44 results on '"Bokhour B"'
Search Results
2. IMPROVING SAFETY, QUALITY, AND VALUE
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Jasuja, G., primary, Engle, R., additional, Skolnik, A., additional, Rose, A., additional, Male, A., additional, and Bokhour, B., additional
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- 2020
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3. Addressing Consumer and Patients’ Preferences and Needs Whole Health System of Care Improves Health and Well‐Being and Reduces Opioid Use for Veterans with Chronic Pain
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Bokhour, B., primary, Gelman, H., additional, Gaj, L., additional, Thomas, E., additional, Barker, A., additional, Whittington, M., additional, Douglas, J., additional, Defaccio, R., additional, Taylor, S., additional, and Zeliadt, S., additional
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- 2020
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4. Deprescribing in the Context of Multiple Providers: Understanding Patient Preferences
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Amy Linsky, Meterko, M., Bokhour, B. G., Stolzmann, K., and Simon, S. R.
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Adult ,Aged, 80 and over ,Male ,Health Knowledge, Attitudes, Practice ,Primary Health Care ,Health Personnel ,Patient Preference ,Middle Aged ,Pharmacists ,Article ,United States ,respiratory tract diseases ,United States Department of Veterans Affairs ,Deprescriptions ,Socioeconomic Factors ,Humans ,Female ,Aged ,Specialization - Abstract
OBJECTIVES: Deprescribing could reduce the risk of harm from inappropriate medications. We characterized patients’ acceptance of deprescribing recommendations from pharmacists, primary care providers (PCPs), and specialists relative to the original prescriber’s professional background. STUDY DESIGN: Secondary analysis of national Patient Perceptions of Discontinuation survey responses from Veterans Affairs (VA) primary care patients with 5 or more prescriptions. METHODS: We created 4 relative deprescribing authority (RDA) outcome groups from responses to 2 yes/no (Y/N) items: (1) “Imagine…a specialist…prescribed a medicine. Would you be comfortable if your PCP told you to stop…it?” and (2) “Imagine…your VA PCP prescribed a medicine. Would you be comfortable if a VA clinical pharmacist [Pharm] told you to stop…it?” Multinomial regression associated patient factors with RDA. RESULTS: Respondents (n = 803; adjusted response rate, 52%) were predominantly men (85%) and older than 65 years (60%). A total of 281 (38%) respondents said no to both questions (PCP-N/Pharm-N) and 146 (20%) said yes to both (PCP-Y/Pharm-Y). A total of 155 (21%) said no to a PCP stopping a specialist’s medicine but yes to a pharmacist stopping a PCP’s (PCP-N/Pharm-Y). A total of 153 (21%) said that a PCP could stop a specialist’s medication but a pharmacist could not stop a PCP’s (PCP-Y/Pharm-N). In adjusted models (reference, PCP-N/Pharm-N), those with greater medication concerns were more likely to respond PCP-Y/Pharm-Y (odds ratio [OR], 1.45; 95% CI, 1.09–1.92). Those with more interest in shared decision making were more likely to respond PCP-N/Pharm-Y (OR, 1.41; 95% CI, 1.04–1.92). Those with greater trust in their PCP were less likely to respond PCP-N/Pharm-Y (OR, 0.52; 95% CI, 0.34–0.81) but more likely to respond PCP-Y/Pharm-N (OR, 2.16; 95% CI, 1.31–3.56) or PCP-Y/Pharm-Y (OR, 1.83; 95% CI, 1.13–2.98). CONCLUSIONS: Understanding patient preferences of RDA can facilitate effective design and implementation of deprescribing interventions.
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- 2019
5. Disclosing large scale adverse events in the US Veterans Health Administration: lessons from media responses.
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Maguire, E. M., Bokhour, B. G., Asch, S. M., Wagner, T. H., Gifford, A. L., Gallagher, T. H., Durfee, J. M., Martinello, R. A., and Elwy, A. R.
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Objectives: We examined print, broadcast and social media reports about health care systems' disclosures of large scale adverse events to develop future effective messaging. Study design: Directed content analysis. Methods: We systematically searched four communication databases, YouTube and Really Simple Syndication (RSS) feeds relating to six disclosures of lapses in infection control practices in the Department of Veterans Affairs occurring between 2009 and 2012. We assessed these with a coding frame derived from effective crisis and risk communication models. Results: We identified 148 unique media reports. Some components of effective communication (discussion of cause, reassurance, self-efficacy) were more present than others (apology, lessons learned). Media about 'promoting secrecy' and 'slow response' appeared in reports when time from event discovery to patient notification was over 75 days. Elected officials' quotes (n = 115) were often negative (83%). Hospital officials' comments (n = 165) were predominantly neutral (92%), and focused on information sharing. Conclusions: Health care systems should work to ensure that they develop clear messages focused on what is not well covered by the media, including authentic apologies, remedial actions taken, and shorten the timeframe between event identification and disclosure to patients. [ABSTRACT FROM AUTHOR]
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- 2016
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6. Discussions about pregnancy prevention with health care clinicians: findings from qualitative interviews with young black women in Boston
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D'Amore, M., primary, McCloskey, L., additional, Bokhour, B., additional, Paasche-Orlow, M., additional, and Parker, V., additional
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- 2012
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7. Patient and provider views on the use of medical services by women with intellectual disabilities
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Wilkinson, J., primary, Dreyfus, D., additional, Bowen, D., additional, and Bokhour, B., additional
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- 2012
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8. How do young, Black women view birth control and talk to their health care providers about family planning?
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D'Amore, M., primary, McCloskey, L., additional, Bokhour, B., additional, Paasche-Orlow, M., additional, Jack, B., additional, and Parker, V., additional
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- 2012
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9. 'It's Easier Said Than Done': Perspectives on Mammography From Women With Intellectual Disabilities
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Wilkinson, J. E., primary, Deis, C. E., additional, Bowen, D. J., additional, and Bokhour, B. G., additional
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- 2011
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10. What constitutes high quality of care for adults with epilepsy?
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Pugh, M.J.V., primary, Berlowitz, D. R., additional, Montouris, G., additional, Bokhour, B., additional, Cramer, J. A., additional, Bohm, V., additional, Bollinger, M., additional, Helmers, S., additional, Ettinger, A., additional, Meador, K. J., additional, Fountain, N., additional, Boggs, J., additional, Tatum, W. O., additional, Knoefel, J., additional, Harden, C., additional, Mattson, R. H., additional, and Kazis, L., additional
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- 2007
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11. Whole Health System of Care Improves Health and Well‐Being and Reduces Opioid Use for Veterans with Chronic Pain.
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Bokhour, B., Gelman, H., Gaj, L., Thomas, E., Barker, A., Whittington, M., Douglas, J., Defaccio, R., Taylor, S., and Zeliadt, S.
- Subjects
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CHRONIC pain , *MEDICAL care , *VETERANS , *CHRONICALLY ill patient care , *WELL-being , *HEALTH self-care - Published
- 2020
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12. Sexuality after treatment for early prostate cancer: exploring the meanings of "erectile dysfunction".
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Bokhour, B G, Clark, J A, Inui, T S, Silliman, R A, and Talcott, J A
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PROSTATE tumors treatment , *COMPARATIVE studies , *COUNSELING , *FOCUS groups , *IMPOTENCE , *RESEARCH methodology , *MEDICAL cooperation , *PHYSICIAN-patient relations , *QUALITY of life , *RESEARCH , *EVALUATION research - Abstract
Objective: To explore perceptions of the impact of erectile dysfunction on men who had undergone definitive treatment for early nonmetastatic prostate cancer.Design: Seven focus groups of men with early prostate cancer. The groups were semistructured to explore men's experiences and quality-of-life concerns associated with prostate cancer and its treatment.Setting: A staff model health maintenance organization, and a Veterans Affairs medical center.Patients: Forty-eight men who had been treated for early prostate cancer 12 to 24 months previously.Results: Men confirmed the substantial effect of sexual dysfunction on the quality of their lives. Four domains of quality of life related to men's sexuality were identified: 1) the qualities of sexual intimacy; 2) everyday interactions with women; 3) sexual imagining and fantasy life; and 4) men's perceptions of their masculinity. Erectile problems were found to affect men in both their intimate and nonintimate lives, including how they saw themselves as sexual beings.Conclusions: Erectile dysfunction, the most common side effect of treatment for early prostate cancer, has far-reaching effects upon men's lives. Assessment of quality of life related to sexual dysfunction should address these broad impacts of erectile function on men's lives. Physicians should consider these effects when advising men regarding treatment options. Physicians caring for patients who have undergone treatment should address these psychosocial issues when counseling men with erectile dysfunction. [ABSTRACT FROM AUTHOR]- Published
- 2001
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13. Understanding the Context of High‐ and Low‐Testosterone Prescribing Facilities in the Veterans Health Administration (VHA): A Qualitative Study.
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Jasuja, G., Engle, R., Skolnik, A., Rose, A., Male, A., and Bokhour, B.
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HEALTH facility administration ,QUALITATIVE research - Published
- 2020
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14. Prescribers' perceptions of medication discontinuation: Survey instrument development and validation
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Amy Linsky, Simon, S. R., Stolzmann, K., Bokhour, B. G., and Meterko, M.
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Male ,Psychometrics ,Attitude of Health Personnel ,Pilot Projects ,Pharmacists ,Article ,Drug Utilization ,Physicians, Primary Care ,United States ,United States Department of Veterans Affairs ,Cross-Sectional Studies ,Prescriptions ,Withholding Treatment ,Surveys and Questionnaires ,Humans ,Female ,Perception - Abstract
OBJECTIVES: Primary care providers (PCPs) and clinical pharmacists have concerns about the adverse consequences of using medications inappropriately and generally support the notion of reducing unnecessary drugs. Despite this attitude, many factors impede clinicians’ ability to discontinue medication in clinical settings. We sought to develop a survey instrument that assesses PCPs’ and pharmacists’ experiences, attitudes, and beliefs toward medication discontinuation. STUDY DESIGN: Survey development and psychometric assessment. METHODS: Based on a conceptual framework, we developed a questionnaire and surveyed a national sample of Department of Veterans Affairs PCPs with prescribing privileges, including physicians, nurse practitioners, physician assistants, and clinical pharmacy specialists. We randomly divided respondents into derivation and validation samples and used iterations of multi-trait analysis to assess the psychometric properties of the proposed measures. Multivariable regression models identified factors associated with the outcome of self-rated comfort with medication discontinuation. RESULTS: Using established criteria for scale development, we identified 5 scales: Medication Characteristics, Current Patient Clinical Factors, Predictions of Future Health States, Patients’ Resources to Manage Their Own Health, and Education and Experience. Three of these dimensions predicted providers’ self-rated comfort with making decisions to discontinue medication (Current Patient Clinical Factors, Predictions of Future Health States, and Education and Experience). CONCLUSIONS: We developed a psychometrically sound instrument to measure prescribers’ attitudes toward, and experiences with, medication discontinuation. This survey will enable identification of perceived barriers to, and facilitators of, proactive discontinuation—an important step toward developing interventions that improve the quality and safety of care in medication use.
15. Use of electronic personal health record systems to encourage HIV screening: an exploratory study of patient and provider perspectives
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McInnes D Keith, Solomon Jeffrey L, Bokhour Barbara G, Asch Steven M, Ross David, Nazi Kim M, and Gifford Allen L
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Medicine ,Biology (General) ,QH301-705.5 ,Science (General) ,Q1-390 - Abstract
Abstract Background When detected, HIV can be effectively treated with antiretroviral therapy. Nevertheless in the U.S. approximately 25% of those who are HIV-infected do not know it. Much remains unknown about how to increase HIV testing rates. New Internet outreach methods have the potential to increase disease awareness and screening among patients, especially as electronic personal health records (PHRs) become more widely available. In the US Department of Veterans' Affairs medical care system, 900,000 veterans have indicated an interest in receiving electronic health-related communications through the PHR. Therefore we sought to evaluate the optimal circumstances and conditions for outreach about HIV screening. In an exploratory, qualitative research study we examined patient and provider perceptions of Internet-based outreach to increase HIV screening among veterans who use the Veterans Health Administration (VHA) health care system. Findings We conducted two rounds of focus groups with veterans and healthcare providers at VHA medical centers. The study's first phase elicited general perceptions of an electronic outreach program to increase screening for HIV, diabetes, and high cholesterol. Using phase 1 results, outreach message texts were drafted and then presented to participants in the second phase. Analysis followed modified grounded theory. Patients and providers indicated that electronic outreach through a PHR would provide useful information and would motivate patients to be screened for HIV. Patients believed that electronic information would be more convenient and understandable than information provided verbally. Patients saw little difference between messages about HIV versus about diabetes and cholesterol. Providers, however, felt patients would disapprove of HIV-related messages due to stigma. Providers expected increased workload from the electronic outreach, and thus suggested adding primary care resources and devising methods to smooth the flow of patients getting screened. When provided a choice between unsecured emails versus PHRs as the delivery mechanism for disease screening messages, both patients and providers preferred PHRs. Conclusions There is considerable potential to use PHR systems for electronic outreach and social marketing to communicate to patients about, and increase rates of, disease screening, including for HIV. Planning for direct-to-patient communications through PHRs should include providers and address provider reservations, especially about workload increases.
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- 2011
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16. Promoting Health and Wellbeing Through Non-Clinical Arts Programming: Multi-Stakeholder Perspectives From the Veterans Health Administration.
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Anderson E, Dones M, Cohen-Bearak A, Barker A, Hyde J, and Bokhour B
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- Humans, United States, Male, Female, Middle Aged, Mental Health, Art Therapy, Interviews as Topic, Adult, Self Concept, Veterans Health, Aged, United States Department of Veterans Affairs organization & administration, Health Promotion organization & administration, Health Promotion methods, Qualitative Research, Veterans psychology
- Abstract
Purpose: While the value of art therapy is well-established and arts are increasingly leveraged to promote health and wellbeing more broadly, little is known about the impacts of non-clinical arts programs. In this preliminary investigation, we sought to fill this gap by exploring diverse stakeholders' perspectives on the impacts of non-clinical arts programming on Veterans receiving care at the Veterans Health Administration (VA)., Design: Semi-structured qualitative interviews with Veterans, VA staff, and community partners., Setting: Interviewees were recruited from 7 VA medical centers that have recently implemented non-clinical arts programming to promote Veterans' health and wellbeing, some of them in partnership with community organizations., Participants: 33 individuals were interviewed, including 9 Veterans, 14 VA staff, and 10 community partners involved in non-clinical arts program implementation., Method: Interview transcripts were analyzed using iterative rounds of qualitative content analysis., Results: The following impacts on Veterans were described: (1) mental health improvements, (2) renewed sense of purpose; (3) increased social connectedness, (4) improved self-esteem, and (5) self-driven engagement in art activities., Conclusion: Non-clinical arts programming was perceived by diverse stakeholders to offer important benefits for Veterans' health and well-being. Offering non-clinical arts programming inside and outside healthcare facilities' walls is a promising direction for the field of public health undergoing a shift towards holistic approaches to improving individual and population health outcomes., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
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- 2024
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17. Nephrologists' perspectives and experiences with hospice among older adults with end-stage kidney disease.
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Wachterman MW, Sinha A, Leveille T, Waikar SS, Widera E, Romero K, and Bokhour B
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- Humans, Male, Female, United States, Aged, Attitude of Health Personnel, Middle Aged, Interviews as Topic, Hospice Care psychology, Kidney Failure, Chronic therapy, Kidney Failure, Chronic psychology, Qualitative Research, Nephrologists
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Background: Hospice care leads to improved patient and family outcomes. Hospice use among older adults with end-stage kidney disease (ESKD) is markedly lower than among older adults with other serious illnesses, and the majority of those with ESKD who use hospice enroll in the last days of life. Here, our aim was to explore barriers to timely receipt of high-quality hospice care for older adults with ESKD., Methods: Utilizing a qualitative study design, we conducted a secondary analysis focused on hospice, a theme that we identified in our larger overarching study that involved semi-structured interviews with 20 nephrologists in the United States focused on treatment decision-making in older adults with advanced chronic kidney disease. We analyzed the interview transcripts using emergent thematic analysis to develop an understanding of barriers to high-quality hospice., Results: With a couple notable exceptions, nephrologists voiced general support for the concept of hospice, but few recalled patients of theirs who had received hospice. Nephrologists' interviews revealed two interrelated contributors to the lack of timely access to high-quality hospice care for seriously ill older adults with ESKD: (1) nephrologists view dialysis and hospice as mutually exclusive models of care; (2) nephrologists feel unsure who should manage hospice care for patients with ESKD. The first contributor was rooted in nephrologists' narrow vision of when to consider hospice (informed, in part, by policy barriers) and, in a couple of cases, strong discomfort with hospice. The second stemmed from nephrologists' belief that neither they nor hospice are adequately prepared to provide hospice care for ESKD., Conclusions: Our findings suggest that, in addition to Medicare policy change, nephrologists need to receive more training in primary palliative care skills including in indications for hospice, initiating conversations about hospice with patients, and collaborating with hospice clinicians to care for these vulnerable patients., (© 2024 The American Geriatrics Society. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA.)
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- 2024
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18. Feasibility of a family-involved intervention to increase engagement in evidenced-based psychotherapies for posttraumatic stress disorder: A pilot study.
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Shepherd-Banigan M, Shapiro A, Stechuchak KM, Glynn S, Calhoun P, Ackland PE, Bokhour B, Edelman D, Falkovic M, Weidenbacher HJ, Eldridge MR, Lanford T, Swinkels C, Dedert E, Wells S, Ruffin R, and Van Houtven CH
- Abstract
Objective: To assess the feasibility of a family-involved intervention, family support in mental health recovery (FAMILIAR), for veterans with posttraumatic stress disorder (PTSD) seeking psychotherapy at a single Veterans Administration Health System., Method: This mixed-methods study reports qualitative and quantitative findings from a single-group pilot of 24 veterans and their support partners (SPs) about experiences with the intervention and interviews with eight VA mental health clinicians and leaders and the study interventionist to explore intervention feasibility. Findings across data sources were merged within domains of Bowen and colleagues' pilot study feasibility framework., Results: Out of 24 dyads, 16 veterans and 15 associated SPs completed the intervention. Participants viewed the intervention to be valuable and feasible. Veterans and SPs reported that they enrolled in the study to develop a shared understanding of PTSD and treatment. While participants identified few logistical barriers, finding a time for conjoint sessions could be a challenge. Veterans, SPs, and providers discussed benefits of the intervention, including that it facilitated conversation between the veteran and SP about PTSD and mental health care and helped to prepare the dyad for treatment. Providers noted potential challenges integrating family-involved interventions into clinical workflow in VA and suggested the need for additional training and standardized procedures for family-centered care., Conclusions: Our study identified potential implementation facilitators (e.g., standard operating procedures about session documentation, confidentiality, and family ethics) and challenges (e.g., clinical workflow integration) that require further study to bring FAMILIAR into routine clinical care. (PsycInfo Database Record (c) 2024 APA, all rights reserved).
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- 2024
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19. How to make PROMs work: qualitative insights from leaders at United States hospitals with successful PROMs programs.
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Hyland CJ, Mou D, Virji AZ, Sokas CM, Bokhour B, Pusic AL, and Mjåset C
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- Humans, United States, Qualitative Research, Delivery of Health Care, Hospitals, Patient Reported Outcome Measures, Primary Health Care, Quality of Life psychology
- Abstract
Purpose: Elucidate facilitators, barriers, and key lessons learned regarding the implementation of system-wide clinical patient-reported outcome measure (PROM) programs among United States (US) healthcare leaders., Methods: We conducted semi-structured interviews with 35 US healthcare leaders, including chief-level executives, data directors, PROM directors, and department chairs involved in PROM implementation across seven diverse healthcare systems from February to June 2020. Transcripts were coded, evaluated for qualitative themes, and categorized according to the consolidated framework for implementation research (CFIR)., Results: According to US hospital leaders with experience in existing clinical PROM programs, there are facilitators and barriers to implementation success in each CFIR domain. Allowing clinicians to select PROM measures and ensuring a user-friendly data platform (intervention); adapting data collection to patient home environments (outer setting); informing clinicians of the multi-faceted use of PROM data for research, clinical care, and business (inner setting); implementing PROM education earlier into clinician training (characteristics of individuals); and establishing specialty-agnostic PROM implementation teams (process) were among key facilitators to implementation success., Conclusion: Leaders of geographically and clinically diverse PROM programs in the US identify common themes that facilitate successful implementation. Drivers of success depend on factors within and outside the clinical environment. These findings may serve to guide both establishing new PROM programs and refining existing PROM programs., (© 2023. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)
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- 2023
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20. Impetus of US hospital leaders to invest in patient-reported outcome measures (PROMs): a qualitative study.
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Mou D, Mjaset C, Sokas CM, Virji A, Bokhour B, Heng M, Sisodia RC, Pusic AL, and Rosenthal MB
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- Emotions, Humans, Patient Reported Outcome Measures, Qualitative Research, Health Facilities, Hospitals
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Objectives: Though hospital leaders across the USA have invested significant resources in collection of patient-reported outcome measures (PROMs), there are very limited data on the impetus for hospital leadership to establish PROM programmes. In this qualitative study, we identify the drivers and motivators of PROM collection among hospital leaders in the USA., Design: Exploratory qualitative study., Setting: Thirty-seven hospital leaders representing seven different institutions with successful PROMs programs across twenty US states., Methods: Semistructured interviews conducted with hospital leaders. Transcripts were analysed using thematic analysis., Results: Leaders strongly believe that collecting PROMs is the 'right thing to do' and that the culture of the institution plays an important role in enabling PROMs. The study participants often believe that their institutions deliver superior care and that PROMs can be used to demonstrate the value of their services to payors and patients. Direct financial incentives are relatively weak motivators for collection of PROMs. Most hospital leaders have reservations about using PROMs in their current state as a meaningful performance metric., Conclusion: These findings suggest that hospital leaders feel a strong moral imperative to collect PROMs, which is also supported by the culture of their institution. Although PROMs are used in negotiations with payors, direct financial return on investment is not a strong driver for the collection of PROMs. Understanding why leaders of major healthcare institutions invest in PROMs is critical to understanding the role that PROMs play in the US healthcare system., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
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- 2022
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21. The Whole Health Transformation at the Veterans Health Administration: Moving From "What's the Matter With You?" to "What Matters to You?"
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Kligler B, Hyde J, Gantt C, and Bokhour B
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- Humans, Veterans Health
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The Veterans Health Administration is undergoing a system-wide transformation to a Whole Person/Whole Health approach to care. The Whole Health model of care is described including early outcome data on utilization and effectiveness. The paper describes the first 10 years of this transformation and provides lessons learned during that process regarding large-scale system change., Competing Interests: The authors declare no conflict of interest., (Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.)
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- 2022
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22. Achieving Whole Health: A Preliminary Study of TCMLH, a Group-Based Program Promoting Self-Care and Empowerment Among Veterans.
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Abadi M, Richard B, Shamblen S, Drake C, Schweinhart A, Bokhour B, Bauer R, and Rychener D
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- Humans, Self Care, Veterans
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Objective: An emerging literature suggests patients with chronic illnesses can benefit from integrated, person-centric approaches to health care, including group-based programs. However, much of the research in this area is disease specific. The objective of this study was to collect preliminary evidence on the efficacy of Taking Charge of My Life and Health (TCMLH), a Whole Health group-based program that emphasizes self-care and empowerment on the overall health and well-being of veterans, a population burdened with high rates of multiple chronic conditions., Method: Self-reported outcomes, including standardized survey measures, were collected at pretest, posttest, and 2-month follow-up from 77 participants across 15 groups at four VA sites. Random intercept mixed-model regressions were used to analyze data., Results: Results from this initial study showed high satisfaction with the program and facilitators, and high attendance. There were significant pre-post gains in self-care attitudes and behaviors, patient motivation, meaning and purpose, mental health, perceived stress, goal progress, and goal-specific hope. Outcomes were maintained at 2-month follow-up for patient motivation, perceived stress, goal-specific hope, and goal progress. Significant gains were observed in health care empowerment and physical health from pretest to follow-up., Conclusions: Preliminary findings support the efficacy of TCMLH, a Whole Health group-based program that emphasizes patient empowerment, self-care practices, and peer support. Future research priorities include a rigorous evaluation with a larger sample size and control group to assess effectiveness.
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- 2022
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23. Lessons Learned From VHA's Rapid Implementation of Virtual Whole Health Peer-Led Groups During the COVID-19 Pandemic: Staff Perspectives.
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Anderson E, Dvorin K, Etingen B, Barker AM, Rai Z, Herbst A, Mozer R, Kingston RP, and Bokhour B
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Background: Committed to implementing a person-centered, holistic (Whole Health) system of care, the Veterans Health Administration (VHA) developed a peer-led, group-based, multi-session "Taking Charge of My Life and Health" (TCMLH) program wherein Veterans reflect on values, set health and well-being-related goals, and provide mutual support. Prior work has demonstrated the positive impact of these groups. After face-to-face TCMLH groups were disrupted by the COVID-19 pandemic, VHA facilities rapidly implemented virtual (video-based) TCMLH groups., Objective: We sought to understand staff perspectives on the feasibility, challenges, and advantages of conducting TCMLH groups virtually., Methods: We completed semi-structured telephone interviews with 35 staff members involved in the implementation of virtual TCMLH groups across 12 VHA facilities and conducted rapid qualitative analysis of the interview transcripts., Results: Holding TCMLH groups virtually was viewed as feasible. Factors that promoted the implementation included use of standardized technology platforms amenable to delivery of group-based curriculum, availability of technical support, and adjustments in facilitator delivery style. The key drawbacks of the virtual format included difficulty maintaining engagement and barriers to relationship-building among participants. The perceived advantages of the virtual format included the positive influence of being in the home environment on Veterans' reflection, motivation, and self-disclosure, the greater convenience and accessibility of the virtual format, and the virtual group's role as an antidote to isolation during the COVID-19 pandemic., Conclusion: Faced with the disruption caused by the COVID-19 pandemic, VHA pivoted by rapidly implementing virtual TCMLH groups. Staff members involved in implementation noted that delivering TCMLH virtually was feasible and highlighted both challenges and advantages of the virtual format. A virtual group-based program in which participants set and pursue personally meaningful goals related to health and well-being in a supportive environment of their peers is a promising innovation that can be replicated in other health systems., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2022.)
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- 2022
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24. Narratives of Gestational Diabetes Provide a Lens to Tailor Postpartum Prevention and Monitoring Counseling.
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Gunn C, Bernstein J, Bokhour B, and McCloskey L
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- Adolescent, Adult, Communication, Female, Focus Groups, Humans, Narration, Postpartum Period, Pregnancy, Prenatal Care, Qualitative Research, Risk Factors, Young Adult, Counseling, Diabetes Mellitus, Type 2 prevention & control, Diabetes, Gestational psychology, Postnatal Care methods
- Abstract
Introduction: Women with gestational diabetes mellitus (GDM) have a marked increased risk of early onset type 2 diabetes, but less than half initiate postpartum glucose testing or connect with a primary care provider for continued follow-up after giving birth. This study analyzed women's narratives about their GDM-affected pregnancies to (1) identify different patterns (narrative archetypes) that capture the GDM experience; (2) explore how these patterns relate to awareness of ongoing risk after pregnancy and affect participation in self-care, monitoring, and preventive health care going forward; and (3) explore the use of identified patterns to tailor conversations with patients during prenatal and postpartum care to their actual perceptions and concerns about future risk., Methods: Open-ended interviews elicited women's experiences and perspectives about GDM and its management. A narrative analysis first identified segments of text related to risk and behaviors and then applied Frank's narrative archetypes (restitution, chaos, quest) as an interpretive lens., Results: Interviews were completed in English (n = 15), Spanish (n = 7), and Haitian Creole (n = 7). We found distinct patterns: stories of restitution (n = 13), quest (n = 4), chaos (n = 4), and mixed narratives (n = 7). Using these archetypes, we found differences in how women respond to challenges related to disease complexity, treatment, and future risks. These patterns led to marked differences in the steps women took to prevent early onset type 2 diabetes., Discussion: Frank's narrative types provided insight into women's responses to clinical protocols, health care advice, and subsequent prevention actions. A restitution pattern may result in premature closure and lack of awareness of risk. Similarly, a chaos pattern may contribute to a sense of helplessness to implement follow-up recommendations, despite risk awareness. Understanding these patterns can help clinicians tailor individualized support as women transition from GDM with its focus on a healthy fetus and newborn to preventive self-care to protect their health., (© 2020 by the American College of Nurse-Midwives.)
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- 2020
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25. Nephrologists' emotional burden regarding decision-making about dialysis initiation in older adults: a qualitative study.
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Wachterman MW, Leveille T, Keating NL, Simon SR, Waikar SS, and Bokhour B
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- Adult, Aged, 80 and over, Conservative Treatment, Death, Female, Humans, Interviews as Topic, Male, Middle Aged, Patient Participation, Patient Preference, Prognosis, Qualitative Research, Renal Dialysis, Uncertainty, Decision Making, Emotions, Kidney Failure, Chronic therapy, Nephrologists psychology
- Abstract
Background: Conservative management, an approach to treating end-stage kidney disease without dialysis, while generally associated with shorter life expectancy than treatment with dialysis, is associated with fewer hospitalizations, better functional status and, potentially, better quality of life. Conservative management is a well-established treatment approach in a number of Western countries, including the United Kingdom (U.K.). In contrast, despite clinical practice guidelines in the United States (U.S.) recommending that nephrologists discuss all treatment options, including conservative management, with stage 4 and 5 chronic kidney disease patients, studies suggest that this rarely occurs. Therefore, we explored U.S. nephrologists' approaches to decision-making about dialysis and perspectives on conservative management among older adults., Methods: We conducted a qualitative research study. We interviewed 20 nephrologists - 15 from academic centers and 5 from community practices - utilizing a semi-structured interview guide containing open-ended questions. Interview transcripts were analyzed using grounded thematic analysis in which codes were generated inductively and iteratively modified, and themes were identified. Transcripts were coded independently by two investigators, and interviews were conducted until thematic saturation., Results: Twenty nephrologists (85% white, 75% male, mean age 50) participated in interviews. We found that decision-making about dialysis initiation in older adults can create emotional burden for nephrologists. We identified four themes that reflected factors that contribute to this emotional burden including nephrologists' perspectives that: 1) uncertainty exists about how a patient will do on dialysis, 2) the alternative to dialysis is death, 3) confronting death is difficult, and 4) patients do not regret initiating dialysis. Three themes revealed different decision-making strategies that nephrologists use to reduce this emotional burden: 1) convincing patients to "just do it" (i.e. dialysis), 2) shifting the decision-making responsibility to patients, and 3) utilizing time-limited trials of dialysis., Conclusions: A decision not to start dialysis and instead pursue conservative management can be emotionally burdensome for nephrologists for a number of reasons including clinical uncertainty about prognosis on dialysis and discomfort with death. Nephrologists' attempts to reduce this burden may be reflected in different decision-making styles - paternalistic, informed, and shared decision-making. Shared decision-making may relieve some of the emotional burden while preserving patient-centered care.
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- 2019
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26. Patient-Centered Care in Primary Care Scale: Pilot Development and Psychometric Assessment.
- Author
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Radwin LE, Cabral HJ, Seibert MN, Stolzmann K, Meterko M, Evans L, Barker A, and Bokhour B
- Subjects
- Female, Humans, Male, Middle Aged, Patient-Centered Care organization & administration, Pilot Projects, Reproducibility of Results, Surveys and Questionnaires, United States, United States Department of Veterans Affairs, Patient-Centered Care methods, Primary Care Nursing, Primary Health Care, Psychometrics methods
- Abstract
Background: Nurse contributions to patient-centered care in primary care clinics are all but ignored in standard patient experience surveys., Purpose: The purpose was to conduct a pilot study to develop and psychometrically assess a scale measuring nurses' and other providers' patient-centered care in Veteran Affairs primary care clinics., Method: We developed a patient experience survey composed of original items and previous studies' items and scales. The survey was field tested online with patients who had a recent clinic appointment. The nonrandom analytic sample comprised 221 patients., Results: Exploratory factor analyses yielded a 36-item, 4-factor solution explaining 76% of the variance. The factors were: (1) Provider Knowing the Person/Individualizing Care (18 items; α = 0.98); (2) Nurse Knowing the Person (8; 0.95); (3) Nurse Individualizing Care (7; 0.94); and (4) Continuity of Care (3; not calculated). A short form with 23 items was created using stepwise regression. It had the same 4 factors as the long form with 76% of the variance explained., Conclusions: Patients reported distinctive nurse contributions that have not been routinely measured.
- Published
- 2019
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27. Exploring Explanatory Models of Risk in Breast Cancer Risk Counseling Discussions: NSABP/NRG Oncology Decision-Making Project 1.
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Gunn CM, Bokhour B, Parker VA, Parker PA, Blakeslee S, Bandos H, and Holmberg C
- Subjects
- Adult, Decision Making, Female, Humans, Middle Aged, Qualitative Research, Risk Assessment, Breast Neoplasms psychology, Counseling, Health Knowledge, Attitudes, Practice, Models, Educational
- Abstract
Background: Explanatory models represent patient understanding of etiology, pathophysiology, illness, symptoms, and treatments, but little attention has been paid to how they are used by patients "at risk" for future disease., Objective: The aims of this study were to elucidate what constitutes an explanatory model of risk and to describe explanatory models of risk related to developing breast cancer., Methods: Thirty qualitative interviews with women identified as at an increased risk for breast cancer were conducted. Interviews were coded to identify domains of explanatory models of risk using a priori codes derived from the explanatory model of illness framework. Within each domain, a grounded thematic analysis described participants' explanatory models related to breast cancer risk., Results: The domains of treatment and etiology remained similar in a risk context compared with illness, whereas course of illness, symptoms, and pathophysiology differed. We identified a new, integrative concept relative to other domains within explanatory models of risk: social comparisons, which was dominant in risk perhaps due to the lack of physical experiences associated with being "at risk.", Conclusions: Developing inclusive understandings of risk and its treatment is key to developing a framework for the care of high-risk patients that is both evidence based and sensitive to patient preferences., Implications for Practice: The concept of "social comparisons" can assist healthcare providers in understanding women's decision making under conditions of risk. Ensuring that healthcare providers understand patient perceptions of risk is important because it relates to patient decision making, particularly due to an increasing focus on risk assessment in cancer.
- Published
- 2019
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28. False-positive mammography and its association with health service use.
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Gunn CM, Bokhour B, Battaglia TA, Silliman RA, and Hanchate A
- Subjects
- Adult, Aged, Electronic Health Records, False Positive Reactions, Female, Humans, Middle Aged, Referral and Consultation statistics & numerical data, Retrospective Studies, Risk Factors, Safety-net Providers, Socioeconomic Factors, Breast Neoplasms diagnosis, Health Services statistics & numerical data, Mammography
- Abstract
Objectives: A false-positive mammogram can result in anxiety, distress, and increased perceptions of breast cancer risk, potentially changing how women utilize healthcare. This study examined whether having an abnormal mammogram, considered a proxy for elevated risk perception, was associated with greater future health service use (outpatient visits and referrals)., Study Design: A retrospective cohort study using electronic health record data, spanning 2008 to 2012, from Boston Medical Center, a safety-net hospital., Methods: We grouped 3920 women aged 40 to 75 years receiving primary care and who had a mammogram between 2010 and 2011 into 3 categories: false-positive mammogram at index date; previous false positive, but normal index mammogram; and no history of false-positive mammograms. We contrasted the longitudinal changes in outpatient visits and provider referrals, before versus after the index mammogram, between women with false-positive mammogram and those without using Poisson regression models with a difference-in-differences specification. Clinical, visit, and demographic data were obtained from the institutional clinical data warehouse., Results: Adjusting for baseline differences in sociodemographic characteristics across risk groups and for secular changes between pre- and postindex periods, a current false-positive mammogram was associated with an 18% increase in overall outpatient visits (incidence rate ratio [IRR], 1.18; 95% CI, 1.07-1.51), but no corresponding increase in provider referrals (IRR, 1.15; 95% CI, 0.99‑1.34), relative to never having a false positive. A previous false-positive mammogram had no associated change in outpatient utilization (IRR, 0.99; 95% CI, 0.91-1.07)., Conclusions: Providers should discuss the implications of mammography findings at the time of screening to help mitigate potential detrimental effects and promote appropriate engagement in health services.
- Published
- 2018
29. Should Human Immunodeficiency Virus Specialty Clinics Treat Patients With Hypertension or Refer to Primary Care? An Analysis of Treatment Outcomes.
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Appenheimer AB, Bokhour B, McInnes DK, Richardson KK, Thurman AL, Beck BF, Vaughan-Sarrazin M, Asch SM, Midboe AM, Taylor T, Dvorin K, Gifford AL, and Ohl ME
- Abstract
Background: Care for people with human immunodeficiency virus (HIV) increasingly focuses on comorbidities, including hypertension. Evidence indicates that antiretroviral therapy and opportunistic infections are best managed by providers experienced in HIV medicine, but it is unclear how to structure comorbidity care. Approaches include providing comorbidity care in HIV clinics ("consolidated care") or combining HIV care with comorbidity management in primary care clinics ("shared care"). We compared blood pressure (BP) control in HIV clinics practicing consolidated care versus shared care., Methods: We created a national cohort of Veterans with HIV and hypertension receiving care in HIV clinics in Veterans Administration facilities and merged these data with a survey asking HIV providers how they delivered hypertension care (5794 Veterans in 73 clinics). We defined BP control as BP ≤140/90 mmHg on the most recent measure. We compared patients' likelihood of experiencing BP control in clinics offering consolidated versus shared care, adjusting for patient and clinic characteristics., Results: Forty-two of 73 clinics (57.5%) practiced consolidated care for hypertension. These clinics were larger and more likely to use multidisciplinary teams. The unadjusted frequency of BP control was 65.6% in consolidated care clinics vs 59.4% in shared care clinics ( P < .01). The likelihood of BP control remained higher for patients in consolidated care clinics after adjusting for patient and clinic characteristics (odds ratio, 1.32; 95% confidence interval, 1.04-1.68)., Conclusions: Patients were more likely to experience BP control in clinics reporting consolidated care compared with clinics reporting shared care. For shared-care clinics, improving care coordination between HIV and primary care clinics may improve outcomes., (Published by Oxford University Press on behalf of Infectious Diseases Society of America 2017. This work is written by (a) US Government employee(s) and is in the public domain in the US.)
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- 2017
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30. Racial Disparities in HIV Care Extend to Common Comorbidities: Implications for Implementation of Interventions to Reduce Disparities in HIV Care.
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Richardson KK, Bokhour B, McInnes DK, Yakovchenko V, Okwara L, Midboe AM, Skolnik A, Vaughan-Sarrazin M, Asch SM, Gifford AL, and Ohl ME
- Subjects
- Black or African American, Anti-HIV Agents therapeutic use, Comorbidity, Diabetes Mellitus, HIV Infections epidemiology, Humans, Racial Groups, United States, White People, Ethnicity statistics & numerical data, HIV Infections therapy, Healthcare Disparities ethnology
- Abstract
Background: Prior studies have described racial disparities in the quality of care for persons with HIV infection, but it is unknown if these disparities extend to common comorbid conditions. To inform implementation of interventions to reduce disparities in HIV care, we examined racial variation in a set of quality measures for common comorbid conditions among Veterans in care for HIV in the United States., Method: The cohort included 23,974 Veterans in care for HIV in 2013 (53.4% black; 46.6% white). Measures extracted from electronic health record and administrative data were receipt of combination antiretroviral therapy (cART), HIV viral control (serum RNA < 200 copies/ml among those on cART), hypertension control (blood pressure < 140/90 mm Hg among those with hypertension), diabetes control (hemoglobin A1C < 9% among those with diabetes), lipid monitoring, guideline-concordant antidepressant prescribing, and initiation and engagement in substance use disorder (SUD) treatment. Black persons were less likely than their white counterparts to receive cART (90.2% vs. 93.2%, p<.001), and experience viral control (84.6% vs. 91.3%, p<.001), hypertension control (61.9% vs. 68.3%, p<.001), diabetes control (85.5% vs. 89.5%, p<.001), and lipid monitoring (81.5% vs. 85.2%, p<.001). Initiation and engagement in SUD treatment were similar among blacks and whites. Differences remained after adjusting for age, comorbidity, retention in HIV care, and a measure of neighborhood social disadvantage created from census data., Significance: Implementation of interventions to reduce racial disparities in HIV care should comprehensively address and monitor processes and outcomes of care for key comorbidities., (Published by Elsevier Inc.)
- Published
- 2016
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31. Intended and unintended effects of large-scale adverse event disclosure: a controlled before-after analysis of five large-scale notifications.
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Wagner TH, Taylor T, Cowgill E, Asch SM, Su P, Bokhour B, Durfee J, Martinello RA, Maguire E, and Elwy AR
- Subjects
- Adult, Aged, Female, HIV Infections diagnosis, HIV Infections transmission, Hepatitis B diagnosis, Hepatitis B transmission, Hepatitis C diagnosis, Hepatitis C transmission, Humans, Male, Middle Aged, United States, United States Department of Veterans Affairs statistics & numerical data, Black or African American psychology, Contact Tracing statistics & numerical data, Disclosure statistics & numerical data, Virus Diseases diagnosis, Virus Diseases transmission, White People psychology
- Abstract
Background and Objective: How patients respond to being notified of a large-scale adverse event (LSAE), such as improper sterilisation of medical equipment that exposes them to bloodborne pathogens, is not well known. The objective of this study was to determine, using administrative data, the intended and unintended consequences of patient notification following a LSAE., Methods: We examined five LSAEs where patients may have been inadvertently exposed to hepatitis C virus (HCV), HIV, and hepatitis B virus (HBV). A total of 9638 cases were identified at five Department of Veteran Affairs (VA) medical facilities between 2009 and 2012. We identified controls at the same facility prior to the exposure period and at neighbouring facilities (n=45,274). Difference-in-differences models were used with Veterans Health Administration (VHA) and Medicare data to examine infectious disease testing rates and subsequent utilisation patterns., Results: Receipt of a LSAE notification was associated with a 73.2, 76.8 and 77.1 adjusted percentage point increase for HCV, HIV and HBV testing, respectively (all p<0.001). Compared with white patients, African-American patients were significantly less likely to return to VHA for follow-up testing. Patients exposed to a dental LSAE reduced their use of preventive and restorative dental care over the subsequent year, but they eventually came back to VHA for dental services 18-months post exposure., Conclusions: The majority of patients notified of a LSAE responded by getting tested for HCV, HIV and HBV, although there remains room for improvement. Potential exposure to a LSAE was associated with increased odds of subsequently using non-VA facilities, but the size and timing of the shift depended on the type of care., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)
- Published
- 2015
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32. Clinical provider perceptions of proactive medication discontinuation.
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Linsky A, Simon SR, Marcello TB, and Bokhour B
- Subjects
- Health Personnel psychology, Humans, Qualitative Research, United States, United States Department of Veterans Affairs, Attitude of Health Personnel, Patient Compliance psychology, Perception, Polypharmacy, Treatment Refusal psychology
- Abstract
Objectives: Polypharmacy and adverse drug events lead to considerable healthcare costs and morbidity, yet there is little to guide clinical providers in the area of discontinuing medications that may not be necessary. We sought to understand providers' beliefs and attitudes about polypharmacy and medication discontinuation., Study Design: Qualitative study using semi-structured interviews of 20 providers with prescribing privileges at 2 US Veterans Affairs Medical Centers, from April 2012 to October 2012., Methods: Transcribed interviews were analyzed using grounded thematic analysis, a systematic approach to deriving qualitative themes from textual data., Results: We identified 10 themes within 4 domains of medication discontinuation. Within the first domain (medication factors), we identified 2 themes: 1) medication characteristics, and 2) uncertainties of why a patient was taking a particular drug. Within the second domain (patient factors), we identified 3 themes: 3) clinical picture of the patient, 4) clinicians' understanding of the patients' knowledge and beliefs, and 5) patients' adherence. Within the third domain (clinical provider factors), we identified 2 themes: 6) professional identity, and 7) providers' decisions related to their own beliefs about medications. Within the fourth domain (system factors), we identified 3 themes: 8) multiple providers, 9) workload, and 10) external directives and policies such as structural components of a healthcare system., Conclusions: Provider decisions to discontinue medications are affected by factors at all levels of the clinical encounter. Our findings have implications for development and implementation of interventions to improve appropriate medication discontinuation via enhanced medication reviews, enriched patient-provider communication, and better system-level structures. This, in turn, may reduce the continued prescribing of potentially inappropriate medications that can lead to adverse outcomes or increased healthcare costs.
- Published
- 2015
33. Patient perceptions of proactive medication discontinuation.
- Author
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Linsky A, Simon SR, and Bokhour B
- Subjects
- Adult, Aged, Drug Prescriptions, Female, Humans, Male, Perception, Qualitative Research, Treatment Refusal, Trust, Communication, Decision Making, Patient Compliance, Patient Participation, Physician-Patient Relations
- Abstract
Objective: While many patients prefer fewer medications, decisions about medication discontinuation involve collaboration between patients and providers. We sought to identify patient perspectives on intentional medication discontinuation in order to optimize medication use., Methods: We conducted 20 interviews and two focus groups with a convenience sample of patients (22 men, 5 women; mean age 66 years) at two US Veterans Affairs Medical Centers. We queried patients' experiences with and attitudes toward taking multiple medications, preferences about taking fewer medications, and communication with their providers about stopping a medicine. Transcripts were analyzed qualitatively., Results: Three main themes emerged to create a conceptual model of medication discontinuation from the patient perspective: (1) conflicting views of medication, encompassing the sub-themes of desire for fewer medications, adherence, and specific versus general; (2) importance of patient-provider relationships, encompassing the sub-themes of trust, relying on expertise, shared decision making, and balancing multiple providers; and (3) limited experience with medication discontinuation., Conclusion: Many patients who have a preference to take fewer medicines do not share their beliefs with providers and recall few instances of provider-initiated medication discontinuation., Practice Implications: Strengthening patient-provider relationships and eliciting patient attitudes about taking fewer medications may enable appropriate discontinuation of unnecessary medications., (Published by Elsevier Ireland Ltd.)
- Published
- 2015
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34. How older black women perceive the effects of stigma and social support on engagement in HIV care.
- Author
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McDoom MM, Bokhour B, Sullivan M, and Drainoni ML
- Subjects
- Attitude of Health Personnel, Black People psychology, Boston, Discrimination, Psychological, Female, HIV Infections drug therapy, HIV Infections ethnology, Humans, Interviews as Topic, Middle Aged, Perception, Prejudice, Qualitative Research, Truth Disclosure, Urban Population, Black or African American psychology, HIV Infections psychology, Patient Acceptance of Health Care psychology, Social Stigma, Social Support
- Abstract
As black women over age 50 represent a growing share of women living with HIV, understanding what helps them persist and engage in ongoing HIV care will become increasingly important. Delineating the specific roles of social support and stigma on HIV care experiences among this population remains unclear. We qualitatively examined how experiences with stigma and social support either facilitated or inhibited engagement in HIV care, from the perspective of older black women. Semi-structured interviews were conducted with 20 older black women currently receiving HIV care at primary care clinics in the Metropolitan Boston area. Women expressed that experiences with stigma and seeking support played an important role in evaluating the risks and benefits of engaging in care. Social support facilitated their ability to engage in care, while stigma interfered with their ability to engage in care throughout the course of their illness. Providers in particular, can facilitate engagement by understanding the changes in these women's lives as they struggle with stigma and disclosure while engaging in HIV care. The patient's experiences with social support and stigma and their perceptions about engagement are important considerations for medical teams to tailor efforts to engage older black women in regular HIV care.
- Published
- 2015
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35. Implementation of nurse-initiated rapid HIV testing at high-prevalence primary care sites within the U.S. Veterans Affairs Health Care System.
- Author
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Anaya HD, Butler JN, Solomon JL, Knapp H, Hoang T, Kan V, Rodriguez-Barradas MC, Hare KA, Kertz B, and Bokhour B
- Subjects
- Female, HIV Antibodies immunology, HIV Seropositivity immunology, HIV Seropositivity nursing, Humans, Male, Middle Aged, Prevalence, United States epidemiology, United States Department of Veterans Affairs, Veterans statistics & numerical data, AIDS Serodiagnosis methods, HIV Seropositivity diagnosis, HIV Seropositivity epidemiology, Mass Screening nursing, Primary Health Care
- Abstract
Nurse-initiated HIV rapid testing (NRT) increases testing/receipt of results compared with traditional testing. We implemented NRT in primary care clinics at 2 Veterans Affairs hospitals.At site 1, 2364 tests were conducted; 5 HIV positives were identified. At site 2, 2522 tests were conducted; 9 HIV positives were identified. Success varied across demographic/clinical strata.
- Published
- 2013
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36. Care transitions from the hospital to home for patients with mobility impairments: patient and family caregiver experiences.
- Author
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Dossa A, Bokhour B, and Hoenig H
- Subjects
- Aged, Aged, 80 and over, Female, Humans, Longitudinal Studies, Male, Nursing Methodology Research, Caregivers psychology, Continuity of Patient Care, Mobility Limitation, Patient Discharge, Rehabilitation Nursing methods
- Abstract
Purpose: Our study described patient and caregiver experiences with care transitions following hospital discharge to home for patients with mobility impairments receiving physical and occupational therapy., Methods: The study was a qualitative longitudinal interview study. Interviews were conducted at 2 weeks, 1 month, and 2 months post discharge. Participants were men, Caucasian, between 70 and 88 years old, and had either a medical or surgical diagnosis., Results: Breakdowns in communication in four domains impacted continuity of care and patient recovery: (a) Poor communication between patients and providers regarding ongoing care at home, (b) Whom to contact post discharge, (c) Provider response to phone calls following discharge, and (d) Provider-provider communication., Discussion and Conclusions: Improved systems are needed to address patient concerns after discharge from the hospital, specifically for patients with mobility impairments. Better communication between patients, hospital providers, and home care providers is needed to improve care coordination, facilitate recovery at home, and prevent potential adverse outcomes., (Published 2012. This article is US Government work and is in the public domain in the USA.)
- Published
- 2012
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37. Implementation of routine rapid HIV testing within the U.S. Department of Veterans Affairs Healthcare System.
- Author
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Anaya HD, Bokhour B, Feld J, Golden JF, Asch SM, and Knapp H
- Subjects
- Female, Hospitals, Veterans, Humans, Interviews as Topic, Male, Nurse-Patient Relations, United States, United States Department of Veterans Affairs, HIV Infections diagnosis, HIV Infections nursing, Mass Screening methods, Veterans Health statistics & numerical data
- Abstract
Current HIV testing methods can be ineffective; patients often do not return for results. HIV rapid testing (RT) provides accurate results in 20 min. Patients find nurse-initiated HIV rapid testing (NRT) more acceptable than current testing methods and increases receipt of test results. Translating research findings into sustainable practice poses widely recognized implementation challenges. To ascertain effectiveness of NRT implementation, formative and process evaluations were conducted within the U.S. Department of Veterans Affairs Healthcare System (VA). Nurses and physicians at 2 VA medical centers were trained to administer RT. A preimplementation formative evaluation was conducted at Site 1. Process evaluations of ongoing RT activities were conducted at Site 2. Interviews were conducted with key informants. Content and thematic analysis was conducted on the field notes. A variety of barriers and facilitators were discovered that impacted the implementation of NRT. Findings indicate concerns regarding training and incorporating NRT into workflow. Process interviews indicated that training concerns could be alleviated through various means. Finally, interviewees highlighted that other clinic settings might be a more preferred setting for NRT than primary care. Findings are currently being used for the implementation of additional NRT interventions, and can also guide NRT adoption in other facilities., (© 2011 National Association for Healthcare Quality.)
- Published
- 2012
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38. "Sometimes I feel overwhelmed": educational needs of family physicians caring for people with intellectual disability.
- Author
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Wilkinson J, Dreyfus D, Cerreto M, and Bokhour B
- Subjects
- Clinical Competence, Female, Humans, Interviews as Topic, Male, Needs Assessment, Physicians, Family psychology, Intellectual Disability therapy, Physicians, Family education
- Abstract
Primary care physicians who care for adults with intellectual disability often lack experience with the population, and patients with intellectual disability express dissatisfaction with their care. Establishing a secure primary care relationship is particularly important for adults with intellectual disability, who experience health disparities and may rely on their physician to direct/coordinate their care. The authors conducted semistructured interviews with 22 family physicians with the goal of identifying educational needs of family physicians who care for people with intellectual disability. Interviews were transcribed and coded using tools from grounded theory. Several themes related to educational needs were identified. Physician participants identified themes of "operating without a map," discomfort with patients with intellectual disability, and a need for more exposure to/experience with people with intellectual disability as important content areas. The authors also identified physician frustration and lack of confidence, compounded by anxiety related to difficult behaviors and a lack of context or frame of reference for patients with intellectual disability. Primary care physicians request some modification of their educational experience to better equip them to care for patients with intellectual disability. Their request for experiential, not theoretical, learning fits well under the umbrella of cultural competence (a required competency in U.S. medical education).
- Published
- 2012
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39. Pay-for-performance in safety net settings: issues, opportunities, and challenges for the future.
- Author
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Young G, Meterko M, White B, Sautter K, Bokhour B, Baker E, and Silver J
- Subjects
- Humans, Medicaid, Surveys and Questionnaires, United States, Emergency Service, Hospital, Health Services Accessibility, Quality Assurance, Health Care economics, Reimbursement, Incentive
- Abstract
A major trend among Medicaid programs is the adoption of pay-for-performance (P4P) programs, but little evidence exists about the impact of these programs on quality improvement. Our in-depth case investigation of P4P in two safety net settings suggests that such programs may have minimal short-term effect on quality improvement. Two potentially important barriers for P4P in safety net settings are limited motivational effects from financial incentives and complex patient care requirements. We did not uncover any opposition against P4P among providers, nor did we find any evidence that P4P programs may compromise quality of care through unintended consequences. Overall, study results point to opportunities to improve the design and implementation of P4P programs in safety net settings.
- Published
- 2010
40. Asthma care quality for children with minority-serving providers.
- Author
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Galbraith AA, Smith LA, Bokhour B, Miroshnik IL, Sawicki GS, Glauber JH, Hohman KH, Gay C, and Lieu TA
- Subjects
- Child, Child, Preschool, Community Health Centers standards, Cross-Sectional Studies, Female, Humans, Male, Massachusetts, Outpatient Clinics, Hospital standards, Practice Patterns, Physicians' statistics & numerical data, Quality of Health Care, Black or African American statistics & numerical data, Asthma therapy, Hispanic or Latino statistics & numerical data, Practice Patterns, Physicians' standards
- Abstract
Objective: To compare asthma care quality for children with and without minority-serving providers., Design: Cross-sectional telephone survey of parents, linked with a mailed survey of their children's providers., Setting: A Medicaid-predominant health plan and multispecialty provider group in Massachusetts., Participants: A total of 563 children with persistent asthma, identified by claims and encounter data. Main Exposure Whether the child's provider was minority serving (>25% of patients black or Latino). Outcomes Parent report of whether the child had (1) ever received inhaled steroids, (2) received influenza vaccination during the past season, and (3) received an asthma action plan in the past year., Results: In unadjusted analyses, Latino children and those with minority-serving providers were more likely to have never received inhaled steroids. In adjusted models, the odds of never receiving inhaled steroids were not statistically significantly different for children with minority-serving providers (odds ratio [OR], 1.29; 95% confidence interval [CI], 0.63-2.64), or for Latino vs white children (OR, 1.76; 95% CI, 0.74-4.18); odds were increased for children receiving care in community health centers (OR, 4.88; 95% CI, 1.70-14.02) or hospital clinics (OR, 4.53; 95% CI, 1.09-18.92) vs multispecialty practices. Such differences were not seen for influenza vaccinations or action plans., Conclusions: Children with persistent asthma are less likely to receive inhaled steroids if they receive care in community health centers or hospital clinics. Practice setting mediated initially observed disparities in inhaled steroid use by Latino children and those with minority-serving providers. No differences by race/ethnicity or minority-serving provider were observed for influenza vaccinations or asthma action plans.
- Published
- 2010
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41. A narrative of resistance: presentation of self when parenting children with asthma.
- Author
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Cohn ES, Cortés DE, Hook JM, Yinusa-Nyahkoon LS, Solomon JL, and Bokhour B
- Subjects
- Anti-Asthmatic Agents therapeutic use, Asthma drug therapy, Child, Child, Preschool, Culture, Drug Utilization, Female, Health Knowledge, Attitudes, Practice, Healthcare Disparities, Humans, Male, Patient Compliance, Professional-Family Relations, Religion, Social Identification, Urban Population, Asthma ethnology, Parents psychology, Poverty, Racial Groups psychology, Self Concept
- Abstract
Using a social constructivist perspective and narrative analysis, the purpose of this paper is to illustrate how an understanding of self-presentation in interactions may inform health care interventions. We examine how a single African American mother, living in poverty, presents her sense of self in the context of obtaining and providing asthma care for her children. By analyzing four separate encounters--two interviews with the children's mother, the clinical encounter between the mother and her children's doctor, and an interview with the doctor, we gain an understanding of the mother's self-presentation and identity and the doctor's view of the mother. The analyses reveal the mother's consistent desire to protect her children in an unpredictable social world. By examining self-presentation, behavior that is typically construed as non-adherence is reframed as resilience, one mother's attempt to assert control. We argue that an understanding of identity production may enable practitioners and patients to create collaborative interventions. The analysis presented in this paper points to the need for a co-constructed intervention that allows for choice and control and honors the mother's sense of self.
- Published
- 2009
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42. Modifiable risk factors for suboptimal control and controller medication underuse among children with asthma.
- Author
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Smith LA, Bokhour B, Hohman KH, Miroshnik I, Kleinman KP, Cohn E, Cortés DE, Galbraith A, Rand C, and Lieu TA
- Subjects
- Anti-Asthmatic Agents economics, Asthma economics, Child, Child, Preschool, Cross-Sectional Studies, Humans, Medicaid, Risk Assessment, Risk Factors, Socioeconomic Factors, Surveys and Questionnaires, United States, Anti-Asthmatic Agents therapeutic use, Asthma drug therapy, Drug Utilization statistics & numerical data
- Abstract
Objectives: Our aims were (1) to describe rates of suboptimal control and controller medication underuse in a diverse population of children with asthma and (2) to identify potentially modifiable parental behaviors and beliefs associated with these outcomes., Methods: We conducted telephone interviews with parents of 2- to 12-year-old children with persistent asthma, in a Medicaid plan and a large provider group. Suboptimal control was defined as >or=4 symptom days, >or=1 symptom night, or >or=4 albuterol use days in the previous 2 weeks. Controller medication underuse was defined as suboptimal control and parent report of <6 days/week of inhaled steroid use. Multivariate analyses identified factors that were independently associated with suboptimal control and controller medication underuse., Results: Of the 754 study children, 280 (37%) had suboptimal asthma control; this problem was more common in Hispanic children (51%) than in black (37%) or white (32%) children. Controller medication underuse was present for 133 children (48% of those with suboptimal asthma control and 18% overall). Controller medication underuse was more common among Hispanic (44%) and black (34%) children than white (22%) children. In multivariate analyses, suboptimal control was associated with potentially modifiable factors including low parental expectations for symptom control and high levels of worry about competing household priorities. Controller medication underuse was associated with potentially modifiable factors including parental estimation of asthma control that was discordant with national guidelines and no set time to administer asthma medications., Conclusions: Deficiencies in asthma control and controller medication use are associated with potentially modifiable parental beliefs, which seem to mediate racial/ethnic and socioeconomic disparities in suboptimal control and controller medication underuse.
- Published
- 2008
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43. Periodic use of inhaled steroids in children with mild persistent asthma: what are pediatricians recommending?
- Author
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Sawicki GS, Smith L, Bokhour B, Gay C, Hohman KH, Galbraith AA, and Lieu TA
- Subjects
- Administration, Inhalation, Child, Data Collection, Drug Administration Schedule, Drug Prescriptions, Humans, Pediatrics, United States, Asthma drug therapy, Steroids administration & dosage
- Abstract
Although asthma treatment guidelines recommend daily inhaled corticosteroid (ICS) use for all persistent asthma, pediatricians may recommend alternative treatment plans for children with mild persistent disease. The authors administered a survey of pediatricians to describe prescribing patterns for mild persistent asthma. More than 99% of providers agreed that periodic ICS could be effective for some asthma patients. Overall, 129/251 providers (51%) reported prescribing daily ICS to most patients with mild persistent asthma, whereas 78 (31%) reported recommending periodic ICS for most such patients. Providers with patient populations > or = 25% black were significantly less likely to report prescribing daily ICS (odds ratio, 0.3; 95% confidence interval, 0.2-0.6) for mild persistent asthma. Further research is needed on the effectiveness of periodic ICS use for children with mild persistent asthma and on underlying reasons for differing provider practice patterns.
- Published
- 2008
- Full Text
- View/download PDF
44. Racial/Ethnic variation in parent perceptions of asthma.
- Author
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Wu AC, Smith L, Bokhour B, Hohman KH, and Lieu TA
- Subjects
- Asthma ethnology, Asthma therapy, Child, Child, Preschool, Cross-Sectional Studies, Female, Humans, Male, Patient Acceptance of Health Care psychology, Physician-Patient Relations, Professional-Family Relations, Asthma psychology, Black People psychology, Hispanic or Latino psychology, Parents psychology, Patient Acceptance of Health Care ethnology, White People psychology
- Abstract
Objective: Black and Latino children with asthma have worse morbidity and receive less controller medication than their white peers. Scant information exists on racial/ethnic differences in parent perceptions of asthma. To compare parent perceptions among black, Latino, and white children with asthma in 4 domains: (1) expectations for functioning with asthma; (2) concerns about medications; (3) interactions with providers; and (4) competing family priorities., Methods: In this cross-sectional study, we conducted telephone interviews with parents of children with persistent asthma in a Medicaid health plan and a multispecialty provider group in Massachusetts. To measure expectations for functioning and other domains, we adapted multi-item scales from past studies. Associations between race/ethnicity and these domains were evaluated in multivariate analyses that controlled for age, gender, household income, parental education, insurance, and language. The response rate was 72%., Results: Of the 739 study children, 24% were black, 21% Latino, and 43% white. Parents of black and Latino children had lower expectations for their children's functioning with asthma (P < .001), higher levels of worry about their children's asthma (P < .001), and more competing family priorities (P = .004) compared with parents of white children. Parents of Latino children had higher levels of concern about medications for asthma than parents of black or white children (P = .002). There were no differences among racial/ethnic groups in reports of interactions with the provider of their children's asthma care., Conclusions: Efforts to eliminate disparities in childhood asthma may need to address variation in expectations and competing priorities between minority and white families.
- Published
- 2008
- Full Text
- View/download PDF
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