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Dr. Lawrence Fulton
Texas State University

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Journal article
Published: 26 July 2021 in Healthcare
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This study estimated the effects of Medicaid Expansion, demographics, socioeconomic status (SES), and health status on disease management of diabetes over time. The hypothesis was that the introduction of the ACA and particularly Medicaid Expansion would increase the following dependent variables (all proportions): (1) provider checks of HbA1c, (2) provider checks of feet, (3) provider checks of eyes, (4) patient education, (5) annual physician checks for diabetes, (6) patient self-checks of blood sugar. Data were available from the Behavioral Risk Factor Surveillance System for 2011 to 2019. We filtered the data to include only patients with diagnosed non-gestational diabetes of age 45 or older (n = 510,991 cases prior to weighting). Linear splines modeled Medicaid Expansion based on state of residence as well as implementation status. Descriptive time series plots showed no major changes in proportions of the dependent variables over time. Quasibinomial analysis showed that implementation of Medicaid Expansion had a statistically negative effect on patient self-checks of blood sugar (odds ratio = 0.971, p< 0.001), a statistically positive effect on physician checks of HbA1c (odds ratio = 1.048, p< 0.001), a statistically positive effect on feet checks (odds ratio = 1.021, p< 0.001), and no other significant effects. Evidence of demographic, SES, and health status disparities existed for most of the dependent variables. This finding was especially significant for HbA1c checks by providers. Barriers to achieving better diabetic care remain and require innovative policy interventions.

ACS Style

Lawrence Fulton; Omolola Adepoju; Diane Dolezel; Tahir Ekin; David Gibbs; Barbara Hewitt; Alexander McLeod; Winston Liaw; Cristian Lieneck; Zo Ramamonjiarivelo; Ram Shanmugam; Lechauncey Woodward. Determinants of Diabetes Disease Management, 2011–2019. Healthcare 2021, 9, 944 .

AMA Style

Lawrence Fulton, Omolola Adepoju, Diane Dolezel, Tahir Ekin, David Gibbs, Barbara Hewitt, Alexander McLeod, Winston Liaw, Cristian Lieneck, Zo Ramamonjiarivelo, Ram Shanmugam, Lechauncey Woodward. Determinants of Diabetes Disease Management, 2011–2019. Healthcare. 2021; 9 (8):944.

Chicago/Turabian Style

Lawrence Fulton; Omolola Adepoju; Diane Dolezel; Tahir Ekin; David Gibbs; Barbara Hewitt; Alexander McLeod; Winston Liaw; Cristian Lieneck; Zo Ramamonjiarivelo; Ram Shanmugam; Lechauncey Woodward. 2021. "Determinants of Diabetes Disease Management, 2011–2019." Healthcare 9, no. 8: 944.

Journal article
Published: 14 July 2021 in Healthcare
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The relationship between healthcare organizational accreditation and their leaders’ professional certification in healthcare management is of specific interest to institutions of higher education and individuals in the healthcare management field. Since academic program accreditation is one piece of evidence of high-quality education, and since professional certification is an attestation to the knowledge, skills, and abilities of those who are certified, we expect alumni who graduated from accredited programs and obtained professional certification to have a positive impact on the organizations that they lead, compared with alumni who did not graduate from accredited programs and who did not obtain professional certification. The authors’ analysis examined the impact of hiring graduates from higher education programs that held external accreditation from the Commission on Accreditation of Healthcare Management Education (CAHME). Graduates’ affiliation with the American College of Healthcare Executives (ACHE) professional healthcare leadership organization was also assessed as an independent variable. Study outcomes focused on these graduates’ respective healthcare organization’s performance measures (cost, quality, and access) to assess the researchers’ inquiry into the perceived value of a CAHME-accredited graduate degree in healthcare administration and a professional ACHE affiliation. The results from this study found no effect of CAHME accreditation or ACHE affiliation on healthcare organization performance outcomes. The study findings support the need for future research surrounding healthcare administration professional graduate degree program characteristics and leader development affiliations, as perceived by various industry stakeholders.

ACS Style

Matthew Brooks; Brad Beauvais; Clemens Kruse; Lawrence Fulton; Michael Mileski; Zo Ramamonjiarivelo; Ramalingam Shanmugam; Cristian Lieneck. Accreditation and Certification: Do They Improve Hospital Financial and Quality Performance? Healthcare 2021, 9, 887 .

AMA Style

Matthew Brooks, Brad Beauvais, Clemens Kruse, Lawrence Fulton, Michael Mileski, Zo Ramamonjiarivelo, Ramalingam Shanmugam, Cristian Lieneck. Accreditation and Certification: Do They Improve Hospital Financial and Quality Performance? Healthcare. 2021; 9 (7):887.

Chicago/Turabian Style

Matthew Brooks; Brad Beauvais; Clemens Kruse; Lawrence Fulton; Michael Mileski; Zo Ramamonjiarivelo; Ramalingam Shanmugam; Cristian Lieneck. 2021. "Accreditation and Certification: Do They Improve Hospital Financial and Quality Performance?" Healthcare 9, no. 7: 887.

Preprint
Published: 11 June 2021
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The impact of organizational accreditation and professional certification and the evidence-based measurable impact of those for both academic programs and affiliates is one of specific interest to universities and individuals in the healthcare management field [1]. The authors’ analysis examined the impact of hiring graduates from higher education programs that held external accreditation from the Commission on Accreditation of Healthcare Management Education (CAHME). Graduates’ affiliation with the American College of Healthcare Executives (ACHE) professional healthcare leadership organization was also assessed as an independent variable. Study outcomes focused on these graduates’ respective healthcare organization’s performance measures (cost, quality, and access) to assess the researchers’ inquiry into the perceived value of a CAHME-accredited graduate degree in healthcare administration and a professional ACHE affiliation [2]. The results from this study found no effect of CAHME accreditation or ACHE affiliation on healthcare organization performance outcomes. The study findings support the need for future research surrounding healthcare administration professional graduate degree program characteristics and leader development affiliations, as perceived by various industry stakeholders.

ACS Style

Matthew Brooks; Brad M Beauvais; Clemens Scott Kruse; Lawrence Fulton; Michael Mileski; Zo Ramamonjiarivelo; Ramalingam Shanmugam; Cristian Lieneck. Accreditation and Certification: Do they Improve Hospital Financial and Quality Performance? 2021, 1 .

AMA Style

Matthew Brooks, Brad M Beauvais, Clemens Scott Kruse, Lawrence Fulton, Michael Mileski, Zo Ramamonjiarivelo, Ramalingam Shanmugam, Cristian Lieneck. Accreditation and Certification: Do they Improve Hospital Financial and Quality Performance? . 2021; ():1.

Chicago/Turabian Style

Matthew Brooks; Brad M Beauvais; Clemens Scott Kruse; Lawrence Fulton; Michael Mileski; Zo Ramamonjiarivelo; Ramalingam Shanmugam; Cristian Lieneck. 2021. "Accreditation and Certification: Do they Improve Hospital Financial and Quality Performance?" , no. : 1.

Journal article
Published: 18 May 2021 in Healthcare
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The physical demands on U.S. service members have increased significantly over the past several decades as the number of military operations requiring overseas deployment have expanded in frequency, duration, and intensity. These elevated demands from military operations placed upon a small subset of the population may be resulting in a group of individuals more at-risk for a variety of debilitating health conditions. To better understand how the U.S Veterans health outcomes compared to non-Veterans, this study utilized the U.S. Centers for Disease Control and Prevention (CDC) Behavioral Risk Factor Surveillance System (BRFSS) dataset to examine 10 different self-reported morbidities. Yearly age-adjusted, population estimates from 2003 to 2019 were used for Veteran vs. non-Veteran. Complex weights were used to evaluate the panel series for each morbidity overweight/obesity, heart disease, stroke, skin cancer, cancer, COPD, arthritis, mental health, kidney disease, and diabetes. General linear models (GLM’s) were created using 2019 data only to investigate any possible explanatory variables associated with these morbidities. The time series analysis showed that Veterans have disproportionately higher self-reported rates of each morbidity with the exception of mental health issues and heart disease. The GLM showed that when taking into account all the variables, Veterans disproportionately self-reported a higher amount of every morbidity with the exception of mental health. These data present an overall poor state of the health of the average U.S. Veteran. Our study findings suggest that when taken as a whole, these morbidities among Veterans could prompt the U.S. Department of Veteran Affairs (VA) to help develop more effective health interventions aimed at improving the overall health of the Veterans.

ACS Style

Jose Betancourt; Paula Granados; Gerardo Pacheco; Julie Reagan; Ramalingam Shanmugam; Joseph Topinka; Bradley Beauvais; Zo Ramamonjiarivelo; Lawrence Fulton. Exploring Health Outcomes for U.S. Veterans Compared to Non-Veterans from 2003 to 2019. Healthcare 2021, 9, 604 .

AMA Style

Jose Betancourt, Paula Granados, Gerardo Pacheco, Julie Reagan, Ramalingam Shanmugam, Joseph Topinka, Bradley Beauvais, Zo Ramamonjiarivelo, Lawrence Fulton. Exploring Health Outcomes for U.S. Veterans Compared to Non-Veterans from 2003 to 2019. Healthcare. 2021; 9 (5):604.

Chicago/Turabian Style

Jose Betancourt; Paula Granados; Gerardo Pacheco; Julie Reagan; Ramalingam Shanmugam; Joseph Topinka; Bradley Beauvais; Zo Ramamonjiarivelo; Lawrence Fulton. 2021. "Exploring Health Outcomes for U.S. Veterans Compared to Non-Veterans from 2003 to 2019." Healthcare 9, no. 5: 604.

Journal article
Published: 06 January 2021 in BMC Medical Education
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Background Assessing competencies or program learning outcomes in educational programs is often a leadership challenge. This case study reports medical education program’s efforts to document undergraduate competency attainment using a pre-post, third-party, objective testing service that allows for inter-university comparison, a testing service that is being adopted by some certification and accrediting bodies. Methods Students completed a pre-test after program acceptance and a post-test at the end of the last didactic semester (1.5 years later) just prior to their required internships. Scores and subscores were evaluated using t-tests (Holm-adjusted p-values). MANOVA models of sub-competency difference scores were also evaluated. Results Results indicate competency improvement for each of the 12 areas based on the n = 55 student sample, (p < .001 for all scores). These improvements were independent of ethnicity, age, gender, and grades. The average student improved by 12.85 points (95% CI of 10.52 to 15.18) with the largest improvements in strategic planning and leadership competency areas (21.30 and 18.33 percentage points, respectively). Conclusions The third-party pre-post has some face validity given that student performance improved after completing a related curriculum as would be expected. Congruent with earlier studies, we find that repeated testing helps document competency attainment and that a single method for assessment is insufficient. We further document limitations of this 3d-party exam.

ACS Style

Lawrence Fulton; Cristian Lieneck; Zo Ramamonjiarivelo; Clemens Scott Kruse; Matthew S. Brooks. Competency assessment of an undergraduate program using a third-party, objective pre-post examination. BMC Medical Education 2021, 21, 1 -13.

AMA Style

Lawrence Fulton, Cristian Lieneck, Zo Ramamonjiarivelo, Clemens Scott Kruse, Matthew S. Brooks. Competency assessment of an undergraduate program using a third-party, objective pre-post examination. BMC Medical Education. 2021; 21 (1):1-13.

Chicago/Turabian Style

Lawrence Fulton; Cristian Lieneck; Zo Ramamonjiarivelo; Clemens Scott Kruse; Matthew S. Brooks. 2021. "Competency assessment of an undergraduate program using a third-party, objective pre-post examination." BMC Medical Education 21, no. 1: 1-13.

Journal article
Published: 27 December 2020 in Healthcare
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Background: Approximately 6.5 to 6.9 million individuals in the United States have heart failure, and the disease costs approximately $43.6 billion in 2020. This research provides geographical incidence and cost models of this disease in the U.S. and explanatory models to account for hospitals’ number of heart failure DRGs using technical, workload, financial, geographical, and time-related variables. Methods: The number of diagnoses is forecast using regression (constrained and unconstrained) and ensemble (random forests, extra trees regressor, gradient boosting, and bagging) techniques at the hospital unit of analysis. Descriptive maps of heart failure diagnostic-related groups (DRGs) depict areas of high incidence. State- and county-level spatial and non-spatial regression models of heart failure admission rates are performed. Expenditure forecasts are estimated. Results: The incidence of heart failure has increased over time with the highest intensities in the East and center of the country; however, several Northern states have seen large increases since 2016. The best predictive model for the number of diagnoses (hospital unit of analysis) was an extremely randomized tree ensemble (predictive R2 = 0.86). The important variables in this model included workload metrics and hospital type. State-level spatial lag models using first-order Queen criteria were best at estimating heart failure admission rates (R2 = 0.816). At the county level, OLS was preferred over any GIS model based on Moran’s I and resultant R2; however, none of the traditional models performed well (R2 = 0.169 for the OLS). Gradient-boosted tree models predicted 36% of the total sum of squares; the most important factors were facility workload, mean cash on hand of the hospitals in the county, and mean equity of those hospitals. Online interactive maps at the state and county levels are provided. Conclusions. Heart failure and associated expenditures are increasing. Costs of DRGs in the study increased $61 billion from 2016 through 2018. The increase in the more expensive DRG 291 outpaced others with an associated increase of $92 billion. With the increase in demand and steady-state supply of cardiologists, the costs are likely to balloon over the next decade. Models such as the ones presented here are needed to inform healthcare leaders.

ACS Style

Clemens Kruse; Bradley Beauvais; Matthew Brooks; Michael Mileski; Lawrence Fulton. Models for Heart Failure Admissions and Admission Rates, 2016 through 2018. Healthcare 2020, 9, 22 .

AMA Style

Clemens Kruse, Bradley Beauvais, Matthew Brooks, Michael Mileski, Lawrence Fulton. Models for Heart Failure Admissions and Admission Rates, 2016 through 2018. Healthcare. 2020; 9 (1):22.

Chicago/Turabian Style

Clemens Kruse; Bradley Beauvais; Matthew Brooks; Michael Mileski; Lawrence Fulton. 2020. "Models for Heart Failure Admissions and Admission Rates, 2016 through 2018." Healthcare 9, no. 1: 22.

Preprint content
Published: 22 October 2020
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Background. About 5.7 million individuals in the United States have heart failure, and the disease was estimated to cost about $42.9 billion in 2020. This research provides geographical incidence models of this disease in the U.S. and explanatory models to account for hospitals’ number of heart failure DRGs using technical, workload, financial, geographical, and time-related variables. The research also provides updated financial and demand estimates based on inflationary pressures and disease rate increases. Understanding patterns is important to both policymakers and health administrators for cost control and planning. Methods. The number of diagnoses is forecast using regression (constrained and unconstrained) and ensemble (random forests, extra trees regressor, gradient boosting, and bagging) techniques at the hospital unit of analysis. Descriptive maps of heart failure diagnosis-related groups (DRGs) depict areas of high incidence. State and county level spatial and non-spatial regression models of heart failure admission rates are performed. Expenditure forecasts were calculated for 2016 through 2018. Results: The incidence of heart failure has increased over time with highest intensities in the East and center of the country; however, several Northern states (e.g., Minnesota) have seen large increases since 2016. The best predictive model for forecasting the number of diagnoses at the hospital unit of analysis was an extremely randomized tree ensemble (predictive R2 = 0.86 applied to a 20% unobserved test set.) The important variables in this model included workload metrics and hospital type. State level spatial lag models using 1st order Queen’s criteria were best at estimating heart failure admission rates (R2 =.816). At the county level, OLS was preferred over any GIS model based on a statistically insignificant Moran’s I and resultant R2; however, none of the traditional models performed well (R2=.169 for the OLS). Gradient boosted tree models were able to predict 36% of the total Sum of Squares; however, and the most important factors were facility workload, mean cash-on-hand of the hospitals in the county, and mean equity of those hospitals.. Online interactive maps at the state and county levels are provided. Conclusions. Heart failure and associated expenditures are increasing. Overall, the total cost of the three DRGs in the study has increased approximately $61 billion from 2016 through 2018 (average of two estimates). The increase in the more expensive DRG (DRG 291) has outpaced others with an associated increase of $92 billion in expenditures. With the increase in demand (linked to obesity and other factors) as well as the relatively steady-state supply of cardiologists over time, the costs are likely to balloon over the next decade. Models like the ones presented here that reliably forecast demand are needed to inform healthcare leaders.

ACS Style

Clemens Scott Kruse; Bradley M. Beauvais; Matthew S. Brooks; Michael Mileski; Lawrence Fulton. Geospatial and Explanatory Models for Heart Failure Admissions, 2016 through 2018. 2020, 1 .

AMA Style

Clemens Scott Kruse, Bradley M. Beauvais, Matthew S. Brooks, Michael Mileski, Lawrence Fulton. Geospatial and Explanatory Models for Heart Failure Admissions, 2016 through 2018. . 2020; ():1.

Chicago/Turabian Style

Clemens Scott Kruse; Bradley M. Beauvais; Matthew S. Brooks; Michael Mileski; Lawrence Fulton. 2020. "Geospatial and Explanatory Models for Heart Failure Admissions, 2016 through 2018." , no. : 1.

Journal article
Published: 14 September 2020 in Healthcare
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Coronavirus (COVID-19) is a potentially fatal viral infection. This study investigates geography, demography, socioeconomics, health conditions, hospital characteristics, and politics as potential explanatory variables for death rates at the state and county levels. Data from the Centers for Disease Control and Prevention, the Census Bureau, Centers for Medicare and Medicaid, Definitive Healthcare, and USAfacts.org were used to evaluate regression models. Yearly pneumonia and flu death rates (state level, 2014–2018) were evaluated as a function of the governors’ political party using a repeated measures analysis. At the state and county level, spatial regression models were evaluated. At the county level, we discovered a statistically significant model that included geography, population density, racial and ethnic status, three health status variables along with a political factor. A state level analysis identified health status, minority status, and the interaction between governors’ parties and health status as important variables. The political factor, however, did not appear in a subsequent analysis of 2014–2018 pneumonia and flu death rates. The pathogenesis of COVID-19 has a greater and disproportionate effect within racial and ethnic minority groups, and the political influence on the reporting of COVID-19 mortality was statistically relevant at the county level and as an interaction term only at the state level.

ACS Style

Ian Feinhandler; Benjamin Cilento; Brad Beauvais; Jordan Harrop; Lawrence Fulton. Predictors of Death Rate during the COVID-19 Pandemic. Healthcare 2020, 8, 339 .

AMA Style

Ian Feinhandler, Benjamin Cilento, Brad Beauvais, Jordan Harrop, Lawrence Fulton. Predictors of Death Rate during the COVID-19 Pandemic. Healthcare. 2020; 8 (3):339.

Chicago/Turabian Style

Ian Feinhandler; Benjamin Cilento; Brad Beauvais; Jordan Harrop; Lawrence Fulton. 2020. "Predictors of Death Rate during the COVID-19 Pandemic." Healthcare 8, no. 3: 339.

Preprint
Published: 11 September 2020
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COVID-19 is a potentially fatal viral infection. This study investigates geography, demography, socioeconomics, health conditions, hospital characteristics, and politics as potential explanatory variables for death rates at the state and county levels. Data from the Centers for Disease Control and Prevention, the Census Bureau, Centers for Medicare and Medicaid, Definitive Healthcare, and USAfacts.org were used to evaluate regression models. Yearly pneumonia and flu death rates (state level, 2014-2018) were evaluated as a function of the governors’ political party using repeated measures analysis. At the state and county level, spatial regression models were evaluated. At the county level, we discovered a statistically significant model that included geography, population density, racial and ethnic status, three health status variables along with a political factor. State level analysis identified health status, minority status, and the interaction between governors’ parties and health status as important variables. The political factor, however, did not appear in a subsequent analysis of 2014-2018 pneumonia and flu death rates. The pathogenesis of COVID-19 has greater and disproportionate effect within racial and ethnic minority groups, and the political influence on the reporting of COVID-19 mortality was statistically relevant at the county level and as an interaction term only at the state level.

ACS Style

Ian Feinhandler; Benjamin Cilento; Brad Beauvais; Jordan Harrop; Lawrence Fulton. Predictors of Death Rate During the COVID-19 Pandemic. 2020, 1 .

AMA Style

Ian Feinhandler, Benjamin Cilento, Brad Beauvais, Jordan Harrop, Lawrence Fulton. Predictors of Death Rate During the COVID-19 Pandemic. . 2020; ():1.

Chicago/Turabian Style

Ian Feinhandler; Benjamin Cilento; Brad Beauvais; Jordan Harrop; Lawrence Fulton. 2020. "Predictors of Death Rate During the COVID-19 Pandemic." , no. : 1.

Journal article
Published: 29 August 2020 in Journal of Medical Internet Research
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Electronic health records (EHRs) are a central feature of care delivery in acute care hospitals; however, the financial and quality outcomes associated with system performance remain unclear. In this study, we aimed to evaluate the association between the top 3 EHR vendors and measures of hospital financial and quality performance. This study evaluated 2667 hospitals with Cerner, Epic, or Meditech as their primary EHR and considered their performance with regard to net income, Hospital Value–Based Purchasing Total Performance Score (TPS), and the unweighted subdomains of efficiency and cost reduction; clinical care; patient- and caregiver-centered experience; and patient safety. We hypothesized that there would be a difference among the 3 vendors for each measure. None of the EHR systems were associated with a statistically significant financial relationship in our study. Epic was positively associated with TPS outcomes (R2=23.6%; β=.0159, SE 0.0079; P=.04) and higher patient perceptions of quality (R2=29.3%; β=.0292, SE 0.0099; P=.003) but was negatively associated with patient safety quality scores (R2=24.3%; β=−.0221, SE 0.0102; P=.03). Cerner and Epic were positively associated with improved efficiency (R2=31.9%; Cerner: β=.0330, SE 0.0135, P=.01; Epic: β=.0465, SE 0.0133, P<.001). Finally, all 3 vendors were associated with positive performance in the clinical care domain (Epic: β=.0388, SE 0.0122, P=.002; Cerner: β=.0283, SE 0.0124, P=.02; Meditech: β=.0273, SE 0.0123, P=.03) but with low explanatory power (R2=4.2%). The results of this study provide evidence of a difference in clinical outcome performance among the top 3 EHR vendors and may serve as supportive evidence for health care leaders to target future capital investments to improve health care delivery.

ACS Style

Bradley Beauvais; Clemens Kruse; Lawrence Fulton; Ramalingam Shanmugam; Zo Ramamonjiarivelo; Matthew Brooks. Electronic Health Record Vendors: An Evaluation of the Association with Hospital Financial and Quality Performance (Preprint). Journal of Medical Internet Research 2020, 23, e23961 .

AMA Style

Bradley Beauvais, Clemens Kruse, Lawrence Fulton, Ramalingam Shanmugam, Zo Ramamonjiarivelo, Matthew Brooks. Electronic Health Record Vendors: An Evaluation of the Association with Hospital Financial and Quality Performance (Preprint). Journal of Medical Internet Research. 2020; 23 (4):e23961.

Chicago/Turabian Style

Bradley Beauvais; Clemens Kruse; Lawrence Fulton; Ramalingam Shanmugam; Zo Ramamonjiarivelo; Matthew Brooks. 2020. "Electronic Health Record Vendors: An Evaluation of the Association with Hospital Financial and Quality Performance (Preprint)." Journal of Medical Internet Research 23, no. 4: e23961.

Preprint content
Published: 29 August 2020
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BACKGROUND Electronic health records are a central feature of care delivery in the acute care hospital, but financial and quality outcomes associated with system performance remain unclear. OBJECTIVE This study evaluates the association between the top three electronic health record vendors and measures of hospital financial and quality performance. METHODS This study evaluates 2,667 hospitals with Cerner, Epic, or Meditech as their primary EHR and considers performance on net income, Hospital Value Based Purchasing (HVBP) Total Performance Score (TPS) and the unweighted sub-domains: Efficiency and Cost Reduction, Clinical Care, Patient and Caregiver-Centered Experience, and Patient Safety. We hypothesize there is a difference among the three vendors on each measure. RESULTS None of the EHR systems was associated with a statistically significant financial relationship in our study. Epic was positively associated with Total Performance Score outcomes (R2 = 23.6%; β:.0159, S.E.:.0079, P = .043) and higher patient perceptions of quality (R2 = 29.3%; β:.0292, S.E.:.0099, P =.003) but negatively associated with patient safety quality scores (R2 = 24.3%; β: -.0221, S.E.:.0102, P =.029). Cerner and Epic were positively associated with improved efficiency (R2 = 31.9%; Cerner: β:.0330, S.E.:.0135, P =.014; Epic: β:.0465, S.E.:.0133, P < .001). Lastly, all three vendors were associated with positive performance in the Clinical Care domain ( Epic: β:.0388, S.E.:.0122, P =.002; Cerner: β:.0283, S.E.:.0124, P =.022; Meditech: β:.0273, S.E.:.0123, P =.026) but with low explanatory power (R2 = 4.2%). CONCLUSIONS The results of this study provide evidence of a difference in clinical outcome performance among the top three EHR vendors and may serve as supportive evidence for healthcare leaders to target future capital investments to improve healthcare delivery.

ACS Style

Bradley Beauvais; Clemens Scott Kruse; Lawrence Fulton; Ramalingam Shanmugam; Zo Ramamonjiarivelo; Matthew Brooks. Electronic Health Record Vendors: An Evaluation of the Association with Hospital Financial and Quality Performance (Preprint). 2020, 1 .

AMA Style

Bradley Beauvais, Clemens Scott Kruse, Lawrence Fulton, Ramalingam Shanmugam, Zo Ramamonjiarivelo, Matthew Brooks. Electronic Health Record Vendors: An Evaluation of the Association with Hospital Financial and Quality Performance (Preprint). . 2020; ():1.

Chicago/Turabian Style

Bradley Beauvais; Clemens Scott Kruse; Lawrence Fulton; Ramalingam Shanmugam; Zo Ramamonjiarivelo; Matthew Brooks. 2020. "Electronic Health Record Vendors: An Evaluation of the Association with Hospital Financial and Quality Performance (Preprint)." , no. : 1.

Journal article
Published: 21 August 2020 in Sustainability
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Sustainability and corporate social responsibility (CSR) strategies of companies delineate the health and the welfare of the communities across the globe. The two major goals of this study are (1) To explore the relationship between the environmental regulations, market value, and adoption of sustainability and CSR strategies of the publicly traded firms listed on the Dow Jones Sustainability Indices (DJSI) and (2) To examine the impact of being added to or deleted from DJSI per different market sectors for the firms in the U.S. and the European Union (EU). The selected starting window, the year 2015, for studying the impact of addition to or deletion from the DJS indices was the Paris Accord proposal by the EU and strict sustainability regulations of the EU versus the U.S. We used event study methodology and regression analyses to explain the cumulative abnormal returns utilizing firms’ characteristics and specific market sectors. In addition, the other focus of the study was on heavy (polluting) industries and investigating if the addition to or deletion of the firms in these industries from the sustainability indices had an impact on the market value. The findings of this study reveal no impact of the environmental rules and regulations on adopting sustainability and CSR strategies by either the EU or the U.S. firms. The novel findings of this study indicate a significant negative impact on the market value of firms in heavy industries, Energy, Basic Materials, and Utilities when added to the DJS indices. The study discusses the underlying reasons for these differences and proposes strategies to enhance the impact of addition to or deletion from the DISI to increase firms’ commitments to sustainability and CSR strategies and altering the attitudes of the investors.

ACS Style

Bryan Schmutz; Minoo Tehrani; Lawrence Fulton; Andreas Rathgeber. Dow Jones Sustainability Indices, Do They Make a Difference? The U.S. and the European Union Companies. Sustainability 2020, 12, 6785 .

AMA Style

Bryan Schmutz, Minoo Tehrani, Lawrence Fulton, Andreas Rathgeber. Dow Jones Sustainability Indices, Do They Make a Difference? The U.S. and the European Union Companies. Sustainability. 2020; 12 (17):6785.

Chicago/Turabian Style

Bryan Schmutz; Minoo Tehrani; Lawrence Fulton; Andreas Rathgeber. 2020. "Dow Jones Sustainability Indices, Do They Make a Difference? The U.S. and the European Union Companies." Sustainability 12, no. 17: 6785.

Journal article
Published: 24 July 2020 in Sustainability
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“Green Cities” are cities with the ultimate goal of achieving a net zero-carbon footprint in energy, transportation, architecture, and the activity cost chain of businesses. These cities define the future of our planet by emphasizing the efficient use of resources and the well-being of communities. This study focuses on “Green Cities” and the restaurant industry. It examines the beliefs of restaurant owners/managers on the positive impact of sustainability practices on financial situation, reputation, and attraction of customers, and the relationship between such beliefs and the extent of engagement in sustainability practices. The research also explores whether declaring a city “Green” enhances the sustainability practices in that city. The results indicate that the restaurant owners/managers in all three studied cities strongly believe that sustainability practices enhance the financial performance, reputation of the restaurant, and attraction of customers, yet a significant percentage of the wastes and by-products of the operations of the studied restaurants are discarded. In addition, the results of the study show no significant impact on sustainability practices in the studied restaurants for the declared “Green” cities of Providence (U.S.) and Nancy (France) versus the city of Springfield (U.S.). The study concludes by highlighting the potential reasons underlying the lack of sustainability practices in the restaurant industry and proposes recommendations that can enhance such practices in this industry.

ACS Style

Minoo Tehrani; Lawrence Fulton; Bryan Schmutz. Green Cities and Waste Management: The Restaurant Industry. Sustainability 2020, 12, 5964 .

AMA Style

Minoo Tehrani, Lawrence Fulton, Bryan Schmutz. Green Cities and Waste Management: The Restaurant Industry. Sustainability. 2020; 12 (15):5964.

Chicago/Turabian Style

Minoo Tehrani; Lawrence Fulton; Bryan Schmutz. 2020. "Green Cities and Waste Management: The Restaurant Industry." Sustainability 12, no. 15: 5964.

Preprint content
Published: 20 July 2020
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Background. About 5.7 million individuals in the United States have heart failure, and the disease was estimated to cost about $42.9 billion in 2020. This research provides geographical incidence models of this disease in the U.S. and explanatory models to account for hospitals’ number of heart failure DRGs using technical, workload, financial, geographical, and time-related variables. The research also provides updated financial and demand estimates based on inflationary pressures and disease rate increases. Understanding patterns is important to both policymakers and health administrators for cost control and planning. Methods. Maps of heart failure diagnosis-related groups (DRGs) from 2016 through 2018 depicted areas of high incidence as well as changes. Spatial regression identified no significant spatial correlations. Simple expenditure forecasts were calculated for 2016 through 2018. Linear, lasso, ridge, and Elastic Net models as well as ensembled tree regressors including were built on an 80% training set and evaluated on a 20% test set. Results: The incidence of heart failure has increased over time with highest intensities in the East and center of the country; however, several Northern states (e.g., Minnesota) have seen large increases in rates from 2016. The best traditional regression model explained 75% of the variability in the number of DRGs experienced by hospital using a small subset of variables including discharges, DRG type, percent Medicare reimbursement, hospital type, and medical school affiliation. The best ensembled tree models achieved R2 over .97 on the blinded test set and identified discharges, percent Medicare reimbursement, hospital acute days, affiliated physicians, staffed beds, employees, hospital type, emergency room visits, medical school affiliation, geographical location, and the number of surgeries as highly important predictors. Conclusions. Overall, the total cost of the three DRGs in the study has increased approximately $61 billion from 2016 through 2018 (average of two estimates). The increase in the more expensive DRG (DRG 291) has outpaced others with an associated increase of $92 billion in expenditures. With the increase in demand (linked to obesity and other factors) as well as the relatively steady-state supply of cardiologists over time, the costs are likely to balloon over the next decade.

ACS Style

Clemens Scott Kruse; Bradley M. Beauvais; Matthew S. Brooks; Michael Mileski; Lawrence Fulton. Geospatial and Explanatory Models for Heart Failure Admissions, 2016 through 2018. 2020, 1 .

AMA Style

Clemens Scott Kruse, Bradley M. Beauvais, Matthew S. Brooks, Michael Mileski, Lawrence Fulton. Geospatial and Explanatory Models for Heart Failure Admissions, 2016 through 2018. . 2020; ():1.

Chicago/Turabian Style

Clemens Scott Kruse; Bradley M. Beauvais; Matthew S. Brooks; Michael Mileski; Lawrence Fulton. 2020. "Geospatial and Explanatory Models for Heart Failure Admissions, 2016 through 2018." , no. : 1.

Journal article
Published: 30 June 2020 in International Journal of Environmental Research and Public Health
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Tobacco product waste (TPW) is one of the most ubiquitous forms of litter, accumulating in large amounts on streets, highways, sidewalks, beaches, parks, and other public places, and flowing into storm water drains, waste treatment plants, and solid waste collection facilities. In this paper, we evaluate the direct and indirect costs associated with TPW in the 30 largest U.S. cities. We first developed a conceptual framework for the analysis of direct and indirect costs of TPW abatement. Next, we applied a simulation model to estimate the total costs of TPW in major U.S. cities. This model includes data on city population, smoking prevalence rates, and per capita litter mitigation costs. Total annual TPW-attributable mean costs for large US cities range from US$4.7 million to US$90 million per year. Costs are generally proportional to population size, but there are exceptions in cities that have lower smoking prevalence rates. The annual mean per capita TPW cost for the 30 cities was US$6.46, and the total TPW cost for all 30 cities combined was US$264.5 million per year. These estimates for the TPW-attributable cost are an important data point in understanding the negative economic externalities created by cigarette smoking and resultant TPW cleanup costs. This model provides a useful tool for states, cities, and other jurisdictions with which to evaluate a new economic cost outcome of smoking and to develop new laws and regulations to reduce this burden.

ACS Style

John E. Schneider; Cara M. Scheibling; N. Andrew Peterson; Paula Stigler Granados; Lawrence Fulton; Thomas E. Novotny. Online Simulation Model to Estimate the Total Costs of Tobacco Product Waste in Large U.S. Cities. International Journal of Environmental Research and Public Health 2020, 17, 4705 .

AMA Style

John E. Schneider, Cara M. Scheibling, N. Andrew Peterson, Paula Stigler Granados, Lawrence Fulton, Thomas E. Novotny. Online Simulation Model to Estimate the Total Costs of Tobacco Product Waste in Large U.S. Cities. International Journal of Environmental Research and Public Health. 2020; 17 (13):4705.

Chicago/Turabian Style

John E. Schneider; Cara M. Scheibling; N. Andrew Peterson; Paula Stigler Granados; Lawrence Fulton; Thomas E. Novotny. 2020. "Online Simulation Model to Estimate the Total Costs of Tobacco Product Waste in Large U.S. Cities." International Journal of Environmental Research and Public Health 17, no. 13: 4705.

Journal article
Published: 29 June 2020 in Healthcare
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The obesity epidemic in the United States has been well documented and serves as the basis for a number of health interventions across the nation. However, those who have served in the U.S. military (Veteran population) suffer from obesity in higher numbers and have an overall disproportionate poorer health status when compared to the health of the older non-Veteran population in the U.S. which may further compound their overall health risk. This study examined both the commonalities and the differences in obesity rates and the associated co-morbidities among the U.S. Veteran population, utilizing data from the 2018 Behavioral Risk Factor Surveillance System (BRFSS). These data are considered by the Centers for Disease Control and Prevention (CDC) to be the nation’s best source for health-related survey data, and the 2018 version includes 437,467 observations. Study findings show not only a significantly higher risk of obesity in the U.S. Veteran population, but also a significantly higher level (higher odds ratio) of the associated co-morbidities when compared to non-Veterans, including coronary heart disease (CHD) or angina (odds ratio (OR) = 2.63); stroke (OR = 1.86); skin cancer (OR = 2.18); other cancers (OR = 1.73); chronic obstructive pulmonary disease (COPD) (OR = 1.52), emphysema, or chronic bronchitis; arthritis (OR = 1.52), rheumatoid arthritis, gout, lupus, or fibromyalgia; depressive disorders (OR = 0.84), and diabetes (OR = 1.61) at the 0.95 confidence interval level.

ACS Style

Jose A. Betancourt; Paula Stigler Granados; Gerardo J. Pacheco; Ramalingam Shanmugam; C. Scott Kruse; Lawrence V. Fulton. Obesity and Morbidity Risk in the U.S. Veteran. Healthcare 2020, 8, 191 .

AMA Style

Jose A. Betancourt, Paula Stigler Granados, Gerardo J. Pacheco, Ramalingam Shanmugam, C. Scott Kruse, Lawrence V. Fulton. Obesity and Morbidity Risk in the U.S. Veteran. Healthcare. 2020; 8 (3):191.

Chicago/Turabian Style

Jose A. Betancourt; Paula Stigler Granados; Gerardo J. Pacheco; Ramalingam Shanmugam; C. Scott Kruse; Lawrence V. Fulton. 2020. "Obesity and Morbidity Risk in the U.S. Veteran." Healthcare 8, no. 3: 191.

Journal article
Published: 19 May 2020 in Energies
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Volatility in energy markets has made the purchase of battery electric vehicles (BEV) or hybrid vehicles (HEVs) attractive versus internal combustion engine vehicles (ICEVs). However, the total cost of ownership (TCO) and true environmental effects, are difficult to assess. This study provides a publicly available, user-driven simulation that estimates the consumer and environmental costs for various vehicle purchase options, supporting policymaker, producer, and consumer information requirements. It appears to be the first to provide a publicly available, user interactive simulation that compares two purchase options simultaneously. It is likely that the first paper to simulate the effects of solar recharging of electric vehicles (EV) on both cost-benefit for the consumer and environmental benefit (e.g., carbon dioxide, oxides of nitrogen, non-methane organic gasses, particulate matter, and formaldehyde) simultaneously, demonstrating how, as an example, solar-based charging of BEVs and HEVs reduces carbon emissions over grid-based charging. Two specific scenarios are explicated, and the results of show early break-even for both BEV and Plug-in HEV (PHEV) options over ICEV (13 months, and 12 months, respectively) with CO2 emissions about ½ that of the gasoline option (including production emissions.) The results of these simulations are congruent with previous research that identified quick break-even for HEVs versus ICEV.

ACS Style

Lawrence Fulton. A Publicly Available Simulation of Battery Electric, Hybrid Electric, and Gas-Powered Vehicles. Energies 2020, 13, 2569 .

AMA Style

Lawrence Fulton. A Publicly Available Simulation of Battery Electric, Hybrid Electric, and Gas-Powered Vehicles. Energies. 2020; 13 (10):2569.

Chicago/Turabian Style

Lawrence Fulton. 2020. "A Publicly Available Simulation of Battery Electric, Hybrid Electric, and Gas-Powered Vehicles." Energies 13, no. 10: 2569.

Journal article
Published: 15 May 2020 in Land
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Intelligent use of rural residential land and sustainable construction is inexorably linked to cost; however, options exist that are eco-friendly and have a positive return on investment. In 2011, a research residence was built to evaluate various land-use and sustainable components. This Texas house has subsequently been used for both residential and research purposes. The purpose of this case study was to evaluate break-even construction considerations, to assess environmental impacts, and to evaluate qualitatively efficacy of sustainable options incorporated in the research residence. Some of the specific components discussed are home site placement (directional positioning); materiel acquisition (transportation); wood product minimization; rainwater harvesting; wastewater management; grid-tied solar array power; electric car charging via a solar array; geothermal heating and cooling; insulation selection; windows, fixtures, and appliance selection; and on-demand electric water heaters for guest areas. This study seeks to identify the impact of proper land use and sustainable techniques on the environment and return-on-investment in rural areas. Break-even and 15-year Net Present Value (NPV) analysis at 3% and 5% cost of capital were used to evaluate traditional construction, partially sustainable construction, and fully sustainable construction options for the case study house, which was built sustainably. The additional cost of sustainable construction is estimated at $54,329. At 3%, the analysis suggests a 15-year NPV of $334,355 (traditional) versus $250,339 million (sustainable) for a difference of $84K. At 5% cost of capital, that difference falls to $63K. The total estimated annual difference in carbon emissions is 4.326 million g/CO2e for this research residence. The results indicate that good choices for quick return-on-investment in rural construction would be the use of engineered lumber, Icynene foam, and Energy Star windows and doors. Medium-term options include photovoltaic systems (PVS) capable of powering the home and an electric car. Sustainable construction options should positively affect the environment and the pocketbook. Regulations and code should require adoption of short-range, break-even sustainable solutions in residential construction.

ACS Style

Lawrence Fulton; Bradley Beauvais; Matthew Brooks; Scott Kruse; Kimberly Lee. Sustainable Residential Building Considerations for Rural Areas: A Case Study. Land 2020, 9, 152 .

AMA Style

Lawrence Fulton, Bradley Beauvais, Matthew Brooks, Scott Kruse, Kimberly Lee. Sustainable Residential Building Considerations for Rural Areas: A Case Study. Land. 2020; 9 (5):152.

Chicago/Turabian Style

Lawrence Fulton; Bradley Beauvais; Matthew Brooks; Scott Kruse; Kimberly Lee. 2020. "Sustainable Residential Building Considerations for Rural Areas: A Case Study." Land 9, no. 5: 152.

Article
Published: 03 April 2020 in Sustainability
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A major consideration for consumers and the residential construction industry is the cost–benefit and break-even of various sustainable construction options. This research provides a publicly available simulation that allows users to compare baseline construction options versus sustainable options and evaluates both break-even costs as well as environmental effects. This R Shiny Monte Carlo simulation uses common pseudo-random number streams for replicability and includes options for solar, rainwater harvesting, wells, Icynene foam, engineered lumber, Energy Star windows and doors, low flow fixtures, aerobic/non-aerobic/city waste treatment, electric versus gasoline vehicles, and many other options. This is the first simulation to quantify multiple sustainable construction options, associated break-even points, and environmental considerations for public use. Using user default parameters, coupled with a 100% solar solution for a baseline 3000 square foot/279 square meter house with 2 occupants results in a break-even of 9 years. Results show that many of the sustainable options are both green for the environment and green for the pocketbook.

ACS Style

Lawrence Fulton; Bradley Beauvais; Matthew Brooks; Clemens Scott Kruse; Kimberly Lee. A Publicly Available Cost Simulation of Sustainable Construction Options for Residential Houses. Sustainability 2020, 12, 2873 .

AMA Style

Lawrence Fulton, Bradley Beauvais, Matthew Brooks, Clemens Scott Kruse, Kimberly Lee. A Publicly Available Cost Simulation of Sustainable Construction Options for Residential Houses. Sustainability. 2020; 12 (7):2873.

Chicago/Turabian Style

Lawrence Fulton; Bradley Beauvais; Matthew Brooks; Clemens Scott Kruse; Kimberly Lee. 2020. "A Publicly Available Cost Simulation of Sustainable Construction Options for Residential Houses." Sustainability 12, no. 7: 2873.

Journal article
Published: 22 March 2020 in Healthcare
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The number one leading cause of death in 2017 for Americans was cardiovascular disease (CVD), and health disparities can exacerbate risks. This study evaluates the 2018 Behavioral Risk Factor Surveillance System (BRFSS) (n = 437,436) to estimate population risks for behavioral, socio-economic, psychological, and biological factors. A general linear model with a quasi-binomial link function indicated higher risks for the following groups: smokers (odds ratio, OR = 0.688), individuals with higher body mass index scores (OR = 1.023), persons unable to work (OR = 2.683), individuals with depression (OR = 1.505), workers who missed more days due to mental issues (OR = 1.12), the elderly, males (OR = 1.954), those in race categories “indigenous Americans, Alaskan non-Hispanics”, “Black Hispanics,” or “other, non-Hispanic,” and individuals with lower income. Surprisingly, increased consumption of alcohol was not found to be a risk factor as in other studies. Additional study of alcohol risk factors is needed. Further, Black non-Hispanics were associated with lower rates of CVD/MI (myocardial infarction), a finding that is supported by recent evidence of more unhealthy behaviors in other races. The results of this study highlight 2018 CVD/MI disparities based on the BRFSS and suggest the need for additional policy interventions including education and providing increased access to health care for the disadvantaged. The principles of beneficence and justice require policy interventions such as these.

ACS Style

Ava Niakouei; Minoo Tehrani; Lawrence Fulton. Health Disparities and Cardiovascular Disease. Healthcare 2020, 8, 65 .

AMA Style

Ava Niakouei, Minoo Tehrani, Lawrence Fulton. Health Disparities and Cardiovascular Disease. Healthcare. 2020; 8 (1):65.

Chicago/Turabian Style

Ava Niakouei; Minoo Tehrani; Lawrence Fulton. 2020. "Health Disparities and Cardiovascular Disease." Healthcare 8, no. 1: 65.