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

Background: Patient complexity is often operationalized by counting multiple chronic conditions (MCC) without considering contextual factors that can affect patient risk for adverse outcomes.Objective: Our objective was to develop a conceptual model of complexity addressing gaps identified in a review of published conceptual models.Data Sources: We searched for English-language MEDLINE papers published between 1 January 2004 and 16 January 2014. Two reviewers independently evaluated abstracts and all authors contributed to the development of the conceptual model in an iterative process.Results: From 1606 identified abstracts, six conceptual models were selected. One additional model was identified through reference review. Each model had strengths, but several constructs were not fully considered: 1) contextual factors; 2) dynamics of complexity; 3) patients' preferences; 4) acute health shocks; and 5) resilience. Our Cycle of Complexity model illustrates relationships between acute shocks and medical events, healthcare access and utilization, workload and capacity, and patient preferences in the context of interpersonal, organizational, and community factors.Conclusions/implications: This model may inform studies on the etiology of and changes in complexity, the relationship between complexity and patient outcomes, and intervention development to improve modifiable elements of complex patients. [ABSTRACT FROM AUTHOR]

Personal autonomy is widely valued. Recognition of its vulnerability in health care contexts led to the inclusion of respect for autonomy as a key concern in biomedical ethics. The principle of respect for autonomy is usually associated with allowing or enabling patients to make their own decisions about which health care interventions they will or will not receive. In this paper, we suggest that a strong focus on decision situations is problematic, especially when combined with a tendency to stress the importance of patients' independence in choosing. It distracts attention from other important aspects of and challenges to autonomy in health care. Relational understandings of autonomy attempt to explain both the positive and negative implications of social relationships for individuals' autonomy. They suggest that many health care practices can affect autonomy by virtue of their effects not only on patients' treatment preferences and choices, but also on their self-identities, self-evaluations and capabilities for autonomy. Relational understandings de-emphasise independence and facilitate well-nuanced distinctions between forms of clinical communication that support and that undermine patients' autonomy. These understandings support recognition of the value of good patient-professional relationships and can enrich the specification of the principle of respect for autonomy. [ABSTRACT FROM AUTHOR]

Background: Failed referrals for specialty care are common and often represent medical errors. Technological structures and processes account for many failures. Scheduling appointments for subspecialty evaluation is a first step in outpatient referral and consultation.Objective: We determined whether moving from paper-based referrals to a Web-based system with automated tracking features was associated with greater scheduling of appointments among referred patients.Design: Staggered implementation of a quality-improvement project, with comparison of intervention and control groups.Participants: Patients 21 or more years of age referred from any of 11 primary-care clinics to any of 25 specialty clinics.Interventions: Faxed referrals were replaced by a Web-based application shared by generalists and specialists, with enhanced communications and automated notification to the specialty office.Measurements: We compared scheduling before and after implementation and time from referral to appointment. A logistic regression analysis adjusted for demographics.Main Results: Among 40,487 referrals, 54% led to scheduled specialty visits before intervention, compared to 83% with intervention. The median time to appointment was 168 days without intervention and 78 days with intervention. Scheduling increased more when duplicate referrals were not generated (54% for single orders, 24% for multiple orders). After adjustment, referrals with the intervention were more than twice as likely to have scheduled visits.Conclusions: With a new Web-based referrals system, referrals were more than twice as likely to lead to a scheduled visit. This system improves access to specialty medical services. [ABSTRACT FROM AUTHOR]

Objective: To comply with pain management standards, Bellevue Hospital in New York City implemented a mandatory computerized pain assessment screen (PAS) in its electronic medical record (EMR) system for every outpatient encounter. We assessed provider acceptance of the instrument and examined whether the intervention led to increased documentation of pain-related diagnoses or inquiries.Design: Cross-sectional survey; a pre- and posthistorically controlled observational study.Subjects and Measurements: The utility of the computerized tool to medicine housestaff and attendings was assessed by an anonymous survey. We conducted an electronic chart review comparing all adult primary care patient encounters over a 2-day period 6 months prior to implementation of the PAS and on 2 days 6 months after its implementation.Results: Forty-seven percent of survey respondents felt that the computerized assessment tool was "somewhat difficult" or "very difficult" to use. The majority of respondents (79%) felt the tool did not change their pain assessment practice. Of 265 preintervention patients and 364 postintervention patients seen in the clinic, 42% and 37% had pain-related diagnoses, respectively (P=.29). Pain inquiry by the physician was noted for 49% of preintervention patients and 44% of the postintervention patients (P=.26). In 55% of postintervention encounters, there was discordance between the pain documentation using the PAS tool and the free text section of the medical note.Conclusion: A mandatory computerized pain assessment tool did not lead to an increase in pain-related diagnoses and may have hindered the documentation of pain assessment because of the perceived burden of using the application. [ABSTRACT FROM AUTHOR]

Background: Financial burden can affect healthcare utilization. Few studies have assessed the short-term associations between material (debt, trouble paying rent) and psychological (worry or distress about affording future healthcare) financial risks, and subsequent outpatient and emergency healthcare use. Worry was defined as concerns about affording future healthcare.Objective: Examine whether worry about affording healthcare is associated with healthcare utilization when controlling for material risk and general anxiety DESIGN: Longitudinal observational study PARTICIPANTS: Kaiser Permanente members with exchange-based federally subsidized health insurance (n = 450, 45% response rate) MAIN MEASURES: Survey measures of financial risks (material difficulty paying for medical care and worry about affording healthcare) and general anxiety. Healthcare use (primary care, urgent care, emergency department, and outpatient specialty visits) in the 6 months following survey completion.Key Results: Emergency department and primary care visits were not associated with material risk, worry about affording care, or general anxiety in individual and pooled analyses (all 95% confidence intervals (CI) for relative risk (RR) included 1). Although no individual predictor was associated with urgent care use (all 95% CIs for RR included 1), worry about affording prescriptions (relative risk (RR) = 2.01; 95% CI 1.14, 3.55) and general anxiety (RR = 0.38; 95% CI 0.15, 0.95) were significant when included in the same model, suggesting the two confounded each other. Worry about affording healthcare services was associated with fewer specialty care visits (RR = 0.40; 95% CI 0.25, 0.64) even when controlling for material risk and general anxiety, although general anxiety was also associated with more specialty care visits (RR = 1.98; 95% CI, 1.23, 3.18).Conclusions: Screening for both general anxiety and financial worry may assist with specialty care utilization. Identifying these concerns may provide more opportunities to assist patients. Future research should examine interventions to reduce worry about cost of care. [ABSTRACT FROM AUTHOR]

Background: Innovations and improvements in care delivery are often not spread across all settings that would benefit from their uptake. Scale-up and spread efforts are deliberate efforts to increase the impact of innovations successfully tested in pilot projects so as to benefit more people. The final stages of scale-up and spread initiatives must contend with reaching hard-to-engage sites.Objective: To describe the process of scale-up and spread initiatives, with a focus on hard-to-engage sites and strategies to approach them.Design: Qualitative content analysis of systematically identified literature and key informant interviews.Participants: Leads from large magnitude scale-up and spread projects.Approach: We conducted a systematic literature search on large magnitude scale-up and spread and interviews with eight project leads, who shared their perspectives on strategies to scale-up and spread clinical and administrative practices across healthcare systems, focusing on hard-to-engage sites. We synthesized these data using content analysis.Key Results: Searches identified 1919 titles, of which 52 articles were included. Thirty-four discussed general scale-up and spread strategies, 11 described hard-to-engage sites, and 7 discussed strategies for hard-to-engage sites. These included publications were combined with interview findings to describe a fourth phase of the national scale-up and spread process, common challenges for spreading to hard-to-engage sites, and potential benefits of working with hard-to-engage sites, as well as useful strategies for working with hard-to-engage sites.Conclusions: We identified scant published evidence that describes strategies for reaching hard-to-engage sites. The sparse data we identified aligned with key informant accounts. Future work could focus on better documentation of the later stages of spread efforts, including specific tailoring of approaches and strategies used with hard-to-engage sites. Spread efforts should include a "flexible, tailored approach" for this highly variable group, especially as implementation science is looking to expand its impact in routine care settings. [ABSTRACT FROM AUTHOR]

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

Background: For at least the past two decades, medical educators have worked to improve patient communication and health care delivery to diverse patient populations; despite efforts, patients continue to report prejudice and bias during their clinical encounters. Targeted instruction in implicit bias recognition and management may promote the delivery of equitable care, but students at times resist this instruction. Little guidance exists to overcome this resistance and to engage students in implicit bias instruction; instruction over time could lead to eventual skill development that is necessary to mitigate the influence of implicit bias on clinical practice behaviors.Objective: To explore student perceptions of challenges and opportunities when participating in implicit bias instruction.Approach: We conducted a qualitative study that involved 11 focus groups with medical students across each of the four class years to explore their perceptions of challenges and opportunities related to participating in such instruction. We analyzed transcripts for themes.Key Results: Our analysis suggests a range of attitudes toward implicit bias instruction and identifies contextual factors that may influence these attitudes. The themes were (1) resistance; (2) shame; (3) the negative role of the hidden curriculum; and (4) structural barriers to student engagement. Students expressed resistance to implicit bias instruction; some of these attitudes are fueled from concerns of anticipated shame within the learning environment. Participants also indicated that student engagement in implicit bias instruction was influenced by the hidden curriculum and structural barriers.Conclusions: These insights can inform future curriculum development efforts. Considerations related to instructional design and programmatic decision-making are highlighted. These considerations for implicit bias instruction may provide useful frameworks for educators looking for opportunities to minimize student resistance and maximize engagement in multi-session instruction in implicit bias recognition and management. [ABSTRACT FROM AUTHOR]

Background: Decision makers are increasingly tasked with reducing health care costs, but the public may be mistrustful of these efforts. Public deliberation helps gather input on these types of issues by convening a group of diverse individuals to learn about and discuss values-based dilemmas.Objective: To explore public perceptions of health care costs and how they intersect with medical mistrust.Design and Participants: This mixed-methods study analyzed data from a randomized controlled trial including four public deliberation groups (n = 96) and a control group (n = 348) comprising English-speaking adults aged 18 years and older. Data were collected in 2012 in four U.S. regions.Approach: We used data from four survey items to compare attitude shifts about costs among participants in deliberation groups to participants in the control group. We qualitatively analyzed deliberation transcripts to identify themes related to attitude shifts and to provide context for quantitative results about attitude shifts.Key Results: Deliberation participants were significantly more likely than control group participants to agree that doctors and patients should consider cost when making treatment decisions (β = 0.59; p < 0.01) and that people should consider the effect on group premiums when making treatment decisions (β = 0.48; p < 0.01). Qualitatively, participants mistrusted the health care system's profit motives (e.g., that systems prioritize making money over patient needs); however, after grappling with patient/doctor autonomy and learning about and examining their own views related to costs during the process of deliberation, they largely concluded that payers have the right to set some boundaries to curb costs.Conclusions: Individuals who are informed about costs may be receptive to boundaries that reduce societal health care costs, despite their mistrust of the health care system's profit motives, especially if decision makers communicate their rationale in a transparent manner. Future work should aim to develop transparent policies and practices that earn public trust. [ABSTRACT FROM AUTHOR]

Background: With emerging global payment structures, medical systems need to understand longer-term impacts of care transition strategies.Objective: To determine the effect of a care transition program using patient navigators (PNs) on health service utilization among high-risk safety-net patients over a 180-day period.Design: Randomized controlled trial conducted October 2011 through April 2013.Participants: Patients admitted to the general medicine service with ≥1 readmission risk factor: (1) age ≥ 60; (2) in-network inpatient admission within prior 6 months; (3) index length of stay ≥ 3 days; or (4) admission diagnosis of heart failure or (5) chronic obstructive pulmonary disease. The analytic sample included 739 intervention patients, 1182 controls.Interventions: Through hospital visits and 30 days of post-discharge telephone outreach, PNs provided coaching and assistance with medications, appointments, transportation, communication with primary care, and self-care.Main Measures: Primary outcomes: (1) hospital-based utilization, a composite of ED visits and hospital admissions; (2) hospital admissions; (3) ED visits; and (4) outpatient visits. We evaluated outcomes following an index discharge, stratified by patient age (≥ 60 and < 60 years), using a 180-day time frame divided into six 30-day periods.Key Results: The PN program produced starkly different outcomes by patient age. Among older PN patients, hospital-based utilization was consistently lower than controls, producing an 18.7% cumulative decrease at 180 days (p = 0.038); outpatient visits increased in the critical first 30-day period (p = 0.006). Among younger PN patients, hospital-based utilization was 31.7% (p = 0.038) higher at 180 days, largely reflecting sharply higher utilization in the initial 30 days (p = 0.002), with non-significant changes thereafter; outpatient visits experienced no significant changes.Conclusions: A PN program serving high-risk safety-net patients differentially impacted patients based on age, and among younger patients, outcomes varied over time. Our findings highlight the importance for future research to evaluate care transition programs among different subpopulations and over longer time periods. [ABSTRACT FROM AUTHOR]

Introduction: In Argentina, the national guidelines for lipid control emphasize the use of relatively inexpensive low- or moderate-potency statins by patients at high risk (>20 %) of a cardiovascular event. The objective of this study was to compare the impact and costs of the current national CVD prevention guidelines with regard to morbidity and mortality in Argentina with the impact and costs of three strategies that incorporate high-potency statins.Methods: We used the CVD Policy Model-Argentina to model the proposed interventions. This model is a national-scale, state-transition (Markov) computer simulation model of the CVD incidence, prevalence, mortality, and costs in adults 35-84 years of age. We modeled three scenarios: scenario 1 lowers the risk threshold for treatment to >10 % according the Framingham Risk Score (FRS); scenario 2 intensifies statin potency under current treatment thresholds; and scenario 3 combines both scenarios by lowering the treatment threshold to ≥10 % FRS and intensifying statin potency.Results: Scenario 1 would translate into 1400 fewer MIs and 500 fewer CHD deaths every year, a 3 % and 2 % reduction, respectively. Scenario 2 would lead to 2000 fewer MIs and 1000 fewer CHD deaths every year. Scenario 3 would result in the greatest reduction in MIs and CHD deaths, with 3400 fewer MIs and 1400 fewer CHD deaths every year, which translates to a 7 % and 6 % reduction, respectively. All scenarios were cost-effective if the cost of a high-potency statin pill was under US$0.25.Conclusion: Incorporating those individuals with greater than 10 % cardiovascular risk and the use of high-potency statins into Argentina's national lipid guidelines could result in fewer CHD deaths and events at a reasonable cost. [ABSTRACT FROM AUTHOR]

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

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

Background: Many Veterans treated within the VA Healthcare System (VA) are also enrolled in fee-for-service (FFS) Medicare and receive treatment outside the VA. Prior research has not accounted for the multiple ways that Veterans receive services across healthcare systems.Objective: We aimed to establish a typology of VA and Medicare utilization among dually enrolled Veterans with type 2 diabetes.Design: This was a retrospective cohort.Participants: 316,775 community-dwelling Veterans age ≥ 65 years with type 2 diabetes who were dually enrolled in the VA and FFS Medicare in 2008-2009.Methods: Using latent class analysis, we identified classes of Veterans based upon their probability of using VA and Medicare diabetes care services, including patient visits, laboratory tests, glucose test strips, and medications. We compared the amount of healthcare use between classes and identified factors associated with class membership using multinomial regression.Key Results: We identified four distinct latent classes: class 1 (53.9%) had high probabilities of VA use and low probabilities of Medicare use; classes 2 (17.2%), 3 (21.8%), and 4 (7.0%) had high probabilities of VA and Medicare use, but differed in their Medicare services used. For example, Veterans in class 3 received test strips exclusively through Medicare, while Veterans in class 4 were reliant on Medicare for medications. Living ≥ 40 miles from a VA predicted membership in classes 3 (OR 1.1, CI 1.06-1.15) and 4 (OR 1.11, CI 1.04-1.18), while Medicaid eligibility predicted membership in class 4 (OR 4.30, CI 4.10-4.51).Conclusions: Veterans with diabetes can be grouped into four distinct classes of dual health system use, representing a novel way to characterize how patients use multiple services across healthcare systems. This classification has applications for identifying patients facing differential risk from care fragmentation. [ABSTRACT FROM AUTHOR]

Background: Over the last decade, various pay-for-performance (P4P) programs have been implemented to improve quality in health systems, including the VHA. P4P programs are complex, and their effects may vary by design, context, and other implementation processes. We conducted a systematic review and key informant (KI) interviews to better understand the implementation factors that modify the effectiveness of P4P.Methods: We searched PubMed, PsycINFO, and CINAHL through April 2014, and reviewed reference lists. We included trials and observational studies of P4P implementation. Two investigators abstracted data and assessed study quality. We interviewed P4P researchers to gain further insight.Results: Among 1363 titles and abstracts, we selected 509 for full-text review, and included 41 primary studies. Of these 41 studies, 33 examined P4P programs in ambulatory settings, 7 targeted hospitals, and 1 study applied to nursing homes. Related to implementation, 13 studies examined program design, 8 examined implementation processes, 6 the outer setting, 18 the inner setting, and 5 provider characteristics. Results suggest the importance of considering underlying payment models and using statistically stringent methods of composite measure development, and ensuring that high-quality care will be maintained after incentive removal. We found no conclusive evidence that provider or practice characteristics relate to P4P effectiveness. Interviews with 14 KIs supported limited evidence that effective P4P program measures should be aligned with organizational goals, that incentive structures should be carefully considered, and that factors such as a strong infrastructure and public reporting may have a large influence.Discussion: There is limited evidence from which to draw firm conclusions related to P4P implementation. Findings from studies and KI interviews suggest that P4P programs should undergo regular evaluation and should target areas of poor performance. Additionally, measures and incentives should align with organizational priorities, and programs should allow for changes over time in response to data and provider input. [ABSTRACT FROM AUTHOR]

The article discusses a project undertaken at Brigham and Womens Hospital (BWH) that focused on electronic referral order systems established in the U.S. and internationally with broad uptake by primary care physicians (PCPs) and improved physician satisfaction. It aims to add to the existing literature on eReferral systems by tracking physician satisfaction across an entire health system and using administrative claims to look at the impact of eReferral on total specialist utlization.

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

Background: Healthcare providers previously using older electronic health records (EHRs) with electronic prescribing (e-prescribing) are transitioning to newer systems to be eligible for federal meaningful use incentives. Little is known about the safety effects of transitioning between systems.Objective: To assess the effect of transitioning between EHR systems on rates and types of prescribing errors, as well as provider perceptions about the effect on prescribing safety.Design, Participants: Prospective, case study of 17 physicians at an academic-affiliated ambulatory clinic from February 2008 through August 2009. All physicians transitioned from an older EHR with minimal clinical decision support (CDS) for e-prescribing to a newer EHR with more robust CDS.Main Measurements: Prescribing errors were identified by standardized prescription and chart review. A novel survey instrument was administered to evaluate provider perceptions about prescribing safety.Key Results: We analyzed 1298 prescriptions at baseline, 1331 prescriptions 12 weeks post-implementation, and 1303 prescriptions one year post-implementation. Overall prescribing error rates were highest at baseline (35.7 per 100 prescriptions, 95% confidence interval (CI) 23.2-54.8) and lowest one year post-implementation (12.2 per 100 prescriptions, 95% CI 8.6-17.4) (p < 0.001). Improvement in prescribing safety was mainly a result of reducing inappropriate abbreviation errors. However, rates for non-abbreviation prescribing errors were significantly higher at 12 weeks post-implementation than at baseline (17.7 per 100 prescriptions, 95% CI 9.5-33.0 versus 8.5 per 100 prescriptions, 95% CI 4.6-15.9) (p <0.001) and no different at baseline than one year (10.2 per 100 prescriptions, 95% CI 6.2-18.6) (p = 0.337). Survey results complemented quantitative findings.Conclusions: Results from this case study suggest that transitioning between systems, even to those with more robust CDS, may pose important safety threats. Recognizing the challenges associated with transitions and refining CDS within systems may help maximize safety benefits. [ABSTRACT FROM AUTHOR]

Background: Surrogate accuracy in predicting patient treatment preferences (i.e., what patients want) has been studied extensively, but it is not known whether surrogates can predict how patients want loved ones to make end-of-life decisions on their behalf.Objective: To evaluate the ability of family members to correctly identify the preferences of seriously-ill patients regarding family involvement in decision making.Design: Cross-sectional survey.Participants: Twenty-five pancreatic cancer and 27 amyotrophic lateral sclerosis (ALS) patients and their family members (52 dyads total).Main Measures: Patients and family members completed the Decision Control Preferences (DCP) scale regarding patient preferences for family involvement in health care decisions using conscious and unconscious scenarios.Key Results: Patient and family member agreement was 56% (29/52 dyads) for the conscious scenario (kappa 0.29) and 46% (24/52 dyads) for the unconscious scenario (kappa 0.15). Twenty-four family members identified the patient's preference as independent in the unconscious scenario, but six of these patients actually preferred shared decision making and six preferred reliant decision making. In the conscious scenario, preference for independent decision making was associated with higher odds of patient-family agreement (AOR 5.28, 1.07-26.06). In the unconscious scenario, cancer patients had a higher odds of agreement than ALS patients (AOR 3.86; 95% CI 1.02-14.54).Conclusion: Family members were often unable to correctly identify patient preferences for family involvement in end-of-life decision making, especially when patients desired that decisions be made using the best-interest standard. Clinicians and family members should consider explicitly eliciting patient preferences for family involvement in decision making. Additional research is still needed to identify interventions to improve family member understanding of patient preferences regarding the decision-making process itself. [ABSTRACT FROM AUTHOR]

Background: Homeless people have high rates of hospitalization and emergency department (ED) use. Obtaining adequate food is a common concern among homeless people and may influence health care utilization.Objective: We tested the hypothesis that food insufficiency is related to higher rates of hospitalization and ED use in a national sample of homeless adults.Design: We analyzed data from the 2003 Health Care for the Homeless (HCH) User Survey.Participants: Participants were 966 adults surveyed at 79 HCH clinic sites throughout the US. The study sample was representative of over 436,000 HCH clinic users nationally.Measures: We determined the prevalence and characteristics of food insufficiency among respondents. Using multivariable logistic regression, we examined the association between food insufficiency and four past-year acute health services utilization outcomes: (1) hospitalization for any reason, (2) psychiatric hospitalization, (3) any ED use, and (4) high ED use (≥ 4 visits).Results: Overall, 25% of respondents reported food insufficiency. Among them, 68% went a whole day without eating in the past month. Chronically homeless (p = 0.01) and traumatically victimized (p = 0.001) respondents were more likely to be food insufficient. In multivariable analyses, food insufficiency was associated with significantly greater odds of hospitalization for any reason (AOR 1.59, 95% CI 1.07, 2.36), psychiatric hospitalization (AOR 3.12, 95% CI 1.73, 5.62), and high ED utilization (AOR 2.83, 95% CI 1.32, 6.08).Conclusions: One-fourth of homeless adults in this national survey were food insufficient, and this was associated with increased odds of acute health services utilization. Addressing the adverse health services utilization patterns of homeless adults will require attention to the social circumstances that may contribute to this issue. [ABSTRACT FROM AUTHOR]

Background: There are growing reports of United States (US) residents traveling overseas for medical care, but empirical data about medical tourism are limited.Objective: To characterize the businesses and business practices of entities promoting medical tourism and the types and costs of procedures being offered. DESIGN, PARTICIPANTS, AND OUTCOMES: Between June and August 2008, we conducted a telephone survey of all businesses engaged in facilitating overseas medical travel for US residents. We collected information from each company including: the number of employees; number of patients referred overseas; medical records security processes; destinations to which patients were referred; treatments offered; treatment costs; and whether patient outcomes were collected.Results: We identified 63 medical tourism companies and 45 completed our survey (71%). Companies had a mean of 9.8 employees and had referred an average of 285 patients overseas (a total of approximately 13,500 patients). 35 (79%) companies reported requiring accreditation of foreign providers, 22 (50%) collected patient outcome data, but only 17 (39%) described formal medical records security policies. The most common destinations were India (23 companies, 55%), Costa Rica (14, 33%), and Thailand (12, 29%). The most common types of care included orthopedics (32 companies, 73%), cardiac care (23, 52%), and cosmetic surgery (29, 66%). 20 companies (44%) offered treatments not approved for use in the US--most commonly stem cell therapy. Average costs for common procedures, CABG ($18,600) and knee arthroplasty ($10,800), were similar to previous reports.Conclusions: The number of Americans traveling overseas for medical care with assistance from medical tourism companies is relatively small. Attention to medical records security and patient outcomes is variable and cost-savings are dependent on US prices. That said, overseas medical care can be a reasonable alternative for price sensitive patients in need of relatively common, elective medical procedures. [ABSTRACT FROM AUTHOR]

Background: US cholesterol guidelines use original and simplified versions of the Framingham model to estimate future coronary risk and thereby classify patients into risk groups with different treatment strategies. We sought to compare risk estimates and risk group classification generated by the original, complex Framingham model and the simplified, point-based version.Methods: We assessed 2,543 subjects age 20-79 from the 2001-2006 National Health and Nutrition Examination Surveys (NHANES) for whom Adult Treatment Panel III (ATP-III) guidelines recommend formal risk stratification. For each subject, we calculated the 10-year risk of major coronary events using the original and point-based Framingham models, and then compared differences in these risk estimates and whether these differences would place subjects into different ATP-III risk groups (<10% risk, 10-20% risk, or >20% risk). Using standard procedures, all analyses were adjusted for survey weights, clustering, and stratification to make our results nationally representative.Results: Among 39 million eligible adults, the original Framingham model categorized 71% of subjects as having "moderate" risk (<10% risk of a major coronary event in the next 10 years), 22% as having "moderately high" (10-20%) risk, and 7% as having "high" (>20%) risk. Estimates of coronary risk by the original and point-based models often differed substantially. The point-based system classified 15% of adults (5.7 million) into different risk groups than the original model, with 10% (3.9 million) misclassified into higher risk groups and 5% (1.8 million) into lower risk groups, for a net impact of classifying 2.1 million adults into higher risk groups. These risk group misclassifications would impact guideline-recommended drug treatment strategies for 25-46% of affected subjects. Patterns of misclassifications varied significantly by gender, age, and underlying CHD risk.Conclusions: Compared to the original Framingham model, the point-based version misclassifies millions of Americans into risk groups for which guidelines recommend different treatment strategies. [ABSTRACT FROM AUTHOR]

Background: Chronic hepatitis B and hepatitis B-associated liver cancer is a major health disparity among Vietnamese Americans, who have a chronic hepatitis B prevalence rate of 7-14% and an incidence rate for liver cancer six times that of non-Latino whites.Objective: Describe factors associated with hepatitis B testing among Vietnamese Americans.Design: A population-based telephone survey conducted in 2007-2008.Participants: Vietnamese Americans age 18-64 and living in the Northern California and Washington, DC areas (N = 1,704).Main Measures: Variables included self-reports of sociodemographics, health care factors, and hepatitis B-related behaviors, knowledge, beliefs, and communication with others. The main outcome variable was self-reported receipt of hepatitis B testing.Key Results: The cooperation rate was 63.1% and the response rate was 27.4%. Only 62% of respondents reported having received a hepatitis B test and 26%, hepatitis B vaccination. Only 54% knew that hepatitis B could be transmitted by sexual intercourse. In multivariable analyses, factors negatively associated with testing included: age 30-49 years, US residence for >10 years, less Vietnamese fluency, lower income, and believing that hepatitis B can be deadly. Factors positively associated with testing included: Northern California residence, having had hepatitis B vaccination, having discussed hepatitis B with family/friends, and employer requested testing. Physician recommendation of hepatitis B testing (OR 4.46, 95% CI 3.36, 5.93) and respondent's request for hepatitis B testing (OR 8.37, 95% CI 5.95, 11.78) were strongly associated with test receipt.Conclusion: Self-reports of hepatitis B testing among Vietnamese Americans remain unacceptably low. Physician recommendation and patient request were the factors most strongly associated with test receipt. A comprehensive effort is needed to promote hepatitis B testing in this population, including culturally-targeted community outreach, increased access to testing, and physician education. [ABSTRACT FROM AUTHOR]

Background: Religiously affiliated hospitals provide nearly 20% of US beds, and many prohibit certain end-of-life and reproductive health treatments. Little is known about physician experiences in religious institutions.Objective: Assess primary care physicians' experiences and beliefs regarding conflict with religious hospital policies for patient care.Design: Cross-sectional survey.Participants: General internists, family physicians, and general practitioners from the AMA Masterfile.Main Measures: In a questionnaire mailed in 2007, we asked physicians whether they had worked in a religiously affiliated hospital or practice, whether they had experienced conflict with the institution over religiously based patient care policies and how they believed physicians should respond to such conflicts. We used chi-square and multivariate logistic regression to examine associations between physicians' demographic and religious characteristics and their responses.Key Results: Of 879 eligible physicians, 446 (51%) responded. In analyses adjusting for survey design, 43% had worked in a religiously affiliated institution. Among these, 19% had experienced conflict over religiously based policies. Most physicians (86%) believed when clinical judgment conflicts with religious hospital policy, physicians should refer patients to another institution. Compared with physicians ages 26-29 years, older physicians were less likely to have experienced conflict with religiously based policies [odds ratio (95% confidence interval) compared with 30-34 years: 0.02 (0.00-0.11); 35-46 years: 0.07 (0.01-0.72); 47-60 years: 0.02 (0.00-0.10)]. Compared with those who never attend religious services, those who do attend were less likely to have experienced conflict [attend once a month or less: odds ratio 0.06 (0.01-0.29); attend twice a month or more: 0.22 (0.05-0.98)]. Respondents with no religious affiliation were more likely than others to believe doctors should disregard religiously based policies that conflict with clinical judgment (13% vs. 3%; p = 0.005).Conclusions: Hospitals and policy-makers may need to balance the competing claims of physician autonomy and religiously based institutional policies. [ABSTRACT FROM AUTHOR]

Background: There are no universally accepted guidelines for the follow-up of individuals with cutaneous melanoma. Furthermore, to date, there have been no randomised controlled trials of different models of melanoma follow-up care. This randomised controlled trial was conducted to evaluate the effects of GP-led melanoma follow-up on patient satisfaction, follow-up guideline compliance, anxiety and depression, as well as health status.Methods: A randomised controlled trial of GP-led follow-up of cutaneous melanoma was conducted over a period of 1 year with assessment by self-completed questionnaires and review of general practice-held medical records at baseline and 12 months later. It took place in 35 general practices in North-east Scotland. Subjects were 142 individuals (51.4% women 48.6% men; mean (s.d.) age 59.2 (15.2) years previously treated for cutaneous melanoma and free of recurrent disease. The intervention consisted of protocol-driven melanoma reviews in primary care, conducted by trained GPs and supported by centralised recall, rapid access pathway to secondary care and a patient information booklet. The main outcome measure was patient satisfaction measured by questionnaire. Secondary outcomes were adherence to guidelines, health status measured by Short Form-36 and the Hospital Anxiety and Depression Scale.Results: There were significant improvements in 5 out of 15 aspects of patient satisfaction during the study year in those receiving GP-led melanoma follow-up (all PConclusions: GP-led follow-up is feasible, engenders greater satisfaction in those patients who receive it, permits closer adherence to guidelines and does not result in adverse effects on health status or anxiety and depression when compared with traditional hospital-based follow-up for melanoma. [ABSTRACT FROM AUTHOR]

Introduction/aims: Training is essential for future health care providers to effectively communicate with limited English proficient (LEP) patients during interpreted encounters. Our aim is to describe an innovative skill-based medical school linguistic competency curriculum and its impact on knowledge and skills.Setting: At Stanford University School of Medicine, we incorporated a linguistic competency curriculum into a 2-year Practice of Medicine preclinical doctoring course and pediatrics clerkship over three cohorts.Program Description: First year students participated in extensive interpreter-related training including: a knowledge-based online module, interactive role-play exercises, and didactic skill-building sessions. Students in the pediatrics clerkship participated in interpreted training exercises with facilitated feedback.Program Evaluation: Knowledge and skills were evaluated in the first and fourth years. First year students' knowledge scores increased (pre-test = 0.62, post-test = 0.89, P < 0.001), and they demonstrated good skill attainment during an end-year performance assessment. One cohort of students participated in the entire curriculum and maintained performance into the fourth year.Discussion: Our curriculum increased knowledge and led to skill attainment, each of which showed good durability for a cohort of students evaluated 3 years later. With a growing LEP population, these skills are essential to foster in future health care providers to effectively communicate with LEP patients and reduce health disparities. [ABSTRACT FROM AUTHOR]

Background: Patient-centered care has been described as one approach to cultural competency education that could reduce racial and ethnic health disparities by preparing providers to deliver care that is respectful and responsive to the preferences of each patient. In order to evaluate the effectiveness of a curriculum in teaching patient-centered care (PCC) behaviors to medical students, we drew on the work of Kleinman, Eisenberg, and Good to develop a scale that could be embedded across cases in an objective structured clinical examination (OSCE).Objective: To compare the reliability, validity, and feasibility of an embedded patient-centered care scale with the use of a single culturally challenging case in measuring students' use of PCC behaviors as part of a comprehensive OSCE.Methods: A total of 322 students from two California medical schools participated in the OSCE as beginning seniors. Cronbach's alpha was used to assess the internal consistency of each approach. Construct validity was addressed by establishing convergent and divergent validity using the cultural challenge case total score and OSCE component scores. Feasibility assessment considered cost and training needs for the standardized patients (SPs).Results: Medical students demonstrated a moderate level of patient-centered skill (mean = 63%, SD = 11%). The PCC Scale demonstrated an acceptable level of internal consistency (alpha = 0.68) over the single case scale (alpha = 0.60). Both convergent and divergent validities were established through low to moderate correlation coefficients.Discussion: The insertion of PCC items across multiple cases in a comprehensive OSCE can provide a reliable estimate of students' use of PCC behaviors without incurring extra costs associated with implementing a special cross-cultural OSCE. This approach is particularly feasible when an OSCE is already part of the standard assessment of clinical skills. Reliability may be increased with an additional investment in SP training. [ABSTRACT FROM AUTHOR]

Background: General internists and other generalist physicians have traditionally cared for their patients during both ambulatory visits and hospitalizations. It has been suggested that the expansion of hospitalists since the mid-1990s has "crowded out" generalists from inpatient care. However, it is also possible that declining hospital utilization relative to the size of the generalist workforce reduced the incentives for generalists to continue providing hospital care.Objective: To examine trends in hospital utilization and the generalist workforce before and after the emergence of hospitalists in the U.S. and to investigate factors contributing to these trends.Design: Using data from 1980-2005 on inpatient visits from the National Hospital Discharge Survey, and physician manpower data from the American Medical Association, we identified national trends before and after the emergence of hospitalists in the annual number of inpatient encounters relative to the number of generalists.Results: Inpatient encounters relative to the number of generalists declined steadily before the emergence of hospitalists. Declines in inpatient encounters relative to the number of generalists were driven primarily by reduced hospital length of stay and increased numbers of generalists.Conclusions: Hospital utilization relative to generalist workforce declined before the emergence of hospitalists, largely due to declining length of stay and rising generalist workforce. This likely weakened generalist incentives to provide hospital care. Models of care that seek to preserve dual-setting generalist care spanning ambulatory and inpatient settings are most likely to be viable if they focus on patients at high risk of hospitalization. [ABSTRACT FROM AUTHOR]

Background: The majority of states have enacted price transparency laws to allow patients to shop for care and to prevent price discrimination of the uninsured. In California, hospitals must provide a price estimate to a requesting uninsured patient and cannot bill for an amount greater than the reimbursement the hospital would receive from a government payer.Objective: To assess the response rate of California hospitals to a patient price request and to compare the price estimates received to Medicare reimbursement.Design: We sent letters to California acute-care hospitals from a fictional uninsured patient requesting an estimate for one of three common elective procedures: a laparoscopic cholecystectomy, a hysterectomy, or routine screening colonoscopy.Participants: Three hundred and fifty-three hospitals in California.Measurements: Hospital response rates, difference between price estimates received, and Medicare reimbursement for equivalent procedures.Results: Only 28% (98/353) of hospitals responded and their response varied in content. Of the 98 responses, 15 (15%) did not provide a quote and instead asked for more information such as the billing code, 55 (56%) provided a price estimate for hospital services only, 10 (10%) included both physician and hospital services, and 18 (18%) did not specify what was covered. The median discounted price estimate was higher than Medicare reimbursement rates for all procedures: hysterectomy ($17,403 vs. $5,569; p<0.001), cholecystectomy ($14,014 vs. $7,196; p<0.001) and colonoscopy ($2,017 vs. $216; p<0.001).Conclusions: Current California legislation fails to meet its objective of enabling uninsured patients to compare prices for hospital-based health care services. [ABSTRACT FROM AUTHOR]

Background: There is accelerating interest in measuring and reporting the quality of care delivered by health care providers and organizations, but methods for defining the patient panels for which they are held accountable are not well defined.Objectives: To examine the potential impact of using alternative algorithms to define accountable patient populations for performance assessment.Research Design: We used administrative data regarding Community Health Center (CHC) visits in simulations of performance assessment for breast, cervical, and colorectal cancer screening.Participants: Fifteen CHC sites in the northeastern US.Measures: We used three different algorithms to define patient populations eligible for measurement of cancer screening rates and simulated center-level performance rates based on these alternative population definitions.Results: Focusing on breast cancer screening, the percentage of women aged 51-75 eligible for this measure across CHCs, if using the most stringent algorithm (requiring a visit in the assessment year plus at least one visit in the 2 years prior), ranged from 28% to 60%. Analogous ranges for cervical and colorectal cancer screening were 18-59% and 26-62%, respectively. Simulated performance data from the centers demonstrate that variations in eligible patient populations across health centers could lead to the appearance of large differences in health center performance or differences in expected rankings of CHCs when no such differences exist. For instance, when holding performance among similar populations constant, but varying the proportion of populations seen across different health centers, simulated health center adherence to screening guidelines varied by over 15% even though actual adherence for similar populations did not differ.Conclusions: Quality measurement systems, such as those being used in pay-for-performance and public reporting programs, must consider the definitions used to identify sample populations and how such populations might differ across providers, clinical practice groups, and provider systems. [ABSTRACT FROM AUTHOR]

Background: Over 35% of returned Iraq and Afghanistan veterans in VA care have received mental health diagnoses; the most prevalent is post-traumatic stress disorder (PTSD). Little is known about these patients' use of non-mental health medical services and the impact of mental disorders on utilization.Objective: To compare utilization across three groups of Iraq and Afghanistan veterans: those without mental disorders, those with mental disorders other than PTSD, and those with PTSD.Design and Participants: National, descriptive study of 249,440 veterans newly utilizing VA healthcare between October 7, 2001 and March 31, 2007, followed until March 31, 2008.Measurements: We used ICD9-CM diagnostic codes to classify mental health status. We compared utilization of outpatient non-mental health services, primary care, medical subspecialty, ancillary services, laboratory tests/diagnostic procedures, emergency services, and hospitalizations during veterans' first year in VA care. Results were adjusted for demographics and military service and VA facility characteristics.Main Results: Veterans with mental disorders had 42-146% greater utilization than those without mental disorders, depending on the service category (all P < 0.001). Those with PTSD had the highest utilization in all categories: 71-170% greater utilization than those without mental disorders (all P < 0.001). In adjusted analyses, compared with veterans without mental disorders, those with mental disorders other than PTSD had 55% higher utilization of all non-mental health outpatient services; those with PTSD had 91% higher utilization. Female sex and lower rank were also independently associated with greater utilization.Conclusions: Veterans with mental health diagnoses, particularly PTSD, utilize significantly more VA non-mental health medical services. As more veterans return home, we must ensure resources are allocated to meet their outpatient, inpatient, and emergency needs. [ABSTRACT FROM AUTHOR]

The optimal role for primary care in providing follow-up for men with prostate cancer is uncertain. A systematic review of international guidelines was undertaken to help identify key elements of existing models of follow-up care to establish a theoretical basis for evaluating future complex interventions. Many guidelines provide insufficient information to judge the reliability of the recommendations. Although the PSA test remains the cornerstone of follow-up, the diversity of recommendations on the provision of follow-up care reflects the current lack of research evidence on which to base firm conclusions. The review highlights the importance of transparent guideline development procedures and the need for robust primary research to inform future evidence-based models of follow-up care for men with prostate cancer. [ABSTRACT FROM AUTHOR]

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

Background: Inappropriate antibiotic use contributes to the emergence and spread of drug resistant infections. Though injection drug users are at increased risk for drug resistant infections, few studies have examined antibiotic use in this population.Objective: To understand patterns and determinants of antibiotic use among injection drug users.Methods: Five focus groups were conducted with 28 current injection drug users recruited from a syringe exchange program in Philadelphia and analyzed using the constant comparative method to identify emergent themes. Twenty-six participants also completed a written survey instrument.Results: Injection drug users reported frequent antibiotic exposure, with 12 of 26 participants reporting use of antibiotic medications at least once in the previous 30 days. Participants reported several patterns of antibiotic use that were potentially harmful, including delays in seeking medical care, failing to fill prescriptions, obtaining antibiotics from non-provider sources, and poor adherence to prescribed regimens. The major determinants of inappropriate antibiotic use were delayed recognition of severity of illness, reluctance to wait to be seen, previous mistreatment by providers, lack of insurance, prioritizing purchasing drugs of abuse over antibiotics, forgetting to take antibiotics because of distractions that accompany drug use, concerns about interactions between antibiotics and other substances, and an irregular diet. Additionally, injection drug users commonly misunderstood the concept of antibiotic resistance and equated it with tolerance.Conclusions: Injection drug users reported potentially dangerous antibiotic use behaviors and described determinants of these behaviors. Outreach and educational interventions to improve antibiotic use should target high-risk populations, such as injection drug users, and consider their distinct antibiotic use behaviors and determinants. [ABSTRACT FROM AUTHOR]

Objective: To identify and describe unintended adverse consequences related to clinical workflow when implementing or using computerized provider order entry (CPOE) systems.Methods: We analyzed qualitative data from field observations and formal interviews gathered over a three-year period at five hospitals in three organizations. Five multidisciplinary researchers worked together to identify themes related to the impacts of CPOE systems on clinical workflow.Results: CPOE systems can affect clinical work by 1) introducing or exposing human/computer interaction problems, 2) altering the pace, sequencing, and dynamics of clinical activities, 3) providing only partial support for the work activities of all types of clinical personnel, 4) reducing clinical situation awareness, and 5) poorly reflecting organizational policy and procedure.Conclusions: As CPOE systems evolve, those involved must take care to mitigate the many unintended adverse effects these systems have on clinical workflow. Workflow issues resulting from CPOE can be mitigated by iteratively altering both clinical workflow and the CPOE system until a satisfactory fit is achieved. [ABSTRACT FROM AUTHOR]

Background: There are no prospective studies that have investigated the effects of an intervention to improve end of life (EOL) care in an underserved population.Objective: To determine whether homeless persons will complete an advance directive (AD).Design: Randomized trial comparing two modes of providing an opportunity for homeless persons to complete an AD. Half of the subjects were randomized to a self-guided group (SG) who were given an AD and written instructions; the other half were given the same material but, in addition, were offered the opportunity to receive guidance to complete the AD (CG).Participants: Fifty-nine homeless persons recruited from a drop-in center.Measures: Rate of AD completion and baseline and 3-month follow-up EOL-related knowledge, attitudes, and behaviors.Results: The overall AD completion rate was 44%, with a statistically significant higher completion rate of 59% in the CG group compared to 30% in the self-guided only group. Frequency of worry about death decreased among those who filled out an AD from 50% to 12.5%, and also among those who did not (25% to 12.5%) (p < .05). Among those who filled out an AD, there were increases in plans to write down EOL wishes (56% to 100%; p < .05) and plans to talk about these wishes with someone (63% to 94%; p < .05).Conclusion: This study demonstrates that people living in dire economic and social situations will complete an AD when offered the opportunity. While offering guidance resulted in higher rates of completion; even a simple self-guided AD process can achieve completion of ADs in this population. [ABSTRACT FROM AUTHOR]

Background: Patient-centered care--including the domains of access and communication--is an important determinant of positive clinical outcomes.Objective: To explore associations between race and HIV-infected patients' experiences of access and communication.Design: This was a cross-sectional survey.Participants: Nine hundred and fifteen HIV-infected adults receiving care at 14 U.S. HIV clinics.Measurements: Dependent variables included patients' reports of travel time to their HIV care site and waiting time to see their HIV provider (access) and ratings of their HIV providers on always listening, explaining, showing respect, and spending enough time with them (communication). We used multivariate logistic regression to estimate associations between patient race and dependent variables, and random effects models to estimate site-level contributions.Results: Patients traveled a median 30 minutes (range 1-180) and waited a median 20 minutes (range 0-210) to see their provider. On average, blacks and Hispanics reported longer travel and wait times compared with whites. Adjusting for HIV care site attenuated this association. HIV care sites that provide services to a greater proportion of blacks and Hispanics may be more difficult to access for all patients. The majority of patients rated provider communication favorably. Compared to whites, blacks reported more positive experiences with provider communication.Conclusions: We observed racial disparities in patients' experience of access to care but not in patient-provider communication. Disparities were explained by poor access at minority-serving clinics. Efforts to make care more patient-centered for minority HIV-infected patients should focus more on improving access to HIV care in minority communities than on improving cross-cultural patient-provider interactions. [ABSTRACT FROM AUTHOR]

Background: Recent reports from the Institute of Medicine emphasize patient-centered care and cross-cultural training as a means of improving the quality of medical care and eliminating racial and ethnic disparities.Objective: To determine whether, controlling for training received in medical school or during residency, resident physician socio-cultural characteristics influence self-perceived preparedness and skill in delivering cross-cultural care.Design: National survey of resident physicians.Participants: A probability sample of residents in seven specialties in their final year of training at US academic health centers.Measurement: Nine resident characteristics were analyzed. Differences in preparedness and skill were assessed using the chi(2) statistic and multivariate logistic regression.Results: Fifty-eight percent (2047/3500) of residents responded. The most important factor associated with improved perceived skill level in performing selected tasks or services believed to be useful in treating culturally diverse patients was having received cross-cultural skills training during residency (OR range 1.71-4.22). Compared with white residents, African American physicians felt more prepared to deal with patients with distrust in the US healthcare system (OR 1.63) and with racial or ethnic minorities (OR 1.61), Latinos reported feeling more prepared to deal with new immigrants (OR 1.88) and Asians reported feeling more prepared to deal with patients with health beliefs at odds with Western medicine (1.43).Conclusions: Cross-cultural care skills training is associated with increased self-perceived preparedness to care for diverse patient populations providing support for the importance of such training in graduate medical education. In addition, selected resident characteristics are associated with being more or less prepared for different aspects of cross-cultural care. This underscores the need to both include medical residents from diverse backgrounds in all training programs and tailor such programs to individual resident needs in order to maximize the chances that such training is likely to have an impact on the quality of care. [ABSTRACT FROM AUTHOR]

Background: Family members of patients in intensive care units (ICUs) are at risk for mental health morbidity both during and after a patient's ICU stay.Objectives: To determine prevalences of and factors associated with anxiety, depression, posttraumatic stress and complicated grief in family members of ICU patients.Design: Prospective, longitudinal cohort study.Participants: Fifty family members of patients in ICUs at a large university hospital participated.Measurements: We used the Control Preferences Scale to determine participants' role preferences for surrogate decision-making. We used the Hospital Anxiety and Depression Scale, Impact of Event Scale, and Inventory of Complicated Grief to measure anxiety and depression (at enrollment, 1 month, 6 months), posttraumatic stress (6 months), and complicated grief (6 months).Results: We interviewed all 50 participants at enrollment, 39 (78%) at 1 month, and 34 (68%) at 6 months. At the three time points, anxiety was present in 42% (95% CI, 29-56%), 21% (95% CI, 10-35%), and 15% (95% CI, 6-29%) of participants. Depression was present in 16% (95% CI, 8-28%), 8% (95% CI, 2-19%), and 6% (95% CI, 1-18%). At 6 months, 35% (95% CI, 21-52%) of participants had posttraumatic stress. Of the 38% who were bereaved, 46% (95% CI, 22-71%) had complicated grief. Posttraumatic stress was not more common in bereaved than nonbereaved participants, and neither posttraumatic stress nor complicated grief was associated with decision-making role preference or with anxiety or depression during the patient's ICU stay.Conclusions: Symptoms of anxiety and depression diminished over time, but both bereaved and nonbereaved participants had high rates of posttraumatic stress and complicated grief. Family members should be assessed for posttraumatic stress and complicated grief. [ABSTRACT FROM AUTHOR]

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

Background: Hospital-based interventions promote smoking cessation after discharge. Strategies to deliver these interventions are needed, especially now that providing smoking cessation advice or treatment, or both, to inpatient smokers is a publicly reported quality-of-care measure for US hospitals.Objective: To assess the effect of adding a tobacco order set to an existing computerized order-entry system used to admit Medicine patients to 1 hospital.Design: Pre-post study.Measurements and Main Results: Proportion of admitted patients who had smoking status identified, a smoking counselor consulted, or nicotine replacement therapy (NRT) ordered during 4 months before and after the change. In 4 months after implementation, the order set was used with 76% of Medicine admissions, and a known smoking status was recorded for 81% of these patients. The intervention increased the proportion of admitted patients who were referred for smoking counseling (0.8 to 2.1%) and had NRT ordered (1.6 to 2.5%) (p < .0001 for both). Concomitantly, the hospital's performance on the smoking cessation quality measure improved.Conclusions: Adding a brief tobacco order set to an existing computerized order-entry system increased a hospital's provision of evidence-based tobacco treatment and helped to improve its performance on a publicly reported quality measure. It provides a model for US hospitals seeking to improve their quality of care for inpatients. [ABSTRACT FROM AUTHOR]

Background: Professionalism is identified as a competency of resident education. Best approaches to teaching and evaluating professionalism are unknown, but feedback about professionalism is necessary to change practice and behavior. Faculty discomfort with professionalism may limit their delivery of feedback to residents.Objectives: A pilot program to implement a 360-degree evaluation of observable professionalism behaviors and determine how its use impacts faculty feedback to residents.Design: Internal Medicine (IM) residents were evaluated during ambulatory rotations using a 360-degree assessment of professional behaviors developed by the National Board of Medical Examiners(R). Faculty used evaluation results to provide individual feedback to residents.Patients/participants: Fifteen faculty members.Measurements and Main Results: Faculty completed pre- and post-intervention surveys. Using a 7-point Likert scale, faculty reported increased skill in giving general feedback (4.85 vs 4.36, p < .05) and feedback about professionalism (4.71 vs 3.57, p < .01) after the implementation of the 360-degree evaluation. They reported increased comfort giving feedback about professionalism (5.07 vs 4.35, p < .05) but not about giving feedback in general (5.43 vs 5.50).Conclusions: A 360-degree professionalism evaluation instrument used to guide feedback to residents improves faculty comfort and self-assessed skill in giving feedback about professionalism. [ABSTRACT FROM AUTHOR]

Background: Little research investigates the role of patient-physician communication in understanding racial disparities in depression treatment.Objective: The objective of this study was to compare patient-physician communication patterns for African-American and white patients who have high levels of depressive symptoms.Design, Setting, and Participants: This is a cross-sectional study of primary care visits of 108 adult patients (46 white, 62 African American) who had depressive symptoms measured by the Medical Outcomes Study-Short Form (SF-12) Mental Component Summary Score and were receiving care from one of 54 physicians in urban community-based practices.Main Outcomes: Communication behaviors, obtained from coding of audiotapes, and physician perceptions of patients' physical and emotional health status and stress levels were measured by post-visit surveys.Results: African-American patients had fewer years of education and reported poorer physical health than whites. There were no racial differences in the level of depressive symptoms. Depression communication occurred in only 34% of visits. The average number of depression-related statements was much lower in the visits of African-American than white patients (10.8 vs. 38.4 statements, p = .02). African-American patients also experienced visits with less rapport building (20.7 vs. 29.7 statements, p = .009). Physicians rated a higher percentage of African-American than white patients as being in poor or fair physical health (69% vs. 40%, p = .006), and even in visits where depression communication occurred, a lower percentage of African-American than white patients were considered by their physicians to have significant emotional distress (67% vs. 93%, p = .07).Conclusions: This study reveals racial disparities in communication among primary care patients with high levels of depressive symptoms. Physician communication skills training programs that emphasize recognition and rapport building may help reduce racial disparities in depression care. [ABSTRACT FROM AUTHOR]

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

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

Background: As patients grow older, accurate communication with health care providers about cancer becomes increasingly important. However, little is known about the cancer communication experiences of older Asian immigrants.Objective: To learn about the cancer-related communication experiences of older Vietnamese immigrants from the insider perspective.Design: Qualitative study (grounded theory, constant comparative method) using individual interviews with older Vietnamese immigrants with the purpose of discussing how they learn about cancer. Interviews were conducted in Vietnamese.Participants: Vietnamese immigrants aged 50-70 years, recruited through community-based organizations. Most had low education and limited English proficiency. The sample size of 20 was sufficient to achieve theoretical saturation.Results: We identified 3 categories of themes concerning informants' experiences with cancer communication in the health care setting: (1) attitudes about addressing screening with providers, (2) issues/problems communicating with physicians about cancer, and (3) language/translation difficulties. There was substantial overlap between informants who mentioned each theme category, and 40% of the participants mentioned all 3 categories.Conclusion: Clinicians should be aware of and act upon specific cancer communication needs/challenges of their older immigrant patients. Moreover, health care systems need to be prepared to address the needs of an increasingly multiethnic and linguistically diverse patient population. Finally, community-level interventions should address baseline knowledge deficits while encouraging immigrant patients to engage their doctors in discussions about cancer screening. [ABSTRACT FROM AUTHOR]

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

Background: The conceptualization of patient complexity is just beginning in clinical medicine.Objectives: This study aims (1) to propose a conceptual approach to complex patients; (2) to demonstrate how this approach promotes achieving congruence between patient and provider, a critical step in the development of maximally effective treatment plans; and (3) to examine availability of evidence to guide trade-off decisions and assess healthcare quality for complex patients.Methods/results: The Vector Model of Complexity portrays interactions between biological, socioeconomic, cultural, environmental and behavioral forces as health determinants. These forces are not easily discerned but exert profound influences on processes and outcomes of care for chronic medical conditions. Achieving congruence between patient, physician, and healthcare system is essential for effective, patient-centered care; requires assessment of all axes of the Vector Model; and, frequently, requires trade-off decisions to develop a tailored treatment plan. Most evidence-based guidelines rarely provide guidance for trade-off decisions. Quality measures often exclude complex patients and are not designed explicitly to assess their overall healthcare.Conclusions/recommendations: We urgently need to expand the evidence base to inform the care of complex patients of all kinds, especially for the clinical trade-off decisions that are central to tailoring care. We offer long- and short-term strategies to begin to incorporate complexity into quality measurement and performance profiling, guided by the Vector Model. Interdisciplinary research should lay the foundation for a deeper understanding of the multiple sources of patient complexity and their interactions, and how provision of healthcare should be harmonized with complexity to optimize health. [ABSTRACT FROM AUTHOR]

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