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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]

While great strides have been made recently in improving end-of-life care in the United States, people with dementia often die with inadequate pain control, with feeding tubes in place, and without the benefits of hospice care. In this paper, we discuss the most important and persistent challenges to providing excellent end-of-life care for patients with dementia, including dementia not being viewed as a terminal illness; the nature of the course and treatment decisions in advanced dementia; assessment and management of symptoms; the caregiver experience and bereavement; and health systems issues. We suggest approaches for overcoming these barriers in the domains of education, clinical practice, and public policy. As the population ages, general internists increasingly will be called upon to provide primary care for a growing number of patients dying with dementia. There are great opportunities to improve end-of-life care for this vulnerable and underserved population. [ABSTRACT FROM AUTHOR]

The article discusses the study on problems posed by language barriers. The authors of this paper turn to a series of papers testing innovative solutions. A pair of interpreters in a hospital ward service has been embedded. A study also compares the use of interpreters to language concordant interactions.

Background: Health care operations managers need to balance scheduling frequent follow-ups for patients with chronic conditions and fitting in patients requiring care for new complaints.Objective: We quantify how frequency of follow-up visits corresponds with access to care for patients receiving care from the Department of Veterans Affairs (VA).Design: We use patient data collected between October 2013 and June 2016 by the Survey of Healthcare Experiences of Patients (SHEP). Our sample is comprised of 94,496 patients. We estimate logistic models with 1-month lagged facility-level predictors.Main Measures: We calculate monthly measures characterizing facility-level service provision, including the average time between successive primary care visits, the average primary care visit length, the percentage of primary care appointments that are overbooked, the percent of visits that are unscheduled (i.e., walk-ins), and the ratio of patients to providers. We control for economic factors that are associated with health care supply and demand, including median household income, veteran priority status, the Zillow Housing Price Index, and veteran unemployment rates. We also control for patient demographics.Patients: We restrict the data to patients with at least one in-person primary care visit who have provided information on their ability to access urgent and routine care.Key Results: We find that shorter average follow-up times are associated with better access for patients needing urgent or routine care. A 1-month increase in the average time between successive primary care visits is associated with 10% (p < 0.001) lower odds of reporting being able to access urgent care within 1 day and 13% (p < 0.001) lower odds of reporting usually or always being able to access routine care when needed.Conclusion: Facilities with higher average follow-up times are more likely to have patients report that they are unable to quickly access urgent or routine primary care. [ABSTRACT FROM AUTHOR]

Background: Evidence is limited and mixed as to how the Patient Protection and Affordable Care Act (ACA) Medicaid expansions affected the utilization of primary care physicians (PCPs) and emergency departments (EDs) at the national level.Objective: To examine the association between the ACA Medicaid expansions and changes in the utilization of PCP and ED visits at the national level during the first 3 years (2014-2016) of the implementation.Design: A difference-in-differences analysis to compare outcomes between individuals in 32 states that expanded Medicaid versus individuals in 19 non-expansion states.Participants: A nationally representative sample of US-born individuals 26-64 years old with family incomes lower than 138% of the federal poverty level from the 2010-2016 Medical Expenditure Panel Survey.Intervention: ACA Medicaid expansions MAIN MEASURES: We examined PCP-related outcomes ((i) whether a participant had any PCP visit during a year and (ii) the annual number of PCP visits per person) and ED-related outcomes ((i) whether a participant had any ED visit during a year and (ii) the annual number of ED visits per person).Key Results: A total of 17,803 participants were included in our analysis. We found that the proportion of individuals with any PCP visit during a year marginally increased (difference-in-differences estimate, + 3.6 percentage points [pp]; 95% CI, - 0.4 pp to + 7.6 pp; P = 0.08) following the Medicaid expansions, without any change in the annual number of PCP visits per person. We found no evidence that ED utilization (both the proportion of individuals with any ED visit during a year and the annual number of ED visits per person) changed meaningfully after the Medicaid expansions.Conclusion: Using the nationally representative data of individuals who were affected by the ACA, we found that the ACA Medicaid expansions were associated with a modest improvement in access to PCPs without an increase in ED use. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: The Veterans Access, Choice and Accountability Act (hereafter, Choice Program) seeks to improve access to care by enabling eligible Veterans to receive care from community providers. Veterans Affairs (VA) primary care providers (PCPs) play a key role in making referrals to community specialists, but their frontline experiences with referrals are not well understood.Objective: To understand VA PCPs' experiences referring patients to community specialists while VA works to expand and refine the implementation of the Choice Program.Design: Qualitative study using interview methods.Participants: Semi-structured telephone interviews were conducted with VA primary care providers (N = 72 out of 599 contacted) recruited nationally.Approach: Open-ended interview questions elicited PCP perceptions and experiences with referrals to community specialists via the Choice Program. Keywords were identified using automated coding features in ATLAS.ti and evaluated using conventional content analysis to inductively describe the qualitative data.Key Results: VA PCPs emphasized problems with care coordination and continuity between the VA and community specialists (e.g., "It is extremely difficult for us to obtain and continue continuity of care because there's not much communication with the community specialist"). They described difficulties with tracking the initial referral, coordinating care after receiving community specialty care, accessing community medical records, and aligning community specialists' prescriptions with the VA formulary.Conclusions: The VA Choice Program provides access to community specialists for VA patients; however, VA primary care providers face challenges tracking referrals to community specialists and in coordinating care. Strategies to improve care coordination between the VA and community providers should focus on providing PCPs with information to follow Veterans throughout the Choice referral process and follow-up. [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: 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: 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. [ABSTRACT FROM AUTHOR]

Background: Public reporting of provider performance can assist consumers in their choice of providers and stimulate providers to improve quality. Reporting of quality measures is supported by advocates of health care reform across the political spectrum.Objective: To assess the availability, credibility and applicability of existing public reports of hospital and physician quality, with comparisons across geographic areas.Approach: Information pertaining to 263 public reports in 21 geographic areas was collected through reviews of websites and telephone and in-person interviews, and used to construct indicators of public reporting status. Interview data collected in 14 of these areas were used to assess recent changes in reporting and their implications.Participants: Interviewees included staff of state and local associations, health plan representatives and leaders of local health care alliances.Results: There were more reports of hospital performance (161) than of physician performance (103) in the study areas. More reports included measures derived from claims data (mean, 7.2 hospital reports and 3.3 physician reports per area) than from medical records data. Typically, reports on physician performance contained measures of chronic illness treatment constructed at the medical group level, with diabetes measures the most common (mean number per non-health plan report, 2.3). Patient experience measures were available in more hospital reports (mean number of reports, 1.2) than physician reports (mean, 0.7). Despite the availability of national hospital reports and reports sponsored by national health plans, from a consumer standpoint the status of public reporting depended greatly on where one lived and health plan membership.Conclusions: Current public reports, and especially reports of physician quality of care, have significant limitations from both consumer and provider perspectives. The present approach to reporting is being challenged by the development of new information sources for consumers, and consumer and provider demands for more current information. [ABSTRACT FROM AUTHOR]

Background: The National Consortium for Multicultural Education for Health Professionals (Consortium) comprises educators representing 18 US medical schools, funded by the National Institutes of Health. Collective lessons learned from curriculum implementation by principal investigators (PIs) have the potential to guide similar educational endeavors.Objective: Describe Consortium PI's self-reported challenges with curricular development, solutions and their new curricular products.Methods: Information was collected from PIs over 2 months using a 53-question structured three-part questionnaire. The questionnaire addressed PI demographics, curriculum implementation challenges and solutions, and newly created curricular products. Study participants were 18 Consortium PIs. Descriptive analysis was used for quantitative data. Narrative responses were analyzed and interpreted using qualitative thematic coding.Results: Response rate was 100%. Common barriers and challenges identified by PIs were: finding administrative and leadership support, sustaining the momentum, continued funding, finding curricular space, accessing and engaging communities, and lack of education research methodology skills. Solutions identified included engaging stakeholders, project-sharing across schools, advocacy and active participation in committees and community, and seeking sustainable funding. All Consortium PIs reported new curricular products and extensive dissemination efforts outside their own institutions.Conclusion: The Consortium model has added benefits for curricular innovation and dissemination for cultural competence education to address health disparities. Lessons learned may be applicable to other educational innovation efforts. [ABSTRACT FROM AUTHOR]

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. [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: An estimated 20-50% of patients do not take medications as recommended. Accepting a doctor's recommendation is the first step in medication adherence, yet little is known about patients' beliefs and preferences about how medications are prescribed.Objective: To explore patients' beliefs and preferences about medication prescribing to understand factors that might affect medication adherence.Methods: Fifty members from 2 health plans in Massachusetts participated in in-depth telephone interviews. Participants listened to an audio-vignette of a doctor prescribing a medication to a patient and were asked a series of questions related to the vignette. Responses were reviewed in an iterative process to identify themes related to participants' beliefs and preferences about medication prescribing.Results: Participants' beliefs and preferences about medication prescribing encompassed 3 major areas: patient-doctor relationships, outside influences, and professional expertise. Important findings included participants' concerns about the pharmaceutical industry's influence on doctors' prescribing practices and beliefs that there is a clear "best" medication for most health problems.Conclusions: Patients' beliefs and preferences about medication prescribing may affect medication adherence. Additional empiric studies that explore whether doctors' relationships with pharmaceutical representatives impact medication adherence by affecting trust are indicated. In addition, it would be worthwhile to explore whether discussions between patients and doctors regarding equipoise (no clear scientific evidence for 1 treatment choice over another) affect medication adherence. [ABSTRACT FROM AUTHOR]

We have identified eight sub-dimensions of patient access to pharmaceuticals: marketing approvals, time of marketing approval, coverage, cost sharing, conditions of reimbursement, speed from marketing approval to reimbursement, extent to which beneficiaries control choice of their drug benefit, and evenness of the availability of drugs to the population. For a sample of commonly used best-selling drugs in the United States (US), we measured these eight access sub-dimensions across four health systems: France, the Netherlands, the United Kingdom (UK), and the US. Although the US approved between 15 and 18% more drugs than the other three countries, the US was slower than France and the UK to approve drugs licensed in all four countries. The percentage of drugs covered is approximately the same for all four countries. For covered drugs, we observe the least cost sharing by patients in the Netherlands. The Netherlands imposes conditions of reimbursement on a much larger percentage of drugs. France seems to be the slowest in respect of speed from marketing approval to reimbursement. The US is the most flexible in terms of the extent to which beneficiaries control their choice of drug benefit but it is the least universal in terms of evenness of the availability of drugs to the population. Our study confirms the frequently cited problems of access in European countries: lag between marketing approval and reimbursement, and inflexibility in respect of the extent to which beneficiaries control their choice of drug benefit. At the same time, our study confirms, qualitatively, different kinds of access problems in the US: relatively high patient cost sharing for pharmaceuticals, and wide variation in coverage. [ABSTRACT FROM AUTHOR]

Objective: Recent reforms in the federal Medicaid program have attempted to integrate beneficiaries into the mainstream by providing them with managed care options. However, the effects of mainstreaming have not been systematically evaluated.Design: Cross-sectional survey.Setting/participants: A sample of 478 adult, nonelderly asthmatics followed by a large Northern California medical group.Measurements and Main Results: We examined differences in self-reported access by insurance status. Compared to patients with other forms of insurance, patients covered by the state's Medicaid program (Medi-Cal) were more likely to report access problems for asthma-related care, including difficulties in reaching a health care provider by telephone, obtaining a clinic appointment, and obtaining asthma medication. Adjusting for relevant clinical and sociodemographic variables, Medi-Cal patients were more likely to report at least one access problem compared to non-Medi-Cal patients (adjusted odds ratio [AOR], 3.34; 95% confidence interval [CI], 1.43 to 7.80). Patients reporting at least one access problem were also more likely to have made at least one asthma-related emergency department visit within the past year (AOR, 4.84; 95% CI, 2.41 to 9.72). Reported barriers to care did not translate into reduced patient satisfaction.Conclusions: Within this population of Medicaid patients, the provision of health insurance and care within the mainstream of an integrated health system was no guarantee of equal access as perceived by the patients themselves. [ABSTRACT FROM AUTHOR]

Studies have highlighted the tensions that can arise between Medicaid managed care organizations and safety net providers. This article seeks to identify what other states can learn from Maryland's effort to include protections for safety net providers in its Medicaid managed care program--HealthChoice. Under HealthChoice, traditional provider systems can sponsor managed care organizations, historical providers are assured of having a role, patients can self-refer and have open access to certain public health providers, and capitation rates are risk adjusted through the use of adjusted clinical groups and claims data. The article is based on a week-long site visit to Maryland in fall 1998 that was one part of a seven-state study. Maryland's experience suggests that states have much to gain in the way of "good" public policy by considering the impact of their Medicaid managed care programs on the safety net, but states should not underestimate the challenges involved in balancing the need to protect the safety net with the need to contain costs and minimize the administrative burden on providers. No amount of protection can compensate for a poorly designed or implemented program. As the health care environment continues to change, so may the need for and the types of protections change. It also may be most difficult to guarantee adequate protections to those who need it most--among relatively financially insecure providers that have a limited management infrastructure and that depend heavily on Medicaid and the state for funds to care for the uninsured. [ABSTRACT FROM AUTHOR]