Introduction: The collaborations between dental care providers and other health care providers are especially needed for underserved populations. There is a deficit of research focused on underserved populations who utilize a safety net facility such as a free clinic in the United States. The purpose of this study is to examine the association between health-related beliefs and oral health behaviors among uninsured adults utilizing a primary care free clinic providing oral health care. Methods: Uninsured primary care patients utilizing a free clinic (N = 585) participated in a self-administered paper survey in May and June, 2016. Results: More than 60% of free clinic patients reported a perceived need for dental treatment. Free clinic patients who brush their teeth more than once a day reported better perceived general health compared with those who do not brush their teeth more than once a day. Free clinic patients who had perceived a need for dental treatment reported worse perceived general health compared to those who did not report dental needs. Conclusions: The results of this study indicate a pressing need for the further development of dental care services at safety-net clinics. By including dental care in health promotion programs, it will have positive impacts not only on oral health but also on a healthy lifestyle and the general health of underserved populations utilizing a safety-net clinic. The implementation and evaluation of the integrated health programs, which include primary care and oral health care together, would be beneficial to reduce oral health disparities.
Objective: To analyze factors associated with and predicting Mexican women seeking primary care mental health services (PCMHS) and provide suggestions to increase PCMHS utilization. Method: We administered a questionnaire to (N = 456) female patients in Mexico City primary care clinics. We conducted chi-square analyses of seeking PCMHS and sociodemographic variables, perceptions of and experiences with PCMHS. Our results and literature review guided our logistic regression model. Results: Women referred to a mental health provider (MHP; odds ratio [OR] = 10.81, 95% CI = 3.59-32.51), whose coping mechanisms included talking to a MHP (OR = 5.53, 95% CI = 2.10-14.53), whose primary worry is loneliness (OR = 8.15, 95% CI = 1.20-55.10), and those who follow doctor’s orders; were more likely to seek PCMHS (OR = 0.28, 95% CI = 0.09-0.92). Conclusions: Primary care providers play a fundamental role in women’s decisions to seek PCMHS. Proper referrals to PCMHS should be encouraged.
Purpose: Each of the participating patient-centered medical home (PCMH) received coaching and participated in learning collaborative for improving teamwork. The objective of the study was to assess the impact of trainings on patient-centered teamwork. Methods: The Teamwork Perception Questionnaire (TPQ) was administered once in spring 2014 and then in fall 2015. The TPQ consists of 35 questions across 5 domains: mutual support, situation monitoring, communication, team structure, and leadership. Based on our objective we compared the frequencies of strongly agree/agree by domain. The difference was tested using chi-square test. We compared the scores on each domain (strongly agree/agree = 1; maximum score = 7) via Wilcoxon rank sum test. Results: The response rate for this survey was n = 29 (80.6%) in spring 2014, and n = 31 (86.1%) in fall 2015. We found that the practice members significantly (P < .05) strongly agreed/agreed more in fall 2015 than spring 2014 for characteristics—"staff relay relevant information in a timely manner" (64.5% vs 83.9%) and "staff follow a standardized method of sharing information when handing off patients" (67.7% vs 90.3%) under communication domain and for characteristic—"staff within my practice share information that enables timely decision making" (74.2% vs 90.3%). However, there was no statistical significant difference observed in the scores for the overall TPQ at the 2 time points. Conclusion: Despite the statistical insignificance, the observations in PCMHs across the spectrum of practices participating in the Maryland Multi-Payer Program demonstrated enhanced teamwork specifically in communication and in leadership. This we believe will continue to result in enhanced patient access to care and safety.
Objective: We examined associations between observed neighborhood conditions (good/adverse) and psychosocial outcomes (stress, depressive symptoms, resilience, and sense of control) among middle-aged and older African Americans. Methods: The sample included 455 middle-aged and older African Americans examined in Wave 10 of the African American Health (AAH) study. Linear regression was adjusted for attrition, self-selection into neighborhoods, and potential confounders, and stratified by the duration at current address (<5 vs ≥5 years) because of its hypothesized role as an effect modifier. Results: Among individuals who lived at their current address for ≥5 years, residing in neighborhoods with adverse versus good conditions was associated with significantly less stress (standardized β = –0.18; P = .002) and depressive symptoms (standardized β = –0.12; P = .048). Among those who lived at their current address for <5 years, residing in neighborhoods with adverse versus good conditions was not significantly associated with stress (standardized β = 0.18; P = .305) or depressive symptoms (standardized β = 0.36; P = .080). Conclusion: Neighborhood conditions appear to have significant, complex associations with psychosocial factors among middle-aged and older African Americans. This holds important policy implications, especially since adverse neighborhood conditions may still result in adverse physical health outcomes in individuals with >5 years at current residence despite being associated with better psychosocial outcomes.
Purpose: Half of US states mandate women be notified if they have dense breasts on their mammogram, yet guidelines and data on supplemental screening modalities are limited. Breast density (BD) refers to the extent that breast tissue appears radiographically dense on mammograms. High BD reduces the sensitivity of screening mammography and increases breast cancer risk. The aim of this study was to determine the potential impact of California’s 2013 BD notification legislation on breast cancer screening patterns. Methods: We conducted a cohort study of women aged 40 to 74 years who were members of a large Northern California integrated health plan (approximately 3.9 million members) in 2011-2015. We calculated pre- and post-legislation rates of screening mammography and magnetic resonance imaging (MRI). We also examined whether women with dense breasts (defined as BI-RADS density c or d) had higher MRI rates than women with nondense breasts (defined as BI-RADS density a or b). Results: After adjustment for race/ethnicity, age, body mass index, medical facility, neighborhood median income, and cancer history, there was a relative 6.6% decrease (relative risk [RR] 0.934, confidence interval [CI] 0.92-0.95) in the rate of screening mammography, largely driven by a decrease among women <50 years. While infrequent, there was a relative 16% increase (RR 1.16, CI 1.07-1.25) in the rate of screening MRI, with the greatest increase among the youngest women. In the postlegislation period, women with extremely dense breasts (BI-RADS d) had 2.77 times (CI 1.93-3.95) the odds of a MRI within 9 months of a screening mammogram compared with women with nondense breasts (BI-RADS b). Conclusions: In this setting, MRI rates increased in the postlegislation period. In addition, women with higher BD were more likely to have supplementary MRI. The decrease in mammography rates seen primarily among younger women may have been due to changes in national screening guidelines.
Physical activity in later years of life is not only essential to healthy aging and independent functioning, but it also helps prevent chronic diseases. We aimed this cross-sectional study to assess the prevalence of physical activity and associated factors among rural elderly Thais. We conducted this study on a sample of 300 elderly in 2 rural districts of Phranakornsiayutthaya province in Thailand. The mean age of participants were 67.5±6 years and 42% of them did not perform physical activity. Prevalence of vigorous and moderate intensity physical activity was 43.7% and 48.7%, respectively. About 43.7% elderly used any active transport and spent 2.81 hours on sedentary activities, daily. Females and those with enough income were 3.64 and 0.59 times, respectively, less likely to be physically active (P < .05). Our study concluded that almost half of the rural Thai elderly were physically inactive. Also male and wealthy elderly were less likely to be engaged in physical activity. We recommend for improved efforts to involve rural Thai elderly in physical activity by offering them opportunities for locally relevant recreational and leisure time physical activities, with special focus on males and higher income elderly.
Objectives: To examine the prevalence of complementary and alternative medicine (CAM) use by race/ethnicity and to identify sociodemographic and health-related factors associated with CAM use among US adults with moderate mental distress (MMD). Methods: We analyzed data from the 2012 National Health Interview Survey (NHIS). We used data for 6016 noninstitutionalized US adults with MMD (3492 non-Hispanic whites, 953 non-Hispanic blacks, 1078 Hispanics, 268 Asians, and 225 others consisted of American Indian, Alaska Native, and those reporting multiple races). The 2012 NHIS asks about 36 types of CAM use in the past 12 months. We constructed (1) overall, any CAM use; (2) 5 major types of CAM use; and (3) individual types of CAM use indicators. Using a cross-sectional design with complex survey techniques, we estimated race/ethnicity-specific CAM prevalence, and odds of past year CAM use by race/ethnicity, sociodemographic, and health-related factors. Results: Nearly 40% of adults with MMD used CAM in the past year compared with 32% of those without MMD (P < .001). In adults with MMD, past year CAM use differed by race/ethnicity, ranging from 24.3% (blacks) to 44.7% (Asians) and 46.8% (others) (P < .001). Being younger, female, living in the west, higher education, being employed, more than 4 ambulatory care visits, and functional limitations were associated with higher odds of CAM use (P < .01). Conclusions: Adults with MMD use CAM more frequently than those without MMD. In addition, CAM use was significantly differed by race/ethnicity in adults with MMD. This underscores the need for good patient-provider communication and suggests opportunity for dialogue about integration between conventional providers and CAM practitioners to facilitate optimal mental health care.
Electronic cigarettes (e-cigarettes) are often advertised as a healthier product when compared with traditional cigarettes. Currently, there are limited data to support this and only a threat of federal regulation from the US Food and Drug Administration. Calls to poison control centers about e-cigarette toxicity, especially in children, and case reports of toxic exposures have increased over the past 3 years. This research letter reports the frequency of hazardous exposures to e-cigarettes and characterizes the reported adverse health effects associated with e-cigarette toxicity.
Purpose: To describe rates of and reasons for follow-up among adolescents and adults receiving contraceptive implants in a Federally Qualified Health Center (FQHC). Methods: Retrospective comparison of patient-initiated implant-related contacts during the 6 months postinsertion among adolescents (110) and adults (154) who had implants placed at a FQHC network. Results: Forty percent of adolescents and 26% of adults initiated follow-up (P = .016). Bleeding changes and discussing removal were the most common reasons for follow-up for both groups. Adolescents (5.5%) and adults (9.0%) had similar removal rates (P = .348). However, among patients who discussed implant removal, adults were more likely to have removals compared with adolescents (P = .002). Conclusions: Other FQHCs may anticipate a similar experience to ours, where adolescents may be more likely than adults to initiate implant-related follow up, with removal rates of less than 10% at 6 months. Further study of physician decision making and patient autonomy regarding implantable contraception removal requests is warranted.
Background: Sickle cell disease (SCD) is a complex chronic disease requiring multidisciplinary care that involves primary care physicians (PCPs) working with a hematologist or SCD specialists. However, PCPs often lack access to SCD specialists and are unaware of SCD guidelines or efficacious treatment. Methods: We partnered with Community Care of North Carolina (CCNC) to identify assigned PCPs for SCD patients with Medicaid across North Carolina. CCNC network administrators distributed a web-based questionnaire for completion. The questionnaire involved 12 self-reported items on a yes-no or a 1 to 5 Likert-type scale that assessed PCP attitudes toward SCD care, awareness of recent guidelines, and comanaging hydroxyurea. Results: Of the 53 PCPs who completed the electronic survey, 73% felt they were comfortable with the number of SCD patients in their practice. Most PCPs reported having infrequent communications with an SCD specialist (67%) and most were also not aware of the 2014 SCD guidelines (66%). Many reported that they would frequently use the new SCD guidelines if provided to them (76%). Furthermore, 51% of PCPs expressed comfort with using mobile apps to access SCD guidelines and provided email contact to receive further information. The majority also reported being comfortable comanaging hydroxyurea with an SCD specialist (65%). Conclusion: Few PCPs in North Carolina were aware of the new SCD guidelines or had regular communication with an SCD specialist. The majority of PCPs, however, demonstrated a favorable attitude toward receiving the SCD guidelines and comanaging hydroxyurea with a specialist. In response to this gap in care, we have developed a mobile-based SCD toolbox specifically for PCPs to provide guidelines, algorithms, and a method to communicate with local SCD specialists. With the interest in receiving these guidelines, we are confident the toolbox will provide an easy to use platform to assist PCPs to utilize the SCD guidelines.
Background: There is a significant disparity in hypertensive treatment rates between those with and without health insurance. If left untreated, hypertension leads to significant morbidity and mortality. The uninsured face numerous barriers to access chronic disease care. We developed the Community-based Chronic Disease Management (CCDM) clinics specifically for the uninsured with hypertension utilizing nurse-led teams, community-based locations, and evidence-based clinical protocols. All services, including laboratory and medications, are provided on-site and free of charge. Methods: In order to ascertain if the CCDM model of care was as effective as traditional models of care in achieving blood pressure goals, we compared CCDM clinics’ hypertensive care outcomes with 2 traditional fee-for-service physician-led clinics. All the clinics are located near one another in poor urban neighborhoods of Milwaukee, Wisconsin. Results: Patients seen at the CCDM clinics and at 1 of the 2 traditional clinics showed a statistically significant improvement in reaching blood pressure goal at 6 months (P < .001 and P < .05, respectively). Logistic regression analysis found no difference in attaining blood pressure goal at 6 months for either of the 2 fee-for-service clinics when compared with the CCDM clinics. Conclusion: The CCDM model of care is at least as effective in controlling hypertension as more traditional fee-for-service models caring for the same population. The CCDM model of care to treat hypertension may offer another approach for engaging the urban poor in chronic disease care.
Background: A shortage of primary care physicians has led to the alternative strategy of nurse practitioners (NPs) as primary care providers for the growing elderly population. Many states have implemented policies that allow NPs to practice independently with no physician oversight. Little is known about the continuity of primary care provided by NPs. Objective: To examine rate and correlates of switching from exclusive NP primary care to receiving some or all primary care from physicians. Design: A retrospective cohort study. Participants: Medicare beneficiaries (n = 38 618) with diabetes, congestive heart failure, or chronic obstructive pulmonary disease who received all their primary care from NPs in 2007. Main Measures: Multivariable logistic regression model was used to assess patient and disease characteristics associated with switching from sole NP primary care in 2007 to receiving some or all primary care from physicians between 2008 and 2010. Results: Of elderly patients receiving all their primary care from NPs in 2007, 53.8% switched to receiving some or all primary care from physicians in 2008-2010. The switching patients had less comorbidity before the switch and were more likely to reside in metropolitan areas, ZIP code areas with high education or states with the most restriction on NP scope of practice. In multivariable analyses, significant predictors of switching included one of the following within 30 days before the switch: emergency room visits (odds ratio [OR] = 1.55, 95% confidence interval [CI] = 1.44-1.68), hospitalization (OR = 1.13, 95% CI = 1.02-1.25), new diagnosis of heart attacks (OR = 5.52, 95% CI = 4.33-7.02), pneumonia (OR = 4.84, 95% CI = 3.71-6.32), atrial fibrillation (OR = 3.99, 95% CI = 2.93-5.44), stroke (OR = 2.94, 95% CI = 2.31-3.74), or cancer (OR = 2.65, 95% CI = 1.94-3.63). Conclusions: About half of Medicare patients under exclusive NP primary care switched to physicians for some or all primary care over a 3-year period. Future study is needed to understand the reasons for switching.
Purpose: The Timed Up and Go (TUG) test is a reliable, cost-effective, safe, and time-efficient way to evaluate overall functional mobility. However, the TUG does not have normative reference values (NRV) for individuals younger than 60 years. The purpose of this study was to establish NRV for the TUG for individuals aged between 20 and 59 years and to examine the relationship between the TUG and demographic, physical, and mental health risk factors. Methods: Two hundred participants, 50 per decade (ages 20-29, 30-39, 40-49, 50-59 years) were selected at their primary care visit, and timed as they performed the TUG by standing up out of a chair, walking 3 m, turning around, walking back to the chair, and sitting down. Information regarding the risk factors socioeconomic status, body mass index, an index of multimorbidities, perceptions of overall physical and mental health was obtained and used as predictors of TUG time independent of age. Results: TUG times were significantly different among the decades (F = 6.579, P = .001) with slower times occurring with the 50-year-old decade compared with the 20s (P = .001), 30s (P = .001), and 40s (P = .020). Slower TUG times were associated with lower SES, higher body mass index, more medical comorbidities, and worse perceived physical and mental health. Regression results indicated that perceived physical and mental health accounted for unique variance in the prediction of TUG time beyond age, gender, and socioeconomic status. Conclusions: This study provided TUG NRV for adults in their 20s, 30s, 40s, and 50s. The TUG may have utility for primary care providers as they assess and monitor physical activity in younger adults, especially those with physical and mental health risk factors.
Objective: Despite barriers, organizations with varying characteristics have achieved full integration of primary care services with providers and services that identify, treat, and manage those with mental health and substance use disorders. What are the key factors and common themes in stories of this success? Methods: A systematic literature review and snowball sampling technique was used to identify organizations. Site visits and key informant interviews were conducted with 6 organizations that had over time integrated behavioral health and primary care services. Case studies of each organization were independently coded to identify traits common to multiple organizations. Results: Common characteristics include prioritized vulnerable populations, extensive community collaboration, team approaches that included the patient and family, diversified funding streams, and data-driven approaches and practices. Conclusions: While significant barriers to integrating behavioral health and primary care services exist, case studies of organizations that have successfully overcome these barriers share certain common factors.
Objective: To determine whether younger dual-eligibles receiving care at federally qualified health centers (FQHCs) have lower rates of ambulatory care sensitive (ACS) hospitalization and emergency department (ED) visits. Data Sources: We used the 100% Medicare Part A and Part B institutional claims from 2007 to 2010 for dual-eligibles younger than 65 years, enrolled in traditional fee-for-service Medicare, who received care at an FQHC or lived in a primary care service area with an FQHC. Methods: Our cross-sectional analysis used negative binomial regressions to model ACS hospitalizations and ED visits as a function of prior year FQHC use. The model adjusted for beneficiary age, gender, race, and chronic diseases, as well as county fixed effects, time trends, and race-FQHC use interactions. Results: FQHC use is associated with a decrease in ACS hospitalization rates for whites (2.8 per 1000 persons), but an increase among blacks (2.5 per 1000 persons). FQHC use is also associated with an increase in ACS ED visits, from 27 to 33 more visits per 1000 persons per year, depending on patient race. Conclusions: ACS hospital use is higher for FQHC users than nonusers, but white FQHC users have fewer ACS hospitalizations. More research is needed to understand how this relationship varies within and between centers.
Introduction: Volume of moderate-to-vigorous physical activity completed during the elementary school day is insufficient, and associated with health risks. Improvements in theory-based psychosocial factors might facilitate increased out-of-school physical activity. Methods: A behaviorally based after-school care protocol, Youth Fit 4 Life, was tested for its association with increased voluntary, out-of-school physical activity and improvements in its theory-based psychosocial predictors in 9- to 12-year-olds. Results: Increases over 12 weeks in out-of-school physical activity, and improvements in self-regulation for physical activity, exercise self-efficacy, and mood, were significantly greater in the Youth Fit 4 Life group (n = 88) when contrasted with a typical care control group (n = 57). Changes in the 3 psychosocial variables significantly mediated the group–physical activity change relationship (R2 = .31, P < .001). Change in self-regulation was a significant independent mediator, and had a reciprocal relationship with change in out-of-school physical activity. In the Youth Fit 4 Life group, occurrence of 300 min/wk of overall physical activity increased from 41% to 71%. Conclusions: Targeting theory-based psychosocial changes within a structured after-school care physical activity program was associated with increases in children’s overall time being physically active. After replication, large scale application will be warranted.
Objectives: Patients with coexisting mental health disorder and chronic disease are more at risk for poor outcomes, including increased acute care utilization. This study was performed to assess the association of mental health disorders on acute care utilization (emergency department [ED] use, hospitalization, and rehospitalization within 30 days) using disease clustering. Methods: A retrospective cohort analysis was performed on 10 408 patients. Adult patients >18 years of age were included in the study if they were seen at least twice in University Internal Medicine primary care clinic at the Medical University of South Carolina from October 10, 2010 through September 30, 2013. The main outcome measure was a count of acute care use (hospital or ED). A linear regression model was used to fit a predictive model for ED and hospital utilization, and agglomerative hierarchical clustering was used to identify patients with similar comorbidities. Results: Covariates associated with increased risk of ED and hospital utilization include non-white race (rate ratio [RR] = 1.35, P < .0001), resident physician (RR = 1.30, P < .0001), and public insurance (RR = 1.56, P < .0001). Patients within the multiple chronic conditions (MCC), chronic obstructive pulmonary disease (COPD)/asthma, or renal disease clusters had 1.80 (P < .0001), 1.50 (P < .0001), and 2.57 (P < .0001) times, respectively, the amount of predicted utilization compared with healthy patients, whereas patients with a mental health diagnosis had 1.41 (P < .0001) times the predicted utilization. There was a significant association with increased utilization in patients with coexisting mental health disorder and chronic disease within the COPD/asthma (RR = 1.20, P = .0038), renal disease (RR = 1.27, P < .0001), and MCC (RR = 1.34, P < .0001) clusters. Conclusions: Patients with co-occurring chronic medical conditions and mental health disorders have higher rates of acute care utilization compared with patients with chronic medical conditions alone. Improving access to mental health care at the primary care clinic may have a positive impact on utilization.
Background: In recent years, there have been dramatic increases in medical imaging use and increasing media attention to increased exposure to ionizing radiation in the United States. Patient perspectives on medical imaging radiation (MIR) use is understudied, but could guide primary care discussions. This study examines prevalence of worry about the health harms from MIR in the US general population. Methods: This cross-sectional study used the 2012-2013 Health Information National Trends Survey conducted by the National Cancer Institute. A nationally representative sample (N = 3532) was drawn from the US general population to observe prevalence of worry about MIR as well as potential covariates, including demographic, medical, and psychological factors, health information-seeking, physician trust in providing cancer information, and cancer fatalism. Results: About 65% of the sample population reported experiencing at least some worry about MIR. Univariable and multivariable logistic regressions indicate higher rates of MIR worry among women, racial/ethnic minorities, those with lower educational attainment, foreign-born Americans, those who self-report poorer health, and those with a personal history of cancer. Lower trust in cancer information from physicians and greater attention to cancer information from popular media were each associated with higher rates of worry about health harms of MIR. Conclusions: An accurate assessment of public worry about MIR will aid primary care providers’ efforts to understand patient responses to medical imaging and identify addressable knowledge gaps regarding benefits and risks of medical imaging. These data may improve risk communication regarding medical imaging among referring primary care physicians, radiologists, and patients.
An outbreak investigation was initiated following an unusual occurrence of hepatitis A reported among people residing in the coastal belt of Vadi to Vedikunnu area, Kollam district, Kerala, southern India. The time frame of disease occurrence, pattern of its distribution, and the incubation period of hepatitis A infection indicated the probability of occurrence of the outbreak as a result of pipe line water contamination due to mixing of sewage from a canal. The results add evidence to the epidemiology of hepatitis A in the state and warrant the establishment of an efficient water quality surveillance system.
Population health management is becoming increasingly important to organizations managing and providing primary care services given ongoing changes in health care delivery and payment systems. The objective of this study is to show how systems science methodologies could be incorporated into population health management to compare different interventions and improve health outcomes.
The New York Academy of Medicine Cardiovascular Health Simulation model (an agent-based model) and data from the Behavioral Risk Factor Surveillance System were used to evaluate a lifestyle program that could be implemented in primary care practice settings. The program targeted Medicare-age adults and focused on improving diet and exercise and reducing weight.
The simulation results suggest that there would be significant reductions projected in the proportion of the Medicare-age population with diabetes after the implementation of the proposed lifestyle program for a relatively long term (3 and 5 years). Similar results were found for the subpopulations with high cholesterol, but the proposed intervention would not have a significant effect in the proportion of the population with hypertension over a time period of <5 years.
Systems science methodologies can be useful to compare the health outcomes of different interventions. These tools can become an important component of population health management because they can help managers and other decision makers evaluate alternative programs in primary care settings.
The average consumption of sugar in the Malaysian population has reached an alarming rate, exceeding the benchmark recommended by experts. This article argues the need of a paradigm shift in the management of sugar consumption in the country through evidence derived from addiction research.
"Food addiction" could lead to high levels of sugar consumption. This probable link could accelerate the development of diabetes and obesity in the community. A total of 94 reports and studies that describe the importance of addiction theory–based interventions were found through a search on PubMed, Google Scholar, and Academic Search Complete.
Research in the field of addiction medicine has revealed the addictive potential of high levels of sugar intake. Preexisting health promotion strategies could benefit from the integration of the concept of sugar addiction. A targeted intervention could yield more positive results in health outcomes within the country.
Current literature seems to support food environment changes, targeted health policies, and special consultation skills as cost-effective remedies to curb the rise of sugar-related health morbidities.
Exercise referral schemes are established within community-based health care; however, they have been criticized for failing to evidence long-term behavior change relative to usual care. As such, recent reviews have called for refinement of their delivery with a focus on embedded strategies targeting client motivation. This research letter presents findings from an initial pilot trial conducted within Wales’ National Exercise Referral Scheme (NERS), examining the feasibility of using validated physical activity monitoring devices and an accompanying online platform within standard scheme delivery. 30 individuals referred to generic or cardiovascular pathways were offered the system; of these 17 agreed to participate. Common reasons for declining were clustered into lack of technology literacy or access, condition severity, or fear of costs associated with losing the device. Analysis of follow-up interviews after 4 weeks of use indicated that while participants found the monitoring devices practical and informative, only a minority (n = 4) were using the system in full. Crucially, the system element most aligned with contemporary theories of motivation (the online portal) was not used as expected. In addition, feedback from exercise referral professionals indicated that there were demands for support from clients, which might be mitigated by more effective independent system use. Recommendations for larger scale trials using similar systems include consideration of targeted patient groups, equity of access, and providing adequate technological support that is currently beyond the capacity of the NERS system.
Objectives: Low-income, inner-city women bear a disproportionate burden of cervical cancer in both incidence and mortality rates in the United States, largely because of low adherence to follow-up recommendations after an abnormal cervical cytology result in the primary care setting. The goals of the present study were to delineate the theory-based psychosocial barriers underlying these persistent low follow-up rates and their sociodemographic correlates. Methods: Guided by a well-validated psychosocial theory of health behaviors, this cross-sectional, correlational study assessed the barriers to follow-up adherence among underserved women (N = 210) who received an abnormal cervical cytology result. Participants were recruited through an inner-city hospital colposcopy clinic, and were assessed by telephone prior to the colposcopy appointment. Results: Participants were largely of African American race (82.2%), lower than high school completion education (58.7%), single, never married (67.3%), and without full-time employment (64.1%). Knowledge barriers were most often endorsed (68%, M = 3.22), followed by distress barriers (64%, M = 3.09), and coping barriers (36%, M = 2.36). Forty-six percent reported more than one barrier category. Less education and being unemployed were correlated with higher knowledge barriers (P < .0001 and P < .01, respectively) and more coping barriers (P < .05 and P < .05, respectively). Women who were younger than 30 years displayed greater distress barriers (P < .05). Conclusion: In the primary care setting, assessing and addressing knowledge and distress barriers after feedback of an abnormal cervical cytology result may improve adherence to follow-up recommendations. The use of structured counseling protocols and referral to navigational and other resources may facilitate this process and thereby reduce disparities in cervical cancer.
Background: Health care professionals (HCPs) play a vital role at various levels of smoking cessation programs to reduce tobacco use in general populations. However, their smoking habits may limit their ability to intervene with their patients who smoke. Aims: To determine prevalence rates of current smoking and examine sociodemographic and work-related factors associated with current smoking among HCPs. Methods: A statewide survey was conducted in a representative sample of 4 groups of HCPs, physicians, nurses, respiratory therapists, and occupational therapists, with active licenses in Texas in 2003. Weighted prevalence estimates of current smoking rates were computed. Survey logistic regression analysis was used to investigate associations between individual characteristics and current smoking. Results: There were 3600 HCPs included in the analysis. The overall prevalence of current smoking was 9% with the highest prevalence (16%) recorded among respiratory therapists and the lowest prevalence (3%) recorded among physicians. In the multivariable logistic regression analysis non-Hispanic white HCPs were almost 4 times as likely to be current smokers (adjusted odds ratio= 3.95, 95% confidence interval = 1.24-12.59) and those working for 50 hours or more per week were twice as likely to be current smokers (adjusted odds ratio = 2.07, 95% CI = 1.20-3.57). Compared with physicians, all other HCP groups had significantly greater odds of currently smoking. HCPs who were female and resided or worked in rural settings had higher smoking rates in univariable analysis only (P < .05). Conclusions: Smoking is prevalent among certain HCP groups. Working long hours was identified as an important occupational factor associated with current smoking.
Background: Although limiting prescription refills is considered as a strategy to increase compliance with the treatment regimen and follow-up, no literature exists to support its effectiveness. We sought to investigate whether decreasing the number of prescription refills affects no-show rate at an urban teaching primary care continuity clinic in New York. Methods: Eight teaching attending physicians and 19 residents implemented a "new prescribing strategy" from February 9 to 22, 2012, which limited the number of refills only to cover until the next intended clinic visit. All adult patient visits were included if follow-up visits were requested to be scheduled within 3 months and prescriptions were given through an electronic prescription system. No-show rates for the first follow-up visits up to 120 days from the initial visits during the interventional period were compared with those during the baseline period (December 15-28, 2011). Results: Two hundred twenty-one patients in the baseline period and 278 in the interventional period were included in the analysis. Median total supply of prescription was 6 and 3 months, respectively (P < .001). The no-show rates were not significantly different between the 2 periods (19.0% [42/221] vs 16.6% [46/278], P = .5). In multivariate regression analysis, the no-show rate did not change significantly during the interventional period compared with the baseline period (odds ratio [OR] 1.0; 95% confidence interval, 0.6-1.5; P = .8). Younger age (OR 1.03 per year, P = .008), male gender (OR 2.0, P = .003), Medicaid or Medicare insurance (OR 3.7, P = .01; OR 4.2, P = .02), and diagnosis of diabetes (OR 1.8, P = .04) or asthma (OR 2.0, P = .03) were associated with higher no-show rates. Conclusions: Reducing the number of refills did not significantly affect no-show rates in the immediate follow-up. Alternative strategies should be considered to minimize no-shows.
Aim: The aim of the current study was to determine the efficacy of the 4 most commonly prescribed statins (rosuvastatin, atorvastatin, pravastatin, and simvastatin) for managing dyslipidemia among diabetic patients with and without metabolic syndrome (MetS). Material and Methods: This was a cohort observational population-based study conducted at Hamad Medical Hospital and Primary Health Care Centre. The participants were 1542 consecutive diabetes patients who were diagnosed with dyslipidemia and were prescribed any of the indicated statins. Sociodemographic and clinical characteristics were taken from medical records, and lipid profile at baseline and 2 years after the initiation of statin therapy were retrieved from electronic medical records database (EMR-viewer). Reduction in different lipid profile after 2 years of therapy was compared among different types of statins between patients with and without MetS. Results: Out of total 1542 subjects, 562(36.4%) were diagnosed with MetS using the criteria of International Diabetes Federation. Among those with MetS, 125 were prescribed with atorvastatin, 162 pravastatin, 177 rosuvastatin, and 98 simvastatin. Among those without MetS, 365 used atorvastatin, 172 pravastatin, 345 rosuvastatin, and 98 simvastatin therapies. Among patients with MetS, rosuvastatin therapy resulted in significantly higher low-density lipoprotein cholesterol and total cholesterol reduction (23%, P = .006; and 20.3%, P = .015, respectively) as compared with other statins. Similarly, significantly higher percentage of patients receiving rosuvastatin therapy were successful in achieving the target of total cholesterol <4 mmol/L and triglycerides <1.7 mmol/L after 2 years (38.4%, P = .012; and 67.2%, P = .010, respectively) as compared with other therapies. In contrast, among patients without MetS, rosuvastatin therapy resulted in highest percentage drop in total cholesterol (20.1%; P = .016) than other statin therapies. Conclusion: The present study confirmed that rosuvastatin therapy in commonly prescribed doses is the most effective statin for low-density lipoprotein cholesterol goal achievement and for improving the lipid profile in hypercholesterolemic diabetic patients with and without MetS.
Objectives: To examine the quality of chronic disease care at federally qualified health centers (FQHCs) as a function of state health agency support. Methods: We merged data from the 2010 Association of State and Territorial Health Officials Public Health Survey, the 2011 Area Resource File, and the 2010 Uniform Data System. Using ordinary least squares regression, we modeled hypertension and diabetes control among FQHC patients as a function of state public health agency support of FQHCs, including financial support, direct collaboration, and electronic health data exchanges. Results: The rate of hypertension control is 63.4%, while the rate of diabetes control (HbA1c <7%) is 41.3%. Some two thirds of FQHCs (67.1%) are in states whose public health agencies are fully engaged in FQHC-supporting activities, and approximately one third (34.6%) are in states whose public health agencies send and receive electronic health record data with FQHCs. However, none of our measures of public health agency support of FQHCs significantly predicted FQHC-specific chronic disease outcomes. Conclusions: We find no evidence that state public health agency support of FQHCs affects chronic disease outcomes for FQHC patients.
Purpose: Hypogonadism is highly prevalent in men older than 45 years and is associated with an increased risk of chronic diseases, including obesity, metabolic syndrome, diabetes, and cardiovascular disease. The objective of this study was to determine whether lifestyle factors such as smoking, diet, and exercise are associated with reduced testosterone levels. Methods: In this cross-sectional study, 147 men older than 44 years were recruited from a collaborative network of primary care clinics in the Dallas/Fort Worth, Texas, metropolitan area. Free testosterone levels were measured in plasma samples via an enzyme-linked immunosorbent assay–based method, and analyzed by simple and multiple linear regression in relationship to age, race/ethnicity, smoking, diet, exercise, obesity, diabetes, hypertension, and dyslipidemia. Results: The participants had a mean free testosterone level of 3.1 ng/mL (standard deviation [SD] = 1.5) and mean age of 56.8 years (SD = 7.9). In simple regression analysis, free testosterone levels were associated with increased age (β = –0.04; P = .02), diet (β = –0.49; P = .05), diabetes (β = –0.9; P = .003), and hypertension (β = –0.55; P = .03) but not with race/ethnicity, smoking, exercise, obesity, or dyslipidemia. In multiple regression analysis, free testosterone values were significantly associated only with age (β = –0.05; P = .01) and diet (β = –0.72; P = .01). Conclusions: This study implicates diet, in addition to advanced age as a possible risk factor in the development of reduced testosterone levels.
The gold standard for health information is the health record. Hospitalization and outpatient diagnoses provide health systems with data on which to project health costs and plan programmatic changes. Although health record information may be reliable and perceived as accurate, it may not include population-specific information and may exclude care provided outside a specific health care facility. Sole reliance on medical record information may lead to underutilization of health care services and inadequate assessment of population health status. In this study, we analyzed agreement, without assuming a gold standard, between self-reported and recorded chronic conditions in an American Indian/Alaska Native cohort. Self-reported health history was collected from 3821 adult participants of the Alaska EARTH study during 2004-2006. Participant medical records were electronically accessed and reviewed. Self-reported chronic conditions were underreported in relation to the medical record and both information sources reported the absence more reliably than the presence of conditions (across conditions, median positive predictive value = 64%, median negative predictive value = 94%). Agreement was affected by age, gender, and education. Differences between participant- and provider-based prevalence of chronic conditions demonstrate why health care administrators and policy makers should not rely exclusively on medical record–based administrative data for a comprehensive evaluation of population health.
Objective: To determine the temporal trends in diagnosis and management of pediatric overweight/obesity by primary care providers at a single medical center. Patients: Children 2 to 18 years old undergoing a general medical examination during 3 calendar years (2003, 2006, and 2009). The number of visits for general medical examination were 6390 in 2003, 6646 in 2006, and 7408 in 2009. Methods: We performed a retrospective review of the electronic medical records for weight related diagnostic and/or management terms and laboratory screening in children with body mass index at or greater than the 85th percentile (n = 1630 in 2003, 1495 in 2006, and 1730 in 2009). Results: There was a significant increase in the diagnosis of obesity among obese children seen in 2009 (53.3%) compared with 2006 (36%, P < .001) and 2003 (24.3%, P < .001). Weight-related counseling was documented in a higher proportion of obese children in 2009 (49.4%) compared with 2006 (34.8%) and 2003 (26.6%). There was a significant increase in counseling regarding screen time in 2009 compared with 2006. A significant increase in screening for nonalcoholic fatty liver disease was also noted (30.5% in 2009 vs 21.9% in 2006, P = .018). Conclusions: There has been steady improvement in the rates of obesity diagnosis and obesity-related counseling by primary care providers. However, continued efforts to increase awareness of these issues are needed as nearly half of obese children remained undiagnosed and recommended laboratory screening for obesity-related comorbidities was performed in only a third of obese children.
Purpose: Our primary aim was to characterize the level of medication use across age-groups by examining electronic medical record data for a large number of patients receiving care in primary care clinics. A secondary aim was to identify factors associated with higher levels of medication use or polypharmacy. Methods: We conducted a retrospective query of electronic medical record data from a clinical data warehouse, evaluating 114 012 patients seen in primary care clinics at least once in the previous 6 months. Medication use was evaluated in 3 different categories: level 1 (0-4 medications), level 2 (5-9 medications), and level 3 (≥10 medications). Multivariate analysis was used to analyze different patient demographics and comorbidities for association with level of medication use. Results: At ages 18 to 24 years, 15% (male) to 23% (female) of patients were taking greater than 5 medications, a trend that continued to increase with older cohorts. Female patients were more likely to have level 2 (odds ratio [OR] = 1.76) and level 3 (OR = 2.73) use compared with men. Level 2 and level 3 use was associated with other patient characteristics, including number of patient encounters (level 2 OR = 2.99; level 3 OR = 8.08 for >7 encounters) and common chronic conditions such as chronic pain (level 2 OR = 2.56; level 3 OR = 6.40), diabetes (level 2 OR = 2.4; level 3 OR = 4.61), heart disease (level 2 OR = 1.99; level 3 OR = 3.65), hypertension (level 2 OR = 2.27; level 3 OR = 2.87), and dyslipidemia (level 2 OR = 1.82; level 3 OR = 2.12). Conclusion: Electronic medical record data may be an important tool for providing more comprehensive information regarding medication usage. Medication usage assessed by electronic medical records, even among the youngest cohort, appears to be greater than other sources of medication usage indicate. Higher levels of medication use were associated with a number of factors, including gender, body mass index, number of patient encounters, and comorbid conditions.
Objectives: To compare colorectal cancer screening rates in veterans receiving primary care (PC) in Veterans Administration (VA) community-based outpatient clinics (CBOCs) and VA medical centers (VAMCs). Methods: The VA Outpatient Care Files were used to identify 2 837 770 patients ≥50 years with ≥2 PC visits in 2010. Veterans undergoing screening/surveillance colonoscopy, sigmoidoscopy, fecal-occult-blood testing (FOBT), and double-contrast barium enema (DCBE) were identified from ICD-9-CM/CPT codes. Patients were categorized as VAMC (n = 1 403 273; 49.5%) or CBOC (1 434 497; 50.5%) based on where majority of PC encounters occurred and as high risk (n = 284 090) or average risk (n = 2 553 680) based on colorectal cancer risk factors and validated ICD-9-CM-based algorithms. Results: CBOC patients were older than VAMC (mean ages 69.3 vs 67.4 years; P < .001), more likely (P < .001) to be male (96.5% vs 95.1%), and white (67.8% vs 64.2%), but less likely to be high-risk (9.4% vs 10.5%; P < .001). Rates of colonoscopy, sigmoidoscopy, and DCBE were all lower in CBOC (P < .001). Among high-risk veterans, rates in CBOC and VAMC, respectively, were 27.4% versus 36.8% for colonoscopy, 1.3% versus 0.8% for sigmoidoscopy, and 0.8% versus 0.5% for DCBE. Among average-risk veterans, these rates were 1.3% versus 1.9%, 0.2% versus 0.1%, and 0.2% versus 0.1%, respectively. The differences remained after adjusting for age/comorbidity. The adjusted odds of colonoscopy for CBOC were 0.73 (95% confidence interval = 0.64-0.82) for average risk and 0.76 (95% confidence interval = 0.67-0.87) for high risk. In contrast, the use of FOBT was relatively similar in CBOCs and VAMCs among both high risk (11.1% vs 11.2%) and average risk (14.3% vs 14.1%). Screening rates were similar between those younger than 65 years and older than 65 years. Conclusions: Veterans receiving PC in CBOCs are less likely to receive screening colonoscopy, sigmoidoscopy, and DCBE than VAMC according to VA records. The lower use in CBOC was not offset by higher use of FOBT, including the degree to which CBOC patients may be more reliant to use non-VA services. The clinical appropriateness of these differences merits further examination.
Chronically ill populations have a strong need for quality public health nutrition services to aid in disease management and improve health outcomes. Evidence suggests that neglecting the importance of adequate nutrition in chronically ill patients has far-reaching implications on the health status of the individual and the health care costs. Research is currently lacking a focus on this topic. This pilot study done through the nonprofit organization MANNA (Metropolitan Area Neighborhood Nutrition Alliance), which serves the greater Philadelphia area, explored the health care expenditures of 65 MANNA clients over time in comparison with a similar group of Medicaid patients who did not receive MANNA services. Health care expenditures were examined before and after clients began receiving services. The study found that the mean monthly health care costs decreased for three consecutive months after initiation of MANNA services. Other health care cost–related factors, such as inpatient costs, length of stay, and number of hospital admissions also displayed a downward trend. These results help show the significance of medical nutrition therapy and home-delivered meal services on overall health care.
The patient-centered medical home (PCMH) is an integrated primary care delivery model particularly suited for patients with poor diabetes control. Although PCMH models targeting adults with diabetes have shown some early success, little is known about the long-term benefits of medical homes in terms of health and cost outcomes. The performance of a PCMH model in adults with poor diabetes control was assessed using simulated controlled trial data obtained from the Archimedes model of disease progression and health care utilization. Using the Cardio-Metabolic Risk data set, we compared health and cost outcomes over a 20-year period between adults with poor diabetes control (HbA1c >9%) receiving standard care and these same adults receiving care under a PCMH model with a 49% HbA1c intervention improvement rate at a per-beneficiary per-month care management cost of $20 per month. The results suggest that the PCMH model has the potential to not only reduce the proportion of the population with bilateral blindness, foot amputations, and myocardial infarctions—and the mortality rate—but it can also do so in a cost-effective manner ($7898 per quality-adjusted life year). The PCMH model is cost saving for the population 50 to 64 years old and it is particularly cost-effective for men ($883 per quality-adjusted life year). Moreover, these effects are relatively large for adults 30 to 49 years old (lower bilateral blindness and death rates), women (lower foot amputation and death rates), and men (lower bilateral blindness and myocardial infarction rates). The PCMH model has potential long-term benefits to both patients with poor diabetes control as well as health care systems and providers willing to invest in this health care delivery approach.
Purpose: Breastfeeding is a potential solution to improve health outcomes for adolescent mothers and infants. Adolescence is a risk factor for low breastfeeding rates and is associated with a higher risk for perinatal complication. This study investigated facilitators and barriers to adolescent breastfeeding initiation and duration in an urban setting. Methods: Four, 1-hour focus groups were conducted. Twenty-nine (N = 29) adolescent mothers and pregnant adolescents participated and described attitudes toward breastfeeding, attitudes among family and friends, current knowledge, and barriers and facilitators for breastfeeding. Results: Four themes emerged, including the following: behavioral histories of breastfeeding, community assets, social support, and barriers. Participants identified positive histories and community resources such as local hospitals and social services as facilitators. Lifestyle, independence, lack of support from family and primary care providers, social stigma/embarrassment, and difficulty with breastfeeding techniques were described as barriers. Conclusion: A comprehensive and integrated primary care and public health community effort is needed to support and improve adolescent breastfeeding. Further examination of integrated interventions focused on adolescent breastfeeding behaviors through an environmental approach is needed.
Background: Clinical supervision (CS) is not an established support system among physicians. Family physicians (FPs) have used Balint groups as a form of clinical supervision. In all, not much is known about the prevalence of physicians’ attendance to or needs for CS. Objective: We studied what proportion of FPs compared with other physicians have attended or report they would need CS and whether having patients who request certain tests or medicines is associated with FPs’ attendance to or need for CS. Design: A postal survey for all working-aged Finnish physicians was performed in 2008. Special questions concerning CS (eg, Balint) and patients’ requests were included. Results: Response rate for the survey was 74% (N = 13 708). Special questions were responded by 10 559 physicians of whom 1252 were FPs. FPs had attended CS more often than other physicians (42% vs 29%, P < .001). Of FPs, 25% reported a need for CS with no availability of it. FPs experienced with or needing for CS were more often than other FPs females, had participated in continuing medical education, and reported that patients with requests have increased in recent years. Conclusion: Both experience of CS and a need for CS with no availability are common among Finnish FPs. Experiences of patients with requests may reflect a need for CS among FPs. Studies on the content, significance and effectiveness CS among FPs are needed.
Background: Sunbed use in childhood increases risk of melanoma. The under-18s sunbed ban was introduced in England, April 2011. Impact on use has not been investigated since. This cross-sectional study estimates the prevalence of under-18s’ use in Sandwell after the commercial ban and identifies factors associated with use/intention. Methods: Adolescents aged 15 to 17 years in schools were surveyed using self-completed anonymous questionnaires. Data collected include demographics, sunbed use, tanning attitudes, knowledge of risks and ban awareness. All Sandwell schools were approached; adolescents available on the survey days were included. Results: Five out of 22 schools participated, 407 adolescents responded (95.1%). Twenty participants (5.3%; 95% confidence interval [CI] = 3.4-8.0) had used sunbeds, of who 16 reported use in commercial settings. After exclusion of one school cohort with atypical use (possibly associated with beauty vocational course and European migrants), the prevalence of use was 1.7% (95% CI = 0.7-3.9, n = 5). Less than half of all were aware of the ban (48.2%; 95% CI = 43.2-53.3). Users/potential users were less aware of associated risks. Being female, having family/friends who use sunbeds increased use/intention 2- to 4-fold. Conclusion: Strategies targeting parents, stricter enforcement, and greater publicity of the ban are needed. Further research exploring the possible association between certain vocational courses, migrants, and sunbed use is required.
Bereavement is common among older adults and may result in major depression or complicated grief (CG). Little is known about the effectiveness of physician care for these conditions. We examined whether, among older adults with CG and/or major depression, using physician support was associated with reductions in grief, depression, or anxiety severity. Outcomes were compared to group and religious support. We analyzed data from the Changing Lives of Older Couples (CLOC) Study, a prospective cohort study of married couples in the Detroit area. Spousal death was tracked over 5 years, and follow-up interviews conducted with widowed participants at 6 months (wave 1) and 18 months (wave 2) post loss. Analyses were limited to those with CG or depression with support-seeking data (weighted n = 89). Yes/no items asked whether participants had seen each provider for help with grief up until wave 1. A 19-item grief severity measure was developed by CLOC researchers. The 20-item Center for Epidemiologic Studies Depression scale measured depression severity. The Symptom Checklist 90–Revised assessed anxiety severity. Regressions indicated that seeking support from a family doctor at wave 1 was not associated with changes in anxiety, depression, or grief severity at wave 2 (P > .05). However, support group use was associated with reductions in grief severity (β = –8.46, P < .05), and religious leader support-seeking associated with reductions in depression severity (β = –10.12, P < .01). Findings imply that physician care for grief may not be effective, and support group referral may be helpful. Physicians may benefit from training in recognizing and appropriate referring for bereavement-related distress.