GSBS Dissertations and Theses



Approval Date


Document Type

Doctoral Dissertation

Academic Program

Clinical and Population Health Research, MD/PhD


Quantitative Health Sciences

First Thesis Advisor

Catarina Kiefe PhD MD


Health Status, Acute Coronary Syndrome, Myocardial Ischemia, Health Services Accessibility, Mortality, Patient Discharge, Transportation


Background: Guideline-concordant therapies for survivors of an acute coronary syndrome (ACS) hospitalization require healthcare access, something that millions of Americans lack.

Methods and Results: Using data from a prospective cohort study of over 2,000 survivors of a hospitalization for an ACS in central Massachusetts and Georgia from 2011 to 2013, the first two aims of this thesis sought to identify the post-discharge consequences for survival and health status of having: 1) financial barriers to healthcare, 2) no usual source of care, and 3) transportation barriers. We found that patients lacking a usual source of care and having a transportation barrier were more likely to have died within two years following hospital discharge compared to those without such barriers. Also, patients with financial barriers to healthcare were more likely to experience clinically meaningful declines in physical and mental health-related quality of life over the six months after hospital discharge. The third aim sought to better understand factors influencing the success of care transitions home after an unplanned hospitalization through a qualitative study of 22 patients. Participants described how adequate healthcare access, particularly having insurance and transportation to clinical appointments, facilitated the receipt of follow-up care and adherence to treatments.

Conclusions: Limitations in healthcare access may contribute to poorer survival, health-related quality of life, and survival. Additional research is needed to identify interventions to improve healthcare access and test whether improved access leads to better patient outcomes.



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Available for download on Friday, December 07, 2018