BackgroundHealth literacy and numeracy influence many health-related behaviors and outcomes. Health literacy and numeracy have been assessed objectively and subjectively, but interrelationships among the measures and the consistency of their association with health knowledge have not been examined.ObjectiveTo increase understanding of the structure and interrelations among objective and subjective health literacy and numeracy and how these constructs relate to knowledge of risk factors of two major diseases.DesignSecondary analysis of cross-sectional survey data, weighted to be representative of the general US population of non-institutionalized adults.ParticipantsParticipants (N?=?1005, 55.2% response rate) were recruited from GfK KnowledgePanel. The unweighted sample included 52% women, 26% racial/ethnic minorities, and 37% with no college experience.Main MeasuresObjective health literacy, subjective health literacy, objective numeracy, subjective numeracy. Objective and perceived knowledge of diabetes and colon cancer risk factors were also assessed.Key ResultsConfirmatory factor analyses indicated that a model with correlated (r?=?0.16–0.56) but separate factors for each of the four literacy/numeracy constructs best fit the data (RMSEA?=?0.055 (95% CI 0.049–0.061), CFI?=?0.94). Consistency between measures in classifying people as having adequate or limited health literacy or numeracy was 60.9–77.1%, depending on the combination of measures. All four literacy/numeracy constructs were independently associated with objective diabetes knowledge and objective colon cancer knowledge (all ps?

BackgroundDespite its rapid expansion, little is known about use of direct to consumer (DTC) telemedicine.ObjectiveTo characterize telemedicine patients and physicians and correlates of patient satisfactionDesignCross-sectional studyParticipantsPatients and physicians of a large nationwide DTC telemedicine serviceMain MeasuresPatient characteristics included demographics and whether or not they reported insurance information. Physician characteristics included specialty, board certification, and domestic versus international medical training. Encounter characteristics included time of day, wait time, length, coupon use for free or reduced-cost care, diagnostic outcome, prescription receipt, and patient/physician geographic concordance. Patients rated satisfaction with physicians on scales of 0 to 5 stars and reported where they would have sought care had they not used telemedicine. Logistic regression was used to assess factors associated with 5-star physician ratings.Key ResultsThe analysis included 28,222 encounters between 24,040 patients and 277 physicians completed between January 2013 and August 2016. Sixty-five percent of patients were under 40 years and 32% did not report insurance information. Family medicine was the most common physician specialty (47%) and 16% trained at a non-US medical school. Coupons were used in 24% of encounters. Respiratory infections were diagnosed in 35% of encounters and 69% resulted in a prescription. Had they not used telemedicine, 43% of patients reported they would have used urgent care/retail clinic, 29% would have gone to the doctor’s office, 15% would have done nothing, and 6% would have gone to the emergency department. Eighty-five percent of patients rated their physician 5 stars. High satisfaction was positively correlated with prescription receipt (OR 2.98; 95%CI 2.74–3.23) and coupon use (OR 1.47; 95%CI 1.33–1.62).ConclusionsPatients were largely satisfied with DTC telemedicine, yet satisfaction varied by coupon use and prescription receipt. The impact of telemedicine on primary care and emergency department use is likely to be small under present usage patterns.

BackgroundResearch on caregivers, defined as designated family members or support persons, in the medical intensive care unit (MICU) has primarily focused on their emotional needs and experiences, thus leaving a gap in knowledge related to their perceptions of team dynamics.ObjectiveTo examine caregivers’ perceptions of team interactions and competencies for interprofessional collaborative practice (IPCP) and overall satisfaction with the MICU team.MethodsThe Support Person Jefferson Teamwork Observation Guide (JTOG)™ was administered to a convenience sample of caregivers in the MICU at a large urban academic medical center between May 2016 and December 2016.ResultsOne hundred sixty-one JTOG surveys were completed. Caregivers agreed on the importance of healthcare professionals working together as a team to provide patient care (3.97 out of 4.0 on Likert response scale where 1 is “Not at all important” and 4 is ‘Extremely important”) and were satisfied with the MICU team (3.74 out of 4.0), positively evaluating the four core competencies for IPCP (3.55 for values/ethics, 3.58 for interprofessional communication, 3.61 for roles/responsibilities, and 3.64 for teams/teamwork) and the patient/family-centeredness sub-competency (3.58 out of 4.0). There was a strong positive correlation between caregivers’ Global JTOG scores and overall satisfaction with the MICU team (r?=?0.596, p?

BackgroundDespite years of intense focus, inpatient and observation readmission rates remain high and largely unchanged. Hospitals have little, robust evidence to guide the selection of interventions effective at reducing 30-day readmissions in real-world settings.ObjectiveTo evaluate if implementation of recent recommendations for hospital transition programs is effective at reducing 30-day readmissions in a population discharged to home and at high-risk for readmission.DesignA non-blinded, pragmatic randomized controlled trial (Clinicaltrials.gov: NCT02763202) conducted at two hospitals in Charlotte, North Carolina.PatientsA total of 1876 adult patients, under the care of a hospitalist, and at high risk for readmissions.InterventionRandom allocation to a Transition Services (TS) program (n =?935) that bridges inpatient, outpatient, and home settings, providing patients virtual and in-person access to a dedicated multidisciplinary team for 30-days, or usual care (n =?941).Main MeasureThirty-day, unplanned, inpatient, or observation readmission rate.Key ResultsThe 30-day readmission rate was 15.2% in the TS group and 16.3% in the usual care group (RR 0.93; 95% [CI, 0.76 to 1.15]; P?=?0.52). There were no significant differences in readmissions at 60 and 90 days or in 30-day Emergency Department visit rates. Patients, who were referred to TS and readmitted, had less Intensive Care Unit admissions 15.5% vs. 26.8% (RR 0.74; 95% [CI, 0.59 to 0.93]; P?=?0.02).ConclusionsAn intervention inclusive of contemporary recommendations does not reduce a high-risk population’s 30-day readmission rate. The high crossover to usual care (74.8%) reflects the challenge of non-participation that is ubiquitous in the real-world implementation of population health interventions.Trial RegistryClinicalTrials.gov; registration ID number: NCT02763202, URL: https://clinicaltrials.gov/ct2/show/NCT02763202

IntroductionNearly 50% of depressed primary care patients referred to mental health services do not initiate mental health treatment. The most promising interventions for increasing depression treatment initiation in primary care settings remain unclear.MethodsWe performed a systematic search of publicly available databases from inception through August 2017 to identify interventions designed to increase depression treatment initiation. Two authors independently selected, extracted data, and rated risk of bias from included studies. Eligible studies used a randomized or pre-post design and assessed depression treatment initiation (i.e., =?1 mental health visit or antidepressant fill) among adults, the majority of whom met criteria for depression. Interventions were classified as simple or complex and sub-classified into intervention strategies that were graded for strength of evidence.ResultsOf 9516 articles identified, we included 14 unique studies representing 16 (4 simple and 12 complex) interventions and 8 treatment initiation strategies. We found low to moderate strength of evidence for collaborative/integrated care (3 studies), treatment preference matching (2 studies), and case management (2 studies) strategies. However, there was insufficient evidence to determine the benefit of cultural tailoring (2 studies), motivation (alone, with reminders or with cultural tailoring (5 studies)), education (1 study), and shared decision-making strategies (1 study). Overall, we found moderate strength of evidence for complex interventions (8 of 12 complex interventions demonstrated statistically significant effects on treatment initiation).DiscussionCollaborative/integrated care, preference treatment matching, and case management strategies had the best evidence for improving depression treatment initiation, but none of the strategies had high strength of evidence. While primary care settings can consider using some of these strategies when referring depressed patients to treatment, our review highlights the need for further rigorous research in this area.

BackgroundAlzheimer’s disease, the most common cause of dementia, goes unrecognized in half of patients presenting to healthcare providers and is associated with increased acute care utilization. Routine cognitive screening of older adults in healthcare settings could improve rates of dementia diagnosis and patterns of healthcare utilization.ObjectiveTo evaluate the impact of screening positive for cognitive impairment on provider action in primary and specialty care practices and patient healthcare utilization.DesignIndividuals asymptomatic for cognitive impairment completed cognitive screening with the Mini-Cog (MC). Outcomes included MC screen-positive rates, provider follow-up actions, and healthcare utilization for all participants over a period of 36 months (18 months prior to and following MC screening). Data were extracted from the electronic medical record (EMR). Healthcare provider interventions and healthcare utilization for screen-positive and -negative groups, before and after screening, were compared.ParticipantsPrimary and specialty care patients (n?=?787) aged =?65 without history of cognitive impairment seen in HealthPartners, an integrated healthcare system in Minnesota and Western Wisconsin.Key ResultsIn primary care and neurology practices combined, over the entire 36-month study window, individuals screening positive showed 32% higher rates of ED visits (p?

BackgroundHealthcare Effectiveness Data and Information Set (HEDIS) quality measures have long been used to compare care across health plans and to study racial/ethnic and socioeconomic disparities among Medicare Advantage (MA) beneficiaries. However, possible gender differences in seniors’ quality of care have received less attention.ObjectiveTo test for the presence and nature of any gender differences in quality of care across MA Plans, overall and by domain; to identify those most at risk of poor care.DesignCross-sectional analysis of individual-level HEDIS measure scores from 23.8 million records using binomial mixed-effect models to estimate the effect of gender on performance. For each measure, we assess variation in gender gaps and their correlation with plan performance.ParticipantsBeneficiaries from 456 MA plans in 2011–2012 HEDIS data.Main MeasuresPerformance on 32 of 34 HEDIS measures which were available in both measurement years. The two excluded measures had mean performance scores below 10%.Key ResultsWomen experienced better quality of care than men for 22/32 measures, with most pertaining to screening or treatment. Men experienced better quality on nine measures, including four related to cardiovascular disease and three to potentially harmful drug-disease interactions. Plans varied substantially in the magnitude of gender gaps for 21/32 measures; in general, the gender gap in quality of care was least favorable to men in low-performing plans.ConclusionsWomen generally experienced better quality of care than men. However, women experienced poorer care for cardiovascular disease-related intermediate outcomes and potentially harmful drug-disease interactions. Quality improvement may be especially important for men in low-performing plans and for cardiovascular-related care and drug-disease interactions for women. Gender-stratified reporting could reveal gender gaps, identify plans for which care varies by gender, and motivate efforts to address faults and close the gaps in the delivery system.

BackgroundIntensive outpatient programs address the complex medical, social, and behavioral needs of individuals who account for disproportionate healthcare costs. Despite their promise, the impact of these programs is often diminished due to patient engagement challenges (i.e., low rates of patient participation and partnership in care).ObjectiveThe objective of this study was to identify intensive outpatient program features and strategies that increase high-need patient engagement in these programs.DesignQualitative study.ParticipantsTwenty program leaders and clinicians from 12 intensive outpatient programs in academic, county, Veterans Affairs, community, and private healthcare settings.ApproachA questionnaire and semi-structured interviews were used to identify common barriers to patient engagement in intensive outpatient programs and strategies employed by programs to address these challenges. We used content analysis methods to code patient engagement barriers and strategies and to identify program features that facilitate patient engagement.Key ResultsThe most common barriers to patient engagement in intensive outpatient programs included physical symptoms/limitations, mental illness, care fragmentation across providers and services, isolation/lack of social support, financial insecurity, and poor social and neighborhood conditions. Patient engagement strategies included concrete services to support communication and use of recommended services, activities to foster patient trust and relationships with program staff, and counseling to build insight and problem-solving capabilities. Program features that were identified as enhancing engagement efforts included: 1) multidisciplinary teams with diverse skills, knowledge, and personalities to facilitate relationship building; 2) adequate staffing and resources to handle the demands of high-need patients; and 3) a philosophy that permitted flexibility and patient-centeredness.ConclusionsPromising clinical, interpersonal, and population-based approaches to engaging high-need patients frequently deviate from standard practice and require creative and proactive staff with adequate time, resources, and flexibility to address patients’ needs on patients’ terms.

BackgroundDespite widespread implementation of mammographic breast density (MBD) notification laws, the impact of these laws on knowledge of MBD and knowledge of breast cancer risk is limited by the lack of tools to promote informed decision-making in practice.ObjectiveTo develop and evaluate whether brief, personalized informational videos following a normal mammogram in addition to a legislatively required letter about MBD result can improve knowledge of MBD and breast cancer risk compared to standard care (i.e., legislatively required letter about MBD included with the mammogram result).Design/ParticipantsProspective randomized controlled trial of English-speaking women, age 40–74 years, without prior history of breast cancer, receiving a screening mammogram with a normal or benign finding (intervention group n?=?235, control group n?=?224). Intervention: brief (3–5 min) video, personalized to a woman’s MBD result and breast cancer risk.Main MeasuresPrimary outcomes were a woman’s knowledge of her MBD and risk of breast cancer. Secondary outcomes included whether a woman reported that she discussed the results of her mammogram with her primary care provider (PCP).Key ResultsRelative to women in the control arm, women in the intervention arm had greater improvement in their knowledge of both their personal MBD (intervention pre/post 39.2%/ 77.5%; control pre/post 36.2%/ 37.5%; odds ratio (OR) 5.34 for change for intervention vs. control, 95% confidence interval (CI) 3.87–7.36; p?

A lack of access to critical drugs in the USA, either due to exorbitant prices or shortages, has become a troubling norm that threatens the quality and safety of healthcare. In 2017, there were shortages of 146 commonly used drugs including electrolytes, chemotherapy, cardiovascular, and antibiotic agents. For example, there currently exists a shortage in intravenous fluids and injectable opioids (both in chronic short supply for years) that has been respectively ascribed to disruptions in pharmaceutical manufacturing by Hurricane Maria and manufacturing delays. These explanations, however, mask a more fundamental and avoidable cause: a lack of healthy competition in the generic drug market which is likely contributing to price hikes and shortages. By understanding this underlying cause, we hope to illuminate a pathway from our current state of complacency, where drug price hikes and shortages are routine, to a future state of effective action, where patients have reliable access to vital drugs. This article outlines a roadmap to influence incentives, regulations, new drug development, and ultimately stakeholder (i.e., patients, providers, and drug makers) behavior to enhance competition, with the ultimate aim of improving the quality and safety of healthcare for our patients.

BackgroundRacial and ethnic discrimination in health care have been associated with suboptimal use of health care. However, limited research has examined how facets of health care utilization influence, and are influenced by, discrimination.ObjectiveThis study aimed to determine if type of insurance coverage and location of usual source of care used were associated with perceptions of racial or ethnic discrimination in health care. Additionally, this study examined if perceived racial or ethnic discrimination influenced delaying or forgoing prescriptions or medical care.DesignData from the 2015–2016 California Health Interview Survey were used. Logistic regression models estimated odds of perceiving racial or ethnic discrimination from insurance type and location of usual source of care. Logistic regression models estimated odds of delaying or forgoing medical care or prescriptions.ParticipantsResponses for 39,171 adults aged 18 and over were used.Main measuresKey health care utilization variables were as follows: current insurance coverage, location of usual source of care, delaying or forgoing medical care, and delaying or forgoing prescriptions. We examined if these effects differed by race. Ever experiencing racial or ethnic discrimination in the health care setting functioned as a dependent and independent variable in analyses.Key resultsWhen insurance type and location of care were included in the same model, only the former was associated with perceived discrimination. Specifically, those with Medicaid had 66% higher odds of perceiving discrimination, relative to those with employer-sponsored coverage (AOR?=?1.66; 95% CI 1.11, 2.47). Race did not moderate the impact of discrimination. Perceived discrimination was associated with higher odds of delaying or forgoing both prescriptions (AOR?=?1.97; 95% CI 1.26, 3.09) and medical care (AOR?=?1.84; 95% CI 1.31, 2.59).ConclusionsHealth care providers have an opportunity to improve the experiences of their patients, particularly those with publicly sponsored coverage.

BackgroundSuccessful implementation of new care models within a health system is likely dependent on contextual factors at the individual sites of care.ObjectiveTo identify practice setting components contributing to uptake of new team-based care models.DesignConvergent mixed-methods design.ParticipantsEmployees and patients of primary care practices implementing two team-based models in a large, integrated health system.Main measuresField observations of 9 practices and 75 interviews, provider and staff surveys to assess adaptive reserve and burnout, analysis of quality metrics, and patient panel comorbidity scores. The data were collected simultaneously, then merged, thematically analyzed, and interpreted by a multidisciplinary team.Key resultsBased on analysis of observations and interviews, the 9 practices were categorized into 3 groups—high, partial, and low uptake of new team-based models. Uptake was related to (1) practices’ responsiveness to change and (2) flexible workflow as related to team roles. Strength of local leadership and stable staffing mediated practices’ ability to achieve high performance in these two domains. Higher performance on several quality metrics was associated with high uptake practices compared to the lower uptake groups. Mean Adaptive Reserve Measure and Maslach Burnout Inventory scores did not differ significantly between higher and lower uptake practices.ConclusionUptake of new team-based care delivery models is related to practices’ ability to respond to change and to adapt team roles in workflow, influenced by both local leadership and stable staffing. Better performance on quality metrics may identify high uptake practices. Our findings can inform expectations for operational and policy leaders seeking to implement change in primary care practices.

BackgroundU.S. health systems, incentivized by financial penalties, are designing programs such as case management to reduce service utilization among high-cost, high-need populations. The major challenge is identifying patients for whom targeted programs are most effective for achieving desired outcomes.ObjectiveTo evaluate a health system’s outpatient complex case management (OPCM) for Medicare beneficiaries for patients overall and for high-risk patients using system-tailored taxonomy, and examine whether OPCM lowers service utilization and healthcare costs.DesignRetrospective case-control study using Medicare data collected between 2012 and 2016 for Ochsner Health System.ParticipantsSuper-utilizers defined as Medicare patients with at least two hospital/ED encounters within 180 days of the index date including the index event.InterventionOutpatient complex case management.Main MeasuresPropensity score-adjusted multivariable logistic regression analysis was conducted for primary outcomes (90-day hospital readmission; 90-day ED re-visit). A difference-in-difference analysis was conducted to examine changes in per membership per month (PMPM) costs based on OPCM exposure.Key ResultsAmong 18,882 patients, 1197 (6.3%) were identified as “high-risk” and 470 (2.5%) were OPCM participants with median enrollment of 49 days. High-risk OPCM cases compared to high-risk controls had lower odds of 90-day hospital readmissions (0.81 [0.40–1.61], non-significant) and lower odds of 90-day ED re-visits (0.50 [0.32–0.79]). Non-high-risk OPCM cases compared to non-high-risk controls had lower odds of 90-day hospital readmissions (0.20 [0.11–0.36]) and 90-day ED re-visits (0.66 [0.47–0.94]). Among OPCM cases, high-risk patients compared to non-high-risk patients had greater odds of 90-day hospital readmissions (4.44 [1.87–10.54]); however, there was no difference in 90-day ED re-visits (0.99 [0.58–1.68]). Overall, OPCM cases had lower total cost of care compared to controls (PMPM mean [SD]: -?$1037.71 [188.18]).ConclusionsUse of risk stratification taxonomy for super-utilizers can identify patients most likely to benefit from case management. Future studies must further examine which OPCM components drive improvements in select outcome for specific populations.

BackgroundMedical students in the USA have negative perceptions of primary care careers, which are exacerbated by the hidden curriculum and medical school culture. Longitudinal integrated clerkships (LICs) have shown promise in ameliorating this situation by promoting student/preceptor continuity relationships and helping students maintain empathy.AimThe aim of this study is to describe the Student Continuity of Practice Experience (SCOPE) program and demonstrate program outcomes using evaluation data from residency match results, course evaluations, and student grades.SettingUniversity of Texas Medical Branch, an academic health center in Galveston, Texas.ParticipantsUndergraduate medical students.Program DescriptionLearners participate in a longitudinal curriculum designed to enhance their skills as primary care physicians. They regularly attend continuity clinic, establishing a panel of patients by their third year. Students receive frequent feedback from a faculty mentor on assignments and clinical performance.Program EvaluationSCOPE students have high primary care residency match rates and experience patient continuity rates comparable to an intern. Their interest in primary care increases between years one and three, a departure from typical medical student trends.DiscussionSCOPE appears to promote and maintain primary care career interest in participants and has transferability to other institutions.

BackgroundOral anticoagulants reduce the risk of stroke in patients with atrial fibrillation. However, many patients with atrial fibrillation at elevated stroke risk are not treated with oral anticoagulants.ObjectiveTo test whether electronic notifications sent to primary care physicians increase the proportion of ambulatory patients prescribed oral anticoagulants.DesignRandomized controlled trial conducted from February to May 2017 within 18 practices in an academic primary care network.ParticipantsPrimary care physicians (n?=?175) and their patients with atrial fibrillation, at elevated stroke risk, and not prescribed oral anticoagulants.InterventionPatients of each physician were randomized to the notification or usual care arm. Physicians received baseline email notifications and up to three reminders with patient information, educational material and primary care guidelines for anticoagulation management, and surveys in the notification arm.Main MeasuresThe primary outcome was the proportion of patients prescribed oral anticoagulants at 3 months in the notification (n?=?972) vs. usual care (n?=?1364) arms, compared using logistic regression with clustering by physician. Secondary measures included survey-based physician assessment of reasons why patients were not prescribed oral anticoagulants and how primary care physicians might be influenced by the notification.Key ResultsOver 3 months, a small proportion of patients were newly prescribed oral anticoagulants with no significant difference in the notification (3.9%, 95% CI 2.8–5.3%) and usual care (3.2%, 95% CI 2.4–4.2%) arms (p?=?0.37). The most common, non-exclusive reasons why patients were not on oral anticoagulants included atrial fibrillation was transient (30%) or paroxysmal (12%), patient/family declined (22%), high bleeding risk (20%), fall risk (19%), and frailty (10%). For 95% of patients, physicians stated they would not change their management after reviewing the alert.ConclusionsElectronic physician notification did not increase anticoagulation in patients with atrial fibrillation at elevated stroke risk. Primary care physicians did not prescribe anticoagulants because they perceived the bleeding risk was too high or stroke risk was too low.Trial RegistrationClinicalTrials.gov identifier NCT02950285