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Objectives: Research on links between social, geographic, and cultural determinants of health has been thwarted by inadequate measures of culture. The purpose of this study was to improve the measurement of community culture, defined as shared patterns of attitudes and behaviors among people within a neighborhood that distinguish it from others, and to examine dimensions of culture, independent of socioeconomic and demographic factors, and their relationships with health., Study Design: A survey research design with correlational analyses was used., Methods: A survey packet including the Community Culture Survey - Revised (CCS-R), demographic, health, and other individual-level measures was administered through convenience sampling across the United States (US) and to a sample in Thailand from 2016 to 2018. US county-level variables were obtained from zip codes., Results: 1930 participants from 49 US states (n = 1592) and Thailand (n = 338) completed all CCS-R items, from which 12 subscales were derived: Social Support & Connectedness, Responsibility for Self & Others, Family Ties & Duties, Social Distress, Urban Diversity, Discontinuity, Church-Engaged, External Resource-Seeking, Locally Owned Business-Active, Power Deference, Next Generation Focus, and Self-Reliance. Neighborhood culture subscale scores varied more by geography than by participant's demographics. All subscales predicted one or more health indicator, and some of these relationships were significant after adjusting for participant age and county-level socioeconomic variables. Most of the significant differences on subscales by race/ethnicity were no longer significant after adjusting for participant's age and county-level socioeconomic variables. Most rural/urban and regional differences in culture within the US persisted after these adjustments. Based on correlational analyses, Social Support & Connectedness and Responsibility for Self & Others were the best predictors of participants' overall health and quality of life, and Responsibility for Self & Others was the best predictor (inversely) of the CDC's measures of social vulnerability., Conclusions: Neighborhood culture is measurable, multi-dimensional, distinct from race/ethnicity, and related to health even after controlling for age and socioeconomic factors. The CCS-R is useful for advancing research and practice addressing the complex interactions between individuals, their neighborhood communities, and health outcomes., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Published by Elsevier Ltd on behalf of The Royal Society for Public Health.)

Objectives: Rural disparities in age-adjusted mortality are growing in the United States. While socioeconomic variables have been found to explain significant variation in life expectancy across US counties, previous research has not examined the role of socioeconomic variables in explaining rural mortality disparities. The purpose of this study was to quantify the rural mortality disparity after controlling for socioeconomic variables., Methods: Recursive partitioning, or tree regression, was used to fit models predicting premature mortality across counties in the United States, adjusted for age, median income, and percent in poverty in 4 time periods (from 2004 to 2012) with and without inclusion of an urban-rural variable., Results: We found median income and percent in poverty explained about 50% of the variation in age-adjusted premature mortality rates across US counties in each of the four time periods. After controlling for these socioeconomic variables, rural mortality disparities largely disappeared, explaining less than 2% of the variance in premature mortality., Conclusions: Addressing poverty and other socioeconomic issues should be a priority to improve health in rural communities. Interventions designed to target social determinants of health in rural areas are needed to address the growing rural mortality disparity that is largely explained by measures of poverty and income. Researchers examining rural health disparities should routinely include socioeconomic variables in their analyses.

Objectives: The primary objective of this report is to describe a quality improvement practice designed to identify and categorize potentially preventable medication-related hospital admissions. The secondary objective is to present data collected from this practice and describe how it was used to improve a pharmacist intervention focused on reducing medication-related readmissions., Setting: This practice was developed as part of the quality improvement system supporting a pharmacist-led care transition model that was implemented across rural and urban counties in Hawaii., Practice Description: Pharmacists systematically assessed readmissions of the high-risk patients who were enrolled in the care transition model to determine the reasons for the admission and whether each was potentially preventable and medication related. This information was then used to improve the care transition model., Practice Innovation: This admission categorization system is the first based on best practice in pharmaceutical care and identifies indication, effectiveness, safety, and adherence problems, as well as subcategories within each of those domains., Evaluation: This quality improvement practice was applied to 401 readmissions. A chi-square test was used to determine if there were differences between urban and more rural areas regarding percentage of readmissions that were potentially preventable and medication related., Results: Twenty-six percent of the readmissions were determined to be potentially preventable and medication related. The most common categories were nonadherence due to patient choice (23.8%), untreated condition for which medication is indicated (13.3%), dose too high (10.5%), and dose too low (10.5%). The percentage of readmissions that were potentially preventable and medication related was significantly higher in more rural areas (30%) compared with urban areas (17%). There were no significant rural-urban differences by major category of potentially preventable medication-related admissions., Conclusion: This systematic and actionable approach to reviewing and categorizing potentially preventable medication-related admissions can facilitate improvement in care and document the value of pharmacists serving in patient care roles., (Copyright © 2017 American Pharmacists Association®. Published by Elsevier Inc. All rights reserved.)

Objectives: To evaluate the association between a system of medication management services provided by specially trained hospital and community pharmacists (Pharm2Pharm) and rates and costs of medication-related hospitalization in older adults., Design: Quasi-experimental interrupted time series design comparing intervention and nonintervention hospitals using a mixed-effects analysis that modeled the intervention as a time-dependent variable., Setting: Sequential implementation of Pharm2Pharm at six general nonfederal acute care hospitals in Hawaii with more than 50 beds in 2013 and 2014. All five other such hospitals served as a contemporaneous comparison group., Participants: Adult inpatients who met criteria for being at risk for medication problems (N = 2,083), 62% of whom were aged 65 or older., Intervention: A state-wide system of medication management services provided by specially trained hospital and community pharmacists serving high-risk individuals from hospitalization through transition to home and for up to 1 year after discharge., Measurements: Medication-related hospitalization rate per 1,000 admissions of individuals aged 65 and older, adjusted for case mix; estimate of costs of hospitalizations and actual costs of pharmacist services., Results: The predicted, case mix-adjusted medication-related hospitalization rate of individuals aged 65 and older was 36.5% lower in the Pharm2Pharm hospitals after implementation than in the nonintervention hospitals (P = .01). The estimated annualized cost of avoided admissions was $6.6 million. The annual cost of the pharmacist services for all Pharm2Pharm participants was $1.8 million., Conclusion: The Pharm2Pharm model was associated with an estimated 36% reduction in the medication-related hospitalization rate for older adults and a 2.6:1 return on investment, highlighting the value of pharmacists as drug therapy experts in geriatric care., (© 2016 The Authors. The Journal of the American Geriatrics Society published by Wiley Periodicals, Inc. on behalf of The American Geriatrics Society.)

Current race/ethnicity categories established by the U.S. Office of Management and Budget are neither reliable nor valid for understanding health disparities or for tracking improvements in this area. In Hawaii, statewide hospitals have collaborated to collect race/ethnicity data using a standardized method consistent with recommended practices that overcome the problems with the federal categories. The purpose of this observational study was to determine the impact of this collaboration on key measures of race/ethnicity documentation. After this collaborative effort, the number of standardized categories available across hospitals increased from 6 to 34, and the percent of inpatients with documented race/ethnicity increased from 88 to 96%. This improved standardized methodology is now the foundation for tracking population health indicators statewide and focusing quality improvement efforts. The approach used in Hawaii can serve as a model for other states and regions. Ultimately, the ability to standardize data collection methodology across states and regions will be needed to track improvements nationally.

Introduction: The availability of rural healthcare is a growing concern in the United States as fewer healthcare providers choose to work in rural areas. Accessing quality continuing education (CE) for rural healthcare practitioners (HCPs) remains a challenge and may pose a barrier to quality care., Methods: To maximize attendance at a live, in-person, free CE program focusing on geriatric medication and issues specifically targeted to HCPs in rural areas, two methods were implemented sequentially. The first method used formal advertising implemented by a professional marketing service to promote CE events. The second method enlisted local healthcare organizations and physician groups to promote the CE event to their employees. Cost per attendee was calculated for comparison., Results: Professional marketing services recruited 31 HCPs (March 2011) and resulted in a per-participant recruitment cost of US$428.62. Local healthcare organizations and physician groups' marketing recruited 48 HCPs (July-August 2011) and resulted in a per-participant recruitment cost of US$55.19., Discussion: Providing free CE coordinated through local healthcare organizations and physician groups was the most cost-effective method of recruiting rural HCPs for CE. Formal advertising added cost without increasing the number of participants per event. Although this is the first study of the cost-effectiveness of recruitment methods targeting HCPs in rural areas, results are consistent with research on cost-effectiveness of outreach to rural lay community members.

Background: Sugar cane harvesting by burning on Maui island is an environmental health issue due to respiratory effects of smoke. Volcanic smog ("vog") from an active volcano on a neighboring island periodically blankets Maui and could confound a study of cane smoke's effects since cane burning is not allowed on vog days. This study examines the association between cane burning and emergency department (ED) visits, hospital admissions, and prescription fills for acute respiratory illnesses., Methods: This retrospective study controlled for confounders that could increase respiratory distress on non-burn days by matching each burn day with a non-burn day and then comparing the ratio of patients with respiratory distress residing in the path of sugar burn smoke to those residing elsewhere on Maui on burn versus non-burn days. Patients with acute respiratory distress were defined as those with one or more acute respiratory diagnoses at one of the hospitals or emergency departments on Maui. Separately, patients with acute respiratory illness were identified through prescription records from four community pharmacies, specifically defined as those who filled prescriptions for acute respiratory distress., Results: There were 1,256 reports of respiratory distress prescriptions and 686 hospital/ED diagnoses of acute respiratory illness. The ratio of cases within to outside of smoke exposure was higher on burn days for both the ED/hospital data and the pharmacy, though not statistically significant. In post-hoc analyses of the pharmacy data based on the number of acres burned as a proxy for volume of smoke, there was a dose response trend for acreage burned such that the highest quartile showed a statistically significant higher proportion of acute respiratory distress in the exposed versus non-exposed regions (P = 0.015, OR 2.4, 95% CI [1.2-4.8])., Conclusions: After adjusting for confounders on non-burn days, there was a significantly higher incidence of respiratory distress in smoke-exposed regions when greater amounts of acres were burned. Health officials should consider actions to reduce the negative health outcomes associated with sugar cane burning practices.

Three strategies designed to maximize attendance at educational sessions on chronic disease medication safety in older adults in rural areas were implemented sequentially and compared for cost-effectiveness: 1) existing community groups and events, 2) formal advertisement, and 3) employer-based outreach. Cost-effectiveness was measured by comparing overall cost per attendee recruited and number of attendees per event. The overall cost per attendee was substantially higher for the formal advertising strategy, which produced the lowest number of attendees per event. Leveraging existing community events and employers in rural areas was more cost-effective than formal advertisement for recruiting rural community members.

Background: In light of the documented physician shortage on Hawai'i Island, the Hawai'i Clinician Recruitment and Retention survey was designed and implemented to assess perceptions of quality of life and the work environment among clinicians on Hawai'i Island and to identify aspects of the environment on Hawai'i Island that predict responses to questions regarding recruitment and retention., Methods: The respondents were 127 Hawai'i Island clinicians, specifically 96 physicians, 15 nurses, five pharmacists, four physician assistants, two social workers, and five "other" healthcare workers. The internal reliability of the survey was high (alpha=.91) and its convergent validity was supported by the significant correlation of item total scores with anchor items that measured overall ratings of the environment and likelihood of recruitment and retention. Given the small number of non-physician clinicians responding, descriptive analyses included only physicians. Physicians who indicated they plan to retire within 5 years were excluded from the correlation analyses to focus on patterns within the target group for retention., Results: Overall, results indicate that, while the majority of physicians who relocated to Hawai'i Island did so primarily for the quality of life, the best predictors of retention are financial sustainability, professional opportunities, community support, and access to good K-12 schools. Survey results also indicate that Hawai'i Island will lose 32% of its current physicians within the next five years due to retirement or other causes., Discussion: These findings indicate that increased urgency to find solutions is warranted.

Organizational culture is defined as the shared values and beliefs that guide behavior within each organization, and it matters because it is related to performance. While culture is generally considered important, it is mysterious and intangible to most leaders. The first step toward understanding organizational culture is to measure it properly. This chapter describes methods for measuring culture in health-care organizations and how these methods were implemented in a large academic medical center. Because of the consistent empirical link between the dimension of communication, other culture dimensions, and employee satisfaction, special attention is focused in this area. Specifically, a case study of successful communication behaviors during a major "change management" initiative at a large academic medical center is described. In summary, the purpose of this chapter is to demystify the concept of culture and demonstrate how to improve it.

We examined archival data to test the hypothesis that absenteeism is inversely related to work productivity among mental health employees at a Veterans Affairs Medical Center outpatient clinic. Results provided partial support for this hypothesis in that there was an inverse correlation between one measure of productivity and the percentage of sick and family care leave taken on Mondays and Fridays (r=.54). No significant relationship between work productivity and total sick and/or family care leave was found, although there was a trend in that direction (r=.34). These data suggest that mental health clinicians who use high levels of sick and/or family care leave are not necessarily unproductive workers. However, high percentages of absenteeism on Mondays and Fridays may represent a red flag for identifying under-performing clinicians. Examination of absenteeism patterns may prove useful for administrators. Management policy strategies to reduce absenteeism are suggested.

Objective: The authors evaluated the reliability and preliminary validity of the Charleston Psychiatric Outpatient Satisfaction Scale, a 15-item measure of patients' satisfaction designed for use in outpatient settings. The instrument uses a 5-point Likert-type response format that minimizes positive response bias and optimizes variability and predictive validity., Methods: The Charleston Psychiatric Outpatient Satisfaction Scale was administered to 282 patients seen in psychiatric outpatient clinics affiliated with a public-academic psychiatric institution over a one-week period in 1995., Results: The internal reliability of the instrument was high (alpha=.87), and its convergent validity was supported by the significant correlation of all items with anchor items that measured overall satisfaction with care and likelihood of recommending the clinic to others. The best predictors of overall ratings of care were the items measuring patients' satisfaction with helpfulness of the services and with the respect shown for patients' opinions about treatment. The best predictors of recommendation of the program to others were the items measuring satisfaction with matching of the treatment plan to patients' individual needs and with the respect shown for patients' opinions about treatment. Mean scores for all items ranged from 3.6 (satisfaction with parking) to 4.5 (satisfaction with helpfulness of the secretary and with the overall quality of care), indicating that overall satisfaction in this sample was high., Conclusions: The results provide preliminary support for the reliability and validity of the Charleston Psychiatric Outpatient Satisfaction Scale:

The interrelationship between the theoretically related constructs of anger and posttraumatic stress disorder (PTSD) symptoms was examined in a group of 42 combat veterans with PTSD using a multimeasure assessment strategy. Scores on several anger measures were found to be quite high in this sample and were significantly correlated with PTSD symptomatology. Furthermore, anger measures were found to be related to employment status independent of PTSD severity, but were not related to disability compensation-seeking status. Clinicians are advised to be aware of the potential implications for physical health and interpersonal functioning, and to incorporate anger management strategies into treatment plans for this population.

Background: Decisions made by quality improvement (QI) teams, as reported in the literature, are usually based on nonexperimental methods for data collection. Pretest-posttest designs, in particular; are common in reports of QI teams' evaluations of changes or interventions. Yet in such designs the results are inherently confounded; it is impossible to rule out alternative explanations for any differences found., Using Experimental Methods to Make Qi Decisions: As suggested by one study, QI teams can design and implement experimental interventions in relevant organizational processes. In an attempt to reduce the no-show rate for first appointments at a Residents Clinic at the Medical University of South Carolina (Charleston), the Youth Outpatient Improvement Team designed an experiment to test two possible modifications to the admission process. Those seeking services were randomly assigned to one of three groups (the control group or one of the experimental groups). Not only did results not support the team's hypothesis that one of the experimental procedures would produce a lower no-show rate, subjects in the experimental groups were less likely to enter treatment. Given these data, the decision was made to maintain current admission procedures., Conclusions: Since the quality of a decision is dependent on the quality of the data on which it is based, QI teams should consider experimental methods when planning data collection to evaluate their recommended interventions. When such methods are not feasible, quasi-experimental strategies can be used to strengthen the quality of nonexperimental data.