• Lighting Retrofit of the Robert L. Nugent Building

      Evans, Sasha; College of Architecture, Planning and Landscape Architecture; Hoffman, Michael; Iuliano, Joseph (The University of Arizona., 2020-05-11)
      The goal of this project is to reduce energy consumption at the University of Arizona by retrofitting the existing light bulbs in the Robert L. Nugent Building. Through Students for Sustainability, this project aimed to apply for grant money from the Green Fund to make sustainable retrofits to buildings on campus. This capstone project serves as a guide for lighting retrofits and explains how to work with organizations on campus to reduce energy consumption.
    • Ocean Pollution Knowledge & Actions

      Smith, Delaney; College of Architecture, Planning and Landscape Architecture; Mullen, Kelly; Iuliano, Joey (The University of Arizona., 2020-05-10)
      With global plastic production on the rise and the continuous amount of mismanaged waste, marine fauna's future is at stake. Plastic pollution is a major environmental concern and efforts are needed globally in order to protect our environment. This report focuses on whether ocean pollution and single-use plastic education and outreach can be a part of a community's solution. This study is a quasi-experimental design based on a survey, intervention, and post-survey format. It was found that ocean pollution education and reducing personal waste guidance can help raise awareness because it can positively impact individuals' environmental attitudes and actions.

      Iuliano, Joey; Valenzuela, Carlos Francisco; College of Architecture, Planning and Landscape Architecture; Adkins, Arlie; Iuliano, Joey (The University of Arizona., 2020-05-08)
      In the United States, from 2015 to 2016, a nine percent increase was recorded in pedestrian-related fatalities from motor vehicle crashes (NHTSA 2017). To reduce the number of pedestrian-related accidents, and to reduce the dependence of the motor vehicle for primary transportation, the roadway infrastructure needs to be centered around pedestrian usage, multiple modes of transportation need to be offered, and the environment needs to be made exciting and comfortable for all users. This study provides an overview of factors that contribute to pedestrian-related accidents and reduce walkability in South Tucson. This study also provides an overview and a step-by-step process of solutions and recommendations for future development in troubled areas. This work will be accomplished through a) US census data analysis, b) crash data analysis, and c) an assessment of roadway/pedestrian infrastructure design. It found that there were some trends between the two zip codes 85713 and 85704 which are; the zip code 85713 had higher poverty status rates, the household income was significantly lower than in zip code 85704, the average population age was younger than in zipcode 85704, and that more people were cycling to work than in zip code 85704. The mapping of the crash data showed there were more pedestrian-related accidents within a South Tucson location than in a location in North Tucson. It also found that the roadway design and pedestrian infrastructure in South Tucson offered significantly fewer safety elements to pedestrians than in North Tucson. To make South Tucson more walkability and pedestrian-friendly, the roadway, which includes; the intersection, streets, crosswalks, and bikeways, needs to be redesigned.
    • Complete Streets Critique

      Wardell, Tyler; College of Architecture, Planning and Landscape Architecture; Keith, Ladd; Iuliano, Joey (The University of Arizona., 2020-05-08)
      People have been traveling for thousands of years in an attempt to improve their lives by some means. “For many centuries individual movement and trade relied on walking, packhorses, and horse-drawn carts and wagons” (Black, 2003). The facilities for these modes were placed along the natural pathways people used to get around. Black (2003) explains, “The first major roads to be built in Europe are attributable to the Roman Empire...among their many and varied skills was a talent for road building... Their roads were built in response to a potential need to move armies quickly from one place to another, and they were built to last forever.” Roads have changed over the centuries since the time of the Romans. Modern materials have replaced cobblestones, and new transportation options have complicated roads. However, the underlying goal is still the same: to move people, goods, and services from A to B. More often then not, we see roads built for moving cars while other transportation options such as walking, cycling, or using transit are often an afterthought. While Tucson roads provide options, they are not necessarily safe or comfortable ones. Sidewalks in Tucson are infrequent outside of the urban core and often without shade. Bike lanes tend to be narrow and unprotected. Transit stops are unshaded and service has a long headway, leaving people to wait in the hot sun. All of which leads to uncomfortable walking conditions, the potential for automotive bike accidents, and heat stroke from sun exposure. It does not have to be this way; roads can be friendly to all modes of transportation with better design and planning. Adding trees along the street can provide shade over sidewalks. Buffers and barriers on bicycle lanes help keep drivers and cyclists separate. Shaded transit stops, and more frequent service creates a more pleasant experience for users. There are so many options that it can be difficult to pick the right ones for any given situation. Wardell 3 Up until recently, policies in place that dictated how to design roads for all users were limited to The American Association of State Highway Transportation Officials (AASHTO) design standards and the Manual of Uniform Traffic Control Devices (MUTCD). The design standards have favored drivers over alternative transportation. However, more cities have started to adopt complete streets policies. These policies often follow designs from NACTO- National Association of City Transportation Officials- which favor a blend of options for all users. In Spring 2019, Tucson passed its Complete Streets Initiative, which put into place new guidelines for building and designing our roads. At the same time, the passing of Prop 407- Parks and Connectivity Bond- provided funding to implement complete street designs. While many roads will not see an upgrade until they are repaved, the city now has a policy in place to elevate non-personal vehicle modes. However, is this a policy that works- will it improve our transportation options and create a more vibrant built environment- or is it one that will gather dust on a shelf? This study sets out to critique and compare Tucson’s Complete Streets Initiative to other examples, one in the Southwest and one in the Northwest to compare a similar climate and a differing one. Our plan will be compared against Albuquerque, New Mexico, and Hailey, Idaho in categories such as enforceability, design standards, and transportation options. The strengths of those plans will be identified and then used to propose ways to improve Tucson’s policy.
    • The Connection between People and Place: A Case Study on Social Interactions in UA Outdoor Public Spaces

      Kramer-Lazar, Sean; Morrissey, Lauran; College of Architecture, Planning and Landscape Architecture; Zuniga-Teran, Adriana; Iuliano, Joseph (The University of Arizona., 2020-05-08)
      This study aims to investigate how the design of three outdoor public spaces on the University of Arizona campus effects the level of social interaction at each site. Social interaction is defined by interchangeable sequences of exchanges where individuals can attach meaning, interpret, and respond; which includes looking, listening, and talking (Salih & Ismail 2017). With similar sizes and locations, The Women’s plaza of Honor, The Highland Bowl, and The University Services Building Courtyard were chosen to compare their ability to promote social interaction through five different criteria: placement, usage, image/design, elements, and access (Salih & Ismail 2017). This study found that the highest count of social interactions directly relate to the diversity of areas and seating for people to interact in. Addtionally, the quality, interest, and comfort of the seating and elements (like grass, art, etc.) had an effect on the success of people using these spaces.
    • Using Desalination in a Sustainable Fashion

      Kilman, Sterling; College of Architecture, Planning and Landscape Architecture; Iuliano, Joey (The University of Arizona., 2020-05-07)
      As the world’s population grows and climate change continues to affect the planet regional water supply has become an important issue for many places. The state of California has its own unique issues with water supply given its drought history and massive population. This case study aims to look at the feasibility of widescale implementation of desalination to supplement and replace California’s supply of Colorado River Water. Using desalination to purify ocean saltwater into potable water is a unique form of water production that has its own advantages and disadvantages.
    • Where am I? Developing Spatial Thinking Skills

      Lukinbeal, Chris; Glueck, Mary (The University of Arizona., 2020-05)
      Middle school students are inundated with a plethora of geographic and GIS instructional resources; however, these students often lack the spatial thinking skills necessary to orient themselves in space and make meaningful geographic connections to the world. The question, “Where am I?”, is challenging without an understanding of spatial orientation, distance, and connections. Developing geographic literacy, even geographic media literacy, being able to locate and connect themselves in the world, is critical to their greater understandings. With this Master’s Project, I document a learner-centered exercise that develops spatial thinking skills. Spatial thinking combines spatial concepts, visualization, and reasoning. Spatial thinking reaches beyond answering “where” with a simple “here” to consider personal awareness of spatial orientation along with spatial connections, and pattern recognition at different spatial scales for problem-solving, decision-making, or policy purposes. Middle school, a time of growth in student understandings from concrete to abstract, is an optimal stage to advance and implement spatial thinking skills. Furthermore, curriculum standards focus on crosscutting concepts of patterns, change, and scale, providing ample opportunity for increasing spatial understandings. This research project involved a sixty-five student cohort that was guided through a geographic inquiry process to build spatial thinking skills and conceptual understandings by orienting themselves in the classroom, applying historical survey methods to create a grid map of the school courtyard, and extending this to GIS-based virtual transects of student-selected connections. Outcomes indicate considerable growth in student spatial thinking skills and understandings. Their knowledge will be applied to future Earth Science investigations ensuring strong engagement and greater spatial understandings. Keywords: Geographic education, reasoning, spatial connections, spatial orientation, visualization
    • Opioid Treatment Accessibility in Maricopa County, Arizona: A Network Analysis of Certified Opioid Treatment Programs and Buprenorphine Providers

      Sanchez-Trigueros, Fernando; Jacobs, Amanda (The University of Arizona., 2020-05)
      The United States opioid epidemic has been at the forefront of national response efforts. Despite tightening regulations on opioid prescribing, opioid addiction continues to be problematic. This study was designed to analyze opioid treatment accessibility in Maricopa County, Arizona, one of the most populous counties in the U.S. Based on data from the Substance Abuse and Mental Health Services Administration, 656 buprenorphine providers and 182 certified opioid treatment center locations in Maricopa County were incorporated to evaluate for treatment accessibility. Using GIS network analyst tools, distance to the closest treatment location was determined for each Maricopa County census tract. To further visualize accessibility, 2.5, 5, and 10-mile service areas were also located. The analysis demonstrated route distances increased moving outwards from the urban city areas of Maricopa County. Likewise, service areas also tended to branch outward from the urban city core. Spatially, rural areas are disproportionately impacted with regards to opioid treatment accessibility and populations living in these areas are at higher risk for encountering barriers to opioid treatment. These findings provide key information that may assist in population health outreach services and potentially useful data for public health policy efforts aimed at improving access to opioid addiction treatment.
    • Feng Shui and Sustainability

      Guo, Longhao; College of Architecture, Planning and Landscape Architecture; Bean, Jonathan; Iuliano, Joseph (The University of Arizona., 2020-05)
      Feng Shui, as ancient environmental art and science, provides a significant reference for many East Asians to choose the living environment and building environment. Nowadays, the concept of Feng Shui has gradually been introduced to some western countries. And some experts have found that the traditional Chinese Feng Shui theory is similar to the western concept of sustainable development in many ways (Mak and Ge, 2013). It can be seen from the analysis results of the building cases; the western sustainable design perspective focuses more on the physical characteristics of the building. However, the focus of Chinese Feng Shui is on the exterior and interior of the building space, and the connection between people and the surrounding living environment (Mak and Ge, 2010). Today’s interpretation of Feng Shui principles has incorporated Western concepts of sustainability, but some of these effects are difficult to measure (Mak and Ge, 2010). This situation also shows that if architects can consider the concept of Feng Shui when designing buildings, and combine it with Western sustainable design concepts, it will be conducive to enhancing the development and application of sustainability. Therefore, scientific research on Feng Shui and how to integrate it with the western concept of sustainable development requires more studies.
    • Assessment of Post-Fire Vegetation Recovery in Washington State Using Landsat and Geographical Data

      Sanchez Trigueros, Fernando; Hare, Leah (The University of Arizona., 2020-05)
      Consequences of wildfires often result in the loss or change of vegetation, causing a reduction of biodiversity and an increase in soil erosion. Studies aiming to understand the potential dynamics in vegetation regeneration after a fire can benefit restoration programs by defining probable contributing factors. This report considered environmental variables and their impact on fire recovery for six fires in Washington State over a five-year period. Variables included the differenced normalized burn ratio (dNBR), the normalized difference vegetation index (NDVI), land cover type, and topological variables. Regression modeling was performed using both Ordinary Least Squares (OLS) and Geographic Weighted Regression (GWR) to determine the best-fit model. Over the five-year period, mixed vegetation showed the highest recovery rate with varied rates for both forested and desert vegetation. OLS regression demonstrated that land cover had high multicollinearity with other variables and land cover factors, thus it was excluded from GWR calculations. The best-fit models revealed a positive relationship with pre-fire NDVI and burn severity for most fire locations, indicating an increase in revegetation based on an increase in burn severity. Topological variable slope had both positive and negative relationships with NDVI. R2 values calculated through GWR were between 0.85 and 0.98. As Washington State is a diverse, widespread area, this study serves as an initial step to understand the potential relationships between fire recovery and the contributing factors. Additional steps should be taken to focus on specific vegetation type and assessing longer recovery time.

      Sanchez-Trigueros, Fernando; Carini, Kiri (The University of Arizona., 2020-05)
      As urban areas grow around the world it is important to understand whether species biodiversity can adapt to these environs. Birds are known to be indicator species of ecosystem health. Furthermore, they are relatively easy to observe. In 2001, the Tucson Bird Count (TBC) was initiated to establish a long-term monitoring effort of bird biodiversity in urban Tucson. This project investigates long-term trends in the relative abundances of six common urban Tucson bird species across land classifications using the latest National Land Cover Database products, spanning 15 years. Using zonal statistics methods to aggregate bird count data within land cover classifications, this analysis determined mean relative abundance for six species over time and across land cover types. The results found that population abundance for these species has been relatively stable over time and consistent across land classifications. While overall bird species populations have declined in North America, in urban Tucson, birds are adapting. Further analysis of the TBC is needed to gain insight into species distribution and the complexities of urban habitats.
    • Hispanic Heritage Park: An Urban Park Proposal for Tucson's Mercado District

      Kramer, Sean; Schmidt, Erika; College of Architecture, Planning and Landscape Architecture; Stoker, Philip; Iuliano, Joseph (The University of Arizona., 2020-04-24)
      Located in the heart of Tucson’s most historic region, the Mercado District offers locals a unique, downtown-like atmosphere through its modern, yet Spanish colonial inspired, shopping plazas and residential complexes. Small businesses, boutiques, and eateries reside within the two popular marketplaces, which increase the tourism draw to this newly developed area. In addition, the Mercado District hosts the All Souls Procession, an annual event celebrating Día de los Muertos, which has made its mark on the community as a symbolic tradition for Tucson residents. Though the Mercado District has become a staple of Tucson and seen successful rates of attendance, it has yet to incorporate green space or a park for its guests to enjoy while visiting. Considering the cultural presence evident throughout the Mercado District, as well as the Hispanic influence present in Tucson’s history and local traditions, a cultural park within the district would not only encourage recreation within the Mercado District but also exemplify a sustainable, desert landscape. For my senior thesis, I am designing a Sonoran-inspired greenspace between W Cushing Street and W Congress Street, along the Santa Cruz River. Though the park will be represented digitally, the Hispanic Heritage Park will be a theoretical urban space that embodies the union of community and heritage, while also promoting natural resources, rainwater harvesting, and landscape design. Themes of sustainability, landscape architecture, and symbolism will be the basis of park design decisions, while specific infrastructure will be determined through research, observations, interviews, and a site analysis. Concept art will be created through hand-drawn sketches and using SketchUp. Ultimately, the Hispanic Heritage Park will allow guests to immerse themselves in a natural, aesthetic environment to commemorate and appreciate Tucson’s unique culture.
    • Adaptive Reuse of Shopping Malls - Case Study of the Foothills Mall in Tucson, AZ

      Brown, Ian; College of Architecture, Planning and Landscape Architecture; Iuliano, Joey (The University of Arizona., 2020-04-23)
      Dead and dying shopping malls are pervasive in the United States and abroad. What were once proxy town centers, created with the best of intentions during the expansion of cities into suburbs after World War II, are now often a blight on the communities they once served. Although malls remained vibrant hubs of activity for decades, drawing in ever more development around them, the model became diluted, focusing far too much on retail and profit. Ultimately, consumers tired of the mall and directed much of their spending to big box stores, the “category killers,” and their free time to a new “third place,” outdoor lifestyle centers. Shopping malls had weathered downturns in the past, but the advent of internet retailing dealt malls a final blow, one that would be unrecoverable while in their current form. How to deal with these properties is a question for landlords and communities in nearly every municipality in the nation. Adaptive reuse has emerged as a promising solution that utilizes the existing infrastructure, limits the demolition of the site, and renews the vibrant activity that once took place in these “town centers.” The Foothills Mall in Tucson, Arizona (currently referred to as “Uptown” on the Bourne Companies website) is a compelling case study for adaptive reuse. It is a prime example of a shopping mall that once flourished during the growth of a city and then went through two downturns into vacancy. A Specific Plan for mixed-use has already been approved by Pima County for its redevelopment, keeping portions of the existing property in-tact. The literature on shopping malls, their history, golden years, decline, and renewal is reviewed along with industry publications and the Specific Plan. Interviews with industry leaders add insights. Best practices are discussed to support, challenge, and guide future decisions.
    • Ideal Elephant Enclosure Design

      Kramer-Lazar, Sean; Hughes, Katie; Eppard, Jessica; College of Architecture, Planning and Landscape Architecture; Dimond, Kirk; Koprowski, John; Iuliano, Joey (The University of Arizona., 2020-04-23)
      This paper attempts to evaluate factors that would lead to an ideal elephant enclosure, providing the best experience for the guests, the keepers, and, most importantly, the elephants themselves. A literature review concerning the history of zoos, current enclosures, and elephant needs was conducted as well as observations at a local zoo and interviews with multiple keepers. Standards used by the Association of Zoos and Aquariums (AZA), which certifies zoos around the country to ensure the highest levels of welfare and being upheld, were used as a baseline for these ideals along with findings from these other sources. Keeper involvement was determined to be imperative to good enclosure design, as well as providing dynamic viewing for guests. Signage that was at a 45° angle rather than straight up and down, preferably that triggers an emotional response was most effective. Guests, on average, spent about 13.55 minutes moving through the exhibit. Observations for this study were only made at one zoo, limiting the broader implications.
    • The Fast Fashion Epidemic

      Iuliano, Joey; Wiebke, Adele; College of Architecture, Planning and Landscape Architecture; Zuniga, Adriana; Iuliano, Joey (The University of Arizona., 2020-04-22)
      The clothing industry is sneaky, polluting our world as we know it without batting an eye. When we think about pollution, our first thoughts go to burning coal and fossil fuels, not to what we put on our bodies every day. Therefore, environmental movements have not targeted the fashion industry directly. The Fast Fashion Epidemic is a global issue—not only does it affect our planet’s environment, through means of being the second-biggest consumer of water, responsible for the production of 20% of global wastewater and 10% of global carbon emissions while also filling our landfills with disregarded textiles and clothes that aren’t accepted at donation sites, but also the lives of everyday people. These fast fashion companies are producing clothing at an alarming rate, faster than the general fashion industry had ever seen before. To be able to make and sell clothes at such low prices can only mean the labor they are using to make said garments are getting unpaid, and are usually in unhealthy conditions. The purpose of this project is to explore why, currently, young adults who can (more specifically, high school/college students) consume fast fashion are consuming it at such an alarming rate, and what solutions can be made to solve this world crisis.
    • Sustainable Event Transportation

      Kramer, Sean; Shorey, Owen; College of Architecture, Planning and Landscape Architecture; Stoker, Philip; Iuliano, Joey (The University of Arizona., 2020-04-04)
      Each year, cities around the world host thousands of different events and sports, stirring passion and providing entertainment for individuals from all around. These events attract millions of people each year to specific areas in a city to partake in or watch an attraction. These types of occurrences are significant to many individuals as it provides them with an escape from their everyday lives. Sporting events and other events like festivals, fairs, and trade shows are crucial to many cities' economies. They attract outsiders from different parts of the world, and this creates a massive uptick in economic activity during those times due to the high volume of people. Unfortunately, while these lustrous events do wonders for the cities or areas they are held, they are not sustainable and can be harmful to the environment, the surrounding neighborhoods, and the air quality. Event locations, such as stadiums, are a pivotal part of the entertainment world that allows fans to connect with celebrities and professionals face to face. Drawing thousands of individuals to a specific location has a direct tie to the increase in the amount of traffic that takes place in that area (Pyun & Humphreys, 2017). Given that cars are emitters of carbon emissions (Environmental Protection Agency, 2018), the more traffic congestion that occurs in a compact area, the more carbon emissions that will be released. Among these emissions, carbon dioxide is known to be one of the driving factors in anthropogenic climate change (NASA, 2019). Currently, impacts from climate change such as the melting of polar ice caps, rising sea levels, and more extreme patterns of weather are occurring at higher rates (NASA, 2019). When an event takes place at an isolated location, traffic jams cause cars to idle while waiting to park or exit the stadium lot. When a vehicle is idling, it uses more fuel and will produce more emissions than when the car is moving. (U.S. Department of Energy, 2015). The emissions from idling cars directly tie into the reduced air quality of the surrounding area that can have harmful effects on human health and contribute to climate change. (Zeisel, 2017) This research project sets out to determine how the University of Arizona can improve on traffic revolving around games and events to reduce the impacts on the surrounding neighborhoods, air quality, and climate change. This is an important aspect of the sports and entertainment world that can go overlooked. These events offer an enormous opportunity to promote the idea of a healthier world to the attendees as the events play a key connecting role between the people and the things they love. To achieve this, it will be necessary first to understand how the fans currently get to the campus. Then by looking at how the University plans for the traffic and discussing with professionals, it will be possible to determine alternative strategies that could assist in bettering the traffic issues. If the University of Arizona can deter enough traffic during games successfully, then this will not only help the local environment but the citizens of Tucson as well.
    • Photocatalysis for Cleaner Cities

      Kramer, Sean; Houk, Ivory; College of Architecture, Planning and Landscape Architecture; Iuliano, Joey (The University of Arizona., 2020-04)
      This study has been done to show how the cleanliness of an environment has an effect on its use. This is being studied with relation to photocatalytic technologies that can be applied in vertical and horizontal structures, with the primary focus being on concrete. This studies the use of two different environments and how waste collection affects the way that it is used, with attention paid to how the use of this technology could alter this. The findings showed that areas that are heavily trafficked are often more cared for by users with respect shown through waste disposal. This study determined what questions still remain about this technology and what research is ongoing with regard to this.
    • Molecular Strategies to Distinguish Key Subphenotypes in Sarcoidosis

      Garcia, Joe G. N.; Casanova, Nancy Gonzalez; Gomez, Jorge; Culver, Melanie; Bime, Christian; Sun, Xiaoguang (The University of Arizona., 2020)
      Sarcoidosis is a multisystemic disease of unknown etiology and unpredictable course, characterized by histopathological conglomerates of inflammatory cells defined as granulomas. These lesions however are non-pathognomonic, and in the absence of an identifiable etiologic agent, there are not specific diagnostic test for sarcoidosis. Despite the variable course of sarcoidosis, the lungs are affected in 90 percent of the cases. Approximately 25-30% of sarcoidosis patients progress to a complicated phenotype with progressive disease, leading to pulmonary fibrosis and organ dysfunction with increased mortality. These cases are in desperate need for biomarkers, conventional sarcoidosis biomarkers have proven to be insufficiently sensitive for implementation in routine clinical care. In this dissertation, I focused on the use of alternate strategies for biomarkers development utilizing genomic base approaches based on high-throughput molecular assays to characterize genotype, gene expression, and epigenetics that define sarcoidosis subphenotypes. Our results demonstrated that the integration of expression quantitative loci (eQTL) studies increase the power of Genome-wide association studies (GWAS). We identified SNPs that were associated to complicated sarcoidosis in African Americans (AA) and in European Americans (EA), and then we validated these SNPs by Massarray. Furthermore, at the transcript level, we identified the Peripheral Mononuclear Cells (PBMCs) responses to TNF-α exposure, a cytokine involved in the initiation of granulomas and progression of fibrosis in sarcoidosis and identified a differential dysregulation in pathways unique to complicated sarcoidosis. At the transcriptome level, we profiled microdisected granulomas from lung and lymph nodes, and identified a hub of genes that were dysregulated only in sarcoidosis in both compartments. Additionally, we compared the genomic profile of these granulomas in Sarcoidosis vs Tuberculosis (TB) and Coccidioidomycosis. We corroborated that some genes previously suggested as potential sarcoidosis markers were also present in fungal or mycobacterium granulomas, pointing to a common mechanistic origin. We also demonstrated a strong similarity at the transcriptional level between Sarcoidosis and TB. The contribution of the epigenetic mechanisms to the clinical presentation of sarcoidosis was assessed through DNA methylation analysis, complicated sarcoidosis reveled a hypo-methylated pattern in genes within HLA complex while the miRNA analysis derived a molecular signature consisting of 17 protein-coding genes, potentially regulated by 8 miRNAs dysregulated in complicated sarcoidosis.
    • Geographic and Racial Disparities in Mortality of Dialysis Patients

      Calhoun, Elizabeth A.; Mohan, Prashanthinie; Roy-Chaudhury, Prabir; Barraza, Leila Fs; Gilliland, Stephen (The University of Arizona., 2020)
      BACKGROUND: The incidence rate and hospitalization rate for patients with End Stage Renal Disease (ESRD) vary across different counties in the U.S. Little information is available on how geography can impact patient mortality through county health status and gaps in supply and demand for hemodialysis services. METHODS: This is a retrospective cohort study where adult patients who initiated in-center hemodialysis between 2007 and 2016 and recorded in the United States Renal Data System (USRDS) were assessed for survival time and mortality rate. The primary exposure variable in Aim 1 was the overall county health status (Most Healthy vs Least Healthy) based on the health factor ranks published by County Health Rankings & Roadmap (CHR&R). The primary exposure variable for Aim 2 was the supply-demand gap for hemodialysis services as measured by the patient-station ratio for each county. The primary exposure variable for Aim 3 was the change in the number of dialysis stations between 2011 and 2016 for each county. Kaplan-Meier estimate used to compute the median survival time and Cox regression analysis was used to compute the hazard rate (HR) for mortality after adjusting for various confounders. RESULTS: Most Healthy counties in the U.S. are likely to be larger urban counties with predominantly white and older patients. On the contrary, Least Healthy counties are comparatively more rural and smaller counties with a higher percentage of African American population, more unemployed and Medicaid patients. Patients residing in Most Healthy counties (HR = 0.899, 95% CI 0.825,0.979) had a lower hazard rate (HR) for mortality compared to patients living in Least Healthy Counties (p value = 0.0143). In Aim 2, counties in Category 1 (counties with no hemodialysis stations), Category 2.1 (underutilized HD stations with population <50,000) and Category 2.2 (underutilized HD stations with population 50,000) had higher HR compared to the reference Category 3. However, when stratified by age and race, the HR was statistically significant for Blacks only for Category 2.2 for all age groups (HR = 1.11, 95% CI 1.06,1.16) and for Whites for Category 1 (aged 40 – 79; HR=1.1) and Category 2.2 (aged 65 – 79; HR=1.11). In Aim 3, counties with No Change had a marginally higher hazard rate (HR=1.04, 95% CI 1.02, 1.07) compared to counties with an increase in dialysis stations. Race was a significant confounder but not an effect modifier to this association (p-value 0.2942). CONCLUSION: County health status and lack of hemodialysis facilities affects survival of ESRD patients. Additionally, patients residing in some suburban counties or smaller metros had a higher hazard rate for mortality despite excess supply of dialysis stations. It is important for care providers and local health officials to understand the health factor profile and spatial distribution of dialysis stations in their county to help ESRD patients navigate barriers to care, reduce rates of dialysis withdrawal, and improve mortality outcomes.
    • Cancer Capacity and Resources in Rural Arizona

      Calhoun, Elizabeth A.; Lent, Adrienne; Jacobs, Elizabeth T.; Barraza, Leila (The University of Arizona., 2020)
      Background: Cancer is the second leading cause of death in the U.S. Rural urban cancer disparities exist nationally and in Arizona. Previous studies on the availability of rural cancer services are cancer-specific, limited to specific points along the cancer care continuum (e.g., screening, diagnosis, or treatment), or require updating to capture the current landscape as it relates to rural health. This study explored the following three aims: 1) Describe the availability of cancer capacity and services for breast, cervical, colorectal and lung cancer across the cancer care continuum in low populous counties in Arizona; 2) Evaluate the association between breast cancer capacity and resources with breast cancer incidence and mortality; and 3) Provide policy recommendations focused on increasing capacity and resources in low populous, rural counties in Arizona. Methods: For Aim 1, a cancer capacity and resources survey was developed and distributed to healthcare organizations operating outside of Arizona’s largest population centered counties, Maricopa and Pima. Numbers of healthcare providers were pulled from the Center for Medicare and Medicaid Services. Numbers of clinical sites and healthcare providers were converted to county-level per capita rates. Rural Urban Continuum (RUC) codes were used to designate county metropolitan status. County demographic information from the U.S. Census Bureau, income data from the US Bureau of Economic Analysis, and unemployment rates from the US Department of Labor were included. Descriptive statistics were used to summarize the results. A student’s t-test was used to evaluate differences between rural and urban counties. For Aim 2, the Arizona Department of Health Services Cancer Registry provided county level cancer incidence and death rates from 2010 through 2016. Linear regression was used to evaluate the association between rural status and breast cancer capacity and services with breast cancer incidence and mortality rates. For Aim 3, current US federal and state level policies focused on increasing the rural workforce were reviewed. Results: Out of Arizona’s 15 counties, 13 were represented. Six were urban (RUC codes 1 – 3) and seven were rural (RUC codes 4 – 7). Urban counties had a larger average population (216,773) than rural counties (49,507) (p-value = 0.01). Rural counties had more per capita clinical sites (20.4) than urban counties (8.9) (p-value = 0.02). Rural counties had more per capita cervical cancer screening sites (18.9) than urban counties (7) (p-value = 0.02) and rural counties had more per capita colorectal cancer screening sites (15.7) than urban counties (2.5) (p-value = 0.02). Urban counties had more per capita gastroenterologists (2.2) than rural counties (0) (p-value = 0.02) and urban counties had more per capita pathologists (1.0) than rural counties (0) (p-value = <0.01). Rural counties had zero medical oncologists. Per capita, rural counties with RUC codes 4 and 6 had hematology and oncology physicians (0.3, 2.5) and radiologists (2.8, 6.0) but those with RUC code 7 had zero. Although not significantly different, rural counties with RUC code 6 had three times as many per capita registered nurses (306.7) than urban counties (90.8). Rural county status was associated with a decrease in breast cancer incidence (β = -20.1, 95% CI: -37.2, 3.1). There was no association between breast cancer incidence and county per capita sites providing breast cancer screening (β = -8.8, 95% CI: -23.9, 6.9), diagnosis (β = -5.2, 95% CI: -22.2, 11.7), treatment (β = -6.5, 95% CI: -23.2, 10.2), and all three services (β = -8.0, 95% CI: -23.9, 7.9) or county per capita primary care physicians (β = 0.0, 95% CI: -0.54, 0.48), hematology oncology physicians (β = -0.9, 95% CI: -15.7, 13.8), medical oncology physicians (β = 35.2, 95% CI: -22.7, 93.0), OBGYN physicians (β = -0.5, 95% CI: -4.2, 3.2), radiologists (β = -0.2, 95% CI: -6.8, 6.4), and surgeons (β = 1.6, 95% CI: -3.1, 6.3). In the unadjusted model, rural RUC codes four (β = -24.1, 95% CI: -41.8, -6.4) and six (β = -32.6, 95% CI: -53.0, -12.2) were associated with breast cancer incidence. There was no association between breast cancer incidence and RUC code 7 (β = -1.8, 95% CI: -22.3, 18.6). In the model adjusted for race (percent of the county population that’s Hispanic) and Ethnicity (percent of the county population that’s American Indian and Alaska Native), RUC codes four (β = -19.0, 95% CI: -37.7, -0.4) and six (β = -32.6, 95% CI: -56.0, -7.9) were associated with breast cancer incidence. There was no association between breast cancer mortality and rural county status (β = -1.1, 95% CI: -7.7, 5.6), county per capita sites providing breast cancer screening (β = -0.2, 95% CI: -4.2, 3.8), diagnosis (β = 0.4, 95% CI: -3.8, 4.6), treatment (β = 0.4, 95% CI: -3.9, 4.6), all three services (0.2, -3.9, 4.3) or county per capita primary care physicians (β = 0.0, 95% CI: -0.1, 0.0), hematology oncology physicians (β = -1.6, 95% CI: -5.3, 2.1), medical oncology physicians (β = -0.9, 95% CI: -17.2, 15.3), OBGYN physicians (β = -0.6, 95% CI: -1.5, 0.3), radiologists (β = -0.7, 95% CI: -2.4, 1.0), and surgeons (β = -0.1, 95% CI: -1.4, 1.2). Conclusions: While rural counties may have more physical infrastructure, they lack specialists integral to providing cancer services. Non-physician clinical providers may be more prevalent in rural areas and represent opportunities for improving cancer care. Compared to urban counties, rural county status was associated with lower breast cancer incidence rates but not associated with breast cancer death. The number of sites delivering breast cancer services and physicians were not associated with breast cancer incidence or mortality at the county level. Other factors may contribute to rural urban differences in breast cancer incidence. Federal and state level policies have been effective in increasing the rural healthcare workforce. However, opportunities for improving rural cancer care through policies and programs exist. Improved data collection and availability from state level workforce data and the FDA mammography database can help improve cancer capacity research. Increased exposure to rural locations during residency, transformation of GME payment, and expansion of loan repayment and scholarship programs may help increase the number of specialists delivering cancer care in rural Arizona and nationally. Increased training opportunities and the scope of work expansions for non-physician clinicians and advanced practice providers may help improve the delivery of cancer prevention and treatment services in rural areas that lack specialist physicians. Future research should explore these factors as well as the association between cancer capacity and resources at a more local level since Arizona counties can be a heterogeneous unit of observation.