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Objectives: To understand the health care access issues faced by Los Angeles (LA) County’s uninsured and residually unin­sured after implementation of the Afford­able Care Act (ACA) and to identify poten­tial solutions using a community-partnered dialogue.Design: Qualitative study using a com­munity-partnered participatory research framework.Setting: Community forum breakout discus­sion.Discussants: Representatives from LA County health care agencies, community health care provider organizations, local community advocacy and service organiza­tions including uninsured individuals, and the county school district.Main Outcome Measures: Key structural and overarching value themes identified through community-partnered pile sort, c-coefficients measuring overlap between themes.Results: Five overarching value themes were identified – knowledge, trust, quality, partnership, and solutions. Lack of knowl­edge and misinformation were identified as barriers to successful enrollment of the eligible uninsured and providing health care to undocumented individuals. Discussants noted dissatisfaction with the quality of tra­ditional sources of health care and a broken cycle of trust and disengagement. They also described inherent trust by the uninsured in “outsider” community-based providers not related to quality.Conclusions: Improving health care for the residually uninsured after ACA implementa­tion will require addressing dissatisfaction in safety-net providers, disseminating knowl­edge and providing health care through trusted nontraditional sources, and using effective and trusted partnerships between community and health care agencies with mutual respect. Community-academic part­nerships can be a trusted conduit to discuss issues related to the health care of vulner­able populations. Ethn Dis. 2015; 25(4)487- 494; doi:10.18865/ed.25.4.487

BackgroundInterpersonal care (IPC) is increasingly emphasized as health care systems focus on implementing patient-centered care. Language barriers may be a particularly important influence on IPC ratings among rural Spanish-speaking Latinos.ObjectiveTo examine the associations between provider Spanish fluency and Spanish-speaking patients' ratings of IPC and between patient-provider language concordance and patient engagement in diabetes self-care activities.DesignCross-sectional survey combined with chart reviews.Setting/participantsTwo hundred fifty Latino adults with diabetes receiving care at safety-net community health centers in two rural California counties.Main measuresUsing a validated questionnaire, we assessed patient ratings of IPC in three areas: communication, decision-making, and interpersonal style. Patient-provider language concordance was measured by physician self-reported fluency in Spanish. We measured participation in diabetes self-care activities by patient self-report. The survey response rate was 68%.Key resultsPatients with language-concordant providers had more favorable IPC ratings (20% to 41% of language-discordant patients had optimal scores for IPC scales vs. 35% to 69% of language-concordant patients, p

BackgroundContinuity of patient care is one of the cornerstones of primary care. ObjectiveTo examine publicly available, Internet-based reviews of adult primary care physicians, specifically written by patients who report long-term relationships with their physicians. MethodsThis substudy was nested within a larger qualitative content analysis of online physician ratings. We focused on reviews reflecting an established patient-physician relationship, that is, those seeing their physicians for at least 1 year. ResultsOf the 712 Internet reviews of primary care physicians, 93 reviews (13.1%) were from patients that self-identified as having a long-term relationship with their physician, 11 reviews (1.5%) commented on a first-time visit to a physician, and the remainder of reviews (85.4%) did not specify the amount of time with their physician. Analysis revealed six overarching domains: (1) personality traits or descriptors of the physician, (2) technical competence, (3) communication, (4) access to physician, (5) office staff/environment, and (6) coordination of care. ConclusionsOur analysis shows that patients who have been with their physician for at least 1 year write positive reviews on public websites and focus on physician attributes.

Background The extent of outpatient adverse drug events (ADEs) remains unclear. Trigger tools are used as a screening method to identify care episodes that may be ADEs, but their value in a population with high chronic-illness burden remains unclear. Methods The authors used six abnormal laboratory triggers for detecting ADEs among adults in outpatient care. Eligible patients were included if they were >18 years, sought primary or urgent care between November 2008 and November 2009 and were prescribed at least one medication. The authors then used the clinical / administrative database to identity patients with these triggers. Two physicians conducted in-depth chart review of any medical records with identified triggers. Results The authors reviewed 1342 triggers representing 622 unique episodes among 516 patients. The trigger tool identified 91 (15%) ADEs. Of the 91 ADEs included in the analysis, 49 (54%) occurred during medication monitoring, 41 (45%) during patient self-administration, and one could not be determined. 96% of abnormal international normalised ratio triggers were ADEs, followed by 12% of abnormal blood urea nitrogen triggers, 9% of abnormal alanine aminotransferase triggers, 8% of abnormal serum creatinine triggers and 3% of aspartate aminotransferase triggers. Conclusions The findings imply that other tools such as text triggers or more complex automated screening rules, which combine data hierarchically are needed to effectively screen for ADEs in chronically ill adults seen in primary care.

Doctor rating websites are a burgeoning trend, yet little is known about their content. To explore the content of Internet reviews about primary care physicians. Qualitative content analysis of 712 online reviews from two rating websites. We purposively sampled reviews of 445 primary care doctors (internists and family practitioners) from four geographically dispersed U.S. urban locations. We report the major themes, and because this is a large sample, the frequencies of domains within our coding scheme. Most reviews (63%) were positive, recommending the physician. We found a major distinction between global reviews, “Dr. B is a great doctor.” vs. specific descriptions which included interpersonal manner, “She always listens to what I have to say and answers all my questions.”; technical competence “No matter who she has recommended re: MD specialists, this MD has done everything right.”; and/or systems issues such as appointment and telephone access. Among specific reviews, interpersonal manner “Dr. A is so compassionate.” and technical competence “He is knowledgeable, will research your case before giving you advice.” comments tended to be more positive (69% and 80%, respectively), whereas systems-issues comments “Staff is so-so, less professional than should be…” were more mixed (60% positive, 40% negative). The majority of Internet reviews of primary care physicians are positive in nature. Our findings reaffirm that the care encounter extends beyond the patient–physician dyad; staff, access, and convenience all affect patient’s reviews of physicians. In addition, negative interpersonal reviews underscore the importance of well-perceived bedside manner for a successful patient–physician interaction.

A 40-year-old woman presented to the emergency department with a chief complaint of a painful rash. She had noticed lesions on her skin accompanied by burning pain that intensified over a 24-hour period. The patient admitted to smoking “crack” cocaine 4 days prior to presentation. She reported having similar symptoms previously. Her complicated past medical history was significant for hepatitis C, anti-phospholipid antibody syndrome, migraine headaches, and chronic lower back pain. She endorsed smoking cigarettes and polysubstance abuse (marijuana, heroin, and daily cocaine use). The patient’s exam was notable for retiform purpuric skin lesions with eschar on her left external pinnae (Figure 1), tongue, roof of her mouth, and bilaterally on her upper and lower extremities (Figure 2). Pus was expressible on palpation of the tibial skin lesions. Laboratory evaluation revealed a white blood cell count of 3.1×109 cells/L and a positive urine toxicology screen for cocaine. A biopsy obtained from her right thigh during a prior similar presentation showed luminally-thrombosed fibrin-containing small vessels surrounded by neutrophils and nuclear dust. The adjacent dermis contained extravasated erythrocytes. Figure 1. Retiform purpuric skin lesions with eschar on pinnae. Figure 2. Retiform purpuric skin lesions with eschar on lower extremities. A vasculitic syndrome associated with levamisole-adulterated cocaine has become increasingly recognized. This syndrome is characterized by purpuric lesions in a retiform pattern that may become necrotic and are commonly distributed on the ears, face, and extremities,1 as evidenced by our patient. Typical laboratory findings include agranulocytosis, leukocopenia, and the production of anti-neutrophil cytoplasmic antibodies.1 There is no evidence for the optimal treatment of levamisole-induced cutaneous vasculitis syndrome. Steroids have been used, but have an unclear benefit. 2 Permanent discontinuation of levamisole-adulterated cocaine use should be advocated. When appropriate, surgical debridement has been used to contain the progression of necrotic tissue spread.2