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Objective: This study tested several hypotheses about why women are more likely than men to have psychiatric disorders noted by their primary care physicians.Design: Patients were screened for mental disorders using the General Health Questionnaire. A stratified sample was assessed using the Schedule for Affective Disorders and Schizophrenia. Information on utilization and identification of mental health problems was abstracted from the medical records.Setting: The study was conducted at a multispecialty group practice in a semirural area of Wisconsin.Patients: Study participants consisted of a stratified probability sample of 247 patients seeking primary care.Results: Patients with a psychiatric illness who were relatively frequent users of the clinic were most likely to be identified by a physician as having a mental health problem. When psychiatric illness and utilization rates were statistically controlled, men and women had comparable identification rates. [ABSTRACT FROM AUTHOR]

Objective: The frequency of Preventable Infectious Dental Disease (PIDD) visits in medical centers was examined pre and post establishment of expanded dental access and adoption of an integrated medical-dental care delivery model., Methods: A retrospective observational study of patient attributes and frequency of unscheduled PIDD visits between January 1, 1990 and February 29, 2020. Chi-squared tests compared (a) the number of PIDD visits (pre/post dental center establishment), (b) age at first diagnosis, (c) gender, (d) race, (e) primary insurance at the time of PIDD visits and (f) healthcare setting where visit occurred., Results: System-wide, 21,957 unique patients were documented with a total of 34,892 PIDD visits as the primary diagnosis. Patients between 18-30 years and patients with Medicaid had the highest frequency of PIDD visits in medical settings. Following the establishment of dental centers, reduced relative risk of PIDD visits was observed for patients with no health insurance or self-pay/other coverage. PIDD visits in primary care settings was 0.87 times as likely as PIDD visits at ED/UCs after dental centers opened., Conclusions: The number of PIDD visits to medical centers increased before the dental infrastructure was established, followed by a decline afterwards, inclusive of disparity populations. Some residual persistence of PIDD visits to primary care settings was identified. This study reinforced importance of dental healthcare access for achieving appropriate PIDD management while reducing PIDD visits to medical settings., (Copyright© 2023 Dennis Barber Ltd.)

Objective: The objective of the study was to investigate temporal trends in non-traumatic dental condition (NTDC) related emergency visits at Emergency Department (ED), urgent care (UC), and at a Federally Qualified Health Center (FQHC) that providing dental services to a mid-sized rural community., Methods: Temporal trends over a 9-year period (2008-2016) in NTDC rates at ED, UC, FQHC and in a region around the FQHC were determined. Statistically significant changes (α = 0.05) in the proportion of NTDC visits between FQHC and UC across each of the time points were investigated., Results: Proportion of NTDC ED visits was relatively stable over the study period; whereas those at FQHC exceeded those at UC site beginning 2012 and were significantly (α = 0.05) higher than that of UC subsequently (2015-2016)., Conclusions: NTDCs are preventable dental conditions and the care provided in treating NTDCs in emergency settings is palliative and does not address the underlying conditions resulting in poor outcomes. The results presented elucidate the critical role of FQHCs in significantly reducing NTDC visits. These might be precursors to a potential shift in NTDC care seeking behavior and expected to favorably impact oral health outcomes., (© 2022 American Association of Public Health Dentistry.)

Introduction: Rates of diabetes/prediabetes continue to increase, with disparity populations disproportionately affected. Previous field trials promoted point-of-care (POC) glycemic screening in dental settings as an additional primary care setting to identify potentially at-risk individuals requiring integrated care intervention. The present study observed outcomes of POC hemoglobin A1c (HbA1c) screening at community health center (CHC) dental clinics (DC) and compliance with longitudinal integrated care management among at-risk patients attending dental appointments. Materials and Methods: POC HbA1c screening utilizing Food and Drug Administration (FDA)-approved instrumentation in DC settings and periodontal evaluation of at-risk dental patients with no prior diagnosis of diabetes/prediabetes and no glycemic testing in the preceding 6 months were undertaken. Screening of patients attending dental appointments from October 24, 2017, through September 24, 2018, was implemented at four Wisconsin CHC-DCs serving populations with a high representation of disparity. Subjects meeting at-risk profiles underwent POC HbA1c screening. Individuals with measures in the diabetic/prediabetic ranges were advised to seek further medical evaluation and were re-contacted after 3 months to document compliance. Longitudinal capture of glycemic measures in electronic health records for up to 2 years was undertaken for a subset ( n = 44) of subjects with available clinical, medical, and dental data. Longitudinal glycemic status and frequency of medical and dental access for follow-up care were monitored. Results: Risk assessment identified 224/915 (24.5%) patients who met inclusion criteria following two levels of risk screening, with 127/224 (57%) qualifying for POC HbA1c screening. Among those tested, 62/127 (49%) exhibited hyperglycemic measures: 55 in the prediabetic range and seven in the diabetic range. Moderate-to-severe periodontitis was more prevalent in patients with prediabetes/diabetes than in individuals with measures in the normal range. Participant follow-up compliance at 3 months was 90%. Longitudinal follow-up documented high rates of consistent access (100 and 89%, respectively), to the integrated medical/DC environment over 24 months for individuals with hyperglycemic screening measures. Conclusion: POC glycemic screening revealed elevated HbA1c measures in nearly half of at-risk CHC-DC patients. Strong compliance with integrated medical/dental management over a 24-month interval was observed, documenting good patient receptivity to POC screening in the dental setting and compliance with integrated care follow-up by at-risk patients., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (Copyright © 2021 Glurich, Berg, Panny, Shimpi, Steinmetz, Nycz and Acharya.)

Objectives: Impact of implementing data-driven performance metric-tracking across a 10-dental center infrastructure established by Family Heath Center of Marshfield (FHC-M) was examined for relative impact on achieving value-based care delivery in serving a patient population characterized by 88% Medicaid representation., Methods: To track progress toward national benchmarks for preventive care delivery, dental quality analytics dashboard tracking was implemented in real time with sharing of performance metrics across centers. Compliance rate with Uniform Data Systems reporting requirements for sealant placement on permanent first molars in children aged 6-9 years of age at moderate-to-high risk of caries was targeted at FHC-M dental centers for comparison with those of other community health centers statewide and nationally. Hygienist-to-dentist ratio to support robust sealant placement capacity was further examined., Results: Uniform Data Systems data for rate of sealant placement between 2016-2018 revealed that FHC-M consistently exceeded rates reported statewide and nationally. For this quality indicator, performance across all dental practices in 27 states reported by Centers for Medicare and Medicaid Services in 2018 achieved 23% in 2017 compared to 73% and 52% placement rates reported by FHC-M and community health centers, respectively. A 1:1 hygienist-to-dentist was documented across FHC-M dental centers compared to 0.5:1 reported nationally., Conclusions: Implementation of quality metric dashboard and a 1:1 dentist-to-hygienist ratio supported realization of value-based dental care delivery relative to caries prevention in a moderate-to-high risk pediatric Medicaid population through achievement of robust sealant placement. Importance of adequate hygienist staffing, "same day" sealant placement and performance feedback supported by technology are highlighted., (© 2020 American Association of Public Health Dentistry.)

Medicaid expansion is an important feature of the "Affordable Care Act" and also is proposed as a component of some incremental plans for universal healthcare coverage. We describe (1) obstacles encountered with Medicaid coverage, (2) their potential resolution by federally qualified community health centers (CHCs), (3) the current status and limitations of CHCs, and (4) a proposed mega CHC model which could help assure access to care under Medicaid coverage expansion. Proposed development of the mega CHC model involves a three-component system featuring (1) satellite neighborhood outreach clinics, with team care directed by primary care nurse practitioners, (2) a hub central CHC which would closely correspond to the logistics and administration of current CHCs, and (3) a teaching hospital facilitating subspecialty care for CHC patients, with high-quality and cost-effectiveness. We believe that this new model, designated as a mega CHC, will demonstrate that CHCs can achieve their potential as a key partner to insure care under Medicaid expansion.

The "VA Mission Act of 2018" will expand the current "Choice Program" legislation of 2014, which has enabled outsourcing of VA care to private physicians. As the ranks of Veteran patients swell, Congress intended that the Mission Act will help relieve the VHA's significant access problems. We contend that this new legislation will have negative consequences for veterans by diverting support from our VA system of 1300 hospitals and clinics. We recommend modification of this legislation, promoting much greater utilization of Community Health Centers (CHCs) for veterans outsourced primary care. In support of this proposal, we describe (1) features of the "VA Mission Act" relevant to outsourcing, (2) the challenges of the present "Choice Program" and likely future obstacles with the new legislation, and (3) the advantages of expanding CHC VA outsourced primary care. This policy would focus more on providing specialized care for veterans in the VA system, while coordinating with CHCs for the necessary expanded outsourced, holistic primary care. We conclude that failure to develop an incremental, cost-effective alternative as described herein represents a potential threat to adequate future support of our VA hospital system, and thus outstanding care for our veterans.

Community health centers (CHCs), a principal source of primary care for over 24 million patients, provide high-quality affordable care for medically underserved and lower-income populations in urban and rural communities. The authors propose that CHCs can assume an important role in the quest for health care reform by serving substantially more Medicaid patients. Major expansion of CHCs, powered by mega teaching health centers (THCs) in partnership with regional academic medical centers (AMCs) or teaching hospitals, could increase Medicaid beneficiaries' access to cost-effective care. The authors propose that this CHC expansion could be instrumental in limiting the added cost of Medicaid expansion via the Affordable Care Act (ACA) or subsequent legislation. Nevertheless, expansion cannot succeed without developing this CHC-AMC partnership both (1) to fuel the currently deficient primary care provider workforce pipeline, which now greatly limits expansion of CHCs; and (2) to provide more CHC-affiliated community outreach sites to enhance access to care. The authors describe the current status of Medicaid and CHCs, plus the evolution and vulnerability of current THCs. They also explain multiple features of a mega THC demonstration project designed to test this new paradigm for Medicaid cost control. The authors contend that the demonstration's potential for success in controlling costs could provide help to preserve the viability of current and future expanded state Medicaid programs, despite a potential ultimate decrease in federal funding over time. Thus, the authors believe that the new AMC-CHC partnership paradigm they propose could potentially facilitate bipartisan support for repairing the ACA.

Escalating prevalence of both diabetes and periodontal disease, two diseases associated with bi-directional exacerbation, has been reported. Periodontal disease represents a modifiable risk factor that may reduce diabetes onset or progression, and integrated models of cross-disciplinary care are needed to establish and manage glycemic control in affected patients. An ad-hoc environmental scan of current literature and media sought to characterize factors impacting status of integrated care models based on review of the existing evidence base in literature and media surrounding: (1) current cross-disciplinary practice patterns, (2) epidemiological updates, (3) status on risk assessment and screening for dysglycemia in the dental setting, (4) status on implementation of quality metrics for oral health, (5) care model pilots, and (6) public health perspectives. The survey revealed: escalating prevalence of diabetes and periodontitis globally; greater emphasis on oral health assessment for diabetic patients in recent medical clinical practice guidelines; high knowledgeability surrounding oral-systemic impacts on diabetes and growing receptivity to medical-dental integration among medical and dental providers; increasing numbers of programs/studies reporting on positive impact of emerging integrated dental-medical care models on diabetic patient healthcare access and health outcomes; a growing evidence base for clinically significant rates of undiagnosed dysglycemia among dental patients reported by point-of-care pilot studies; no current recommendation for population-based screening for dysglycemia in dental settings pending a stronger evidence base; improved definition of true periodontitis prevalence in (pre)/diabetics; emerging recognition of the need for oral health quality indicators and tracking; evidence of persistence in dental access disparity; updated status on barriers to integration. The potential benefit of creating clinically-applicable integrated care models to support holistic management of an escalating diabetic population by targeting modifiable risk factors including periodontitis is being recognized by the health industry. Cross-disciplinary efforts supported by high quality research are needed to mitigate previously- and newly-defined barriers of care integration and expedite development and implementation of integrated care models in various practice settings. Implementation of quality monitoring in the dental setting will support definition of the impact and efficacy of interventional clinical care models on patient outcomes., Competing Interests: Financial Disclosure: AA receives funding from Delta Dental, which provided funding for the study, including the cost of publication., (© 2017 Marshfield Clinic.)

Objective: This study tested several hypotheses about why women are more likely than men to have psychiatric disorders noted by their primary care physicians., Design: Patients were screened for mental disorders using the General Health Questionnaire. A stratified sample was assessed using the Schedule for Affective Disorders and Schizophrenia. Information on utilization and identification of mental health problems was abstracted from the medical records., Setting: The study was conducted at a multispecialty group practice in a semirural area of Wisconsin., Patients: Study participants consisted of a stratified probability sample of 247 patients seeking primary care., Results: Patients with a psychiatric illness who were relatively frequent users of the clinic were most likely to be identified by a physician as having a mental health problem. When psychiatric illness and utilization rates were statistically controlled, men and women had comparable identification rates.

To determine the degree to which enrollees of the Greater Marshfield Community Health Plan were representative of the community the plan was designed to serve, a telephone survey of 1,838 households in the 30-township area was undertaken. The response rate was 93%, and data were obtained from 1,718 households containing 5,260 persons. Of these, 484 households had at least one health plan member. Since the plan accepts only persons under age 65, analysis of the data was limited to those persons aged 64 and younger. Results indicate that enrollees showed good representation of demographic variables such as age, sex, and relationship to the household head when they were compared to the under 65 population of the area. When the enrollee's socioeconomic characteristics (education, income, and occupation) were studied, it was found that, although enrollees showed good representation for most categories they tended to underrepresent the under 65 area population in the lowest income and education classes, as well as in the semiskilled or unskilled occupations. The opposite was true for the upper income and educational classes. Data on location of residence indicated that a strong relationship existed between enrollment and proximity to Marshfield, where the major health care center is located. The use of health services was found to be positively related to membership, with enrollees overrepresented among those with recent hospital or physician contacts. The ability to obtain coverage through employment or by other means was found not to be related to membership. Satisfaction as expressed by participants was much higher in the prepaid program than among those with other forms of coverage.

The study assessed the effect of screening for mental disorder by means of the General Health Questionnaire (GHQ) on the rate of detection of mental disorder by fourteen physicians in a primary-care clinic. After completing the GHQ, patients were randomised into control (722 patients) and experimental (730 patients) groups. GHQ results of the experimental group were made available to the physicians; those of the control group were not. Sociodemographic factors influenced the physicians' rate of diagnosis of mental disorders (rates were lower for men, students, and patients with at least a partial college education than in subjects who had a low income, less than 7 years of school, or were widowed) but there was no difference between control and experimental groups (16.8% vs 16.0%). Among patients with a prior diagnosis of a mental disorder, twice as many were found to have mental disorders by the physicians as by the GHQ (70% vs 33%).

The authors provide an overview of the Marshfield Clinic's four-year demonstration contract with HCFA that resulted in the enrollment under a prospective risk contract of over 8,900 Medicare beneficiaries. Public policy implications are discussed along with recommendations for group practices contemplating Medicare prospective contracts. Recommendations include the attention which must be paid to potential adverse selection, hospital utilization control, and potential technical and methodological problems with the prospective reimbursement system. Data from the demonstration will be of significant value to other groups interested in prospective contracting with HCFA. The concept of prepaid Medicare, if appropriately refined, can serve the best interests of Medicare beneficiaries, providers, and

The division of responsibility between general medical staff and mental specialists for care of persons with medical record diagnoses of mental disorders is documented in four organized health care settings. Rates of mental disorders identified in all departments ranged from 35.6 to 122.8 per 1,000 population. Specialty mental health departments treated most severe psychotic and personality disorders, plus transient situational disturbances, whereas neurotic, childhood behavior, and psychophysiological disorders received as much or greater attention in general medical departments. Mental disorder diagnoses were associated with greater patient use of general medical departments. However, joint specialty mental health/general medical treatment of these patients was associated with lower general medical department visit rates in all settings. Such joint care was facilitated by the low average visit frequency use of mental health departments. (2.2 to 8.9 visits per patient per year).

Using venography as the reference procedure, this study examined the utility of fibrinogen I 125 scanning for the detection or demonstration of deep venous thrombosis. The results demonstrate the inability of leg scanning to detect accurately the presence or absence of thrombi in the deep venous system. Most striking was the lack of sensitivity of this procedure in areas where the propensity for embolization is greatest. Sensitivity is extremely low in the anatomic areas where leg scanning demonstrates reasonable specificity. The results are nearly identical in the extremity not operated upon. The validity of all prior studies relying heavily or exclusively on 125I leg scans to determine the presence or absence of thrombi must be critically reassessed.

The General Health Questionnaire (GHQ) and a structured psychiatric interview (lifetime version of the Schedule for Affective Disorders and Schizophrenia) were administered to a sample of primary care patients in the United States. Responses to the GHQ tended to form factors that have substantive interpretations, such as depression, anxiety, sleep problems, and social functioning. However, there seems to be little gain in using subscale scores to help identify persons with different types of psychiatric disorders.

This study examines the co-occurrence of psychiatric and medical morbidity in primary care patients utilizing a health care clinic in Marshfield, Wisconsin. Previous research has shown that individuals with psychiatric disorders have higher rates of medical illness than people without psychiatric illness, but most prior studies have tended to confound the measures of psychiatric and medical morbidity. In addition, appropriate controls for bias resulting from different medical utilization patterns have sometimes been absent. The present study reports the medical diagnoses of persons who had been assessed for psychiatric disorder with a standardized psychiatric interview using research diagnostic criteria independent of their medical assessment. Psychiatric diagnoses are analyzed in relation to medical diagnoses at the time of the interview and for a one-year period--six months before and six months after that date. The results indicate that persons with mental disorder diagnoses have significantly more morbidity for the one-year study period. Although considerable congruence exists in the physical diagnoses recorded for both groups, those with mental disorders are more likely to have diagnoses of the digestive and genitourinary systems. Some sex differences are also explored.

The differential use of medical services by patients with and those without a diagnosis of mental disorder was examined in four adult populations by age, sex, diagnosis, and medical department used. The four settings offered comprehensive services to patients who varied greatly in socioeconomic status. In all four settings patients with a diagnosis of mental disorder used all services and general health services more than patients without such a diagnosis. Results document increased medical morbidity and a greater likelihood of a diagnosis of an ill-defined condition in patients with mental disorder than that found in patients without a diagnosis of mental disorder.