BackgroundMichigan expanded Medicaid under the Affordable Care Act (Healthy Michigan Plan [HMP]) to improve the health of low-income residents and the state’s economy.ObjectiveTo understand HMP’s impact on enrollees’ health, ability to work, and ability to seek employmentDesignMixed methods study, including 67 qualitative interviews and 4090 computer-assisted telephone surveys (response rate 53.7%)ParticipantsNon-elderly adult HMP enrolleesMain MeasuresChanges in health status, ability to work, and ability to seek employmentKey ResultsHalf (47.8%) of respondents reported better physical health, 38.2% better mental health, and 39.5% better dental health since HMP enrollment. Among employed respondents, 69.4% reported HMP helped them do a better job at work. Among out-of-work respondents, 54.5% agreed HMP made them better able to look for a job. Among respondents who changed jobs, 36.9% agreed HMP helped them get a better job. In adjusted analyses, improved health was associated with the ability to do a better job at work (aOR 4.08, 95% CI 3.11–5.35, p?

BackgroundIndividuals with limited English proficiency (LEP) have worse healthcare access and report lower quality of care compared to individuals who are proficient in English. Policy efforts to improve patient-provider communication for LEP individuals have been going on for decades but linguistic disparities persist.ObjectiveTo describe trends in patient-provider communication by limited English proficiency (LEP) from 2006 to 2015.DesignWe estimated interrupted time series models for three measures of patient-provider communication, testing for differences in both means (intercepts) and trends (slopes) before and after 2010 and differences in differences by English proficiency.ParticipantsA nationally representative sample of the US non-institutionalized population with at least one office-based medical visit from the 2006–2015 Medical Expenditure Panel Survey (N?=?27,001).Main MeasuresPatient-provider communication is measured with three variables indicating whether individuals reported that their providers always explained things in a way that was easy to understand, showed respect for what they had to say, and listened carefully.Key ResultsAlthough patient-provider communication improved for all groups over the study period, before 2010, it was getting worse among LEP individuals and disparities in patient-provider communication were widening. After 2010, patient-provider communication improved for LEP individuals and language disparities by English proficiency either narrowed or remained the same. For example, between 2006 and 2010, the percent of LEP individuals reporting that their provider explained things clearly declined by, on average, 1.4 percentage points per year (p value?=?0.102); after 2010, it increased by 3.0 percentage points per year (p value?=?0.003).ConclusionsOur study sheds light on trends in patient-provider communication before and after 2010, a year that marked substantial efforts to reform the US healthcare system. Though patient-provider communication among LEP individuals has improved since 2010, linguistic disparities persist and constitute a formidable challenge to achieving healthcare equity, a long-standing US policy goal.

BackgroundAs of 2015, the Centers for Medicare & Medicaid Services (CMS) pays for chronic care management (CCM) services for Medicare beneficiaries with two or more chronic conditions. CMS requires eligible providers to first obtain patients’ verbal (and, prior to 2017, written) consent, to ensure that patients who participate in CCM services understand their rights and agree to any applicable cost sharing. CCM providers must also enhance patients’ access to continuous and coordinated care, including ongoing care management.ObjectiveTo understand patients’ perceptions of the consent process, their reasons for choosing to participate, and their experiences receiving CCM services.DesignQualitative study using semi-structured interviews with Medicare beneficiaries who had two or more CCM claims submitted by an eligible provider. Beneficiaries were selected from a sampling frame of Medicare claims submitted between January and September 2015.Key ResultsMost patients reported no concerns about being asked to participate in CCM. The majority of patients had secondary insurance (or Medicaid) that covered any coinsurance for CCM and therefore could not say with certainty whether they would participate if they had to pay for CCM services out-of-pocket. Reasons for participating included having insurance that covered the copay and peace of mind about having access to the CCM team. Patients reported multiple benefits of participating in CCM services, including better access to their primary care team, improved continuity of care, and improved care coordination. Most patients reported no downside to participating in CCM services, although some felt they were relatively healthy and questioned whether they needed CCM services.ConclusionsThese findings on patients’ experiences participating in CCM services during the first 9 months of the policy’s implementation can help providers and policymakers understand their perceived benefits and unintended consequences. Our findings also have implications for providers when approaching patients about CCM services.

BackgroundHospital readmission is considered an adverse health outcome in older people, adding additional pressure on clinical resources within health care services. Despite numerous studies on risk factors for readmissions, studies find different strengths of respective determinants and there is a need to explore and identify patterns of risk factors in larger cohorts.ObjectiveExploring and identifying patterns of risk factors for acute, all-cause 30-day readmission in a Danish cohort of patients aged 65+.DesignRegister-based cohort study using individual-level linkable information on demographics, social determinants, clinical conditions, health care utilization, and provider determinants obtained from primary and secondary health care.ParticipantsHistoric cohort of 1,267,752 admissions in 479,854 patients, aged 65+, discharged from Danish public hospitals from January 2007 to September 2010.Main MeasuresWe included patient-level variables and admission-level variables. Outcome was acute, all-cause 30-day readmission. Data was analyzed by univariable and multivariable logistic regression. Strength of associations was analyzed using Wald test statistics. Receiver operating characteristic (ROC) analysis was used for quantification of predictive ability. For validation, we used split-sample design.Key ResultsAcute admission and number of days since previous hospital discharge were factors strongly associated with readmission. Patients at risk of future readmission suffered from comorbidity, consumed more drugs, and were frequent users of in- and outpatient health care services in the year prior to the index admission. Factors related to index admission were only weakly associated with readmission. The predictive ability was 0.709 (0.707–0.711) for acute readmission.ConclusionsIn a general population of older people, we found that pre-hospital factors rather than hospital factors account for increased risk of readmission and are dominant contributors to predict acute all-cause 30-day readmission. Therefore, risk for excess readmission should be shared across sectors and focus the care trajectory over time rather than distinct care episodes.

BackgroundSelf-management of health is important for improving health outcomes among primary care patients with chronic disease. Anxiety and depressive disorders are common and interfere with self-regulation, which is required for disease self-management. An insurance-reimbursable mindfulness intervention integrated within primary care may be effective for enhancing chronic disease self-management behaviors among primary care patients with anxiety, depression, trauma, and stress-related and adjustment disorders compared with the increasingly standard practice of referring patients to outside mindfulness resources.ObjectiveMindfulness Training for Primary Care (MTPC) is an 8-week, referral-based, insurance-reimbursable program integrated into safety-net health system patient-centered medical homes. We hypothesized that MTPC would be more effective for catalyzing chronic disease self-management action plan initiation within 2 weeks, versus a low-dose comparator (LDC) consisting of a 60-min mindfulness introduction, referral to community and digital resources, and addition to a 6-month waitlist for MTPC.ParticipantsPrimary care providers (PCPs) and mental health clinicians referred 465 patients over 12 months. All participants had a DSM-V diagnosis.Design and InterventionsParticipants (N?=?136) were randomized in a 2:1 allocation to MTPC (n?=?92) or LDC (n?=?44) in a randomized controlled comparative effectiveness trial. MTPC incorporates mindfulness, self-compassion, and mindfulness-oriented behavior change skills and is delivered as insurance-reimbursable visits within primary care. Participants took part in a chronic disease self-management action planning protocol at week 7.Main MeasuresLevel of self-reported action plan initiation on the action plan initiation survey by week 9.Key ResultsParticipants randomized to MTPC, relative to LDC, had significantly higher adjusted odds of self-management action plan initiation in an intention-to-treat analysis (OR?=?2.28; 95% CI?=?1.02 to 5.06, p?=?0.025).ConclusionsAn 8-week dose of mindfulness training is more effective than a low-dose mindfulness comparator in facilitating chronic disease self-management behavior change among primary care patients.

BackgroundThere is a growing focus on improving the quality and value of health care delivery for high-cost patients. Compared to fee-for-service Medicare, less is known about the clinical composition of high-cost Medicare Advantage populations.ObjectiveTo describe a high-cost Medicare Advantage population and identify clinically and operationally significant subgroups of patients.DesignWe used a density-based clustering algorithm to group high-cost patients (top 10% of spending) according to 161 distinct demographic, clinical, and claims-based variables. We then examined rates of utilization, spending, and mortality among subgroups.ParticipantsSixty-one thousand five hundred forty-six Medicare Advantage beneficiaries.Main MeasuresSpending, utilization, and mortality.Key ResultsHigh-cost patients (n?=?6154) accounted for 55% of total spending. High-cost patients were more likely to be younger, male, and have higher rates of comorbid illnesses. We identified ten subgroups of high-cost patients: acute exacerbations of chronic disease (mixed); end-stage renal disease (ESRD); recurrent gastrointestinal bleed (GIB); orthopedic trauma (trauma); vascular disease (vascular); surgical infections and other complications (complications); cirrhosis with hepatitis C (liver); ESRD with increased medical and behavioral comorbidity (ESRD+); cancer with high-cost imaging and radiation therapy (oncology); and neurologic disorders (neurologic). The average number of inpatient days ranged from 3.25 (oncology) to 26.09 (trauma). Preventable spending (as a percentage of total spending) ranged from 0.8% (oncology) to 9.5% (complications) and the percentage of spending attributable to prescription medications ranged from 7.9% (trauma and oncology) to 77.0% (liver). The percentage of patients who were persistently high-cost ranged from 11.8% (trauma) to 100.0% (ESRD+). One-year mortality ranged from 0.0% (liver) to 25.8% (ESRD+).ConclusionsWe identified clinically distinct subgroups of patients within a heterogeneous high-cost Medicare Advantage population using cluster analysis. These subgroups, defined by condition-specific profiles and illness trajectories, had markedly different patterns of utilization, spending, and mortality, holding important implications for clinical strategy.

BackgroundVitamin K antagonist (VKA) anticoagulant use is suspected to increase the risk of bone fracture through inhibition of vitamin K–dependent cofactors of bone formation, an effect not seen with non-vitamin K antagonist oral anticoagulants (NOACs). The purpose of our systematic review and meta-analysis is to investigate the association between VKA use and fracture.MethodsWe searched PubMed, EMBASE, and Cochrane Library for studies analyzing fracture in adults using VKAs versus controls. Two authors independently reviewed articles. We assessed for risk of bias using the Newcastle-Ottawa Quality Assessment Scale and the Cochrane Risk of Bias Tool and calculated pooled effects using random effects models.ResultsWe included 23 articles (22 observational studies and 1 randomized controlled trial), studying 1,121,582 subjects. There was no increased odds of fracture in VKA users versus controls (pooled OR 1.01, 95% CI 0.89, 1.14) or in VKA users versus NOAC users (pooled OR 0.95, 95% CI 0.78, 1.15). Subjects using a VKA for 1 year or longer did not have increased odds of fracture (pooled OR 1.07, 95% CI 0.90, 1.27). Compared to controls, there was increased odds of fracture in women (pooled OR 1.11, 95% CI 1.02, 1.21) and older VKA users (=?65) (pooled OR 1.07, 95% CI 1.01, 1.14).DiscussionWe found no increase in odds of fracture in VKA users versus controls or NOAC users. There was a small increase in odds of fracture among female and elderly VKA users, which may not be clinically important when accounting for other considerations in choosing an anticoagulant. Our findings suggest that, when anticoagulation is necessary, fracture risk should not be a major consideration in choice of an agent. Future studies directly comparing VKA to NOAC users and studies with longer duration of VKA use may be needed.

BackgroundImplementation of new practice guidelines for statin use was very poor.ObjectiveTo test a multi-component quality improvement intervention to encourage use of new guidelines for statin use.DesignCluster-randomized, usual-care controlled trial.ParticipantsThe study population was primary care visits for patients who were recommended statins by the 2013 guidelines, but were not receiving them. We excluded patients who were over 75 years old, or had an ICD9 or ICD10 code for end-stage renal disease, muscle pain, pregnancy, or in vitro fertilization in the 2 years prior to the study visit.InterventionsA novel quality improvement intervention consisting of a personalized decision support tool, an educational program, a performance measure, and an audit and feedback system. Randomization was at the level of the primary care team.Main MeasuresOur primary outcome was prescription of a medium- or high-strength statin. We studied how receiving the intervention changed care during the quality improvement intervention compared to before it and if that change continued after the intervention.Key ResultsAmong 3787 visits to 43 primary care providers, being in the intervention arm tripled the odds of patients being prescribed an appropriate statin (OR 3.0, 95% CI 1.8–4.9), though the effect resolved after the personalized decision support ended (OR 1.7, 95% CI 0.99–2.77).ConclusionsA simple, personalized quality improvement intervention is promising for enabling the adoption of new guidelines.ClinicalTrials.gov IdentifierNCT02820870

BackgroundHigh-cost patients are a frequent focus of improvement projects based on primary care and other settings. Efforts to characterize high-cost, high-need patients are needed to inform care planning, but such efforts often rely on a priori assumptions, masking underlying complexities of a heterogenous population.ObjectiveTo define recognizable subgroups of patients among high-cost adults based on clinical conditions, and describe their survival and future spending.DesignRetrospective observational cohort study.ParticipantsWithin a large integrated delivery system with 2.7 million adult members, we selected the top 1% of continuously enrolled adults with respect to total healthcare expenditures during 2010.Main MeasuresWe used latent class analysis to identify clusters of alike patients based on 53 hierarchical condition categories. Prognosis as measured by healthcare spending and survival was assessed through 2014 for the resulting classes of patients.ResultsAmong 21,183 high-cost adults, seven clinically distinctive subgroups of patients emerged. Classes included end-stage renal disease (12% of high-cost population), cardiopulmonary conditions (17%), diabetes with multiple comorbidities (8%), acute illness superimposed on chronic conditions (11%), conditions requiring highly specialized care (14%), neurologic and catastrophic conditions (5%), and patients with few comorbidities (the largest class, 33%). Over 4 years of follow-up, 6566 (31%) patients died, and survival in the classes ranged from 43 to 88%. Spending regressed to the mean in all classes except the ESRD and diabetes with multiple comorbidities groups.ConclusionsData-driven characterization of high-cost adults yielded clinically intuitive classes that were associated with survival and reflected markedly different healthcare needs. Relatively few high-cost patients remain persistently high cost over 4 years. Our results suggest that high-cost patients, while not a monolithic group, can be segmented into few subgroups. These subgroups may be the focus of future work to understand appropriateness of care and design interventions accordingly.

Astute observation is a fundamental component of the art of medicine. Yet most schools and residencies offer little formal teaching of this skill, with some outsourcing the entire subject matter to art museums and instructors. Curiously, it was nineteenth century medicine that may have provided the conceptual framework for what is now known as Visual Thinking Strategy, the technique used by many art-based programs in order to teach observation. We suggest that the time is ripe for medicine to regain ownership of the teaching of this skill, not only because it may enhance clinical care but also because only the eyes of a skilled physician can best interpret crucial medical details. To this end, we shall revisit both the method of Zadig, which William Osler practiced and taught to his students, and its application to the observation of art first pioneered by the Italian physician Giovanni Morelli. As an example of this skill, we shall use focused observation to decode a fifteenth century portrait that hangs at the Philadelphia Museum of Art, thus turning a seemingly non-descript Renaissance painting into a treasure trove of personal, social, and medical information.

Iron overload disorders lead to excess iron deposition in the body, which can occur as a result of genetic or secondary causes. Genetic iron overload, referred to as hereditary hemochromatosis, may present as a common autosomal recessive mutation or as one of several uncommon mutations. Secondary iron overload may result from frequent blood transfusions, exogenous iron intake, or certain hematological diseases such as dyserythropoietic syndrome or chronic hemolytic anemia. Iron overload may be asymptomatic, or may present with significant diseases of the liver, heart, endocrine glands, joints, or other organs. If treated appropriately prior to end-organ damage, life expectancy has been shown to be similar compared to matched populations. Alongside clinical assessment, diagnostic studies involve blood tests, imaging, and in some cases liver biopsy. The mainstay of therapy is periodic phlebotomy, although oral chelation is an option for selected patients.

BackgroundOveruse of health care resources has been identified as the leading contributor to waste in the US health care system.ObjectiveTo explore health care system factors associated with regional variation in systemic overuse of health care resources as measured by the Johns Hopkins Overuse Index (JHOI) which aggregates systemic overuse of 20 health care services.DesignUsing Medicare fee-for-service claims data from beneficiaries age 65 or over in 2008, we calculated the JHOI for the 306 hospital referral regions in the United States. We used ordinary least squares regression and multilevel models to estimate the association of JHOI scores and characteristics of regional health care delivery systems listed in the Area Health Resource File and Dartmouth Atlas.Key ResultsRegions with a higher density of primary care physicians had lower JHOI scores, indicating less systemic overuse (P?

IntroductionRates of sexually transmitted infection (STI) are rising in the USA, yet STI risk remains under-addressed by providers, even in HIV care, and with high-risk patients. We interviewed primary care patients living with and without HIV regarding circumstances surrounding sexual risk behavior to identify opportunities for providers to address and reduce STI risk.MethodsWe conducted semi-structured 1:1 interviews with patients living with and without HIV reporting =?1 sex partner and varying STI exposure risk in the past 12 months from four geographically diverse US HIV and primary care clinics. We audio-recorded, transcribed, and coded interviews by circumstance type, using double-coding to ensure inter-coder reliability. We used Fisher’s exact and T tests to determine associations with demographic/risk factors.ResultsPatients (n?=?91) identified a mean of 3 of 11 circumstances. These included substance use (54%), desire for physical/emotional intimacy (48%), lack of HIV/STI status disclosure (44%), psychological drivers (i.e., coping, depression; 38%), personal dislike of condoms (22%), partner condom dislike/refusal (19%), receiving payment for sex (13%), and condom unavailability (9%). Higher proportions of those who were high STI-exposure risk patients, defined as those with =?2 sex partners in the past 3 months reporting never or sometimes using condoms, reported disliking condoms (p?=?.006); higher proportions of the high-risk and moderate-risk (=?2 partners and condom use “most of the time”) groups reported substance use as a circumstance (p?=?.04).ConclusionCircumstances surrounding perceived STI exposure risk were diverse, often overlapping, and dependent on internal, environmental, and partner-related factors and inadequate communication. Meaningful care-based interventions regarding HIV/STI transmission behavior must address the diversity and interplay of these factors.

BackgroundAccumulating evidence suggests that clinician racial/gender decision-making biases in some instances contribute to health disparities. Previous work has produced evidence of such biases in medical students.ObjectiveTo identify contextual attributes in medical schools associated on average with low levels of racial/gender clinical decision-making biases.DesignA mixed-method design using comparison case studies of 15 medical schools selected based on results of a previous survey of student decision-making bias: 7 schools whose students collectively had, and 8 schools whose students had not shown evidence of such biases.ParticipantsPurposively sampled faculty, staff, underrepresented minority medical students, and clinical-level medical students at each school.Main MeasuresQuantitative descriptive data and qualitative interview and focus group data assessing 32 school attributes theorized in the literature to be associated with formation of decision-making and biases. We used a mixed-method analytic design with standard qualitative analysis and fuzzy set qualitative comparative analysis.Key ResultsAcross the 15 schools, a total of 104 faculty, administrators and staff and 21 students participated in individual interviews, and 196 students participated in 29 focus groups. While no single attribute or group of attributes distinguished the two clusters of schools, analysis showed some contextual attributes were seen more commonly in schools whose students had not demonstrated biases: longitudinal reflective small group sessions; non-accusatory approach to training in diversity; longitudinal, integrated diversity curriculum; admissions priorities and action steps toward a diverse student body; and school service orientation to the community.ConclusionsWe identified several potentially modifiable elements of the training environment that are more common in schools whose students do not show evidence of racial and gender biases.