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

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

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

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

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

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

Diabetic patients are nearly three times as likely to have depression as their nondiabetic counterparts. Patients with diabetes are already at risk for poor cardiovascular health. Using cross-sectional data from the translating research into action for diabetes (TRIAD) study, the authors tested the association of depression with cardiovascular risk factors in diabetic patients. Depression was measured using the patient health questionnaire (PHQ8). Patients who scored greater than 9 on the PHQ8 were classified as depressed and were compared with those who were not depressed(n=2,341). Depressed patients did not have significantly different blood pressure levels than those who were not depressed. However, those who were depressed had higher HbA1c levels than those who were not depressed(P<0.01)and higher BMIs than those who were not depressed(P<0.01). These results indicate that depressed diabetic patients are at greater risk of having poor control of cardiovascular risk factors and suggest that depression screening should be a standard practice among this patient group.

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

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

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

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

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

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

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

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