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To examine by age, the veterans' report on whether components of age-friendly health systems were discussed during primary care visits.Veterans Affairs (VA) Survey of Healthcare Experience of Patients from October 2015 to September 2019.Cross-sectional survey of VA users by age group (18-44 years, 45-64 years, 65+ years; N = 1,042,318). We used weighted logistic regression models to evaluate disparities in whether veterans discussed with anyone in their provider's office: health goals, depression symptoms, stress, personal problems, and medications. Models were adjusted for socio-demographic characteristics (sex, socioeconomic status, education, rurality) and comorbidity.Surveys were administered by mail and online. Additional veteran characteristics were extracted from VA administrative data.In unadjusted analyses, VA users age 18-44 had a higher (-8.2%; CI: -9.0, -7.3) and users aged 45 to 64 had lower (4.0%; CI: 3.7, 4.3) predicted, probably discussing health goals compared to age 65+. Fewer VA users age 65+ reported discussing depression symptoms, personal problems, and stress than other age groups, whereas more VA users age 65+ discussed medications. Results were unchanged after adjusting for socio-demographics and comorbidity.Delivery of goal-concordant care relies on understanding the needs of individual patients. Lower rates of discussing what matters and mood represent potential missed opportunities to deliver age-friendly care for older veterans.

This study examined the association between serious mental illness diagnoses and COVID-19 vaccination among Veterans Health Administration (VHA) patients.The sample (N=4,890,693) comprised veterans ages ≥18 years with VHA outpatient visits from March 1, 2018, through February 29, 2020. Veterans with serious mental illness were identified withPatients with serious mental illness and patients without serious mental illness were equally likely to receive a vaccination (48% and 46%, respectively; average effect of serious mental illness=-0.4%, 95% confidence interval=-0.8% to 0.1%).VHA outreach activities have contributed to equitable distribution of the COVID-19 vaccine.

Objectives American Indian and Alaska Native (AI/AN) communities have been disproportionately affected by the coronavirus disease 2019 (COVID-19) pandemic. This study examines whether neighborhood characteristics mediate AI/AN versus White-non-Hispanic Veteran COVID-19 infection disparities, and whether mediation differs based on proximity to reservations. Methods Using Veteran Health Administration’s (VHA) national database of VHA users evaluated for COVID-19 infection (3/1/2020–8/25/2020), we examined whether census tract neighborhood characteristics (percent households overcrowded, without complete plumbing, without kitchen plumbing, and neighborhood socioeconomic status [n-SES]) mediated racial disparities in COVID-19 infection, using inverse odds-weighted logistic models controlling for individual-level characteristics. Using moderated mediation analyses, we assessed whether neighborhood mediating effects on disparities differed for those residing in counties containing/near federally recognized tribal lands (i.e., Contract Health Service Delivery Area [CHSDA] counties) versus not. Results The percent of households without complete plumbing, percent without kitchen plumbing, and n-SES partially mediated AI/AN-White-non-Hispanic COVID-19 infection disparities (accounting for 17–35% of disparity) to a similar extent in CHSDA and non-CHSDA counties. The percent of households without kitchen plumbing had stronger mediating effects for CHSDA than non-CHSDA residents. Conclusions Neighborhood-level social determinants of health may contribute to the disproportionate COVID-19 infection burden on AI/ANs; differences are exacerbated among AI/ANs living near reservations.

Black men who have sex with men and women (BMSMW) experience pressure to fill hypermasculine ideals and may not identify with “gay” cultural norms. Existing measures of gender role expectations and internalized homophobia are not culturally appropriate for BMSMW. Researchers generally measure categorical identification with race, gender, and sexual orientation groups separately, whereas BMSMW may identify with multiple categories. We modified the Gender Role Conflict Scale to create the M-GRCS and the Internalized Homophobia Scale to include biphobia (Internalized Bi/Homophobia Scale, IBHS). To examine identification at the intersection of race, gender, and sexual orientation, we created 11 Integrated Race and Sexuality Scale (IRSS) items. With data from 429 BMSMW, we conducted exploratory factor analysis of the 59 items using categorical principal axis factoring with unweighted least squares extraction and Promax factor rotation. We created simple-summated multi-item scales and evaluated their construct validity. The rotated solution yielded four factors with 47 items and a simple factor structure: M-GRCS defined two factors (α = .93 for restricted emotionality/affection; .87 for success/power/competition); the IBHS (α = .89) and IRSS (α = .74) each defined a single factor. The IRSS factor was positively correlated with the Lukwago Racial Pride Scale, r(417) = .40. The IBHS factor was negatively correlated with the IRSS factor, r(414) = − .22. The two M-GRCS factors suggest that the construct of hypermasculinity impacts BMSMW. The high IBHS reliability indicates that homophobia and biphobia were positively correlated in this sample. These three scales have potential for future studies with BMSMW.

Author(s): Wong, Michelle S; Steers, W Neil; Hoggatt, Katherine J; Ziaeian, Boback; Washington, Donna L | Abstract: ObjectiveTo examine mediation and moderation of racial/ethnic all-cause mortality disparities among Veteran Health Administration (VHA)-users by neighborhood deprivation and residential segregation.Data sourcesElectronic medical records for 10/2008-9/2009 VHA-users linked to National Death Index, 2000 Area Deprivation Index, and 2006-2009 US Census.Study designRacial/ethnic groups included American Indian/Alaskan Native (AI/AN), Asian, non-Hispanic black, Hispanic, Native Hawaiian/Other Pacific Islander, and non-Hispanic white (reference). We measured neighborhood deprivation by Area Deprivation Index, calculated segregation for non-Hispanic black, Hispanic, and AI/AN using the Isolation Index, evaluated mediation using inverse odds-weighted Cox regression models and moderation using Cox regression models testing for neighborhood*race/ethnicity interactions.Principal findingsMortality disparities existed for AI/ANs (HRn=n1.07, 95%CI:1.01-1.10) but no other groups after covariate adjustment. Neighborhood deprivation and Hispanic segregation neither mediated nor moderated AI/AN disparities. Non-Hispanic black segregation both mediated and moderated AI/AN disparities. The AI/AN vs. non-Hispanic white disparity was attenuated for AI/ANs living in neighborhoods with greater non-Hispanic black segregation (Pn=n.047). Black segregation's mediating effect was limited to VHA-users living in counties with low black segregation. AI/AN segregation also mediated AI/AN mortality disparities in counties that included or were near AI/AN reservations.ConclusionsNeighborhood characteristics, particularly black and AI/AN residential segregation, may contribute to AI/AN mortality disparities among VHA-users, particularly in communities that were rural, had greater black segregation, or were located on or near AI/AN reservations. This suggests the importance of neighborhood social determinants of health on racial/ethnic mortality disparities. Living near reservations may allow AI/AN VHA-users to maintain cultural and tribal ties, while also providing them with access to economic and other resources. Future research should explore the experiences of AI/ANs living in black communities and underlying mechanisms to identify targets for intervention.

Background Stable, affordable housing is an established determinant of health. As affordable housing shortages across the USA threaten to displace people from their homes, it is important to understand the implications of cost-related residential moves for healthcare access. Objective To examine the relationship between cost-related moves and unmet medical needs. Design We performed a cross-sectional analysis of 7 waves (2011–2017) of the California Health Interview Survey. Participants We included all respondents ages 18 and older. Main Measures The primary predictor variable was residential move history in the past 5 years (cost-related move, non-cost-related move, or no move). The primary outcome was unmet medical needs in the past year (necessary medications and/or medical care that were delayed or not received). Key Results Our sample included 146,417 adults (42–47% response rate), representing a weighted population of 28,518,590. Overall, 20.3% of the sample reported unmet medical needs in the past year, and 4.9% reported a cost-related move in the past 5 years. In multivariable logistic regression models, adjusted risk of unmet medical needs increased for adults with both cost-related moves (aOR 1.38; 95% CI 1.19–1.59) and non-cost-related moves (aOR 1.17; 95% CI 1.09–1.26) compared to those with no moves. Among people who had moved, those with cost-related moves were more likely to report unmet medical needs compared to people with non-cost-related moves (p = 0.03). Conclusions People who have moved due to unaffordable housing represent a population at increased risk for unmet medical needs. Policy makers seeking to improve population health should consider strategies to limit cost-related moves and to mitigate their adverse effects on healthcare access. Supplementary Information The online version contains supplementary material available at 10.1007/s11606-020-06347-3.

OBJECTIVE: The purpose of this study was to assess associations between BMI and severe coronavirus disease 2019 (COVID-19) outcomes: hospitalization, intensive care unit (ICU) admission, and mortality. A secondary aim was to investigate whether associations varied by age. METHODS: The cohort comprised patients in the Veterans Health Administration (VHA) who tested positive for COVID-19 (N = 9,347). For each outcome, we fit piecewise logistic regression models with restricted cubic splines (knots at BMI of 23, 30, and 39), adjusting for age, sex, comorbidities, VHA nursing home residence, and race/ethnicity. Supplemental analyses included age-by-BMI interaction terms (α = 0.05). RESULTS: We found evidence of a nonlinear J-curve association between BMI and likelihood of hospitalization and mortality. BMI was associated with increased odds for hospitalization, ICU admission, and mortality among patients with BMI 30 to 39 but decreased odds of hospitalization and mortality for patients with BMI 23 to 30. Patients under age 75 with BMI between 30 and 39 had increased odds for mortality with increasing BMI. CONCLUSIONS: Odds for severe outcomes with COVID-19 infection increased with increasing BMI for people with, but not without, obesity. This nonlinear relationship should be tested in future research. COVID-19 public health messages in VHA, and broadly, should incorporate information about risks associated with all classes of obesity, particularly for those under age 75.

To examine mediation and moderation of racial/ethnic all-cause mortality disparities among Veteran Health Administration (VHA)-users by neighborhood deprivation and residential segregation.Electronic medical records for 10/2008-9/2009 VHA-users linked to National Death Index, 2000 Area Deprivation Index, and 2006-2009 US Census.Racial/ethnic groups included American Indian/Alaskan Native (AI/AN), Asian, non-Hispanic black, Hispanic, Native Hawaiian/Other Pacific Islander, and non-Hispanic white (reference). We measured neighborhood deprivation by Area Deprivation Index, calculated segregation for non-Hispanic black, Hispanic, and AI/AN using the Isolation Index, evaluated mediation using inverse odds-weighted Cox regression models and moderation using Cox regression models testing for neighborhood*race/ethnicity interactions.Mortality disparities existed for AI/ANs (HR = 1.07, 95%CI:1.01-1.10) but no other groups after covariate adjustment. Neighborhood deprivation and Hispanic segregation neither mediated nor moderated AI/AN disparities. Non-Hispanic black segregation both mediated and moderated AI/AN disparities. The AI/AN vs. non-Hispanic white disparity was attenuated for AI/ANs living in neighborhoods with greater non-Hispanic black segregation (P = .047). Black segregation's mediating effect was limited to VHA-users living in counties with low black segregation. AI/AN segregation also mediated AI/AN mortality disparities in counties that included or were near AI/AN reservations.Neighborhood characteristics, particularly black and AI/AN residential segregation, may contribute to AI/AN mortality disparities among VHA-users, particularly in communities that were rural, had greater black segregation, or were located on or near AI/AN reservations. This suggests the importance of neighborhood social determinants of health on racial/ethnic mortality disparities. Living near reservations may allow AI/AN VHA-users to maintain cultural and tribal ties, while also providing them with access to economic and other resources. Future research should explore the experiences of AI/ANs living in black communities and underlying mechanisms to identify targets for intervention.

Patient-centered medical homes (PCMH) are primary care delivery models that improve care access and population-level health outcomes, yet they have not been observed to narrow racial-ethnic disparities in the Veteran Health Administration (VHA) or other health systems. We aimed to identify and compare underlying drivers of persistent hypertension and diabetes control differences between non-Hispanic Black (Black) and Hispanic versus non-Hispanic White (White) patients before and after PCMH implementation in the VHA. Among Black and Hispanic versus White VHA primary care patients in 2009 (nhypertension = 26,906; ndiabetes = 21,141) and 2014 (nhypertension = 83,809; ndiabetes = 38,887), we retrospectively examined hypertension control (blood pressure

Colorectal cancer (CRC) is a deadly but largely preventable disease. Screening improves outcomes, but screening rates vary across healthcare coverage models. In the Veterans Health Administration (VA), screening rates are high; however, it is unknown how CRC screening rates compare for Veterans with other types of healthcare coverage. To determine whether Veterans with Veteran-status-related coverage (VA, military, TRICARE) have higher rates of CRC screening than Veterans with alternate sources of healthcare coverage. We conducted a cross-sectional analysis of Veterans 50–75 years from the 2014 Behavioral Risk Factor Surveillance System survey. We examined CRC screening rates and screening modalities. We performed multivariable logistic regression to identify the role of coverage type, demographics, and clinical factors on screening status. The cohort included 22,138 Veterans. Of these, 76.7% reported up-to-date screening. Colonoscopy was the most common screening modality (83.7%). Screening rates were highest among Veterans with Veteran-status-related coverage (82.3%), as was stool-based screening (10.8%). The adjusted odds of up-to-date screening among Veterans with Veteran-status-related coverage were 83% higher than among Veterans with private coverage (adjusted OR = 1.83, 95% CI = 1.52–2.22). Additional predictors of screening included older age, black race, high income, access to medical care, frequent medical visits, and employed or married status. CRC screening rates were highest among Veterans with Veteran-status-related coverage. High CRC screening rates among US Veterans may be related to system-level characteristics of VA and military care. Insight to these system-level characteristics may inform mechanisms to improve CRC screening in non-VA settings.

Black men who have sex with men and women (BMSMW) experience pressure to fill hypermasculine ideals and may not identify with "gay" cultural norms. Existing measures of gender role expectations and internalized homophobia are not culturally appropriate for BMSMW. Researchers generally measure categorical identification with race, gender, and sexual orientation groups separately, whereas BMSMW may identify with multiple categories. We modified the Gender Role Conflict Scale to create the M-GRCS and the Internalized Homophobia Scale to include biphobia (Internalized Bi/Homophobia Scale, IBHS). To examine identification at the intersection of race, gender, and sexual orientation, we created 11 Integrated Race and Sexuality Scale (IRSS) items. With data from 429 BMSMW, we conducted exploratory factor analysis of the 59 items using categorical principal axis factoring with unweighted least squares extraction and Promax factor rotation. We created simple-summated multi-item scales and evaluated their construct validity. The rotated solution yielded four factors with 47 items and a simple factor structure: M-GRCS defined two factors (α = .93 for restricted emotionality/affection; .87 for success/power/competition); the IBHS (α = .89) and IRSS (α = .74) each defined a single factor. The IRSS factor was positively correlated with the Lukwago Racial Pride Scale, r(417) = .40. The IBHS factor was negatively correlated with the IRSS factor, r(414) = - .22. The two M-GRCS factors suggest that the construct of hypermasculinity impacts BMSMW. The high IBHS reliability indicates that homophobia and biphobia were positively correlated in this sample. These three scales have potential for future studies with BMSMW.

Purpose: To evaluate whether exposure to MyFamilyPlan—a web-based preconception health education module—changes the proportion of women discussing reproductive health with providers at well-woman visits. Design: Cluster randomized controlled trial. One hundred thirty participants per arm distributed among 34 clusters (physicians) required to detect a 20% change in the primary outcome. Setting: Urban academic medical center (California). Participants: Eligible women were 18 to 45 years old, were English speaking, were nonpregnant, were able to access the Internet, and had an upcoming well-woman visit. E-mail and phone recruitment between September 2015 and May 2016; 292 enrollees randomized. Intervention: Intervention participants completed the MyFamilyPlan module online 7 to 10 days before a scheduled well-woman visit; control participants reviewed standard online preconception health education materials. Measures: The primary outcome was self-reported discussion of reproductive health with the physician at the well-woman visit. Self-reported secondary outcomes were folic acid use, contraceptive method initiation/change, and self-efficacy score. Analysis: Multilevel multivariate logistic regression. Results: After adjusting for covariates and cluster, exposure to MyFamilyPlan was the only variable significantly associated with an increase in the proportion of women discussing reproductive health with providers (odds ratio: 1.97, 95% confidence interval: 1.22-3.19). Prespecified secondary outcomes were unaffected. Conclusion: MyFamilyPlan exposure was associated with a significant increase in the proportion of women who reported discussing reproductive health with providers and may promote preconception health awareness; more work is needed to affect associated behaviors.

Patient-centered medical homes are widely promoted as a primary care delivery model that achieves better patient outcomes. It is unknown if their benefits extend equally to all racial/ethnic groups. In 2010 the Veterans Health Administration, part of the Department of Veterans Affairs (VA), began implementing patient-centered medical homes nationwide. In 2009 significant disparities in hypertension or diabetes control were present for most racial/ethnic groups, compared with whites. In 2014 hypertension disparities were similar for blacks, had become smaller but remained significant for Hispanics, and were no longer significant for multiracial veterans, whereas disparities had become significant for American Indians/Alaska Natives and Native Hawaiians/other Pacific Islanders. By contrast, in 2014 diabetes disparities were similar for American Indians/Alaska Natives, blacks, and Hispanics, and were no longer significant for Native Hawaiians/other Pacific Islanders. We found that the modest benefits of the VA's implementation of patient-centered medical homes were offset by competing multifactorial external, health system, provider, and patient factors, such as increased patient volume. To promote health equity, health care innovations such as patient-centered medical homes should incorporate tailored strategies that account for determinants of racial/ethnic variations. Evaluations of patient-centered medical homes should monitor outcomes for racial/ethnic groups.

Objectives To compare the strength of the association between depression and mortality between elderly and younger individuals with diabetes mellitus. Design A survival analysis conducted in a longitudinal cohort study of persons with diabetes mellitus to test the association between depression and mortality in older (≥65) and younger (18-65) adults. Setting Managed care. Participants Persons aged 18 and older with diabetes mellitus who participated in the Wave 2 survey of the Translating Research Into Action for Diabetes (TRIAD) Study (N = 3,341). Measurements The primary outcome was mortality risk, which was measured as days until death using linked data from the National Death Index. Depression was measured using the Patient Health Questionnaire. Results After controlling for age, sex, race and ethnicity, income, and other comorbidities, mortality risk in persons with diabetes mellitus was 49% higher in those with depression than in those without, although results varied according to age. After controlling for the same variables, mortality risk in persons aged 65 and older with depression was 78% greater than in those without. For those younger than 65, the effect of depression on mortality was smaller and not statistically significant. Conclusion This analysis suggests that the effect of depression on mortality in persons with diabetes mellitus is most significant for older adults. Because there is evidence in the literature that treatment of depression in elderly adults can lead to lower mortality, these results may suggest that older adults with diabetes mellitus should be considered a high-priority population for depression screening and treatment. © 2014, Copyright the Authors Journal compilation © 2014, The American Geriatrics Society.

Our objective was to characterize the tasks of emergency radiologists and emergency physicians and quantify the proportion of time spent on these tasks to assess their roles in patient evaluation. Our study involved emergency radiologists and emergency physicians at an urban academic level I trauma medical center. Participants were observed for continuous 2-h periods during which all of their activities were timed and categorized into the following tasks: patient history, patient physical findings, assessment/plan, procedures, technical/administration, paperwork, and personal time. We performed multivariate analyses to compare the proportion of time spent on task categories between specialties. Twenty physicians (10 emergency medicine and 10 radiology) were observed for a total of 146,802 s (2,446.7 min). Radiologists spent a significantly larger combined proportion of time on determining physical findings and paperwork than emergency physicians (61.9 vs. 28.3 %, p

Background Medicare Part D beneficiaries with diabetes are at risk of medication non-adherence and forgoing necessities due to cost pressures. Generic drug coverage during the Part D gap may attenuate these potentially adverse behaviors.

Background: Versus whites, blacks with diabetes have poorer control of hemoglobin A1c (HbA1c), higher systolic blood pressure (SBP), and higher low-density lipoprotein (LDL) cholesterol as well as higher rates of morbidity and microvascular complications. Objective: To examine whether several mutable risk factors were more strongly associated with poor control of multiple intermediate outcomes among blacks with diabetes than among similar whites. Design: Case-control study. Subjects: A total of 764 blacks and whites with diabetes receiving care within 8 managed care health plans. Measures: Cases were patients with poor control of at least 2 of 3 intermediate outcomes (HbA1c ≥ 8.0%, SBP ≥ 140 mmHg, LDL cholesterol ≥ 130 mg/dL) and controls were patients with good control of all 3 (HbA1c

Author(s): Tseng, Chien-Wen; Dudley, R Adams; Brook, Robert H; Keeler, Emmett; Steers, W Neil; Alexander, G Caleb; Waitzfelder, Beth E; Mangione, Carol M | Abstract: ObjectivesTo determine whether elderly patients with high drug expenditures want and receive providers' help in managing drug costs.DesignCross-sectional survey.SettingA Medicare managed care plan (g400,000 members) in one state in 2002.ParticipantsOne thousand one hundred six seniors (62% response rate) sampled so that half exceeded caps on their drug benefits the previous year, and all had total drug expenditures in the top quartile of members in their cap level.MeasurementsParticipants' preferences and experiences with providers discussing costs and participation in choosing medications.ResultsTwo-thirds reported difficulty paying for medications, and one-fourth decreased medication use because of cost. Most wanted providers to ask about medication affordability (81%), consider cost (86%), offer choices (70%), and to persuade them or decide for them which medication to use (88%), but few said providers asked about affordability (17%), usually or always discussed prices (19%), or offered choices (45%), although nearly all said providers chose their medications (93%). Sixty-two percent had asked providers for help with drug costs, although 34% who used less medication because of cost or had difficulty paying for medications had not asked for help.ConclusionProviders should be aware that elderly patients want their help in managing drug costs but do not always receive it or ask for help when they need it. Providers could improve communication by initiating conversations about cost and by asking patients about preferences when prescribing.

OBJECTIVE: To examine the association between physician-reported percent of total compensation from salary and quality of diabetes care. DESIGN: Cross-sectional analysis. PARTICIPANTS: Physicians (n = 1248) and their patients with diabetes mellitus (n = 4200) enrolled in 10 managed care plans. MEASUREMENTS: We examined the associations between physician-reported percent compensation from salary and processes of care including receipt of dilated eye exams and foot exams, advice to take aspirin, influenza immunizations, and assessments of glycemic control, proteinuria, and lipid profile, intermediate outcomes such as adequate control of hemoglobin A1c, lipid levels, and systolic blood pressure levels, and satisfaction with provider communication and perceived difficulty getting needed care. We used hierarchical logistic regression models to adjust for clustering at the health plan and physician levels, as well as for physician and patient covariates. We adjusted for plan as a fixed effect, meaning we estimated variation between physicians using the variance within a particular health plan only, to minimize confounding by other unmeasured health plan variables. RESULTS: In unadjusted analyses, patients of physicians who reported higher percent compensation from salary (>90%) were more likely to receive 5 of 7 diabetes process measures and more intensive lipid management and to have an HbA1c

Author(s): Mendez-Luck, Carolyn A; John Geldhof, G; Anthony, Katherine P; Neil Steers, W; Mangione, Carol M; Hays, Ron D | Abstract: Purpose of the studyTo develop the Caregiver Orientation Scale for Mexican-Origin Women and evaluate its psychometric properties.Design and methodsWe developed a questionnaire to measure domains of cultural orientation to the caregiver role based on formative research and on the Cultural Justifications for Caregiving Scale. We conducted a series of exploratory factor analyses (EFAs) on data collected from 163 caregivers. We estimated internal consistency reliability (Cronbach's coefficient alpha) and assessed construct validity by estimating correlations between all latent factors and self-rated health, interview language, and weekly hours of care.ResultsEFAs suggested four factors representing familism, obligation, burden, and caregiving intensity that displayed good fit (χ2 (df = 63) = 70.52, p = .24; RMSEA = .03 [90% CI: 0.00, 0.06]; comparative fit index = .99). Multi-item scales representing the four domains had coefficient alphas ranging from .68 to .86. Obligation was positively associated with burden (.46, p l .001) and intensity (.34, p l .01), which were themselves positively correlated (.63, p l .001). Familism was positively associated with obligation (.25, p l .05) yet negatively associated with burden (-.35, p l .01) and intensity (-.22, p l .05). Weekly hours of care were positively associated with burden (.26, p l .01) and intensity (.18, p l .05), whereas self-rated health and burden (-.21, p l .05) and Spanish language and intensity (-.31, p l .001) were negatively correlated.ImplicationsThe study shows that Mexican-origin caregiver orientation is multidimensional and that caregivers may have conflicting motivations for caregiving.

Author(s): Moin, Tannaz; Steers, W Neil; Ettner, Susan L; Duru, O Kenrik; Turk, Norman; Neugebauer, Romain; Chan, Charles; Luchs, Robert H; Ho, Sam; Mangione, Carol M

BACKGROUND Unit-based teams (UBTs), initially developed by Kaiser Permanente and affiliated unions, are natural work groups of clinicians, managers, and frontline staff who work collaboratively to identify areas for improvement and implement solutions. OBJECTIVE We evaluated the UBT model implemented by the Los Angeles County Department of Health Services in partnership with its union to engage frontline staff in improving patient care. DESIGN We conducted a quasi-experimental study, comparing surveys at baseline and 6 months, among personnel in 10 clinics who received UBT training to personnel in 5 control clinics. We also interviewed staff from 5 clinics that received UBT training and 3 control clinics. PARTICIPANTS We conducted 330 surveys and 38 individual, semi-structured interviews with staff at an outpatient facility in South Los Angeles. INTERVENTIONS Each UBT leader received an 8-hour training in basic performance improvement methods, and each UBT was assigned a team "coach." MAIN MEASURES Our outcome measure was 6-month change in the "adaptive reserve" score, the units' self-reported ability to make and sustain change. We analyzed transcripts of the interviews to find common themes regarding the UBT intervention. KEY RESULTS The survey response rate was 63% (158/252) at baseline and 75% (172/231) at 6 months. There was a significant difference-in-change in adaptive reserve between UBTs and non-UBTs at 6 months (+0.11 vs -0.13; P = .02). Nine of the 10 UBTs reported increases in adaptive reserve and 8 UBTs reported decreased no-show rates or patient length of stay in clinic. Staff overwhelmingly felt the UBTs were a positive intervention because it allowed all levels of staff to have a voice in improvement. CONCLUSIONS Our results indicate that partnership between management and unions to engage frontline staff in teams may be a useful tool to improve delivery of health care in a safety-net setting.

An earlier pilot study found that US DHHS guidelines for antiretroviral treatment were not being successfully implemented (Mann et al., 2000). A brief and inexpensive intervention (visual aid checklist) was developed with the assistance of HIV-expert physicians in order to aid HIV/AIDS health care providers' and their patients' decisions about antiretroviral therapy. The visual aid checklist consisted of a two-page coloured diagram and explanation of key concepts (T-cell, viral load and resistance) and a checklist of the benefits and risks of antiretroviral therapy. Twenty adult HIV-positive subjects and eight health care providers were studied. Ten subjects were observed with their providers without the intervention being used, and then ten subjects were observed with the intervention. A pre-/post-test format was used to assess the patients' antiretroviral knowledge, patient-provider discussion of the DHHS guidelines, and provider satisfaction with the intervention. No differences in baseline HIV knowledge were found between the two groups. Results showed that patients in the intervention condition had greater knowledge of the benefits and risks of antiretroviral therapy than patients in the control condition. Providers reported that the intervention was useful in aiding and encouraging communication as well as conveying knowledge.

Two studies assessed the goodness of fit of ideal, quasi-, and noncircumplex models of interpersonal traits. Study 1 (N = 132) represents a secondary data analysis using J.S. Wiggins's (1979) original Interpersonal Adjectives Scales (IAS) and reported by J.S. Wiggins, J.H. Steiger, and L. Gaelick (1981). Study 2 (N = 401) represents a primary data analysis using Wiggins's revised IAS (J.S. Wiggins, P. Trapnell, & N. Phillips, 1988). Results of both studies indicated that a quasi-circumplex model provided a better fit to the correlational data than did either ideal or noncircumplex models. Also, in Study 2, results for a subsample (n = 113) indicated that an ideal circumplex model yielded a significant positive path coefficient from Nurturance to interpersonal trust (J.K. Rempel, J.G. Holmes, & M.P. Zanna, 1985) but not from Dominance to interpersonal trust, whereas a quasi-circumplex model yielded significant positive paths from both Dominance and Nurturance to interpersonal trust.

Background: Although Medicare Part D improved drug benefits for many beneficiaries, its impact on the coverage of Medicare Advantage Part D (MAPD) enrollees depended on their pre-existing benefits and whether they had gap coverage under Part D. Objective: To examine changes in prescription drug utilization and expenditures associated with drug benefit changes resulting from the implementation of Part D. Patients: We studied 248,773 continuously enrolled MAPD patients in eight states. Patients whose insurance product or Census block could not be identified or who had atypical benefits, low-income subsidies or Medicaid coverage were excluded. Main Measures: The main outcomes were changes in prescription drug days supply and expenditures from 2005 to 2006 and 2005 to 2007. Design: We linked Census data with 2005-7 MAPD claims, encounter, enrollment, and benefits data and estimated associations of the outcomes with changes in drug benefits, controlling for 2005 comorbidities, demographics, and Census population characteristics. Key Results: MAPD enrollees whose drug benefits became potentially less generous after Part D had the smallest increases in drug utilization and expenditures (e.g., drug expenditures increased by $130 between 2005 and 2006), while those who potentially gained the most from Part D experienced the largest increases ($302). The differences in benefit design changes had a stronger association with drug utilization and outcomes among patients at high risk of gap entry than among the entire sample. Conclusions: Although Medicare Part D unambiguously improved drug coverage for many elderly, it led to heterogeneous changes in drug benefits among MAPD enrollees, who already had generic and sometimes branded drug benefits. After 2006, benefits were worse for individuals who had branded drug coverage in 2005 but now had a coverage gap, but benefits may have improved for individuals who acquired branded drug coverage. Commensurate with these differential changes in benefits following Part D, changes in drug utilization and expenditures varied substantially as well. © 2011 Society of General Internal Medicine.

To determine whether elderly patients with high drug expenditures want and receive providers' help in managing drug costs.Cross-sectional survey.A Medicare managed care plan (400,000 members) in one state in 2002.One thousand one hundred six seniors (62% response rate) sampled so that half exceeded caps on their drug benefits the previous year, and all had total drug expenditures in the top quartile of members in their cap level.Participants' preferences and experiences with providers discussing costs and participation in choosing medications.Two-thirds reported difficulty paying for medications, and one-fourth decreased medication use because of cost. Most wanted providers to ask about medication affordability (81%), consider cost (86%), offer choices (70%), and to persuade them or decide for them which medication to use (88%), but few said providers asked about affordability (17%), usually or always discussed prices (19%), or offered choices (45%), although nearly all said providers chose their medications (93%). Sixty-two percent had asked providers for help with drug costs, although 34% who used less medication because of cost or had difficulty paying for medications had not asked for help.Providers should be aware that elderly patients want their help in managing drug costs but do not always receive it or ask for help when they need it. Providers could improve communication by initiating conversations about cost and by asking patients about preferences when prescribing.

Generic-only drug benefits are a way to provide some coverage, as opposed to no coverage.To examine how switching from brand name to generic-only drug coverage affected seniors' medication use and financial burden.Data are from a 2002 cross-sectional survey conducted for a separate study on benefit caps. Participants belonged to a Medicare managed care plan in one state and had $2000 capped brand name benefits in 2001 but generic-only benefits in 2002.Participants reported their cost-cutting strategies before and after the change to generic-only coverage, the medications affected, and their financial burden. We conducted bivariate and multivariate analyses of cost-cutting strategies and financial burden before and after implementation of generic-only benefits.Among 611 participants (63% response), rates of switching medications increased after discontinuation of brand name coverage (27% vs 8%, P.001). Switches were from brand name drugs to generic equivalents (14%) (eg, Prozac to fluoxetine hydrochloride), to nonequivalent generics (26%) (eg, Paxil to fluoxetine), and to different brand name drugs (45%) (eg, Paxil to Zoloft). Ninety percent of brand name switches remained in the same therapeutic class (eg, selective serotonin reuptake inhibitors). After discontinuation of brand name coverage, participants reported higher rates of decreased medication use (28% vs 17%) and greater difficulty paying for prescriptions (65% vs 37%) (P.001 for both).Changing from brand name benefits to generic-only drug coverage led many participants to switch to less expensive medications but also decreased medication use and increased financial burden. Insurers need to actively help patients adjust to a discontinuation of brand name coverage.

Background: Although disease management programs are widely implemented, little is known about their effectiveness. Objective: To determine whether disease management by physician groups is associated with diabetes care processes, control of intermediate outcomes, or the amount of medication used when intermediate outcomes are above target levels. Design: Cross-sectional study. Setting: Patients were randomly sampled from 63 physician groups nested in 7 health plans sponsored by Translating Research into Action for Diabetes (87%) and from 4 health plans with individual physician contracts (13%). Patients: 8661 adults with diabetes who completed a survey (2000-2001) and had medical record data. Measurements: Physician group and health plan directors described their organizations' use of physician reminders, performance feedback, and structured care management on a survey; their responses were used to determine measures of intensity of disease management. The current study measured 8 processes of care, including most recent hemoglobin A1c level, systolic blood pressure, serum low-density lipoprotein cholesterol level, and several measures of medication use. Results: Increased use of any of 3 disease management strategies was significantly associated with higher adjusted rates of retinal screening, nephropathy screening, foot examinations, and measurement of hemoglobin A1c levels. Serum lipid level testing and influenza vaccine administration were associated with greater use of structured care management and performance feedback. Greater use of performance feedback correlated with an increased rate of foot examinations (difference, 5 percentage points [95% CI, 1 to 8 percentage points]), and greater use of physician reminders was associated with an increased rate of nephropathy screening (difference, 15 percentage points [CI, 6 to 23 percentage points]). No strategies were associated with intermediate outcome levels or level of medication management. Limitations: Physician groups were not randomly sampled from population-based listings, and disease management strategies were not randomly allocated across groups. Conclusions: Disease management strategies were associated with better processes of diabetes care but not with improved intermediate outcomes or level of medication management. A greater focus on direct measurement, feedback, and reporting of intermediate outcome levels or of level of medication management may enhance the effectiveness of these programs.

To make cultural and age-specific modifications to a self-care empowerment intervention.Focus groups with self-administered surveys.Two public health diabetes and geriatrics clinic and two senior centers in and around South Los Angeles.African Americans and Latinos agedor = 55 years with diabetes (N=79), and two groups of health educators (N=16).After describing the proposed intervention, the focus group facilitators asked participants: 1) whether the community of interest would be interested in the proposed empowerment intervention; 2) why or why not; and 3) how the intervention could be modified to better address the concerns of the study community of interest. All groups were audiotaped, transcribed, and (when appropriate) translated into English. Three independent investigators read all transcripts and completed standardized coding forms for each transcript. In addition, at the end of each focus group, all participants completed a self-administered written survey asking them to rate aspects of the proposed intervention.Older African Americans and Latinos endorsed the intervention but desired an expanded dietary educational component and identified disability as an important missing content area. Participants rejected the use of an audio learning tool and did not believe that matching group-facilitator sociodemographic characteristics was important as long as facilitators demonstrated cultural competency.These findings illustrate a model of participatory research in which researchers and community members work together to develop an empowerment intervention that will meet community needs and will have greater cultural appropriateness. Modifying the intervention in accordance with these findings should enhance the relevance and impact of the self-care intervention.

ContextThe majority of Medicare drug benefits in managed care (Medicare + Choice) have annual dollar limits or caps and many beneficiaries face temporary but potentially significant gaps in coverage after exceeding caps before the end of the year. In the new national Medicare drug benefit, beneficiaries with high medication expenditures will also face a period without drug coverage when their total drug costs exceed annual caps but are not high enough to qualify for catastrophic coverage.ObjectiveTo describe strategies adopted by beneficiaries exceeding annual drug benefit caps to lower prescription costs, the type of medications involved, and their financial burden.Design, setting, and participantsA survey (completed in 2002) of Medicare + Choice beneficiaries aged 65 years and older with high medication costs and benefits capped on the plan's share of drug costs (65% response rate). The different caps offered in different counties were used as a natural experiment. Study participants (n = 665) exceeded a 750 dollars or 1200 dollars yearly cap in 2001 and had coverage gaps of 75 to 180 days. Control participants (n = 643) had 2000 dollars caps, which they did not exceed. Study and control participants were matched by average total drug expenditures per month.Main outcome measuresProportion of beneficiaries reporting specific strategies to decrease medication costs, medications affected, and difficulty paying for prescriptions.ResultsIn multivariate analyses adjusting for demographic and health characteristics, a higher proportion of patients exceeding caps reported using less prescribed medication than controls (18% vs 10%, respectively; P

Publisher Summary This chapter addresses the ways in which individuals communicate various emotions towards their friends. The emotional communication of friends within the circumplex model is reviewed. Four pairs of opposing emotions—joy versus sadness, acceptance versus disgust, fear versus anger, and surprise versus anticipation comprise the domain of primary emotions. An additional four pairs of opposing emotions—love versus remorse, submission versus contempt, awe versus aggressiveness, and optimism versus disappointment—comprise the domain of secondary emotions. The chapter discusses each of the pairs of opposing emotions. The expressions of joy and sadness in friendships are contingent upon individuals' age as well as gender. Although the propensity towards expressing joy and sadness remains constant, individuals' expression of joy and sadness may become more muted as they develop and presumably succumb to societal norms. In adolescent and adult friendships, individuals may feel aggressive and act accordingly when they expect to be made angry by their peers. Aggressive feelings often are communicated through accusatory “you” statements. Such statements, in turn, may create psychological distance within friendships to the extent that they evoke alienation as well as relationship-threatening, aggressive verbal and nonverbal responses from the recipients of those statements.

Although controversial, the use of financial incentives in health care has garnered increasing interest (Berwick 1995; Miller and Sage 1999; Bailit Health Purchasing LLC and Sixth Man Consulting Inc. 2001; Institute of Medicine 2001; Rolnick 2002; Fernandopulle et al. 2003; Maio et al 2003). For example, in a recent major initiative in the U.K., primary care physicians (PCPs) have entered into a government contract that will provide incentives for high-quality care (Roland 2004). To date, however, the literature on the effects of physician reimbursement incentives has largely been limited to conceptualization of the issues (Hillman 1990; Berwick 1996; Dudley et al. 1998; Glass, Pieper, and Berlin 1999; Goldfarb 1999; Tufano, Conrad, and Liang 1999; Robinson 2001; Conrad and Christianson 2004). With at least one notable exception (Keating et al., 2004), empirical studies have focused on quantity of services delivered rather than process measures or quality of care and have yielded conflicting conclusions (Dudley et al. 1998; Armour et al. 2001; Bailit Health Purchasing LLC and Sixth Man Consulting Inc. 2001; Conrad and Christianson 2004; Rosenthal et al. 2004). This study assessed the associations between the reimbursement strategies used for PCPs and the care processes and satisfaction of their managed care patients with diabetes and examined how this relationship may be confounded by physician organizational model. Diabetes and its complications are common, complex, and costly, presenting formidable challenges to the U.S. health system (Centers for Disease Control and Prevention 1997; American Diabetes Association 1998). Diabetes complications and comorbidities may be delayed or avoided altogether through timely and effective treatments, but unfortunately many of these treatments are not uniformly implemented in routine clinical practice (Marrero 1994; Martin, Selby, and Zhang 1995; Centers for Disease Control and Prevention 1997; Pan et al. 1997; Harris 2000). A better understanding of the factors influencing care processes across diverse health care systems, including the role of physician reimbursement strategies, is needed to close the gap between actual and optimal care. To that end, this study tested three hypotheses based on the theoretical and empirical literature previously cited. The first hypothesis is that processes of care are better, and hence satisfaction greater, among managed care patients with diabetes whose PCPs total compensation depends more heavily on fee-for-service (FFS) reimbursement than on salary or capitated reimbursement, because there are no cost containment incentives in a FFS system that might restrict the care received by the patient (Dudley et al. 1998; Armour et al. 2001; Institute of Medicine 2001; Robinson 2001; Grignon et al. 2002; Kuhn 2003; Conrad and Christianson 2004). The counter-hypothesis is that capitation is associated with better care processes because capitated plans reap any (short-term) financial gains that might result from better disease management. The counter-hypothesis is more compelling if patient disenrollment is lower, as the plan might otherwise be unable to recoup investments in patient health quickly enough. The second hypothesis is that processes of care are better, and satisfaction greater, among managed care patients with diabetes whose PCPs total compensation is based in part on quality or patient satisfaction (Bailit Health Purchasing LLC and Sixth Man Consulting Inc. 2001; Institute of Medicine 2001; Conrad and Christianson 2004). The third hypothesis is that processes of care are worse, and satisfaction lower, among managed care patients with diabetes whose PCPs total compensation depends on outpatient utilization, i.e., are paid more when their patients are less costly (Armour et al. 2001; Bailit Health Purchasing LLC and Sixth Man Consulting Inc. 2001; Institute of Medicine 2001). Again, a counter-hypothesis can be made if short-term investments in the patient's health are more than offset by longer-term reductions in cost, although such reductions seem more likely to show up in inpatient settings, where they would not contribute to the physician's compensation. An earlier study using the same dataset (Kim et al. 2004) found associations of diabetes care processes with physician organizational model (independent practice association [IPA] versus medical group [MG]) and hypothesized that these associations could be mediated by factors such as physician reimbursement strategies, but did not examine the role played by those strategies. We sought to build on this earlier work by estimating the association between reimbursement strategies and care processes, with and without controlling for physician organizational model.