A non-linear discrete stochastic optimization model for Advanced Access patient appointment scheduling

Access to healthcare is a major problem in which patients are deprived of receiving timely admission to healthcare. Poor access has resulted in significant but avoidable healthcare cost, poor quality of healthcare, and deterioration in the general public health. Advanced Access is a simple and direct approach to appointment scheduling in which the majority of a clinic's appointments slots are kept open in order to provide access for immediate or same day healthcare needs and therefore, alleviate the problem of poor access the healthcare. This research formulates a non-linear discrete stochastic mathematical model of the Advanced Access appointment scheduling policy. The model objective is to maximize the expected profit of the clinic subject to constraints on minimum access to healthcare provided. Patient behavior is characterized with probabilities for no-show, balking, and related patient choices. Structural properties of the model are analyzed to determine whether Advanced Access patient scheduling is feasible. To solve the complex combinatorial optimization problem, a heuristic that combines greedy construction algorithm and neighborhood improvement search was developed. The model and the heuristic were used to evaluate the Advanced Access patient appointment policy compared to existing policies. Trade-off between profit and access to healthcare are established, and parameter analysis of input parameters was performed. The trade-off curve is a characteristic curve and was observed to be concave. This implies that there exists an access level at which at which the clinic can be operated at optimal profit that can be realized. The results also show that, in many scenarios by switching from existing scheduling policy to Advanced Access policy clinics can improve access without any decrease in profit. Further, the success of Advanced Access policy in providing improved access and/or profit depends on the expected value of demand, variation in demand, and the ratio of demand for same day and advanced appointments. The contributions of the dissertation are a model of Advanced Access patient scheduling, a heuristic to solve the model, and the use of the model to understand the scheduling policy trade-offs which healthcare clinic managers must make. ^

The health and nutritional status of multiethnic perimenopausal women

An integrated, dual-phase study design assessed the health and nutritional status and practices of African-American (A-A), Caribbean (A-C), and white non-Hispanic (W-A) women during perimenopause (40–55 years). During Phase I, four focus groups (n = 37) of male and female participants discussed the health and social implications of perimenopause. A conceptual framework for the main study (Phase II) was developed from the focus groups' findings, in concert with the main study's specific aims and objectives. ^ The main study, a cross-sectional survey, quantitatively assessed the health and nutritional status of a convenience sample of 109 women (25 A-A, 31 A-C and 53 W-A), who met specific eligibility criteria. Using seven instruments, sociodemographic, dietary, medical, reproductive health, health practice and anthropometric data were collected. ^ The groups were of comparable age, education, and socioeconomic status (SES). Despite these similarities, statistically significant interethnic nutritional status differences were found. Significantly more total energy and energy from fat were consumed by A-A than W-A and A-C women. Also, significantly more A-A and A-C than W-A women were overweight or obese with android-type weight patterning. ^ Overall, iron and calcium Recommended Dietary Allowances (RDA's) were not met by 35% and 68% of participants, respectively. Iron deficiency anemia was reported by 29% of participants while 33% reported heavier menstrual bleeding. Coupled with suboptimal iron intakes, this is likely to present a serious public health problem. Similarly, increased bone demineralization characteristic of perimenopause, coupled with suboptimal calcium intakes could precipitate another public health problem, osteoporosis. ^ Participants had different expectations about the role of medical care during perimenopause. Significantly more white (57%) than black (38% [A-A and AC]) women sought medical attention for symptoms. Whereas Hormone Replacement Therapy (HRT) was prescribed for 25% of them, only 13% were compliant at enrollment. ^ The trends and statistically significant findings of this study have huge public health policy implications. It is imperative that appropriate policies are formulated to ensure that America's ethnically diverse perimenopausal women have ready access to culturally appropriate care. This would optimize their health outcomes, and enhance their quality of life and productive capacities at this critical juncture of their lives. ^

Dean of the school board: An oral history of the distinguished career of G. Holmes Braddock

Effective school board leadership is often an ephemeral ideal in today's highly politicized public education arena. However, effective leadership is necessary in order to ensure a fair and equitable education for all students. This dissertation described and explained one school board member's perspective of his career as a lens from which to view and assess public educational policy making in Miami-Dade County. ^ Now retired after thirty-eight years of service, G. Holmes Braddock is the longest serving, contemporary, urban school board member in the country. Spanning nearly four decades, his perspective provides a comprehensive view of urban education both locally and nationally. The significance of his longevity and the impact of his leadership on educational policy-making was the focus of indepth interviews with Mr. Braddock and other key educational “influentials.” From this transcript data, recurring themes were revealed and categorized. Five elements of his perspective, i.e., teacher professionalization; desegregation; athletics; bilingual education; and his comprehensive leadership role, were identified and analyzed, as were five variables of his perspective, i.e., fairness; integrity; honesty; courage; and the situational context. Other secondary source material, such as excerpts from newspaper articles, school board minutes, and items from Mr. Braddock's own personal effects further augmented and triangulated the data. ^ Given that the purpose of this study was to describe and explain Mr. Braddock's perspective of his school board career, the findings can be understood from two different viewpoints. The elements of Mr. Braddock's perspective describe or characterize his career and represent the significant policy issues in which he demonstrated exceptional vision and leadership. However, taken alone, these elements cannot fully explain his distinguished career. Rather, an analysis of the variables of Mr. Braddock's perspective provides an explanation for the effectiveness of his leadership role. Personality traits such as fairness, integrity, honesty and courage and the impact of the situational context were factors that strongly influenced Mr. Braddock's decision-making. Thus, Mr. Braddock's school board career can be holistically understood as the intersection of person, place and time with significant public education policy issues. ^ The results of this study provide a unique and historical perspective of school board politics in Miami-Dade County. From Mr. Braddock's perspective, we are able to view one individual's leadership role over time and its impact on local public education policy. ^

Black churchgoers, environmental activism, and the preservation of nature in Miami, Florida

The goal of this project was to explore activism, attitudes, and imagery connecting Black churchgoers in Miami, Florida and the natural environment. The research approach was qualitative, began as exploratory research, and used the techniques of snowball sampling, participant observation, and semi-structured interviews. Three case studies representing various socio-economic levels, denominations, participant education levels, and environmental facets were chosen for in-depth ethnographic research. There are three major findings in the research. First, there is a link between the preservation of Black history and the preservation of the environment among Black churchgoers, who feel strong connections to a sense of place, rural life, and the past. However their work is strongly directed to bring about benefits for people and the environment in the present and the future. Second, public access to public lands is a basic and important right espoused by these Black churchgoing activists. Third, the vocabulary used by Black churchgoing activists regarding the natural environment differs from today's “mainstream” environmentalists. The concept of “beauty” is pivotal to Black appreciation of and activism toward the environment and is reminiscent of the early environmental protection movement in the United States and conservationists such as John Muir. These findings concerning how Black spirituality relates to the environment adds to the sparse literature on the subject, and provides for potential linkages between Blacks and “mainstream” environmental groups to benefit both parties. An understanding of the connections between Black spirituality and perceptions of the environment should facilitate the development of better programs to improve and protect the environment. Environmental projects may also address the social and economic needs of Black communities, churches, and congregations, as well as the ecosystem. ^

Assessing Administrative and Political Factors in Implementing a Living Wage Ordinance

Since 2000, the number of living wage ordinances has steadily increased throughout the country. While most of the current research has focused on the beneficial outcomes of living wages, little has been published on their administrative practices. To address this shortcoming, this study focused on the identification of key administrative and political factors involved impacting the implementation of living wage ordinances in Miami-Dade and Broward Counties. The study utilized a triangulation of interviews, surveys, and direct observation. The author conducted interviews of administrators and members of the living wage oversight boards in both counties and observed the monthly meetings held by each county’s oversight board from January 2006 to June 2007. These findings were buttressed with a national survey of senior staff in other living wage communities. The study utilized descriptive statistics, Chi Square, Cronbach’s Alpha, and Spearman’s Rank Correlation Coefficient (Spearman’s rho). Interviews indicated that administrators in Dade and Broward are seriously under-staffed and budgeted. Ambiguities in the enabling ordinances have lead to loopholes that undermine implementation and accountability for participating contractors. Survey results showed that policy ambiguity, organizational politics, and a lack of organizational capacity were significant negative factors in the implementation process while an organizational culture emphasizing consistent enforcement was a positive factor. Without the proper inputs, an organization hinders itself from meeting its outputs and outcomes. This study finds that Broward and Miami-Dade Counties do not provide the necessary administrative support to implement a living wage effectively – in stark contrast to the high hopes and strong political support behind their passage. For a living wage to succeed, it first needs an organizational culture committed to providing the necessary resources for implementation as well as transparent, consistent accountability mechanisms.

Access to better education: The school choice experience of families served by low-performing elementary public schools in Miami-Dade County

Public school choice education policy attempts to create an education marketplace. Although school choice research has focused on the parent role in the school choice process, little is known about parents served by low-performing schools. Following market theory, students attending low-performing schools should be the primary students attempting to use school choice policy to access high performing schools rather than moving to a better school. However, students remain in these low-performing schools. This study took place in Miami-Dade County, which offers a wide variety of school choice options through charter schools, magnet schools, and open-choice schools. ^ This dissertation utilized a mixed-methods design to examine the decision-making process and school choice options utilized by the parents of students served by low-performing elementary schools in Miami-Dade County. Twenty-two semi-structured interviews were conducted with the parents of students served by low-performing schools. Binary logistic regression models were fitted to the data to compare the demographic characteristics, academic achievement and distance from alternative schooling options between transfers and non-transfers. Multinomial logistic regression models were fitted to the data to evaluate how demographic characteristics, distance to transfer school, and transfer school grade influenced the type of school a transfer student chose. A geographic analysis was conducted to determine how many miles students lived from alternative schooling options and the miles transfer students lived away from their transfer school. ^ The findings of the interview data illustrated that parents’ perceived needs are not being adequately addressed by state policy and county programs. The statistical analysis found that students from higher socioeconomic social groups were not more likely to transfer than students from lower socioeconomic social groups. Additionally, students who did transfer were not likely to end up at a high achieving school. The findings of the binary logistic regression demonstrated that transfer students were significantly more likely to live near alternative school options.^

Access to Better Education: The School Choice Experience of Families Served by Low-Performing Elementary Public Schools in Miami-Dade County

Public school choice education policy attempts to create an education marketplace. Although school choice research has focused on the parent role in the school choice process, little is known about parents served by low-performing schools. Following market theory, students attending low-performing schools should be the primary students attempting to use school choice policy to access high performing schools rather than moving to a better school. However, students remain in these low-performing schools. This study took place in Miami-Dade County, which offers a wide variety of school choice options through charter schools, magnet schools, and open-choice schools. This dissertation utilized a mixed-methods design to examine the decision-making process and school choice options utilized by the parents of students served by low-performing elementary schools in Miami-Dade County. Twenty-two semi-structured interviews were conducted with the parents of students served by low-performing schools. Binary logistic regression models were fitted to the data to compare the demographic characteristics, academic achievement and distance from alternative schooling options between transfers and non-transfers. Multinomial logistic regression models were fitted to the data to evaluate how demographic characteristics, distance to transfer school, and transfer school grade influenced the type of school a transfer student chose. A geographic analysis was conducted to determine how many miles students lived from alternative schooling options and the miles transfer students lived away from their transfer school. The findings of the interview data illustrated that parents’ perceived needs are not being adequately addressed by state policy and county programs. The statistical analysis found that students from higher socioeconomic social groups were not more likely to transfer than students from lower socioeconomic social groups. Additionally, students who did transfer were not likely to end up at a high achieving school. The findings of the binary logistic regression demonstrated that transfer students were significantly more likely to live near alternative school options.