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Background: Primary care practices are responding to calls to incorporate patients' social risk factors, such as housing, food, and economic insecurity, into clinical care. Healthcare likely relies on the expertise and resources of community-based organizations to improve patients' social conditions, yet little is known about the referral process.Objective: To characterize referrals to community-based organizations by primary care practices.Design: Qualitative study using semi-structured interviews with healthcare administrators responsible for social care efforts in their organization.Participants: Administrators at 50 diverse US healthcare organizations with efforts to address patients' social risks.Main Measures: Approaches used in primary care to implement social needs referral to community-based organizations.Results: Interviewed administrators reported that social needs referrals were an essential element in their social care activities. Administrators described the ideal referral programs as placing limited burden on care teams, providing patients with customized referrals, and facilitating closed-loop referrals. We identified three key challenges organizations experience when trying to implement the ideal referrals program: (1) developing and maintaining resources lists; (2) aligning referrals with patient needs; and (3) measuring the efficacy of referrals. Collectively, these challenges led to organizations relying on staff to manually develop and update resource lists and, in most cases, provide patients with generic referrals. Administrators not only hoped that referral platforms may help overcome some of these barriers, but also reported implementation challenges with platforms including inconsistent buy-in and use across staff; integration with electronic health records; management and prioritization of resources; and alignment with other organizations in their market.Conclusion and Relevance: Referrals to community-based organizations were used in primary care to improve patients' social conditions, but despite strong motivations, interviewees reported challenges providing tailored and up-to-date information to patients. [ABSTRACT FROM AUTHOR]

Racial-ethnic minorities receive lower quality and intensity of health care compared with whites across a wide range of preventive, diagnostic, and therapeutic services and disease entities. These disparities in health care contribute to continuing racial-ethnic disparities in the burden of illness and death. Several national medical organizations and the Institute of Medicine have issued position papers and recommendations for the elimination of health care disparities. However, physicians in practice are often at a loss for how to translate these principles and recommendations into specific interventions in their own clinical practices. This paper serves as a blueprint for translating principles for the elimination of racial-ethnic disparities in health care into specific actions that are relevant for individual clinical practices. We describe what is known about reducing racial-ethnic disparities in clinical practice and make recommendations for how clinician leaders can apply this evidence to transform their own practices. [ABSTRACT FROM AUTHOR]

Objectives: The objective of this paper was to describe primary care prescribers' perspectives on electronic prescribing drug alerts at the point of prescribing.Design: We used a mixed-method study which included clinician surveys (web-based and paper) and focus groups with prescribers and staff.Participants: Prescribers (n = 157) working in one of 64 practices using 1 of 6 e-prescribing technologies in 6 US states completed the quantitative survey and 276 prescribers and staff participated in focus groups.Measurements: The study measures self-reported frequency of overriding of drug alerts; open-ended responses to: "What do you think of the drug alerts your software generates for you?"Results: More than 40% of prescribers indicated they override drug-drug interactions most of the time or always (range by e-prescribing system, 25% to 50%). Participants indicated that the software and the interaction alerts were beneficial to patient safety and valued seeing drug-drug interactions for medications prescribed by others. However, they noted that alerts are too sensitive and often unnecessary. Participant suggestions included: (1) run drug alerts on an active medication list and (2) allow prescribers to set the threshold for severity of alerts.Conclusions: Primary care prescribers recognize the patient safety value of drug prescribing alerts embedded within electronic prescribing software. Improvements to increase specificity and reduce alert overload are needed. [ABSTRACT FROM AUTHOR]

Background: The Veterans Health Administration (VA) is the largest integrated health system in the US and provides access to comprehensive primary care. Women Veterans are the fastest growing segment of new VA users, yet little is known about the characteristics of those who routinely access VA primary care in general or by age group.Objective: Describe healthcare needs, utilization, and preferences of women Veterans who routinely use VA primary care.Participants: 1,391 women Veterans with 3+ primary care visits within the previous year in 12 VA medical centers (including General Primary Care Clinics, General Primary Care Clinics with designated space for women, and Comprehensive Women's Health Centers) in nine states.Methods: Cross-sectional survey (45% response rate) of sociodemographic characteristics, health status (including chronic disease, mental health, pain, and trauma exposure), utilization, care preferences, and satisfaction. Select utilization data were extracted from administrative data. Analyses were weighted to the population of routine users and adjusted for non-response in total and by age group.Key Results: While 43% had health coverage only through VA, 62% received all primary care in VA. In the prior year, 56% used VA mental healthcare and 78% used VA specialty care. Common physical health issues included hypertension (42%), elevated cholesterol (39%), pain (35%), and diabetes (16%). Many screened positive for PTSD (41%), anxiety (32%), and depression (27%). Chronic physical and mental health burdens varied by age. Two-thirds (62%) had experienced military sexual trauma. Respondents reported satisfaction with VA women's healthcare and preference for female providers.Conclusions: Women Veterans who routinely utilize VA primary care have significant multimorbid physical and mental health conditions and trauma histories. Meeting women Veterans' needs across the lifespan will require continued investment in woman-centered primary care, including integrated mental healthcare and emphasis on trauma-informed, age-specific care, guided by women's provider preferences. [ABSTRACT FROM AUTHOR]

With the impending surge in the number of older adults, primary care clinicians will increasingly need to manage the care of vulnerable elders. Caring for vulnerable elders is complex because of their wide range of health goals and the interdependence of medical care and community supports needed to achieve those goals. In this article, we identify ways a primary care practice can reorganize to improve the care of vulnerable elders. We begin by identifying important outcomes for vulnerable elders and three key processes of care (communication, developing a personal care plan for each patient, and care coordination) needed to achieve these outcomes. We then describe two delivery models of primary care for vulnerable elders--co-management, and augmented primary care. Finally, we discuss how the physical plant, people, workflow management, and community linkages in a primary care practice can be restructured to better serve these patients. [ABSTRACT FROM AUTHOR]

Background: Practice facilitation is an implementation strategy used to build practice capacity and support practice changes to improve health care outcomes. Yet, few studies have investigated how practice facilitation strategies are tailored to different primary care contexts.Objective: To identify contextual factors that drive facilitators' strategies to meet practice improvement goals, and how these strategies are tailored to practice context.Design: Semi-structured, qualitative interviews analyzed using inductive (open coding) and deductive (thematic) approaches. This study was conducted as part of a larger study, HealthyHearts New York City, which evaluated the impact of practice facilitation on adoption of cardiovascular disease prevention and treatment guidelines.Participants: 15 facilitators working in two practice contexts: small independent practices (SIPs) and Federally Qualified Health Centers (FQHCs).Main Measures: Strategies facilitators use to support and promote practice changes and contextual factors that impact this approach.Key Results: Contextual factors were described similarly across settings and included the policy environment, patient needs, site characteristics, leadership engagement, and competing priorities. We identified four facilitation strategies used to tailor to contextual factors and support practice change: (a) remain flexible to align with practice and organizational priorities; (b) build relationships; (c) provide value through information technology expertise; and (d) build capacity and create efficiencies. Facilitators in SIPs and FQHCs described using the same strategies, often in combination, but tailored to their specific contexts.Conclusions: Despite significant infrastructure and resource differences between SIPs and FQHCs, the contextual factors that influenced the facilitator's change process and the strategies used to address those factors were remarkably similar. The findings emphasize that facilitators require multidisciplinary skills to support sustainable practice improvement in the context of varying complex health care delivery settings. [ABSTRACT FROM AUTHOR]

Background: Workforce projections indicate a potential shortage of up to 31,000 adult primary care providers by the year 2025. Approximately 80 % of internal medicine residents and nearly two-thirds of primary care internal medicine residents do not plan to have a career in primary care or general internal medicine.Objective: We aimed to explore contextual and programmatic factors within primary care residency training environments that may influence career choices.Design: This was a qualitative study based on semi-structured, in-person interviews.Participants: Three primary care internal medicine residency programs were purposefully selected to represent a diversity of training environments. Second and third year residents were interviewed.Approach: We used a survey guide developed from pilot interviews and existing literature. Three members of the research team independently coded the transcripts and developed the code structure based on the constant comparative method. The research team identified emerging themes and refined codes. ATLAS.ti was used for the analysis.Key Results: We completed 24 interviews (12 second-year residents, and 12 third-year residents). The age range was 27-39 years. Four recurrent themes characterized contextual and programmatic factors contributing to residents' decision-making: resident expectations of a career in primary care, navigation of the boundary between social needs and medical needs, mentorship and perceptions of primary care, and structural features of the training program.Conclusions: Addressing aspects of training that may discourage residents from careers in primary care such as lack of diversity in outpatient experiences and resident frustration with their inability to address social needs of patients, and strengthening aspects of training that may encourage interests in careers in primary care such as mentorship and protected time away from inpatient responsibilities during primary care rotations, may increase the proportion of residents enrolled in primary care training programs who pursue a career in primary care. [ABSTRACT FROM AUTHOR]

Background: The healthcare system is ill-equipped to meet the needs of adults on the autism spectrum.Objective: Our goal was to use a community-based participatory research (CBPR) approach to develop and evaluate tools to facilitate the primary healthcare of autistic adults.Design: Toolkit development included cognitive interviewing and test-retest reliability studies. Evaluation consisted of a mixed-methods, single-arm pre/post-intervention comparison.Participants: A total of 259 autistic adults and 51 primary care providers (PCPs) residing in the United States.Interventions: The AASPIRE Healthcare toolkit includes the Autism Healthcare Accommodations Tool (AHAT)-a tool that allows patients to create a personalized accommodations report for their PCP-and general healthcare- and autism-related information, worksheets, checklists, and resources for patients and healthcare providers.Main Measures: Satisfaction with patient-provider communication, healthcare self-efficacy, barriers to healthcare, and satisfaction with the toolkit's usability and utility; responses to open-ended questions.Key Results: Preliminary testing of the AHAT demonstrated strong content validity and adequate test-retest stability. Almost all patient participants (>94 %) felt that the AHAT and the toolkit were easy to use, important, and useful. In pre/post-intervention comparisons, the mean number of barriers decreased (from 4.07 to 2.82, p < 0.0001), healthcare self-efficacy increased (from 37.9 to 39.4, p = 0.02), and satisfaction with PCP communication improved (from 30.9 to 32.6, p = 0.03). Patients stated that the toolkit helped clarify their needs, enabled them to self-advocate and prepare for visits more effectively, and positively influenced provider behavior. Most of the PCPs surveyed read the AHAT (97 %), rated it as moderately or very useful (82 %), and would recommend it to other patients (87 %).Conclusions: The CBPR process resulted in a reliable healthcare accommodation tool and a highly accessible healthcare toolkit. Patients and providers indicated that the tools positively impacted healthcare interactions. The toolkit has the potential to reduce barriers to healthcare and improve healthcare self-efficacy and patient-provider communication. [ABSTRACT FROM AUTHOR]

Background: It is unclear if primary care physicians are following guidelines or using other patient characteristics and factors to determine when to perform spirometry in patients at risk for COPD. It is also unclear to what degree a diagnosis of COPD is accurately reflected by spirometry results.Objectives: To examine characteristics associated with use of spirometry in primary care for patients with increased risk for COPD and to determine the accuracy of COPD diagnosis in patients with spirometry.Design: Retrospective cohort study.Subjects: A cohort that met the following criteria was identified: ≥35 years of age; ≥ 2 primary care visits in internal medicine clinic in 2007; at least one respiratory or smoking cessation medication, or diagnosis of COPD or shortness of breath or dyspnea in 2007.Main Measures: Medical records of all primary care physician visits prior to the time of inclusion in 2007 were reviewed. Data on patient demographics, co-morbidities, respiratory medication use, presence of symptoms, history of tobacco use, and pulmonary function tests were extracted.Key Results: A total 1052 patients were identified. Dyspnea on exertion (Adjusted odds ratio (AOR) 1.52 [95% CI 1.06-2.18]) and chronic cough (AOR 1.71 [1.07-2.72]) were the only chronic symptoms associated with use of spirometry. Current (AOR 1.54 [0.99-2.40]) or past smoking (AOR 1.09 [0.72-1.65]) status were not associated with use of spirometry. Of the 159 patients with a diagnosis of COPD, 93 (58.5%) met GOLD criteria and 81(50.9%) met lower limit of normal (LLN) criteria for COPD.Conclusion: Clinicians use spirometry more often among patients with symptoms suggestive of COPD but not more often among patients with current or past tobacco use. For patients who had a spirometry and a diagnosis of COPD, primary care physicians were accurate in their diagnosis only half of the time. [ABSTRACT FROM AUTHOR]

Background: Practice system tools improve chronic disease care, but are generally lacking for the care of depression in most primary care settings.Objective: To describe the frequency of various depression-related practice system tools among Minnesota primary care clinics interested in improving depression care.Design: Cross-sectional survey.Participants: Physician leaders of 82 clinics in Minnesota.Main Measures: A survey including practice systems recommended for care of depression and chronic conditions, each scored on a 100-point scale, and the clinic's priority for improving depression care on a 10-point scale.Key Results: Fewer practice systems tools were present and functioning well for depression care (score = 24.4 [SD 1.6]) than for the care of chronic conditions in general (score = 43.9 [SD 1.6]), p < 0.001. The average priority for improving depression care was 5.8 (SD 2.3). There was not a significant correlation between the presence of practice systems for depression or chronic disease care and the priority for depression care except for a modest correlation with the depression Decision Support subscale (r = 0.29, p = 0.008). Certain staffing patterns, a metropolitan-area clinic location, and the presence of a fully functional electronic medical record were associated with the presence of more practice system tools.Conclusions: Few practice system tools are in place for improving depression care in Minnesota primary care clinics, and these are less well-developed than general chronic disease practice systems. Future research should focus on demonstrating whether implementing these tools for depression care results in much-needed improvements in care for patients with depression. [ABSTRACT FROM AUTHOR]

Background: The quality of health care for older Americans with chronic conditions is suboptimal.Objective: To evaluate the effects of "Guided Care" on patient-reported quality of chronic illness care.Design: Cluster-randomized controlled trial of Guided Care in 14 primary care teams.Participants: Older patients of these teams were eligible to participate if, based on analysis of their recent insurance claims, they were at risk for incurring high health-care costs during the coming year. Small teams of physicians and their at-risk older patients were randomized to receive either Guided Care (GC) or usual care (UC).Intervention: "Guided Care" is designed to enhance the quality of health care by integrating a registered nurse, trained in chronic care, into a primary care practice to work with 2-5 physicians in providing comprehensive chronic care to 50-60 multi-morbid older patients.Measurements: Eighteen months after baseline, interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care (PACIC) survey by telephone. Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care.Results: Of the 13,534 older patients screened, 2,391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 18 months, 95.3% and 92.2% of the GC and UC recipients who remained alive and eligible completed interviews. Compared to UC recipients, GC recipients had twice greater odds of rating their chronic care highly (aOR = 2.13, 95% CI = 1.30-3.50, p = 0.003).Conclusion: Guided Care improves self-reported quality of chronic health care for multi-morbid older persons. [ABSTRACT FROM AUTHOR]

Background: The Patient-Centered Medical Home (PCMH), a popular model for primary care reorganization, includes several structural capabilities intended to enhance quality of care. The extent to which different types of primary care practices have adopted these capabilities has not been previously studied.Objective: To measure the prevalence of recommended structural capabilities among primary care practices and to determine whether prevalence varies among practices of different size (number of physicians) and administrative affiliation with networks of practices.Design: Cross-sectional analysis.Participants: One physician chosen at random from each of 412 primary care practices in Massachusetts was surveyed about practice capabilities during 2007. Practice size and network affiliation were obtained from an existing database.Measurements: Presence of 13 structural capabilities representing 4 domains relevant to quality: patient assistance and reminders, culture of quality, enhanced access, and electronic health records (EHRs).Main Results: Three hundred eight (75%) physicians responded, representing practices with a median size of 4 physicians (range 2-74). Among these practices, 64% were affiliated with 1 of 9 networks. The prevalence of surveyed capabilities ranged from 24% to 88%. Larger practice size was associated with higher prevalence for 9 of the 13 capabilities spanning all 4 domains (P < 0.05). Network affiliation was associated with higher prevalence of 5 capabilities (P < 0.05) in 3 domains. Associations were not substantively altered by statistical adjustment for other practice characteristics.Conclusions: Larger and network-affiliated primary care practices are more likely than smaller, non-affiliated practices to have adopted several recommended capabilities. In order to achieve PCMH designation, smaller non-affiliated practices may require the greatest investments. [ABSTRACT FROM AUTHOR]

Background: Effective treatments can be rendered useless by poor patient recall of treatment instructions. Studies suggest that patients forget a great deal of important information and that recall can be increased through recall-promoting behaviors (RPBs) like repetition or summarization.Objective: To assess how frequently RPBs are used in primary care, and to reveal how they might be applied more effectively.Design: Recordings of 49 unannounced standardized patient (SP) visits were obtained using hidden audiorecorders. All SPs presented with typical gastroesophageal reflux disease symptoms. Transcripts were coded for treatment recommendations and RPBs.Participants: Forty-nine primary care physicians.Results: Of 1,140 RPBs, 53.7% were repetitions, 28.2% were communication of the rationale for a treatment, 11.7% were categorizations of treatments (i.e., stating that a treatment could be placed into a treatment category, such as medication-related or lifestyle-related categories), and 3.8% were emphasis of a recommendation's importance. Physicians varied substantially in their use of most RPBs, although no physicians summarized or asked patients to restate recommendations. The number of RPBs was positively correlated with visit length.Conclusions: Primary care physicians apply most RPBs inconsistently, do not utilize several RPBs that are particularly helpful, and may use RPBs inefficiently. Simple principles guiding RPB use may help physicians apply these communication tools more effectively. [ABSTRACT FROM AUTHOR]

Background: We conducted a cluster randomized controlled trial to examine the effectiveness of computerized decision support (CDS) designed to improve hypertension care and outcomes in a racially diverse sample of primary care patients.Methods: We randomized 2,027 adult patients receiving hypertension care in 14 primary care practices to either 18 months of their physicians receiving CDS for each hypertensive patient or to usual care without computerized support for the control group. We assessed prescribing of guideline-recommended drug therapy and levels of blood pressure control for patients in each group and examined if the effects of the intervention differed by patients' race/ethnicity using interaction terms.Measurements and Main Results: Rates of blood pressure control were 42% at baseline and 46% at the outcome visit with no significant differences between groups. After adjustment for patients' demographic and clinical characteristics, number of prior visits, and levels of baseline blood pressure control, there were no differences between intervention groups in the odds of outcome blood pressure control. The use of CDS to providers significantly improved Joint National Committee (JNC) guideline adherent medication prescribing compared to usual care (7% versus 5%, P < 0.001); the effects of the intervention remained after multivariable adjustment (odds ratio [OR] 1.39 [CI, 1.13-1.72]) and the effects of the intervention did not differ by patients' race and ethnicity.Conclusions: CDS improved appropriate medication prescribing with no improvement in disparities in care and overall blood pressure control. Future work focusing on improvement of these interventions and the study of other practical interventions to reduce disparities in hypertension-related outcomes is needed. [ABSTRACT FROM AUTHOR]

Background: Patient-administered computerized questionnaires represent a novel tool to assist primary care physicians in the delivery of preventive health care.Objective: The aim of this study was to assess patient-reported ease of use with a self-administered tablet computer-based questionnaire in routine clinical care.Design: All patients seen in a university-based primary care practice were asked to provide routine screening information using a touch-screen tablet computer-based questionnaire. Patients reported difficulty using the tablet computer after completion of their first questionnaire.Patients: Ten thousand nine hundred ninety-nine patients completed the questionnaire between January 2004 and January 2006.Measurements: We calculated rates of reporting difficulty (no difficulty, some difficulty, or a lot of difficulty) using the tablet computers based on patient age, sex, race, educational attainment, marital status, and number of comorbid medical conditions. We constructed multivariable ordered logistic models to identify predictors of increased self-reported difficulty using the computer.Results: The majority of patients (84%) reported no difficulty using the tablet computers to complete the questionnaire, with only 3% reporting a lot of difficulty. Significant predictors of reporting more difficulty included increasing age [odds ratio (OR) 1.05, 95% confidence interval (CI) 1.05-1.05)]; Asian race (OR 2.3, 95% CI 1.8-2.9); African American race (OR 1.4, 95% CI 1.2-1.6); less than a high school education (OR 3.0, 95% CI 2.6-3.4); and the presence of comorbid medical conditions (1-2: OR 1.3, 95% CI 1.2-1.5; > or =3: OR 1.7 95% CI 1.5-2.1).Conclusions: The majority of primary care patients reported no difficulty using a self-administered tablet computer-based questionnaire. While computerized questionnaires present opportunities to collect routine screening information from patients, attention must be paid to vulnerable groups. [ABSTRACT FROM AUTHOR]

Background: Although multiple co-occurring chronic illnesses within the same individual are increasingly common, few studies have examined the challenges of multimorbidity from the patient perspective.Objective: The aim of this study is to examine the self-management learning needs and willingness to see non-physician providers of patients with multimorbidity compared to patients with single chronic illnesses.Design: This research is designed as a cross-sectional survey.Participants: Based upon ICD-9 codes, patients from a single VHA healthcare system were stratified into multimorbidity clusters or groups with a single chronic illness from the corresponding cluster. Nonproportional sampling was used to randomly select 720 patients.Measurements: Demographic characteristics, functional status, number of contacts with healthcare providers, components of primary care, self-management learning needs, and willingness to see nonphysician providers.Results: Four hundred twenty-two patients returned surveys. A higher percentage of multimorbidity patients compared to single morbidity patients were "definitely" willing to learn all 22 self-management skills, of these only 2 were not significant. Compared to patients with single morbidity, a significantly higher percentage of patients with multimorbidity also reported that they were "definitely" willing to see 6 of 11 non-physician healthcare providers.Conclusions: Self-management learning needs of multimorbidity patients are extensive, and their preferences are consistent with team-based primary care. Alternative methods of providing support and chronic illness care may be needed to meet the needs of these complex patients. [ABSTRACT FROM AUTHOR]

Background: Language barriers in medical care are a large and growing problem in the United States. Most research has focused on how language barriers affect patients. Less is known of the physician perspective and the efforts they are making to overcome these barriers.Objective: To learn about current approaches to communicating with limited English-proficient (LEP) patients and the associated financial and nonfinancial constraints that private practice physicians and managers perceive in providing these services.Design: Computer-assisted telephone focus groups with open-ended discussion guide.Setting: Small private practices in geographic areas that have experienced recent dramatic increases in LEP populations.Participants: Primary care physicians, specialists, and practice managers.Approach: Focus group transcripts were systematically coded using grounded theory analysis. The research team then identified common themes that arose across the groups.Results: Citing the cost, inaccessibility, and inconvenience of using professional interpreters, physicians commonly used family and friends as interpreters. Few recalled any actual experience with professional interpreters or were well-informed about the cost of their services. Physicians and office managers voiced uniform concern about how language barriers impede quality and safety of patient care and increased malpractice risk.Conclusions: Health care providers in private practice recognize the importance of overcoming language barriers. However, perceived barriers to implementing cost-effective strategies to these barriers are high. Physicians in private practice would benefit from information about how to best overcome language barriers in their practices efficiently and affordably. [ABSTRACT FROM AUTHOR]

Background: The UK has a universal health care system that is free at the point of access. Over the past decade, the UK government has implemented an ambitious agenda of quality improvement initiatives in chronic disease management.Objective: To assess the quality of diabetes care and intermediate clinical outcomes within a multiethnic population after a sustained period of investment in quality improvement.Design: Population based cross-sectional survey, using electronic general practice records, carried out between November 2005 and January 2006.Patients: Seven thousand six hundred five adults (>or=18 years) with diabetes registered with 32 primary care practices.Measurements: Percentage achievement by ethnic group (black, south Asian, or white) of the quality indicators for diabetes in a new pay-for performance contract.Results: There were only modest variations in recording of process measures of care between ethnic groups, with no significant differences in recent measurement of blood pressure, HbA1c, cholesterol, micro-albuminuria, creatinine, or retinopathy screening attendance. Blacks and south Asians were significantly less likely to meet all three national treatment targets for diabetes (HbA1c Conclusions: Our findings suggest that substantial investment in quality improvement initiatives in the UK may have led to more systematic and equitable processes of care for diabetes but have not addressed ethnic disparities in intermediate clinical outcomes. [ABSTRACT FROM AUTHOR]

Background: Prostate cancer screening (PCS) is controversial. Ideally, patients should understand the risks and benefits of screening before undergoing PSA testing. This study assessed whether primary care physicians routinely discuss PCS and explored the barriers to and facilitators of these discussions.Methods: Qualitative pilot study involving in-depth, semistructured interviews with 18 purposively sampled, academic and community-based primary care physicians. Barriers and facilitators of PCS discussions were ascertained using both interviews and chart-stimulated recall--a technique utilizing patient charts to probe recall and provide context to physician decision-making during clinic encounters. Analysis was performed using consensus conferences based on grounded theory techniques.Results: All 18 participating physicians reported that they generally discussed PCS with patients, though 6 reported sometimes ordering PSA tests without discussion. A PCS discussion occurred in only 16 (36%) of the 44 patient-physician encounters when patients were due for PCS that also met criteria for chart-stimulated recall. Barriers to PCS discussion were patient comorbidity, limited education/health literacy, prior refusal of care, physician forgetfulness, acute-care visits, and lack of time. Facilitators of PCS discussion included patient-requested screening, highly educated patients, family history of prostate cancer, African-American race, visits for routine physicals, review of previous PSA results, extra time during encounters, and reminder systems.Conclusions: PCS discussions sometimes do not occur. Important barriers to discussion are inadequate time for health maintenance, physician forgetfulness, and patient characteristics. Future research should explore using educational and decision support interventions to involve more patients in PCS decisions. [ABSTRACT FROM AUTHOR]

Context: Despite theoretical concerns that health care related distrust may lead to poor health outcomes by interfering with effective health care, little is currently known about the prevalence or outcomes of distrust of the health care system in the United States.Objective: To investigate the association between distrust of the health care system and self-reported health status among the general population in the United States.Design: Random-digit-dialing telephone survey.Participants: Nine hundred and sixty-one adult residents of the continental U.S.Primary Measures: Distrust of the health care system and self-reported health status.Results: Distrust of the health care system is relatively high in the United States, with between 20% and 80% of respondents reporting distrust for each item on the Health Care System Distrust scale and a median scale score of 31 (potential range from 10 to 50). Distrust of the health care system is strongly associated with self-reported fair/poor health (odds ratio [OR] 1.40%, 95% confidence interval [CI] 1.12 to 1.75 for each standard deviation increase in distrust), even after adjusting for sociodemographic characteristics, access to health care and trust in primary physicians. In contrast, low trust in one's primary physician is much lower (only 10% to 20% of respondents reported distrust for each item) and is not associated with health status.Conclusions: Distrust of the health care system is relatively high in the general population in the United States and is strongly associated with worse self-reported health. Further studies are needed to assess the direction of this association and the mechanisms involved. [ABSTRACT FROM AUTHOR]

Background: Differences in provider-patient health perceptions have been associated with poor patient outcomes, but little is known about how patients' cultural identities may be related to discordant perceptions.Objective: To examine whether health care providers and American-Indian patients disagreed on patient health status ratings, and how differences related to these patients' strength of affiliation with American-Indian and white-American cultural identities.Design: Survey of patients and providers following primary care office visits.Participants: One hundred and fifteen patients > or =50 years and 7 health care providers at a Cherokee Nation clinic. All patients were of American-Indian race, but varied in strength of affiliation with separate measures of American-Indian and white-American cultural identities.Measurements: Self-reported sociodemographic and cultural characteristics, and a 5-point rating of patient's health completed by both patients and providers. Fixed-effects regression modeling examined the relationships of patients' cultural identities with differences in provider-patient health rating.Results: In 40% of medical visits, providers and patients rated health differently, with providers typically judging patients healthier than patients' self-rating. Provider-patient differences were greater for patients affiliating weakly with white cultural identity than for those affiliating strongly (adjusted mean difference=0.70 vs 0.12, P=.01). Differences in ratings were not associated with the separate measure of affiliation with American-Indian identity.Conclusions: American-Indian patients, especially those who affiliate weakly with white-American cultural identity, often perceive health status differently from their providers. Future research should explore sources of discordant perceptions. [ABSTRACT FROM AUTHOR]