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Background: In 2014, hypertension guidelines for older adults endorsed increased use of fixed-dose combinations, prioritized thiazide diuretics and calcium channel blockers (CCBs) for Black patients, and no longer recommend beta-blockers as first-line therapy., Objective: To evaluate older adults' antihypertensive use following guideline changes., Design: Time series analysis., Patients: Twenty percent national sample of Medicare Part D beneficiaries aged 66 years and older with hypertension., Intervention: Eighth Joint National Committee (JNC8) guidelines MAIN MEASURES: Quarterly trends in prevalent and initial antihypertensive use were examined before (2008 to 2013) and after (2014 to 2017) JNC8. Analyses were conducted among all beneficiaries with hypertension, beneficiaries without chronic conditions that might influence antihypertensive selection (hypertension-only cohort), and among Black patients, given race-based guideline recommendations., Key Results: The number of beneficiaries with hypertension increased from 1,978,494 in 2008 to 2,809,680 in 2017, the proportions using antihypertensives increased from 80.3 to 81.2%, and the proportion using multiple classes and fixed-dose combinations declined (60.8 to 58.1% and 20.7 to 15.1%, respectively, all P<.01). Prior to JNC8, the use of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and CCBs was increasing. Use of CCBs as initial therapy increased more rapidly following JNC8 (relative change in quarterly trend 0.15% [95% CI, 0.13-0.18%), especially among Black beneficiaries (relative change 0.44% [95% CI, 0.21-0.68%]). Contrary to guidelines, the use of thiazides and combinations as initial therapy consistently decreased in the hypertension-only cohort (13.8 to 8.3% and 25.1 to 15.7% respectively). By 2017, 65.9% of Black patients in the hypertension-only cohort were initiated on recommended first-line or combination therapy compared to 80.3% of non-Black patients., Conclusions: Many older adults, particularly Black patients, continue to be initiated on antihypertensive classes not recommended as first-line, indicating opportunities to improve the effectiveness and equity of hypertension care and potentially reduce antihypertensive regimen complexity., (© 2022. The Author(s), under exclusive licence to Society of General Internal Medicine.)

Background: Medicaid expansion in Michigan, known as the Healthy Michigan Plan (HMP), emphasizes primary care and preventive services., Objective: Evaluate the impact of enrollment in HMP on access to and receipt of care, particularly primary care and preventive services., Design: Telephone survey conducted during January-November 2016 with stratified random sampling by income and geographic region (response rate = 53.7%). Logistic regression analyses accounted for sampling and nonresponse adjustment., Participants: 4090 HMP enrollees aged 19-64 with ≥ 12 months of HMP coverage MAIN MEASURES: Surveys assessed demographic factors, health, access to and use of health care before and after HMP enrollment, health behaviors, receipt of counseling for health risks, and knowledge of preventive services' copayments. Utilization of preventive services was assessed using Medicaid claims., Key Results: In the 12 months prior to HMP enrollment, 33.0% of enrollees reported not getting health care they needed. Three quarters (73.8%) of enrollees reported having a regular source of care (RSOC) before enrollment; 65.1% of those reported a doctor's office/clinic, while 16.2% reported the emergency room. After HMP enrollment, 92.2% of enrollees reported having a RSOC; 91.7% had a doctor's office/clinic and 1.7% the emergency room. One fifth (20.6%) of enrollees reported that, before HMP enrollment, it had been over 5 years since their last primary care visit. Enrollees who reported a visit with their primary care provider after HMP enrollment (79.3%) were significantly more likely than those who did not report a visit to receive counseling about health behaviors, improved access to cancer screening, new diagnoses of chronic conditions, and nearly all preventive services. Enrollee knowledge that some services have no copayments was also associated with greater utilization of most preventive services., Conclusions: After enrolling in Michigan's Medicaid expansion program, beneficiaries reported less forgone care and improved access to primary care and preventive services.

Background: Health risk assessments (HRAs) and healthy behavior incentives are increasingly used by state Medicaid programs to promote enrollees' health., Objective: To evaluate enrollee experiences with HRAs and healthy behavior engagement in the Healthy Michigan Plan (HMP), a state Medicaid expansion program., Design: Telephone survey conducted in Michigan January-October 2016., Participants: A random sample of HMP enrollees aged 19-64 with ≥ 12 months of enrollment, stratified by income and geographic region., Main Measures: Self-reported completion of an HRA, reasons for completing an HRA, commitment to a healthy behavior, and choice of healthy behavior., Key Results: Among respondents (N = 4090), 49.3% (95% CI 47.3-51.2%) reported completing an HRA; among those with a primary care provider (PCP) (n = 3851), 85.2% (95% CI 83.5-86.7%) reported visiting their PCP during the last 12 months. Most enrollees having a recent PCP visit reported discussing healthy behaviors with them (91.1%, 95% CI 89.6-92.3%) and were more likely to have completed an HRA than enrollees without a recent PCP visit (52.7%, 95% CI 50.5-52.8% vs. 36.2%, 95% CI 31.7-41.1%; p < 0.01). Among enrollees completing an HRA, nearly half said they did it because their PCP suggested it (45.9%, 95% CI 43.2-48.7%), and most reported it helped their PCP understand their health needs (89.7%). Awareness of financial incentives was limited (28.1%, 95% CI 26.3-30.0%), and very few reported it as the primary reason for HRA completion (2.5%, 95% CI 1.8-3.4%). Most committed to a healthy behavior (80.7%, 95% CI 78.5-82.8%), and common behaviors chosen were nutrition/diet (57.2%, 95% CI 54.2-60.2%) and exercise/activity (52.6%, 95% CI 49.5-55.7%)., Conclusions: In the Healthy Michigan Plan, PCPs appeared influential in enrollees' completion of HRAs and healthy behavior engagement, while knowledge of financial incentives was limited. Additional study is needed to understand the relative importance of financial incentives and PCP engagement in impacting healthy behaviors in state Medicaid programs.

Background: Although the Medicare Shared Savings Program (MSSP) created new incentives for organizations to improve healthcare value, Accountable Care Organizations (ACOs) have achieved only modest reductions in the use of low-value care., Objective: To assess ACO engagement of clinicians and whether engagement was associated with clinicians' reported difficulty implementing recommendations against low-value care., Design: Cross-sectional survey of ACO clinicians in 2018., Participants: 1289 clinicians in the Physician Organization of Michigan ACO, including generalist physicians (18%), internal medicine specialists (16%), surgeons (10%), other physician specialists (27%), and advanced practice providers (29%). Response rate was 34%., Main Measures: Primary exposures included clinicians' participation in ACO decision-making, awareness of ACO incentives, perceived influence on practice, and perceived quality improvement. Our primary outcome was clinicians' reported difficulty implementing recommendations against low-value care., Results: Few clinicians participated in the decision to join the ACO (3%). Few clinicians were aware of ACO incentives, including knowing the ACO was accountable for both spending and quality (23%), successfully lowered spending (9%), or faced upside risk only (3%). Few agreed (moderately or strongly) the ACO changed compensation (20%), practice (19%), or feedback (15%) or that it improved care coordination (17%) or inappropriate care (13%). Clinicians reported they had difficulty following recommendations against low-value care 18% of the time; clinicians reported patients had difficulty accepting recommendations 36% of the time. Increased ACO awareness (1 standard deviation [SD]) was associated with decreased difficulty (- 2.3 percentage points) implementing recommendations (95% confidence interval [CI] - 3.8, - 0.7), as was perceived quality improvement (1 SD increase, - 2.1 percentage points, 95% CI, - 3.4, - 0.8). Participation in ACO decision-making and perceived influence on practice were not associated with recommendation implementation., Conclusions: Clinicians participating in a large Medicare ACO were broadly unaware of and unengaged with ACO objectives and activities. Whether low clinician engagement limits ACO efforts to reduce low-value care warrants further longitudinal study.

Background: It is uncertain how Medicaid expansion under the Affordable Care Act influences the diagnosis of chronic health conditions, and the care and health of enrollees with chronic conditions., Objective: Describe the prevalence of new and pre-existing chronic health conditions among Medicaid expansion enrollees. Examine whether perceived changes in specific types of access and self-rated health status differed between enrollees with chronic conditions and those without. Examine how gaining Medicaid coverage affected chronic disease management and well-being., Design: Mixed-methods study including a telephone survey and semi-structured interviews., Setting: Michigan's Medicaid expansion, the "Healthy Michigan Plan" (HMP)., Participants: 4090 survey respondents (response rate 54%) with ≥ 12 months HMP enrollment and 67 interviewees with ≥ 6 months enrollment., Main Measures: Self-reported chronic condition diagnoses, changes in physical/mental health, and healthcare access. Descriptive survey data were adjusted for survey design and nonresponse. Semi-structured interview questions about how gaining HMP coverage led to changes in health status., Key Results: Among enrollees, 68% had a self-reported diagnosis of a chronic health condition; 42% of those were newly diagnosed since HMP enrollment. In multivariable models, enrollees with chronic conditions were significantly more likely to report improved physical (adjusted odds ratio (aOR) 1.70, 95% CI (1.40, 2.07)) and mental health (aOR 1.75, (1.43, 2.15)) since HMP enrollment than enrollees without chronic conditions. Among enrollees with chronic conditions, the strongest predictors of improvements in health were having seen a primary care physician, improved mental health care access, and improved medication access. Interviewees with chronic conditions described how increased access to health care led to improvements in both physical and mental health., Conclusions: Enrollees with expanded Medicaid coverage commonly reported detection of previously undiagnosed chronic conditions. Perceived health status and access improved more often among enrollees with chronic health conditions. Improved access was associated with improved physical and mental health among this vulnerable group.

Background: Michigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state's economy., Objective: To understand HMP's impact on enrollees' health, ability to work, and ability to seek employment DESIGN: Mixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%) PARTICIPANTS: Non-elderly adult HMP enrollees MAIN MEASURES: Changes in health status, ability to work, and ability to seek employment KEY RESULTS: Half (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11-5.35, p < 0.001), seek a job (aOR 2.82, 95% CI 1.93-4.10, p < 0.001), and get a better job (aOR 3.20, 95% CI 1.69-6.09, p < 0.001), but not with employment status (aOR 1.08, 95% CI 0.89-1.30, p = 0.44). In interviews, several HMP enrollees attributed their ability to get or maintain employment to improved physical, mental, and dental health because of services covered by HMP. Remaining barriers to work cited by enrollees included older age, disability, illness, and caregiving responsibilities., Conclusions: Many low-income HMP enrollees reported improved health, ability to work, and job seeking after obtaining health insurance through Medicaid expansion.

Background: Michigan's approach to Medicaid expansion, the Healthy Michigan Plan (HMP), emphasizes primary care, prevention, and incentives for patients and primary care practitioners (PCPs)., Objective: Assess PCPs' perspectives about the impact of HMP on their patients and practices., Design: In 2014-2015, we conducted semi-structured interviews then a statewide survey of PCPs., Setting: Interviewees came from varied types of practices in five Michigan regions selected for racial/ethnic diversity and a mix of rural and urban settings. Surveys were sent via mail., Participants: Interviewees were physician (n = 16) and non-physician practitioners (n = 3). All Michigan PCPs caring for ≥ 12 HMP enrollees were surveyed (response rate 55.5%, N = 2104)., Measurements: PCPs' experiences with HMP patients and recent changes in their practices., Results: Interviews include examples of the impact of Medicaid expansion on patients and practices. A majority of surveyed PCPs reported recent increases in new patients (52.3%) and patients who had not seen a PCP in many years (56.2%). For previously uninsured patients, PCPs reported positive impact on control of chronic conditions (74.4%), early detection of serious illness (71.1%), medication adherence (69.1%), health behaviors (56.5%), emotional well-being (57.0%), and the ability to work, attend school, or live independently (41.5%). HMP patients reportedly still had more difficulty than privately insured patients accessing some services. Most PCPs reported that their practices had, in the past year, hired clinicians (53.2%) and/or staff (57.5%); 15.4% had colocated mental health care. Few (15.8%) reported established patients' access to urgent appointments worsened., Limitations: PCP reports of patient experiences may not be accurate. Results reflect the experiences of PCPs with ≥ 12 Medicaid patients. Differences between respondents and non-respondents present the possibility for response bias., Conclusions: PCPs reported improved patient access to care, medication adherence, chronic condition management, and detection of serious illness. Established patients' access did not diminish, perhaps due to reported practice changes.

Background: Diabetes is a costly and common condition, but little is known about recent trends in diabetes management among Medicare beneficiaries., Objective: To evaluate the use of diabetes medications and testing supplies among Medicare beneficiaries., Design/setting: Retrospective cohort analysis of Medicare claims from 2007 to 2014., Participants: Traditional Medicare beneficiaries with a diagnosis of diabetes in the current or any prior year., Main Measures: We analyzed choices of first diabetes medication for those new to medication and patterns of adding medications. We also examined the use of testing supplies, use of statins and ACE inhibitors/angiotensin receptor blockers, and spending., Key Results: Diagnosed diabetes increased from 28.7% to 30.2% of beneficiaries from 2007 to 2014. The use of metformin as the most commonly prescribed first medication increased from 50.2% in 2007 to 70.2% in 2014, whereas long-acting sulfonylureas decreased from 16.6% to 8.2%. The use of thiazolidinediones fell considerably, while the use of new diabetes medication classes increased. Among patients prescribed insulin, long-acting insulin as the first choice increased substantially, from 38.9% to 56.8%, but short-acting or combination regimens remained common, particularly among older or sicker beneficiaries. Prescriptions of testing supplies for more than once-daily testing were also common. The mean total cost of diabetes medications per patient increased over the period due to the increasing use of high-cost drugs, particularly by those patients with costs above the 90th percentile of spending, although the median costs decreased for both medications and testing supplies., Conclusions: The use of metformin and long-acting insulin have increased substantially among elderly Medicare patients with diabetes, but a substantial subgroup continues to receive costly and complex treatment regimens.

Background: A large proportion of justice-involved individuals have mental health issues and substance use disorders (SUD) that are often untreated due to high rates of uninsurance. However, roughly half of justice-involved individuals were estimated to be newly eligible for health insurance through the Affordable Care Act (ACA)., Objective: We aimed to assess health insurance trends among justice-involved individuals before and after implementation of the ACA's key provisions, the dependent coverage mandate and Medicaid expansion, and to examine the relationship between health insurance and treatment for behavioral health conditions., Design: Repeated and pooled cross-sectional analyses of data from the National Survey on Drug Use and Health (NSDUH)., Participants: Nationally representative sample of 15,899 adults age 19-64 years between 2008 and 2014 with a history of justice involvement during the prior 12 months., Main Measures: Uninsurance rates between 2008 and 2014 are reported. Additional outcomes include adjusted treatment rates for depression, serious mental illness, and SUD by insurance status., Key Results: The dependent coverage mandate was associated with a 13.0 percentage point decline in uninsurance among justice-involved individuals age 19-25 years (p < 0.001). Following Medicaid expansion, uninsurance declined among justice involved individuals of all ages by 9.7 percentage points (p < 0.001), but remained 16.3 percentage points higher than uninsurance rates for individuals without justice involvement (p < 0.001). In pooled analyses, Medicaid, relative to uninsurance and private insurance, was associated with significantly higher treatment rates for illicit drug abuse/dependence and depression., Conclusion: Given the high prevalence of mental illness and substance use disorders among justice-involved populations, persistently elevated rates of uninsurance and other barriers to care remain a significant public health concern. Sustained outreach is required to reduce health insurance disparities between individuals with and without justice involvement. Public insurance appears to be associated with higher treatment rates, relative to uninsurance and private insurance, among justice-involved individuals., Competing Interests: Compliance with Ethical Standards Funders This research was funded with support from the Robert Wood Johnson Clinical Scholars Program, the University of Michigan, and Ann Arbor VA Healthcare System. Conflict of Interest All authors declare no conflicts of interest.

Background: Ongoing efforts to increase colorectal cancer (CRC) screening rates have raised concerns that these exams may be overused, thereby subjecting patients to unnecessary risks and wasting healthcare resources., Objective: Our aim was to measure overuse of screening and surveillance colonoscopies among average-risk adults, and to identify correlates of overuse., Design, Setting, and Participants: Our approach was a retrospective cohort study using electronic health record data for patients 50-65 years old with no personal history of CRC or colorectal adenomas with an incident CRC screening colonoscopy from 2001 to 2010 within a multispecialty physician group practice., Main Outcome Measures: We measured time to next screening or surveillance colonoscopy and predictors of overuse (exam performed more than one year earlier than guideline recommended intervals) of colonoscopies., Key Results: We identified 1,429 adults who had an incident colonoscopy between 2001 and 2010, and they underwent an additional 871 screening or surveillance colonoscopies during a median follow-up of 6 years. Most follow-up screening colonoscopies (88%) and many surveillance colonoscopies (49%) repeated during the study represented overuse. Time to next colonoscopy after incident screening varied by exam findings (no polyp: median 6.9 years, interquartile range [IQR]: 5.1-10.0; hyperplastic polyp: 5.7 years, IQR: 4.9-9.7; low-risk adenoma: 5.1 years, IQR: 3.3-6.3; high-risk adenoma: 2.9 years, IQR: 2.0-3.4, p < 0.001). In logistic regression models of colonoscopy overuse, an endoscopist recommendation for early follow-up was strongly associated with overuse of screening colonoscopy (OR 6.27, 95% CI: 3.15-12.50) and surveillance colonoscopy (OR 13.47, 95% CI 6.61-27.46). In a multilevel logistic regression model, variation in the overuse of screening colonoscopy was significantly associated with the endoscopist performing the previous exam., Conclusions: Overuse of screening and surveillance exams are common and should be monitored by healthcare systems. Variations in endoscopist recommendations represent targets for interventions to reduce overuse.

Background: The Medicare Accountable Care Organization (ACO) programs encourage integration of providers into large groups and reward provider groups for improving quality, but not explicitly for reducing health care disparities. Larger group size and better overall quality may or may not be associated with smaller disparities., Objective: To examine differences in patient characteristics between provider groups sufficiently large to participate in ACO programs and smaller groups; the association between group size and racial disparities in quality; and the association between quality and disparities among larger groups., Design and Participants: Using 2009 Medicare claims for 3.1 million beneficiaries with cardiovascular disease or diabetes and linked data on provider groups, we compared racial differences in quality by provider group size, adjusting for patient characteristics. Among larger groups, we used multilevel models to estimate correlations between group performance on quality measures for white beneficiaries and black-white disparities within groups., Main Measures: Four process measures of quality, hospitalization for ambulatory care-sensitive conditions (ACSCs) related to cardiovascular disease or diabetes, and hospitalization for any ACSC., Key Results: Beneficiaries served by larger groups were more likely to be white and live in areas with less poverty and more education. Larger group size was associated with smaller disparities in low-density lipoprotein (LDL) cholesterol testing and retinal exams, but not in other process measures or hospitalization for ACSCs. Among larger groups, better quality for white beneficiaries in one measure (hospitalization for ACSCs related to cardiovascular disease or diabetes) was correlated with smaller racial disparities (r = 0.28; P = 0.02), but quality was not correlated with disparities in other measures., Conclusions: Larger provider group size and better performance on quality measures were not consistently associated with smaller racial disparities in care for Medicare beneficiaries with cardiovascular disease or diabetes. ACO incentives rewarding better quality for minority groups and payment arrangements supporting ACO development in disadvantaged communities may be required for ACOs to promote greater equity in care.

Cardiovascular disease is a major cause of mortality and disability. We analyzed the National Health and Nutrition Examination Survey (1998-2008). We used logistic regression analysis to compare the odds of having undiagnosed and uncontrolled hypertension and hyperlipidemia among FB and US born adults sequentially adjusting for (1) age and gender, (2) income and education, and (3) insurance status. Among FB individuals, we identified factors independently associated with having each outcome using logistic regression analyses. Of 27,596 US adults, 22.6 % were foreign-born. In age- and -gender adjusted analyses, FB were more likely to have undiagnosed hypertension (OR 1.35, 95 % CI 1.13-1.63, p < 0.001), uncontrolled hypertension (OR 1.37, 95 % CI 1.15-1.64, p < 0.001), and uncontrolled hyperlipidemia (OR 1.35, 95 % CI 1.11-1.63, p = 0.002), while undiagnosed hyperlipidemia approached significance (OR 1.24, 95 % CI 0.99-1.56, p = 0.057). Having insurance was associated with a 5-15 % decrease in FB-US born disparities. Immigrants are at increased risk of undiagnosed and uncontrolled hypertension and hyperlipidemia., Competing Interests: All authors report no conflicts of interest.

Background: Despite a growing need for primary care physicians in the United States, the proportion of medical school graduates pursuing primary care careers has declined over the past decade., Objective: To assess the association of medical school research funding with graduates matching in family medicine residencies and practicing primary care., Design: Observational study of United States medical schools., Participants: One hundred twenty-one allopathic medical schools., Main Measures: The primary outcomes included the proportion of each school's graduates from 1999 to 2001 who were primary care physicians in 2008, and the proportion of each school's graduates who entered family medicine residencies during 2007 through 2009. The 25 medical schools with the highest levels of research funding from the National Institutes of Health in 2010 were designated as "research-intensive.", Key Results: Among research-intensive medical schools, the 16 private medical schools produced significantly fewer practicing primary care physicians (median 24.1% vs. 33.4%, p < 0.001) and fewer recent graduates matching in family medicine residencies (median 2.4% vs. 6.2%, p < 0.001) than the other 30 private schools. In contrast, the nine research-intensive public medical schools produced comparable proportions of graduates pursuing primary care careers (median 36.1% vs. 36.3%, p = 0.87) and matching in family medicine residencies (median 7.4% vs. 10.0%, p = 0.37) relative to the other 66 public medical schools., Conclusions: To meet the health care needs of the US population, research-intensive private medical schools should play a more active role in promoting primary care careers for their students and graduates.

Background: The growing number of cancer survivors combined with a looming shortage of oncology specialists will require greater coordination of post-treatment care responsibilities between oncologists and primary care physicians (PCPs). However, data are limited regarding these physicians' views of cancer survivors' care., Objective: To compare PCPs and oncologists with regard to their knowledge, attitudes, and practices for follow-up care of breast and colon cancer survivors., Design and Subjects: Mailed questionnaires were completed by a nationally representative sample of 1,072 PCPs and 1,130 medical oncologists in 2009 (cooperation rate = 65%). Sampling and non-response weights were used to calculate estimates to reflect practicing US PCPs and oncologists., Main Measures: PCPs and oncologists reported their 1) preferred model for delivering cancer survivors' care; 2) assessment of PCPs' ability to perform follow-up care tasks; 3) confidence in their knowledge; and 4) cancer surveillance practices., Key Results: Compared with PCPs, oncologists were less likely to believe PCPs had the skills to conduct appropriate testing for breast cancer recurrence (59% vs. 23%, P < 0.001) or to care for late effects of breast cancer (75% vs. 38%, P < 0.001). Only 40% of PCPs were very confident of their own knowledge of testing for recurrence. PCPs were more likely than oncologists to endorse routine use of non-recommended blood and imaging tests for detecting cancer recurrence, with both groups departing substantially from guideline recommendations., Conclusion: There are significant differences in PCPs' and oncologists' knowledge, attitudes, and practices with respect to care of cancer survivors. Improving cancer survivors' care may require more effective communication between these two groups to increase PCPs' confidence in their knowledge, and must also address oncologists' attitudes regarding PCPs' ability to care for cancer survivors.

Secondary analyses of large datasets provide a mechanism for researchers to address high impact questions that would otherwise be prohibitively expensive and time-consuming to study. This paper presents a guide to assist investigators interested in conducting secondary data analysis, including advice on the process of successful secondary data analysis as well as a brief summary of high-value datasets and online resources for researchers, including the SGIM dataset compendium ( www.sgim.org/go/datasets ). The same basic research principles that apply to primary data analysis apply to secondary data analysis, including the development of a clear and clinically relevant research question, study sample, appropriate measures, and a thoughtful analytic approach. A real-world case description illustrates key steps: (1) define your research topic and question; (2) select a dataset; (3) get to know your dataset; and (4) structure your analysis and presentation of findings in a way that is clinically meaningful. Secondary dataset analysis is a well-established methodology. Secondary analysis is particularly valuable for junior investigators, who have limited time and resources to demonstrate expertise and productivity.

Background: Although Native Americans experience substantial disparities in health outcomes, little information is available regarding healthcare delivery for this population., Objective: To analyze trends in ambulatory quality of care and physician reports of barriers to quality improvement within the Indian Health Service (IHS)., Design: Longitudinal analysis of clinical performance from 2002 to 2006 within the IHS, and a physician survey in 2007., Participants: Adult patients cared for within the IHS and 740 federally employed physicians within the IHS., Main Measures: Clinical performance for 12 measures of ambulatory care within the IHS; as well as physician reports of ability to access needed health services and use of quality improvement strategies. We examined the correlation between physician reports of access to mammography and clinical performance of breast cancer screening. A similar correlation was analyzed for diabetic retinopathy screening., Key Results: Clinical performance significantly improved for 10 of the 12 measures from 2002 to 2006, including adult immunizations, cholesterol testing, and measures of blood pressure and cholesterol control for diabetes and cardiovascular disease. Breast cancer screening rates decreased (44% to 40%, p = 0.002), while screening rates for diabetic retinopathy remained constant (51%). Fewer than half of responding primary care physicians reported adequate access to high-quality specialists (29%), non-emergency hospital admission (37%), high-quality imaging services (32%), and high-quality outpatient mental health services (16%). Breast cancer screening rates were higher at sites with higher rates of physicians reporting routine access to mammography compared to sites with lower rates of physicians reporting such access (46% vs. 35%, ρ = 0.27, p = 0.04). Most physicians reported using patient registries and decision support tools to improve patient care., Conclusions: Quality of care has improved within the IHS for many services, however performance in specific areas may be limited by access to essential resources.

Background: Racial/ethnic disparities exist in the prevalence and outcomes of diabetes and hypertension in the U.S. A better understanding of the health beliefs and experiences of non-Hispanic Blacks and Latinos with these diseases could help to improve their care outcomes., Methods: We conducted eight focus groups stratified by participants' race/ethnicity, with 34 non-Hispanic Blacks and Latinos receiving care for diabetes and/or hypertension in one of 7 community health centers in Boston. Focus groups were designed to determine participants' levels of understanding about their chronic illness, assess their barriers to the management of their illness, and inquire about interventions they considered may help achieve better health outcomes., Results: Among both groups of participants, nutrition (traditional diets), genetics and environmental stress (e.g. neighborhood crime and poor conditions) were described as primary contributors to diabetes and hypertension. Unhealthy diets were reported as being a major barrier to disease management. Participants also believed that they would benefit from attending groups on management and education for their conditions that include creative ways to adopt healthy foods that complement their ethnic diets, exercise opportunities, and advice on how to prevent disease manifestation among family members., Conclusions: Interactive discussion groups focused on lifestyle modification and disease management should be created for patients to learn more about their diseases. Future research evaluating the effectiveness of interactive diabetes and hypertension groups that apply patient racial/ethnic traditions should be considered.

Background: Because Pacific Islanders and Asian Americans have often been aggregated in federal health surveys, we assessed whether they differ substantially in important health measures., Design: Retrospective analyses of the 2005-2007 Behavioral Risk Factor Surveillance System (BRFSS) surveys., Participants: A total of 2,609 Pacific Islanders, 17,892 Asians, and 894,289 whites over age 18., Measurements: We compared self-reported health risk factors (smoking, BMI > or = 25 kg/m(2), alcohol intake, physical activity, fruit/vegetable intake), chronic diseases (diabetes, hypertension, coronary heart disease, asthma, hypercholesterolemia, arthritis, fair or poor health status), and access to care (insurance status, cost barriers, and regular physician) for Pacific Islanders relative to Asian Americans and whites. Logistic regression was used to adjust for sociodemographic factors., Results: Pacific Islanders were more likely than Asian Americans to report an elevated body-mass index (adjusted odds ratio 2.26; 95% confidence interval 1.80, 2.84), current smoking (2.15; 1.57, 2.93), and high alcohol intake (3.14; 1.60, 6.18), but also more likely to report adequate physical activity (1.62; 1.23, 2.14). Pacific Islanders reported higher adjusted rates of hypertension (1.50; 1.06, 2.13), diabetes (1.82; 1.25, 2.63), asthma (2.32; 1.65, 3.25), and arthritis (1.68; 1.20, 2.35). Pacific Islanders also more frequently reported having fair or poor health (1.46; 1.05, 2.04). Most differences in self-reported health status and chronic disease outcomes were mediated by higher rates of overweight and obesity, but not higher rates of smoking, among Pacific Islanders. Differences in smoking, hypertension, and diabetes were more pronounced among Pacific Islander women than men. Relative to whites, Pacific Islanders were more likely to report a diagnosis of diabetes (1.56; 1.13, 2.14) and less likely to report arthritis (0.61; 0.46, 0.82). All other outcomes measures were statistically similar for whites and Pacific Islanders., Conclusion: Health surveys and policies should distinguish between Pacific Islanders and Asian Americans given the significantly higher rates of health risks and chronic diseases among Pacific Islanders.

Background: Completing pre-transplant evaluations may be a greater barrier to renal transplantation for blacks with end-stage renal disease (ESRD) than for whites., Objective: To determine whether social support networks facilitate completing the pre-transplant evaluation and reduce racial disparities in this aspect of care., Design, Setting, and Participants: We surveyed 742 black and white ESRD patients in four regional networks 9 months after they initiated dialysis in 1996 and 1997. Patients reported instrumental support networks (number of friends or family to help with daily activities), emotional support networks (number of friends or family available for counsel on personal problems) and dialysis center support (support from dialysis center staff and patients). The completion of pre-transplant evaluations, including preoperative risk stratification and testing, was determined by medical record reviews., Outcome Measurement: Complete renal pre-transplant evaluations., Results: Compared to patients with low levels of instrumental support, those with high levels were more likely to have complete evaluations (25% versus 46%, respectively, p < .001). In adjusted analyses, high levels of instrumental support were associated with higher rates of complete evaluations among black women (p < .05), white women (p < .05), and white men (p < .05), but not black men. Among black men, but not other groups, private insurance was a significant predictor of complete evaluations., Conclusions: Instrumental support networks may facilitate completing renal pre-transplant evaluations. Clinical interventions that supplement instrumental support should be evaluated to improve access to renal transplantation. Access to supplemental insurance may also promote complete evaluations for black patients.

Background: Most colorectal cancers develop from adenomatous polyps. National guidelines recommend surveillance colonoscopy within 5 years after such polyps are removed., Objective: To determine whether surveillance colonoscopy can be increased among overdue patients by reminders to their primary physicians., Design: Randomized, controlled trial of patient-specific reminders mailed to 141 physicians in 2 Massachusetts primary care networks during April, 2006., Patients: Seven hundred seventeen patients who had colorectal adenomas removed during 1995 through 2000 and no follow-up colonoscopy identified via automated review of electronic records through March, 2006., Measurements and Main Results: The use of colonoscopy and detection of new adenomas or cancer were assessed at 6 months by a blinded medical record review in all patients. Among 358 patients whose physicians received reminders, 33 (9.2%) patients underwent colonoscopy within 6 months, compared with 16 (4.5%) of 359 patients whose physicians did not receive reminders (P = 0.009). In prespecified subgroups, this effect did not differ statistically between 2 primary care networks, elderly and nonelderly patients, or women and men (all P > 0.60 by Breslow-Day test). New adenomas or cancer were detected in 14 (3.9%) intervention patients and 6 (1.7%) control patients (P = 0.06), representing 42.4% and 37.5% of patients who underwent colonoscopy in each group, respectively. Despite using advanced electronic health records to identify eligible patients, 22.5% of enrolled patients had a prior follow-up colonoscopy ascertained only by visual record review, and physicians reported 27.9% of intervention patients were no longer active in their practice., Conclusions: Among patients with prior colorectal adenomas, physician reminders increased the use of surveillance colonoscopy, but better systems are needed to identify eligible patients (ClinicalTrials.gov ID number NCT00397969).

Background: Primary-care clinicians can play an important role in reducing racial disparities in diabetes care., Objective: The objective of the study is to determine the views of primary-care clinicians regarding racial disparities in diabetes care., Design: The design of the study is through a survey of primary-care clinicians (response rate = 86%)., Participants: The participants of the study were 115 physicians and 54 nurse practitioners and physician assistants within a multisite group practice in 2007., Measurements and Main Results: We identified sociodemographic characteristics of each clinician's diabetic patient panel. We fit multivariable logistic regression models to identify predictors of supporting the collection of data on patients' race and acknowledging the existence of racial disparities among patients personally treated. Among respondents, 79% supported the collection of data on patients' race. Whereas 88% acknowledged the existence of racial disparities in diabetes care within the U.S. health system, only 40% reported their presence among patients personally treated. Clinicians caring for greater than or equal to 50% minority patients were more likely to support collection of patient race data (adjusted odds ratio [OR] 9.0; 95% confidence interval [CI] 1.2-65.0) and report the presence of racial disparities within their patient panel (adjusted OR 12.0; 95% CI 2.5-57.7). Clinicians were more likely to perceive patient factors than physician or health system factors as mediators of racial disparities; however, most supported interventions such as increasing clinician awareness (84%) and cultural competency training (88%)., Conclusions: Most primary-care clinicians support the collection of data on patients' race, but increased awareness about racial disparities at the local level is needed as part of a targeted effort to improve health care for minority patients.

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.

Background: Variations in hospice use are not well understood., Objective: Assess whether care before death, including the types of physicians seen, number of outpatient visits, and hospitalizations, was associated with hospice use and the timing of enrollment., Design/setting: Observational study of a population-based sample of advanced breast cancer patients included in the Surveillance, Epidemiology, and End Results--Medicare database., Patients: There were 4,455 women aged > or =65 diagnosed with stage III/IV breast cancer during 1992-1999 who died before the end of 2001., Measurements: Hospice use and, among enrollees, enrollment within 2 weeks of death. Independent variables of interest included hospitalizations, outpatient visits, and physicians seen before death., Results: Adjusted hospice use rates were higher for hospitalized patients (45% if hospitalized for 1-7 days, 46% if 8-20 days, 35% if > or =21 days) than those not hospitalized (31%, P < 0.001). Adjusted rates were also higher among patients seeing a cancer specialist and primary care provider (PCP; 41%) and those seeing a cancer specialist and no PCP (38%) than among those seeing a PCP and no cancer specialist (30%) or neither type of physician (22%; P < 0.001). Hospice use also increased with increasing frequency of outpatient visits (P < 0.001). Hospitalizations, physicians seen, and visits were not associated with referral within 2 weeks of death (all P > or = 0.10)., Discussion: Care before death is associated with hospice use among older women with advanced breast cancer. Additional research is needed to understand better how differences in patient characteristics and disease status influence cancer care before death and the role of various types of physicians in hospice referrals.

Background: Physicians often rely on colleagues for new information and advice about the care of their patients., Objective: Evaluate the network of influential discussions among primary care physicians in a hospital-based academic practice., Design: Survey of physicians about influential discussions with their colleagues regarding women's health issues. We used social network analysis to describe the network of discussions and examined factors predictive of a physician's location in the network., Subjects: All 38 primary care physicians in a hospital-based academic practice., Measurements: Location of physician within the influential discussion network and relationship with other physicians in the network., Results: Of 33 responding physicians (response rate = 87%), the 5 reporting expertise in women's health were more likely than others to be cited as sources of influential information (odds ratio [OR] 6.81, 95% Bayesian confidence interval [CI] 2.25-23.81). Physicians caring for more women were also more often cited (OR 1.03, 95% CI 1.01-1.05 for a 1 percentage-point increase in the proportion of women patients). Influential discussions were more frequent among physicians practicing in the same clinic within the practice than among those in different clinics (OR 5.03, 95% CI 3.10-8.33) and with physicians having more weekly clinical sessions (OR 1.33, 95% CI 1.15 to 1.54 for each additional session)., Conclusions: In the primary care practice studied, physicians obtained information from colleagues with greater expertise and experience as well as colleagues who were accessible based on location and schedule. It may be possible to organize practices to promote more rapid dissemination of high-quality evidence-based medicine.

Background: Little is known about the relation between perceptions of health care discrimination and use of health services., Objectives: To determine the prevalence of perceived discrimination in health care, its association with use of preventive services, and the contribution of perceived discrimination to disparities in these services by race/ethnicity, gender, and insurance status., Design, Setting, and Participants: Cross-sectional study of 54,968 respondents to the 2001 California Health Interview Survey., Measurements: Subjects were asked about experience with discrimination in receiving health care and use of 6 preventive health services, all within the previous 12 months., Methods: We used multivariate logistic regression with propensity-score methods to examine the adjusted relationship between perceived discrimination and receipt of preventive care., Results: Discrimination was reported by 4.7% of respondents, and among these respondents the most commonly reported reasons were related to type of insurance (27.6%), race or ethnicity (13.7%), and income (6.7%). In adjusted analyses, persons who reported discrimination were less likely to receive 4 preventive services (cholesterol testing for cardiovascular disease, hemoglobin A1c testing and eye exams for diabetes, and flu shots), but not 2 other services (aspirin for cardiovascular disease, prostate specific antigen testing). Adjusting for perceived discrimination did not significantly change the relative likelihood of receipt of preventive care by race/ethnicity, gender, and insurance status., Conclusions: Persons who report discrimination may be less likely to receive some preventive health services. However, perceived discrimination is unlikely to account for a large portion of observed disparities in receipt of preventive care.

Background: Gender differences in inpatient quality of care are well known. However, whether men and women receive equivalent ambulatory care is less well understood., Objective: To study gender differences in quality of care for patients receiving primary care in the Veterans Affairs (VA) Health Care System., Design: Cross-sectional samples of VA enrollees during fiscal years 1999 to 2000., Participants: Samples of 6,442 to 86,405 men and women treated at VA facilities for whom at least 1 of 9 quality measures was available., Measurements: Appropriate general preventive services (pneumococcal vaccination, influenza vaccination, colorectal cancer screening), and specific services for diabetes (annual hemoglobin A1c [HbA1c] testing, good glycemic control, annual diabetic eye exam), hypertension (good blood pressure control), or prior myocardial infarction (use of beta-blockers or aspirin)., Results: In adjusted analyses, there were no substantial gender differences in rates of appropriate care. For women compared with men, the adjusted relative risk for appropriate care ranged from 0.96 for blood pressure control (95% confidence interval: 0.93 to 0.99; P=.02) to 1.05 for HbA1c< or =8.0% (95% confidence interval: 1.03 to 1.07; P<.01). Analyses stratified by age demonstrated equivalent care between men and women in 9 of the 14 subgroups evaluated., Conclusions: In this large national health care system that predominantly serves men, the quality of ambulatory care is equivalent for women and men on numerous measures.

Objective: To determine whether outpatient cholesterol management varies by gender or race among patients with atherosclerosis, and assess factors related to subsequent cholesterol control., Design: Retrospective cohort study., Setting: Primary care clinics affiliated with an academic medical center., Participants: Two hundred forty-three patients with coronary heart disease, cerebrovascular disease, or peripheral vascular disease and low-density lipoprotein cholesterol (LDL-C)>130 mg/dl., Measurements and Main Results: The primary process of care assessed for 1,082 office visits was cholesterol management (medication intensification or LDL-C monitoring). Cholesterol management occurred at 31.2% of women's and 38.5% of men's visits (P=.01), and 37.3% of black and 31.7% of white patients' visits (P=.09). Independent predictors of cholesterol management included female gender (adjusted risk ratio [ARR], 0.77; 95% confidence interval [CI], 0.60 to 0.97), seeing a primary care clinician other than the patient's primary care physician (ARR, 0.23; 95% CI, 0.11 to 0.45), and having a new clinical problem addressed (ARR, 0.60; 95% CI, 0.48 to 0.74). After 1 year, LDL-C <130 mg/dl occurred less often for women than men (41% vs 61%; P=.003), black than white patients (39% vs 58%; P=.01), and patients with only Medicare insurance than with commercial insurance (37% vs 58%; P=.008). Adjustment for clinical characteristics and management attenuated the relationship between achieving an LDL-C <130 mg/dl and gender., Conclusions: In this high-risk population with uncontrolled cholesterol, cholesterol management was less intensive for women than men but similar for black and white patients. Less intense cholesterol management accounted for some of the disparity in cholesterol control between women and men but not between black and white patients.

Objective: Although nearly all elderly Americans are insured through Medicare, there is substantial variation in their use of services, which may influence detection of serious illnesses. We examined outpatient care in the 2 years before breast cancer diagnosis to identify women at high risk for limited care and assess the relationship of the physicians seen and number of visits with stage at diagnosis., Design: Retrospective cohort study using cancer registry and Medicare claims data., Patients: Population-based sample of 11,291 women aged > or =67 diagnosed with breast cancer during 1995 to 1996., Measurements and Main Results: Ten percent of women had no visits or saw only physicians other than primary care physicians or medical specialists in the 2 years before diagnosis. Such women were more often unmarried, living in urban areas or areas with low median incomes (all P> or =.01). Overall, 11.2% were diagnosed with advanced (stage III/IV) cancer. The adjusted rate was highest among women with no visits (36.2%) or with visits to physicians other than primary care physicians or medical specialists (15.3%) compared to women with visits to either a primary care physician (8.6%) or medical specialist (9.4%) or both (7.8%) (P<.001). The rate of advanced cancer also decreased with increasing number of visits (P<.001)., Conclusions: Even within this insured population, many elderly women had limited or no outpatient care in the 2 years before breast cancer diagnosis, and these women had a markedly increased risk of advanced-stage diagnosis. These women, many of whom were unmarried and living in poor and urban areas, may benefit from targeted outreach or coverage for preventive care visits.

Objective: To describe the practice settings, financial arrangements, and management strategies experienced by generalist physicians and identify factors associated with reporting pressure to limit referrals, pressure to see more patients, and career dissatisfaction., Design: Cross-sectional mail survey., Participants and Setting: Six hundred nineteen generalist physicians (62% response rate) caring for managed care patients in 3 Minnesota health plans during 1999., Measurements and Main Results: Twenty-six percent of physicians reported pressure to limit referrals. In adjusted analyses, female physicians and those who were board certified acted as gatekeepers for most of their patients, received incentives based on performance reports and quality profiles, and received direct income from capitation, and were more likely than others to report this pressure (all P <.05). Sixty-two percent reported pressure to see more patients. In adjusted analyses, this pressure was more frequent among physicians in practices owned by health systems, those using physician extenders, and among physicians paid by salary with performance adjustment or those receiving at least some capitation (all P <.05). One-quarter (24%) of physicians were dissatisfied with their career in medicine. In adjusted analyses, physicians reporting pressure to limit referrals (risk ratio, 1.12; 95% confidence interval, 1.01 to 1.19) and those reporting pressure to see more patients (risk ratio, 1.37; 95% confidence interval, 1.08 to 1.66) were more likely to be dissatisfied than other physicians., Conclusions: Pressures to limit referrals and to see more patients are common, particularly among physicians paid based on productivity or capitation, and they are associated with career dissatisfaction. Whether future changes in practice arrangements or compensation strategies can decrease such physician-reported pressures, and ultimately improve physician satisfaction, will be an important area for future study.

Objective: To assess use of cholesterol-lowering therapy and related beliefs among middle-aged adults after myocardial infarction., Design: Telephone survey and administrative data., Setting: National managed-care company., Participants: Six hundred ninety-six adults age 30 to 64 surveyed in 1999, approximately 1 to 2 years after a myocardial infarction., Measurements: Use of cholesterol-lowering drugs, beliefs about the importance of lowering cholesterol, and knowledge of personal cholesterol level, adjusting for demographic and clinical factors with logistic regression., Main Results: Among respondents, 62.5% reported they were taking a cholesterol-lowering drug. In adjusted analyses, these drugs were used significantly less often by African-American patients and those with congestive heart failure or peripheral vascular disease, and more often by college graduates, patients with hypertension, and those who had seen a cardiologist since their myocardial infarction. Lowering cholesterol was viewed as "very important"; by 87.1% of patients, but significantly less often by smokers and more often by those who had undergone coronary angioplasty or bypass surgery. Only 42.5% of respondents knew their cholesterol level, and this knowledge was significantly less common among less-educated or less-affluent patients, African-American patients, and patients who smoked or had diabetes or peripheral vascular disease., Conclusions: Although most patients recognized the importance of lowering cholesterol after myocardial infarction, several clinical and demographic subgroups were less likely to receive cholesterol-lowering therapy, and many patients were unaware of their cholesterol level. Health-care providers and managed-care plans can use these findings to promote cholesterol testing and treatment for patients with coronary heart disease who are most likely to benefit from these efforts.

Objective: To examine whether patients' experiences with nontechnical aspects of care such as patient education and discharge planning are associated with long-term outcomes., Design: Observational cohort study., Setting: Twenty-three New Hampshire hospitals during 1996 and 1997., Participants: Acute myocardial infarction (AMI) patients (N=2,272) enrolled prior to discharge., Measurements: Surveys asking about problems with care and health were mailed to patients 1, 3, and 12 months after discharge. Patients were stratified into "worse" or "better" care groups on the basis of their hospital care problem score. Outcomes included self-reported overall health, physical health, mental health, chest pain, and shortness of breath. Other clinical measures were obtained from hospital discharge abstracts., Main Results: The 1-, 3-, and 12-month surveys were returned by 1,346 (59.2%), 1,046 (46%), and 964 (42.4%) enrolled patients, respectively. The primary analytic cohort consisted of the 762 patients who completed both the 1- and 12-month surveys. After adjustment for postdischarge health status and other clinical factors, patients experiencing worse hospital care had lower ratings of overall health (48.4 vs 52.5 on 100-point scale; P=.02) and physical health (59.7 vs 68.4; P <.001), and were more likely to have chest pain (odds ratio [OR], 1.6; confidence interval [CI], 1.0 to 2.4; P=.04) 12 months after their AMI than other patients. However, differences in reports of chest pain were reduced if patients reporting worse hospital care had better experiences with subsequent ambulatory care., Conclusions: Patients' experiences with nontechnical processes of AMI hospital care are associated with long-term outcomes; however the association between a negative hospital experience and subsequent chest pain may be offset by more positive outpatient experiences.

Little is known about the prevalence of focused expertise (special areas of expertise within a clinical field) among physicians, yet such expertise may influence how care is delivered. We surveyed general internists, pediatricians, cardiologists, infectious disease specialists, and orthopedic surgeons to describe the prevalence of focused expertise and identify associated physician and practice characteristics. About one quarter of generalists and three quarters of specialists reported a focused expertise within their primary specialty. Hospital-based physicians more often reported such expertise, and physicians reimbursed by capitation less often reported expertise. Learning how focused expertise affects processes and outcomes of care will contribute to decisions about physician training and staffing of medical groups.

To assess attitudes that could contribute to gender differences in the use of coronary procedures, we surveyed 322 patients presenting for exercise testing at a major teaching hospital. Adjusting for sociodemographic and clinical factors, women and men did not differ significantly in their willingness to seek a second opinion, reduce physical activity, or take drugs to avoid major cardiac surgery, but men were more likely than women to describe themselves as risk takers on a three-item personality measure (adjusted odds ratio 2.5; 95% confidence interval 1.4-4.6). Patients' attitudes about risk should be explored further in studies of gender differences in the use of coronary procedures.