs among countries, service providers, and HaH models. Nurses are often responsible for the majority of care, with specialist and HaH-dedicated nurses employed by many programs (Askim et al., 2004; Caplan et al., 2006; Harris et al., 2005). The meta-analysis performed by Sheppherd et al. (2009b) found physiotherapy and occupational therapy to be the most commonly provided allied health services. The physician's role in HaH varies widely. Early discharge models generally involve physician supervision from a distance, while admission avoidance models report varied doctor roles. In some models, community-based general practitioners are available for home visits to patients. In other models, doctors make rounds at the patient’s home every day based upon the premise that HaH patients require the same care that they would have received inside the hospital (Cheng, Montalto, and Leff, 2009). The appropriate clinical skills and competencies required to deliver HaH are dependent on the service delivery model of the program and the range of clinical duties associated with provision of care. The medical skills for delivering HaH care are found across clinical specialties. General practice, emergency medicine, geriatrics and general hospital medicine in particular are clinical areas with direct relevance to HaH. However, in addition to these skills areas, the ability to adapt a clinical unit model to a patient’s home is required. This aspect of HaH care is novel and therefore suggests that HaH may be an emerging clinical specialty in its own right. The need for further development of the “specialty” ha s been recognized (Montalto, 2002), but there appears to be no published literature regarding specialty training for HaH, or the existence of separate colleges (or faculties within colleges) to support continuing professional development of medical practitioners in this field. The nursing skills for delivering HaH care are drawn from a range of specialty areas. The benefits of nursing specialization in HaH have been acknowledged, however formal development of the nursing specialty of HaH across countries has been variable (Duke and Street, 2003). Referrals By definition, HaH units depend upon referrals to obtain patients, normally from medical practitioners who make key decisions regarding care requirements. Many programs spend significant time and effort in generating these referrals, employing staff to identify patients, providing information sessions and written material for staff, and using personal contacts to increase and maintain referrals. In most admission avoidance HaH programs, patient referral is from a hospital’s Emergency Department, but patients are also referred from medical practitioners in the community. Early discharge HaH referrals are predominantly from inpatient situations (Shepperd, 2009a). Service Profiles and Outcomes

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Post-surgical Post-surgical care has been studied within HaH service delivery models for a range of surgical conditions. Much post-surgical care has been demonstrated to be safe and effective, with a strong patient preference for receipt of services at home. Orthopedic surgery in particular is an area of extensive study of HaH models of post-surgical care. Studies have demonstrated both clinical and financial advantages to orthopedic after-care in home settings, provided that postoperative pain can be adequately controlled (Russon et al., 2009; Stevens et al., 2004). Models are predominantly led by nurses, but often also involve allied health practitioners. Patients are admitted to HaH service for orthopedic postoperative care through early hospital discharge with generally low readmission rates. In one study, mean length of hospital stay post hip or knee replacement was reduced by over 42% for total hip replacement and by 33% by provision of post-operative care at home. Complication rates were equivalent and there were no statistically significant differences in clinical outcomes between inpatient and HaH. Patients in this study rated HaH care highly (Russon et al., 2009). There is also evidence that delivery of post-operative HaH care following other types of surgery - including surgery for hernia and varicose veins (Adler et al., 1977; Ruckley et al., 1978), coronary artery bypass grafting (Booth et al., 2004), and cataract surgery (Willins, Grant and Kearns, 1999) - is safe and effective. Internal medicine Numerous examples exist in the literature where subspecialty HaH models have been used to provide medical services successfully to patients. Some of the more common subspecialty models described are for the treatment of diabetes, respiratory failure and complex chronic illnesses. Looking at diabetes treatment in the home, HaH units can effectively commence insulin for patients with type 1 and type 2 diabetes (Monalto et al., 2001). Subspecialty HaH services, usually provided by endocrinologists and diabetes educators, can manage 43% of newly diagnosed children wholly at home, and reduce the number and duration of hospital admissions without deterioration in blood glucose control (McEvilly and Kirk, (2005). Diabetic infections, normally treated in inpatient settings, are also able to be successfully treated using a HaH model of care (Esposito et al., 2008). HAH services have also been demonstrated to be safe and effective for service delivery across a range of other general medical conditions including: • provision of parenteral nutrition, blood transfusion, and for percutaneous endoscopic gastrostomy (PEG) management in health systems where these services are usually provided in acute in-patient settings (Dollard and Dunn, 2004); • the management of acute and chronic pediatric respiratory, gastro-intestinal and infectious diseases (Bagust et al., 2002; Sartain et al., 2002); • complex wound care and ulcer management (Montalto, Portelli, and B. Collopy, 1999; Genoud and Weller, 2008); and • provision of acute anticoagulation treatment, including for deep vein thrombosis (Smith et al., 2002. Home management of deep vein thrombosis with low molecular weight heparin has been shown to be safe and effective. Patients treated at home with low molecular weight heparin have a lower recurrence of venous thromboembolism, less major bleeding and fewer deaths than those managed as inpatients. Home-based care is also more cost-effective than inpatient care (Othieno, Abu Affan, and Okpo, 2007). Patients with sub-massive pulmonary embolism (PE) can be treated as outpatients or in the home. Studies report good outcomes with outpatient treatment of patients with PE (Ong et al., 2005). HaH have been shown to be safe and effective for cardiac treatment and rehabilitation across a range of countries and for a number of cardiac conditions (Dalal et al., 2010; Taylor et al., 2007). Home-based intravenous diuretic and inotropic therapies can be safely and effectively delivered via HaH services to treat acute and severe decompensated heart failure. Patients can remain at home to receive appropriate medical care, reducing inpatient hospitalizations (Madigan, 2008; Ryder et al., 2008). Home-based versus hospital-based cardiac rehabilitation after acute myocardial infarction achieves equivalent outcomes at up to 9 months post MI (Taylor et al., 2007). HaH have been applied quite successfully to the treatment of acute exacerbations of COPD, a major source of inpatient admissions for many hospitals world-wide (Davison et al., 2006: Utens et al., 2012). There is some evidence of reduced mortality rates (Jeppesen et al., 2012) and length of stay (Aimonino, 2008) for COPD treated via HaH instead of traditional inpatient hospitalization. No significant difference in hospital readmissions between patients treated in HaH and traditional inpatient care have been demonstrated. However, both patients and care givers prefer HaH to inpatient care (Ram et al., 2009).

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Conclusions Internationally, one of the fastest-growing approaches to what has been known for years as “inpatient” care is the provision of acute care to patients in their homes. Acute home care medical models have been accepted in many countries, particularly in the United Kingdom, Europe, and the Middle East. Only a few such programs currently exist in the U.S. (Graham, 2012a; Senior, 2012). However, the increasing pressure in the U.S. to lower health care costs and improve the quality of medical care could lead to the widespread acceptance of such programs in the U. S. as the model become better understood.

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Shepperd, S., H. Doll, J. Broad, J. Gladman, S. Iliffe, P. Langhorne, S. Richards, F. Martin, and R. Harris, (2009b), “Early Discharge Hospital at Home,” Cochrane Library of Systematic Reviews (Online), Jan 21;(1):CD000356. Shepperd, Sasha, Helen Doll, Robert M. Angus, Mike J. Clarke, Steve Iliffe, Lalit Kalra, Nicoletta Aimonio Ricauda, Vittoria Tibaldi, and Andrew D. Wilson (2009a), “Avoiding Hospital Admission through Provision of Hospital Care at Home: A Systematic Review and Meta-Analysis of Individual Patient Data,” Canadian Medical Association Journal, 180 (2), 175-182. Siu, Albert L., Lynn H. Spragens, Sharon K. Inouye, R. Sean Morrison and Bruce Leff (2009), “The Ironic Business Case for Chronic Care in the Acute Care Setting,” Health Affairs, 31 (6), 113 -125. Smith, B., J. S. Weekley, L. Pilotto, T. Howe and R. Beven (2002), “Cost Comparison of At -Home Treatment of Deep Venous Thrombosis with Low Molecular Weight Heparin to Inpatient Treatment with Unfractionated Heparin,” Internal Medicine Journal, 32 (1-2), 29-34. Stevens, Martin, Inge Van den Akker-Scheek, Alette Spriensma, Natalie A. D. Boss, Ron L. Diercky, and Jim R. van Horn, (2007), “Groningen Orthopedic Exit Strategy (GOES): Validation of a Support Program after Total Hip or Knee Arthroplasty,” Patient Education and Counseling, 54 (1), 95-99. Taylor, R., A. Watt, H. M. Dalal, P. H. Evans, J. L. Campbell, K. L. Read, A. J. Mourant, J. Wingham, D. R. Thompson, and Gray D. J. Pereira (2007), “Home -based Cardiac Rehabilitation versus Hospital-Based Rehabilitation: A Cost Effectiveness Analysis,” International Journal of Cardiology, 119 (2), 196 -201. Utens, Cecile M.A. J. A.M. Maarse, Onno C .P. van Schayck, Boudewijn L.P. Maesen, and Frank W.J.M. Smeenk (2012), “Care Delivery Pathways for Chronic Obstructive Pulmonary Disease in England and the Netherlands: A Comparative Study,” International Journal of Integrated Care, downloaded July 1, 2012 from http://www.ijic.org/index.php/ijic/article/ viewArticle/811/1548. Willins, L., B. Grant and P. P. Kearns (19 99), “Domiciliary Post-Operative Assessment Following Cataract Surgery Carried Out by Specialist Nurses,” Eye, 13 (Pt 3a), 336 -338.

David P. Paul, III Leon Hess Business School Monmouth University

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UNDERSTANDING EMERGENCY NURSES’ EXPERIENCES IN CARING FOR PEOPLE DURING MENTAL HEALTH CRISIS
Ginger Taylor Truitt, RN, MSN, Doctoral Student, Georgia State University Ptlene Minick, PhD, RN, Associate Professor, Georgia State University ABSTRACT INTRODUCTION: Emergency department (ED) overcrowding is a big concern with adverse events that can result. A patient population contributing to ED overcrowding are those individuals with mental illness. According to some results, individuals with mental health needs have ED lengths of stay 3.2 times longer than those individuals with non-mental health related needs. Many state mental health facilities have closed and more are slated for closure. According to the World Health Organization, one in four people are affected by mental illness. Given the growing population, this number is expected to rise. Mental health facility closings contribute to inadequate access to care and result in more of these individuals seeking care in the ED when they have a crisis. Emergency nurses, however, have little experience in managing patients who present with mental health crisis. The purpose of this study is to understand the emergency department nurse’s experiences in caring for individuals with severe mental illness. W hen patients have a mental health crisis and seek care in the ED, they wait for long periods until placement in a psychiatric facility is found. If we can determine what nurses need while caring for patients in crisis, then interventions can be developed to help them to improve the quality of care provided. METHOD: A qualitative method was chosen for this study because of the usefulness in revealing findings that are unknown and are meaningful to the ED nurse when providing care to this vulnerable patient population. Participants must have a minimum of two years nursing experiences and currently work in the ED setting. Word of mouth recruitment was chosen to select participants. Semi-structured auto-taped individual interviews, transcribed verbatim, were chosen for data collection. A team approach of four qualitative researchers is being used to interpret data. Written summaries and details from the interviews are discussed initially. Line by line coding is being conducted. After all interviews are completed, codes will be collapsed into categories and themes identified. Interviews will continue until saturation is obtained. RESULTS: To date, three interviews have been conducted. Participants include one male and two female nurses with a median ED work experience of four years. The preliminary analysis suggests three main issues. ED nurses report that individuals with mental illness require more time than patients with non-mental health related needs. Secondly, nurses feel ill-prepared to care for individuals with severe mental illness and this often leads to feelings of incompetence and frustration. Finally, ED nurses are typically able to alert physicians to salient features of a patient’s physical condition preventing complications, yet they feel inad equately prepared to identify the salient features of a changing mental health problem. Thus, they feel that they cannot intervene early to prevent further problems with mental health crisis. RECOMMENDATIONS/IMPLICATIONS: ED nurses are on the front line of caring for individuals who have a mental health crisis. Quality of care and safety are of high priority in healthcare. Findings from this study will assist in understanding nurses’ experiences when providing care to individuals with severe mental il lness. Having a better understanding could lead to improved education and training in providing care for patients with severe mental illness. Ginger Taylor Truitt 2703 Bartley Road LaGrange, GA 30240 Email: gtruitt1@student.gsu.edu Phone: 706-333-8287

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THE PARADOX OF PARITY: LIMITATIONS IN THE BREAKTHROUGH LAW FOR MENTAL HEALTH EQUALITY
Jessica Dowches, University of Scranton Daniel J. West, Jr., University of Scranton

ABSTRACT The intent of parity laws is to improve equity in private insurance coverage for mental health care. The groundbreaking legislation of the 1996 Mental Health Parity Act (MHPA) was initially hailed as a major achievement in improving mental health coverage. However, research suggests that because of political compromises and employer exemptions, the potential impact of the MHPA was weakened. This paper summarizes the extent and scope of the 1996 Mental Health Parity Act and the 2008 Mental Health Parity and Addiction Equity Act, highlighting the goals and accomplishments of each; examines limitations of the legislation, explicitly accounting for exemptions, uninsured Americans, and access to care; and provides recommendations for further improvement and implementation of mental health coverage.

Jessica Dowches, MHA Candidate 2013 University of Scranton Phone: (570) 856-5730 Email: jessica.dowches@scranton.edu Daniel J. West, Jr., Ph.D., FACHE, FACMPE Professor and Chairman Department of Health Administration University of Scranton Phone: (570) 941-4126 Email: daniel.west@scranton.edu

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TRACK HEALTHCARE MARKETING

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RELATIVE IMPORTANCE OF EXTRINSIC AND INTRINSIC PRODUCT ATTRIBUTES: A CONJOINT ANALYSIS OF CONSUMER PREFERENCES FOR OTC ANALGESICS
Abhishek Sahu, St John’s University Rajesh Nayak, St John’s University

ABSTRACT OBJECTIVES: To evaluate the relative importance of extrinsic and intrinsic product attributes of over-thecounter (OTC) analgesic using Conjoint Analysis. METHOD: The study reports findings of a pilot phase, which analyzed consumer preferences for product attributes along multiple dimensions of an analgesic OTC product. An orthogonal design technique was implemented to design the profile cards for three different sets, first for extrinsic set with price, brand image and promotion as three attributes, second for intrinsic set with dose regimen, side-effects and effectiveness as three attributes and lastly the third set with two factors extrinsic and intrinsic as two attributes. A cross sectional research design, utilizing a self-administered paper-and-pencil, questionnaire and convenience sampling technique was adopted for the pilot survey. RESULTS: Kendall Tau correlation test was used for the validation of the profile cards (n=32). Significant positive correlation was found between the actual cards and the holdout cards (.889 for the intrinsic attribute, .857 for the extrinsic attribute and .873 for the combination of intrinsic and extrinsic against 1.00 for all the three set of holdout cards). Conclusion: Validation results indicated that the sets of cards were significant enough to put for the survey amongst the real population out in the market. The survey would further test for the factors and levels preference.

Mr. Abhishek Sahu, Graduate Student. St. John’s University College of Pharmacy and Health Sciences 8000 Utopia Parkway Queens, NY 11439 Phone: 732-533-4033 (Cell) Email: Abhishek.sahu10@stjohns.edu Dr. Rajesh Nayak, Associate Professor. St. John’s University College of Pharmacy and Health Sciences 8000 Utopia Parkway Queens, NY 11439 Phone: 718-990-5007 Email: nayakr@stjohns.edu

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EFFECTIVE MECHANISM OF DISRUPTIVE INNOVATION’S DIFFUSION IN MEDICAL MARKETS
Mohammad Hajhashem, Manchester Business School

Introduction This research is basically about accelerating the diffusion of disruptive innovations in high-tech medical markets. Indeed while most of the previous studies on disruptive innovations have been trying to shed more lights on the concept of disruptive innovation since Christensen (1997) (Droege and Johnson,2010) , this research tends to focus more on the competition of disruptive innovations candidates to get into the market and disrupt it prior than the other competitors. In other word this research takes a step forward and discuss about the dynamic of disruptive innovation from infancy to demise. Taking a fragile unknown potential disruptive innovation from its dark corner and disrupting the market relying it, this research will focus on two main leverages: accelerating the diffusion and facilitating the disruption process. However, the main originality of this research is obtained from the research point of view toward the innovation diffusion studies. While both macro and micro level models of innovation diffusion consider the economic issues as the main concern of diffusion curves, this research tries to disencumber itself from the bonds of economical point of view toward the diffusion studies. To this respect, one of the most original findings of this research proof that in high-tech medical markets, technological, marketing and cultural issues has more impact on the adoption of new revolutionary innovations. While most of the diffusion studies have tried to make a new economic models relying on quantitative methods, this research positions itself in the middle of market and tries to figure out the affecting factors and strategies on accelerating the diffusion of disruptive innovations through the main market incumbents. Conducting interviews with the key decision makers of launching new innovations in the market, this research will come up with genuine practical lessons from the market experience. Considering the validity and reliability of research, a market case study and some eminent data bases of diffused innovations through the market during the last 10 years has been studied in accompany with semi-structured interviews. The study has been done based on a 10 years longitude case study of cardiovascular business in Iran. The main focus of this paper is on the emergence and obsolesces of three subsequent generations of “Coronary Stents” in the Iranian medical market. How the first generation disrupt the market and change the medical procedure? How the second generation disrupt the first generation’s market? What was the market dynamics? What was the role of incumbents and new comers? What are the main leverages of market disruption in medical business? These are some questions that this paper is trying to raise and look for some reasonable answers. Conducting this longitude cases study, 30 interviews (elite interviewing) have been conducted with the main decision makers of the launched coronary stents’ projects during the last 10 years. They are mainly from the top four incumbents of the Iranian medical market including: Cordis, Medtronic, Boston Scientific and Abbott Laboratories. These qualitative data are supported with some quantitative findings including the sales reports and pre-market trial (PMA) results. The final results are extracted by analysing the market trends, compared with the PMA results and also the incumbents’ launch strategies. Analysing the data in this way, the main leverages of market disruption in medical business have been figured out. Moreover, the efficiency of the variety of launching strategies has been studied. The main contribution of this paper is to elucidate the market dynamic of disruptive innovations during their diffusion phases while they are trying to disrupt the main stream market and get into a dominant position. Indeed the study of this dynamic will elaborate to understand the main mechanism of making a reliable disruptive innovation to disrupt the current market out of an unknown potential candidate of disruptive innovation.

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Literature review Patterns of Technological Changes Patterns of technological changes are a sequence of radical and incremental changes which are usually disrupted by discontinuity which leads to the next generation of technology (Rothwell and Gradiner, 1985; Tushman and Anderson, 1990). Tidd and Bassent (2009) believe that technological changes usually occur in constant interaction of demand pull and supply push. Advanced or radical innovation usually takes place following new scientific knowledge generated by different scientific associations (most of which is based on the technology push nature of innovation), while incremental innovations usually take place in the on-going competition of incumbents within the business sector to satisfy market needs (Tushman and Anderson, 1990; Utterback and Abernathy, 1975; Tecee, 1986; Sahal, 1981; Abernathy, 1978). This continuous sequence of radical and incremental technological changes is usually disrupted by some technological discontinuity, as illustrated in Figure 1 (Tushman and Anderson, 1990). This discontinuity could occur for various reasons, such as emergence of a new market, different national rules, and political reasons, among others (Tidd and Bassent, 2009). According to Tushman and Anderson (1990), technological discontinuity may be classified as competenceenhancing and competence-destroying, which implies the compatibility of the existing competence of a competitor with the essence of new market competition. Crawford (1994) mentions three levels of innovation: pioneering, adapting, and imitation. He discusses the rate of innovativeness which Kleinschmidt and Cooper (1991) studied and named innovativeness ratio. Many scholars have studied the patterns of technological innovation, but Callahan’s (2007) studies seem more comprehensive in discussing the notion of dominant design in technological changes. Based on Callahan’s (2007) studies and support from Anderson and Tushman (1990), this research will discuss the concept of dominant design and its position within different patterns of technological innovation based on Utterback and Abernathy (1975), Abernathy (1978) and Abernathy and Clark (1985). The most important element in identifying industrial innovation patterns is Utterback and Abernathy’s model (1975) of dynamic innovation (Callahan, 2007). Uttterback and Abernathy define innovation as the simultaneous process of product and process innovation classified into three continues phases: fluid, transitional, and specific (Utterback and Abernathy, 1975; Abernathy and Townsend, 1975). In the fluid phase, the rate of product change is higher than process innovation. In this phase radical innovations usually take place and many different designs of product appear, resulting in different market standards (Abernathy, 1978; Abernathy and Clark, 1985). There is no direct competition in this period, and the process is flexible and inefficient (Abernathy and Townsend, 1975). The transitional phase is important due to the emergence of dominant design (Utterback, 1994). In this phase the major process changes and architectural innovations usually occur (Utterback and Abernathy, 1975). The number of competitors in the market will decline after the emergence of dominant design (Abernathy and Clark, 1985). The existence of dominant design in the market will affect the third phase (Abernathy and Clark, 1985). After issuing numerous product design standards in the market, most of the competitors cannot adapt to the new regulations and will inevitably vanish from the market (Utterback, 1996). Incremental innovations then generally occur in order to improve the performance of dominant design (Utterback and Abernathy, 1975). In this phase, efficiency of process is vital in order to improve the process productivity (Abernathy, 1978). This stable market situation and incremental innovation could be challenged by new disruptive or architectural innovation that could lead to disruptive changes in the market structure and business model (Abernathy, 1978; Anderson and Tushman, 1990). Following these disruptive changes, a new generation of product will emerge in the new market structure based on the previous market situation (Utterback and Abernathy, 1975). This dynamic innovation model with fluid, transitional and specific phases will repeat itself as it is the dynamic nature of industrial innovation which takes place in the technological context (Anderson and Tushman, 1990). Although this model has

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limitations, it seems appropriate for the purpose of this research. Next, a medical innovation model will be generated based on technological patterns of innovation and existing literature on medical innovations. Positioning the Concept of Dominant Design Dominant design has such a significant role in technological patterns that Anderson and Tushman (1990) claimed it as the second watershed after discontinuous disruption. Abernathy (1978) and Sahal (1981) mention that once a dominant design emerges, the rest of the technological progression happens incrementally to increase the performance of dominant design. A great many scholars incorporate dominant designs into models of technological evolution. This research will attempt to position the concept of dominant design within the notion of technological discontinuity. As Anderson and Tushman (1990) state, a technological discontinuity will not itself become a dominant design. Unlike the emergence of technological discontinuity as a first watershed in the technology cycle, the emergence of dominant design doesn’t take place solely due to technological superiority (Teece, 1986); dominant designs reflect technical, social, and political constraints. Then it seems that at least there is another substitution that could be superior in one of this perspective compare with dominant design (Utterback and Tecee, 2005). Therefore, as Anderson and Tushman (1990) mention, a dominant design will not be located on the frontier of technical performance at the time it becomes dominant. This research will discuss how high-tech industries could facilitate and accelerate the process of attaining the dominant design position. Disruptive Innovation Models There have been many scholars who focused on the continuous parts of technological cycles, and there are studies which have focused on discontinuous innovation. Robert and Veryzer’s (1998) study is arguably one of the prominent studies on discontinuous innovations. They mention that “although many new-products professionals may harbour hopes of developing the next big thing in their respective industries, most product development efforts focused on incremental innovations” (Robert and Veyzer,1998). In this comment, Robert and Veryzer (1998) try to describe the differences between continuous and discontinues innovations. Discontinuous innovation is defined as a radical new product which leaps in terms of customer familiarity and use. They position different types of innovation based on their continuity. They illustrate continuity and discontinuity defined from both the technology and product capability perspectives. The only criticism of this notion is the idea of positioning radical innovations as a discontinuous change which doesn’t seem justified. According to Tushman and Anderson (1990), Utterback and Abernathy (1975), and Abernathy and Clark (1985), radical innovation usually occurs between two discontinuous changes of technology and usually before getting into dominant design (Figure 1). Positioning radical innovation into discontinuous categories leads to confusion between radical and disruptive innovation. However, in solving this problem, Christensen (1997) arrived at a new definition of discontinuous innovation, or what he called disruptive innovation. “Disruptive innovation is a powerful means of broadening and developing new markets and providing new functionality, which, in turn, may disrupt existing market linkages ” (Christensen,1997). Christensen (1997) mentioned that by focusing on the high margin of the market (i.e. the top of the market pyramid, or the most demanding customers) incumbents often forget about the mainstream and low-end market needs. By focusing on the high-end market, the needs of the mainstream market would be over served (Christensen et al, 2000). As Christensen et al (2000) state, these events make the market suitable for new entrants seeking to introduce their cheaper, simpler and more convenient disruptive innovations to satisfy the mainstream market needs. This innovation then establishes a new generation of technology trends which could attain the dominant design position in the future (Moor, 2006). Although, Christensen (1997), Christensen et al (2000), and Christensen and Raynor (2003) have issued and clarified this concept, there has been criticism of this definition and dispute over this concept.

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One of the most constructive debates has taken place between Daneels (2002, 2004) and Christensen (1997, 2006). “Although disruptive technologies initially underperformed established ones in serving the mainstream market, they eventually displace the established technologies”. Daneels adds that since disruptive innovations do not satisfy the mainstream market requirements in the initial emergence steps, incumbents consider it an inappropriate innovation (2004). The main disputable issue comes up when the initial disruptive innovation takes place in order to satisfy the needs of small niches in the market. Both innovators and some incumbent R&D sections will improve the performance of this initial disruptive innovation in order to make it appropriate to satisfy the mainstream market requirements. According to Tushman and Anderson (1990) this is the ferment period of the technology cycle preceding the dominant design position. Most incumbents underestimate the potential power of disruptive innovation to grab the market (Daneels, 2004). In the ferment period, new entrants will usually compete for the dominant position, while incumbents are engaged in improving their existing innovations to serve the high-end market (Daneels, 2002; Christensen and Raynor, 2003). The typical consequences are one of the following scenarios: If innovators have sufficient financial support to invest in their R&D sections, they will continue their innovation improvement efforts to attain the dominant position in the market (Adner, 2002). If unable to support their R&D endeavours, other incumbents will typically acquire new entrants and invest in their innovation if merited (Christensen and Raynor, 2003). Likewise King and Tucci’s (1999, 2002) findings are totally different from Christensen’s (1997) not ions. They and Chesbrough (2003) indicate that the ferment period competition does not only include newcomers to the market. Market leaders with strategic plans for long term survival are also included in the post-disruptive innovation competition. Moreover, King and Tucci (2002) argue that incumbents have a good chance to win the competition and attain the dominant design based on their accumulated experience in the market. The last statement by King and Tucci (2002) is different from those made by Christensen (1997) and Christensen et al (2000). Considering all of these notions, it is still disputable who the competitors of the ferment period in disruptive innovations are: incumbents, new entrants, or both (Droege and Johnson, 2010). Adner (2002) and Daneels (2004) mention that Christensen (1997) does not offer specific criteria to distinguish disruptive innovation from the others. Daneels (2004) sees this as “a technology that changes the bases of competition by changing the performance metrics along which firms compete”. Daneels (2004) also challenges the notion of market penetration from the low-end of the market. Although he does not refute the characteristics that Christensen et al (2000) mention about disruptive innovations, he believes that market penetration could begin from the mainstream market rather than the low-end market (or the base of the pyramid2). Despite the widespread use of disruptive innovations by practitioners and academics, there are points needing clarification (Markides, 2006). Providing more clarification to the concept of disruptive innovations, Markides (2006) classifies them into three different categories” business models, new product, and technology innovations. Previously Markides and Geroski (2005) mentioned that Christensen’s (1997) concept of disruptive innovation included technology, product, and business model innovation simultaneously, which leads to misunderstanding of the concept. Markides (2006) adds that these classifications are important since they arise in different ways (Charitou, 2001). New entrants have an advantage over the competition in attainting the dominant design position in technological disruption over product disruption because the ability to launch is considered as the strength of incumbents based on their experience in the market (Markides, 2006). The notion of first mover advantages is mentioned by Christensen and Raynor (2003) as a competitive benefit for entrants new to the market after disruptive innovations. Markides (2006) refuted this idea by introducing the concept of last mover advantages, which points to the advantages incumbents have over their competition. Discussion thus far has focused on the concept of disruptive innovation as an appropriate explanation of discontinuous innovations, a prominent type of innovation in high-tech industries. Most literature on disruptive innovation seeks to clarify the concept rather than the surrounding issues. However, this research seeks to analyse the dynamic of disruptive innovation diffusion and positions the main triggers at the diffusion phases of innovation life cycle rather than the emergence stages.
2

Hart and Christensen (2002) terminology

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Methodology Focusing on the dynamic of disruptive innovation diffusion, this research has chosen the high-tech medical market of Iran as the main target of empirical field work. Novelty of this concept in medical markets and also appropriateness of invasive cardiovascular devices business in terms of great amount of disruptive innovations per year, make this case study suitable for the purpose of this research. Therefore, conducting a longitude case study of Iranian invasive cardiovascular market during the past 10 years, this research conducts 30 semi-structured interviews with the key decision makers of the four main incumbents of Iranian invasive cardiovascular market about launching their new disruptive innovations including: Johnson and Johnson (Cordis), Abbott Laboratories, Boston Scientific and Medtronic. However, conducting semi-structured interviews implies the understanding of the dynamic of disruptive medical innovations from strategic and technical points of view. Considering all of these issues we have to target the interviewees who are actively involved in the diffusion of disruptive medical innovations. Then a number of key decision makers of launching and diffusing medical innovations in each incumbent company were chosen to be interviewed. Also we chose some physicians who are acting in Iranian cardiovascular medical market as the main nodes of diffusion in the market in order to avoid any fix-sample selection bios. As a result, there are different groups that have been targeted to conduct the semi-structured interviews of this research. Moreover the findings of semi-structured interviews are supported by the findings of archival research in terms of diffusion information of medical devices during the past 10 years in order to provide more valid ity and reliability to the interviews’ findings. The findings of semi-structured interviews in accompany with the findings of participative observations and action research (by attending in most of the managerial meetings in each company) are initially analysed through the template analysis in order to identify the main topics of discourses and later on will be complementarily analysed by the use of discourse analysis in order to find out the main discussion around each topic. Longitude case study The first record of bare metal stent (BMS) 3 intervention in Iran is back to 1997 when the first Iranian interventionist Dr.Nazeri, came back to Iran after finishing his study in US and operated the first stenting operation. He is considered as the father of cardiac intervention of Iran. Before the creation of stenting method, open heart surgery was prevalence. before 1998, most of the patients with cardiac disease were being sent to UK by the government since there was a belief that UK is competent in heart surgery. Since the economy was public and centralized before 1998, there was a currency problem in the market that was called hard currency issue. It means that government was in charge of allocating currency. Therefore there was a committee that was responsible to allocate currency for sending patients to UK for further treatments. It was called the currency committee (TCC). After the first Stenting in 1997, and educating some interventionists by Dr.Nazeri, TCC decided to import the needed medical devices into the country rather than sending patients abroad. On that time this expertise was getting established in Iranian medical societies and therefore TCC began to import some amount of BMS after consulting with some experts. Although Palmaz-Schatz was the first BMS in the world by Cordis but it just came to Iran for educational usage. At the initial times, BMS couldn’t disrupt the open heart surgery market but step by step in 2000 it happened and the amount of interventions were significantly equivalent with open heart surgeries.

3

): In the technical vocabulary of medicine, a stent is an artificial 'tube' inserted into a natural passage/conduit in the body to prevent, or counteract, a disease-induced, localized flow constriction. It is a mesh-like tube of thin wire (Ring,2001)

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The BMS generation sales trend couldn’t show any significant differences since all of these products were imported by TCC and they were trying to import equally from each brand to keep the market balanced. The role of educating new interventionist and also TCC supports were tremendously important in disrupting the open heart surgery market. However, by the time the economic situation was getting more liberal and facilitated for real competition. From 2000, that Cordis took its own collaboration with TCC back, they tried to shape their own structure as a strong private sector representative in the market. Although TCC was getting benefit from public privileges such as tax, tariffs and other cost exemptions, Cordis was competing with them and invested on its own structure and position in the market. Therefore they could get a promising market share on their third generation of BMS (Sonic and Velocity). While the others were competing and innovating incrementally and radically in order to improve the efficiency of BMSs, Cordis was working on the revolutionary idea of the new generations of stents: drug eluting stent (DES)4. In February 2002, the first DES was released in the US market and four month later it was launched in Iran. Iran was within the first seven countries that launched DES for the first time. “Cypher” by Cordis was the first DES in the world and also it was the only DES in the market for two years. The trial results of Cypher were significantly fabulous and it succeeded to improve the rate of restenosis5 and thrombosis6 tremendously.

4

is a peripheral or coronary stent (a scaffold) placed into narrowed, diseased peripheral or coronary arteries that slowly releases a drug to block cell proliferation. This prevents fibrosis that, together with clots (thrombus), could otherwise block the stented artery, a process called restenosis. The stent is usually placed within the peripheral or coronary artery by an Interventional cardiologist or Interventional Radiologist during an angioplasty procedure (Moes et al,2003) 5 : literally means the reoccurrence of stenosis, a narrowing of a blood vessel, leading to restricted blood flow. Restenosis usually pertains to an artery or other large blood vessel that has become narrowed, received treatment to clear the blockage and subsequently become re-narrowed. This is usually restenosis of an artery, or other blood vessel, or possibly a vessel within an organ. This term is common in vascular surgery, cardiac surgery, and angioplasty, all branches of medicine that frequently treat narrowing of blood vessels (Forgos,2004) 6 : is the formation of a blood clot inside a blood vessel, obstructing the flow of blood through the circulatory system. When a blood vessel is injured, the body uses platelets (thrombocytes) and fibrin to form a blood clot to prevent blood loss. Alternatively, even when a blood vessel is not injured, blood clots may form in the body if the proper conditions present themselves. If the clotting is too severe and the clot breaks free, the travelling clot is now known as an embolus (Furie and Furie, 2008).

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Indeed based on the advantage of first mover, Cypher could be the market leader for the long time. This disruptive innovation was challenged by different competitors such as Taxus, Endover and Promous that were getting benefit from the other types of drugs but their PMA were not as promising as Cypher.

At 2006 two important events take placed. Firstly after around six or seven years struggling between interventionist and cardiac surgeons, they came up with the idea that stenting is not a substitution of surgery and it depends on the disease situation. Secondly since DES was more expensive than BMS it is not necessary for all the cases to use DES. Therefore these two critical events changed the market structure and in post-DES generation cardiac surgeries and improved BMSs took some part of the market. Therefor the total market share of DES declined dramatically. At the same time “Xience” was launched by Abbott Laboratories in the market. It was getting benefit o f last mover advantages. Xience based its advantages on Cypher’s weaknesses. The shape of stent made it easier for interventionists to intervene the stent and also it accelerated the procedures. Another advantage was the UBD or expiry time of Xience that made it superior on Cypher. Nevertheless, Cypher didn’t lose the total market and became the second market product after Xience. It deserves to mention that Abbott Laboratories has announced to release the third generation of stents that is called Bio absorbable stents (AMS) which the metal will absorb to the veins after drug releasing. Findings and Results 1. The Role of clear market definition in accelerating the diffusion rate of revolutionary innovations to disrupt the market

The research findings mention that the foremost important stage of market disruption is having a clear idea about the actual size of a potential market. Indeed most of the market incumbents cannot find the potential size of the future

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market and therefore they cannot make decision to allocate budget to their R&D sections to create revolutionary options to disrupt the market. Even in accelerating the process of diffusion the market should be studied accurately in order to find the main diffusion nodes to facilitate the process of market diffusion. In other word market disruption never happens unless all the opportunities to diffuse the innovation and disrupt the market are considered. Consequently having a clear market definition is the first step of perfect market disruption based on the research findings. For instance the main reason that Cordis.Co could get into the Iranian cardiovascular market was inaccurate market size estimation by the other incumbents. To this respect Cordis.Co sales manager says:” Our competitors had a wrong imagination of the market. They were covering just 15% of the market that they imagined was the whole market. Actually their understanding was not true about the actual and potential markets. They thought that we will be vanished soon but they were wrong. Because they thought of the market as the small island that they were seeing, but the actual market size were seven to eight times bigger than what they had thought ”. Different incumbents define their market by various criteria. Indeed the research findings show that medical markets are complex to be defined. Since there are doctors, hospitals and patients in this market, therefore there is not the issue of consuming or organizational market. There are different decision makers in the process of medical procurement effecting on the final decision. For instance Boston Scientific sales manager says: “ We define our market based on the hospitals. Indeed hospitals are in charge of procurement process. But doctors have a great impact on this process at the same time. They make the main decisions and hospitals perform based on them. At the same time patients could effect on doctors’ decisions regarding their financial situations. This is how the system works. The flow of decision is like this: doctors, hospitals and patients at the end”. But Medtronic marketing manager has different opinion:”We mostly consider doctors as our market in private hospitals but in public sector we define it by hospitals. Basically it defined by the main decision makers of the procurement market. Indeed the main point of having a clear market definition is to find the disruption opportunity in the market. The research findings show that having a clear market definition is considered as the planning stage to disrupt a given mainstream market. However, some of the interviewees mention that clear market definition won’t help to find any disruption opportunity. Indeed they believe that in order to find any disruption opportunity, they have to focus on illness and its causes. Following this trend they can find the opportunity to disrupt the market. In other word they believe that by observing the market to find the pre-evidences of a given disease, they may predict the future trends of the illness and focus on prevention or treatment of the future illness from now. Then it seems that based on the findings of this research, a clear market definition is related to the market disruption positively. 2. Market creation and market preparation phases are the most critical steps of market disruption. It usually happens by increasing the customers’ knowledge of products and procedures through the training courses in seminars and conferences.

Regarding this issue the Cordis.Co marketing manager says: “In order to launch a new revolutionary innovation in to the market to disrupt the main stream market, we have two different leverages: sales and marketing team. Marketing group has to increase the market knowledge about the product and sales team is responsible to make the product available in the market at a fair price. The marketing team has to increase the market knowledge by asking different question from the market actors. Increasing the market’s knowledge of new innovation, you need to draw the practitioner’s attention to the main performance value of that innovation and this is a completely culture intensive task. Indeed, the method of attracting market’s attention and also the ways of increasing market’s knowledge are totally based on the market’s cultural context. Understanding this culture and performing based on it can help a given innovation to disrupt the market as fast as it possible. In Iranian market asking question is the best way of introducing any new innovation to the market. In other word we have to ask about the main value of new innovation and tell them wouldn’t it better if the product does have this performance value? Asking these sorts of questions the market’s mind will get prepared to introduce our new innovation. If a given revolutionary innovation shows significant results in pre-market trials, more than 90% of the market would react positively to this new innovation. Doctors who reply positively are selected and given more information including: pre-market trial results, studies and so on. After that we give them free samples to test this new innovation. Intentionally or unintentionally doctors try to get the same results as like as the previous published studies that they have been given. Indeed we do a positive marketing and by giving them the trial results prior to their sample studies, we tell them what their results should be”.

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Also Abbott sales manager says:”Market development strategies at the same time are really important for us. We usually launch a new innovation in the markets that we have our core business over there and then we have some reputation in the market. Also we launch our core product in new markets since we have an experience about that product and we can make a good impression about it over there ”. Indeed the research findings mention that the most important barriers of new innovation acceptance in any given market are lack of knowledge. A given revolutionary innovation is unknown for the market and they are afraid of unknown devices because of the plausible implicit risks of performance. Therefore the main task of companies who want to disrupt the market is to remove any information barriers around a new revolutionary innovation. To this respect the Cordis.Co CEO says: “The main point of medical high-tech diffusion is increasing the knowledge of users. In medical market we encounter with the users who don’t want anybody to know that their knowledge of recent developed practices in the world is few. Therefore the way of dealing with them is really delicate and important. Therefore we put our simulator machine in our central lab and let doctors to come and practice their cases over there. Each doctor had its own private time with the machine in order to understand more about new stents and stenting operations without any hesitation. The only issue is that this machine is working just with Cordis stents. Therefore this educational tool helps the cardiology’s society to nurture more interventionists and also make the stenting operation more prevalent. At the same time they learnt the stenting and intervention procedure with the Cordis stents. In other word the first stents that they learn stenting by is Cordis stents. Therefore it makes young medical student loyal to the Cordis brand. Indeed we spend a huge amount of money on this simulator but at the same time we guarantee our futures market. As you can see , our credo, values , educational goals, market creation, understanding potential and actual market, all of them are fixed together to help us disrupt the market. We believe if we allocate just 5% of our sales to the educational programs (such as simulator idea) we could get it back by selling more in next year. Actually we are the first company in Iran that sent nurses to the conferences. We believed that our medicine knowledge hasn’t developed as like as our doctors and we need to increase the knowledge of nurses in order to make balance. We did so and the first nurse that we sent to the conference has one of the best rates of publications in different seminars such as PCR and European heart conference”. Cordis.Co franchise manager also says: “Cordis decided to build a capacity in the market by making the attraction for new innovations. The main problem of TCC was that they didn’t give any choice to the surgeons to choose between different stents based on their needs. They just presented some specific stent’s brand in the market and the hospitals made the surgeons to use them. Therefore Cordis tried to fill this gap and provide more options for the surgeons. Making this important distinguish, Cordis understood that it is needed to increase the knowledge of practitioners about new innovations which necessitate learning of new practices. Because of that Cordis established the scientific team inside the organization to work on these affairs. Regarding to Iranian culture if the scientific team talked about the price, market would reluctant to be in touch with them. Therefore Cordis separated the sales, marketing and scientific teams from each other in order to increase their productivity. Then Cordis followed the strategy of better selling rather than selling more. It means that they focused on the quality of sales rather than quantity. They try to increase the customers’ satisfaction rather than the sales volume. They believe that better selling could lead finally to the high volume of sales”. Regarding the Cordis.Co success in removing the information barriers away from new innovations, Cordis.Co sales manager also states: “However we believed that we need to increase the doctors’ knowledge of products and procedures since our products were a sort of high-tech products and the doctors needed to know more about them. Therefore we started to educate the doctors and allocate some amount of budget for their educations. We divided the education into three different levels: elementary, intermediate and advance and based on the doctors’ need we define their educations and their level of studies. But defining these levels was really difficult since doctors didn’t like to be sorted and evaluated by the companies. Then it was better to classify them invisibly. In other word we classified them when we were inviting them to different conferences. Based on the level of conferences we invited different groups of specialists and by doing this we tried to manage the education of specialists. We are the only cardiovascular company in the region that has got a simulator machine at the same time. This machine is a sort of educational tools that can simulate the patient situation and doctors can rehearsal the intervention operation on it and see the feedback rather than practicing on real human beings. The doctors can use this simulator for free to indicate their cases and see the results, which could decrease the rate of resistant for using the new devices. Therefore it can accelerate the rate of diffusion. This simulator cost something around 300,000 dollars for us. But this amount should be invested and dedicated in order to accelerate the diffusion rate of innovation and therefore

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facilitate the market disruption. Since our priority is patients’ treatment rather than making money, increasing the doctors’ knowledge by using simulator machine is the best strategy ”. Abbott marketing manager also shares the same idea with Cordis managers. He says: “ On the other hand running different training sessions would be highly important in order to disrupt the market. By having this training session we will remove the last barriers of consumption for the doctors. All of these educational strategies are costly but this is the price that you have to pay for market disruption. For instance one of the strategies to increase the future market share is to choose the young fellowships that have been graduated from the medical schools recently and send them to internal and external workshops to learn how to work with the new innovations. Indeed whatever that the young fellows have taught in medical schools will make not more than 40 percent of their knowledge. The rest of it is the workshops that they will be sent to and the practical educations that they will get from these medical devices companies. Indeed they are providing a huge amount of valuable supports for young fellowships ”. However based on the research’s findings another leverages for market preparation is building reputation by the other accessory products at the same market. Indeed these accessories products could make a respectable reputation in the market and prepare the market for launching new innovation by the same brand. Regarding this issue the Medtronic marketing manager says: “One of the competitive advantages of Cordis is that they are pioneer in accessory market such as catheter and guide wires. At the same time the entire new medical student use Cordis accessory products from the first days and because of that the brand name will stay in their mind. It’s really difficult if you want to visit all the doctors all over Iran. But you should know there are just three different universities that all of those doctors would be graduated from. Therefore by investing on educational universities and target them you can ensure the future market share for yourself. At the same time considering the key doctors as the main nodes of diffusion is tremendously important. Tehran, Mashhad, Shiraz and Isfahan are the main universities that have intervention fellowship courses”. Also the technology manager of Cordis.Co states: “The way that Cordis is working will make a huge foundation for the future. When the rest of our competitors don’t care about the brand management and just think a bout their daily sales volume, we are thinking about our credo, reputation and brand power ”. Also there is another trick that if a given innovation has a failure in the market incumbents usually tries to remove it from the market’s mind by introducing the new version of it ,in different names. For instance Boston Scientific sales manager says: “ All the great incumbents of the market were trying to launch a new version of their product in order to compete for dominancy in the market. For instance Cordis lau nched “Cypher Select” and “Cypher Select Plus” in the market. Cypher and Xience launched the new versions of their product by the same name but Taxus introduce the new product in a new name. Taking this strategy Taxus could convince the market that the new version of products was something different from the previous one.” 3. Media are mastering the minds and shape the consumption pattern in medical high-tech businesses

Based on the findings of this research the role of pre-market trial results are really important to convince the physicians to use a new revolutionary innovation. At the same time it is really important to know that how much a given study is scientific. Sometimes there are more commercial than scientific. Therefore doctors should consider these tricks in the market. There is something about business strategies that make a competent product vanished from the market. Victor by Medtronic was one of those examples. It seems that the company couldn’t present it very well while the others could get the most of the market share. There is a different between scientific evidences and scientific illusions. Sometimes the studies are shown in a way to convince the market. Or some others try to show a different side of any new innovation. Therefore they can s hape the market’s mind by publishing any new studies. Indeed media could master the minds. Therefore shaping the market’s mind is really important in accelerating the diffusion rate of a given revolutionary innovation. 4. Positioning the new performance value in the customers’ values framework and showing the market how important it is. (The relation between product identity and the possibility of market disruption)

Regarding this issue Boston Scientic’s sales manager says: “At the same time we should be careful that not to ruin the product prestige and identity by too much flexibility in pricing strategies. Indeed I have to say that market disruption needs a balance between product prestige and sales strategies’ flexibility. There are always people who

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know the price of everything and the value of nothing. The most important issue about innovation identity is the value of it. In order to disrupt the market we need to show the value of the new innovation to the market. Otherwise they never can understand the value of that product and we will get failed to position the new innovation in the market. Innovation’s attributes, raw materials, the producer reputation, the brand power and the services that incorporated in a new innovation will determine the product’s values. Therefore if a given innovation has some remarkable values itself, in the next step we have to show and unveil these values to the market by increasing the market’s knowledge around it. The innovation value is the mo st important leverage of diffusion in the market”. Cordis franchise manager adds: “Indeed we do believe that if we sell the products by any means we will lose the game. We believe that one of the most important issues of any given innovation in order to disrupt the market is its prestige and the positioning way of it into the market. We do believe that we are doing in the right way and we will make a potential for the future competition. At the same time we should issue some competition strategies delicately in order to react to the market suicidal competition actions”. Perhaps it is more useful if we hear the notion of doctors at the hospitals and underhand the importance of a sophisticate presentation of a revolutionary innovation from them. To this respect Dr.Kazemi-Saleh says:” If I want to think about a medical device I will first need to know about the studies that have been done on this product. After that I will ask the company to satisfy me with CE and FDA certificates which make me more confident about that product. After providing all of these issues they worth it for me to spend my time and talk with them about the new innovation. After that I need a sample to see the quality and productivity of the product in practice. I use these samples in the most complex cases in order to see the result and performance of this new innovation. At the last stage I ask them to give me their follow up studies about their drugs. But rarely companies can present a follow up studies”. Therefore as it is evident from the research findings, positioning the new innovation and its new performance value is the most critical point in disrupting the market. 5. The most important issue is the risk tolerance of the market disruptor in moving beyond the market boundaries in order to create a new market.

Perhaps Cordis.Co is one of the best examples of risk tolerance. They were the first company in the market that disrupt the BMS market by their new product Cypher. To this respect the Cordis CEO says: “ The first DES was launched at June of 2002 in Iranian medical market. Although it was a bit risky to launch this product into the market but we did it since it had some promising trial results and at the same time we believed that launching new innovations into the market we need to have ambiguity tolerance capability. At the initial launch times, the expiry dates of products were so short and we should sell the products as soon as possible. This contradiction was solved by our patience. We accepted to lose some amount of money in order to launch and diffuse this product in the market properly in order to disrupt the market and get the dominant position. Indeed we didn’t lose this money and instead of that we invested it to position this new innovation in the market and for 5 brilliant years this product was the market leader and gave us a huge market share and surplus”. Cordis franchise manager tells the story in different way. He says:” TCC was so strong because they had some privileges including tax exemption, tariffs and barriers exemption and all the other public cost exemptions while the other competitors should pay all these costs. Actually it was totally unfair competition. We told TCC that we want to get the surpluses from our investments and marketing capabilities rather than just transferring papers. We offer the same prices all over Iran. All the practitioners in the market told me that if TCC doesn’t buy your product you will get bankrupted. The main reason of this fear was that nobody had studied the market before and they didn’t have any idea of the amount of interventions and also they didn’t have any assumption of potential market. We studied the market and found out that this fear is rootless. Abbott laboratory, Medtronic, Boston Scientific and after that Guidant were major market incumbents in 2002. Medtronic was leader on that time and after that Boston and Guidant were following them”. Finally Cordis marketing manager states: “Reports and statistics include the most important part of our decision making process and rarely you can find a company in Iran to do it. There have been a huge amount of Cypher consumed and we nurtured more than 80 interventionists during our educational program. Now a day, Iran has become one of the eminent centers of intervention and stenting in Middle East. It deserves to mention again that if you have a good product and good service and fair price but your product is not available in the market, you will be vanished from the market. Our strength point was that we didn’t afraid of stocki ng product. We were brave enough to import a huge amount of product, stock it and then sell it. We could tolerate the possible risk of product expiry in

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case of sales failure. But our competitors couldn’t take this risk and they lost the market to us. They are still afraid of importing stents like us”. Conclusion If we want to suggest a definition for the concept of disruptive innovation diffusion based on Rogers (1985) definition, perhaps it would be as such: the process by which an innovation is communicated through certain channels over time among the members of a social system (market) in order to disrupt the main stream market and generate a new market instead or beside the current one. The research findings suggest that a given disruptive innovation should get communicated about three different types of knowledge: existence knowledge of the innovation, the usage knowledge of it and the superiority knowledge of that innovation over the other options. The first couple of knowledge could get disseminated by conferences, seminars and workshops all over the world. The third type of knowledge usually needs one step further by releasing the strength of pre-market trials over the other options to the public. The findings show that the companies usually show their superiority by making direct or indirect comparative trials studies with the other competing products. However, these communications should take place through some specific channels in order to be more effective which lead to disrupt the mainstream market. Based on the findings of this research, hospitals could be considered as the main marketplace of medical devices. It implies the importance of three main distribution channels such as key physicians, practicing nurses and young fellowship medical students. Based on the findings of this research the first channels should be considered as the most important nodes of diffusion in medical markets. At the initial period of diffusion (introduction period) most of the efforts should be put on convincing this part of market. The second priority should be devoted to the head nurses and practicing nurses of the cardio centres. They are one of the most influential actors of market specially at growth and maturity time of the innovation when it is getting too much close to disrupt the market and get to the critical mass point. Young fellowships and medicine students should be the other priority to guarantee the future market shares. Consequently, the mechanism of main stream market disruption begins with outlying a clear image of the future market. At this stage, company should have a bright idea of the new performance value by which they want to disrupt the current market. Reaching to this level is mainly the outcome of the R&D departments of the incumbents. After coming up with a reliable performance value, it is the time to propose it to the market at the beginning of the market creation phase. At this point, all the types of knowledge in regards to the potential disruptive innovation should get diffused wisely through the selected diffusion channels. In other word, market creation or preparation phase is a transition stage between an unknown potential disruptive innovation to a vigorous market disruptor. The main obstacle in this phase is the market fear of adopting new innovation into their performances and overcoming this obstacle needs a comprehensive knowledge diffusion movement. A successful outcome of this phase will lead to the emergence of a new market instead or besides the current one. But the dynamic of market disruption would not get finished at this point. Keeping a disruptive innovation at the dominant position in the market would necessitate the existence of some back up planes of the next generations of the market disruptors in order to reply the potential reactions of competitors. References ABERNATHY, W. J. 1978. The Productivity Dilemma, Baltimore, John HopkinsUniversity Press. ABERNATHY, W. J. & CLARK, K. 1985. Innovation:Mapping the wind of creative destruction. Research Policy, 14, 3-22. ABERNATHY, W. J. & TOWNSEND, P. L. 1975. Technology, Productivity and Process of changes. Technology Forcasting and Social changes, 7, 379-396. ABERNATHY, W. J. & UTTERBACK, J. 1978. Patterns of Innovations in Industry. Technology Review, 80, 40-47. ADNER, R. 2002. When are Technologies Disruptive?A demand based view of emergence of competion. Strategic Management Journal, 23, 667-688. ANDERSON, P. & TUSHMAN, M. 1990. Technological discontinuities and Dominent Design: A Cyclical model of technological change. Administrative Science Quarterly, 35, 604-633.

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CALLAHAN, J. 2007. Patterns of technological innovation, Boston, Boston University Press.

CHARITOU, C. 2001. The Response of Established Firms to Disruptive Strategic Innovation: Empirical Evidence from Europe and North America. PhD, London Business School. CHARITOU, C. & MARKIDES, C. 2003. Responses to disruptive strategic innovation. Solan Management Review, 44, 55-63. CHESBROUGH, H. 2001. Assembeling the elephant: A review of emperical studies on the impact of technical change upon incumbent firms. In: CHESBROUGH, H. & BURGELMAN, R. (eds.) Comparative Studies of technological Evolutions. Oxford CHRISTENSEN, C. M. 1997. The Innovator's Dilemma:When New Technology Cause Graet Firms to Fail, Boston,MA, Harward Business School. CHRISTENSEN, C. M. 2006. The ongoing Process of building a theory of disruption JOURNAL OF PRODUCT INNOVATION MANAGEMENT, 23, 39-55. CHRISTENSEN, C. M., BOHMER, R. & KENEGAY, J. 2000. Will disruptive innovation cure health care? Harvard Business Review. CHRISTENSEN, C. M. & RAYNOR, M. E. 2003. The innovators' solution : Creating and Sustaining successful growth, Harvard Business School Press. COOPER, R. G. & KLEINSCHMIDT, E. J. 1993. Stage Gate Systems for New Product Success. Marketing Management, 1, 20-29. CRAWFORD, M. E. 1994. New Product development, Boston, Irwin. DANEELS, E. 2002. The dynamics of product innovations and firm competences. Strategic Management Journal, 23, 1095-1121. DANEELS, E. 2004. Disruptive technology reconcidered : A critique and reserach agenda. JOURNAL OF PRODUCT INNOVATION MANAGEMENT, 21, 246-258. DROEGE, S. & JOHNSON, N. B. 2010. Limitations of low end disruptive innovation strategies. The International Journal of Human Rsource mangement, 21, 242-259. ENGEL. S.J. 2011. Accelerating the corporate Management innovation: lessons from venture capital Research Technology

GOVINDARAJAN.V, KOPALLA.P.K and DANEELS.E. 2011. The Effects of Mainstream and Emerging Customer Orientations on Radical and Disruptive Innovations. J PROD INNOV MANAG;28(S1):121 –132 KING, A. & TUCCI, C. 2002. Incumbent entery into new market niches: the role of expirience and managarial choice in the creation of capabilities. Management Science, 48, 171-186. KLEINSCHMIDT, E. J. & COOPER, R. G. 1991. The impact of product innovativeness on performance Journal of Product Innovation Management, 8, 240-251. MARKIDES, C. 2006. Disruptive innovation : in need of better theory JOURNAL OF PRODUCT INNOVATION MANAGEMENT, 24, 19-25. MARKIDES, C. & GEORSKI, P. 2005. FastSecond: How smart companies bypass radical innovation to enter and dominate new market, San Francisco, Jossey -Bass.

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ROBERT, W. & VERYZER, J. 1998. Discontinous innovation and the new development process. JOURNAL OF PRODUCT INNOVATION MANAGEMENT, 15, 304-321. ROTHWELL, R. & GARDINER, P. 1985. Invention,Innovation, Re-innovation and The Role of The Users. Technovation, 4, 161-169 SAHAL, D. 1981. Patterns of technological innovation, MA, Addision - Wesely. TEECE, D. 1986. Profiting from technological innovation:Implications for integration , collaboration and public policy. Research Policy, 15 285-305. TIDD, J. & BESSANT, J. 2009. Managing Innovation, Wiley and Sons Ltd.

TUSHMAN, M. & ANDERSON, P. 1986. Technological discontinuities and organizational environment. Administrative Science Quarterly, 31, 439-465. UTTERBACK, J. 1996. Mastering the dynamics of innovation, Harvard Business School. UTTERBACK, J. & ABERNATHY, W. J. 1975. A dynamic process and product innovation. Omega, 33, 639-656. UTTERBACK, J. & ACEE, H. J. 2005. Disruptive technology: An expended view. International Journal of Innovation Management, 9, 1-17. YU ,AN DAN, HANG.CHANG CHIE 2011. Creating technology candidates for disruptive innovation. Technovation 31 401–410

Mohammad Hajhashem Manchester Business School

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THE NEW ERA OF HEALTHCARE: CONSUMER – DRIVEN MARKETING
Robert J. Spinelli, University of Scranton

ABSTRACT Consumer Driven Healthcare relates to the fundamental changes that have occurred in recent healthcare practices. Marketing is creating, communicating, delivering, and exchanging offerings. This concept is almost limitless in most industries. The healthcare industry’s marketing techniques must be carefully evaluated and implemented as they promote service. Services within the marketing industry can be one of the hardest areas to generate effective, successful marketing that creates value for both the consumer and the company. This presentation gives an insight to the ways that the healthcare industry is transforming. It examines the consumer-driven market, its history and evolution and illustrates how marketing practices have evolved in the healthcare sector. The presentation embraces the advantages of “technology-enabled marketing”. Recommendation for future directions of healthcare marketing for administrators is examined.

Robert J. Spinelli, DBA Assistant Professor and Program Director Department of Health Administration & Human Resources The University of Scranton 423 McGurrin Hall, Scranton, PA 18510 Telephone: 570-941-5872 E-mail: spinellir2@scranton.edu

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PHARMACY-BASED COST GROUPS AND ITS CURRENT UTILIZATION WHITHIN INSSURANCE SYSTEMS IN EUROPE
Robert Babela, St. Elizabeth University, Slovakia Vladimir Krcmery, St. Elizabeth University, Slovakia

ABSTRACT Adequate risk adjustment is critical to the success of market-oriented health care reforms in many countries. The purpose of these reforms is to make resource allocation in health care more efficient and more responsive to the consumers’ preferences. Faced with challenges of an adequate source allocation within insurance system, it is interesting to look at morbidity rates and at population insured by each insurance company. Resources can be distributed more adequately when considering real risk carried by patients. Pharmacy-based Cost Groups (PCG) is system based on monitoring of prescribed drugs used for chronic diseases and divided into several groups. Information about chronic conditions deduced from the prior use of prescribed drugs have been shown to be good predictors of future health care expenditures. PCGs were implemented in several European countries (e.g. Netherland) because of its predictive value and the availability of data. We expect to have PCGs incorporated into Slovak system from beginning of 2013. This paper lays the groundwork for structure of the Slovak insurance system and expected changes, which should bring more efficiency and better resource allocation in near future.

Robert Babela St. Elizabeth University Slovakia Vladimir Krcmery St. Elizabeth University Slovakia

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TRACK HEALTHCARE EDUCATION

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DEVELOPING EFFECTIVE PRECEPTORS FOR FUTURE HEALTH AND AGING SERVICE ADMINISTRATORS
Jennifer Johs-Artisensi, Health Care Administration Program, University of Wisconsin – Eau Claire LaNette Flunker, Health Care Administration Program, University of Wisconsin – Eau Claire Douglas Olson, Health Care Administration Program, University of Wisconsin – Eau Claire

ABSTRACT The field of health and aging services administration is experiencing increasing demand for competent leaders, and one of the key factors in the professional development of these leaders is an effective, supervised, field experience. This paper describes the development of a Preceptor Certification program, for long term care administrators supervising the practicum or Administrator-in-Training experience of future long term care leaders. This innovative program provides online training and support to preceptors working with undergraduate practicum students. The main objective of the Preceptor Certification program is to enhance the learning outcomes of students by better preparing and supporting preceptors for their roles. The University of Wisconsin – Eau Claire has created a four-module, online, self-paced, asynchronous program. A task force, consisting of active preceptors and the advisory board for our Center for Health Administration and Aging Services Excellence offered suggestions at the inception of program development. Evaluations have thus far been positive, with academics, preceptors and training directors who have reviewed the certification course to ensure the included information is applicable and the modules, are well planned with thoughtful learning objectives. same aspects would likely expected to have greatest appeal to the most consumers. It would likely meet their needs for information and encourage them to use DTC genetic testing in order to better their own health.

INTRODUCTION Like many health professions, with the aging of our population, experienced long term care administrators are reaching retirement age just as we are seeing a rise in the numbers of recipients needing care services. With more people exiting than entering the profession, the field is experiencing an employment cliff. Since 1998 the number of examinations administered to candidates seeking initial licensure as nursing home administrators has declined by more than 40% with only a slight increase in recent years (NAB, 2007). At the same time the field is experiencing approximately the same 40% level of turnover, as reported in numerous studies (Angelelli, et. al. 2001; Castle, N. 2008), and there is concern that this crisis has the potential to negatively impact care and service to our senior population (IOM Report, 2001, Tellis-Nayak 2007, Castle 2001, Singh, et. al 1996). To fill this anticipated need, recruitment of interested individuals to serve as LTC administrators will need to occur. It is imperative that new administrators are adequately educated and trained to ensure they will possess the management and leadership skills necessary for success in leading organizations that provide high quality care to recipients in this rapidly changing field. Enhanced educational experiences in their field experience will ultimately increase the likelihood they will remain in the field, as research suggests the practicum/AIT experience has a strong influence on future success. In a recent study (Siegel, 2009) the preliminary evidence suggests that AIT experience is critical to the effective development of healthcare administration competencies. In a white paper commissioned by ACHCA and the NAB Foundation, Dana and Olson (2007) discussed the importance and uniqueness of the field experience in long-term care, and it is clear that the practicum/AIT is an essential educational component which is critical to both the short- and long-term success of potential administrators. In a recent White Paper based on a research project commissioned by the Commonwealth Fund and the NAB Foundation, Johs-Artisensi & Olson (2012) concluded that several factors contribute to the quality of a trainee’s practicum experience, including certain characteristics of the preceptor, as well as the broader culture of learning within the training organization.

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Currently, state licensing boards differ greatly in their requirements for practicum training sites, programs, and preceptors. For example, only about half of states specify content for the practicum, and specifications vary widely. Salsberg, Langelier, and Wing (2004), as part of a Commonwealth study, reported there is a great deal of variability across state licensure requirements, especially as it relates to parameters of the required field experience. A majority of state licensing boards provide no guidelines in terms of the size or scope of service of training sites, and those who do have minimum size requirements vary from 25 to 75 SNF beds. Many also require preceptors be approved, but only some specify standards for approval. The most common preceptor requirement addresses years of experience, but even those vary greatly. Some boards may provide training and certification for preceptors, but they differ in detail (Johs-Artisensi & Olson, 2012). As indicated in the chart in Appendix A, the standards for preceptor selection and the type of preceptor training available or required is also extremely variable. Yonge, Myrick, Billay, & Luhanga (2007) define a “preceptorship” as a professional relationship between a student and practitioner for a limited period of time in which the practitioner and the student work together in a clinical setting to achieve the student's course goals and objectives. “Preceptorships” in undergraduate long term care administration practicums are designed to provide students with an effective long term care experience, help senior-level students transition into the professional role, and provide opportunities to hone management and leadership competencies by working directly with residents, families, staff, managers, and the executive director (Crawford, Dresen, & Tschikota, 2000; Wieland, Altmiller, Dorr, & Wolf, 2007). These preceptors are usually volunteers who take on the added responsibility of a student while maintaining their own practice workload. Without proper support and training, this dual role can lead to burnout (Council of University Teaching Hospitals, 2001; Hautala, Saylor, & O'Leary-Kelley, 2007; Lambert & Glacken, 2005). Support such as more information about school expectations of preceptors and students, more visits from liaison faculty, user-friendly documentation, and student motivation, are frequently requested (Pulsford, Boit, and Owen, 2002). Similarly, Bourbonnais and Kerr (2007) also identified the importance of a preceptor training workshop. Precepting exists in many of the health sciences, such as nursing, pharmacy, medical residencies, and more, but literature studying the role and development of precepting in long term care administration is almost nonexistent. While standards and requirements for preceptors in the health disciplines may also be variable across states, there are several researchers who have documented critical components or developed preceptor training programs for their respective disciplines (DeWolfe, Laschinger, & Perkin, 2010; Schaubhut & Gentry, 2010; MAHEC, 2001; Kleffner, 2010). Johs-Artisensi & Olson (2012) recommend that since Preceptors have been shown to be one of the most significant factors influencing an AIT’s success, that development of a preceptor training course using adult education techniques to help preceptors better understand the content areas their student should be exposed to, how to mentor and develop their trainee, and how to develop a strong culture of learning within their organization would enhance the success of student trainees, as would networking with other preceptors and gaining access to relevant contemporary resources from experts within the field. Many characteristics are critical to a good preceptor, and clearly, simply being a good administrator does not mean one will be a successful preceptor, and studies have shown that preceptors perform better in their role if they receive some type of formal preparation (Altmann, 2006; Burns, Beauchesne, Ryan-Krause, & Sawin, 2006). A preceptor should be engaged in their profession, and passionate about helping to prepare future students to join the industry (Johs-Artisensi & Olson, 2012). A good preceptor will have a solid understanding of adult learning principles and communication styles, and will be well skilled in orienting, coaching, and eventually mentoring their trainee. In addition, they will cultivate a spirit of learning within their organization, and among their leadership team. Department managers and front line staff also play a critical role in helping the administrative trainee in understanding the “team approach” and the cooperation and communication necessary across departments (Johs Artisensi & Olson, 2012; Vrba, 1994). A skilled administrator will leverage the “teaching” skills of all the members of their care community in the development of their practicum student. PROGRAM DEVELOPMENT The main objective of the Preceptor Certification program was to support the learning outcomes of students by preparing and supporting preceptors for their roles. The resultant program is a teaching and learning process dedicated to student and preceptor achievement. Overall program goals were developed and coordinated as a result of a preceptor focus group, comprised of approximately 20 active and experienced preceptors, including several corporate senior care education directors, a review of existing preceptor training requirements and training programs

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offered by long term care administration academic programs and various state licensing boards, and a review of the preceptor training literature, both in health care administration as well as other health science related disciplines such as nursing, pharmacy, and medical residencies. Goals, learning objectives, and key content areas emerged as a result of this process and were incorporated into four modules which comprise the certification program. As a result, an online, asynchronous, certification course was developed, and delivered on the web-based Desire 2 Learn platform. Each module was developed first by establishing learning objectives, and then developing a written commentary with embedded web-resources or recorded instruction as appropriate, an applied assignment to reinforce concepts, and a competency quiz, which must be completed with 80% accuracy before the preceptor is allowed to access the next module. Modules were peer reviewed, as well as reviewed by several preceptors and senior care corporate education directors. The certification program will be piloted with over 40 preceptors in spring 2013. Feedback will be solicited and any relevant revisions made, and the certification will become mandatory for all preceptors supervising our students by 2014. Module 1 – Objectives & Content Summary  Explain the need for preceptors and AIT experiences  Describe the structure of the University of Wisconsin – Eau Claire Health Care Administration Practicum experience  Identify different roles of preceptor, including facilitator and evaluator Our first module establishes the need for and role of the preceptor. Preceptors facilitate the orientation, development, and growth of future administrators who will one day become their peers, and a relationship, where trust and responsibilities grow gradually, facilitates the students’ professional develo pment, and the important role the preceptor plays in this growth is well-established (Johs-Artisensi & Olson, 2012; Barker & Pittman, 2010). The practicum or AIT experience is based on a strong preceptor relationship, where an inexperienced person (practicum student) is assigned to a competent and experienced person (preceptor) in a one-on-one teaching and learning relationship so the inexperienced person can participate in day-to-day practice with a teacher, resource person, and role model immediately available within the practice setting (Kaviani & Stillwell, 2000). In our opening module, supporting the value of the preceptor and explaining the various roles they will play in the students’ development, an overview of how our practicum program is structured is shared, as are the applied learning experiences and departmental rotations the practicum student is required to experience. A program with a less developed practicum experience could use existing resources such as the NAB Domains of Practice (NAB Domains of Practice, 2008), the NAB AIT Manual (Allen & Brown, 2007), or any relevant AIT Training Manual or requirements established by their respective state licensing boards. In a review of several existing long term care preceptor training programs offered by licensing boards or industry associations, the authors found that often preceptor training would be comprised entirely of the content espoused in our first module. Yet, we believed it was critical to go beyond setting expectations for experiences and evaluation, and to arm preceptors with a greater understanding of the orientation and learning experience of the student, as well as contemporary best practices, which may be beyond the scope of entry level licensing exams. This philosophy is what contributed to the development of the remaining three modules. Module 2 Objectives – Objectives & Content Summary  Identify strategies for cultivating a welcoming learning environment for practicum students  Discuss principles of adult learning or various/the 4 major learning styles  Describe the role of the preceptor in orientation of the practicum student  Explain strategies to support the four transitional phases a new trainee may progress through as they reconcile ideals learned in school with the practical reality of the health care environment In Johs-Artisensi & Olson’s (2012) recent research on factors that contribute to a quality practicum experience, one of the major factors was ensconced in the “learning environment” factor. They discovered that ta ngible signs of welcome, such as office space with technology access and a company email account, which supported integration into the organization, set the tone for a positive experience. In addition, the role of department managers and staff also emerged as playing a role, as lower turnover rates on the leadership team seemed to support a better experience. They recommended preceptors be equipped with more knowledge about how students learn, and how they can

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empower their leadership team to play a more active role in the learning experience of the student. This concept had already been popularized in the business culture, when Senge (1990) with the ‘fifth discipline’ concept emphasized the importance of a strong learning environment to organizational performance. In long-term care, the teaching nursing home model (Bonner, 2004; Mezey, Mitty, & Burger, 2007) has advanced the importance of a climate of support and partnership with educational programs, and so became the focus our second module. We wanted to arm preceptors with knowledge and skills they could employ to cultivate a “culture of learning” within their organization, in an effort to facilitate the orientation and transition of the student into their new living, learning environment. Module 3 Objectives – Objectives & Content Summary  Identify how preceptors help students develop professional skills and relationships  Explain the importance of verbal and nonverbal communication  Discuss three communication patterns used by students and preceptors  Demonstrate guidelines for providing effective feedback  Describe the transition from coaching to mentorship The primary focus of our third module was to move beyond the orientation and transition of the student from novice in the direction of leader. Content focused around developing preceptor skills in facilitating learning and increasing knowledge and practice through open communication and regular interactions with their student. Strategies for building necessary self-efficacy to lead their own long term care community one day are taught, alongside coaching techniques to ensure students will develop and integrate several important professional skills, including competencies related to the Domains of Practice (NAB, 2008), as well as broader leadership characteristics. Communication patterns are discussed, and strategies for providing effective feedback are shared. In addition, as the student begins to develop further, preceptors are encouraged to evolve their coaching relationship to one of mentoring (Bell, 2002), which may allow the relationship to prosper long after the practicum experience itself is complete (Olson, Lester, Eide, & Blasko, 2010). Finally, strategies for advancing critical thinking development, conflict management, and motivation of the student are introduced (Greene & Puetzer, 2002). Module 4 Objectives – Objectives & Content Summary  Identify resources to stay up to date on evidence-based and contemporary practices in long term care administration  Describe at least four recommended contemporary evidence-based practices beyond the skill sets expected of entry-level administrators  Demonstrate critical thinking and problem-solving behaviors and how you can develop these skills in your practicum student The intent of the fourth module is to provide resources for preceptors that will enhance their own approaches for using current and new evidence-based, contemporary leadership and management practices. The goal is to leverage the important role of the preceptor in demonstrating skillful clinical and management practices (Irby, 1994). Ideally, we would like preceptors to not only expose our students to these concepts, but to role model these practices for our students and demonstrate how they can effectively use these approaches to maximize the success of their organizations. Some of the new skill sets, in several contemporary “evidence -based practices” include things such as:  Embedding a broader organizational systems-oriented approach to evaluating the performance of their organization, such as espoused by the National Baldrige Model (NIST, 2012)  Using good quality improvement approaches and tools, such as root cause analysis and other resources available at a variety of websites (ASQ, 2012, AHRQ, 2012)  Staying current with federal quality and performance initiatives, including programs like the Quality Assessment and Performance Initiative being put forward by the Center for Medicare and Medicaid (CMS NH QAPI, 2012; Kulus, 2012)  The ability to use data to drive decision making across the organization and using effective benchmarking approaches, for example, the Advancing Excellence in America’s Nursing Homes Campaign (Advancing Excellence, 2012).

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 

Practicing effective change management strategies using a variety of leadership resources (Kotter & Cohen, 2002, Dana and Olson, 2007) that would be effective in the health and aging service environment, also including industry specific resident-centered care movements, such as the Pioneer Network. Finally, engagement with professional and trade organizations that represent the field that have a wealth of resources available for their members

The goal is not to “go deep” in the module, but rather to highlight these “best practices” and provide resources where preceptors could get more information. We realize organizations have their own culture and administrators have their own leadership styles and practices, but we expect that both preceptors and their protégés could use knowledge gained in this module, to motivate them to stay abreast of current developments in the dynamic field of healthcare, to solve problems, and to create opportunities (Center for Creative Leadership, 2007). It is our hope that some of these resources would be advanced in applied projects or initiatives within their organizations that could provide the practicum student a hands-on application and learning experience using these practices. This module is one that especially requires an ongoing review and dialogue with the field to stay current and credible as an academic program, which in turn truly makes it a win-win-win scenario for the students, practitioners and University. BEYOND THE PRECEPTOR CERTIFICATION COURSE OFFERING Although it was important to us to develop the Preceptor Certification program in a way that would meet the needs of our academic program as well as our preceptors, as well as be efficient and flexible (which is why we opted for the asynchronous, online format, in lieu of a face-to-face approach), we also wanted to offer both virtual and face-to-face networking opportunities to our preceptors, and give newer preceptors the opportunity to interact with more seasoned veterans. To that end, we have maintained several other important elements in our overall preceptor training approach. Each year we share contact information for all our preceptors with each other. We also maintain a regular “preceptor session” at our annual spring networking event, where updat es can be given and where that important relationship building among the network can be fostered. We also offer technology-assisted or onsite visits and any relevant on-site training for preceptors (and even department managers, on request) who are new to our program or who may be struggling in their precepting relationship with their student. We will continue to explore other ways we might facilitate this critical “networking” component in other ways, such as partnering with industry or professional associations or exploring other online approaches. Our hope is that preceptors will find value in the certification modules not only in assisting them in maximizing development of their future students, but also in coaching and mentoring their own management talent, as well as perhaps exposing them to innovative and contemporary practices in the field of long term care administration. The Preceptor Certification program will be offered free of charge to our preceptors, and will also be approved for NAB continuing education credit. Feedback on relevancy on how to improve content will be conducted with participants on completion of the course, and a regular survey of our advisory board will help us to offer relevant updates to contemporary practices in preceptoring and the broader field of health administration. It is imperative that the Preceptor Certification course content remain current and relevant so those who are required to take it will view it as a value-added resource. Beyond requiring preceptors who supervise our students to complete the Preceptor Certification requirement, we have also established some criteria for selection of sites and preceptors we believe are best equipped to serve our students’ needs. We require all potential sites to offe r diversity in the scope of services they offer, so our students can be exposed to a broader continuum of care than offered at a typical stand-alone nursing home, as well as require them to ensure the student can also gain exposure to Medicare certified services and either assisted or independent living. In addition, we require all organizations who serve as our practicum sites to provide space and technology access (desk, computer, phone, and company email communications) to their student. Finally, to ensure quality, we also require preceptors in our program to have a minimum tenure as an NHA of at least 2 years, with a preference for those practicing for 5 or more years, and at least 2 years at their current organization (Johs-Artisensi & Olson, 2012). CONCLUSION

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The Preceptor Certification program at the University of Wisconsin – Eau Claire offers our academic program a way to enable preceptors to enhance their knowledge base of teaching skills, communication techniques, and evaluation strategies, as well as expand their repertoire of contemporary best practices in health and aging services administration. The program uses a variety of methods, such as an online course and an annual preceptor networking event to support these administrators. Success of the preceptor-student experience impacts not only the student and the mentoring relationship that evolves between the pair, but also the future experiences of both participants and the students who will follow. Successful learning outcomes for the practicum student are highly dependent on the relationship and effectiveness of the precepting relationship. The online Preceptor Certification program offers a convenient way to provide important professional development for preceptors, and systematizing the training of preceptors within established program policies helps to ensure a more standardized experience for all participants. The Administrator-in-Training experience is an essential educational component that serves as an important transition between the student and their inaugural leadership role, and it is critical to both the short- and long-term success of potential administrators. As the need for health and aging service administrators and continues to grow, it is critical that academic programs work closely with administrative preceptors to prepare and support them in their role, to ensure that the leaders of tomorrow are well prepared for the challenges they will face. APPENDIX A State Licensing Board Requirements for Nursing Home Administrator Preceptors Preceptor Training Offered (Y/N) Preceptor Training Required

State

Preceptor Requirements

Type of Training

CEU's included

Cost

Alabama

The preceptor must be of morale character. The preceptor must not supervise training of his/her immediate family. Licensed in Alaska, employed at the practicum site, weekly supervisory conference with AIT Licensed in Arizona, completion of preceptor training

N

N/A

N

N/A

N/A

Alaska

N/A

N/A

N/A

N/A

N/A

Arizona

Y

6 hours Offered by Office of Long Term Care

Y

6

Varies

Arkansas

Licensed in Arkansas, completion of preceptor training

Y

Y

N/A

N/A

California

Licensed in California, practiced for 2 years in CA or 4 years as assistant administrator Licensed in Colorado, practiced for 3 years in CO, only 1 student at a time N/A

N/A

N/A

N/A

N/A

N/A

Colorado

N/A

N/A

N/A

N/A

N/A

Connecticut

N/A

N/A

N/A

N/A

N/A

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State

Preceptor Requirements

Preceptor Training Offered (Y/N) N/A

Type of Training

Preceptor Training Required

CEU's included

Cost

Delaware

Licensed in Delaware, practiced for 2 years in Delaware Licensed in Florida, practiced for 3 years in Florida, take a 6 hour course Licensed in Georgia, employed fulltime at practicum site, practiced for 5 years as an administrator at an approved site N/A Licensed in Idaho, practiced 2 consecutive years, completed 6 hour preceptor coursed, recertified every 10 years N/A Licensed in Indiana, attended a preceptor program within 5 years, worked as an administrator 2 of the last 3 years, can only have one student at a time Licensed in Iowa, practiced for 2 years, present in facility at least 75% of the time, cannot be related to student Licensed in Kansas, practiced for 3 years or 5000 hours of experience, full time at practicum site, limit 2 students at a time N/A N/A Licensed in Maine, 5 years of experience, completed preceptor training with last 3 years

N/A

N/A

N/A

N/A

Florida

Y

In class

Y

6

Varies

Georgia

N

N/A

N

N/A

N/A

Hawaii

N/A

N/A

N/A

N/A

N/A

Idaho

N/A

N/A

N/A

N/A

N/A

Illinois

N/A

N/A Online course through IHCA

N/A

N/A

N/A

Indiana

Y

N/A

N/A

N/A

Iowa

N/A

N/A

N/A

N/A

N/A

Kansas

N/A

N/A

N/A

N/A

N/A

Kentucky Louisiana

N/A N/A

N/A N/A

N/A N/A

N/A N/A

N/A N/A

Maine

N/A

N/A

N/A

N/A

N/A

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State

Preceptor Requirements

Preceptor Training Offered (Y/N)

Type of Training

Preceptor Training Required

CEU's included

Cost

Maryland

Licensed in Maryland for at least 1 year, employed fulltime 2 of the past 3 years, completion of preceptor certification course Licensed in Massachusetts, practiced for 5 years immediately preceding, work fulltime in practicum site, meet with student at least weekly, submits reports to the licensing board N/A Licensed in Minnesota, practiced for 2 years, cannot supervise a relative Licensed in Mississippi, practiced for 3 years in Mississippi, preceptor must be certified, evaluate students at 3 and 6 months, can have 2 students, must work within 100 miles of practicum site Licensed in Missouri, practiced for 3 years, completion of a preceptor certification course Licensed in Montana Licensed in Nebraska, practiced for 2 years Licensed in Nevada, practiced for 2 years Licensed in New Hampshire, practiced for 5 years Licensed in New Jersey, practiced for 2 years, completion of preceptor course

Y

Certification course

Y

N/A

N/A

Massachusetts

N/A

N/A

N/A

N/A

N/A

Michigan

N/A

N/A

N/A

N/A

N/A

Minnesota

N/A

N/A

N/A

N/A

N/A

Mississippi

N/A

N/A

N/A

N/A

N/A

Missouri

Y

In class

Y

6 CEUs

$350 (new) $150 (returning) N/A Varies from program to program N/A

Montana

Y

N/A

N/A

N/A Course must be at least 8 CEUs N/A

Nebraska

Y

In class

Y

Nevada New Hampshire

N

N/A

N

N/A

N/A

N/A

N/A

N/A

New Jersey

N/A

N/A

Y

N/A

N/A

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State

Preceptor Requirements

Preceptor Training Offered (Y/N) N/A

Type of Training

Preceptor Training Required N/A

CEU's included

Cost

New Mexico

N/A

N/A

N/A May earn CEUs for precepting N/A

N/A

New York

Approved by the Board

N/A

N/A

N/A

N/A

North Carolina

Licensed in North Carolina, 3 years of experience, preceptor orientation Licensed in North Dakota, 1 year of experience in North Dakota and 3 years experience overall, completion of a preceptor training course, and at least one year as a North Dakota nursing home administrator Licensed in Ohio, 2 years of experience in the last 5 years, completion of preceptor training course Licensed in Oklahoma, 2 years of experience, completion of preceptor training seminar, provide board notice of student’s completion Licensed in Oregon, 3 years of experience, completion of preceptor training within 3 years N/A N/A Licensed in South Carolina, 3 years of experience, employed at practicum site, worked for 2 year in facility that accepts Medicare and Medicaid Licensed in North Dakota for 4 years

N/A

N/A

N/A

N/A

North Dakota

N/A

N/A

Y

N/A

N/A

Ohio

Y

N/A

Y

N/A

N/A

Oklahoma

N/A

N/A

Y

N/A

N/A

Oregon

Y

N/A

Y

N/A

N/A

Pennsylvania Rhode Island

N/A N/A

N/A N/A In person training course; Required every 3 years N/A

N/A N/A

N/A N/A

N/A N/A

South Carolina

Y

Preceptors may obtain CE hours

Depends

Varies

North Dakota

N/A

N/A

N/A

N/A

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State

Preceptor Requirements

Preceptor Training Offered (Y/N) N/A

Type of Training

Preceptor Training Required

CEU's included

Cost

Tennessee

Licensed in Tennessee for 3 years, completion of preceptor course Licensed in Texas for 2 years, 5 years of experience, completion of preceptor training, work full time at practicum site, meet with student regularly Licensed in Utah, 3 years of experience, work fulltime at the practicum site, no more than 2 students at a time Licensed in Vermont, 5 years of experience Licensed in Virginia, employed in a training facility for 1 of the past 4 years Licensed in Washington, full time at practicum site, complete preceptor training, weekly meetings, can supervise 2 students at a time Licensed in West Virginia for 3 years and practiced in West Virginia the preceding year, approved by board as preceptor N/A Licensed in Wyoming

N/A

Y

N/A

N/A

Texas

N/A

N/A

Y

N/A

N/A

Utah

N/A

N/A

N/A

N/A

N/A

Vermont

N/A

N/A

N/A

N/A

N/A

Virginia

N

N/A

N

N/A

N/A

Washington

N/A

N/A

Y

N/A

N/A

West Virginia

N

N/A

N

N/A

N/A

Wisconsin Wyoming

N/A N

N/A N/A

N/A N/A

N/A N/A

N/A N/A

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Hautala, K. T., Saylor, C. R., & O'Leary-Kelley, C. (2007). Nurses' perceptions of stress and support in the preceptor role. Journal for Nurses in Staff Development, 23, 64-70. Institute of Medicine. (2001). Quality of care in nursing homes. Washington, DC: National Academy Press. Irby, F. (1994). What clinical teachers in medicine need to know. Academic Medicine, 69(5), 333-4. Johs-Artisensi, J. & Olson, D. (2012). Advancing Practices to Enhance the Field Experience of Developing Long Term Care Administrators, White Paper, The Commonwealth Fund and NAB Foundation. Kaviani, N., & Stillwell, Y. (2000). An evaluative study of clinical preceptorship. Nurse Education Today, 20, 218– 226. Kleffner, J.H. (2010). Becoming an Effective Preceptor, The University of Houston, Texas Southern University, Texas Tech Health Science Center, & The University of Texas at Austin College of Pharmacies. Kotter, J. P. & Cohen, D. (2002). The Heart of Change. Boston: Harvard Business School Press. Kulus, J. (2012). Getting Ready For QAPI. Provider, November 2012 (http://www.providermagazine.com/) Lambert, V., & Glacken, M. (2005). Clinical education facilitators: A literature review. Journal of Clinical Nursing, 14, 664-673. Lindner, R. (2007) Testimony to National Commission for Quality Long-Term Care. National Board of Examiners for Nursing Home Administrators. Washington, DC: (www.nabweb.org). MAHEC Office of Regional Primary Education. (2001). The Effective Preceptor. Monograph resulting from HRSA Family Medicine Training Grant (http://www.mahec.net/pdp/default.aspx). Mezey M., Mitty, M. & Burger S. (2007). Rethinking Teaching Nursing Homes: Potential for Improving Long-Term Care, The Gerontologist, 48(1), 8-15. NAB Domains of Practice. (2008). National Association of Boards of Examiners of Long Term Care Administrators. NIST. (2012). Baldrige national quality program criteria for performance excellence . Gaithersburg, MD: NIST (www.baldrige.nist.gov). Olson, D., Lester, S. W., Eide, D. B., & Blasko, J. (2010). Exploring a Mentoring Approach and Model for the Health and Aging Services Administration Profession. Leadership & Organizational Management Journal, 2010 (1), 30-37. Pulsford, D., Boit, K., & Owen, S. (2002). Are mentors ready to make a difference? A survey of mentors' attitudes towards nurse education. Nurse Education Today, 22, 439-446. Salsberg, E., Langelier, M., & Wing P. (2004). A legal practice environment index for nursing home administrators in the fifty states. A study funded by Commonwealth Fund.

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Schaubhut, R. & Gentry, J. (2010). Nursing preceptor workshops: partnership and collaboration between academia and practice. Journal of Continuing Education for Nursing, 41(4):155-62. Senge, P. (1990). The Fifth Discipline. New York: Double Day Publishing. Siegel, E. (2009). Reaching peak performance with education, training, and experience, research , Presentation to Winter Marketplace, American College of Health Care Administrators, December Las Vegas, NV. Singh, D. A., R. L. Amidon, L. Shi, and M. E. Samuels. (1996). Predictors of quality of care in nursing facilities. Journal of Long-Term Care Administration 24(3): 22-26. Tellis-Nayak, V. (2007). The Satisfied but Disenchanted Leaders in Long-Term Care: The Paradox of the Nursing Home Administrator, Seniors Housing & Care Journal. Vrba, J.F. (1995). The ‘grass roots’ training of a young administrator. Nursing Homes: Long Term Care Management, 44(3), p. 20. Wieland, D. M., Altmiller, G. M., Dorr, M. T., & Wolf, Z. R. (2007). Clinical transition of baccalaureate nursing students during preceptored, pregraduation practicums. Nursing Education Perspectives, 28, 315-321. Yonge, O., Myrick, F., Billay, D., & Luhanga, F. (2007). Preceptorship and mentorship: Not merely a matter of semantics. International Journal of Nursing Education Scholarship, 4, Article 19.

Jennifer Johs-Artisensi Health Care Administration Program University of Wisconsin – Eau Claire johsarjl@uwec.edu LaNette Flunker Health Care Administration Program University of Wisconsin – Eau Claire Douglas Olson Health Care Administration Program University of Wisconsin – Eau Claire

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SOCIAL SERVICE MANAGEMENT CAREER PRIMER: WHAT GRADUATE SCHOOL WON’T TEACH YOU
Kevin C. Flynn, The University of Scranton Daniel J. West, Jr., The University of Scranton

ABSTRACT Many people begin their careers in social service with the benefit of an impressive education and a genuine desire to serve others. However, aspirations and textbook instruction will not teach what can only be learned through experience. There are three things to reflect on, which are borne from direct work in the field: 1.Humility is the underlying virtue that can ensure a successful career in social services. Managers need to learn humility in order to deal effectively with clients and patients. Moreover; they need to stay humble throughout their career. Many of us are taught that the fall from pride occurs when we refuse to consider we have something new to learn. True humility is the perfect remedy for pride, which can adversely affect patients, colleagues and subordinates. Social service careers are actually a vocation, which almost never provide the recognition one expects or deserves. 2.Experience is the best teacher, but only occurs if one learns from their mistakes. All social service managers need to develop an ongoing relationship with a mentor who can guide them through challenges to make the right decisions. Managers are paid to think and must exercise their experience to develop solutions and answers instead of cataloguing more questions. Managers who possess an authentic passion for serving others are more likely to improve their performance. 3.The core curriculum of any social service degree program can never predict the exact type of patient experiences one will encounter. Many patients suffer from poverty of spirit, which manifests itself in unstable behavior. Managers should never lose their capacity for surprise because they might be missing an opportunity to learn how to adapt and become a better leader.

Kevin C. Flynn kevin.flynn@scranton.edu Department of Health Administration & Human Resources The Panuska College of Professional Studies The University of Scranton Scranton, PA 18510 Daniel J. West, Jr., daniel.west@scranton.edu Department of Health Administration & Human Resources The Panuska College of Professional Studies The University of Scranton Scranton, PA 18510

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REFORMATION OF HIGHER EDUCATION SYSTEM IN COUNTRIES FROM CENTRAL AND EASTERN EUROPE: STRUCTURAL IMPACTS OF THE BOLOGNA PROCESS
Cristinel Mîinea, University of Scranton Daniel West, Jr., University of Scranton

ABSTRACT The fall of the communist regimes in Central and Eastern Europe in 1989 marked the beginning of an ample reform process that marked the return to the social values of democratic societies. Higher education has gone through an extensive reorganization with the initial intent to restore academic autonomy and separation of higher education institutions from government tutelage. The joint declaration of 27 European Ministers of Education in 1999 signaled a new direction in reforming higher education in order to create the European Higher Education Area, a geographic area addressing concerns about increased labor mobility in the European market. The political process that ensued to the Bologna Declaration was enthusiastically embraced by Central and Eastern Europe countries, as an opportunity to reaffirm their commitment to European values. This presentation examines evolution of the structural changes of higher education for countries from Central and Eastern Europe - Bulgaria, Czech Republic, Hungary, Poland, Romania and Slovak Republic. It also analyzes their convergent efforts to implement harmonization and coordination objectives instituted by the Bologna process.

Cristinel Mîinea, Ph.D., Department of Health Administration and Human Resources The University of Scranton 415 McGurrin Hall Scranton, PA 18510 Tele: 570 941-4350; Fax: 570 941-5882 Daniel West, Jr., Ph.D. Department of Health Administration and Human Resources The University of Scranton 415 McGurrin Hall Scranton, PA 18510 Tele: 570 941-4126; Fax: 570 941-5882

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DEVELOPING A SUCCESSFUL MHA STUDENT MENTOR-MENTEE PROGRAM
Aliya Shaikh, University of Scranton Daniel J West, Jr., University of Scranton

ABSTRACT A student mentor program can impact the overall experience of an academic program and establishes a connection between students. It creates a platform for students to ask specific questions, learn more about the curriculum and professional opportunities and compare tips on how to approach institutions for career building positions. Topics such as conducting a residency search, finding an external mentor, and navigating through academic projects are often stressful components of the MHA curriculum. This stress and confusion can be reduced by engaging students to actively communicate and utilize university resources through the mentor program. Future opportunities exist for growth and expansion of the mentor programs within an existing or newly established MHA program. Key factors to successful integration of a student mentor-mentee program are open communication and transparency between students, program chair and faculty. This presentation compares past methods of implementation with newer approaches. In addition, the various models of mentor programs will be discussed within the academic environment of an MHA program.

Aliya Shaikh 436 Gravel Pond Road Clarks Summit, PA 18411 Aliya.shaikh@scranton.edu Daniel J. West, Jr., Ph.D., FACHE, FACMPE Professor and Chairman Department of Health Administration & Human Resources The University of Scranton Daniel.west@scranton.edu

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NURSING EDUCATION IN SAUDI ARABIA: CHALLENGES AND FUTURE IMPLEMENTATIONS
Adel S. Bashatah, College of Nursing, King Saud University, Saudi Arabia. Osama Samarkandiy, Faculty of Applied Medical Science, Al Baha University, Saudi Arabia.

ABSTRACT Nursing in Saudi Arabia has established in the begging of 1954 under the administration of the Ministry of Health (MOH). During the past 50 years, nursing has faced many obstacles and challenges to reform nursing among Saudi community. Now, according to the ministry of health, the number of the majority of nurses are holding a diploma degree exceeds 10,000 nurses with diploma degree. In response to the challenges, and in order to improve the quality of nursing education in the country, the Ministry of Health (MOH), in collaboration with Ministry of Higher Education (MOHE) have recommended that Baccalaureate of nursing is the minimum required degree for professionalism, and the entry level to the practice. Yet, with shortage of nurses, qualified preceptors, and difficulties of clinical settings, the poor outcome of nursing practice has affected nursing image. Moreover, the revolution of higher education in health specialties including nursing has been emerged to reach up to 25 nursing program with average of 1000 students per year. This paper will address the history of Saudi nursing education identifying the challenges of creating qualified new nurses to be ready in the field of care. Furthermore, it will explore the current nursing workforce and ways to improve nursing images at Saudi Arabia.

Adel S. Bashatah Assistant Professor Department of Nursing Administration & Education College of Nursing King Saud University Saudi Arabia Osama Samarkandiy Assistant Professor Department of Nursing Faculty of Applied Medical Science Al Baha University Saudi Arabia

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TRACK CHANGES IN HEALTHCARE PROVIDERS AND ACCESS

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EXPANDING THE CAREER PATHWAYS OF DENTAL HYGIENISTS: ADDING HEALTHCARE MANAGEMENT
Susan I. Duley, R.D.H., Ed.D., L.P.C., West Coast University Peter G. Fitzpatrick, Ed.D., R.Ph., Clayton State University

ABSTRACT The oral health care delivery system in the United States is confronted with many issues and problems. One major issue is access to care. New emerging models for addressing this problem in a cost effective manner are presented in this paper. As new oral health practitioners develop it is essential that these providers have knowledge and skills related to healthcare management. This article presents educational models that address this concern and would work to support the success of the new oral health care practitioner.

Introduction: The traditional education models for healthcare practitioners have been fairly singularly focused. They are structured to prepare their graduates to be able to fulfill the scope of practice for their respective professions and not cross over into other areas of delivery. Historically this model has worked as long as the demand for any particular group of practitioners has exceeded the supply. The recent trends in the profession of dental hygiene indicate that in fact the supply of hygienists is exceeding the demand (Dentistry I Q, 2011). Clearly, the implications of this trend will be the existence of an increasing number of unemployed and underemployed hygienists. A very reasonable argument can be made that programs that prepare students to become dental hygienists have a fiduciary responsibility to these students. As such, this responsibility would be obviated by collecting their tuition dollars and then issuing them diplomas which they can use to fan themselves as they stand on the unemployment lines. If these programs are taking their responsibility seriously, they must look at alternative educational paradigms for their students. The time has arrived when we educate and train dental hygienists to have expanded scopes of practice, and at the same time incorporate training that will support all aspects of this expanded role. The model that this paper is supporting is one that will enhance the theoretical and clinical competencies of hygienists and at the same time give them a thorough knowledge base in healthcare management. The vision is to have hygienists practicing a wider array of oral healthcare services and possess the delivery management skills to make the model as efficient as possible. Currently there are programs is some universities where dental hygienists receive the basic dental hygiene program and the opportunity to take a prescribed minimum number of healthcare management courses to receive a double major. Both degrees, while certainly useful, provide only a somewhat truncated opportunity to go beyond the traditional dental hygienist practice settings. What is needed is a completely integrated approach that will allow advanced dental hygiene practitioners to work not only with a greater level of autonomy, but also with the entrepreneurial skills to succeed with this independence. OVERSUPPLY AND LACK OF ACCESS One of the more glaring paradoxes of the healthcare delivery system of the United States is that we currently have a surplus of dental hygienists (see Figure 1).

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State Number of Dental Schools 2011 California Colorado Florida Illinois Louisiana Maine Michigan Minnesota Pennsylvania Texas Virginia Washington Total 6 1 3 3 1 0 2 1 3 3 1 1 25

Number of Dental Graduates 2011

Number of Dental Hygiene Programs 2011

Number of Dental Hygiene Graduates 2011 620 67 467 346 67 67 335 231 315 541 205 212 3,473

Dental Hygiene Jobs (indeed.com) May, 2011

591 73 186 112 53 0 196 104 319 273 95 53 2,055

25 3 21 13 3 2 13 10 12 23 6 9 140

53 29 64 10 1 2 11 5 12 82 14 29 312

Figur e1. Denta l Hygie ne and Denta l Gradu ates in Twel ve States

Total number of dental hygiene programs in the U.S. in May, 2011 – 323 Total number of DDS/DMD programs in the U.S. in May, 2011 – 60

Even though we have a surplus of dental hygienists we have large numbers of people with limited access to dental care. Notable among the underserved populations are certain groups of children and many of our elderly (Tomar & Reeves, 2009; Ku, 2009). Non-Hispanic black and Mexican American, and all children living in households at or close to poverty levels are especially vulnerable (Tomar & Reeves, 2009). Adult populations have similar problems of access to adequate dental care. This is particularly true of adults who are residents in long-term care facilities (Guay, 2005). The lack of access in both populations is exacerbated by the dramatic drop off of dentists who are accepting Medicaid (Duley & Fitzpatrick, 2012). Expanding the scope of practice for dental hygienists would go a long way to solve these access problems. Dental hygienists, who would practice on a model similar to the nurse practitioner one, would provide venues for care and work in alternative practice settings.

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In 2008 the American Dental Hygienists’ Association (ADHA) adopted “Competencies for the Advanced Dental Hygiene Practitioner” (ADHP). Since that time several models have developed to address oral health care needs (see Figure 2). Figure 2. ADHA Oral Health Care Workforce Oral Health Care Workforce – Current and Proposed Providers Advanced Dental Hygiene Practitioner (ADHP) Alaskan Dental Health Aide Therapist (DHAT) Minnesota Dental Therapist /Advanced Dental Therapist (DT/ADT) Community Dental Health Coordinator (CDHC)

Developed by

American Dental Hygienists’ Association www.adha.org/adhp

Alaska Native Tribal Health Consortium (ANTHC) – Community Health Aide Program www.anthc.org

Minnesota State Statute and Rules www.dentalboard.state.mn.us

American Dental Association www.ada.org

Stage of Development

ADHP educational competencies were finalized in 2008. The first educational program based on ADHP competencies began in Fall 2009. Master’s level education at accredited institution; open to individuals currently licensed as dental hygienists who have a Bachelors degree

DHAT practice began in Alaska in 2004. The first graduates from the U.S.‐ based DENTEX program began practice in 2008.

Educational programs for the DT (at the University of Minnesota School of Dentistry) and ADT (at Metropolitan State University) began in Fall 2009.

Curriculum complete and initial educational pilot program began in Winter 2009.

Education/ Training

24 month program administered by ANTHC in partnership with the University of Washington DENTEX program

DT – minimum Baccalaureate degree ADT – Master’s degree

Completion of 18 months of training.

Regulation/ Licensure

Providers are already state licensed dental hygienists. ADHP is envisioned to be state licensed and

Providers are certified and regulated by Indian Health Service’s Community

Providers required to hold state license; can be dually licensed as a dental hygienist and administer dental hygiene scope.

Providers envisioned to be certificated; no formal state licensure

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regulated.

Health Aide Program

Proposed Settings

Community and public health settings, possibly private practice

Remote Alaskan villages

Settings that serve low‐ income and underserved patients, or are located in designated dental health professional shortage areas. DT – General or indirect supervision depending on service ADT ‐ Collaborative management agreement with dentist, presence of a dentist not required for most services

Community and public health settings

Proposed Supervision

Collaborative arrangement envisioned with strong communication and referral networks; presence of a dentist not required; use of teledentistry.

Remote/general supervision of a dentist; presence of a dentist not required; use of teledentistry

Onsite or general supervision, depending on service

Oral Health Care Workforce – Current and Proposed Providers Advanced Dental Hygiene Practitioner (ADHA) Alaskan Dental Health Aide Therapist (DHAT) Minnesota Dental Therapist /Advanced Dental Therapist (DT/ADT) Community Dental Health Coordinator (CDHC)

Other Relevant Information

ADHA convened an ADHP Task Force, an ADHP Advisory Committee, and sought input from approximately 200 stakeholder groups in developing ADHP competencies. Several national stakeholders, including the National Rural Health Association and National Rural Education

Formal evaluations of DHAT practice have demonstrated that irreversible dental procedures can be safely and effectively delivered by non‐dentists.

Minnesota is the first state to legislate new, mid‐level oral health providers, the DT and ADT. A thirteen‐member workgroup, comprised of various stakeholders, made recommendations on scope, supervision and education.

The ADA convened an internal workgroup to develop CDHC curriculum

Dental therapist models are prevalent in more than 50 counties internationally.

The ADT education program at Metropolitan State University is guided by the ADHP competencies, competencies for the New General Dentist, and

The ADA and ADA Foundation have committed nearly $7 million to fully fund CDHC pilot programs

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Association, support the ADHP model

requires students to be licensed and actively practicing as a dental hygienist.

over five years.

Language in the report accompanying the FY 2006 Labor/HHS Appropriations encourages federal agency support of the ADHP Metropolitan State University is the first education program to begin guided by ADHP

DHAT providers are often Alaskan Natives who reside or grew up in the remote villages they serve.

The DT program at the University of Minnesota does not require an oral health‐ based baccalaureate degree or licensure as a dental hygienist for admission to the program.

The University of Oklahoma, UCLA (in conjunction with Salish Kootenai College in Montana) and Temple University in Philadelphia are CDHC pilot sites.

The Kellogg Foundation began a comprehensive two‐year study to evaluate effectiveness in 2008.

Initial graduates of DT/ADT programs are anticipated to enter the workforce in mid‐ 2011.

CDHC trainees are recruited from the communities the provider is intended to serve.

competencies. Eastern Washington University and the University of Bridgeport Fones School of Dental Hygiene have formal commitments to begin ADHP programs.

Oral Health Care Workforce – Current and Proposed Providers Advanced Dental Hygiene Practitioner (ADHA) Dental Health Aide Therapists in Alaska Therapist ‐ Oral health and nutrition Education ‐ Full range of dental hygiene preventive ‐ Oral health and nutrition education ‐ Sealant placement ‐ Oral health and nutrition education ‐ Sealant placement ‐ Sealant placement (ADA) ‐ Oral health and nutrition education Minnesota Dental Therapist/Advanced Dental Community Dental Health Coordinator

Preventive Scope

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services, including complete prophylaxis, sealant placement, fluoride treatments, caries risk assessment, oral cancer screenings ‐ Expose radiographs ‐ Advanced disease prevention and management therapies (e.g. chemotherapeutics) Periodontal Scope Restorative Scope ‐Provide non‐surgical periodontal therapy. ‐ Preparation and restoration of primary and permanent teeth ‐Placement of temporary restorations ‐ Placement of pre‐formed crowns ‐Temporary recementation of restorations ‐Pulp capping in primary and permanent teeth ‐Pulpotomies on primary teeth ‐ Uncomplicated extractions of primary and permanent teeth ‐Place and remove sutures ‐Provide simple repairs and adjustments on removable prosthetic appliances

‐ Fluoride treatments ‐ Coronal polishing ‐ Prophylaxis ‐ Expose radiographs

‐ Fluoride varnishes ‐ Coronal polishing ‐ Oral cancer screenings ‐ Caries risk assessment ‐ Expose radiographs

‐ Fluoride treatments ‐ Coronal polishing ‐ Scaling for Type I Periodontal patients ‐ Collection of diagnostic data

‐Provide non‐surgical periodontal therapy ‐ Restorations of primary and permanent teeth ‐ Placement of pre‐formed crowns ‐ Pulpotomies ‐ Non‐surgical extractions of primary and permanent teeth

N/A

N/A

‐ Restorations of primary and permanent teeth ‐ Placement of pre‐formed crowns ‐ Placement of temporary crowns ‐ Extractions of primary teeth ‐ Nonsurgical extractions of permanent teeth (ADT only) ‐ Direct /Indirect Pulp Capping ‐ Pulpotomies on primary teeth ‐ Atraumatic restorative therapy

‐ Palliative temporization (with hand instrumentation only) ‐ Placement of temporary restorations

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Additional Competencies

‐ Local anesthesia and nitrous oxide administration ‐ Diagnosis within scope of practice ‐ Limited prescriptive authority (for prevention, infection control and pain management) ‐ Triage ‐ Case management ‐ Healthcare policy and advocacy ‐Health promotion for individuals, families, communities ‐ Patient referral

‐ Local anesthesia administration ‐ Patient referral

‐ Local anesthesia nitrous oxide administration ‐ Dispense analgesics, anti‐inflammatories, and

‐ Development and implementation of community‐based oral health programs

antibiotics ‐ Provide, dispense, administer analgesics, anti‐inflammatories, and antibiotics (ADT only) ‐ Assessment and treatment planning as authorized by collaborating dentist (ADT only) ‐ Repair of defective prosthetic devices ‐ Placement and removal of space maintainers ‐ Stabilization of reimplanted teeth

‐ Case coordination ‐ Administrative/office management procedures ‐ Triage

American Dental Hygienists’ Association www.adha.org Last modified January 2010

MANAGEMENT OF ORAL HEALTHCARE DELIVERY Of the models presented, the Advanced Dental Hygiene Practitioner (ADHP) provides courses needed for healthcare management in their sample curriculum (ADHA, 2008). These courses include: 1. Healthcare Policy, Systems and Financing for Advanced Practice Roles 3 credit hours This course prepares the practitioner to influence and interpret public health policy and recognize its role as a determinant of health. Students develop skills; participate in health policy development and political action, healthcare financing and delivery, and in the measurement of care delivery and practitioner effectiveness. This course focuses on the political, ethical, societal, and professional issues in advanced practice. 2. Management of Oral Healthcare Delivery 3 credit hours Theories will be used to develop skills in negotiation and conflict resolution. The student examines current and emerging advanced practice issues including entrepreneurship, fundamentals of tax laws, overhead costs, benefit packages, billing and negotiation with third party payer and facilities. Principles of management and community partnerships in clinical settings will be emphasized with focus on leadership skills, coalition building, and constructive use of power, influence, and politics. 3. Cultural Issues in Health and Illness 3 credit hours

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This course explores cultural issues in healthcare delivery that are designed to enhance the delivery and quality of healthcare offered to diverse and disadvantaged communities. Topics will include how patient and provider ethnicity, socioeconomic status, education, and cultural competence affect health, illness and the delivery of care. The domains and competencies in the curriculum include: Domain II: Healthcare Policy and Advocacy The advanced dental hygiene practitioner contributes to health policies that address disparities in oral health and access to care for the underserved. The practitioner supports and applies health policy at the institutional, local, state, regional, and national levels. Competencies: 1. Healthcare Policy 1-1 Articulate health policies and advocate change from the perspectives of the underserved and other stakeholders. 1-2 Integrate oral healthcare within other health and social services organizations. 1-3 Promote the role of the advanced dental hygiene practitioner in the healthcare system. 2. Advocacy 2-1 Identify community resources to increase access to care (e.g., transportation, interpretation, translation). 2-2 Advocate for the underserved through community-based committees, boards, or task forces. 2-3 Support legislative and regulatory efforts that enhance the access to effective oral healthcare. 2-4 Advocate for quality, cost-effective oral healthcare for the underserved.

Domain III: Management of Oral Healthcare Delivery The advanced dental hygiene practitioner integrates practice management, finance principles, and health regulations to analyze, design and develop initiatives that will improve clinical outcomes and the quality and safety of care. The practitioner demonstrates effective business skills for healthcare and practice environments. Competencies: 1. Practice Management 1-1 Create business plans for oral healthcare delivery that enhance the fiscal viability of a practice. 1-2 Integrate principles of human and material resource management to create an efficient, effective, and equitable practice environment. 1-3 Adhere to reimbursement guidelines and regulations. 2. Quality Assurance 2-1 Implement protocols for records management, occupational and environmental safety, and periodic systems review. 2-2 Maintain accountability for quality to ensure patient safety and minimize liabilities. 2-3 Implement principles of continuous quality improvement. Fiscal Management 3-1 Design and implement methods to monitor cost-effectiveness of care. 3-2 Partner with dentists, third-party providers and the government to establish fee schedules, preauthorization protocols, and direct reimbursement strategies. 3-3 Seek financial advice and sources of funding for operational expenses in the delivery of oral healthcare.

3.

As with any business a comprehensive knowledge of the workings of the business, as well as a thorough understanding of the environment in which the business operates, is essential for success. This also clearly applies to healthcare in general and dental services in particular. The delivery model envisioned requires that dental hygienists not only have an expanded scope of practice, but also possess adequate knowledge of the principles and practice

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management of oral healthcare delivery. Thus the development and integration of expanded practice skills along with the study of a variety of healthcare management courses would be the norm. The advanced dental hygiene practitioner model would offer a program of study that would provide this integration. From the healthcare management perspective the coursework would include healthcare finance and economics. Other topics presented would include human resource management, healthcare marketing, managerial epidemiology, primary and long-term care, administration of managed care, legal issues in healthcare, and healthcare policy. The exposure to these topics would enable the advanced practice dental hygienists to develop the business acumen to successfully operate practice settings. SUMMARY There has been much conversation about the need to improve healthcare delivery and outcomes in the United States. In the opinion of the authors one of the most significant causes of failure is the lack of integration within the healthcare delivery system. Any meaningful change will necessitate the establishment of delivery that is carefully structured to allow all levels of care to share information and be aware of what is being done and prescribed at all levels. Closely on the heels of this integration is the need to reach our underserved populations. Again, different and innovative approaches are essential. We must confront the access problem by making some fundamental changes in how we deliver care. Problems with access have been with us for an extensive period of time, and yet we are still discussing the problem and not solving it. Simply stating that we must improve access is not a solution. Our current healthcare delivery system is complex, expensive, and inefficient. Any major changes are fraught with political implications and partisan resistance. Operant wisdom maintains that Medicare and Social Security are the third rails of American politics, but we would suggest that major changes to healthcare can easily become the de facto third rail. To overcome these barriers we are suggesting incremental change that will potentially lead to overall change across all sectors. Our proposal in this paper is to revamp the practice model for a key practitioner group by expanding the scope of practice and building in integration in delivery into this expanded scope. Dental hygienists have largely been restricted in what they have been allowed to do by way of their scope of practice, regulated by state dental practice acts. In our estimation this has been an incredible waste of education and talent. By adding to their didactic and clinical education we envision an advanced dental hygiene practitioner modeled on the nurse practitioner paradigm. These hygienists will operate with supervised autonomy and be permitted to do a significant portion of the duties performed by dentists. They will work in clinics, medical offices, public health centers, and long-term care facilities where dental care is currently not available. The addition of healthcare management courses will provide the necessary understanding of the business of healthcare delivery and how to succeed in an entrepreneurial environment. This proposed model will also begin to address the previously mentioned need to integrate delivery. With the well-established linkages between oral and systemic health issues in hand what is needed are practitioners who understand these linkages and can use them to promote better outcomes. When an advanced practice hygienist goes into a long-term care facility and does oral assessments, she/he will be able to notify primary care physicians and other practitioners about the presence of oral markers indicating various systemic disorders. Not having these assessments done because of a lack of access would mean that this valuable diagnostic tool is absent and a great opportunity lost. It is also necessary because of the economics of healthcare delivery to develop alternative delivery strategies. With the Supreme Court’s decision to uphold most of the provisions of the Patient Protection and Affordable Care Act, many of the states have a difficult decision to make. If starting in 2014 they want to continue participation in the Medicaid Program, they will have to enroll all residents who have household incomes of 133 percent or less of the federal poverty guideline. For many states this will mean adding a significant number of enrollees. In many of these same states, their Medicaid programs are already in extremely difficult financial conditions. The additional enrollment may only be able to be achieved by cutting already low reimbursement rates. This will almost surely drive more providers out of the Medicaid program and even further exacerbate the access problem. Additional access models, therefore, must be planned and prepared.

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CONCLUSION Change is usually not easy, but in general the larger obstacle is the resistance to change. What we are proposing is not a catastrophic upheaval of the healthcare delivery system. Rather it is an approach that looks at available resources and implementing a plan to further develop these resources, and then put them to maximum use. The outcomes we believe will demonstrate how the dual problems of integration and access can be addressed. If even the longest journey must start with a first step, then the better development and utilization of dental hygienists could be the first step for truly comprehensive healthcare reform. REFERENCES Dentistry I Q, 2011, The Mood Out There: Dental hygienists comment on the impact of the economy on their careers, RDH, January 2011. Tomar, S.L., & Reeves, A.F. (2009). Changes in the oral health of U.S. children and adolescents and dental public health infrastructure since the release of the healthy people 2010 objectives. Academic Pediatrics, Nov/Dec 2009, V. 9, N. 6, pp. 388-396. ADHA, (2010) Governmental Affairs, Practice Issues, Charts, Oral Healthcare Workforce – Current and Proposed Providers. http://www.adha.org/governmental_affairs/downloads/Oral_Health_Care_Workforce_Chart.pdf http://wwwrdh.com/index/display/article-isplay/4713484933/articles/rdh/volume-31/issue-1/features/themood-out-there.html ADHA, (2008) ADHP, Competencies for the Advanced Dental Hygiene Practitioner, pp. 12-13. http://www.adha.org/downloads/competencies.pdf Duley, S.I., & Fitzpatrick, P.G. (2012). Dental hygiene practice and health care reform: taking advantage of opportunities, Journal of Management Policy and Practice, Spring 2012, V. 13, N. 1, pp. 107-112. Guay, A.H. (2005). The oral health status of nursing home residents: what do we need to know? Journal of Dental Education, V. 69, N. 9, pp. 1015-1017. Ku, L. (2009). Medical and dental care utilizations and expenditures under Medicaid and private health insurance. Medical Care Research & Review, V. 66, N. 4, pp. 1015-1017. Susan I. Duley, R.D.H., Ed.D., L.P.C. West Coast University Peter G. Fitzpatrick, Ed.D., R.Ph. Clayton State University

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Primary Care in the U.S.: A Preliminary Report of the Differential Impact of State Specific Scope of Practice Regulations to Access to Nurse Practitioners
Scott Stegall, Health Care Management, College of Business, Clayton State University, Morrow, GA Thomas McIlwain, Health Care Management, College of Business, Clayton State University, Morrow, GA Qiu Fang, Health Care Management, College of Business, Clayton State University, Morrow, GA Deborah Gritzmacher, Health Care Management, College of Business, Clayton State University, Morrow, GA Peter Fitzpatrick, Health Care Management, College of Business, Clayton State University, Morrow, GA

ABSTRACT Nurse practitioners (NPs) can provide 90% of the care provided by primary care physicians. If physicians ($163k per year) focused on intense cases and NPs ($92k per year) treated the remaining cases, the total cost of primary care diminishes. There is, however, considerable state-to-state variation in NP “scope of practice.” Reported are analyses of the county level “Area Resource File” estimating the decrease in NPs per 10,000 residents associated with states requiring physician supervision of NP practice compared with states allowing NPs to practice independently.

INTRODUCTION In 2009 the United States (U.S.) expended 17.4% of its gross domestic product on health, the highest level of 30 OECD countries reported with the second highest being the Netherlands with 12.0% (OECD, 2012). However, as much as $750 billion is considered health care waste; an amount that exceeds by over $100 billion the 2009 Department of Defense budget (IOM, 2012, p. S-8). This waste compares to employers and employees in other industrial countries spending only about 63% on health care compared to the U.S. (IOM, 2010, p. 71). Health care waste occurs not only in terms of money but also in lost lives with Starfield (2000) estimating over 200,000 deaths annually from iatrogenic causes. The U.S. also sees a much higher rate of amendable deaths (deaths that occur due to lake of timely and effective health care) than found in many European countries (Nolte and McKee, 2012). This occurs at a time when over 47 million lack health insurance in the U.S. (Smith, 2008). One component of this waste is using physicians to treat patients when mid-level providers such as nurse practitioners (NPs) and physician assistants (PAs) would be able to provide the same care. Bauer, J. (2010) reports that nurse practitioners can successfully substitute for medical services. The rate of substitution ranges from 25% in specialty areas to 90% in primary care with equivalent or better quality. Mecklenburg and Kaplan (IOM, 2010, p. 121) estimate that 50% of outpatient visits at Virginia Mason Medical Center could be performed by NPs and PAs. The potential savings associated with appropriate substitution is suggested with the 2008 average earnings for nurse practitioners at $92,000 and $162,500 for primary care physicians and internists (Bauer, J, 2010). The Association of American Medical Colleges (AAMC, 2012) estimates a 45,000 shortage of primary care physicians by 2020 and advocates for the increases in both medical school capacity and the release of Medicare funding of medical residencies. An alternative view is to consider this a shortage of not “primary care physicians” but of “primary care practitioners;” a term inclusive of physicians, physician assistants, nurse practitioners and other advance practice nurses. The ability of nurse practitioners to meet the growing demand for primary care services may be limited by state-by-state regulations. State regulatory boards define professional “scopes of practice” that delineate what activities licensed individuals may perform within a specific state. The scope of practice for NPs varies considerably across the states. In 2007, ten states and the District of Columbia allowed NPs to practice independently. These independent NPs are able to diagnose, order tests, refer and prescribe drugs without any physician involvement. In

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contrast, ten states allowed NPs to practice only under of the explicit supervision of a physician. In the remaining 30 states, the NP scope of practice fell between these extremes (Christian, Dower, & O'Neill, 2007). Two potential outcomes from limiting nurse practitioners’ scope of practice to less than their training are considered in this paper. The first is that potential employers of NPs operating in states limiting the NP scope of practice would hire other professionals (physicians) who would provide the scope of practice flexibility to meet patient demand for services but at a higher salary. The second is that NPs would prefer to work in states that allow them to fully utilize their training. Both outcomes suggest relatively more NPs in states with scopes of practice allowing independent practice than those states requiring physician supervision of NPs. If true, then scope of practice regulation may itself represent a barrier to needed primary care. The research question addressed in this paper is “Do counties in states providing NP independent p ractice have a greater number of NPs per 10,000 in county population than counties in states that required NPs to work under physician supervision?” DATA AND METHODS The core data for this research were obtained from the Area Resource File (ARF), which is a county specific database containing more than 6,000 variables on health facilities, professions, demographic and other variables (Area Resource File, 2012). Variables utilized from the ARF file include the 2010 values for the number of nurse practitioners and physician assistants (those with a national provider identifier (NPI)), MD/DO primary care physicians (exclusive of residents), the number of Federally Qualified Health Centers (FQHCs), the number of hospitals, and whether the county was rural, micropolitan, or metropolitan (2009 data). The presence of a FQHC is important in that these centers bring into a county NPs funded through the National Health Service Corps through a process outside the full influence of state based scope of practice. Also obtained was the 2010 county population census. The U.S. Census Bureau defines a micropolitan as a statistical area with an urban core between 10,000 but less than 50,000 residents. A metropolitan statistical area is one of 50,000 or more residents and areas classified neither as micro- or metropolitan are labeled “rural.” The raw number of NP, PA, and primary care physicians in a county was converted to a value representing the number of practitioners per 10,000 residents. Counties, and independent cities, with small populations are sensitive to this process of creating per 10,000 residents resulting in extreme outliers. In this study only counties within three standard deviations of the mean number of NPs per 10,000 residents were analyzed, reducing the sample size from 1272 to 1224. The 2007 study by Christian et al. was used to determine the scope of practice for NPs. Eleven states were identified as allowing NPs to practice independently: AK, AZ, DC, ID, IA, ME, MT, NH, NM, OR, and WA. Ten states require, to varying degrees, physician supervision of NP practice and they are: FL, MA, NE, NC, OK, PA, SC, TX, VA, and WI. Only counties in the lower 48 states (DC is excluded) represented by these two lists were analyzed. Four additional counties with missing values reduced the final sample size to 1220. The t-test and the linear regression from IBM SPSS Statistics version 20 were used to analyze the database. RESULTS AND LIMITATIONS The descriptive statistics are presented in Table 1. The mean number of NPs per 10,000 residents was 2.484. Similarly there are 2.179 PAs and 5.378 primary care physicians. Each county averaged slightly over 2 hospitals and 46.1% had at least one Federally Qualified Health Center. The statistical areas were split as 34.7% metropolitan, 21.5% micropolitan, leaving 43.8% as rural. The scope of practice was coded as “1” for physician supervision required and “3” for independent NP practice, allowing “2” to represent the mix scopes between. Since only “1” and “3” were used in this study, the mean of 1.553 indicates that 53.5% of the counties in the study were in states with independent NP practice allowed.

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Table 1: Descriptive Statistics Mean NP per 10k pop (trimmed at 3 std) NP Scope-Indp (Ref: Physician Supervise) Metropolitan Micropolitan Primary Physician per 10k pop PA per 10k pop Federally Qualified Health Center present Total Number Hospitals 2.484 1.553 .347 .215 5.378 2.179 .461 2.060 Std. Deviation 1.846 .895 .476 .411 3.204 1.979 .499 4.044 N 1220 1220 1220 1220 1220 1220 1220 1220

A t-test indicated a significant difference (at the 0.001 level) between the number of NPs per 10,000 population in counties in states allowing NPs to practice independently (2.91 per 10,000) and counties in states requiring physician supervision (2.32 per 10,000). This represents 20.3% fewer NPs in counties in states requiring physician supervision. The results of the linear regression analysis are presented in Table 2. The ANOVA is significant at the 0.001 level and the adjusted R squared is 0.212. The VIF indicates that collinearity is not an issue with this model. The constant is 0.661 NPs per 10,000 residents. There is not a significant difference in NPs per 10,000 between rural, micro-, and metropolitan areas. The largest standardized coefficient is associated with the number of primary care physicians in the county. For each additional physician per 10,000 residents, 0.194 NPs per 10,000 residents are added. The largest unstandardized coefficient is 0.492 additional NPs per 10,000 residents if a FQHC is present in the county which is suggestive of the ability of this program to place primary care practitioners into a community. Both PAs (0.081) and hospitals (0.051) are significantly associated with the increase in NPs in the community. Primary interest is in the coefficient associated with NP scope of practice. While controlling for the above variable, there is still a statistically significant increase in the number of NPs in counties in states allowing independent practices than those requiring physician supervision. The 0.176 NP per 10,000 residents is a 26.6% increase over the constant.

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Table 2: Linear Regression Coefficientsa with Independent Variable NP per 10k Population Modelb Unstandardized Coefficients Standardized Coefficients B (Constant) NP Scope-Independent .176 (Ref: Physician Supervise) Metropolitan (Ref: Rural) Micropolitan (Ref: Rural) Primary Physician per 10k pop PA per 10k pop FQHCc (Ref: No FQHC in county) Total Number Hospitals a. b. c. -.001 -.011 .194 .081 .492 .051 .117 .125 .016 .025 .100 .013 .000 -.002 .337 .087 .133 .112 -.005 -.086 12.333 3.242 4.928 4.029 .996 .932 .000 .001 .000 .000 .707 .828 .865 .899 .886 .834 1.414 1.207 1.156 1.112 1.128 1.200 .054 .085 3.244 .001 .939 1.065 .661 Std. Error .132 Beta 5.027 .000 t Sig. Collinearity Statistics Tolerance VIF

Dependent Variable: NP per 10k pop (trimmed at 3 std) ANOVA significant at 0.001 level; Adjusted R Squared 0.212; N=1220 Federally Qualified Health Center

There are several limitations to this study. First, although county level analysis is more sensitive than state level, county level still fails to detect the street level variation in access to care often found in some cities. Second, regional variation in the provision of care is not evaluated in this study. Often the four census regions of Northeast, Midwest, South, and West are used as dummy variables to control for this variation. In this study there were no physician supervised NPs in the West and no independent NPs in the South and this generated significant correlation in the independent variables. Third, the scope of practice for NPs continues to change with as many as 16 states in 2012 potentially being considered as independent practice states for NPs. Obviously the states included in such a dynamic environment may be in different stages of completing the response to the change in regulations. Finally, with an adjusted R squared of 0.212, it is obvious that this model is not fully specified. Future studies will include additional variables associated with the demographic characteristics of the county and search beyond the main effects with models including variable interactions and non-linear relationships. SUMMARY AND CONCLUSIONS Counties within states requiring physician supervision of NPs have available significantly fewer (20.3%, 2.32 vs. 2.91) NPs per 10,000 residents than counties in states that allow NPs to practice independently. Linear regression was utilized to hold constant the variables of the county being a metropolitan, micropolitan or rural, the number of primary care physicians per 10,000 residents, the number of physician assistants per 10,000 residents, whether there was a Federally Qualified Health Center within the county, and the number of hospitals located in the county. After controlling for these factors, counties in states that allow NPs to practice independently have 0.176

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more NPs per 10,000 residents than those counties where the state NP scope of practice requires physician supervision. These results suggest that a significant increase of the number of primary care “practitioners” is possible with changing the scope of practice of NPs to allow for their independent practice. The expanded use of NPs and PAs is not without critics. Liu and D’Aunno (2012) demonstrate that the model of care utilized in ambulatory settings can negate much of the salary savings if physician time is used to supervise and mid-level providers (NPs and PAs) spend more time with patients than what is supported by their lower salaries. Also, a significant movement of nurses into NP roles could also further aggravate the current shortage of RNs and the educational resources used to produce them (Potempa, Buerhaus, Auerbach, & Staiger, 2009). The American Academy of Family Physicians (AAFP) strongly advocates for “physician -led team for every patient” based upon its view of the relative lack of training of mid -level practitioners compared to physicians (AAFP, 2012). Obviously, the AAFP is advocating for a more limited scope of practice for nurse practitioners. The issues of access to care in the U.S. healthcare system are extremely complex. It is generally recognized that access to healthcare services is innately tied to costs/expenditures and quality of care issues (Feldstein, 2012). Cost, quality, and access have been the values used to assess U.S. healthcare policies at least since the early ‘70s (Barton, 2010). As access to care is expanded, costs/expenditures will increase and quality in terms of outcomes may increase because medical conditions are treated earlier in the disease process. “Quality” is care that is provided in a timely manner, is patient centered, delivered equitably, and is delivered efficiently (IOM, 2001). Quality might decrease because of over-utilization of care that is not needed (Goldman & McGlynn, 2005) and may occur because of lack of capacity in the system to care for the numbers of people seeking needed care. The IOM defines quality as when people “get the care they need” and “need the care that they receive” (IOM, 2001). But are physicians the only profession that can provide for this need? If the needed care is provided by a resource more expensive than an alternative resource, the decreasing marginal returns on limited resources potentially reduce quality due to the lack of access. The case for NPs is one of value —equal quality provided at lower costs that allows more access for the same cost. Ironically, the analyses in this paper suggest that the state regulations limiting the scope of practice for NPs in the name of quality appear to be associated with a decrease in access to NP practitioners within the counties of those states. Policy makers can now begin to estimate the cost to their state of a narrowly defined NP scope of practice. REFERENCES American Academy of Family Physicians (AAFP) (2012). Primary Care for the 21st Century: Ensuring a Quality, Physician-led Team for Every Patient. Retrieved from http://www.aafp.org/online/en/home/membership/initiatives/nps/patientcare.html Area Resource File (ARF). 2011-2012. U.S. Department of Health and Human Services, Health Resources and Services Administration, Bureau of Health Professions, Rockville, MD. Retrieved from http://arf.hrsa.gov/purchase.htm Association of American Medical Colleges (AAMC). (2012). Physician Shortages to Worsen Without Increases in Residency Training. Retrieved from https://www.aamc.org/download/150584/data/physician_shortages_factsheet Bauer, J.C. (2010). Nurse practitioners as an underutilized resource for health reform: Evidence-based demonstrations of cost-effectiveness. Journal of the American Academy of Nurse Practitioners, 22 (2010), 228-231.

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Barton, P. L. (2010). Understanding the U.S. Health Services System, 4 th ed. Chicago, Il: Health Administration Press. Christian S, Dower C, O'Neill E. (2007). Overview of Nurse Practitioner Scopes of Practice in the United States. San Francisco, CA: USCF Center for the Health Professions. Retrieved from http://futurehealth.ucsf.edu/Public/Publications-andResources/Content.aspx?topic=Overview_of_Nurse_Practitioner_Scopes_of_Practice_in_the_United_States Feldstein, P.J. (2012). Health care economics, 7th ed. Clifton Park, NY: Delmar/Cengage Learning. Goldman, D.P. and McGlynn, E.A. (2005). U.S. health care: Facts about cost, access, and quality. Retrieved from http://www.rand.org/pubs/corporate_pubs/2005/RAND_CP484.1.pdf. Institutes of Medicine. (2001). Institute of Medicine, Committee on Quality of Health Care in America, Crossing the Quality Chasm: A New Health System for the 21st Century. Washington DC: National Academies Press, p. 364. Institute of Medicine. (2010). The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary. Washington, DC: The National Academies Press. Institute of Medicine. (2012). Best care at lower cost: The path to continuously learning health care in America. Washington, DC: The National Academies Press. (Prepublication copy) Liu, N., & D'Aunno, T. (2012). The productivity and cost-efficiency of models for involving nurse practitioners in primary care: a perspective from queueing analysis. Health Services Research, 47(2), 594-613. doi:10.1111/j.14756773.2011.01343.x Nolte, E., & McKee, C. (2012). In Amenable Mortality--Deaths Avoidable Through Health Care--Progress In The U.S. Lags That Of Three European Countries. Health Affairs (Project Hope), 31(9), 2114-2122. OECD. (2012). "Total expenditure on health", Health: Key Tables from OECD, No. 1. Retrieved from doi: 10.1787/hlthxp-total-table-2012-1-en Potempa, K., Auerbach, D. I., Buerhaus, P. I., & Staiger, D. O. (2012). A Future Nursing Shortage?... David Auerbach, Peter Buerhaus, and Douglas Staiger [Dec 2011]. Health Affairs, 31(3), 652. doi:10.1377/hlthaff.2012.0119 Smith, D. (2008). The uninsured in the U.S. healthcare system. Journal Of Healthcare Management, 53(2), 79-81. Starfield, B. (2000). Is U.S. health really the best in the world? JAMA: The Journal Of The American Medical Association, 284(4), 483-485. Scott Stegall Health Care Management College of Business Clayton State University Morrow, GA Thomas McIlwain Health Care Management College of Business Clayton State University Morrow, GA

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Qiu Fang Health Care Management College of Business Clayton State University Morrow, GA Deborah Gritzmacher Health Care Management College of Business Clayton State University Morrow, GA Peter Fitzpatrick Health Care Management College of Business Clayton State University Morrow, GA

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QUALITIES OF WORKPLACE ENVIRONMENTS ASSOCIATED WITH NURSES’ DECISIONS TO REMAIN EMPLOYED IN THEIR CURRENT WORK SETTINGS
Larecia Gill, MSN/Ed., RN; Doctoral Student, Georgia State University Ptlene Minick, PhD, RN; Associate Professor, Georgia State University

ABSTRACT INTRODUCTION: The current nursing shortage is exacerbated by increasing nursing attrition caused in part by burnout among nurses. While much work has been done over the years to conceptualize the variables and relationships of why nurses stay, little work has been conducted from the nurses’ perspective. Therefore, a gap in knowledge exists that focuses exclusively on why registered nurses remain in current work settings. The advent of Magnet designation (and preceding research) highlighted factors essential for a healthy work environment (HWE). In 2004, Kramer and Schmalenberg examined the work processes/relationships essential to a HWE, determined how nurses in Magnet facilities perceived their work environments, and compared nurses’ perceptions of wor k environments in Magnet versus non-Magnet facilities. Results indicated that initial designation of Magnet status does not ensure that the basic tenets of magnetism will be continuously upheld. However, the Magnet facilities did score higher in the study indicating greater job satisfaction amongst its nurses. However, recent studies have found that the working conditions in Magnet and non-Magnet facilities do not differ significantly, and that non-Magnet hospitals had better staffing and patient outcomes than Magnet facilities. This is contradictory to expected findings. As a result, the researcher questions whether the basic tenets of Magnetism are essential to a HWE, why the results are contradictory, and what qualities of the workplace influenced nurses’ decisions to remain in current work settings. METHOD: A qualitative research method is being used to obtain nurses’ perceptions of environmental factors associated with their decision to remain in their current work setting, A sample of registered nurses (RNs) are being recruited for the study with recruitment continuing until saturation of data is obtained. Word-of-mouth is being used to recruit participants. Inclusion criteria include: RNs with a minimum of Associate’s Degree in Nursing (ADN); licensed to practice in Georgia; currently employed full-time, part-time, or an as needed basis in a clinical area; age 23 and above; possess a minimum of three years’ experience practicing as an RN; and demonstrate the ability to read and speak English. Exclusion criteria include nurse educators, nurse administrators, and nurse practitioners (NPs). Data collection consists of semi-structured audio-taped interviews. After the interview is transcribed verbatim, a constant comparative method of analysis is being conducted as recruitment continues. Initially, a research team of four qualitative researchers prepares a summary of each interview. Summaries are read and details about each interview discussed. Data are then coded, line-by-line. After saturation is reached, the codes will be collapsed into categories and themes will be developed. RESULTS: To date, four interviews have been conducted with a sample of majority female RNs (n=3) who have a mean age of 34.25 years (+4.57) and 9 years (+6.7) of experience working as an RN. Several themes are present across the four interviews; however, the most important theme identified involved personal relationships (including trust) and the revelation that it is not the environment that influences whether the participant chose to remain in his/her current position, it is his/her relationships with the people he/she work with. Adequate staffing, supportive managers, autonomy and personal control of practice, presence of patient-centered cultural values, and competent staff were also reported as factors that contributed to the decision to remain in their positions. Despite the importance of these factors, all study participants identified work environments that were lacking in one or more of these components, yet they chose to remain employed. Many identified such environments as ‘healthy’ despite contrary evidence. Their relationships with their coworkers were likened to ‘family’ and were the main influence in participants’ decisions to remain employed in an environment. The profession of nursing is struggling with several issues including the nursing shortage, burnout, and attrition. These issues are directly attributable to the workplace environment. The information gleaned from the current study can be used to develop measures to encourage a HWE and enact effective retention strategies to address the nursing shortage and stop nursing attrition.

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Larecia Gill 210 Martindale Drive Albany, Georgia 31721 (229) 883-0024 (H) (229) 317-6671 (F) lareciagill@bellsouth.net

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SOME OPTIONS TO STEM THE NEGATIVE EFFECTS OF THE HEALTH CARE “BRAIN DRAIN.”
Charley Braun, College of Business – Marshall University Ivan Muslin, College of Business – Marshall University Margie McInerney, College of Business – Marshall University

ABSTRACT One of the major contributors to dysfunctional access in health care systems is the mal-distribution of care providers. Within the United States, medical providers are often drawn to wealthier cities and suburban areas due to the strong economic environments they offer. Because there are only so many qualified providers, those decisions often result in shortfalls of health care providers within less-munificent environments such as inner-city precincts and the rural areas of Appalachia and the Great Plains states. These service deficits often force residents to travel significant distances in order to receive even the most basic medical care. On a global level, developing nations with few providers have been facing increasing pressure from a continuing exodus of their limited number of medical providers to wealthier countries seeking to mitigate their shortfalls by engaging in a form of human resource piracy. While this “brain drain” may have alleviated some of provider shortfalls in Europe and America, it likely exacerbated the problems among people who are the least able to secure alternative sources of treatment. Put another way: When the health care providers of wealthy nations import medical talent from poor countries, they also export additional problems back to the source of their new employees. The purpose of this paper is to examine some options that will help minimize the ill effects of the brain drain through proactive efforts such as cooperative training programs sponsored by the wealthier employers and offered in the developing nations where new talent is found.

Charley Braun, PhD 420 Corbly Hall College of Business Marshall University Huntington, WV 25755 (304) 696-2674 (Office) braun@marshall.edu Ivan Muslin, PhD 426 Corbly Hall College of Business Marshall University Huntington, WV 25755 (304) 696-2596 (Office) muslin@marshall.edu Margie McInerney, PhD 111 Corbly Hall College of Business Marshall University Huntington, WV 25755 (304) 696-2675 (Office) mcinerne@marshall.edu

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ACCESS TO CARE IMPROVEMENT PLAN
Robert D. Fenstermacher, University of Scranton Robert J. Spinelli DBA, University of Scranton

ABSTRACT A plan to improve access that organizations can implement will be discussed. Some theories and techniques will also be presented.

According to George Halvorson in our textbook “The Best Practice” as a pure business model, health care is winning. Healthcare is taking all your money and is doing it without having to be particularly accountable in how the money is spent. Healthcare will never ever reform itself. The model is too lucrative. At the end of the day a patient/consumer is the most important person. Some organizations are preaching that the online patient portal enhances members access to and involvement in their care. Online patient care is not overall suitable to all members. In order for organizations to assure their status as "the best not-for-profit," the focus needs to get back on quality and access to care. Resolving a problem via telephone limits access to care. To separate yourself from competition the use of the linked or bonded evaluation process could use some innovations. With the 3 levels of care, education, intervention, and prevention should be implemented in all levels of care to increase quality. As a whole, quality needs to be met at adequate levels. The fact that regional autonomy occurs in a decentralized fashion doesn't keep everyone on the same page. Autonomy doesn't allow full input to have quality care. Board members don't always grasp the broad scale on what needs to be done to maintain quality care. Some organizations iformation technology enhancements are very informative. However, the baby boomers and those who aren't capable of utilizing a computer are at a disadvantage of this. According to some organizations, they operate in a decentralized fashion. These examples may or may not be typical of the program as a whole. This statement shows a mediocre form of quality. There are various strategies that we see that may help improve quality and access to care. Getting back to realizing that the consumer/patient comes first is much needed. The level of loyalty will increase throughout all regions. The normative re-educative strategy will help with this issue. It helps with identifying what the problem is, and in a team effort finding a solution that benefits everyone. As mentioned in one of our sources, rapid change is not always the answer. By utilizing the normative re-educative strategy it allows change to happen gradually. This particular strategy supports a lot of organizations peer review and teamwork for high value care because it allows all changes to occur from in house only. A goal setting theory should be seen as another strategy as well. Don't get caught up with long term goals, focus on current issues that lead to future endeavors. Goal setting theory focuses on setting goals and responding to them. Our overall bigger picture is providing quality and access to care and goal setting theory supports that. Service is also a part of our quality improvement plan. We know there will be challenges to implementing this. We will eliminate the competition if we focus on various issues. Organizations are willing to spend the money, but they need to keep people healthy. Primary care physicians need to be a focal point in improving quality and access to care. With regards to reimbursement, there are some unique reimbursement systems that act as a barrier to great customer service. Some monetary rewards will allow organizations to raise the bar in all aspects of all three interdependent parts. For the future of many healthcare organizations our strategic planning goals over 2 years have various key points in order to reach them. Healthcare organizations needs to stay ahead with all the advancements in technology. Be aware of the connectors within our field. They must always focus on quality over quantity. The baby boomers are factored in our improvement. Education, intervention, and prevention will complement using some of the productive quality characteristics that an organization already has. We need to make sure everyone is on the same page. Primary care doctors need to have a more important role. The specialists don't really care about the importance of quality as a whole. They only are worried about themselves. The long term patient/ physician relationships will provide better quality and access to care. The doctor needs better communication with the patient. The fact that scale economics aren’t used means the incentives aspect is not present. An interpersonal relationship determines how well the clinician relates to the patient on a human level.

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Our concepts that we want to implement will help organizations deal with any innovations and other issues currently and in the future. Since the patient is the most important person, we need to always be aware of the concerns that they have. Any feedback that is given to us by our patients needs to always be taken into consideration. Once patients realize that their voice is being heard and not swept under the rug it will help us in all aspects of the company. The structure needs to focus on the relatively important characteristics of the individuals who provide care and the settings in which the care is delivered. Focused assessment is most revealing when deficiencies are found. Good quality is unlikely if you do not implement this. This allows us to see what are our mistakes, and various things we are missing to stay ahead of the competition. A specific process will give the hands on approach to improve the access to care. Our specific skills need to be carried out efficiently. Good outcomes of care for patients will keep us ahead with our competitors. When we capture our goals it always helps the outcome and whether we continue to provide great quality Access to care is a major part of our plan to make healthcare organizations better. Only northern California has five targeted areas that are imperative of personal care which are: patients have a personal primary care physician, they are able to see that physician, callers have a short telephone wait, they receive timely appointments, and patients have a superior care experience. You need to make sure the organization keeps up with changes in health policies, especially HIPPA. You also need to always be aware of new groups of patients covered before. We need to pay attention and have enough staff and clinical personnel to handle the volume of patients. Access is determined by the degree to which the individuals and groups are able to obtain needed services. The amenities help improve the healthcare settings in the hospital to provide comfort, convenience and privacy to patients. Our strategy will include reeducation. Continuing education is important for this organization to make sure skills are up to date. It is important that members of the organization stay abreast of the most current technology and techniques. Continuing education must happen gradually so that change can happen gradually. Change that is implemented all at one time does not usually work that well. By having continuing and reeducation it also will allow people within the organization to be able to figure out what the problems are within the organization. This really helps to benefit everyone within the organization. Continuing education can take place with a variety of different methods. This can take place within the organization or through additional on the job training and mentoring which is the most cost effective method. Some healthcare organizations and hospitals are involved in collaborative learning to promote consistently high clinical performance and to prevent adverse events such as hospital-acquired infections, pressure ulcers, and patient falls using rapid change interventions of evidence based practices, with performance feedback to hold leaders accountable. Other methods of continuing and reeducation include hiring outside educators and consultants for brief training sessions as well as sending personnel from the organization to outside conferences or training sessions. By using continuing education, personnel should become aware of more techniques and strategies to improve quality and better access to care. Through education an organization can utilize a computer, and cell phone to their advantage. Patients who are home that have chronic illnesses can get data concerning their weight, blood sugar levels, blood pressure, and other various information through mobile devices. Healthcare organizations will also need to use numerous other strategies in addition to education. These include cohesiveness and collaboration. There are a number of methods used to be able to use cohesiveness and collaboration. Some of the things that need to be done include minimizing selfish behavior. In a lot of organizations, the people often just think about their own needs and wants. However, if people put their needs aside and think of what they can do for the organization as a whole quality and standards can be raised. This is very important so people within the organization can communicate and also form relationships better. Teams also should not be too large within an organization. When teams end up being larger than 11 or 12 people, they do not communicate or function as well. By keeping teams smaller it is possible for everyone to know everyone. In teams that are larger, people often do not always know that much about each other and everyone involved that they are working with. It is also encouraged that the organization occasionally once a month hold a couple social events so that members may socialize. This way members of the organization can meet other workers from other departments. Another very important technique in improving quality and access to care is goal setting theory. To achieve new types of performance standards certain goal benchmarks need to be set. By using goal setting theory it is easier to identify what problems are within the organization as well as be able to find ways to fix them. Small goals should be set at first with looking at setting longer and larger goals later. People that set goals within the organization have to look at the bigger long term picture. Starting out by setting weekly goals with also monthly, six month, and annual goals in

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mind. By setting these goals it also gives people something to aim for within the organization and some definitive performance standards to reach. Inpatient care setting quality is also critically important to evaluate the current situation of the organization and also to improve it. Inpatient care first needs to be evaluated. The current principles concerns deal with care for the patient, communicate about unanticipated adverse outcomes, report to appropriate parties, check the medical record, follow up and provide closure, and the support the patient care team. Some ways that can be used to evaluate this includes administering surveys. By using surveys and evaluative tools it is possible to see what patients prefer within a healthcare organization. Many organizations report that patients have positive feedback when this is implemented. Once these surveys are administered people within the organization can come up with a strategic plan and time plan to make changes within the organization. This process needs to be continuously reevaluated within the organization and make changes as necessary. It is important that surveys be given to both people within the organization as well as patients and potential patients. The organization also needs to look at and make sure it has and is choosing the right people. One of the leadership experts who talks about this and has a number of theories regarding this is Jim Collins. One of the keys to higher performance in an organization is eliminating the wrong people and having the right people to work with. Usually the right people within an organization are disciplined and tend to work harder and perform at a higher level. Wrong people within organizations tend to bring other peoples performance down within the organization. These people can also cause numerous people to become unmotivated and hurt morale within the organization. A successful organization first has to have highly capable individuals that have talent, skills, knowledge and a good work ethic. They also need to have contributing team members that work effectively, accomplish group objectives and work effectively with people in group settings. Some people within the organization also have to provide leadership and competent management. A competent manager organizes people and uses resources toward effective and efficient use of predetermined objectives. Effective leaders have a clear and compelling vision that can stimulate higher performance. This kind of clear vision by the right people can help motivate many people within the organization. Finally, an organization must have the right executive leader to run it. Having the right person to run the organization helps build greatness through a combination of personal humility and professional will. This person can help lead the organization to new heights of performance and reach goals in the future. Healthcare organizations can also take a look at future trends that will be occurring in the healthcare industry. Some of these trends include things such as the increasing age in the population. The increasing age of the population will affect the type of customers and kind of products and services that are in demand. Changing health policy is another trend in the future that can affect the performance of the organization. Health policy is changing very quickly within the U.S. With the new healthcare reform bill taking affect in the upcoming years it is very imperative for any healthcare organization to keep up with changing policy. There are a number of other future trends to look at that the organization needs to be aware of. One of these includes a shift in the focus on value. There will be an increased expectation of higher healthcare value through lower cost per health outcome. This will provide a lower tolerance for provider variation in care. This will probably cause more consumers out of pocket costs. Other trends include a shift to outpatient care. With more outpatient care this will change healthcare in the sense it will strain hospitals and drive for more integration. Another upcoming trend includes more market regulation. Health reform is making all kinds of new rules regarding controlling the market. This will create numerous challenges for healthcare organizations in the industry. The organization must strategically plan and look ahead to combat future trends and changes. Only then can it stay current and abreast with what is happening in the field and industry. Halvorson realizes various problems that need to be fixed, which supports our quality and access to care improvement plan. Chronic illness is one of the focal points that he points out. Halverson says "He observes that 70 percent of the nation's cost of care goes to less than 10 percent of the population, largely patients with one or more of five chronic diseases: diabetes, congestive heart failure, coronary artery disease, asthma, and depression (Best practice 241). The transition of electronic medical recording will be a part of the future of healthcare and Halverson feels the same way. Halverson is disturbed by the lack of data in health care because he views data as the lifeblood of improvement. Paper files in doctor's offices cannot be sliced, diced and analyzed the way computerized information can be. He also feels that a clinician has no way of knowing whether he or she is performing near the top or bottom of the pack they know. Evidence based care needs to coincide with the growth of technology. Another important issue that healthcare organizations needs to look at is regarding change and competition. The famous late business professor Peter Drucker talks about this and some other concepts that organizations need to

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realize and stay on top of. One of the issues that Drucker talks about is change and competition. There is always new competition that is happening and organizations need to be prepared for the new businesses and mergers that can be new competition for the organization. This means an organization needs to be flexible and be constantly changing to be able to deal with new competition and technology. Organizations also need to realize that customer needs are constantly changing. Since the population in the U.S. is aging there is going to be a growing need for healthcare needs in general. While in some ways this higher demand is a good thing, it also means there will need to be a higher production of drugs to meet these demands. The elderly population will also want care that is very efficient and without long waiting times for appointments. They will also want the latest new medicines and the most up to date technologies and treatments for health problems. Drucker also advocates talks about knowledge management. Organizations can use the people within their organization to gain knowledge and managers should seek out to utilize this internal resource. Employees within the organization can share their knowledge with management and by utilizing this, it can increase performance. Organizational knowledge can also accelerate change and help an organization to stay ahead of the competition. Employees within the organization also gain knowledge and gain confidence by the sharing of information as well as collaborating and working together. This increases overall organizational morale. Decision making is another very important topic that impacts the performance of the organization. Decision making is what holds a lot of organizations together and obviously also affects performance. When making decisions managers within the organization need to know what risks to take. Managers need to take the right risk, but not the least risks. Some questions managers need to ask when making decisions are as follows. They need to ask whether they have built time to focus on making critical decisions and whether they have lightened their load? Other questions include whether the organization is willing to commit to the decision once it is made and does the culture and organization support making the right decision with contingency plans? Lastly, when decisions are being made it needs to be looked at whether enough resources are allocated to support the decision. Guidelines also need to be followed to whether action is required and who should make decisions if they’re needed? Action is usually needed when the condition is likely to degenerate the organization or the opportunity is likely to disappear with no action. No action is required when the condition will take care of itself or the organization is prepared to act on the opportunity. Further investigation is usually needed when the situation is not likely to take care of itself and unlikely to degenerate on its’ own. A couple issues need to be looked at regarding who should make the decisions. The organization needs to look at how quickly the decision needs to be made, the number of people or areas that are affected, the time frame of the commitment, level of social considerations, as well as to what extent to which precedent is being set. The organization needs to weigh these issues when deciding who will make important decisions. Selecting the appropriate and right people within the organization to make decisions can be very crucial to improving as well as maintaining performance within an organization. Some organizations have some consideration with the elderly patient/consumer. The adult children who take care of their parents gain access to their parents’ health records to check medications, understand proposed treatments, and query clinicians. When looking to improve performance, another issue that needs to be looked at includes a few new concepts. Some of these new concerns include issues such as some of societies concerns and needs. Other issues to look at include efficiency, cost effectiveness, technical aspects of quality, as well as access to care. The organization needs to assess quality as well as the context of cost. With performance it is also very important for an organization to prioritize quality over quantity. Some organizations are only interested in how many patients they serve which is why their performance is not where it should be. Patient awareness also has to be emphasized. By paying attention to patient needs it is possible to know their needs and much easier to improve organizational performance. It is also very important to respond to patient and employee needs in a timely manner. Patients expect phone calls and emails to be returned, appointments to be able to be made, as well as services being made acceptable and the waiting time in waiting rooms not to be very long. These patients are going to also expect the most up to date technology, but the organization also has to be careful that technology does not become too much of a burden. Technology can be very helpful in improving performance, but sometimes especially with older patients it can become confusing and not user friendly. Self competency assessments are a way that people within an organization can diagnose weaknesses and how they can improve on these weaknesses. There are many different assessment tools out there to help healthcare managers do a self-diagnosis. One of the most well-known self diagnostic tools in the healthcare administration profession is the American College for Healthcare Executives Health Executive Competencies Assessment Tool. This tool is published every year annually and downloadable online. The assessment measures many different areas of competency. The

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competency has questions where people can rate themselves from a rating of 1 to 5. It evaluates communication skills dealing with relationship management, communication skills, and facilitation and negotiation. It also evaluates leadership skills such as leadership skills and behavior, organizational climate and culture, communicating vision, and being able to manage change. The assessment tool goes on to evaluate professionalism and breaks these evaluations down into personal and professional accountability, professional development and lifelong learning, and contributions to the community and profession. Knowledge of the healthcare environment is a vital skill. The competency assessment by ACHE evaluates knowledge regarding healthcare systems and organizations, healthcare personnel, and the community and environment. The last part of the assessment measures business skills and knowledge. These business skills include skills such as general management, financial management, human resource management, organizational dynamics and governance, strategic planning and marketing, information management, risk management, and quality improvement. At the end of each section the assessment also has a development plan that each assessment taker should complete. By using this assessment tool as well as tools similar to ACHE’s, organizations can use this as part of their diagnostic tools to improve performance. Boards of directors are another critical part to any healthcare organization. Organizations should also look at the performance of its’ own board of directors in assessing its’ current performance level. The CEO of any organization needs to make sure that board members are educated on how the organization functions and what goes on in the organization. If board members are found to not be competent and educated on affairs of the organization, a board member skills development program needs to be developed and implemented. A board should be able to function independently and make decisions to improve the organization’s performance. The board should take a look at the organization and develop specific performance targets. The CEO of the organization should also assess the performance of the board and take action if performance is not satisfactory. Even once a board is performing adequately, continuing education needs to continue to keep the board functioning properly. Newer board members of course need to also be educated as well as trained. The board of directors should start out with small performance targets and then gradually move on to larger future goals and targets for the organization in the future. The board members should use strategic planning in planning its performance goals as well as those of the organization. When assessing performance the organization should also look at trust. Trust is a very basic form of human relationships and is vital and important to organizational performance. When people are trusting within an organization this can motivate and increase performance. Trust must be built over time, but can be lost very quickly and take a lot of time to rebuild. When an organization examines trust within the organization there are a number of components it can look at to evaluate trust. Some components of trust include integrity, competence, consistency, loyalty, and openness. By achieving trust within an organization it is possible that there will be less gossip, resentment, and better communication within the organization. Trust also promotes collaboration and morale within the organization. Conflict management should also be evaluated and looked upon closely within an organization. Managing conflict is a skill that any healthcare organization should have. Organizations should have a conflict management policy and root out any potential causes of conflict. Some principles that can help with conflict management include being able to root out causes of conflict, insisting on collaboration, and establishing a format that should be followed when there is a conflict for members of a team to meet and resolve the issue. There can be a number of different kinds of conflicts within organizations. One kind of conflict is called functional conflict. Functional conflict is when there is confrontation between two groups that enhances and benefits the organization’s performance. These two groups may agree on the goal to achieve, but not on how to achieve it. Usually this kind of conflict can be beneficial in that both groups exchange, negotiate and then combine some of each group’s ideas. Another type of conflict called dysfunctional conflict can be much more harmful to the organization. This type of conflict is any type of conflict that harms the organization. Sometimes conflicts that seem beneficial can turn into harmful ones. Organizations need to look at both the causes and resolutions to conflict. Some causes of conflict can be things that prevent work interdependence or differences in goals. Sometimes limited resources or inaccurate perceptions are also reasons that conflict occurs within organizations. There are a number of techniques to help resolve conflicts of these types. Some of these techniques include an expansion of resources, smoothing which is emphasizing the common interests of the group, avoidance, compromise, or using authoritative command. Prioritizing also is a contribution to our plan. It’s imperative to stick to your plan and goals. When you are busy we naturally believe that we are achieving. Prioritizing requires leaders to continually think ahead. Prioritizing causes us to do things that are at least uncomfortable and sometimes downright painful. We need to focus on what is

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required at all times. The need to find what gives the greatest return. The greatest reward allows you to reap all the benefits of prioritizing. Eliminate all brown nosing because that’s the kind of people who brings companies down. Motivation can also improve performance. There are a number of theories on motivation which include operant conditioning. The achievement motivation theory is what gets you up in the morning to go to work. Being a high achiever, you like situations in which they take responsibility for finding solutions to problems. High achievers tend to be moderate risk takers rather than a high or low risk taker. Some of the principles of operant conditioning include positive reinforcement, negative reinforcement, and punishment. When people talk about motivation, organizations need to look at what drives people to perform at a higher level. What motivates one employee within an organization may not motivate another. People are fueled by different desires, needs, and wants which is what motivates them. Some people are more concerned with external rewards than self-satisfaction where other people are more driven by self-satisfaction type of wants and desires. Usually people who are looking for self-satisfaction almost always outperform the others in the long term. Mastering a skill or task is another motivating type of desire for people to perform. Some people are also motivated by competition from within an organization, so sometimes healthy competition can be a good thing. People also like to know and have a sense of purpose. Purpose often motivates and helps give people a sense that they are accomplishing something that is worthwhile and will lead to larger goals and projects. You need to communicate with openness and sincerity and you have to know your audience. Be aware of the audience, because you need to give your message with focus on your patients. A sense of enthusiasm within an organization can also increase motivation along with basic economics. If higher performance means an increase in money for a person, this can be a high motivating factor. Some people also desire attention, and higher performance can be a motivator to gain this attention and respect from other people. There are also some people who are just perfectionists at everything they do. Perfectionism also leads to higher performance by driving people to higher performance to achieve perfection. Motivation is a very key issue to higher performance and by the organization using some diagnostic tools and evaluations to be able to tell what the level of motivation of the organization and employees are. Motivation can then be increased to increase both organizational and individual performance. Motivation brings a lot to the company. Once you join an organization if a person is motivated they are more likely to remain in it. While you are at work you need to feel like you add value and perform well. In order to perform you need ability and motivation. Without desire and commitment you have no communication. We need to be in tuned with our motivators. We all have some hidden needs that people don’t see. Our symbolic needs give us that confidence knowing that we are very important people. Putting forth the best effort to reaching your short term and long term needs gives you a personal rewards system. Momentum is what separates yourself from the competition. The Law of Momentum that was mentioned in class connects with strides into improving quality and access to care. Momentum is the great exaggerator. It makes leaders look better than they are. It helps followers perform better than they are. You surround yourself with individuals who add just as much value as the leader does. When you have momentum it is easier to steer ahead then to start. Many people don’t believe that momentum is the most po werful change agent. As a leader it is your responsibility to have momentum. When an organization has momentum people can see within the organization that goals are much more within reach. Competition between organizations as well as individuals within the company can increase and accelerate momentum. Momentum is also a very important way of being able to increase motivation. When small goals are initially achieved a lot of times momentum slowly starts to speed up and increase. Usually when an organization has momentum this also increases morale which helps to increase the quality of performance and the overall state of the organization. By having momentum this gives an organization confidence that a positive future is within grasp. Momentum can also help to receive funding from investors and people who can potentially help the organization through financing to reach its’ goals. Momentum is a key component and factor to an organization being able to increase its’ performance. By having continuous momentum an organization knows that it will be able to maintain high quality performance for a long period of time. In conclusion healthcare organizations need to evaluate its current state and implement some strategies and principles that we mentioned. Strategic planning should happen frequently. Evaluations should be in the first month, sixth months, one year, and two years. Healthcare organizations need to be able to apply a number of the theories and principles as outlined in our research study. By using some of the diagnostic tools talked about and finding the weaknesses that are within the organization the organization can come up with plans that it can use to make improvements. It is important for organizations to do this type of evaluation within the organization on a regular basis. Only by the organization seeking continuous improvement will they be able to maintain a respectable place in the future market. Organizations that do not change or do anything new could face a situation where new organizations and

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competition catches up with them. It is also important for organizations to look at improvement and quality since the market and customers continuously change. A lot of the theories and methods studied and talked about in our research have been proven and studied by other organizations. These organizations have used a lot of these theories and concepts and been able to improve their performance and quality. Organizations should also continue to do research and look for new strategies and theories that could possibly improve the organization. The organization can also attempt to create and develop new strategies on its’ own which can help to keep them ahead of competition. It is likely that healthcare organizations will be able to come up with new strategies for care and continue to retain and hire quality people for its’ organization. The healthcare market will have a higher demand in upcoming years which should help to give a positive outlook for an organization.

REFERENCES Dye, Carson F (2010). Leadership in Healthcare, Chicago, IL: Health Administration Press Pink, Daniel H (2009). Drive New York, NY: Penguin Group Tang, Paul (2011). Meaningful Use of Health Information Technology: Future Scan 2011pp.32-36.

Eadie, Doug (2009). Extraordinary Board Leadership: Sudbury, MA Jones and Bartlett Publishers Collins, Jim (2005). Good to Great and The Social Sectors: San Francisco, CA Elements Design Group Gibson, James L (2012). Organizations Behavior, Structure, Processes: New York, NY: Mcgraw-Hill Irwin Axelrod, Alan (2008). Revolutionary Management John Adams on Leadership: Guilford, CT. The Lyons Press Arnold, Frank (2005). What Makes Great Leaders Great: New York, NY: Mcgraw-Hill Irwin Meyer, Christopher & Kirby, Julia (2010). Leadership in the Age of Transparency. Harvard Business Review April 2010 pp. 38-46. Drucker, Peter F. (2002). Managing in the Next Society.: New York, NY: St Martin’s Press Edersheim, Elizabeth Haas (2007). The Definitive Drucker: New York, NY: Mcgraw-Hill Irwin Kenney, Charles (2008). The Best Practice: New York, NY: Public Affairs Books McCarthy, Douglas, Mueller, Kimberly, Wrenn, Jennifer (2009). Kaiser Permanente: Bridging The Quality Divide with Integrated Practice, Group Accountability, and Health Information Technology. Case Study: Organized Health Care Delivery System. pp.1-27.

Robert D. Fenstermacher University of Scranton Robert J. Spinelli DBA University of Scranton

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TRACK HEALTHCARE INFORMATICS AND TECHNOLOGY

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Technology: Driving Dentistry for the 21st Century
David P. Paul, III, Leon Hess Business School, Monmouth University

Introduction The dental technology market in the United States is large and growing. In 2010, this market was valued at $2.2 billion, and was expected to grow at a compound annual growth rate 10%, reaching $4.2 billion by 2016 (Gunnam, 2008). The baby boomers are contributing significantly to the growth in this market, which is driven by strong demand for dental implants, the changing dynamics of patient choice and the ever increasing demand for cosmetic dentistry. These technological advances in dentistry make possible the provision of older dental procedures in more efficient ways and new dental procedures in new ways, all to satisfy the demands of the market for dental services. To the casual observer, there may not appear to have been much that has changed in dentistry over the years. However, technology is constantly evolving and will shape the future workplace (Challenger, 2000), transforming the field of dentistry. New technologies are always being developed, with a focus on developing products and techniques that can be used by dentists to help prevent, diagnose and/or treat dental conditions and diseases early and more effectively (Ranft, 2009). This paper examine some technologies which have substantially changed the practice of dentistry has changed over the past 25 years, as well as attempt to develop some insight as to what the future holds in the form of technological change for the practice of dentistry. The paper will be arranged in sections associated with dental office functions and various dental specialties. There will, of course, be some overlap in the contribution of various new dental technological developments, and these will be cross referenced as they occur. It is important to remember that new technologies are, just that, “new.” Because th ese products and services are in the early stage of the product life cycle, they are, by definition, being adopted by innovators and early adopters. Because the vast majority of new products fail, it is unknown at this time which of these innovative dental technologies will survive “the test of time.” The Dental Front/Business Office Perhaps the greatest technological changes to the practice of dentistry are found in the “front office” of the dental practice. Today, virtually all front office functions have been digitalized, leading to what may be called, if not the “paperless office,” at least the “chartless office.” Digitalization of Records Where 25 years ago the presence of a computer in the front office would have been a bit unusual, the absence of such a device now would be almost astounding. Many offices now allow patients to make appointments online. The days of photocopying patient ledger cards to send out bills seem quaint, as would looking up charge card numbers in a paper booklet to determine if the account had a problem or not. Greatly facilitating this transition is the use of software packages, microphone headsets, electronic probes and light pens, all making the process of recording the dental examination much easier and quicker (Anonymous, 2010). Patient Communication Associated with this digitalization of the dental front office is how the practice of today keeps in touch with patients. Despite the legality of doing so, most dentists do not choose to advertise via traditional media outlets, probably because this approach still holds the stigma of being unprofessional. Most dentists today probably have a website for their practice, but this alone may not be enough. The use of social media (e,g., Facebook, Twitter, LinkedIn) to maintain contact with dental patients does not seem to have the same connotation as advertising, and dentists are beginning to understand the need to avail themselves of this new opportunity to maintain contact with existing patients and seek new ones (Lipscomb, 2012). The various social media offer a variety of opportunities for dentists to connect with their patients and others in dentistry, by providing an opportunity for people to discuss their experiences, share tips and tricks, and generally interact with each other. If dentists were to become more active in

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social-media, it could give them the chance to expand their patient base and forge deeper and more meaningful connections with colleagues (Hughes, 2012). Diagnostics When a patient seeks dental care, an accurate diagnosis of the patient’s problem(s) must be determined. In the past, virtually the only diagnostic tools widely employed by dentists were periapical and “bite wing” radiographs and a visual clinical examination. While these techniques are certainly still in use, and will continue to be used into the future, there are numerous other diagnostic approached available to dentists today, and all are driven by technological developments. Caries Detection Caries detection solutions are liquid dyes that can be applied to a tooth to confirm that all tooth decay was removed from an affected area that is in the process of being treated. This solution is very similar to plaque disclosing tablets that are used after brushing to highlight any areas missed when brushing and flossing teeth which weren’t thoroughly cleaned. This approach has shown promise (Thomas et al., 2000), but remains controversial, if only because no widely accepted system exists to determine the presence of dental decay (Ismail, 2004; Pretty, 2006). DIAGNOdent® is a hand-held laser device for the detection of decay on the occlusal (“biting”) surfaces of teeth. It is FDA approved and its use allows the dentist to detect incipient decay much more effectively than using more traditional methods. Finding decay when its small allows the dentist to limit the size of the filling required (Bader and Shugars, 2004; Ranft, 2009). Research has demonstrated the device to be both reliable and valid (AlwasDanowska et al., 2002; Lussi and Hellwig 2006). X-Rays Dental radiography has advanced drastically. Few dentists continue to use conventional x-ray film packets (“bite down on the paper and hold still”). Instead, digital x -rays are now almost universally used ( Child, 2011; Digital Dentist, 2009), as they require greatly decreased radiation exposure for the patient - four digital radiographs require about the same radiation exposure as one traditional dental X-ray (Ranft, 2009). The resulting images can be stored in a computer, freeing up space. The images can also easily be magnified, providing greatly increased diagnostic capability. As an adjunct to digital radiography, software is even available which is said to substantially increase the dentist’s ability to detect clinically significant decay between teeth and often on their biting surfaces (Christensen, 2011; Gaikenheimer, 2002). Traditional x-ray imaging techniques in dentistry have been essentially 2-dimensional representation of 3dimensional objects. However new to the scene is cone-beam computed tomography (CBCT), which has received considerable notice as a viable 3D imaging modality. The image can be rotated in any direction and the software can virtually peel away the bone to show the dentition or vice versa (Nesari, Rossman, and Kratchman, 2009). The adoption of CBCT has been relatively rapid, due to decreasing costs, multiple options from which to choose, increased number of general dentists placing implants, greatly decreased radiation compared to conventional CT scans, and rapid adoption by universities and specialists (Child, 2011). This treatment modality is especially helpful in orthodontics, oral surgery, endodontics and implantology. The U. S. military has even using CBCT to record the anatomy of soldiers' heads before sending them into a combat zone (Lark, 1998). Soft Tissue Diagnosis Aids The VELscope is an FDA-approved tool to screen patients for early stage oral cancer and pre-cancer, as well as viral, fungal and bacterial infections that might otherwise be difficult to diagnose (Huff, Stark and Solomon, 2009; Truelove, 2011). It uses enhanced tissue fluorescence technology to allow the dentist to view the oral mucosa more effectively than possible using the naked eye, and offers cordless convenience and an optional digital camera which makes it easy for dentists to photo-document suspicious lesions. In 2012, the VELscope was awarded "Best of Class" by the Pride Institute, one of only 5 dental technology devices to receive this award for two years running (Marketwire Canada, 2012). It was even featured on the Doctors TV show in November of 2008

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(http://www.youtube.com/watch?v=dZZWksiU-9U&feature=plcp) and on the Dr. Oz TV in June of 2011 (http://www.youtube.com/watch?v=6b9lcagllwU). A similar product is ViziLite® Plus with TBlue®, which uses both a chemiluminescent light source and a toluidine blue dye which fluoresces. The light source identifies suspicious areas which are then stained with the dye to make further examination easier (Epstein et al., 2008; Kerr, Sirois, and Epstein, 2006). Although ViziLite is FDA approved, it was denied the American Dental Association Seal of Approval in 2005 (Barrett, 2011), perhaps because its use has not been demonstrated to significantly increase the detection rate of oral cancer (Oh and Laskin, 2007). Operative Dentistry Operative dentistry is a broad term referring to removal of tooth structure and replacement of what was removed with some sort of dental restoration or “filling”). Its domain is restoration of the single tooth, using “pliable” materials such as dental amalgam and composite resin materials. Many of the technologies discussed in this section will also apply to Fixed and Removable Prosthodontics, the next section. Operating Microscopes Magnification enlarges images allowing the viewer to observe structures not easily visible to the naked eye. Twenty years ago, perhaps one in twenty general dentists used magnification, and most were using simple loupes. Now, over 80% use loupes. Interest in dental microscopes has been slow to develop (Selden, 2002), but this will undoubtedly change now that there is little doubt that procedures done under magnification are better than those done without such technology (Mitsuhsahi et al., 2009). The dental operating microscope is an excellent instrument for detecting fractures, cracks, open margins, “extra” nerve canals – virtually any restorative or endodontic abnormality that is difficult or impossible to see, even with unaided vision or loupes. In fact, proficiency in use of the operating microscope for successful completion of endodontic programs has been required since 2005 (AAE Position Statement, 2012). Anesthesia Dental anesthesia has been a difficult hurdle for patients to overcome for decades. In fact, nothing seems to scare patients as much as the dreaded “shot.” While topical (“rub on”) anesthetic has been used for many decades in an attempt to remove the initial discomfort of the needle insertion, this doesn’t seem to be sufficient for many patients, as the painful sensation often associated with the injection itself is caused by the expansion of the soft tissues during to the injection of the liquid anesthetic (Ranft, 2009). Several technological advances in this field are making this procedure much easier on patients. Two new technologies designed to minimize or even eliminate the pain of the local anesthesia injection are The Wand and the DentalVibe Injection Comfort System. The slow and gentle delivery associated with The Wand often makes injections virtually painless. The Wand (technical name is STA Single Tooth Anesthesia System® Unit, but virtually everyone calls it “the wand” due to its shape) is a computer -controlled dental injection which uses real time feedback regarding pressure in the soft tissue. Because the flow rate of the local anesthetic is controlled by a computer, the injection is always slow and steady and therefore virtually imperceptible to the patient (Friedman and Hochman, 1998; Heffler, 2008). The DentalVibe Injection Comfort System is a patented scientific instrument that blocks injection pain by sending soothing pulsations deep into the tissue. These pulses stimulate the nerve sensory receptors, close the pain gate, and prevent the brain from feeling the pain. The device is said to eliminate pain of dental injections completely (“Dentistry Today” 2012, Diaz, 2010). Electronic anesthesia (based on the principal of transcutaneous electric nerve stimulation) for dentistry has been investigated, and shows some promise. It has been shown to be as effective as topical anesthesia (Ravela et al., 1995). For operative dentistry in children, electronic anesthesia was shown to be as approximately as effective as traditional local anesthesia (Baghdadi, 1999). More recent research, using more modern technology, electronic anesthesia demonstrated better results: it was perceived to be significantly effective in terms of comfort and efficacy by both dentist and child patient, but only for relatively minor procedures (Dhindsa et al., 2011; Lodaya et al., 2011). Although it was not deemed quite as effective as traditional local anesthesia, patients overwhelmingly preferred electronic anesthesia (Dhindsa et al., 2011).

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While everyone wants profound anesthesia during a dental procedure, ever yone would like for the “numb face” to go away more quickly. A new drug –OraVerse – is now available to reverse the effects of traditional injected local anesthesia and speed up the return of normal sensation. It cuts the “numb time” by half, by dilating blood vessels and thus increasing blood flow to the injected area (Carr, 2011). It has been shown to be safe and effective for both adults (Hersh et al., 2008) and children (Tavares et al., 2008). It obtained FDA approval in 2008, and appeared on the market soon afterward (Belden, 2008). Dental Handpieces Perhaps nothing in dentistry is so disconcerting to patients as the high speed whine of the traditional air turbine handpiece. Operating at speeds up to 400,000, its shrill sound often is a major fa ctor in many individuals’ fear of dentistry. Fortunately, there are some new technological alternatives in this area. In other parts of the world, especially Europe and Asia, it not at all uncommon for dentists to use electric dental handpieces for tooth preparation. Even though American dentists have been using electric laboratory handpieces for many years, only recently has the electric handpiece received much interest in the U. S. In Europe 80% of restorative practices are employing electric handpieces (Kurtzman, 2007). These electric handpieces have much greater torque than traditional air-driven handpieces, allowing more precise tooth preparations with less noise and vibration (Anonymous, 2006). Electric handpieces cost more to purchase and repair, and are heavier in weight, which may create difficulties with ergonomics and may result in reduced visual access (Atlas, 2011). Because of these disadvantages, electric handpieces have only a small market share in the U. S. (Christensen, 2002). Approximately 40% of U.S. dentists currently own and use an electric handpiece (“Dentalcompare's Survey”, 2012), however, more that 50% of U.S. dentists surveyed indicated that they planned on buying one in the near future (“Dentalcompare Releases”, 2012). Air-abrasion technology allows the removal of tooth structure through a blast of pellets consisting of air and aluminum oxide. It is primarily used to treat small cavities, preserving healthy tooth structure and may not even require the use of a local anesthetic (Ranft, 2009). The technology for dental applications was introduced over 60 years ago, but was not popular due to three major factors. First, air abrasion could not be used for tooth preparations with the well-defined walls and margins required for restorative materials available then. Second, the introduction of the air turbine handpiece in the 1951 made it possible to make conventional cavity preparations more quickly. Finally, because high-velocity suction was non-existent at that time, the efficient evacuation of the used aluminum oxide particles was difficult. These problems have been overcome, and air abrasion dentistry is becoming more popular (Hegde and Khatavkar, 2010), especially when bonded restorations are planned. A number of air abrasion systems are available today such as the PrepMaster or EtchMaster (Groman Inc.), Airbrator (North Bay/Bioscience, LLC), PrepStart and PrepAir (Danville Engineering), and CrystalMark (CrystalMark Inc.). Lasers are just recently being used for restorative dentistry. Early lasers used for tooth removal were found to cause irreversible pulpal changes, however newer laser technology (Er-YAG) lasers produce significantly less heat and are therefore better for hard tissue removal. A major advantage of lasers for tooth removal is the absence of noise, vibration and pain associated with traditional drilling, which has been shown to a significant psychological benefit for patients (Miglani et al., 2011). Although Rice (2011) believes that using Er-YAG lasers for operative dentistry leads to “predictable outcomes,” adoption of this technology remains scant. Much additional research must be done in this area before lasers are more widely used for operative dentistry. Fixed and Removable Prosthodontics Fixed prosthodontics involves the replacement of missing teeth, using restorations which are cemented permanently in place. As fixed prosthodontics requires anesthesia and “drilling” of teeth, much of the technology discussed in the previous section is also used in this discipline. Removable prosthodontics, in contradistinction to fixed prosthodontics, involves dental appliances which are cemented in place. Dentures and partial dentures have not changed hardly at all, but the methods of stabilizing them in the patient’s mouth have changed drastically due to the now widespread use a new generation of dental implants.

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Digital Impressions After whatever dental preparation required has been accomplished, an impression is taken so that the dental laboratory will be able to develop an accurate replica of the mouth on which to fabricate the prosthesis. Digital imaging provides numerous benefits for both the dentist and the patient over traditional impressions which used uncomfortable trays and "a mouthful of goop" (Garg, 2008). The dentist uses a camera on a “wand” to take digital pictures of teeth which have been prepared for a dental crown or bridge. The digital imaging procedure takes about 2-3 minutes, after which the digitalized images are sent over high speed internet to a dental laboratory which will fabricate the dental restoration(s). This method is purported to provide the most accurate dental impressions currently available. The prostheses fabricated using digital scanning for impressions require very little or no chairside adjustment in order to fit onto the prepared tooth structure, resulting in a reduction in patient time in the dental chair and thus an increase in patient satisfaction. Manufacturers of these systems have integrated their software and hardware with dental laboratories, expanded the scope of indications for the use of their respective systems in the dental office, and developed educational and training programs for the dentist and dental staff. The leading systems appear to be the CAD/CAM products CEREC® (Sirona Dental Systems, www.sirona.com) and E4D Dentist (D4D Technologies, www.d4dtech.com) (Birnbaum and Aaronson, 2011). CAD/CAM Closely related to digital imaging is the use of computer-aided design/computed-aided manufacture (CAD/CAM). This approach uses the same digital imaging technique previously discussed, but allows the option of sending the resulting images to a dental laboratory some distance from the dental office or sending them to a milling machine located in the dental office itself. This milling machine fabricates a crown or bridge directly, usually in an hour or so, completely alleviating the need for temporary restorations and a return visit to the office weeks later. One CAD/CAM manufacturer even touts its pattern-recognition-like design software as so comprehensive that it reduces the time needed to design crowns and bridges to zero (Sirona Dental Systems LLC, 2011). Currently, there are multiple companies offering intraoral imaging devices needed for dental CAD/CAM. A leading independent testing organization, CR Foundation (Clinicians Report), has researched these scanning systems and concluded that they are as accurate as traditional conventional methods (i.e., stone die systems). Most are more accurate, faster, and easier than traditional approaches to dental impression taking. The only drawback to this approach appears to be cost. However, the advantages in terms of speed, ease, and patient comfort imply that adoption of CAD/CAM in dentistry is not a question of “Will this technology be adopted by dentists?” but of “When will this technology be adopted by dentists?” (Child, 2011). Implants The modern era of dental implants began with the work of P. I. Brånemark, a Swedish surgeon, who partnered with Nobelpharma AB in the 1980s, establishing the company to focus on dental implantology. The track record of Brånemark-type implants has been quite good: millions of these implants have been placed successfully. However, due to the large diameter of Brånemark-type implants (4-5 mm), they could only be placed in areas of relatively thick bone. If sufficient bone for successful placement was available, the Brånemark-type implants were used successfully for both fixed and removable prosthodontics, although a wait of between 3 and 6 months was usually required before any restorative dentistry could begin. Once it was realized that it was the length of the implant that was important instead of the diameter (Block, Delgado, and Fontenot, 1990), the mini dental implant (MDI) (1.8-2.9 mm in diameter) became feasible. Although the MDI has a reduced surface area compared with a conventional Brånemark-type implant (Siddiqui, Sosvicka and Goetz, 2006), both have been shown to undergo osseointegration (Balkin, Steflik and Naval, 2001) and perhaps most important, the percentage of bone to implant contact for the mini implant is comparable to Brånemark-type implants (Simon and Caputo, 2002). Initially used for orthodontic anchorage (Kanomie, 1997) and temporary fixation of transplanted teeth (Nagata and Nagata, 2002), MDIs are now more widely used as fixtures for both fixed and removable dental

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restorations. MDIs proving to be extremely valuable for edentulous patients who have loose fitting dentures (especially lower dentures) and want an easy solution to secure them in place (Shatkin et al., 2007); they can also be used as a base on which one or more missing teeth can be placed. In the edentulous arch, multiple MDIs have been found to be more stable than two Brånemark-type implants (English and Bohle, 2003). Decisions about the quality and quantity of bone available for MDI placement were made much easier with the use of CBCT (McEowen, 2011). MDIs are often placed immediately after tooth extraction, and careful restorative dentistry can begin immediately after implant placement (Christensen and Child, 2011; Richards, 2006). Restoration of single teeth, multiple teeth, and an entire dental arch can be accomplished, depending on the number of implants which can successfully be placed. There are substantial advantages to MDIs. Perhaps the most important advantages to the patient are decreased cost and decreased time until treatment is completed. The MDIs cost 25-50% as much to place as Brånemark-type implants, and since treatment can often commence immediately without the 4-6 month waiting period required for Brånemark-type implants to osseointegrate with the bone, total treatment time is greatly reduced. Also, the minimally invasive surgical insertion technique used for the MDI brings greater postoperative comfort and decreased morbidity for the patient, allowing patients with health problems who formerly would have been precluded from extensive surgical procedures the option of dental implants to stabilize restorative dentistry (Choi, 2007). Conclusions Dentistry has been technology-driven from its inception. Huge advances have been made in many areas of dentistry in the past 25 years, and many have been driven by new technologies. There seems no reason why this trend should not be expected to change. Who knows what dentistry 25 years from now will be like? REFERENCES AAE Position Statement (2012), “Use of Microscopes and Other Magnification Techniques,” American Association of Endodontists, downloaded July 9, 2012 from http://www.aae.org/ uploadedFiles/Publications_and_Research/Guidelines_and_Position_Statements/microscopesstatement.pdf. Alwas-Danowska, Hanna M., Alphons J. Plasschaert, Stanislaw Suliborski, and Emiel H. Verdonschot (2002), “Reliability and Validity Issues of Laser Fluorescence Measurements in Occlusal Caries Diagnosis,” Journal of Dentistry, 30 (4), 129-134. Anonymous (2006), “A Review of Electric Handpieces,” Dental Economics, 96 (11), downloaded July 9, 2012 from http://www.dentaleconomics.com/articles/print/volume-96/issue-11/features/a-review-of-electric-handpieces.html Anonymous (2010), “Advancements in Dentistry,” Articlebase: Free Online Articles Directory, downloaded July 4, 2010 from http://www.articlesbase.com/dental-care-articles/advancements-in-dentistry-2512439.html Atlas, Alan M. (2011), “Handpiece and Diamond Selection,” Inside Dentistry, 7 (9), downloade d July 10, 1012 from http://www.dentalaegis.com/id/2011/10/handpiece-and-diamond-selection Bader, James D. and Dan A. Shugars (2004), “A Systematic Review of the Performance of a Laser Fluorescence Device for Detecting Caries, Journal of the American Dental Association, 135 (10), 1413-1426. Balkin, Burton E., David E. Steflik and Francie Naval (2001), “Mini -Dental Implant Insertion with the AutoAdvance Technique for Ongoing Applications,” Journal of Oral Implantology, 27 (1), 32 -37.

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Barrett, Stephen (2011), “ViziLite Screening: Does It Make Sense?” Dental Watch, downloaded July 9, 2012 from http://www.dentalwatch.org/questionable/vizilite/overview.html. Baghdadi, Ziad D. (1999), “Evaluation of Electronic Dental Anesthesia in Children,” Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology, 88 (4), 418-423. Belden, Heidi (2008), “OraVerse Is FDA Approved for the Reversal of Dental Anesthesia,” Drug Topics, downloaded July 12, 2012 from http://drugtopics.modernmedicine.com/drugtopics/ Treatment+Areas/OraVerse-isFDA-approved-for-the-reversal-of-denta/ ArticleStandard/ Article/detail/517205 Birnbaum, Nathan S. and Heidi B. Aaronson (2011), “Digital Dental Impression Systems,” Inside Dentistry, 7 (2), downloaded July 10, 2012 from http://www.dentalaegis.com/id/ 2011/02/digital-dental-impression-systems Block, Michael S., Armando Delgado, and Mark G. Fontenot (1990), "The Effect of Diameter and Length of Hydroxyapatite-Coated Dental Implants on Ultimate Pullout Force in Dog Alveolar Bone," Journal of Oral and Maxillofacial Surgery, 48 (2), 174–178. Carr, Alan (2011), “OraVerse: Reversing Dental Numbness,” Mayo Clinic website, downloaded July 12, 2012 from http://www.mayoclinic.com/health/oraverse/AN02002/ Challenger, John A. (2000), “24 Trends Reshaping the Future,” The Futurist, 34 (5), 35 -41. Child, Paul L., Jr. (2011), “Digital Dentistry: Is This the Future of Dentistry?” Dental Economics, 101 (10), Downloaded July 4, 2012 from http://www.dentaleconomics.com/articles/ print/volume-101/issue10/features/digital-dentistry-is-this-the-future-of-dentistry.html Choi, Raymond (2007), “Incorporating Mini -Implants within the General Dental Practice,” Practical Procedures in Aesthetic Dentistry, 19 (6, Supplement), 1-5. Christensen, Gordon J. (2002), “Are Electric Handpieces an Improvement?” Journal of the American Dental Association, 133 (10): 1433-1434. Christensen, Gordon J. (2011), “New Caries Detection Systems: Reliable and Accurate,” Clinicians Report, 4 (11), 1-3. Christensen, Gordon J. and Paul L. Child (2011), “The Truth about Small -Diameter Implants,” Inclusive: Restorative Driven Implant Solutions, 2 (2), 6-9. “Dentistry Today (2012), “DentalVibe,” Dentistry Today, downloaded August 26, 2012 from http://dentistrytoday.com/top25endo-d01/7238-dentalvibe. “Dentalcompare Releases” (2012), “Dentalcompare Releases Comprehensive Report on Dental Handpiece Usage Within the US,” CompareNteworks, downloaded August 26, 2012 from http://corp.comparenetworks.com/Press Room/112219-Dentalcompare-Releases-Comprehensive-Report-on-Dental-Handpiece-Usage-Within-the-US/. “Dentalcompare's Survey (2012), “Dentalcompare's Survey on Dental Handpiece Usage within the United States,” Dentalcompare, downloaded August 26, 2012 from http://www.dentalcompare.com/Featured-Articles/111744Dental-Handpiece-Usage-within-the-United-States/.

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Dhindsa, Abhishek, I. K. Pandit, Nikhil Srivastava, and Neeraj Gugnani (2011), “Comparative Evaluation of the Effectiveness of Electronic Dental Anesthesia with 2% Lignocaine in Various Minor Pediatric Dental Procedures: A Clinical Study,” Contemporary Clinical Dentistry, 2 (1), 27 -30. Diaz, Jesus (2010), “New Gadget Eliminates Pain in Dental Injections by Tricking Your Brain,” Gizmodo, downloaded August 29, 2012 from http://gizmodo.com/5485007/new-gadget-eliminates-pain-in-dental-injectionsby-tricking-your-brain. English, C. E. and George C. Bohle (2003), “Diagnostic, Procedural, and Clinical Issues with the Sendax Mini Dental Implants,” Compendium, 24 (11 Supplement 1), 1-23. Epstein, J. B., S. Silverman, Jr., J. D. Epstein, S. A. Lonky, and M. A. Bride (2008), “Analysis of Oral Lesion Biopsies Identified and Evaluated by Visual Examination, Chemiluminescence and Toluidine Blue,” Oral Oncology, 44 (6), 538-544. Friedman, Mark J. and Mark K. Hochman (1998), “The AMSA Injection: A New Concept for Local Anesthesia of Maxillary Teeth Using a Computer-controlled Injection System,” Quintessence International, 29 (5), 297 -303. Gakenheimer, David C. (2002) “The Efficacy of a Computerized Caries Detector in Intraoral Digital Radiography,” Journal of the American Dental Association, 133 (7), 883-890. Garg, A. K. (2008), “Cadent iTero's Digital System for Dental Impressions: The End of Trays and Putty?” Dental Implantology Update, 19 (1), 1-4. Gunnam, Rajesh (2008), “Dental Devices Market to 2016 - Cosmetic Dentistry and Dental Implants to be the Key Growth Drivers,” EzineMark.com, downloaded July 4, 2012 from http://dental.ezinemark.com/dental -devicesmarket-to-2016-cosmetic-dentistry-and-dental-implants-to-be-the-key-growth-drivers-16730751cd2.html. Hegde, Vivek S. and Roheet A. Khatavkar (2010), “A New Dimension to Conservative Dentistry: Air Abrasion,” Journal of Conservative Dentistry, 13 (1), 4-8. Helfer, Allen R. (2008), “Profound Anesthesia Made Easy with the STA System,” Endo Tribune, November, 10 -11, downloaded July 9, 2012 from http://www.milestonescientific.com/ pdfs/endo_nov08.pdf. Hersh, Elliot V., Paul A. Moore, Athena S. Papas, J. Max Goodson, Laura A Navalta, Siegfried Rogy, Bruce Rutherford, John A. Yagiela, and the Soft Tissue Anesthesia Recovery Group (2008), “Reversal of Soft -Tissue Local Anesthesia with Phentolamine Mesylate in Adolescents and Adults,” Journal of the American Dental Association, 139 (8), 1080-1093. Huff, Kevin, Paul C. Stark, and Lynn W. Solomon (2009), “Sensitivity of Direct Tissue Fluorescence Visualization in Screening for Oral Premalignant Lesions in General Practice,” General Dentistry, 57 (1), 34 -38. Hughes, Kate (2012), “Social Media: Connecting Patients and Practices,” Inside Dentistry, 8 (5), downloaded July 5, 2012 from http://dentalaegis.com/id/2012/05/social-media. Ismail, Amid I. (2004), “Visual and Visuo-tactile Detection of Dental Caries,” Journal of Dental Research, 83 (supplement 1), C56-C66. Kanomi, R. (1997), “Mini-implant for Orthodontic Anchorage,” Journal of Clinical Orthodontics, 31 (11), 763 - 767.

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Kerr, Alexander Ross, David A. Sirois, and Joel B. Epstein (2006), “Clinical Evaluation of Chem iluminescent Lighting: An Adjunct for Oral Mucosal Examinations,” Journal of Clinical Dentistry, 17 (3), 59 -63. Kurtzman, Gregori M. (2007), “Electric Handpieces: An Overview of Current Technology,” Inside Dentistry, 3 (2), downloaded August 26, 2012 from http://www.dentalaegis.com/id/2007/ 02/focus-on-electric-handpieces-anoverview-of-current-technology. Lark, Matthew R. (1998), “How Cone Beam Technology Revolutionized my Practice,” Dental Economics, 98 (6), downloaded July 2011 from http://www.dentaleconomics.com/articles/print/ volume-98/issue-6/features/focuson/how-cone-beam-technology-revolutionized-my-practice.html Lipscomb, Jason (2012), “Social Media for the Savvy Dentist,” American Dental Association, podcast #23, available at http://www.ada.org/51.aspx#Episode23. Lodaya, Rahul, Chetan Bhat, Sachin C. Gugwad, Preetam Shah, and Dayand Shirol 2011), “Clinical Evaluation of Transcutaneous Electrical Nerve Stimulation (TENS) for Various Treatment Procedures in Pediatric Dentistry,” International Journal of Clinical Dental Science, 1 (1), 20-25. Lussi, A. and E. Hellwig (2006), “Performance of a New Laser Fluorescence Device for the Detection of Occlusal Caries in Vitro,” Journal of Dentistry, 34 (7), 467 -471. Marketwire Canada (2012), “VELscope Vx System Named "Best of Class" by Pride Institute,” MarketsNews & Commentary, downloaded July 9, 2012 from https://research.tdwaterhouse.ca/ research/public/Markets/NewsArticle/100-164u0169-1 McEowen, Daniel (2011), “Missed Diagnosis Using Conventional 2 -D Radiography,” Inclusive: Restorative Driven Implant Solutions, 2 (3), 14-17. Miglani, Rohit, Neeraj Taneja, Rajul Mehta, and Rajnish Bansal (2011), “Lasers in Restorative Dentistry,” Journal of the Indian Dental Association, 5 (1), 66-68. Mitsuhsahi, Akira, Noriko Mutoh, Tetsuya Hirata, and Nobuyuki Tani-Ishii (2009), “Precision Treatment with the Dental Operating Microscope: Analysis of Microleakage and Marginal Adaptation Using MTA Cement,” International Journal of Microdentistry, 1 (1), 56-60. Nagata, M, and S. Nagata (2002), “Mini-implant Is Effective as a Transitional Fixation Anchorage for Transplantation of Teeth,” Japanese Journal of Conservative Dentistry, 45, 69 -73. Nesari, Royeen, Louis E. Rossman, and Samuel I. Kratchman (2009), “Cone -Beam Computed Tomography in Endodontics: Are We There Yet?” Compendium of Continuing Education in Dentistry, downloaded July 4, 2012 from http://www.cdeworld.com/courses/12-cone-beam-computed-tomography-in-endodontics-are-we-there-yet Oh, Ester S. and David N. Laskin (2007), “Efficacy of the ViziLite System in the Identification of Oral Lesions,” Journal of Oral and Maxillofacial Surgery, 65 (3), 424-426. Pretty, Iain I. (2006), “Caries Detection and Diagnosis: Novel Technologies,” Journal of Dentistry, 34, 727-739. Ranft, Lesli (2009), “Dental Technologies: The Leading Edge of Dental Care,” Consumer Guide to Dentistry, downloaded July 4, 2012 from http://www.yourdentistryguide.com/dental-technologies/.

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Ravela, E. D., E. F. de Guzman, A. V. Masa, J. C. Locs in, K. S. Ahn, and H. G. Uy (1995), “Electronic Dental Anesthesia Versus Topical Anesthesia for the Control of Pain Caused by Nasopalatine Block Injections,” Journal of the Philippine Dental Association, 47 (2), 35-43. Rice, Janet Hatcher (2011), “Erbium Laser Technology,” Dentistryiq, downloaded July 10, 2012 from http://www.dentistryiq.com/articles/wdj/print/volume-1/issue-4/science/erbium-laser-technology.html Richards, Dell (2006), “Looks, Ease Driving Use of Mini-implants,” California Dental Association Journal, 34 (8), 577-579. Selden, Howard S. (2002), “The Dental-Operating Microscope and Its Slow Acceptance,” Journal of Endodontics, 28 (3), 206-207. Shatkin, Todd E., Samuel Shatkin, Benjamin D. Oppenheimer, and Adam J. Oppenheimer (2007), "Mini Dental Implants for Long Term Fixed and Removable Prosthetics: A Retrospective Analysis of 2514 Implants Placed over a Five Year Period," Compendium, 28 (2), 36 –41. Siddiqui, Azfar A., Mark Sosvicka and Mark Goetz (2006), “Use of Mini Implants for Replacem ent and Immediate Loading of 2 Single-Tooth Restorations: A Clinical Case Report,” Journal of Oral Implantology, 32 (2), 82 -86. Simon, Harel and Angelo A. Caputo (2002), “Removal Torque of Immediately Loaded Transitional Endosseous Implants in Human Subjects,” International Journal of Oral and Maxillofacial Implants, 17 (6), 839 -845. Sirona Dental Systems LLC (2011), “Sirona Advances CAD/CAM to Help Dentistry Go Digital,” Compendium, 32 (4), downloaded July 2012 from http://www.dentalaegis.com/cced/ 2011/05/sirona-advances-cad-cam-to-helpdentistry-go-digital Tavares, Mary, J. Max Goodson, Deborah Studen-Pavlovich, John A. Yagiela, Laura A. Navalta, Siegfried Rogy, Bruce Rutherford, Sharon Gordon, Athena S. Papas, and the Soft Tissue Anesthesia Reversal Group (2008), “Reversal of Soft-Tissue Local Anesthesia With Phentolamine Mesylate in Pediatric Patients,” Journal of the American Dental Association, 139 (8), 1095-1104. Truelove, Edmond L., David Dean, Samuel Maltby, Matthew Griffith, Kimberly Huggins, Mickealla Griffith, and Stuart Taylor (2011), “Narrow Band (Light) Imaging of Oral Mucosa in Routine Dental Patients. Part I: Assessment of Value in Detection of Mucosal Changes,” General Dentistry, 59 (4), 281 -289.

David P. Paul, III Leon Hess Business School Monmouth University

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IMPORTANCE OF NEW TECHNOLOGIES FOR DIABETES MONITORING
David P. Paul, III, Monmouth University Joey Priest, Marshall University Zach Garrett, Marshall University Alberto Coustasse, Marshall University

ABSTRACT Diabetes and its ramifications and treatments are presented, followed by discussion of the importance of communication between patient and clinician. Improved communication approaches, including telephone consultations, blood glucose communications to a provider with feedback, and active electronic diaries on smartphones for both type 1 and type 2 diabetes mellitus, are reviewed.

WHAT EXACTLY IS DIABETES? Diabetes is a metabolic disease: a disorder of how the body uses food. Most of the food eaten is digested into glucose, which enters into the bloodstream, where cells use it for growth and energy. Insulin, a hormone produced by the pancreas, must be present for glucose to be absorbed into cells. Normally, when people eat, the pancreas produces the proper amount of insulin necessary for glucose to be moved from the blood stream into the cells. In individuals with diabetes the pancreas produces either insufficient or no insulin, or the body’s cells do not respond correctly to the insulin which is produced. The net result: the body loses its fuel source even though the bloodstream contains more than sufficient glucose. Three types of diabetes mellitus exist: (1) type 1 diabetes (formerly called juvenile diabetes); (2) type 2 diabetes (formerly called adult onset diabetes); and (3) gestational diabetes. Type 1 diabetes accounts for about 510% of diagnosed diabetes in the U.S. and occurs mostly in children and young adults but can appear at any age (“Types of Diabetes”, 2012). It occurs because the body’s immune system attacks and destroys the insulinproducing cells in the pancreas. If not diagnosed and treated with insulin, an individual with type 1 diabetes can lapse into a life-threatening coma, called diabetic ketoacidosis. Most people who develop type 1 are otherwise healthy (Kasper et al., 2005). About 90-95% of diabetics have type 2 diabetes, which is most often associated with older age, obesity, family history of diabetes, previous history of gestational diabetes, physical inactivity, and certain ethnicities. About 80% of people with type 2 diabetes are overweight or obese. In 2010, type 2 diabetes was diagnosed in more than 25.8 million adults over the age of 20 in the U.S., while another 7.1 million went undiagnosed; 81.5 million had prediabetes (Roger et al., 2011). The prevalence of type 2 diabetes in all age, gender and ethnic groups in the U.S. is expected to more than double (from a prevalence of 5.6% to a prevalence of 12%) between 2005 and 2050 (Narayan et al., 2006). Type 2 diabetes is increasingly being diagnosed in children and adolescent. When type 2 diabetes is diagnosed, the pancreas is usually producing sufficient insulin, but for unknown reasons the insulin cannot be used effectively by the body and eventually a decrease in insulin production occurs. The result is the same as for type 1 diabetes: glucose increases in the blood and the body cannot use of its main source of fuel efficiently. Clearly, type 2 diabetes is a significant and growing medical problem in the U.S. Some women develop gestational diabetes during pregnancy. Although gestational diabetes usually disappears postpartum, women who have had it have a 40-60% likelihood of developing type 2 diabetes within 5 to 10 years. Maintaining a reasonable body weight and being physically active may help prevent development of type 2 diabetes.

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Whatever the type, diabetes is associated with multiple long-term complications affecting virtually all parts of the body. The disease often leads to blindness, heart and blood vessel disease, stroke, kidney failure, amputations, and nerve damage (American Diabetes Association, 2010). Uncontrolled diabetes can complicate pregnancy, and birth defects are more common in babies born to women with diabetes. Before the discovery of insulin in 1921, a diagnosis of type 1 diabetes was a death sentence – all patients died within a few years after diagnosis. Insulin, while not a cure, was the first major breakthrough in the treatment of diabetes. Basic therapies for type 1 diabetes include healthy eating, physical activity, and taking insulin; basic treatment for type 2 diabetes are the same as for type 1, except that oral medication may be substituted for insulin. Blood glucose levels should be closely monitored through frequent blood glucose checking; patients with diabetes should also monitor blood glucose levels several times a year with a laboratory test called the HbA1c, results of which reflect average blood glucose levels over a 2-3 month period. This entire monitoring procedure has been characterized by many diabetics as complex (Kouris et al., 2010) People with diabetes should see a health care provider who will help them learn to manage their diabetes and who will monitor and assist in their diabetes control. Most people with diabetes receive care from primary care physicians—internists, family practitioners, or pediatricians but occasionally a team of providers is necessary to manage diabetes care successfully. The goal of diabetes management is to keep levels of blood glucose, blood pressure, and cholesterol as close to the normal range as safely possible. People with diabetes must take responsibility for their day-to-day care, much of which involves keeping blood glucose levels from going too low or too high. When blood glucose levels drop too low a person can become nervous, shaky, and confused. Judgment can be impaired, and if blood glucose falls too low, fainting can occur. A person can also become ill if blood glucose levels rise too high. USES OF COMMUNICATION TECHNOLOGIES IN DIABETES The healthcare industry is slowly adopting new strategies to deal with the swelling prevalence of chronic disease, including diabetes, due largely to market dynamics. Healthcare organizations constrained by revenues and less than adequate tools to manage chronic care patients systematically are changing from being centered on the provider to more centered on the patient. Unfortunately, traditional forms of patient communication have not been particularly effective in improving patient adherence to lifestyle and medical lifestyle changes (Boland, 2006). However a host of new communication and remote monitoring technologies are becoming available so that providers can interact with patients virtually “anywhere, anytime” (Boland, 2007). Health authorities seem to have high expectations for telemedicine (Brown, et al., 2007; Franc et al, 2011), which addresses several major challenges: improved access to healthcare (especially for patients in remote or underserved areas); assistance in overcoming the scarcity of qualified clinicians in the face of a diabetes epidemic; and the reduction of costs while improving (or, at least, maintaining) quality. The aims of telemedicine in the field of diabetes differ according to the type of diabetes. In type 1 diabetes which is associated with relatively complex insulin regimens, the goal of telemedicine is to assist patients in achieving better blood glucose control via more accurate adjustment of insulin doses. In type 2 diabetes there are two basic goals of telemedicine: (1) accurate and timely adjustment of insulin dosage and (2) improvement in blood glucose control by means of dietary and/or physical activity changes. Currently, there appear to be two promising approaches (Franc et al, 2011): (1) hand-held communication devices, especially smartphones, have been shown to improve blood glucose control. These systems can provide immediate patient assistance (e. g., insulin-dose calculation for specific meals and/or food choices), and all data stored in the device can be transmitted to authorized caregivers, enabling remote monitoring and even teleconsultation. Although these systems were initially developed for type 1 diabetes, they also appear to offer many possibilities for type 2 diabetes as well. systems combining an interactive Internet system (or a mobile phone coupled to a remote server) with a system of communication between the patient and the healthcare provider (e.g., by e-mail, texting or telephone calls) have also been demonstrated to be beneficial for blood glucose control. Primarily aimed at patients with type 2 diabetes, these systems generally provide patient motivational support as well.

(2)

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TYPE 1 DIABETES STUDIES Telephone Consultations Several studies (Ładyzynski and Wójcicki, 2007; Lehmkuhl et al., 2010) reported on use of traditional (i.e., landline) telephone contacts to better manage type 1 diabetes. Despite somewhat different protocols, both reported that both experimental and control groups demonstrated decreased mean HbA1c levels at the program, but neither group’s decrease was statistically significant. Another study (Thompson, Kozak, and Sheps, 1999) did yield significant results. Regular telephone contacts were proposed for patients with poorly controlled type 1 diabetes (HbA1c > 8.5%). Patients in the experimental group had 15 minute telephone contacts three times a week. After 6 months, the mean HbA1c in this group had decreased from 9.6% to 7.8% while in the standard-care control group, the decrease in mean HbA1c was from 9.4% to only 8.9%. This difference in mean improvement in HbA1c levels between the two groups was statistically significant (P < 0.01) and clinically relevant, and therefore the system was considered effective, as (the researchers noted) would any system involving close management of diabetic patients. However, patient follow-up was expensive: nurses spent an average of 17.25 hours per week calling patients, the equivalent of an almost halftime employee to cover 23 patients. Mobile telephone communications allow interaction with individuals more frequently and while those individuals’ behavior is actually occurring, making potential interventions more effective (Hitman, 2011; Riley et al., 2011). As of December 2011, there were over 331.6 million wireless telephone subscribers in the US, a 39% increase in 5 years (CITA Advocacy, 2012), and an estimated 78% worldwide owned cell phones in 2010, the latest data available (Sanou, 2011). The vast use of cellular phones should make this type of communication system a very viable option (Brown, et al., 2007), as cellular phones have been demonstrated to be especially suited for engaging the self-care of patients while leveraging providers’ the expertise and time (Boland, 2006, 2007). Measurable improvements, however, have not been demonstrated. The combination of a glucose meter combined with the battery pack of a cell phone to make the determination of blood glucose easier has been reported (Carroll, Marrero and Downs, 2007; Malasanos, 2008). Although this approach sounds promising, significant improvements in blood glucose control using it have not been demonstrated (Carroll et al., 2011). Blood Glucose Data Transmission to a Provider with Feedback Numerous studies have been published using different systems to transmit blood glucose data. These may be subdivided into three categories. The first consists of simple teletransmission of blood glucose values from a glucose meter with a memory function. Many such studies have been published, most sponsored by firms that market blood glucose meters. In one study (Montori et al., 2004), patients with type 1 diabetes who were poorly controlled despite receiving intensive insulin therapy sent their blood glucose data to the care team regularly over a 6-month period using a modem. The experimental group received telephone “feedback” from a nurse within 24 hours of each transmission, and these patients’ mean HbA1c levels decreased significantly ( p = 0.03). Reduction in mean HbA1c in the control group did occur, but was thought to be potentially related to a possible study effect. In another study, patients with type 1 diabetes and poorly controlled blood sugar transmitted their data regularly by telephone from a glucose meter (Jansà et al., 2004). After 6 months, both the experimental and control groups results were similar, but the experimental group’s costs were considerably higher than those of the control group. Nevertheless, more sophisticated systems have been developed. For example, in the Telematic Management of Insulin-Dependent Diabetes Mellitus (T-IDDM) project, patients were provided with desktop computers, allowing them to send data in addition to blood glucose values. Unfortunately, the preliminary results did not demonstrate significant changes in HbA1c (Bellazzi et al., 2002; d’Annunzio et al., 2003). Overall, the results of transmission of blood glucose values with retrospective feedback have been disappointing, regardless of the technology employed. One meta-analysis (Montori et al., 2004) included 7 randomized trials of type 1 diabetic adults showed statistically significant, but very limited (0.4%), improvement in HbA1c in the telemedicine group compared with controls, but this improvement was obtained only after one of the seven studies examined was excluded. These systems generally failed to incorporate truly effective feedback from

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the caregiver other than an increase in frequency of telephone contact with the patients, which is infeasible in routine practice in the long term. As a number of other studies (Lawson, 2005; Nunn, 2006; MacLean et al., 2012) have also failed to demonstrate a significant difference in HbA1c levels between experimental and control groups when telephone coaching alone was used, it appears safe to conclude that this approach is not particularly useful or costeffective. Active Electronic Diaries on Smartphones There is a growing interest in self-management of diabetes via mobile health applications. Chomutare et al. (2011) found 60 diabetes applications for iPhones; within a year and a half, the number had increased to 260 (over a 40% increase). Other mobile platforms reflect a similar trend. Complex systems can transmit data such as insulin intake, blood glucose, dietary consumption, and physical activity in a readily available format for the clinician, allowing more rapid help for patients in determining their appropriate insulin dose Kouris et al., 2010). A secure website coupled with a smartphone can easily do this (Gammon et al., 2005; Rossi et al., 2009), and is probably more attractive (as well as more prompt and accurate) than the traditional paper diary for patients with diabetes. Such a system has no autonomy or responsibility, but merely puts the data into an electronic format, with the insulin prescription remaining the physician’s sole responsibility. A number of researchers (Rami et al., 2006; Benhamou et al., 2007; Istepanian et al., 2009) have demonstrated that mobile communication tools can potentially enhance the cost effective self-management of diabetes and improve HbA1c levels. Several such systems are under development. One, the “Diabetes Interactive Diary” (DID) (Ro ssi et al, 2009) meets the above description, and also features an electronic illustrated food list, which allows patients to simply select the quantities and types of foods they intend to eat, and the software automatically calculates the equivalent amount of carbohydrates and insulin required (Rossi et al., 2011). Unfortunately, a weakness of the DID system is poor interaction with the doctor via text messages. Also, results have been mixed. Rossi et al. (2010) found little difference between control and experimental groups, with no significant difference in terms of decreased HbA1c levels (p = 0.68). Another system is the Diabeo system, which also incorporates the features previously discussed using a Personal Digital Assistant, but adds insulin doses for both basal and prandial blood glucose, and also for patients whose blood glucose falls regularly outside a predetermined range (“Multi -Technology Solutions”, 2012). Evaluations of the Diabeo system (Franc et al., 2009) showed good results for mean blood glucose values, which were quite similar pre- and post-meals. Excellent patient satisfaction was observed, with a large majority expressing the wish to continue using the system even at their own expense, rather than continuing to use a traditional passive glycemic diary. A 6-month multicenter randomized study using 80 adults with poorly controlled type 1 diabetes clearly showed marked metabolic improvement with the Diabeo system (Charpentier et al., 2011), and a follow-up study involving 700 patients and 100 healthcare professionals is planned for 2012 in France, where it will be the largest telemedicine study ever conducted in that country (“Clinical Results” , 2012). Type 2 Diabetes Studies As the prevalence of type 2 diabetes far exceeds that of type 1 diabetes, studies involving telemedicine for these patients have been done on a somewhat larger-scale. In addition to the studies previously described for type 1 diabetes which also used apply to type 2 diabetes, studies designed to inform and deliver an educational message to patients at a lower cost also exist. These systems generally allow patients to transmit a variety of additional useful data, in addition to blood glucose and HbA1c values, for diabetes management. Literature is reviewed using the following typology: Internet-based blood glucose control systems, systems using a cellphone connected to a remote server, and active electronic diaries on smartphones. Telephone Consultations Early studies (Weinberger et al., 1995; Aubert et al., 1998) showed nurses’ telephone follow -up of diabetic patients improved patients’ blood glucose. However, these early interventions proved expensive and timeconsuming. Telephone interventions using a call center manned by non-medical staff have also been tested. One such study was conducted in England. Using a call center to monitor a large population of type 2 diabetes patients

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with limited resources (Young et al., 2005) yielded a 0.31% reduction in HbA1c in the intervention group compared with the control group (P = 0.003). Other studies generally support the earlier findings. A 2000 study (Piette et al., 2000) involving 280 English- or Spanish-speaking adults with diabetes who were treated in a county health care system found that blood glucose levels were significantly (P = 0.002) lower among intervention patients than patients receiving traditional care; a 2001 study by Piette et al. (2001) of 272 diabetic VA patients, found that an intervention by telephone nurses resulted in a statistically significant (P = 0.04) reduction of HbA1c at one year. More recently, (Walker et al., 2011) conducted a study involving a low-income insured minority population with type 2 diabetes and poor blood glucose control. They showed modest results of a telephone compared to a printed intervention, with a small but statistically improvement in HbA1c (p = 0.009) between the two groups at 1 year. Unfortunately, the above results are not always seen. Krein et al. (2004) conducted a randomized controlled trial at two VA Medical Centers involving 246 veterans with poorly controlled diabetes. Two nurse practitioner case managers worked with patients and their primary care providers, monitoring and coordinating care for the intervention group through the use of telephone contacts, collaborative goal setting, and treatment algorithms. Control patients received educational materials and usual care from their primary care providers. After 18 months, the difference in HbA1c levels between the experimental and control groups was not statistically significant (P = 0.65), although the intervention patients were substantially more satisfied with their diabetes care. The combination of a glucose meter combined with the battery pack of a cell phone for the determination of blood glucose for type 1 diabetes was discussed earlier, and negative results were noted (Carroll et al., 2011). Interestingly, when this same approach was used for patients with type 2 diabetics, statistically significant (P = 0.01) improvements in blood glucose were observed (Cho et al., 2009). There are now 3 such Smartphone apps available on the market (Lieberman, 2012). These results, based upon quite different population types, suggest that a simple inexpensive telephone intervention by non-clinical health educators can be useful. Blood Glucose Data Transmission with Feedback from a Provider Internet-Based Blood Glucose Control Systems The use of computers by the public continues to increase, and many patients use this medium to find information about healthcare (Noh et al., 2010). The most frequently used technology in diabetes management is the Internet, which has been shown to increase patients’ knowledge, support their engagement with treatment, increase patients’ self-efficacy, and facilitate behavior change (Brown, Lustria, and Rankins, 2007). Some approaches have been aimed at indirect control of blood glucose levels; e.g., through weight reduction or increased physical activity. An Internet-based supplement to traditional diabetes care used the remote intervention of coach in an attempt to increase patients’ physical activity. This system was evaluated in 78 sedentary type 2 diabetes patients over 8 weeks. A moderate increase in physical activity was found in the experimental group as opposed to the control group, but the lack of objective measures of blood glucose or HbA1c made evaluation of the true effectiveness of this approach impossible (McKay et al., 2001). Examining effects of diet, Tate, Jackvony, and Wing (2003) showed that Internet-based behavioral counseling significantly (P = 0.04) improved weight loss in overweight and obese adults at risk of type 2 diabetes. Patients received weekly counseling and feedback via e-mail after submitting calorie and exercise information. Unfortunately, as with the McKay et al., 2001) study, objective measures of improvement of type 2 diabetes were not reported. Systems Using a Cell Phone with a Remote Server The ubiquitous spread of cellphones among the US population has already been discussed. Krishna and Boren (2008), in a review of the literature, found that 9 out of 10 studies that examined the use of a cell phone for health information for persons with diabetes or obesity reported significant improvement in HbA1c levels of experimental groups. Quinn et al. (2008), in a small study (30 patients), found that patients receiving real-time cellphone feedback regarding blood glucose levels analyzed by WellDoc proprietary software had significantly decreased (P < 0.02) decreased HbA1c levels compared with patients not receiving such feedback. In a study

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involving cell phone use and the internet for overweight patients with type 2 diabetes, Yoo et al. (2009) found statistically significant reduction of HbA1c in their experimental group, but as the study was short (only 12 weeks), it could not be determined if the effects observed were long-term ones or not. The combination of mobile behavioral coaching and lifestyle behavior, blood glucose data, and patient self-management data individually analyzed and presented with evidence-based guidelines to providers significantly (P = 0.001) reduced HbA1c levels over 1 year (Quinn et al 2011). Other systems have been tested using dedicated computers allowing patients to transmit more complex data from their homes. The Informatics for Diabetes Education and Telemedicine (IDEATel) study (Shea, 2007; Shea et al., 2009) was a large (1665 participants) randomized trial involving older, ethnically diverse, medically underserved, Medicare beneficiaries with type 2 diabetes. Participants in the intervention group received a computer with Internet access via modem to an existing telephone line and videoconferencing capabilities. The patients’ existing primary care physicians were contacted when a case managed determined that a change in patient management was indicated. The intervention group had a statistically significant decrease in HbA1c relative to usual care (P = 0.001), but the decrease was not deemed to be clinically significant. Unfortunately, no Medicare cost savings were observed (Moreno et al., 2008). Other Internet-based systems for the management of patients with poorly controlled type 2 diabetes showed more favorable results. In one (McMahon et al., 2005), all patients attended a half-day diabetes educational meeting, and the interventional group patients met with a team of educators consisting of a pharmacist, a nurse, and a nutritionist. This group also received an electronic notebook, and a system for the home monitoring of their blood glucose. They had access to a secure website from which data from the monitoring system could be viewed (by both patients and caregivers), and provided diabetes educational modules, and the capability for patients to communicate with caregivers. A statistically significant reduction in HbA1c was achieved in both groups (P < 0.001) at 3, 6, 9 and 12 months from baseline, and was greater at 12 months in the interventional group compared with the control group (P < 0.05). Unfortunately, results in a more recent study (Fonda et al., 2009) were not impressive. Fonda et al. (2009) used a small sample (52 each in experimental and control groups) where the experimental group received a notebook computer, a glucose meter, training in the use of these devices, toll-free dial-up Internet service, and secure access to the study website. Subjects interacted with the study’s advanced practice nurse (a certified diabetes educator) both via the internal messaging system of the computer and occasionally through telephone contact. The Web site accepted electronic transmissions from the glucose monitoring devices and displayed these data in graphic and tabular form for both the subject and the nurse to review. Subjects could send and receive secure messages to and from the care manager. Web-enabled diabetes educational modules and links to other Web-based diabetes resources were provided. After 12 months, decreases in HbA1c in the experimental group, although observed, were not statistically significant (P = 0.25). Recently, an Internet-based patient monitoring system which involves no active clinician input has been noted (Lim et al., 1022), relying instead on a “rule engine” based on the clinical guidelines of the American and Korean Diabetes Associations. Patients were send weekly directions based upon their weekly and monthly blood glucose and HbA1c levels. The mean HbA1c and fasting blood glucose levels during the study decreased significantly in experimental group compared with the control group (P = 0.007). Because this system allows patients to make self-adjustments to their treatment based on automatic algorithms, it enhances patient empowerment in diabetes care. The preponderance of evidence seems to support the use of mobile telephones combined with web-based electronic communications for better control of blood glucose for type 2 diabetics. Based upon a meta-analysis of English-language articles published between January 2002 and March 2012, ( Liu and Ogwu, 2012, 17) concluded that “overall, significant improvements were observed in blood glucose and/or HbA1c concentration” when mobile telephone interventions and mobile telephones were used. RESULTS The effect of patients using blood glucose monitors alone has shown to have little improvement of diabetes health, but does improve patient education of overall health and what factors may be necessary for successful improvements. As new technologies have been developed in the self-management of diabetes, these devices can help to achieve and maintain blood glucose targets by improving the overall capability of monitoring glucose levels (Boyle, 2008).

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Telemedicine shows great promise in the monitoring and treatment of diabetes patients (Brown, et al., 2007; Franc et al, 2011). Telemedicine allows the physician to monitor a patient via the web, without having to make a trip to the doctor’s office. The total cost of these monitoring systems can be quite variable, ranging from five dollars per patient to $6,340 (Jackson et al., 2006). Results for effectiveness of diabetes technology varied with the different comparisons of monitoring systems and technological preventative tools; improvements in HbA1c were often significant, albeit relatively small. Discussion This study reviewed new technological approaches to the monitoring and control of blood glucose. The results demonstrated that using technologies such as cell phones, wireless blood glucose monitoring devices, and the internet to monitor blood glucose may be beneficial to both the patient and the physician. The patients benefit from these technologies was by allowing for continuous and real time monitoring of their blood glucose levels. Physicians benefited by improving the quality and productivity of their care giving. New technologies have been demonstrated to have had a positive effect on diabetes monitoring, and new applications continue to be developed. The Ford Motor Co. and Medtronic have developed a blood glucose monitoring system that can be worn by the driver or passenger, and monitors the blood glucose levels of the person by using Bluetooth technology to link up to the very popular Sync system developed by Microsoft which is installed in many Ford vehicles. The program can place glucose levels, signs and symptoms of confusion, blurry vision and lightheadedness for passengers wearing the device when levels become too low alerting one to take proper action at the appropriate time reducing the risk hypoglycemia and dangerous risk factors for driving. Ford has even recently released a prototype automobile app featuring both a Bluetooth-enabled in-dash continuous glucose monitoring device and a voice controlled cellphone-based diabetes monitoring service which could potentially decrease risks, accidents or deaths (Tenderich, 2011). Current systems for continuous glucose monitoring (CGM) are the result of progressive technological improvement, and beneficial effects on glucose control have increasingly been demonstrated. Developing and as yet unknown technologies should only be more exciting and potentially effective in patients’ contribution to diabetes self-management in the future. Conclusions The utilization of current and future HIT have been shown to have a positive effect on both type 1 and type 2 diabetes monitoring. Specifically, smartphones and telemedicine have also been shown to be effective in blood glucose monitoring. REFERENCES American Diabetes Association (2010), “Standards of Medical Care in Diabetes – 2011,” Diabetes Care, 34 (Supplement 1), S11-S61. American Diabetes Association (2012). Prevention or Delay of Type 2 Diabetes. Retrived on November 3, 2012 from http://care.diabetesjournals.org/content/27/suppl_1/s47.full d’Annunzio, Giuseppe, Riccardo Bellazzi, Cristiana Larizza , Stefania Montani, Cristina Pennati, Claudia Castelnovi, Mario Stefanelli, Giorgio Rondini, Renata Lorini (2003), “Telemedicine in the Management of Young Patients with Type 1 Diabetes Mellitus: A Follow-Up Study,” Acta Bio-Medica, 74 (Supplement 1), 49-55. Aubert, Ronald E., William H. Herman, Janice Waters, William Moore, David Sutton, Bercedis L. Peterson, Cathy M. Bailey, and Jeffrey P. Koplan (1998), “Nurse Case Management To Improve Glycemic Control in Diabetic Patients in a Health Maintenance Organization: A Randomized, Controlled Trial,” Annals of Internal Medicine, 129 (8), 605-612.

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Benhamou, P.-Y., V. Melki, R. Boizel, F. Perreal, J. L. Quesada, S. Bessieres-Lacombe, J.-L. Bosson, S. Halimi, and H. Hanaire (2007), “One-Year Efficacy and Safety of Web Based Follow-Up Using Cellular Phone in Type 1 Diabetic Patients under Insulin Pump Therapy: The Pumpnet Study,” Diabetes & Metabolism, 33 (3), 220-226. Bellazzi, R., C. Larizza, S. Montani, A. Riva, M. Stefanelli, G. d’Annunzio, R. Lorini, .J. Gomez, E. Hernando, E. Brugues, J. Cermeno, R. Corcoy, A. de Leiva, C. Cobelli, G. Nucci, S. Del Prato, A. Maran, E. Kilkki, and J. Tuominen (2002), “A Telemedicine Support for Diabetes Management: The T-IDDM Project,” Computer Methods and Programs in Biomedicine, 69 (2), 147–161. Boland, Peter (2006), “Better Health Well in Hand. Cell Phones Have the Capacity to More Frequently and Efficiently Connect Chronically Ill Patients with Caregivers,” Healthcare Informatics, 23 (4), 56-57. Boland, Peter (2007), “The Emerging Role of Cell Phone Technology in Ambulatory Care,” Journal of Ambulatory Care Management, 30 (2), 126-133. Boyle, Mary E. (2008),”Optimizing the Treatment of Type 2 Diabetes Using Current and Future Insulin Technologies,” MEDSURG Nursing, 17 (6), 383-390. Brown, Linda Lockett, Mia Liza A. Lustria, and Jenice Rankins (2007), “A Review of Web-Assisted Interventions for Diabetes Management: Maximizing the Potential for Improving Health Outcomes,” Journal of Diabetes Science and Technology, 1 (6), 892–902. Carroll, Aaron E., D. G. Marrero, and S. M. Downs (2007), “The HealthPia GlucoPack Diabetes Phone: A Usability Study,” Diabetes Technology and Therapeutics, 9 (2), 58-164. Carroll, Aaron E. Linda A. DiMeglio, Stephanie Stein, and David G. Marrero (2011), “Using a Cell Phone–Based Glucose Monitoring System for Adolescent Diabetes Management,” The Diabetes Educator, 37 (1), 59-66. CITA Advocacy (2012), “Wireless Quick Facts: Year End Figures,” Downloaded September 25, 2012 from http://www.ctia.org/advocacy/research/index.cfm/AID/10323 Charpentier, G. P.-Y. Benhamou, D. Dardari, A. Clergeot, S. Franc, P. Schaepelynck Belicar, B. Catargi, V. Melki, L. Chaillous, A. Farret, J.-L. Bosson, A. Penfornis, on Behalf of the TeleDiab Study Group (2011), “The Diabeo Software Enabling Individualized Insulin Dose Adjustments Combined with Telemedicine Support Improves HbA1c in Poorly Controlled Type 1 Diabetic Patients: A 6-month, Randomized, Open-Label, Parallel-Group, Multicenter Trial (TELEDIAB 1 Study),” Diabetes Care 34 (3), 533-539. Cho, J. H., H. C. Lee, D. J. Lim, H. S. Kwon, and K. H. Yoon (2009), “Mobile Communication Using a Mobile Phone with a Glucometer for Glucose Control in Type 2 Patients with Diabetes: As Effective as an Internet-Based Glucose Monitoring System,” Journal of Telemedicine and Telecare, 15 (2), 77-82. Chomutare, Taridzo, Luis Fernandez-Luque, Eirik Årsand, and Gunnar Hartvigsen (2011), “Features of Mobile Diabetes Applications: Review of the Literature and Analysis of Current Applications Compared Against EvidenceBased Guidelines,” Journal of Medical Internet Research, 13 (3), e65. Downloaded August 31, 2012 from URL: http://www.jmir.org/2011/3/e65/ “Clinical Results” (2012), “Clinical Results: TELEDIAB 1 Study (2007-2009,” Voluntis Connected Therapeutics. Downloaded October 10, 2012 from http://www.voluntis.com/en/therapeutic-solutions/clinical-results.html Fischer, Henry H., Susan L. Moore, David Ginosar, Arthur J. Davidson, Cecilia M. Rice-Peterson, Michael J. Durfee, Thomas D. Mackenzie, Raymond O. Estacio, and Andrew W. Steele (2012), “Care by Cell Phone: Text Messaging for Chronic Disease Management,” American Journal of Managed Care, 18 (2), e42-e47.

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Fonda, Stephanie J., Graham T. McMahon, Helen E. Gomes, Sara Hickson, and Paul R. Conlin (2009), “ Changes in Diabetes Distress Related to Participation in an Internet-Based Diabetes Care Management Program and Glycemic Control,” Journal of Diabetes Science and Technology, 3 (1), 117-124.

Franc, S., A. Daoudi, S. Mounier, B. Boucherie, D. Dardari, H. Laroye, B. Neraud, E. Requeda, L. Canipel, and G. Charpentier (2011), “Review Telemedicine and Diabetes: Achievements and Prospects,” Diabetes & Metabolism, 37 (6), 463-476. Gammon, Deede, Eirik Årsand, Ole Anders Walseth, Niklas Andersson, Martin Jenssen, and Ted Taylo (2005), “Parent-child Interaction using a Mobile and Wireless System for Blood Glucose Monitoring,” Journal of Medical Internet Marketing, 7 (5), e57. Hitman, G. A. (2011), “Mobile Phone Intervention for Diabetes,” Diabetic Medicine, 28 (4), 381. Istepanian, R. S., K. Zitouni, D. Harry, N. Moutosammy, A. Sungoor, B. Tang, and K. A. Earle (2009), “Evaluation of a Mobile Phone Telemonitoring System for Glycaemic Control in Patients with Diabetes,” Journal of Telemedicine and Telecare, 15 (3), 125-128. Jackson, Chandra L., Shari Bolen, Frederick L. Brancati, Marian L. Batts-Turner, and Tiffany L. Gary (2006), “A Systematic Review of Interactive Computer-Assisted Technology in Diabetes Care. Interactive Information Technology in Diabetes Care,” Journal of General Internal Medicine, 21 (2) 105-110. Jansà, M., M. Vidal, J. Viaplana, I. Levy, R. Conget, R. Gomis and E. Esmatjes (2006), “Telecare in a Structured Therapeutic Education Programme Addressed to Patients with Type 1 Diabetes and Poor Metabolic Control,” Diabetes Research and Clinical Practice, 74 (1), 26–32. Kasper, Dennis L., Eugene Braunwald, Stephen Hauser and Dan Longo (2005). Harrison's Principles of Internal Medicine, 16th ed., New York: McGraw-Hill. Krein, Sarah L., Mandi L. Klamerus, Sandeep Vijan, Jan L. Lee, James T. Fitzgerald, Alan Pawlow, Pamela Reeves, Rodney A. Hayward (2004), “Case Management for Patients with Poorly Controlled Diabetes: A Randomized Trial,” American Journal of Medicine, 116 (11), 732-739. Kouris, Ioannis, Stavroula Mougiakakou, Luca Scarnato, Dimitra Iliopoulou, Peter Diem, Andriani Vazeou, and Dimitris Koutsouris (2010), “Mobile Phone Technologies: An Advanced Data Analysis towards the Enhancement of Diabetes Self-Management,” International Journal of Electronic Healthcare, 5 (4), 386-402. Krishna, Santosh and Suzanne Austin Boren (2008), “Diabetes Self-Management Care via Cell Phone: A Systematic Review,” Journal of Diabetes Science and Technology, 2 (3), 509-517. Ładyzynski, P. and J. M. Wójcicki (2007), “Home Telecare During Intensive Insulin Treatment--Metabolic Control Does Not Improve as Much as Expected,” Journal of Telemedicine and Telecare, 13 (1), 44-47. Lawson, M. L., N. Cohen, C. Richardson, E. Orrbine (2005), “A Randomized Trial of Regular Standardized Telephone Contact by a Diabetes Nurse Educator in Adolescents with Poor Diabetes Control,” Pediatric Diabetes, 6 (1), 32-40. Lehmkuhl, Heather D. , Eric A. Storch, Christina Cammarata, Kara Meyer, Omar Rahman, Janet Silverstein, Toree Malasanos, and Gary Geffken (2010), “Telehealth Behavior Therapy for the Management of Type 1 Diabetes in Adolescents,” Journal of Diabetes Science and Technology, 4, (1), 199-208.

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Lieberman, Danny (2012), “How Sweet It Is: Smartphone App and Glucometer Mashup,” HealthWorks Collective. Downloaded October 17, 2012 from http://healthworkscollective.com/danny-lieberman/49801/how-sweet-itsmartphone-app-and-glucometer-mashup Lim, Soo, Seon Mee Kang, Hayley Shin, Hak Jong Lee, Ji Won Yoon, Sung Hoon Yu, So-Youn Kim, Soo Young Yoo, Hye Seung Jung, Kyong Soo Park, Jun Oh Ryu, and Hak C. Jang (2011), “Improved Glycemic Control Without Hypoglycemia in Elderly Diabetic Patients Using the Ubiquitous Healthcare Service, a New Medical Information System,” Diabetes Care, 34 (2), 308-313. Liu, Longjian and Stella-Maris Ogwu (2012), “A Meta-Analysis of Mobile Health and Risk Reduction in Patients with Diabetes Mellitus: Challenge and Opportunity,” Journal of Mobile Technology in Medicine, 1 (3), 17-24. MacLean, Linda Garrelts, John R. White Jr., Shirley Broughton, Jennifer Robinson, Jill Armstrong Shultz, Douglas L. Weeks, and Megan N. Willson (2012), “Telephone Coaching to Improve Diabetes Self-Management for Rural Residents,” Clinical Diabetes, 30 (1), 13-16. Malasanos, Toree (2008), “Mobile Phones Integrated into Diabetes Management: A Logical Progression,” Journal of Diabetes Science and Technology, 2 (1), 154-155. McKay, H. Garth, Diane King, Elizabeth G. Eakin, John R. Seeley, and Russell E. Glasgow (2001), “The Diabetes Network Internet-Based Physical Activity Intervention: A Randomized Pilot Study,” Diabetes Care, 4 (8), 13281334. McMahon, Graham T., Helen E. Gomes, Sara Hickson Hohne, Tang Ming-Jye Hu, Betty A. Levine, and Paul R. Conlin (2005), “Web-Based Care Management in Patients with Poorly Controlled Diabetes,” Diabetes Care, 28 (7), 1624-1629. Montori, Victor M., Pamela K. Helgemoe, R. Gordon H. Guyatt, Diana S. Dean, Teresa W. Leung, Steven A. Smith, and Yogish C. Kudva (2004), “Telecare for Patients With Type 1 Diabetes and Inadequate Glycemic Control: A Randomized Controlled Trial and Meta-Analysis,” Diabetes Care, 27 (5), 1088-1094. Moreno, Lorenzo, Rachel Shapiro, Stacy B. Dal, Leslie Foster, and Arnold Chen (2008), “ Final Report to Congress on the Informatics for Diabetes Education and Telemedicine (IDEATel) Demonstration, Phases I and II,” Mathematica Policy Research, Inc. Downloaded October 17, 2012 from http://www.mathematicampr.com/publications/ pdfs/health/IDEATel_rptCongress.pdf

“Multi-Technology Solution” (2012), “Multi-Technology Solution,” Voluntis Connected Therapeutics. Downloaded September 8, 2012 from http://www.voluntis.com/en/ therapeutic-solutions/diabeo.html Narayan, K., M. Venkat, James P. Boyle, Linda S. Geiss, Jinan B. Saaddine, and Theodore J. Thompson (2006), “Impact of Recent Increase in Incidence on Future Diabetes Burden U.S., 2005–2050,” Diabetes Care, 29 (9), 21142116. Noh, Jung-Hyun, Young-Jung Cho, Hong-Woo Nam, Jung-Han Kim, Dong-Jun Kim, Hye-Sook Yoo, Young-Woo Kwon, Mi-Hye Woo, Jae-Won Cho, Myeong-Hee Hong, Joo-Hwa Yoo, Min-Jeong Gu, Soon-Ai Kim, Kyung-Eh An, Soo-Mi Jang, Eun-Kyung Kim, and Hyung-Joon Yoo (2010), “Web-Based Comprehensive Information System for Self-Management of Diabetes Mellitus,” Diabetes Technology & Therapeutics, 12 (5), 333-337.

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Nunn, E., B. King, C. Smart, and D. Anderson (2006), “A Randomized Controlled Trial of Telephone Calls to Young Patients with Poorly Controlled Type 1 Diabetes,” Pediatric Diabetes, 7 (5), 254-259. Piette, J. D., M. Weinberger, F. B. Kraemer, and S. J. McPhee (2001), “Impact of Automated Calls with Nurse Follow-Up on Diabetes Treatment Outcomes in a Department of Veterans Affairs Health Care System: A Randomized Controlled Trial,” Diabetes Care, 24 (2), 202-208. Piette, J. D., M. Weinberger, S. J. McPhee, C. A. Mah, F. B. Kraemer, and L. M. Crapo (2000), “Do Automated Calls with Nurse Follow-Up Improve Self-Care and Glycemic Control among Vulnerable Patients with Diabetes?” American Journal of Medicine, 108 (1), 20-27. Quinn, Charlene C., Michelle D. Shardell, Michael L. Terrin, Erik A. Barr, Shoshana H. Ballew, and Ann L. Gruber-Baldini (2011), “Cluster-Randomized Trial of a Mobile Phone Personalized Behavioral Intervention for Blood Glucose Control,” Diabetes Care, 34 (9), 1934–1942. Quinn, Charlene C, Suzanne Sysko Clough, James M Minor, Dan Lender, Maria C. Okafor, and Ann Gruber-Baldini (2008), “WellDoc Mobile Diabetes Management Randomized Controlled Trial: Change in Clinical and Behavioral Outcomes and Patient and Physician Satisfaction,” Diabetes Technology & Therapeutics, 10 (3), 160-168. Rami, B., C. Popow, W. Horn, T. Waldhoer, and E. Schober (2006), “Telemedicine Support to Improve Glycemic Support in Adolescents with Type 1 Diabetes Mellitus, European Journal of Pediatrics, 165 (10), 701-705. Riley, William T., Daniel E. Rivera, Audie A. Atienza, Wendy Nilsen, Susannah M. Allison, and Robin Mermelstein (2011), “Health Behavior Models in the Age of Mobile Interventions: Are Our Theories Up to the Task?” Translational Behavioral Medicine, 1 (1), 53-71. Roger, Véronique L., Alan S. Go, Donald M. Lloyd-Jones, Robert J. Adams, Jarett D. Berry, Todd M. Brown, Mercedes R. Carnethon, Shifan Dai, Giovanni de Simone, Earl S. Ford, Caroline S. Fox, Heather J. Fullerton, Cathleen Gillespie, Kurt J. Greenlund, Susan M. Hailpern, John A. Heit, P. Michael Ho, Virginia J. Howard, Brett M. Kissela, Steven J. Kittner, Daniel T. Lackland, Judith H. Lichtman, Lynda D. Lisabeth, Diane M. Makuc, Gregory M. Marcus, Ariane Marelli, David B. Matchar, Mary M. McDermott, James B. Meigs, Claudia S. Moy, Dariush Mozaffarian, Michael E. Mussolino, Graham Nichol, Nina P. Paynter, Wayne D. Rosamond, Paul D. Sorlie, Randall S. Stafford, Tanya N. Turan, Melanie B. Turner, Nathan D. Wong and Judith Wylie-Rosett (2011), “Risk Factor: Diabetes Mellitus,” in Heart Disease and Stroke Statistics --2011 Update: A Report From the American Heart Association, Circulation., e18-e209. Downloaded September 4, 2012 from http://circ.ahajournals.org/content/123/4/e18.full.pdf Rossi, Maria C. E., Antonio Nicolucci, Paolo Di Bartolo, Daniela Bruttomesso, Angela Girelli, Francisco J. Ampudia, David Kerr, Antonio Ceriello, Carmen De La Questa Mayor, Fabio Pellegrini, David Horwitz, and Giacomo Vespasiani (2010), “Diabetes Interactive Diary: A New Telemedicine System Enabling Flexible Diet and Insulin Therapy while Improving Quality of Life,” Diabetes Care, 33 (1), 109-115. Rossi, Maria C. E., Antonio Nicolucci, Paolo Di Bartolo, David Horwitz, and Giacomo Vespasiani (2011), “The Diabetes Interactive Diary: A Useful Tool for Diabetes Management?” European Endocrinology, 6 (1), 39-42. Rossi, Maria C., Antonio Nicolucci, Fabio Pellegrini, Daniela Bruttomesso, Paolo Di Bartolo, G. Marelli, M. Dal Pos, M. Galetta, David Horwitz, and Giacomo Vespasiani (2009), “Interactive Diary for Diabetes: A Useful and Easy-To-Use New Telemedicine System to Support the Decision Making Process in Type 1 Diabetes,” Diabetes Technology and Therapeutics, 11 (1), 19-24. Sandou, Brahima (2011), “Measuring the Information Society [Executive Summary],” International

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Telecommunication Union, downloaded September 25, 2012 from http://www.itu.int/ITUD/ict/publications/idi/material/2011/MIS2011-ExceSum-E.pdf Shea, Steven (2007), “The Informatics for Diabetes and Education Telemedicine (IDEATel) Project,” Transactions of the American Clinical and Climatological Association, 118, 289-304. Shea, Steven, Ruth S. Weinstock, Jeanne A. Teresi, Walter Palmas, Justin Starren, James J. Cimino, Albert M. Lai, Lesley Field, Philip C. Morin, Robin Goland, Roberto E. Izquierdo, Susana Ebner, Stephanie Silver, Eva Petkova, Jian Kong, Joseph P. Eimicke, for The Ideatel Consortium (2009), “A Randomized Trial Comparing Telemedicine Case Management with Usual Care in Older, Ethnically Diverse, Medically Underserved Patients with Diabetes Mellitus: 5 Year Results of the IDEATel Study,” Journal of the Medical Informatics Association, 16 (4), 446-456. Tenderich, Amy (2011), “Newsflash: Ford & Medtronic demonstrate in-car glucose Monitoring,” Diabetes Mine. Downloaded March 6, 2012 from http://www.diabetesmine.com/2011/05/newsflash-ford-medtronic-demonstrate-incar-glucose-monitoring.html. Thompson, David M., Sharon E. Kozak, and Sam Sheps (1999), “Insulin Adjustment by a Diabetes Nurse Educator Improves Glucose Control in Insulin-Requiring Diabetic Patients: A Randomized Trial,” Canadian Medical Association Journal, 161 (8), 959-962. “Types of Diabetes” (2012), “Types of Diabetes,” National Diabetes Statistics, 2011. Downloaded October 17, 2012 from http://diabetes.niddk.nih.gov/dm/pubs/statistics/ Young, Robert J., Jean Taylor, Tim Friede, Sally Hollis, James M. Mason, Pauline Lee, Edna Burns, Andrew F. Long, Tina Gambling, John P. New, and J. Martin Gibson (2005), “Pro -Active Call Center Treatment Support (PACCTS) to Improve Glucose Control in Type 2 Diabetes,” Diabetes Care, 28 (2), 278-282. Walker, Elizabeth A., Celia Shmukler, Ralph Ullman, Emelinda Blanco, Melissa Scollan-Koliopoulus, and Hillel W. Cohen (2011), “Results of a Successful Telephonic Intervention to Improve Diabetes Control in Urban Adults: A Randomized Trial,” Diabetes Care, 34 (1), 2-7. Weinberger, M., M. S. Kirkman, G. P. Samsa, E. A. Shortliffe, P. B. Landsman, R. A. Cowper, D. L. Simel, and J. R. Feussner (1995), “A Nurse-Coordinated Intervention for Primary Care Patients with Non-Insulin-Dependent Diabetes Mellitus: Impact on Glycemic Control and Health-Related Quality of Life,” Journal of General Internal Medicine, 10 (2), 59-66. Yoo, H. J., M. S. Park, T, N Kim, S. J. Yang, G. J. Cho, T. G. Hwang, S. H. Baik, D. S. Choi, G. H. Park, and K. M. Choi (2009), “A Ubiquitous Chronic Disease Care System Using Cellular Phones and the Internet,” Diabetic Medicine, 26 (6), 628-635. David P. Paul, III Monmouth University Joey Priest Marshall University Zach Garrett Marshall University Alberto Coustasse Marshall University

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POTENTIAL BENEFITS OF USING FACEBOOK IN THE HEALTHCARE INDUSTRY: A LITERATURE REVIEW
Chelsea Slack, Marshall University William Willis, Marshall University Alberto Coustasse, Marshall University

ABSTRACT Facebook has become a worldwide social phenomenon, encompassing more than 800 million active users as of January 2012. Facebook is an inexpensive tool for healthcare organizations to help increase recognition, educate the public, and reach new patients and increase market share. A revolutionary way of sharing and communicating information, it can substantially influence healthcare services. The methodology for this qualitative study was a literature review using case studies as well. The search was limited to sources published in the last ten years because Facebook did not exist before then. Thirty-nine references supported this research study. The vast majority of hospitals had below 1,000 followers. The information typically presented on Facebook include, but was not limited, to patients’ stories, expert opinions by medical professionals, details about w hat to expect from a particular test or procedure, and health tips. The most common interactive feature was photo-sharing. The majority of organizations connected their Facebook with YouTube videos and Twitter pages. In one in-direct case of Facebook utilization, Facebook helped physicians treat a patient in the Emergency Department. The majority of hospitals are not actively engaging in Facebook. Health care suppliers using Facebook can improve patient and staff communication, marketing coverage, and provider recognition. Limitations for this study are there was little previous research on the utilization of Facebook by the healthcare establishment. The practical implication of this study indicates healthcare organizations, in particular hospitals, need to have a policy of social media for providers to follow. Physicians must adhere to all patient privacy and confidentiality and refrain from posting recognizable patient information online.

INTRODUCTION The number of people using the internet continues to rise. By 2016, three billion people will be online. 1 Out of every seven minutes spent on the internet, one minute is expended on Facebook. 2 Since its origination in 2004, Facebook has become a worldwide social phenomenon, encompassing more than 800 million active users as of January 2012 .3 In 2011, Facebook had sales of $3.7 billion with $1 billion profit margin and an estimated net worth between $75 -$100 billion.4 The delivery of healthcare is in a transition as more individuals are seeking the internet for medicinal information.5 The practice of online medicine has allowed for greater accessibility and efficiency to meet patient’s needs.6 Approximately 20% of patients seek medical advice through social media networks and Facebook is the sound network.7 Women between ages 45 and 65 years old are the primary users of Facebook, as well as main purchasers of healthcare .8 This has a positive correlation for healthcare providers because the opportunity is given to target the accurate consumer. Facebook opened registration to organizations in April of 2006, and in two weeks 4000 groups had joined.3 As of October 2011, 1,068 United States (U.S.) hospitals had a Facebook page.9 Hospitals have developed a new profession titled social media manager or interactive marketing specialist. The purpose of this position is to oversee social media presence, communicate with patients through social media,

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and teach physicians how to use social media without violating any legal or ethical guidelines. 10 It is important for healthcare organizations to tailor marketing efforts into those that are more consumer driven.11 Hospitals can use social media for advertisement of services, communication with existing customers and recruitment of new patients.12 Facebook is an inexpensive tool for healthcare organizations to help increase recognition, educate the public, reach new patients and increase market share.8 Other traditional media outlets like newspapers or magazines, charge a fee to print pictures or information instead Facebook provides healthcare organizations the opportunity to post unlimited material at no cost. Unlike other health related websites that may post erroneous medical information, Facebook has allowed hospitals to provide accurate health facts to patients. 11 Facebook has forced public relation departments to modify relationship building approaches. 13 Many organizations have started incorporating the use of Facebook into public relations planning. Kaiser Permanente has taken advantages of social media networks, like Facebook, to attract more positive media attention, up by almost 500% in the past five years.14 Non-profit organizations can use Facebook to advance the organizations mission and programs, streamline management functions, interact with volunteers and donors, and educate others about programs and services.15 Facebook is used for 71% of all health promotion activities. 16 Facebook has produced several user friendly applications to make fundraising and relationship building as simple as possible.17 Creation of fundraising applications like Causes, Justgiving, and ChipIn on Facebook has made it easy for users to donate and recruit supporters.18 Facebook has promoted interactions between users and spread of information.19 Patients can “like” a hospitals page and receive updates on the news feed. Hospitals can post about events at the hospital, physician backgrounds, and articles related to preventive health.10 There has been a reported increase in crime rates throughout hospitals in the U.S. In 2009, there were 660 aggravated assaults and 2,720 simple assaults.20 Facebook has been used for communication in emergency situations to prevent violence or counteract a violent situation.20 On the other hand, Facebook has been used by medical students, nurses, residents, attending physicians, and other health professionals in the hospital actively networking with each other to discuss medical issues.21 Facebook has made it possible for physicians to communicate and share information quickly to reach millions of people easily. Facebook can support physicians’ personal views and promote networking within the profession.22 Physicians must adhere to all patient privacy and confidentiality and refrain from posting recognizable patient information online. The Health Insurance Portability and Accountability Act (HIPPA) of 1996 requires that a patients identity and personal health information be protected.23 If an organization wants to publish patient’s photos or stories, it would be in their best interest to obtain an authorized release form. 24 If interacting with patients online, physicians must maintain appropriate boundaries of the patient-physician relationship in accordance with professional ethical guidelines, equivalent to any other context exchange. 22 This type of physician behavior is referred to as e-professionalism.25 It has been a topic of debate whether healthcare professionals should be friends with patients on Facebook.25 Mixing a professional relationship with a more personal one on Facebook could be considered unethical. It is going to be important for physicians to learn about the new medical professionalism policies because interactions with patients via Facebook are bound to become more popular in the future. 21 Healthcare is one of the U.S. largest industries in terms of size but often lags behind in healthcare information technology.26 Facebook cannot be overlooked, as it is believed by some physicians that communicating with patients on social media sites will eventually be the norm.7 It is a revolutionary way of sharing and communicating information, which can substantially influence healthcare delivery.27 The more Facebook is used, the more likely the quality of diagnosis and treatment will improve. 28 Facebook can ultimately drive a deeper provider-patient relationship, focusing on a more patient centered healthcare system. 28 Research Purpose The purpose of this research project was to analyze how the healthcare industry can benefit from the utilization of Facebook. METHODOLOGY

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The methodology utilized in this literature review conformed to the principles of a systematic search. For the intent of this research query, a comprehensive and exhaustive review was not feasible due to the abundance of studies of heterogeneous quality along with time constraints. The literature review was conducted in distinct stages including the following: determining the search strategy, establishing inclusion criteria, scrutinizing the texts for validity and relevancy, and extracting and analyzing the data. The methodology for this qualitative study was a literature research and review of case studies. The electronic databases of PubMed, Academic Search Premier, and ProQuest were searched for the terms ‘Facebook’, OR ‘social media networks’, AND ‘modern healthcare’. Reputable websites of the American Medical Association, the New England Journal of Medicine, and other reliable healthcare websites were also used. Citations and abstracts identified by the search were assessed in order to identify relevant articles. The search was limited to sources published in the last ten years, because Facebook did not exist before then, and to sources attainable as full texts and written in the English language. After the methodology and results of the identified texts were analyzed, key papers were identified and included within the research query. A total of 39 references were reviewed and selected for this research study. RESULTS The results presented were extracted from case studies, journal articles, and different websites from diverse sources, including consulting companies. Assessment of various healthcare systems were compared to illustrate the utility of Facebook. A marketing consulting firm, Verasoni, conducted a study in partner with Simon Associates Management, on how hospitals across the U.S. are using social media, particularly Facebook. 29 The study was conducted during December 15, 2010 through January 12, 2011. This was an observational study of 120 hospitals ranging from academic medical centers, community hospitals and safety net hospital located in all 50 states. Of the 120 hospitals selected, all had some type of presence on Facebook, regardless of the type of institution or facility size. 29 Merill reported how many members were connected with each hospital’s Facebook page. Seven percent of the hospitals had more than 10,000 supporters while only four percent had over 5,000.30 The vast majority of hospitals, over 50%, had below 1,000 followers. Children’s hospitals had more members than non -children’s hospitals. The Children’s Hospital of Boston had 465, 073 fans, Seattle’s Children Hospital had 15,5 10, and The Children’s Hospital in Colorado had 7,033.31 The frequency of posts of healthcare information and hospital-related news on the hospital’s Facebook page was measured by Dolan (2011). Fewer than 40% posted daily, 25% posted twice a week, and 23% once a month.32 The remainder of hospitals had little to no activity. Only 5% of hospitals used Facebook to post about events directly on the ‘Wall’. Fifty-two percent did however use Facebook’s event calendar to notify members of activities, while 43% did not post anything about happenings at all.30 A marginal number of hospitals used Facebook’s discussion boards. Seventy-four percent of hospitals encouraged no feedback or response-stimulating questions.30 Gallant, Irizarry, Boone, & Kreps (2011) published a study examining how 14-top ranked U.S. hospitals electronically connected with patients through social media. It was found that the majority of top-ranked hospitals used Facebook to communicate with patients. The information typically presented on Facebook included but was not limited to patients’ stories, expert opinions by medical professionals, details about what to expect from a particular test or procedure, health tips, pediatric care, and cancer prevention. 33 The hospitals’ Facebook pages have promoted discussion through a forum to encourage relationship building between health care providers and patients. Each of the hospitals’ Facebook page displayed communication to some extent between hospital employees and patients inquiring about care and hospital staff directing patients to the appropriate source to obtain health related information. In general, the hospitals’ Facebook pages stimulated followers to interconnect about health issues, services provided, affairs at the hospital, and any concerns or complaints.33

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Park, Rodgers, and Stemmie (2011) analyzed how health organizations used Facebook for advertising and promotion purposes. Branding or advertising was defined as an organization using self-promotion activities like photos and biographies to increase brand awareness.34 Since there are a plethora of healthcare organizations on Facebook, this study narrowed the facilities down to those only dealing with health literacy. All posts by healthcare establishments were open to the public so anyone could access and view the organizations page. The number of members actually following the healthcare organizations’ page varied from one up to 713. From May 2008, to July 2010, the frequency of wall posts per month on Facebook by the healt h organizations’ was calculated. March 2010 had the most posts, followed by April 2010, and February 2010. 35 The use of interactive features by healthcare organizations on Facebook has also been analyzed because interactive features have been shown to entertain visitors and have encouraged repeat usage of site. The most common interactive feature was photo-sharing, then blogging, following by video sharing, RSS feed, email, and enewsletter.36 Creative logos customized to each healthcare organization can be used to facilitate greater recognition and brand identity.34 All Government organizations and hospitals showed some type of logo on their Facebook page. School affiliated health facilities have been the least likely to provide a logo, followed by nonprofit organizations, and businesses. All healthcare organizations, regardless of type, have posted photos to visually demonstrate healthcare execution or to stimulate the delivery of health related information. 35,37 Nonprofit organizations were the most active in posting on Facebook but the least likely to utilize interactive features like blogging and videos. Nonprofit organizations did not partake in many branding techniques like other for profit organizations did. The only organizations that pr ovided a biography of the company’s history on their page were businesses and nonprofit organizations.35 Facebook can also be used to connect followers to other social media avenues like Twitter, YouTube, and blogs. All the observed hospitals in this study had their Facebook page linked with their Twitter site, whereas no government agencies made the association. The majority of organizations connected their Facebook with YouTube videos; Businesses and nonprofit however were the least likely, but still over 50%. Government agencies, hospitals, and schools were most likely to link their Facebook to a blog. Again, businesses and nonprofit did not take advantage of this function. 35 In one in-direct case of Facebook utilization, Facebook helped physicians treat a patient in the Emergency Department (ED). A 34-year old woman was brought in to the ED displaying a confused state of behavior. The patient was unable to provide any contact information other than her husband’s first name. 38 After exhausting other efforts, the physicians turned to Facebook to find out where her husband was employed so he could be contacted. Facebook was able to help the healthcare providers connect with the patients family so further treatment could be given.38 DISCUSSION Facebook has been around for almost 10 years and healthcare organizations have just recently established a presence on the network. The majority of hospitals are not actively engaging in Facebook as only a few hospitals across the country are using it to its full potential.29 The hospitals that are fully utilizing Facebook are the topranked hospitals that have more attainable resources. Patients appreciate direct contact with healthcare providers and few physicians participate in discussion on Facebook. Physicians could be gaining referrals from patient’s interaction on Facebook, contingent upon abiding HIPAA and employer social media guidelines. 32 Being on Facebook alone is not enough to draw attention to an organization. Healthcare providers need to not only have a Facebook page, but post frequently, and interact with the community and patients to see benefits. Facebook can be used as a feedback tool for providers so business associates, patients, and other community followers can voice concerns and improvements can be made throughout the institute. Healthcare organizations furthermore underutilize Facebook to acquire social support for sick patients and gain awareness. 39 This study was limited to the fact that there was little previous research on healthcare establishment’s usage of Facebook. Most of the research that has been done was provided in the form of blogs, or websites that were not peer reviewed, and may contain biased or faulty information.

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Many of the healthcare organizations do not fully utilize Facebook to its maximum potential. One of the reasons healthcare providers do not use Facebook is because of the fear of violating HIPAA, which could lead to fines as high as $250,000 and/or jail time up to 10 years. 24 This fear has caused healthcare organizations to miss out on the plethora of opportunities Facebook has to offer. Kaiser Permanente has solved this issue by supplying employees with a document entitled the Principles of Responsibility to provide clear instructions and strategies relevant to using social media.14 The practical implication of this study was healthcare organizations, in particular hospitals; need to have a policy of social media for providers to follow. CONCLUSION Facebook use by healthcare suppliers can improve patient and staff communication, marketing coverage, and provider recognition. It is imperative for healthcare organizations to take advantage of the opportunities Facebook offers to remain current in the delivery of healthcare. REFERENCES: 1. Boston Consulting Group [BCG]., The G-20’s Internet Economy Is Set to Reach $4.2 Trillion by 2016—Up From $2.3 Trillion in 2010 – As Nearly Half the World’s Population Become Web Users, Says Report by the Boston Consulting Group. 2012. Retrieved on March 8, 2012 from http://www.marketwire.com/pressrelease Protalinksi, E. Facebook accounts for 1 in every 7 minutes spent online. December 27, 2011. Retrieved on March 8, 2012 from http://www.zdnet.com/blog/facebook/facebook-accounts-for-1-in-every-7-onlineminutes/6639 Facebook. Facebook Factsheet. 2012. Retrieved February 10, 2012 from http://newsroom.fb.com/ The Economist. The value of friendship. The Economist Newspaper Limited. February 4, 2012. Retrieved on February 10, 2012 from http://www.economist.com/node/21546020 Frydman, G. Patient-Driven Research: Rich Opportunities and Real Risks. J Particp Med. 2009, 1(1), 12. Lacson, S., Bradley, C., & Arkfeld, D. Facebook Medicine. J Rheumatol, 2009, 36 (1), 211. Haupt, A. How Doctors Are Using Social Media to Connect With Patients. November 21, 2011. Retrieved on January 20, 2012 from http://health.usnews.com/health-news/most-connectedhospitals/articles/2011/11/21/how-doctors-are-using-social-media-to-connect-with-patients Friedenberger, A. Medical media: Hospitals using Facebook as marketing strategy . 2011. Retrieved on January 20, 2012 from http://www.altoonamirror.com/page/content.detail/id/550735/Medical-media--Hospitalsusing-Facebook-as-marketing-strategy.html?nav=738 Bennett, E. Hospital Social Network List. 2011. Retrieved on January 19, 2012 from http://ebennett.org/hsnl/ Cook, B. Hospitals’ new specialist: Social media manager. November 8, 2010. American Medical News. Retrieved on February 29, 2012 from http://www.ama-assn.org/amednews/2010/11/08/bisa1108.htm Howell, W. Facebook Isn’t Just for Status Updates or Playing Games Anymore. Hosp Health Netw. 2011, 85 (4), 13. Mullin, E. Tweeting Their Way to New Patients. 2010. Retrieved February 29, 2012 from http://www.portfolio.com/industry-news/health-care/2010/08/12/hospitals-using-social-media-to-drawnew-patients/ Christ, P. Internet technologies and trends transforming public relations. Journal of Website Promotion, 2005, 1(4), 3-14. Kiron, D. Social Business at Kaiser Permanente: Using Social Tools to Improve Customer Service, Research and Internal Collaboration. Management of Technology and Innovation, Social Business. March 6, 2012.

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Retrieved on April 4, 2012 from http://sloanreview.mit.edu/feature/kaiser-permanente-using-social-toolsto-improve-customer-service-research-and-internal-collaboration/ Waters, R. D. The Use of Social Media by Nonprofit Organizations: An Examination from the Diffusion of Innovations Perspective. In S. Dasgupta (Ed.), Social Computing: Concepts, Methodologies, Tools, and Applications. 2010. 1420-1432 doi:10.4018/978-1-60566-984-7.ch090 Gold, J., Pedrana, A., Sacks-Davis, R., Hellard, M., Chang, S., Howard, S,et al. A systematic explanation of the use of online social networking sites for sexual health promotion. BMC Public Health, 2011. 11(583): 1-9. Facebook Fundraising Applications. Giving in a digital world. 2007. Retrieved on March 8, 2012 from http://www.givinginadigitalworld.org Waters, R., Burnett, E., Lamm, A., & Lucas, J. Engaging stakeholders through social networking: How nonprofit organizations are using Facebook. Public Relations Review, 2009, 35 (1), 102-106. Moubarak, G., Guiot, A., Benhamou, Y., Benhamou, A., & Hariri, S. Facebook activity of residents and fellows and its impact on the doctor – patient relationship. J Med Ethics, 2010, 37(2), 101-104. Howell, W. Violence in Hospitals: Prevent and Protect. Hosp Health Netw. 2011, 85(1), 26. Jain, S. Practicing medicine in the age of Facebook. N Engl J Med. 2009, 361 (7):649-51. American Medical Association (AMA). AMA Policy: Professionalism in the Use of Social Media. 2012. Retrieved on January 19, 2012 from http://www.ama- assn.org/ama/pub/meeting/professionalism-socialmedia_print.html U.S. Department of Health & Human Services (DHHS). The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules. 1996. Retrieved on April 4, 2012 from http://www.hhs.gov/ocr/privacy Geyser, B. Social Media and HIPAA: What You Need To Know. October 19, 2009. Retrieved on April 4, 2012 from http://www.carenetworks.com/social-media-and-hipaa-what-you-need-to-know Aase, S. Toward E-Professionalism: Thinking through the Implications of Navigating the Digital World. J Am Diet Assoc. 2010, 110(10), 1442-1449. Vogel, L. Finding Value from IT Investments: Exploring the Elusive ROI in Healthcare. J Healthc Inf Manag. 2003, 17(4), 20-28. Stadler, W. Prognosis and Prediction in a Facebook World. Cancer, 2009, 115 (23), 5368-5370. Hawn, C. Take Two Aspirin and Tweet Me In The Morning: How Twitter, Facebook, And Other Social Media are Reshaping Health Care. Health Aff. 2009, 28(2), 361-368. Verasoni. Hospitals and Facebook: A Case Study. February 25, 2011. Retrieved on January 20, 2012 from http://verasoni.com/ahha3/2216/ Merill, M. Study: Hospitals’ Facebook use is poor. February 28, 2011. Healthcare IT News. Retrieved on March 1, 2012 from http://www.healthcareitnews.com/news Galloro, V. Status update; Hospitals are finding ways to use the social media revolution to raise money, engage patients and connect with their communities. Mod Healthc. 2011, 41(11), 6. Dolan, P. Conversation lags on hospital Facebook pages. March 23, 2011. American Medical News. Retrieved on February 29, 2012 from http://www.ama-assn.org/amednews/2011/03/21/bise0323.htm Gallant, L., Irizarry, C., Boone, G., & Kreps, G. Promoting Participatory Medicine with Social Media: New Media Applications on Hospital Websites that Enhance Health Education and e-Patients’ Voices. Journal of Participatory Medicine, 2011, 3: e49. Scott, D. The New Rules of Marketing and PR: How to Use Social Media, Blogs, News Releases, Online Video, and Viral Marketing to Reach Buyers Directly. Hoboken, NJ: John Wiley & Sons 2007. Park, H., Rodgers, S., & Stemmie, J. Health Organizations’ Use of Facebook for He alth Advertising and Promotion. Journal of Interactive Advertising, 2011, 12(1), 1525-2019. Zarella, D. The Social Media Marketing Book. 2009. Sebastopol, CA: O’Reilly Media Inc. Center for Disease Control and Prevention [CDC]. The Health Communicator’s Social Media Toolkit. 2011. Retrieved on April, 4, 2012 from http://www.cdc.gov/socialmedia Ben-Yakov, M. & Snider, C. How Facebook Saved Our Day! Acad Emerg Med. 2011, 18 (11): 1217-1219.

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39. Skeels, M., Unruh, K., Powell, C., & Pratt, W. Catalyzing Social Support for Breast Cancer Patients. Cambridge Health Institute Conference Proceedings, 2010, 173-182. Chelsea Slack, MS Health Care Administration Program College of Business Marshall University Graduate College 100 Angus E. Peyton Drive South Charleston, WV 25303 (304) 746-1968 (304) 746-2063 FAX slack18@live.marshall.edu William Willis, DrPH, MSHA Assistant Professor Health Care Administration Program College of Business Marshall University Graduate College 100 Angus E. Peyton Drive South Charleston, WV 25303 (304) 746-8946 (304) 746-2063 FAX Alberto Coustasse, DrPH, MD, MBA, MPH – CONTACT AUTHOR Associate Professor Health Care Administration Program College of Business Marshall University Graduate College 100 Angus E. Peyton Drive South Charleston, WV 25303 (304) 746-1968 (304) 746-2063 FAX coustassehen@marshall.edu

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Virtual Information Systems Teams in the Healthcare Industry
Nadene A. Chambers, DePaul University Linda V. Knight, DePaul University

ABSTRACT The use of virtual teams, i.e. geographically dispersed work groups, to manage software development and implementation projects in healthcare has been expanding, in large part because of the wide-spread implementation of electronic health records and other supporting technologies. The healthcare industry is a unique domain because of its size, complexity and the high significance of technology project implementation errors. Virtual teams in health care can take the form of “global”, “clinical and technical” and “large scale information network”. An exploratory study using a focus group of healthcare information systems professionals affirms the expanding use of virtual teams in healthcare and articulates some of the challenges faced by such teams, particularly that of communication.

Introduction Virtual teams, whose members are geographically dispersed, have become popular in businesses because they offer access to human resources in a manner that companies would otherwise not have. Global virtual teams are groups that are recognized by their organizations and members as a team, are responsible for making and/or implementing decisions; are important to the organization's global strategy; use technology-supported communication substantially more than face-to-face communication; and work and live in different countries [1]. Healthcare’s use of virtual teams has expanded in the area of information technology to mirror the aforementioned uses in business. Particularly, healthcare has been using virtual teams to facilitate the project management of new technologies being introduced into delivery care organizations. The authors conducted an initial study of the use of virtual teams in healthcare by using a focus group. The value of the focus group was to provide context to a practice that is becoming more common but not well studied. Significance and nature of the healthcare domain The healthcare industry’s size in the United States, as measured in cost, has grown exponentially since 1960. According to the statistics published by The US Centers for Medicare & Medicaid Services (CMS), in 1960, healthcare costs were $28B while in 2007 they were $2,241B [2]. Total health expenditures in 2008 reached $2.379B (or approximately $2.3 trillion), which accounted for 16.2 percent of the nation's Gross Domestic Product [3]. CMS projects these costs to continue rising, with estimates of total spending in 2011 and 2016 being $2,770B and $3,790B, respectively. These data show that the healthcare industry accounts for a significant portion of the spending that occurs nationally in the United States (US), and will continue to grow. From an economic standpoint, this industry has significant relevance to the government and, consequently, the citizens of the US. In recognition of the growing costs of the healthcare industry to the US, the federal government enacted the Health Information Technology for Economic and Clinical Health Act (HITECH Act) of 2009. Included in this law is $22 B, $19.2 B of which is intended to be used to increase the use of Electronic Health Records (EHR) by physicians and hospitals [4]. In 2008, the Healthcare Information and Management Systems Society (HIMSS) conducted a survey on the use of EHR/EMR adoption and the results showed that 30% of the respondents in 2008 had an EMR, which was up from 26% in 2006 [5]. The results also showed that a major barrier to adoption of EHR/EMR is cost. Given the significant infusion of capital from the HITECH Act into the healthcare system, organizations nationwide can be expected to prepare themselves to take advantage of these funds by either hiring their own or retaining consultative services to implement EHRs and other ancillary technology-related projects (such as those related to privacy, security, interoperability of clinical databases and claims submissions) in their facilities that will be supported/supplemented by EHRs. EHRs tend to be large, enterprise-wide projects, and in the case of large healthcare facilities, these projects can mean implementation of a system that will be distributed over a number of sites, some of which may be interstate. These projects are therefore likely candidates for the use of virtual

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information systems project teams. While the number of virtual IT projects may increase as a result of the HITECH Act, it must be realized that the industry, like others, faces difficulty in managing IT projects. They include the lack of adequate clinical input into clinically-related systems [6], difficulty in communicating with external vendor software and systems developers [7], and a failure to recognize that, in some instances, the organization and the technology transform each other during the implementation process [8]. While challenged IT projects are universally faced in all industries, in healthcare, those challenges can have significant consequences. These can include financial losses, facility closure, and patient death. Though the insurance companies, the government, employers and consumers spend significant sums of money in the healthcare industry, healthcare organizations tend to operate on fairly thin margins, leaving them particularly vulnerable to financial losses. The American Hospital Association reports that the average total margin for hospitals reporting financial information to Databank fell to -7.8% in fourth-quarter 2008 from 4.6% in fourth-quarter 2007 [9]. Enterprise systems such as electronic health records (EHRs)/electronic medical records (EMRs) can cost between $15,000 and $30,000 for physician practices [10]. Gross revenues for multi-specialty physician practices in 2008 was $637,677 but this represents a drop in practice revenues [11]. This means that even in a multi-specialty practice, acquiring an EHR can be up to 21% of total operating costs, which has to be concerning given lower practice revenues, and the impact of the economy. For hospitals, vendor-built, server-based EHR systems typically carry license fees upwards of $75,000 each and overall costs of $25 to $50 million for a 500-bed hospital [12]. This leaves little room for error if a project of this type fails, and could mean closure of a facility if these losses occur. Furthermore, these risks for healthcare organizations mean that they have: increased liability for medication errors if software fails; responsibility for maintaining the accuracy and privacy of medical records; and responsibility for maintaining round-the-clock life-saving IT applications. Failure of these systems could mean risking the life of one or more patients. Furthermore, the industry has begun to participate in outsourcing, a staffing phenomenon that has gained widespread use in IT organizations in industries other than healthcare. The healthcare industry is projected to have an increased use in outsourcing because it is one of the most complex in needs, client essentials, data demands, regulation, legislation, revenue models, market sizes, geographies, core functions, non-patient care functions, and outsourcing niche vendors. Thus healthcare IT outsourcing was projected to be one of the fastest growing segments of outsourcing growth in 2008-2009 [13]. The healthcare industry is subject to governmental regulation (via laws), policy changes (via recommendations from various medically-related societies and agencies), price and payment adjustments (via insurance carriers), changes in the manner that care is delivered (via clinicians), and changes in available service options (via consumers). The complexities of this industry make it one of the most challenging to manage, and the information systems departments in most healthcare delivery organizations face the daunting task of assisting their parent organizations to satisfy the above-mentioned requirements, while having to maintain departmental efficiencies and managing the applications used to support their enterprise. The information technology applications themselves are unique primarily because they are not only complex, but the data they produce require enhanced security measures (via government encryption standards [14]). This is due to the sensitivity of the data and the significant lengths of time for keeping medical data (which ranges from 3-27 years [15]). Furthermore these applications exist as part of a fragmented system, which limits or prevents the timely and/or accurate transfer of data from one member of the industry to another because there is no mandatory standard for electronic data interchange in healthcare. For the aforementioned reasons, the industry is a good one for further study. Ensuring that applications in the healthcare system work, and indeed, ensuring that the system of healthcare itself works, requires the extensive use of teams. The goal of these teams is to work towards a common shared objective of improving care for the patient, and to this end, communicate effectively via the transfer of knowledge to achieve this objective [16]. Healthcare has also become more distributed across service delivery areas, and consequently, there has been a reliance on project teams that are geographically dispersed for the purposes of harvesting the experience of these individuals into a project [17]. We will now offer a more in-depth exploration of the virtual team itself. Virtual Teams The term “virtual team” has been defined by Lipnack and Stamps (1997) as “a group of people who interact

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through interdependent tasks guided by a common purpose” [18]. Their definition further states that these individuals work across “space, time and organizational boundaries with links strengthened by webs of communication technologies”. Some authors use the term “virtual” only for groups that never meet face to fa ce [19], [20]. Several authors, however, refer to a virtual team as one that is conducted with the assistance of at least some form of technology [21], [22], [23]. Virtual teams are being used in the health care industry to support the implementation of various information technologies largely financed through the HITECH Act. The healthcare industry has used a number of types of virtual information systems project teams. The forms these take can include the following: a) Global teams: In this type of team an IT development group may exist in one or more countries with a project office in the United States coordinating the group’s activities, for example. b) Clinical and Technical: In this type of team clinical specialists may reside in a team in one hospital, physicians in another facility, and technology services (perhaps via a vendor) in another location. This distributed group would potentially work on an enterprise-related technology project, such as an EMR. c) Large-scale information network: In this case, multiple healthcare and payor organizations collaborate either in a video-conferencing medium or "in the cloud" to deliver a comprehensive solution to provide access to patient information across multiple facilities and institutions. A regional health information organization (RHIO) offers such an example. These types of teams are not mutually-exclusive; for example, it is possible to have a clinical and technical team with a global component. This study will included all three of these types of teams, with special emphasis on “Clinical and Technical” teams. Each of these types of virtual teams can be complex, therefore the industry has a heavy reliance on vendors and consultants. A recent search revealed over 170 “leading healthcare IT vendors and consultants” [24]. The list includes vendors such as GE, Siemens, Cerner, IBM and SAP —all companies which have a presence in consulting in general business and industry as well as in healthcare. These are companies known to have outsourced functionality with their general business and industry clients, and have similarly outsourced some of the work they do for healthcare clients. This level of activity demonstrates that the virtual information systems project team has arrived to the healthcare industry. An inquiry by the researcher in May 2010 to the project management special interest group (SIG) of the Healthcare Information Management and Systems Society (HIMSS) on the use of virtual teams revealed that several of the SIG’s represented organizations use virtual teams in healthcare IT (ex. GE Healthcare, Eclypsis, Medical Data Solutions, Hewlett Packard, United Health Group, North Bronx Healthcare Network, Parkland Health and Hospital System, US Department of Defense, US Department of Veterans Administration, AllScripts), yet there is little information on their effectiveness and best ways to optimize virtual teams in the healthcare IT literature. The researchers conducted a focus group to further evaluate the use of virtual teams in the healthcare delivery system and results of that study are described next. Focus Group A focus group of project management experts with at least 2 years of experience working on virtual information systems project teams from academic medical centers in the Chicagoland area was formed for the purpose of eliciting iterative, controlled feedback to questions on virtual information systems project teams. One module of the focus group’s structure was on virtual teams. The focus group was asked to define “virtual team” in the context within which it was used in their organizations and to discuss challenges of those virtual teams. Definition of virtual The participants’ definition of “virtual” emphasized geographical dispersion, and one participant cited a difference in the healthcare industry from other industries by stating that there is less opportunity in healthcare information systems to work with end users directly “because they’re clinical people”. This meant that because end users are at the bedside, IS staff can’t be there as they deliver care. It was also stated that “users are more virtual as well” in the way they work because they may work in multiple facilities (ie. Hospitals, clinics or physician office practices within the system).

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Most participants immediately focused on the difficulty of working virtually, emphasizing that the communication aspects are especially problematic: “It’s so hard…you need so much more commitment to it to be able to gather everyone virtually” “It’s very difficult not to see everyone, and communication being one of the major success factors as it relates to projects…you need to have that eyeball to eyeball presence every now and again..” “It’s difficult to assess body language and that’s an important part of communication that we sometimes tend to forget” Focus group participants noted that engagement of participants in virtual work was particularly difficult: “..I find myself multi-tasking and when I didn’t have anybody watching me…[saying] “I’m sorry I missed that. Can you repeat?” ” “…we turned on our video equipment for status calls and it’s completely made a difference...because there I am, they can see what I’m doing, I can see them and I feel more engaged and in touch and that keeps me on task” Some focus group participants even compared the experience of working in a virtual group to online educational courses “I experienced a lot of online classes…sometimes there’s just no way to be successful in a project unless you have someone there to tell you “hey we need to do this” “I actually went to (a university) and experienced my first time havin g a class and it was in 2 locations. And the one thing I found interesting about that, and it still plays out in the work world, is it was almost like whoever had the teacher in the room that was where it was more interactive. Participants stated that the terms “virtual”, “distributed” and “collocated” teams are rarely, if ever used in their workplaces. They call this type of work “working remote”, or as one participant said “We call it ‘geographically dispersed’ when we’re talking about the challenge of it. ‘Geographical challenges’ I think we usually say”. Other Challenges In addition to the communication challenges previously stated, participants discussed other challenges they found in this type of working. Top challenges cited were: a) sharing documentation,

b) managing competing priorities (ie. Having to manage your project with the knowledge that your project’s resources are not dedicated to your project exclusively), c) working with “cultural differences” (ie. Hours kept by IT staff are differe nt from hours kept by clinical staff),

d) lack of engagement when people are working from home, e) IT project work not being perceived as high priority because in the healthcare environment patient care and patient safety are considered the highest priorities.

Some of these findings are in keeping with what other researchers have discovered about working in virtual teams. For example, Lee-Kelley and Sankey (2008) found that time zone and cultural differences in particular, affected

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communication and team relations [25]. A propensity for miscommunication [26] and conflict [27] is also supported in the literature. Conclusion The healthcare industry is expanding its use of virtual teams in information technology project management, largely because of a wave of implementations of technologies such as the electronic medical record. While there are benefits to these teams (such as accessing human resources for a project wherever they may be), there are challenges including communication, lack of engagement and cultural differences among team members. The healthcare industry is unique and so are the information systems used in the industry. The systems are as complex as the industry itself but there is a dearth of literature on studies done in healthcare with respect to the role of virtual teams. While this initial study is obviously limited in terms of our ability to generalize results, it does illuminate some of the unique challenges associated with virtual information systems teams in the healthcare industry. It also substantiates the practice of using virtual information systems project teams in healthcare, as well as the need for further study in this area. REFERENCES [1] [2] M. L. Maznevski and K. M. Chudova, "Bridging Space Over Time: Global Virtual Team Dynamics and Effectiveness," Organization Science, vol. 11 September-October, pp. 473-492, 2000. Centers for Medicare & Medicaid Services. (2007, June 1). National Health Expenditures--Summary, 1960 to 2007, and Projections, 2008-2018. Available: http://www.census.gov/compendia/statab/2010/tables/10s0127.pdf Centers for Medicare & Medicaid Services. (2010, June 1). National Health Expenditure Data. Available: http://www.cms.gov/NationalHealthExpendData/02_NationalHealthAccountsHistorical.asp#TopOfPage HITECH Answers. (2010, June 1). About the HITECH Act of 2009. Available: http://hitechanswers.net/about HIMSS Analytics, "2008 HIMSS/HIMSS Analytics Ambulatory Healthcare IT Survey," Healthcare Information and Systems Society, Chicago, IL2008. H. Heathfield and J. Wyatt, "Philosophies for the design and development of clinical decision support systems," Methods Inf Med, vol. 31, 1993. A. D. Brown and M. R. Jones, "Doomed to Failure: Narratives of Inevitability and Conspiracy in a Failed IS Project," Organization Studies, vol. 19, pp. 73-88, 1998. M. Berg, "Implementing information systems in health care organizations: myths and challenges," International Journal of Medical Informatics, vol. 64, pp. 143-156, 2001. AHANewsNow. (2009, June 1). Hospital margins sink with economy. Available: http://www.ahanews.com/ahanews_app/jsp/display.jsp?dcrpath=AHANEWS/AHANewsArticle/data/AHA _News_090316_Report_hospital&domain=AHANEWS K. Terry. (2003, June 1). EMRs: What you need to know. Available: http://www.modernmedicine.com/modernmedicine/article/articleDetail.jsp?id=111372 V. Stagg Elliott. (2009, June 1). Practices lose financial ground as recession outpaces productivity . Available: http://www.ama-assn.org/amednews/2009/10/26/bil21026.htm K. Congdon. (2009, June 1). How much will an EHR system cost you? Available: http://www.healthcaretechnologyonline.com/article.mvc/How-Much-Will-An-EHR-System-Cost-You0001?VNETCOOKIE=NO BusinessWire. (2008, May 16). Healthcare IT Outsourcing Is Projected to Be One of the Fastest Growing Segments of Outsourcing Growth in 2008-2009. Available: http://findarticles.com/p/articles/mi_m0EIN/is_2008_Feb_21/ai_n24318735/ HIPAA-Encryption.com. (2010, August 3). Government Encryption Standard | Advanced Encryption Standard (AES). Available: http://hipaa-encryption.com/HIPAA-Compliance/phi-encryption/governmentencryption-standard-advanced-encryption-standard-aes/

[3] [4] [5] [6] [7] [8] [9]

[10] [11] [12]

[13]

[14]

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[15] [16] [17] [18] [19] [20] [21] [22] [23] [24] [25] [26] [27]

AHIMA Body of Knowledge. (August 3). Practice Brief-Retention of Health Information (updated). Available: http://library.ahima.org/xpedio/groups/public/documents/ahima/bok1_012547.pdf D. Clements and J. Helmer, "CHSRF Knowledge Transfer: Teamwork in Healthcare: Pulling It All Together," Healthcare Quarterly, vol. 9, pp. 16-17, 2006. L. Kimball and A. Eunice, "The virtual team: Strategies to optimize performance," Health Forum Journal, vol. 42 May/Jun 1999, pp. 58-62, 1999. J. Lipnack and J. Stamps, Virtual Teams--Reaching Across Space, Time and Organizations with Technology. New York: John Wiley & Sons, 1997. A. L. Kristof, et al., The virtual team: A case study and inductive model vol. 2. Greenwich, CT: JAI Press, 1995. S. Canney Davison and K. Ward, Leading International Teams. Berkshire, England: McGraw-Hill International, 1999. B. Geber, "Virtual Teams," Training, vol. 32, pp. 36-42, 1995. K. Melymuka. (1997) Virtual Realities. Computerworld. 70-72. R. Young, "The wide-awake club," People Management, vol. 4, pp. 46-49, 1998. OnLine Consultant Software. (2000-2007, May 14). Healthcare Software Vendors. Available: http://www.health-infosys-dir.com/vendors.htm L. Lee-Kelley and T. Sankey, "Global virtual teams for value creation and project success: A case study," International Journal of Project Management, vol. 26, pp. 51-62, 2008. C. Cramton, "The mutual knowledge problem and its consequences for dispersed collaboration," Organization Science, vol. 12, pp. 346-371, 2001. E. Mannix, et al., The phenomenology of conflict in distributed work teams. Cambridge, MA: The MIT Press, 2002.

Nadene A. Chambers DePaul University Linda V. Knight DePaul University

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TRACK INTERNATIONAL HEALTHCARE

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Global Healthcare Management Education: Research Findings and Future Implications
Daniel J. West, Jr., University of Scranton

ABSTRACT Global transformation impacts all sectors of the economy and provides unique challenges and opportunities to rethink business strategy. A borderless world in higher education provides mobility of students and faculty to enhance and reshape the global academic landscape. New opportunities exist for growth and innovation in accreditation, certification, graduate education and professional development of healthcare professionals. Educating and training of healthcare executives remains a priority for most countries that recognize the need for effective leadership, efficient management structures, competency development, evidence based management, increased economic competitiveness, and maintaining international reputation. Globalization has impacted graduate education in the USA. The commission on Accreditation of Healthcare Management Education (CAHME) in the USA recognized the need to survey CAHME accredited programs. With funding from the Aramark Charitable Fund, two research studies were authorized to gather specific information and answer important questions impacting graduate healthcare management education in the USA. This presentation examines the research results and discusses future implications for international accreditation and graduate education.

Daniel J. West, Jr., Ph.D., FACHE, FACMPE Professor and Chairman Department of Health Administration & Human Resources The University of Scranton 417 McGurrin Hall Scranton, PA 18510 Tele: 570 941-4126 FAX: 570 941-5882 E-mail: daniel.west@scranton.edu

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EUROPEAN ECONOMIC CRISIS: EFFECTS IN ROMANIA, CZECH REPUBLIC, AND HUNGARY
Stephanie Hill, University of Scranton

ABSTRACT The economic crisis has hit Europe hard. The impact of the crisis on healthcare systems threatens the quality of services provided to patients. This paper will examine the effects of the economic crisis on three countries: Romania, the Czech Republic, and Hungary. The effects will focus on the financial sustainability of healthcare organizations, government funding of healthcare and government budgets, the demands on the healthcare workforce to reduce costs, and the increased costs of healthcare on individual patients. Lastly, this paper will review best practices and make recommendations on how to sustain the healthcare systems in these countries after the changes caused by the economic crisis.

Stephanie Hill MHA Student The University of Scranton Scranton, PA 18510

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ANALYSIS OF THE INTEGRATED MEDICAL INFORMATION SYSTEM IMPLEMENTATION: THE CASE OF HEALTHCARE ORGANIZATIONS IN THE REPUBLIC OF KAZAKHSTAN
Aisulu Zholdybayeva, Kazakh National Medical University S.D.Asfendiyarov, Kazakh National Medical University Zhansulu Baikenova, KIMEP University, Kazakhstan Dilbar Gimranova, KIMEP University, Kazakhstan Alma Alpeissova,KIMEP University, Kazakhstan

ABSTRACT Like in many other countries, each healthcare organization in the Republic of Kazakhstan reports on a regular basis to the Ministry of Healthcare and its regional administration that requires the provision of a large number of documents. During the past several decades since the Republic of Kazakhstan has got its independence, the quality requirements for these documents significantly tightened and the amount of documentation has grown. Therefore the routine gathering and analysis of medical and statistical data is becoming increasingly time-consuming at the expense of time spent with patients. Moreover, in most of the cases document processing is done manually that reduces the quality and reliability of the data storage and may have a lack of factual information of the healthcare organization. The centralized integrated electronic medical information system has been designed in order to resolve such issues in many healthcare systems in other countries. It has been proved that the implementation of electronic documentation circulation should assist to monitor the quality and efficiency of the healthcare organization; however, it may not always be advantageous. For instance, there are some evidences of appreciating the presentation form of the records rather than the content of it, and of the hospitals that are not showing better results in the quality of diagnosis and treatment. This paper aims to assess the advantages and disadvantages of the implementation of electronic integrated medical information system and develop recommendations to assist healthcare organizations in the Republic of Kazakhstan. Aisulu Zholdybayeva Kazakh National Medical University S.D.Asfendiyarov Kazakh National Medical University Zhansulu Baikenova KIMEP University Kazakhstan Dilbar Gimranova KIMEP University Kazakhstan Alma Alpeissova KIMEP University Kazakhstan

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UNDERSTANDING THE DRIVERS OF MEDICAL TOURISM: AN EXPLORATORY EMPIRICAL STUDY
Vivek S. Natarajan, Lamar University Avinandan Mukherjee, Montclair State University

ABSTRACT Rising healthcare costs are a major concern to most Americans. One way of coping with increased healthcare costs has been the option of Medical Tourism- travelling to overseas destinations with cheaper healthcare costs for treatments. The main factors driving medical tourism are significant cost savings on healthcare costs and the opportunity to travel to a new destination. The purpose of this study was to investigate the factors that affect the patient satisfaction and behaviors and understand the factors that are important to patients in their selection of the destinations for medical tourism. We collected data using a national panel and obtained about 350 responses. Primary care Physicians, Family and Friends emerged as the most important sources of referrals for decisions to go abroad for treatment. Accreditation, English language skills of the foreign hospital, and Safety of the foreign country emerged as key factors that impact the choice of foreign hospital.

Dr. Vivek S. Natarajan Associate Professor of Marketing, Lamar University, Beaumont,Tx-77710 US Phone: 409-880-8643 vivek.natarajan@lamar.edu

Dr. Avinandan Mukherjee Chairman and Professor of Marketing School of Business, Montclair State University Montclair, NJ 07043, USA Phone: 973-655-5126 mukherjeeav@mail.montclair.edu

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MEDICAL TOURISM AND INTERNATIONAL HEALTHCARE OPTIONS
David Conley, Marshall University Andrew Sikula, Sr., Marshall University William Willis, Marshall University Alberto Coustasse, Marshall University

ABSTRACT Medical tourism has evolved from traveling to the United States (U.S.) and a select few other countries, such as India and Thailand, to a global trend in affordable alternative healthcare. Medical tourism in the U.S. and in other countries has evolved because of cost and lengthy waiting periods. Some insurance companies are marketing kidney transplants and joint replacements through medical choice programs in order to save overall expense. As an economical approach to controlling rising health care costs in the U.S., medical tourism is becoming a valid alternative.

INTRODUCTION During the recent past several decades, local healthcare costs have continued to rise placing an economic strain on many individuals throughout the world. It has been estimated that in 2000, the average person paid upwards of $315,000 throughout their lifetime to receive adequate insurance coverage in the United States (Alemayehu & Warner, 2004). Throughout history, those who have sought medical attention have traveled, sometimes to other countries, to receive what is considered as the best medical attention available. Some of these medical breakthroughs during the 19th and early 20th centuries ranged from vaccines for diphtheria, rabies and tetanus to the successful use of alternative surgeries (Pearson Education, 2007). Medical alternatives have not necessarily changed, but now instead of a person traveling to just the U.S., this practice is seen throughout the world, reaching many countries such as India, Brazil, Australia, Germany, Korea, Thailand Turkey and many more (Woodman, 2009). In recent decades, many have sought medical treatment in countries other than their own for two main factors: time and cost. In these cases, citizens may travel to other developed and developing countries in an effort to receive treatment for a fraction of domestic expenses even when travel and host expenses are included (Eggerston, 2006). Also, the time that they can save may determine the outcome of a procedure and its overall expense. Physicians in countries that practice medical choice are generally U.S. Board Certified doctors, or the equivalent in other countries (Joint Commission, 2011). Over 2.2 million persons traveled to India and Thailand in 2004 for healthcare and it has been estimated that approximately six million people did the same in 2010 to generate nearly $4.4 billion in revenue for countries that accept foreign medical transplants (Horowitz, Rosensweig & Jones, 2007). According to Sachdeva & Sachdeva (2010), the average heart bypass in the U.S. cost approximately $133,000 while in India it costs an average of $7,000. Some insurance companies are encouraging foreign medical alternatives as part of standard medical healthcare insurance programs. Blue Cross Blue Shield has enabled those covered by their programs in Florida and

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Wisconsin eligibility to consider off-shore medical facilities as a low-cost alternative (Keckley, 2009). In this practice, some of the personal costs have been waived such as airfares and deductibles (Horowitz, et. al., 2007). Similarly, in California, Blue Shield has several programs in place to assist patients of global medical operations and practices. They have been allowed access to physicians in Mexico as part of their health plans (Hansen, 2008). Such plans are geared largely towards Mexican Americans, and account for nearly 20,000 patients (Black, 2008). South Carolina’s Blue Cross Blue Shield policy holders are able to seek treatment at Bumrungrad International Hospital in Thailand, which is accredited by the Joint Commission International (J.C.I). In 2007, this hospital treated approximately 400,000 foreigners including about 80,000 Americans (Hansen, 2008). Bumrungrad International Hospital (BIH), which is in Bangkok, Thailand, includes about 200 U.S. BoardCertified physicians and more than 900 nurses, clinicians and therapists, many of whom hold licensures in Europe, Australia, or Japan (Bumrungrad International Hospital, 2011). BIH staff help patients with travel arrangements, housing, and assistance such as interpreters and other arrangements. Unlike typical health insurance policies and payout procedures in the U.S., approximately 75% of patients pay directly for services rather than receiving financing through insurance (Herrick, 2007). Introduced in 2007, Colorado General Assembly 07-1143 proposed to establish incentives for employees covered by state health insurance programs to seek medical care from foreign health centers for a lower cost ( CO 07-1143 2007). This bill established some of the same motivations as a West Virginia House Bill (HB) 2841, although it was never formally approved and was indefinitely tabled by the House Committee on Business Affairs and Labor. For some years, medical tourism has been proposed on a state-by-state basis, and while neither of these legislative bills passed committee scrutiny, group state insurance plans are beginning to consider foreign medical off-shore alternatives as a cost/benefit choice of their patrons (Keckley, 2009). As stated previously, West Virginia, as recent as 2007, considered legislation, West Virginia H.B. 2841, which provided financial incentives to state employees who volunteered to travel to off-shore medical destinations outside the U.S. that were accredited by the J.C.I. The bill specifically would have waived co-pays and deductibles, reimbursed for round-trip airfare and lodging for the employee and one companion, allowed seven days sick leave, and a 20% cost savings rebate. However, this bill died in committee and was not approved ( WV HB 2841 2007: Keckley, 2009). In Canada, the practice of foreign medical choice has been part of the Canadian nationalized healthcare system for many years. More than 15 government approved travel agencies promote medical tourism as a mainstay in Canadian healthcare, some of which includes patients to the U.S. (Johnston, et. al., 2011). Some entrepreneurial companies have specialized in medical tourism and have sent clients all over the world for procedures ranging from cosmetic surgeries and fertilization treatment to cancer therapies and kidney transplants (Turner, 2007). Partnerships throughout the world have expanded to certain medical facilities including a Vancouver agency directing patients to Thailand while a competitor in Quebec prefers accommodations in India (Turner, 2007). The purpose of this study was to determine the economic benefits of foreign medical choice alternative venues and how U.S. citizens can use this practice to successfully lower the total cost of healthcare. METHODOLOGY The methodology for this literature review was conducted using a systematic search of key words that are related to the content of medical tourism, or medical practices that accept international patients for non-elective surgeries. The terms used for the research were “medical tourism,” or “international medical practices,” or “off -

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shore medical destinations,” or “heart care cost,” or “renal transplant,” and “joint replacement.” Publications that were either written or translated in English were used and the search was limited to the last 25 years. For this literature review, three procedures, namely, renal replacement, Coronary Artery Bypass Graft (CABG), and joint replacement (specifically hip and knee replacements) were examined for their economic value and how such offshore medical choices have evolved into common practice today. To identify articles that were relevant, several databases were used to search for writings pertaining to this literature review and included PubMed, Marshall University and Alderson Broadus College library’s online journals. Other databases included Google Scholar, the World Health Organization, Indian Journal of Community Medicine, the Joint Commission International, the New England Journal of Medicine, Medscape General Medicine, Canadian Family Physician, Health Affairs, Institute of Public Affairs, National Center for Policy Analysis, along with other medical search engines and websites. The literature review yielded 37 articles which were assessed for information pertaining to this research project. Fifteen articles were used in the results section. Reviews, commentaries and editorials were used as well as primary and secondary data. The literature search was conducted by co-authors DC and DL and validated by AC and AS. RESULTS Comparing Kidney Transplant Surgery in the U.S. vs. India Patients in the past that have used off-shore medical tourism for cosmetic surgery, joint replacement, and other medical procedures in order to have them performed at less expense. Whether the person had insurance with limited coverage or was not insured, all patients who performed healthcare procedures abroad did so because of reduced cost (Milstein & Smith, 2006). There are many healthcare procedures that can be considered as non-elective surgeries such as a kidney transplant for individuals who have End Stage Renal Disease (ESRD), and are in desperate need of a kidney transplantation (Cardoen, Demeulemeester, & Beli¨en, 2008). Individuals diagnosed with ESRD in the U.S. have three choices of treatment: (1) hemodialysis (2) peritoneal dialysis, and (3) kidney transplantation (Moeller, Gioberge, & Brown, 2002). Patients with ESRD that seek treatment by dialysis will have to remain on dialysis until a donor kidney is located for them. Seeking foreign treatment can be very expensive, for both the individual as well as for the insurance companies (Moeller, et al., 2002). In 2007, 527,283 U.S. residents were under treatment as of the end of the calendar year (National Kidney and Urologic Diseases Information Clearinghouse, 2010). On the other hand, seeking domestic treatment for ESRD via a kidney transplant is also a very expensive treatment option in the US. The U.S. Renal Data System (USRDS) has stated that the U. S. performs 45-50 kidney transplants per million people every year. This is one of the highest rates in the world (Friedlaender, 2002). The U.S. has performed more kidney transplants than any other nation and shows a high quality of care among recipients (Friedlaender, 2002). Since a kidney transplant can be considered as non-elective surgery, patients can use medical tourism to receive treatment for ESRD. ESRD is a problem in the U.S. with 83,950 people awaiting a suitable kidney transplant in May 2010 (NKUDIC, 2010). With only 13,743 kidney transplants actually performed in 2008, there is much more demand than supply (National Organ Procurement and Transplantation Network, 2009). The large gap between the supply and the demand of kidney transplants in the U.S. means that it may be faster and more cost efficient for a potential kidney transplant patient to travel abroad (Sheehy, Conrad, Brigham, Luskin, & Weber, 2003). Dheeraj Bojwani Consultants is an example of a medical tourism company in India. This company arranges medical trips for people who are seeking low cost surgery in India. Dheeraj Bojwani Consultants has recently launched their latest marketing technique, a kidney transplant surgery (Dheeraj Bojwani Consultants, 2011). Dheeraj Bojwani offers a full package deal for the patient and a spouse to make the entire trip easier on the patient. When a patient receives treatment, including both before and after the operational procedures, the spouse or caregiver is also given accommodations that are similar to a vacation. Although the expenses for these all inclusive medical tourism trips vary, the cost of a kidney transplant in India is anywhere from $13,000 to $30,000 (Aarex India, 2006).

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Transplant

Table 1: Estimated U.S. Average 2008 First-Year Billed Charges per Transplant 30 days Hospital Physician 180 days Procurement Immunopretransplant during post suppressants transplant transplant admission transplant admission $16,700 $67,500 $92,700 $17,500 $47,000 $17,200

Total

Kidney only

$259,000

Source: United Network for Organ Sharing, 2011. In an article published in The New York Times in 2009 (Sack, 2009), the Center for Medicare and Medicaid Services (CMS) reported paying $100,000 or more for kidney transplants and services for patients that are effected by ESRD. CMS does in fact pay for these services with an annual price tag of approximately $23 billion. This cost includes the cost of the surgery and anti-rejection medication for up to 36 months per transplant. Anti-rejection drugs cost anywhere from $1,000 to $3,000 U.S. dollars per month (Sack, 2009). Typical charges for a dialysis patient, which are also covered by the CMS, can range up to $9,300 a month. The average expenses for yearly dialysis treatments are $71,000 compared to $106,000 for a transplant, which includes monitoring for 12 months after the procedure (Sack, 2009). These costs do not include additional fees structured by individual hospitals and medical facilities which can exceed an additional $150,000 for a total expense of over $250,000 (Table 1). In India, however, typical costs for the entire procedure of a kidney transplant average $10,000 U.S. dollars which include all hospital charges and medication expenses for the first 12 to 18 months when done at a public hospital. At a privatized hospital, costs for the initial services could average up to 60% more, although the cost of medication is relatively the same (Sakhuja & Sud, 2003).With companies such as Dheeraj Bojwani Consultants offering medical tourism trips to India for a variety or healthcare procedures, it is no wonder that it is now offering kidney transplantation surgery as an option for ERSD patients in the U.S. and Europe (Dheeraj Bojwani Consultants, 2011). Given that the data have shown it can be economically beneficial to the patient and their families if they seek kidney transplant abroad, a potential patient then has to question the quality and safety of the foreign care rendered (Kher, 2006). Medical Tourism and Cardiac Procedures The American Heart Association asserts that Cardio Vascular Disease (CVD) in the U.S. has claimed 831,272 lives in 2006 (American Heart Association [AHA], 2011). CVD did account for 34.3 % of all deaths or 1 of every 2.9 deaths in 2006. Furthermore, the AHA estimates that, in 2006, there were 81.1 million people in the U.S. who have had one or more forms of CVD. Expenses have been recorded with a high of $210,842 for the cost of heart bypass surgery, in the U.S. in 2006, whereas in India the total expenditure is $10,000 (Table 2).

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Procedure Heart Bypass Heart-value Replacement Hip Replacement Knee Replacement

Table 2: The Cost of Medical Procedures in Selected Countries in 2006 (U.S. dollars) U.S. Retail U.s. Insurers’ India** Thailand** Singapore** Price* Price* $210,842 $274,395 $75,399 $69,991 $94,277 $112,969 $31,485 $30,358 $10,000 $9,500 $9,000 $8,500 $12,000 $10,500 $12,000 $10,000 $20,000 $13,000 $12,000 $13,000

* Retail price and insurer cost represent the mid-point between low and high ranges ** U.S. rates include at least one day of hospitalization. International rates include airfare, hospital and hotel. Source: Unmesh Kher, “Outsourcing your heart,” Time, May 21, 2006. With the U.S. having a large number of people having CVD, plus high expenditures associated with this large number of surgeries having been performed in previous years, it could be assumed that the cost of such procedures would be comparable to or lower than other countries around the world offering the same procedures. In fact, based upon figures obtained through the National Center for Policy Analysis, a person could have received cardiac surgery in countries such as India, Thailand, and Singapore for a fraction of the cost in the U.S. The average cost of cardiac surgery in India was $10,000; in Thailand it was $12,000; and in Singapore the total expense is $20,000 (Table 2). Another company, similar to Dheeraj Bojwani Consultants, Tours 2 India 4 Health, Inc. focuses on matching potential patients from other nations with Indian physicians for certain services. The physicians working in this company have been trained or have worked in some of the best medical institutions in the U. S., United Kingdom, Europe, and other countries across the globe (tours2india4health.com 2011). There are a large number of J.C.I. accredited hospitals in India where foreigners are receiving cardiac procedures (Milstein & Smith, 2006). Medical Tourism and Joint Replacement In 2009, more than 193,000 total hip replacements were performed in the U.S. (American Academy of Orthopedic Surgeons, [AAOS], 2009). Approximately 581,000 knee replacements were performed in the same year in the U.S. (AAOS, 2009). In 2003, more than 638,000 hip or knee replacement surgeries were done (AAOS, 2007). These hip and knee replacement surgical procedures cost insurance companies on average $75,399 and $69,991, respectively (Table 2). Joint replacement is not as prevalent and life limiting as some of the other medical operations previously discussed, but for a patient with osteoarthritis, for example, a hip or knee surgery might be the only way that a person can retain a certain high level of mobility and quality of life (March, et al., 2011). Joint replacement surgery, specifically hip and knee, is costing the U.S. population a great deal, for both health insurance companies and for individuals. With the U.S. performing such a large number of hip and knee replacement surgeries, the costs for these procedures should be lower than that of other countries. However, actually joint replacement in the U.S. is much more costly as shown in Table 2. Expenses for these procedures average 1/3 the cost of foreign providers. Knee replacement surgeries, in 2006, were performed in India for $8,500 and hip replacement surgeries are approximately $9,000, while the U.S. domestic retail price of the same procedures was $69,991 (Table 2). In Thailand and Singapore, knee replacements were $10,000 and $13,000, respectively. These international prices include hospitalization and airfare as well as a financial money allotment for a family stay in a hotel. The insurer coverage price of $30,358 for a knee replacement is about half the cost or less to obtain similar services outside the U.S.

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This large gap in price is making the use of foreign medical choice viable for joint replacement surgeries. Indicure is a third example of a company that offers complete trips to other countries for the purpose of receiving a medical procedure (Indicure, 2011). Indicure and other similar companies offer such procedures as well as travel and follow-up costs as part of their surgery packages. DISCUSSION There is a movement in American medicine going from inpatient to outpatient treatment over the past several decades for certain surgeries. In 2006, nearly 35 million U.S. citizens had out-patient surgeries; triple the number of patients in 1996 (Keckley, 2009). Though this is not just an American trend, out-patient surgeries comprise a large bulk of medical tourism procedures caused by the long wait times associated with many noninvasive and/or elective operations. While not as predominate as in the U.S., many counties such as Canada, the U.K, Germany and Australia have created a normalcy of foreign medical operations (Hansen, 2008). While this review mainly discusses in-patient procedures, it is vital to determine the importance of the movement from in-patient to out-patient treatment. Technology is one of the driving forces behind medical mobility and medical tourism. The averages for uninsured hospitalizations have increased by 34% from 1997 to 2006 (Merrill, et. al., 2009). For both insured and uninsured patients, hospitals stays are becoming shorter as technology helps to trend major surgeries to becoming less invasive, consequently reducing patient recovery times, lengths of stay, and decreasing expenses for the patient, physician and facility. In California in 2009, the most expensive median charge per stay for a cardiac operation was over $417,000 at Centennial Hospital Medical Center in Inglewood with an average stay of seven days. The cheapest median charge for the same procedure was at Antelope Valley Hospital in Lancaster at under $80,000 with an average stay of 5.5 days (Office of California Statewide Health Planning and Development, 2011). As another example, consider Mr. Jones, who is in need of a double Coronary Artery Bypass Graft, or CABG x 2 (double bypass open heart surgery). Mr. Jones is underinsured having minimal health insurance coverage that will pay only $10,000 towards this procedure. This will leave the patient with a large medical bill that could be as high as $20,000 or more based on the same fee schedule that Medicare paid in 2002 (Barry, & Hallam, 2005). This could put massive financial strain on Mr. Jones, or it could be financially impossible for him to pay for this procedure even with his insurance. However, if the patient were to use this $10,000, which his insurance is going to pay, towards the operation in a foreign country, then this surgical procedure could leave him with minimal, if any, out-of-pocket expenses. Mr. Jones, by taking advantage of medical choice abroad, can receive a CABG x 2 outside the U.S., and can return to the workforce in the U.S. as a productive member of society quickly. Using an alternative medical venue choice for Mr. Jones would not only help him, but it would also help his insurance company by offering extended coverage to more people at lower rates for heart surgeries by patients seeking medical treatment abroad. If more insurance companies in the U.S. can promote provisions including medical tourism, it could result in millions of Americans receiving foreign quality treatment for CVD and other ailments. The example of Mr. Jones could also be used when considering joint replacement and kidney transplantations (including ESRD treatment) all based on fee structures as shown in Tables 1 & 2. In the United States, CMS could cover a bulk of these fees. However, it is still more cost effective to consider medical options abroad. CMS could save money on the cost of these procedures for beneficiaries by supporting and funding programs through alternative foreign medical options. In the United States, as in Canada and other countries institutionalizing medical travel companies, the Medical Tourism Association, based in West Palm Beach, Florida, has undertaken the task of educating patients around the world about the economic benefits of international medical location alternatives (MTA, 2010). Even though there are substantial economic benefits to the practice of medical tourism, there are some potential downfalls. One of the most important issues today is the spread of MRSA and other staff disease-related operational complications concerning procedures performed outside a patient’s home country. For example, commonly referred to as the Indian superbug, foreign medical procedures have been documented in cases around the world directly linking surgery procedures and a virus obtained in India. Follow-up and medication renewals, or lack of standard monitoring systems, are also causes for concern that additional expenses sometimes occur and have the potential to negate effective treatment (Srivastava, 2011).

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Specifically in the U.S., nearly one of every four Americans is being denied a healthcare request because of economic hardship (National Association of Insurance Commissioners, 2008). As a solution, several states in the U.S. including California, Florida, South Carolina, and Wisconsin are considering or have partnered with insurance programs to aid their citizens with more affordable healthcare by utilizing international medical travel and treatment. For the past several years, the U.S. and many other industrialized counties around the world have weathered an economic recession, although the costs of healthcare have stayed parallel or continued to rise despite the economic downturn. When considering such a significant difference in prices between the US and India, it is no wonder why U.S. citizens have begun using medical tourism to seek treatment for CVD that is offered in India. If there are patients that are in need of cardiac surgery and do not possess health insurance that will pay for this procedure, they are underinsured. In cases of uninsured individuals, using medical foreign travel becomes an economically smart option that is increasingly feasible with today’s globalized economy. Limitations This research could be expanded to include operational procedures beyond those of only heart failures, kidney transplantation, and hip and knee replacements. Expanding the list of non-essential and cosmetic operations should reveal the same conclusions as those reached in this study. Another limitation of this research is that the quality of outcomes has largely been left unexamined. It is generally assumed, often incorrectly, that American physicians provide the best care and the most favorable surgical outcomes. This quality gap is becoming less and less prevalent, as Board Certifications have improved assessment outcomes and accreditation demands and activities. Cost and quality are not always directly related. Additionally, the timing of procedures has also become a critical factor along with cost and quality parameters. CONCLUSION Economically, alternative foreign medical shopping has become a valid option to consider when determining healthcare cost, especially in cases of inpatient surgeries and procedures. Medical choice has the opportunity to assist in curtailing the rising cost of healthcare in the U.S. Although, this is not a widespread option for those who are insured, it is nonetheless a growing trend in U.S. healthcare. REFERENCES Aarex India. (2006). Kidney transplants, Retrieved March 3, 2011 from: http://www.aarexindia.com/kidney.asp Alemayehu, B. & Warner, K. (2004). The lifetime distribution of health care costs. Health Services Research, June 39(3): 627-642, Retrieved February 8, 2011 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361028/ American Academy of Orthopedic Surgeons [AAOS] (2007). Preparing for joint replacement Surgery. Retrieved June 14, 2011 from: http://orthoinfo.aaos.org/topic.cfm?topic=a00220 American Academy of Orthopedic Surgeons [AAOS] (2009). Total hip replacement. Retrieved June 14, 2001 from: http://orthoinfo.aaos.org/topic.cfm?topic=a00377 American Heart Association (2011). Cardio vascular disease statistics. Retrieved March 31, 2011: from:h ttp :/ / www. a mer ica n he ar t.o r g /p r e se n ter .j h t ml? id e nt i fi er=4 4 7 8 Barry, T, & Hallam, K. (2005). Heart surgery costs 83% more in U.S. than in Canada, Study says. Retrieved March 31, 2011 from: http://www.bloomberg.com/apps/news?pid=newsarchive&sid=a4J.ER8r4CrM&refer=ca nada Black, T. (March. 26, 2008). Mexico gets tourists as health net sends U.S. patients. Bloomberg, Retrieved June 14, 2011 from: http://www.bloomberg.com/apps/news?pid=newsarchive&sid=aFXAEi5eek5I&refer=asia Bumrungrad International Hospital, (2011). Frequently asked questions. Retrieved March 31, 2011 from: http://www.bumrungrad.com/overseas-medical-care/faq-s.aspx Cardoen, B., Demeulemeester, E., & Beli¨en, J. (2008). Operating room planning and scheduling: A literature review. FED Research Report KBI 0807. Katholike Universiteit Leuven, Retrieved March 31, 2011 from:

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http://www4.ncsu.edu/~saerdoga/SurgeryScheduling_Erdogan_Denton_2010.pdf Colorado General Assembly 07-1143 (2007). Legislation to consider: Geographic location for rating insurance. Retrieved March 31, 2011 from: http://www.colorado.gov/cs/Satellite?blobcol=urldata&blobheader=application%2Fpdf&blobkey=id&blobtable=Mu ngoBlobs&blobwhere=1232524018870&ssbinary=true Dheeraj Bojwani Consultants (2011). Dr. Dheeraj Bojwani, India, Retrieved March 31, 2011 from: http://www.dheerajbojwani.com/medical-treatment-india.html Eggerston, L (2006). Wait-list weary Canadians seek treatment abroad. Canadian Medical Association Journal, 174:1247. Retrieved March 31, 2011 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1435972/ Friedlaender, M. (2002). The right to sell or buy a kidney: Are we failing our patients? Lancet. 359(9310): 971-97. Retrieved March 3, 2011 from: https://www.firmaweb.ch/docs/9e7a962d26b14161630973624c692dbd/dl1.pdf Hansen, F (2008). A revolution in healthcare – Medicine meets the marketplace. Institute of Public Affairs. 59(4): 43-45. Retrieved March 31, 2011 from: http://www.ipa.org.au/library/59-4_HANSEN.pdf Herrick, D (2007). Medical tourism: Global competition in health care. National Center for Policy Analysis, Report No. 304, November. 2007. Retrieved March 31, 2011 from: www.ncpa.org/pub/st/st304 Horowitz, M., Rosensweig, J. & Jones, C. (2007) Medical tourism: Globalization of the healthcare marketplace. Medscape General Medicine. 9(4): 33, Retrieved March 3, 2011 from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2234298/ Indicure (2011). Joint replacement surgery. Retrieved June 14, 2011 from: http://indicure.com/treatments/joint-replacement-surgery.htm Joint Commission International (JCI) (2011). JCI Accredited Organizations .Retrieved March 3, 2011 from: http://www.jointcommissioninternational.org/jci-accredited-organizations/ Johnston, R., Crooks, V., Adams, K., Snyder, J., & Kingsbury, P. (2011). An industry perspective on Canadian patients’ involvement in medical tourism: Implications for public health. BioMed Central Public Health, 11:416, Retrieved June 15, 2011 from: http://www.biomedcentral.com/1471-2458/11/416 Kher, U. (2006). “Outsourcing your heart.” Time, May 21, 2006. Retrieved March 31, 2011 from: http://www.time.com/time/magazine/article/0,9171,1196429-5,00.html Keckley, P. (2009). Medical tourism: Update and implications. Deloitte Center for Health Solutions. Retrieved March 3, 2011 from: http://www.deloitte.com/assets/DcomUnitedStates/Local%20Assets/Documents/us_chs_MedicalTourism_111209_web.pdf March L., Cross M., Lapsley H., Brnabic A., Tribe K., Bachmeier C., Courtenay B., & Brooks P., (1999). Outcomes after hip or knee replacement surgery for osteoarthritis. Medical Journal or Australia, 171(235-238), Retrieved June 14, 2011 from: https://www.mja.com.au/public/issues/171_5_060999/march/march.html Medical Tourism Association [MTA] (2010). About the MTA. Retrieved June 14, 2011 from: http://www.medicaltourismassociation.com/en/about-the-MTA.html Merrill, C., Stocks, C. & Stranges, E., (February, 2009). Trends in uninsured hospital stays, 1997-2006. Healthcare cost and utilization project, Agency for Healthcare Research and Quality, Statistical Brief # 67. Retrieved April 23, 2011 from: http://www.hcup-us.ahrq.gov/reports/statbriefs/sb67.pdf Milstein A, & Smith, M.(2006). America’s new refugees: Seeking affordable surgery offshore . New England Journal of Medicine 355(16): 1637-1640. Retrieved March 3, 2011 from: http://www.nejm.org/doi/full/10.1056/NEJMp068190 Milstein, A. & Smith, M. (2007). Will the surgical world become flat? Health Affairs, 26,(1): 137-141. Retrieved March 31, 2011 from: http://content.healthaffairs.org/content/26/1/137.full Moeller, S., Gioberge, S., & Brown, G. (2002). ERSD patients in 2001: Global overview of patients, treatment modalities and development trends. Oxford Journals,17(12) 2071-2076. Retrieved March 31, 2011 from: http://ndt.oxfordjournals.org/content/17/12/2071 National Association of Insurance Commissioners (August 12, 2008). Weakening U.S. economy takes toll on American health. Retrieved April 19, 2011 from: http://www.naic.org/Releases/2008_docs/economy_health_toll.htm National Kidney and Urologic Diseases Information Clearinghouse (NKUDIC) (2010). Kidney and urologic diseases statistics for the United States 10 (3895). Retrieved March 31, 2011from:

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http://kidney.niddk.nih.gov/kudiseases/pubs/kustats/ National Organ Procurement and Transplantation Network (2009). Number of U.S. transplants per year,1988–2008. Retrieved March 3, 2011 from: http://www.infoplease.com/science/health/us-transplants-year-1988-2007.html Office of Statewide Health Planning and Development (2011). Common surgeries and charges comparison (CABG, 2009). CA.GOV, Retrieved on April 23, 2011 from: http://www.oshpd.ca.gov/commonsurgery/Default.aspx Pearson Education (2007). Medical advances timeline, infoplease: Family education network. Retrieved June 14, 2011 from: http://www.infoplease.com/ipa/A0932661.html Sachdeva, S., & Sachdeva, R. (July, 2010). Keeping an eye on the future: Medical tourism. Indian Journal of Community Medicine. 35(3): 376-378, Retrieved March 3, 2011 from: http://www.ijcm.org.in/article.asp?issn=09700218;year=2010;volume=35;issue=3;spage=376;epage=378;aulast=Jose Sack, K. (2009). “U.S. cost-saving policy forces new kidney transplant.” New York Times, September 13, 2009. Retrieved June 14, 2001 from: http://www.nytimes.com/2009/09/14/health/policy/14kidney.html Sakhuja, V. & Sud, K. (2003). End-stage renal disease in India and Pakistan: Burden of disease and management issues. Kidney International 63, S115-S118. Retrieved June 14, 2011: http://www.nature.com/ki/journal/v63/n83s/full/4493749a.html Sheehy, E., Conrad, S., Brigham, E., Luskin, R., & Weber, P. (2003). Estimating the number of potential organ donors in the United States. New England Journal of Medicine, 349(7): 667-74. Retrieved March 31, 2011 from: http://www.nejm.org/doi/pdf/10.1056/NEJMsa021271 Srivastava, R., Ichhpujani, R., Khare, S., Arvind R., & Chauhan, L. (2011). Superbug. Indian Journal of Medical Research 133(4)458-460. Retrieved June 14, 2011 from http://www.ijmr.org.in/article.asp?issn=09715916;year=2011;volume=133;issue=5;spage=458;epage=460;aulast=Srivastava Tours2india4health.com (2011). Medi tours and health tourism services, India. Retrieved from: http://www.tour2india4health.com/fissure-treatment-Nigerian-Chennai-India.html Turner, L. (October, 2007) Medical tourism, Family medicine and international health-related travel. Canadian Family Physician Vol. 53(10): 1639-1641. Retrieved March 3, 2011 from: http://www.cfp.ca/cgi/content/full/53/10/1639 United Network for Organ Sharing (UNOS) (2011). TransplantLiving.org. Retrieved June 14, 2011 from: http://www.transplantliving.org/beforethetransplant/finance/costs.aspx Wachter, R (2006). International teleradiology. New England Journal of Medicine, February 2006: 354(7): 662-663. Retrieved March 31, 2011 from: http://www.nejm.org/doi/pdf/10.1056/NEJMp058286 U.S. Department of Health and Human Resources (2010). What is heart surgery? Retrieved March 31, 2011 from: http://www.nhlbi.nih.gov/health/health-topics/topics/hs/ Woodman, J (2009). Patients beyond boarders: Everybody’s guide to affordable, World class medical travel. Chapel Hill, N.C.: Healthy Travel Media. West Virginia House Bill 2841(2007). Authorization for treatment in foreign health care facilities accredited by the Joint Commission International (JCI): Incentives for covered employees; Rebate of savings. Retrieved March 3, 2011 from: http://www.legis.state.wv.us/Bill_Text_HTML/2007_SESSIONS/RS/BILLS/hb2841%20intr.htm

David Conley, MS College of Business, Graduate School of Management Marshall University Tel: 304-746-1968 Fax: 304-746-2063 Conley85@live.marshall.edu

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Andrew Sikula, Sr., Ph.D. College of Business, Graduate School of Management Marshall University Tel: 304-746-1956 Fax: 304-746-2063 sikula@marshall.edu William Willis, Dr.PH. College of Business, Graduate School of Management Marshall University Tel: 304-746-8967 Fax: 304-746-2063 willis23@marshall.edu Alberto Coustasse, Dr.PH. MD, MBA, MPH College of Business, Graduate School of Management Marshall University Tel: 304-746-1968 Fax: 304-746-2063 coustassehen@marshall.edu

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PAIN ASSESSMENT IN THE CRITICALLY ILL, INTUBATED PATIENT
Colleen Meade, Oakland University Matthew Ripper, Siena Heights University

ABSTRACT Purpose: To evaluate the reliability and validity of the FLACC Pain Assessment Tool with the critically ill, intubated patient incorporating five categories of pain behaviors: facial expression; leg movement; activity; cry; and consolability. Method: One-hundred critically ill, intubated patients aged 19 and greater will be admitted to the ICU/CVICU via the acceptance of the Intensivist and observed for pain assessment. The purpose of this study was to establish the 1) usefulness, 2) inter-rater reliability, and 3) significance of the demographic data of the Faces, Legs, Activity, Cry, and Consolability (FLACC) pain assessment tool in critically ill, intubated patients (CIIP). The results of this study showed statistical significance usefulness, inter-rater reliability at the p<0.01 level with no demographic significance. The results of this study also showed a financial savings with standardizing pain assessment.

Colleen Meade, PhD Oakland University Matthew J. Ripper, MPA. Assistant Professor of Business Siena Heights University 1247 E. Siena Heights Drive Adrian, Michigan 49221 (517) 264-7622

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MANAGEMENT OF SOCIAL SERVICES IN THE POST COMMUNIST COUNTRY – SLOVAKIA
Libusa Radkova University of Health and Social Care of st. Elisabeth, Bratislava, Slovakia Anna Pavlovicova University of Health and Social Care of st. Elisabeth, Bratislava, Slovakia

ABSTRACT Social services in Slovakia during the years of communism were practices that dehumanized people. Under communism, the state wanted to show that social problems did not exist or that the problems had been solved. Socially needy clients such as those who were elderly, orphans and mentally or physically disabled were placed into institutions that treated them more like objects than like people. The authorities usually selected old buildings, often abandoned palaces that often had unsuitable living conditions. They were high capacity facilities that usually held 100 or more residents. Residents shared rooms with three or more roommates. There rarely existed conditions that regarded individual needs for privacy. Thus it was necessary to transform this kind of social service from an impersonal state regime to a system that reflects a democratic society that respects humanity regardless of their social, physical and mental condition. After 1989 perspectives about social services were seriously evaluated. One of the changes was the oversight of social care facilities. Whereas they were previously overseen by state authorities, now the responsibility for managing was delegated to local and regional governments. This decentralization also led to many charitable, church and non-governmental organizations that began to provide social services. It has not been a simple process. It demands new ways of looking at problems and solutions. It requires the complicated transformation from one system and facility to another kind of system and facilities. It is not just about pragmatically managing a budget, clients and staff. Just as important, the administrator must have a deep internal motivation to serve others. There is no greater opportunity, responsibility, and obligation given to a man than that of serving as a helping professional. In responding to the suffering of others the modern, professional manager needs technical skills, psychological and sociological knowledge, and human compassion. He/she will use his skills with courage, wisdom and humility to provide exceptional services for his fellowman. In doing so, he will build an enduring character within himself. His work is not only a profession. It is a calling. Putting into practice the thoughts of Carl Rogers and Victor Emil Frankl in the approach to a client gives to managers of social services deep internal motivation. In the transformed system of social services in Slovakia, social workers can themselves discover meaning and value in their own lives. There are those who are not capable to face the traps and difficulties of life due to mental or physical handicaps. There are the elderly and those limited by their age and condition of health. To help these people to live their lives with dignity and meaning can motivate a manager and help him find personal fulfillment and contentment in his own life. The approach to social services that is focused on the individual means empowering a unique approach to understanding personality and human relationships. This is the new application in management of social services today in Slovakia. There are more examples of good management that changed lives of many social clients. Libusa Radkova, Ph.D. University of Health and Social Care of st. Elisabeth Palackeho street 1, 810 00 Bratislava, Slovakia E-mail address: libusa.radkova@gmail.com Phone:+421 911450212 Anna Pavlovicova, Ph.D. University of Health and Social Care of st. Elisabeth Palackeho street 1,810 00 Bratislava, Slovakia E-mail address: pavlovicovaanna@zupa-tt.sk phone: +421 905404254

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THE TRANSITIONS FROM ADOLESCENCE TO ADULTHOOD OF YOUNG PEOPLE WITH DISABILITIES IN SLOVAKIA
Jozef Matulník, St. Elizabeth University of Health and Social Sciences Mária Orgonášová, St. Elizabeth University of Health and Social Sciences Jana Adamcová, St. Elizabeth University of Health and Social Sciences

ABSTRACT Data from the two surveys are used to estimate the effect of disability on young people's progress toward five adult transitions: completing education, finding full-time employment, establishing an independent, residence, marrying and having children. The two populations were subject for the surveys. The first sample was consisted of the students with disabilities attending different types of secondary schools (comprehensive, vocational, special) in Slovakia. The expectations expressed by students with disabilities regarding their future education, employment, leaving home and starting family are analyzed. The second sample was consisted of the more adult young people with disabilities (age 21 – 35). The effect of type of disability (hearing, visual, physical impairment, mental health problems) on young people's progress to adulthood is discussed.

Jozef Matulník St. Elizabeth University of Health and Social Sciences Mária Orgonášová St. Elizabeth University of Health and Social Sciences Jana Adamcová St. Elizabeth University of Health and Social Sciences

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LEISURE TIME AND HEALTH OF YOUNG PEOPLE IN SLOVAKIA
Roman Kollár, St. Elizabeth Univerzity of Health and Social Work Margita Minichová, St. Elizabeth Univerzity of Health and Social Work

ABSTRACT The paper deals with the relationship between leisure time and young people´s health. Many empirical sociological researches (e.g. Mensink, Loose, Oomen 1997, Sutton 2009) indicate a strong associations between active leisure time and good health. Data from the representative sociological research (n=750) were used to investigate the relationship between active leisure time and health of young people (age 18 - 29) in Slovakia. The associations between sport activities and other factors on health are discussed.

Roman Kollár, St. Elizabeth Univerzity of Health and Social Work Margita Minichová, St. Elizabeth Univerzity of Health and Social Work

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A GLOBAL PERSPECTIVE ON HEALTH AND WELLNESS PROGRAMS IN THE WORKPLACE: UNITED STATES VS. CENTRAL EUROPE (CZECH REPUBLIC)
Jessika Haynos, University of Scranton Robert Spinelli, University of Scranton

ABSTRACT As healthcare organizations in the U.S look for ways to control increasing healthcare expenditures, the country has begun to promote the wellness of individuals. By focusing on promoting healthy lifestyles, U.S healthcare organizations hope that they will be able to curb these increasing costs. One way to improve the health status of the population is through the use of wellness programs in the workplace. Research shows that U.S companies have been addressing employee wellness for many years, while European companies do not believe that they should be as deeply involved. This presentation will focus on the trend in workplace health promotion in the United States and in Central European countries to examine the importance these countries place on employee wellness, their effectiveness, and benefits of each system.

Jessica Haynos MHA Student University of Scranton Scranton, PA 18510 Robert Spinelli, D.B.A Assistant Professor University of Scranton Scranton, PA 18510

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WHY EASTERN EUROPE LAGS BEHIND WESTERN EUROPE?
Julius Horvath, Central University

ABSTRACT This presentation deals with the issue of convergence between the western European core countries and the eastern European periphery. We review the historical, cultural and institutional aspects behind lagging of eastern European lands behind the core countries. We also discuss the current economic model of transition in these countries, their success in the first two decades of transition as well as current vulnerabilities.

Julius Horvath Central University Budapest

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IS THE EURO REALLY IRREVERSIBLE? THE PUZZLES OF THE EUROPEAN MONETARY INTEGRATION
Julius Horvath, Central University

ABSTRACT This presentation evaluates the pros and cons of keeping euro in light of recent developments. It also discusses the issue of costs of the break-up of the monetary union, and the costs of opting-out, or not joining from the viewpoint of a small country. Different scenarios are reviewed.

Julius Horvath Central University Budapest

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CHRONIC DISEASES AS KEY CHALLENGE OF PUBLIC HEALTH ADMINISTRATION IN EUROPE AND IN USA
Robert Babela, St. Elizabeth University Steven Szydlowski, University of Scranton Vladimir Krcmery, St. Elizabeth University Daniel J. West, University of Scranton, PA

ABSTRACT Chronic diseases in Europe are responsible for 86% of all deaths and for approximately 77% of total healthcare costs. These diseases threaten to overwhelm Euro pe’s healthcare system. The United Nations Population Division reports that life expectancy in Europe has risen by an average of ten years since 1960 and two years in the past decade alone. It forecasts that average life spans across Europe will rise from 75 years currently to 82 years by 2050. This paper lays the groundwork for rising burden of chronic illness that is threatening the viability of Europe’s healthcare systems to cope with increasing numbers of long-term/chronic patients. It is estimated that by 2030 will global economic burden of chronic disease reach 43,4 tr. USD – which is double compared to 2010. In US only The Milken Institute estimated in 2009 that total treatment expenditures for chronic disease reached 277 bn. USD and lost economic output 1,047 bn. USD. The European Union has established the European Innovation Partnership aimed at improving co-ordination between the EU and member states to encourage innovation. We would like to discuss ongoing activities and several recommendations for effective public health administration of chronic disease in Europe and USA.

Robert Babela St. Elizabeth University Slovakia Steven Szydlowski University of Scranton USA Vladimir Krcmery St. Elizabeth University Slovakia Daniel J. West University of Scranton USA

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INNOVATIONS AS KEY STRATEGY FOR SUSTAINABLE HEALTHCARE IN CEE REGION
Robert Babela, St. Elizabeth University, Slovakia Vladimir Krcmery, St. Elizabeth University, Slovakia Mariana Mrazova, St. Elizabeth University, Slovakia Jana Hruskova, St. Elizabeth University, Slovakia Marian Fasko, St. Elizabeth University, Slovakia

ABSTRACT Central Eastern Europe (CEE) is facing same economic crisis as the rest of European Union, even though several countries shows still positive GDP growth. This paper lays the groundwork for understating innovations as one of the key factors that can contribute to successful recovery from a post-crisis economy to a stronger, sustainable one. It will also cover innovations as basis for new businesses and new jobs in CEE region and in Slovakia. Innovations are essential in improving competitiveness, diversifying economic activities and moving towards activities with a higher added value. This is related also to healthcare innovations, which are cornerstone for sustainability (and growth) in healthcare mainly from aspect of aging population of European Union, where life expectancy is expected to reach 82 years in 2050. Paper is exploring current situation in CEE region from healthcare innovations perspective with key focus on Slovakia. According to the European Innovation Scoreboard 2009, Slovakia has internationally ranked among countries with the lowest innovation performance, standing at only 66% of the EU average. Average expenditure in the EU27 stands at 1.82% of GDP, whereas in Slovakia it is 0.48% of GDP, with public funds accounting for 55% of the total expenditure in science and research. In our paper we also would like to discuss ongoing and future solutions improving situation in healthcare innovation in CEE region, as well as in Slovakia.

Robert Babela St. Elizabeth University Slovakia Vladimir Krcmery St. Elizabeth University Slovakia Mariana Mrazova St. Elizabeth University Slovakia Jana Hruskova St. Elizabeth University Slovakia Marian Fasko St. Elizabeth University Slovakia

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HEALTH ECONOMICS: A NEW TOOL FOR REIMBURSEMENT PROCESS IN SLOVAKIA
Robert Babela, St. Elizabeth University, Slovakia Tomas Tesar, UNION health insurance, Slovakia

ABSTRACT We see many different pharmaceutical markets varying across the globe and many new measures incorporating health economics into decision making process – mainly from perspective of payers. Paper will outline key trends we see worldwide in health economics that influenced also our region and our country. Under all consideration, we need to look at the processes outside of our borders, which are directly or indirectly influencing decision makers locally. For example the German Healthcare program has experienced substantial reform over the past decade as the government seeks to contain increasing costs, particularly in terms of expenditure on pharmaceuticals. The French Government is seeking to contain health-spending growth under the 3% threshold and has reduced reimbursement for 200 drugs to 15% (down from 35%). Spain made significant cutbacks via a new Real Decree RDL 16/2012 with many changes including modifications to the reference pricing system. Slovakia has decided to incorporate several health economic measures into new legislation valid from previous year with key focus on reimbursement process and new molecules asking for reimbursement. We would like to share key legislation changes from health economic aspect, current status and some examples of successful and also not so successful health economic applications and their influence on decision making process within reimbursement process.

Robert Babela St. Elizabeth University Slovakia Tomas Tesar UNION health insurance Slovakia

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TRACK CULTURAL DIFFERENCES EFFECTING HEALTHCARE OUTCOMES

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BREASTFEEDING EXPERIENCES AMONG AFRICANAMERICAN AND CARIBBEAN-AMERICAN WOMEN
Joanne Carrega, Georgia State University Ptlene Minick, Georgia State University

ABSTRACT Background: One-third of children in the United States are currently overweight or obese. Obesity rates in African American children double those of Caucasian children of the same age. Formula-fed infants are 1.5 times more likely to be overweight than breastfed infants. While 75% of U.S. women choose breastfeeding, only 59% of African-American women choose to do so. Few studies have that explored African American beliefs about breastfeeding. If factors associated with the decision-making surrounding breastfeeding in African American women are better understood, then more effective interventions to encourage and support these women may be developed. Objective: The purpose of this study was to explore breastfeeding experiences among American women of African descent. Method: A qualitative, phenomenological design was used. Six women, in their early 30s, (3 AA and 3 Caribbean women), with breastfeeding experience participated in semi-structured interviews. Constant comparative analysis was used to code line-by-line, collapse the codes into categories, and identify prominent themes. Preliminary Results: Breastfeeding support for all participants was inconsistent, especially in the postpartum period. Some participants described teasing and negative comments about breastfeeding from friends and extended family. Support from significant others buffered negative comments for these women. Nurses play a vital role in guiding AA women’s decision to breastfeed during each phase of pregnancy and into the postp artum period. Discussion: Cultural differences in breastfeeding beliefs between African American and Caribbean-American women were evident in this study. Future research is needed in this area. Better understanding of cultural beliefs surrounding breastfeeding among African-American and Caribbean-American women will assist health care providers in development of interventions that will improve breastfeeding rates and support for both groups.

Joanne Carrega Georgia State University Ptlene Minick Georgia State University

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HIV INFECTED AFRICAN AMERICANS: BARRIERS TO QUALITY CARE AND STRATEGIES TO IMPROVE HEALTH OUTCOMES
Caryn Ewbank, University of Scranton Steven Szydlowski, University of Scranton

ABSTRACT The presentation reviews disproportionate representations of African Americans in the number of new HIV cases diagnosed each year. An overview of HIV infections in various populations and ethnic groups is provided. The presenters provide an in-depth literature review discussing the alarming statistics that threaten this population. Barriers pertaining to cost, quality, and access to services and insurance are discussed as well as other socioeconomic factors. The presenters identify potential strategies to improve health outcomes based on the literature and discuss future implications for addressing this disparate population related to HIV. The presenters conclude with implications health care reform can have on HIV infected African Americans.

Caryn Ewbank University of Scranton caryn.ewbank@scranton.edu Steven Szydlowski University of Scranton

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A COMPARATIVE STUDY OF LONG TERM CARE IN US AND CHINA: THE GOVERNMENT’S ROLE
Qiu Fan, Clayton State University Xiaomei Pei, Tsinghua Univerisity Deborah Gritzmacher, Clayton State University Scott Stegall, Clayton State University Peter Fitzpatrick, Clayton State University

ABSTRACT This paper reviews the history of the development of the long term institutional care market in US for insights on China’s future development. The financial perspective is quite different in the two countries. By examining different financing models and the government’s role for the past 30 years, we analyze the underlying factors that drive the development in the context of the overall economic environment. In the US, the past three decades saw the transition from home-care to facility-care for the elderly, with one of the reasons being increasing labor mobility and employment opportunities for women. As China now faces the very similar situation, it explores the new territory with much needed caution and careful planning. The paper aims to shed light on Chinese government’s role in the development of its domestic long term facility care market.

Qiu Fang qiufang@clayton.edu Department of Health Care Management Clayton State University Morrow, GA 30267 Xiaomei Pei peixm@tsinghua.edu.cn Department of Sociology Tsinghua University Beijing, China 100084 Deborah Gritzmacher deborahgritzmacher@clayton.edu Department of Health Care Management Clayton State University Morrow, GA 30267 Scott Stegall scottstegall@mail.clayton.edu Department of Health Care Management Clayton State University Morrow, GA 30267 Peter Fitzpatrick peterfitzpatrick@clayton.edu Department of Health Care Management Clayton State University Morrow, GA 30267

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EUROPEAN ECONOMIC CRISIS: EFFECTS IN ROMANIA, CZECH REPUBLIC, AND HUNGARY
Stephanie Hill, University of Scranton

ABSTRACT The economic crisis has hit Europe hard. The impact of the crisis on healthcare systems threatens the quality of services provided to patients. This paper will examine the effects of the economic crisis on three countries: Romania, the Czech Republic, and Hungary. The effects will focus on the financial sustainability of healthcare organizations, government funding of healthcare and government budgets, the demands on the healthcare workforce to reduce costs, and the increased costs of healthcare on individual patients. Lastly, this paper will review best practices and make recommendations on how to sustain the healthcare systems in these countries after the changes caused by the economic crisis.

Stephanie Hill MHA Student The University of Scranton Scranton, PA 18510

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ARABIC TRANSLATION AND ADAPTATION OF THE HOSPITAL CONSUMER ASSESSMENT OF HEALTHCARE PROVIDERS AND SYSTEMS (HCAHPS) PATIENT SATISFACTION SURVEY INSTRUMENT
James Dockins, Rockhurst University Ramzi Abuzahrieh., King Faisal Specialist Hospital and Research Centre Martin Stack, Rockhurst University

ABSTRACT Objective. To translate and adapt an effective, validated, benchmarked, and widely used patient satisfaction measurement tool for use with an Arabic-speaking population. Setting. Three hundred-bed tertiary care hospital in Jeddah, Saudi Arabia. Participants. 645 patients discharged during 2011 from the hospital’s inpatient care units. Interventions. The HCAHPS instrument was translated into Arabic, a randomized weekly sample of patients was selected, and the survey was administered via telephone during the period January, 2011 through December, 2011 to patients or their relatives. Main outcome measures. Scores were compiled for each of the HCAHPS questions and then for each of the six HCAHPS clinical composites, two non-clinical items, and two global items. Results. Clinical composite scores, as well as the two non-clinical and two global items were analyzed for the 645 respondents. Clinical composites were analyzed using Sp earman’s correlation coefficient and Cronbach’s alpha to demonstrate acceptable internal consistency for these items and scales demonstrated acceptable internal consistency for the clinical composites. (Spearman’s correlation coefficient = 0.327 – 0.750, P<0.01; Cronbach’s alpha = 0.516 – 0.851) All ten HCAHPS measures were compared quarterly to US national averages with results that closely paralleled the US benchmarks. Conclusion. The Arabic translation and adaptation of the HCAHPS is a valid, reliable, and feasible tool for evaluation and benchmarking of inpatient satisfaction in Arabic speaking populations.

Background Patient satisfaction has been a key indicator for healthcare quality and the measure of health outcomes for many years (Donabedian, 1966; Ware, Davies, Stewart, & Rand Corporation, 1977). The primary goal of measuring consumer perception of quality of healthcare services is to utilize these measures to enhance and improve the delivery of care (Ware et al., 1977). During the past 40 years we have seen a continuous evolution of instruments for the measurement of patient satisfaction (Liu, Squires, & You, 2011). A key strategy for driving improvements in healthcare quality is providing comparative patient satisfaction information to consumers (“HCAHPS Facts,” 2012). As noted by Shaller et al (2003), “This strategy will not work, and could even be counterproductive, unless (1) consumers are convinced that there are quality problems that are real and consequential and the quality can be approved improved; (2) purchasers and policymakers must make sure that quality reporting a standardized in a universal manner; (3) consumers are given the quality information that is relevant and easy to understand and utilize; (4) the dissemination of quality information is improved; and (5) purchasers reward quality improvements and providers create the information and organizational infrastructure to achieve them” (p. 95). U.S. based accomplishments in this field have included standardizing survey and implementation protocols, developing incentives for healthcare providers based upon improvement in patient satisfaction measures, and promotion of public reporting and transparency to enhance accountability of care providers (Lindenauer et al., 2007). Further enhancements have included structuring the design of payment systems to reward improved and toptier scores (Giordano, Elliott, Goldstein, Lehrman, & Spencer, 2010). The US health care delivery system has made strides during the past decade on a number of these goals (Elliott et al., 2010).

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Accreditation Hospital achievement of accreditation standards for international agencies such as Joint Commission International (JCI) and American Nurse Credentialing Center (ANCC) Magnet Recognition Program require a robust system for collection and analysis of patient satisfaction data as a part of the organizations continuous quality improvement cycle (Joint Commission International Accreditation Standards for Hospitals, 2010; “Magnet nursing requirements,” n.d.). Joint Commission International requires measures selected related to important managerial areas including patient and family expectations and satisfaction (Joint Commission International Accreditation Standards for Hospitals, 2010). The accreditation standards of the Magnet Recognition Program requires patient satisfaction data to be collected at a unit-specific level and benchmarked against other hospitals (“Magnet nursing requirements,” n.d.). U.S. Public Reporting Consumer comparison and selection of hospital service providers has been made easier in the United States during recent years with benchmarked patient satisfaction data for over 4,000 US Medicare-certified hospitals being easily accessible to consumers via the US Department of Health and Human Services Hospital Compare website (“HCAHPS Facts,” 2012). Establishment of financial incentives for US hospital participation in standardized patient satisfaction data collection and reporting came in fiscal year 2008 when the Centers for Medicare & Medicaid Services (CMS) tied Annual Payment Updates (APU) for Inpatient Perspective Payment System (IPPS) hospitals (Giordano et al., 2010). In addition, UnitedHealth Group, the largest US health insurer announced in early 2012 a restructuring of compensation for doctors and hospitals that includes patient satisfaction as one of the key metrics for payment (Frier & Armstrong, n.d.). Saudi Arabia Hospital Patient Satisfaction Implementation of quality improvement systems, including patient satisfaction assessment, will be pivotal in Saudi Arabia as well as the other countries that make up the Gulf Cooperation Council (GCC) as we continue to see significant growth and development of health services within the region. Saudi Arabia’s Ninth Five-Year Plan allocates $73 billion (SR273.9) for healthcare initiatives that include the construction of 117 hospitals, 750 primary health care centers, and 400 emergency centers (“Ninth Five-Year Plan Includes $385 Billion in New Spending,” 2012) . A number of US-based hospital service providers such as Methodist International, Johns Hopkins, and Cleveland clinic are already in the GCC managing hospital resources and bringing US models of care delivery and processes to the region (“GCC Healthcare Industry Report,” 2012). Despite continued investment of government and private sector capital resources into the healthcare infrastructure of hospitals in the GCC, the providers of care continue to lag behind the standards of developed markets. Demand for healthcare services in the region is expected to continue to grow rapidly due to rising income levels, population growth, increased insurance penetration, and a prevalence of lifestyle-related diseases (“GCC Healthcare Industry Report,” 2012). Chassin (2010) reported, “Measuring the consumer perception of quality of healthcare and using those measurements to promote improvements in the delivery of care, to influence payment for services, and to increase transparency are now commonplace. These activities, which now involve virtually all US hospitals, are migrating to ambulatory and other care settings and are increasingly evident in healthcare systems worldwide.” To summarize, as hospitals and health systems within the Middle East region continue to develop Western healthcare infrastructure, it will be important that these providers are able to demonstrate quality of care and outcomes that are comparable to other developed healthcare systems and structures, particularly those based in North America (Margolis, Al-Marzouqi, Revel, & Reed, 2003). Hospital Challenges When King Faisal Specialist Hospital & Research Centre, a Joint Commission International accredited hospital, began the accreditation process for the ANCC Magnet Recognition Program it found that while its current patient satisfaction monitoring system would not be adequate as it did not have nursing unit specific data that is benchmarked at the national level, as required in the ANCC standards for accreditation (“Magnet nursing requirements,” n.d.). As King Faisal Specialist Hospital began to investigate possible alternative patient satisfaction survey instruments, it needed one that met the Magnet Recognition Program required components, was a wellvalidated and commonly used instrument, and provided a straightforward survey process that had a cultural transferability. The survey needed to be administrable by telephone as in Saudi Arabia there is no widely utilized postal service/address system for written post-discharge survey distribution in the country. Key objectives of the hospital in evaluation of survey instruments included:

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Produce data about patient perspectives of care that is objective and meaningful, allowing for benchmarked comparative analysis. (ii) Be prepared for future public reporting of patient satisfaction and utilize the tool to improve quality of care. (iii) Utilize an instrument that would enhance accountability by increasing transparency. (iv) Meet Magnet Recognition Program requirements for unit-based, nationally benchmarked data for patient satisfaction with nursing; providing an output of quarterly data for every nursing unit on required measures of Pain, Education, Courtesy and respect from nurses, Careful listening by nurses, and Response times. The hospital Magnet Recognition Program application team’s evaluation of potential survey instruments with national/international benchmarks included the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that was ultimately selected for use. HCAHPS, in use by the U.S. Department of Health & Human Services, currently has more than 2.8 million completed surveys from 3,858 hospitals in its HospitalCompare database as of July 2012 (“HCAHPS Facts,” 2012). The HCAHPS survey is the first national, standardized, publicly reported survey of patient perspectives of hospital care. It is a 27-item survey instrument and data collection methodology for measuring patients perceptions of their hospital experience. Since 2008, HCAHPS has allowed valid comparisons to be made across hospitals locally regionally, and nationally(“HCAHPS Facts,” 2012). The HCAHPS survey has been endorsed by the National Quality Forum, a national organization that represents the consensus of many healthcare providers, consumer groups, professional associations, purchasers, federal agencies, and researching quality organizations.(“HCAHPS Facts,” 2012) The HCAHPS survey includes six composite measures of clinical care, two individual items related to nonclinical aspects of the care environment, and two global items for overall satisfaction and willingness to recommend the hospital. The majority of all items utilize a 4-point Likert scale with responses scored as follows: Always = 4, Usually = 3, Sometimes = 2, and Never = 1. The Discharge information composite utilizes a Yes/No for each of its two questions. The Global items overall utilize a 10-point Likert response of Best hospital possible = 10 through Worst hospital possible = 0 for the hospital rating, and a 4-point Likert scale of Definitely yes = 4, Probably yes = 3, Probably no = 2, and Definitely no = 1 on the recommendation of hospital to family and friends question.

(i)

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Table 1 HCAHPS Survey Instrument Ten Patient Satisfaction Measures

Clinical Composite Measures: 1. Communication with nurses (Q1, Q2, Q3)* 2. Communication with doctors (Q5, Q6, Q7)* 3. Responsiveness of hospital staff (Q4, Q11)* 4. Pain management (Q13, Q14)* 5. Communication about medicines (Q16, Q17)* 6. Discharge information (Q19, Q20) (Yes/No Scale) *Likert Scale 1-4

Individual Items: 1. Cleanliness of hospital environment (Q8)* 2. Quietness of hospital environment (Q9)* *Likert Scale 1-4

Global Items: 1. 2. Overall hospital rating (Q21) (Likert Scale 1-10) Recommend the hospital (Q22) (Likert Scale 1-4)

Methods The HCAHPS instrument is currently available in a written format as English, Spanish,Chinese, Russian, and Vietnamese. A telephone script is available in English and Spanish (“HCAHPS Survey Instruments,” 2012). To create a telephone script in Arabic, the English language telephone script was utilized. Arabic Translation There have been a number of studies that document translation of healthcare specific English to Arabic survey instruments with good success using a forward-backward translation (Brown & Hijazi, 2008; Shadmi, Zisberg, & Coleman, 2009). A hospital HCAHPS implementation team was formed with membership from the Quality Management, Nursing, Patient Services, Research Center, Hospital Operations, and Medical & Clinical Operations departments. The hospital team first translated the HCAHPS English language telephone script into Arabic, and then a second independent team performed a back translation of the Arabic draft into English. This forward-backward translation process was conducted twice and then a final meeting of all individuals involved was conducted for fine tuning of the Arabic language HCAHPS telephone script. Of the 27 questions in the U.S. HCAHPS telephone survey script, questions 25, 26, and 27 were omitted. These three questions ask if the individual is of Spanish, Hispanic or Latino origin or descent, the race of the individual, and the language mainly spoken at home. As a Saudi Arabia government-owned hospital, virtually all patients are Saudi Arabia citizens of Arab descent and the language spoken at home is Arabic. Survey Process A determination was made by the HCAHPS implementation team to utilize random sampling of ten (10) percent of discharged inpatients with telephonic survey initiated between 48 hours and six weeks (42 calendar days)

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after discharge by a trained member of the Patient Services department staff, following the HCAHPS Quality Assurance Guidelines sampling protocol, available from the Centers for Medicare & Medicaid Services “www.hcahpsonline.org” website (“HCAHPS Quality Assurance,” n.d., p. 43). Patient eligibility inclusion criteria for the HCAHPS survey were set in accordance with the HCAHPS quality assurance guidelines to include patients 18 years of age or older, and admission of a minimum one overnight stay in the hospital, non-psychiatric principle diagnosis at discharge, and alive at time of discharge (“HCAHPS Quality Assurance,” n.d., p. 43). Patients discharged to hospice or nursing home facilities were not included in the HCAHPS survey sample (“HCAHPS Quality Assurance,” n.d., p. 43) . Benchmarking The HCAHPS implementation team made the decision to benchmark against the US national average since no other hospitals in Saudi Arabia were known to be utilizing the HCAHPS survey at the time. It was also determined that the hospital would utilize the survey to identify areas for improvement as they became apparent from the survey results. An additional retrospective review of HCAHPS survey results at the nursing unit level as compared to ongoing inpatient chart review findings for similarity of issues was also determined to be an appropriate implementation action.

Table 2 Survey Administration & Quality Improvement Process Steps

1.

Hospital Admissions Office forwards a list of inpatient discharges to Research Center every Saturday.

2.

Research Center selects a random sample and forwards patient names to survey administrators.

3.

Survey is administered via telephone and results are entered into a database.

4.

Quality Management Department generates statistical reports (targeted minimum of 300 completed surveys) with benchmarks against publicly reported U.S. national score, and forwards to hospital leadership and all concerned management team members.

5.

Concerned patient care units/areas develop action plans and initiate process improvement projects based upon the results. Quality Management Department monitors action plans and facilitates related process improvement projects.

6.

Results During the period of the study 645 telephonic surveys were completed for patient discharges between January 1, 2011 and December 31, 2011 surveys with more than 95% of all 24 HCAHPS questions in the telephone instrument answered by the interviewee. In addition to the 24 HCAHPS items collected, the surveyors also collected Date of Discharge, Date of Interview, Discharging Medical Service Name, Discharging Nursing Unit Name, Patient Age, Patient Gender, and Interviewee (Patient/Relative) for each survey in the database. Of the 645 interviewees, 275 (42.6%) were the patient and 370 (57.4%) were relatives. 340 of the 645 patients were females (52.7%).

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Table 3 HCAHPS Question 23: Self-report of perceived overall health status Self-Reported Health Status Excellent Very Good Good Fair Poor Number of Patients 256 213 126 38 12 Percent 39.7% 32.9% 19.6% 5.9% 1.9%

Table 4 HCAHPS Question 24: Highest Grade Level Completed Highest Grade Level Completed 8th grade or less Some high school, did not graduate High school graduate or GED Some college or 2-year degree 4-year college graduate More than 4-year college degree Number of Patients 90 52 129 66 261 44 Percent 14.0% 8.1% 20.1% 10.3% 40.6% 6.9%

Scores for the 645 respondents were analyzed using Spearman’s correlation coefficient and Cronbach’s alpha to demonstrate acceptable internal consistency for the six HCAHPS clinical composite items. Scales demonstrated acceptable internal consistency for the clinical composites (Spearman’s correlation coefficient = 0.327 - 0.750, p <0.01; Cronbach’s alpha = 0.516 - 0.851). For each of the 10 HCAHPS measures, results were compared to US national averages as a benchmark comparison, and as noted above, for each of the six clinical composite items, Spearman’s correlation and Cronbach’s alpha as indices of internal consistency were highly significant. Table 5 Survey Responses: Inpatient Discharges, January 1, 2011 through December 31, 2011

Quarter 1, 2011

Quarter 2, 2011

Quarter 3, 2011

Quarter 4, 2011

Initial Sample

270

275

269

388

# Respondents

168

162

172

143

% Respondents

62.2%

58.9%

63.9%

36.8%

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Table 6 HCAHPS Patient Satisfaction Top-Box Results HCAHPS Measures (*Percent Top-Box) Communication with Nurses Communication with Doctors Responsiveness of Hospital Staff Pain Management Communication About Medicines Cleanliness of Hospital Environment Quietness of Hospital Environment Discharge Information Overall Hospital Rating Recommend the Hospital Survey Response Rate Q1 55.3 79.1 52.3 59.5 50.0 76.7 66.7 38.6 60.7 80.9 62.2 Q2 73.4 82.7 67.9 69.2 51.5 82.7 85.8 41.9 53.0 77.7 58.9 Q3 84.8 89.5 77.3 73.8 75.2 90.1 89.5 45.0 71.5 76.7 63.9 Q4 88.1 86.0 74.8 45.9 79.0 90.2 83.2 34.5 61.5 74.8 36.8 **US Benchmark 77 81 65 70 62 72 59 83 68 70 32

* HCAHPS results are publicly reported on Hospital Compare as “top -box,” “bottom-box” and “middle-box” scores. The “top-box” is the most positive response to HCAHPS survey questions (“HCAHPS Summary Analysis,” n.d.).

** Summary of HCAHPS Survey Results: http://www.hcahpsonline.org/executive_insight/default.aspx. (July 2012 Public Report). Centers for Medicare & Medicaid Services, Baltimore, Maryland, September 21, 2012

Discussion The results of the study support the use of this Arabic translation and adaptation of the HCAHPS survey instrument and data collection methodology for measuring patient’s perspectives on hospital care and enabling comparison of hospitals nationally within Saudi Arabia, as well as internationally in Arabic-speaking populations. The hospital was able to achieve its key objectives of producing benchmarked patient perspective data, preparing for future increases in transparency of patient satisfaction, as well as meeting Magnet Recognition Program requirements for unit-based, nationally benchmarked data for patient satisfaction on nursing care, including specific measures for pain, education, courtesy and respect from nurses, careful listening by nurses, and response times.

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Upon performing a comparison of scores against international benchmarks, the hospital was able to make some general correlations with inpatient chart audit findings related to patient discharge education and pain management. As evidenced by quarter-to-quarter changes in top-box HCAHPS scores, the hospital’s efforts at developing action plans for identified areas of quality improvement on specific measures does appear to be working in several instances. Limitations Limitations during the HCAHPS survey implementation included no prior experience or locally accessible training, challenges in achieving a sample size to improve reliability, having to internally developed processes modeled on US-based documentation that could have possibly introduced bias into the survey process. These limitations were also coupled with the inability to utilize a written instrument because of a lack of access to postal services by the discharged patients and a dependence solely upon the telephonic survey process. Additionally, there was no patient-mix adjustment for the survey data, and the HCAHPS tool does not cover critical care areas and outpatients services. Challenges during the implementation process for the team included staffing for the additional workload of identifying a random sample of patients, completing telephonic surveys, and performing data analysis and reporting on the HCAHPS measures. The implementation team was not able to locate any other hospitals in Saudi Arabia or the Middle East region that are currently utilizing the HCAHPS survey instrument, thus benchmarking on a local or regional basis was not possible. Future plans for the organization include ongoing utilization and further HCAHPS survey process refinement, as well as engagement and encouragement of other Saudi Arabian hospitals to collaborate on patient satisfaction benchmarking. Ongoing clinical process improvement activities based upon survey results are ongoing. Acknowledgments The authors particularly wish to acknowledge Dr. Bakr Bin Sadiq and his staff of the Research Centre at King Faisal Specialist Hospital Centre in Jeddah, Saudi Arabia for the continuous support in bringing the HCAHPS project to fruition. Your leadership and guidance is is deeply appreciated.

References Brown, A., & Hijazi, M. (2008). Arabic translation and adaptation of Critical Care Family Satisfaction Survey. International Journal for Quality in Health Care, 20(4), 291–296. doi:10.1093/intqhc/mzn013 Chassin, M. R., Loeb, J. M., Schmaltz, S. P., & Wachter, R. M. (2010). Accountability Measures — Using Measurement to Promote Quality Improvement. New England Journal of Medicine, 363(7), 683–688. doi:10.1056/NEJMsb1002320 Donabedian, A. (1966). Evaluating the Quality of Medical Care. The Milbank Memorial Fund Quarterly, 44(3), 166–206. doi:10.2307/3348969 Elliott, M. N., Lehrman, W. G., Goldstein, E., Hambarsoomian, K., Beckett, M. K., & Giordano, L. A. (2010). Do Hospitals Rank Differently on HCAHPS for Different Patient Subgroups? Medical Care Research and Review, 67(1), 56–73. doi:10.1177/1077558709339066 Frier, S., & Armstrong, D. (n.d.). UnitedHealth Will Tie Doctors’ Payments to Quality of Care in U.S. Shift. Bloomberg. Retrieved October 8, 2012, from http://www.bloomberg.com/news/2012-02-09/unitedhealth-overhauls-doctorpayments-by-tying-them-to-quality-of-care.html GCC Healthcare Industry Report. (2012, October 7).Alpen Capital Group. Retrieved October 7, 2012, from http://www.alpencapital.com/media-reports.htm Giordano, L. A., Elliott, M. N., Goldstein, E., Lehrman, W. G., & Spencer, P. A. (2010). Development, Implementation, and Public Reporting of the HCAHPS Survey. Medical Care Research and Review, 67(1), 27–37. doi:10.1177/1077558709341065

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HCAHPS Executive Insight Letter. (2012, September 21). Retrieved September 21, 2012, from http://www.hcahpsonline.org/executive_insight/default.aspx HCAHPS Fact Sheet. (2012, September 21).HCAHPS Hospital Care Quality Information from the Consumer Perspective. Retrieved September 21, 2012, from http://hcahpsonline.org/Facts.aspx HCAHPS Quality Assurance. (n.d.).HCAHPS Hospital Care Quality Information from the Consumer Perspective . Retrieved September 21, 2012, from http://www.hcahpsonline.org/qaguidelines.aspx HCAHPS Summary Analysis. (n.d.).HCAHPS Hospital Care Quality Information from the Consumer Perspective. Retrieved September 21, 2012, from http://hcahpsonline.org/SummaryAnalyses.aspx HCAHPS Survey Instruments. (2012, September 21). HCAHPS Hospital Care Quality Information from the Consumer Perspective. Retrieved from http://hcahpsonline.org/surveyinstrument.aspx Joint Commission International Accreditation Standards for Hospitals . (2010). (4th ed.). Oakbrook Terrace, IL 60181: Joint Commission Resources, Inc. Lindenauer, P., Remus, D., Roman, S., Rothberg, M., Benjamin, E., Ma, A., & Bratzler, D. (2007). Public Reporting and Pay for Performance in Hospital Quality Improvement. The New England Journal of Medicine, 2007(356), 486–496. Liu, K., Squires, A., & You, L.-M. (2011). A pilot study of a systematic method for translating patient satisfaction questionnaires. Journal of Advanced Nursing, 67(5), 1012–1021. doi:10.1111/j.1365-2648.2010.05569.x Magnet Recognition Program® FAQ: Data and Expected Outcomes. (n.d.). Retrieved September 21, 2012, from http://www.nursecredentialing.org/FunctionalCategory/FAQs/DEO-FAQ.html#I1 Margolis, S. A., Al-Marzouqi, S., Revel, T., & Reed, R. L. (2003). Patient satisfaction with primary health care services in the United Arab Emirates. International Journal for Quality in Health Care, 15(3), 241–249. doi:10.1093/intqhc/mzg036 Ninth Five-Year Plan Includes $385 Billion in New Spending. (2012, October 7). U.S.-Saudi Arabian Business Council. Retrieved from http://www.us-sabc.org/custom/news/details.cfm?id=775 Shadmi, E., Zisberg, A., & Coleman, E. A. (2009). Translation and validation of the Care Transition Measure into Hebrew and Arabic. International Journal for Quality in Health Care, 21(2), 97–102. doi:10.1093/intqhc/mzp004 Shaller, D., Sofaer, S., Findlay, S. D., Hibbard, J. H., Lansky, D., & Delbanco, S. (2003). Consumers And Quality-Driven Health Care: A Call To Action. Health Affairs, 22(2), 95–101. doi:10.1377/hlthaff.22.2.95 Summary of HCAHPS Survey Results. Hcahpsonline.org/HCAHPS_Executive_Insight. [July 2012 Public Report]. Centers for Medicare & Medicaid Services, Baltimore, MD. Sept 21, 2012. . (n.d.). http://www.hcahpsonline.org. Retrieved from http://www.hcahpsonline.org/files/July%202012%20Summary%20of%20HCAHPS%20Survey%20Results%20Tabl e.pdf Ware, J. E., Davies, A. R., Stewart, A. L., & Rand Corporation. (1977). The measurement and meaning of patient satisfaction : a review of the literature. Santa Monica, Calif.: Rand Corporation.

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James Dockins Helzberg School of Management Rockhurst University 1100 Rockhurst Road Kansas City, MO 64110-2561 816-501-4564 816-501-4650 Fax James.Dockins@rockhurst.edu Corresponding Author Ramzi Abuzahrieh King Faisal Specialist Hospital and Research Centre PO Box 40047 Jeddah, 21499, Saudi Arabia +966 26692313 rabuzahrieh@kfshrc.edu.sa Martin Stack Helzberg School of Management Rockhurst University 1100 Rockhurst Road Kansas City, MO 64110-2561 816-501-4094 Martin.Stack@rockhurst.edu

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REFORMATION OF HIGHER EDUCATION SYSTEM IN COUNTRIES FROM CENTRAL AND EASTERN EUROPE: STRUCTURAL IMPACTS OF THE BOLOGNA PROCESS
Cristinel Mîinea, University of Scranton Daniel West, Jr., University of Scranton

ABSTRACT The fall of the communist regimes in Central and Eastern Europe in 1989 marked the beginning of an ample reform process that marked the return to the social values of democratic societies. Higher education has gone through an extensive reorganization with the initial intent to restore academic autonomy and separation of higher education institutions from government tutelage. The joint declaration of 27 European Ministers of Education in 1999 signaled a new direction in reforming higher education in order to create the European Higher Education Area, a geographic area addressing concerns about increased labor mobility in the European market. The political process that ensued to the Bologna Declaration was enthusiastically embraced by Central and Eastern Europe countries, as an opportunity to reaffirm their commitment to European values. This presentation examines evolution of the structural changes of higher education for countries from Central and Eastern Europe - Bulgaria, Czech Republic, Hungary, Poland, Romania and Slovak Republic. It also analyzes their convergent efforts to implement harmonization and coordination objectives instituted by the Bologna process.

Cristinel Mîinea, Ph.D., Department of Health Administration and Human Resources The University of Scranton 415 McGurrin Hall Scranton, PA 18510 Tele: 570 941-4350; Fax: 570 941-5882 Daniel West, Jr., Ph.D. Department of Health Administration and Human Resources The University of Scranton 415 McGurrin Hall Scranton, PA 18510 Tele: 570 941-4126; Fax: 570 941-5882

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MIRROR MIRROR: A COMPARATIVE STUDY OF MALFEASANCE AMONG THE HEALTH CARE PROFESSIONS
Vivek Pande, University of Wisconsin - La Crosse Steven Thornburg, University of Wisconsin - La Crosse

ABSTRACT Misconduct by healthcare professionals remains a serious problem in the United States. Healthcare fraud alone costs the nation an estimated $60 billion - $250 billion per year (the exact amount cannot be determined with any certainty because much of this fraud is never detected). The victims of wrongdoing by medical professionals are numerous. First, the professional healthcare providers themselves may suffer severe consequences when apprehended, such as license revocation, fines, and possible imprisonment. Second, patients suffer from abuse, overbilling and errors, including complications from unnecessary or improper services. Lastly, all taxpayers are victims of public entitlement fraud and default on government guaranteed educational loans. This paper analyzes the types and rates of malfeasance among healthcare providers. We define malfeasance as (i) felony and misdemeanor convictions for healthcare fraud, patient abuse, and controlled substances violations, (ii) license revocation and suspension, (iii) claims for excessive charges/services, and (iv) default on educational loan or scholarship obligations. The healthcare providers analyzed include (i) physicians, (ii) nurses and nurses aides, (iii) dentists, (iv) pharmacists, (v) psychologists, (vi) chiropractors, (vii) healthcare aides, (viii) opticians and optometrists, (ix) podiatrists, and (x) social workers. Data regarding the perpetrators was gathered from (i) public databases (such as the Office of the Inspector General, Department of Health and Human Services’ List of Excluded Individuals and Entities), (ii) news reports, (iii) court records, and (iv) records from professional healthcare licensing bodies. Finally, in light of this accumulated data, the paper makes specific recommendations regarding the training, licensing and discipline of healthcare professionals to reduce the amount of wrongdoing perpetrated by healthcare providers in the future.

Vivek V. Pande University of Wisconsin - La Crosse 223C Wimberly Hall 1725 State Street La Crosse, WI 54601 Phone: (608) 785-6833 Fax: (608) 785-6795 Email: vpande@uwlax.edu Steven W. Thornburg University of Wisconsin - La Crosse 412E Wimberly Hall 1725 State Street La Crosse, WI 54601 Phone: (608) 785-6824 Fax: (608) 785-6795 Email: sthornburg@uwlax.edu

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GLOBAL HEALTHCARE MANAGEMENT EDUCATION: RESEARCH FINDINGS AND FUTURE IMPLICATIONS
Daniel J. West, Jr., University of Scranton

ABSTRACT Global transformation impacts all sectors of the economy and provides unique challenges and opportunities to rethink business strategy. A borderless world in higher education provides mobility of students and faculty to enhance and reshape the global academic landscape. New opportunities exist for growth and innovation in accreditation, certification, graduate education and professional development of healthcare professionals. Educating and training of healthcare executives remains a priority for most countries that recognize the need for effective leadership, efficient management structures, competency development, evidence based management, increased economic competitiveness, and maintaining international reputation. Globalization has impacted graduate education in the USA. The commission on Accreditation of Healthcare Management Education (CAHME) in the USA recognized the need to survey CAHME accredited programs. With funding from the Aramark Charitable Fund, two research studies were authorized to gather specific information and answer important questions impacting graduate healthcare management education in the USA. This presentation examines the research results and discusses future implications for international accreditation and graduate education.

Daniel J. West, Jr., Ph.D., FACHE, FACMPE Professor and Chairman Department of Health Administration & Human Resources The University of Scranton 417 McGurrin Hall Scranton, PA 18510 Tele: 570 941-4126 FAX: 570 941-5882 E-mail: daniel.west@scranton.edu

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TRACK STUDENT LED PAPERS

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SINGLE PARENTHOOD: EXPLORING POSITIVE CHILD UPBRINGING STRATEGIES
Brittany LeCleir, Viterbo University Kem Gambrell, Viterbo University Background The number of children born to unmarried women is on the rise. According to an article by Doherty and Craft (2011), the rate of births to non-married women in 2010 grew to 40% in the United States. The reasons for these women being un-married vary from divorce, being widowers, or women who have never been married (Baharudin, Krauss, Yacoob, & Pei, 2011). This statistic, however, lends itself to the explanation for the increase in single parent families throughout the world. Doherty and Craft (2011) assert, “Overall, by adolescence, nearly one in five children in the United States has no contact of any kind with the father” (p.63). To date there has been extensive research conducted on the negative effects single parenting has on children. These have included: low test scores in school (Lee & Kushner, 2008), high school graduation rates (Strohschein, Roos, & Brownell, 2009), teen pregnancy (Sibulkin & Butler, 2005), and drug related issues (Bjorklund, Ginther, & Sundstrom, 2007). According to Roman (2011), single-mother families are “stereotypically described as deviant, with married mothers perceived as the ‘standard’ against which other mothers, for example, never married, widowed, or divorced mothers, are rated (p. 578).” As in indicated by Doherty and Craft (2010), more than 40% of children in the world today are being raised by un-married mothers. This problem is not only in the United States; international divorce rates are also on the rise. Roman (2011) reports South African rates on the rise amongst all racial groups residing there. Africans are currently at a 35% rate, Indians/Asians 6%, and whites 33%. Research concludes single parenthood presents detriment to children and, thus, there is a need to determine how single parents can combat drug use, early pregnancy, and high school non completion in their parenting methods. Due to this growing trend, research surrounding how to raise productive contributing children by single parents is needed. Thus, the research question for this study is, “What can single parents do to influence their children’s decisions to reduce the risk of drug use (Bjorkland et al., 2007), early parenthood (Sibulkin & Butler, 2005), and low education levels (Strohschen et al., 2009)?” Therefore, the purp ose of this study will be to explore parenting practices of single parents that are positive contributors to child upbringing. The intention of this study is to garnish the perceptions of these parenting tactics through the eyes of adult children of single parents. This study will aid single parents who want to provide the best foundation for their children’s success as contributing members of society in their adult lives. The reduction of drug use, early pregnancy, and high school drop-out rates will contribute to less crime, less poverty, and tax payer dollars being allotted to the management of these issues (Brotman, O’Neal, Huang, Gouley, Rosenfelt, & Shrout, 2009; Wilson, Bryant, Holt, & Treloar, 2010). Literature/Background Throughout the past three decades an increase in divorce rates and births to un-married women have made the picture perfect family of mom, dad, and their two children the minority in the realm of family structure (Doherty & Craft, 2011). According to this study, the rate of births to non-married women in 2010 had grown to 40%. This statistic does not change when the international community is observed. Roman (2011), reports the divorce rates for several minority groups in South Africa are also on the rise. In Malaysia, the number of female-only headed households doubled in the span of the last two decades (Baharudin et al., 2011). The existence of a single parent, most often single mother, family, has negative connotations. The largest of those are the delinquency rates among the children who are products of this type of upbringing. There is extensive research which examines the way in which parental attitudes, gender, socio-economic status, and the means in which the single parent family was formed affect children. According to research conducted by Doherty and Craft (2011), attitudes of mothers greatly affect the way their children are raised. Single mothers who have negative attitudes toward men and relationships are highly likely to pass those views on to their children. Children are also more likely to maintain a positive relationship with their fathers if the relationship between the two parents

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remains amicable. In certain situations the non-present parent is entirely nonexistent, in others there is very little contact, and it is assumed there will be a difference in adults who knew their non-present biological parent versus those who never had contact (Doherty & Craft, 2011). An article by Hyunjoon Park (2007) reports the likelihood of delinquency in children raised by single parents due to the death of the other parent is significantly lower than the likelihood of the same in children who were raised by a single parent due to divorce. This study concludes the trauma that comes from negative emotion, fighting, and continued parental conflict has a lasting effect on the children of that relationship. Strohschein, Roos, and Brownell (2009) discuss the formation of a single parent family due to a death of a parent; this situation does not often have negative implications such as change of residence, economic hardship, and conflict. Yet another study was conducted on the same concept by Baharudin, Krauss, Yacoob, and Pei (2011), and it concluded the most important contributors to delinquency in children of single parent families was family competency and parenting behaviors. The study also indicates children who are raised by a single parent who remarries tend to have increased behavioral issues due to the lessor amount of attention or finances available to their personal needs (Baharudin et al., 2011). These authors used the notion of nature versus nurture in their study which provides insight as to which behaviors can be changed and which characteristics are engraved in who a person is. The article by Strohschein et al. (2009) looked at successful graduation from high school in comparison with family structure using a life course approach. In this study, a sample of data from the 1984 Manitoba birth cohort was collected to determine children born or adopted in to married families. These children were monitored throughout adolescence and it was noted that children whose parental marital status changed once or more throughout this time were less likely to complete high-school (Strohschein et al., 2009). Hyunjoon Park (2007) studied the effect of socio-economic background along with family structure on education opportunity of children in Korea. Although much of the article focuses on many different factors for lack of educational opportunity such as gender, socio-economic status, government regulation and funding, etc. Park (2007) notes a main reason for lack of educational success in children of single parents is the parent’s lack of involvement in the child’s education. Strohschen et al. (2009) also comment on reasons for deficiencies in educational outcomes in single-parent structured families; greater economic hardship, and the lack of a team as a parental unit to provide structure and discipline. The same is true for children living in situations with step-parents as these parents may not be as committed to the education or upbringing of a child who does not biologically belong to them (Strohschein et al., 2009). Studies have found education levels and age of entry in to parenthood to be linked (Sibulkin & Butler, 2005). The longer women wait to have their first child, the more likely they are to obtain higher levels of education; both high school and post-secondary degrees. The Sibulkin & Butler (2005) study dissects the reasons for this to be true. Students who enter in to parenthood are often forced to leave school to devote time and resources to their children. The study takes in to account the year in which a student enters parenthood, and compares these figured with college and high school graduation rates. Drug use is another prevalent in children of single parents. Hemovich & Crano (2009), explain drug use is more prevalent amongst children