Medical Care (MED CARE)

Publications in this journal

• Article: Consumer governance and the provision of enabling services at community health centers

  Brad Wright
  Medical Care 08/2012; 50(8):668-675.
• Article: Physician Patient-sharing Networks and the Cost and Intensity of Care in US Hospitals

  Michael L. Barnett, Nicholas A. Christakis, James O’Malley, Jukka-Pekka Onnela, Nancy L. Keating, Bruce E. Landon
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  ABSTRACT: Background: There is substantial variation in the cost and intensity of care delivered by US hospitals. We assessed how the structure of patient-sharing networks of physicians affiliated with hospitals might contribute to this variation. Methods: We constructed hospital-based professional networks based on patient-sharing ties among 61,461 physicians affiliated with 528 hospitals in 51 hospital referral regions in the US using Medicare data on clinical encounters during 2006. We estimated linear regression models to assess the relationship between measures of hospital network structure and hospital measures of spending and care intensity in the last 2 years of life. Results: The typical physician in an average-sized urban hospital was connected to 187 other doctors for every 100 Medicare patients shared with other doctors. For the average-sized urban hospital an increase of 1 standard deviation (SD) in the median number of connections per physician was associated with a 17.8% increase in total spending, in addition to 17.4% more hospital days, and 23.8% more physician visits (all P<0.001). In addition, higher “centrality” of primary care providers within these hospital networks was associated with 14.7% fewer medical specialist visits (P<0.001) and lower spending on imaging and tests (−9.2% and −12.9% for 1 SD increase in centrality, P<0.001). Conclusions: Hospital-based physician network structure has a significant relationship with an institution’s care patterns for their patients. Hospitals with doctors who have higher numbers of connections have higher costs and more intensive care, and hospitals with primary care-centered networks have lower costs and care intensity.
  Medical Care 01/2012; 50(2):152–160.
• Article: The Development, Evolution, and Modifications of ICD-10: Challenges to the International Comparability of Morbidity Data

  Nathalie Jetté, Hude Quan, Brenda Hemmelgarn, Saskia Drosler, Christina Maass, Lori Moskal, Wansa Paoin, Vijaya Sundararajan, Song Gao, Robert Jakob, Bedihran Üstün, William A. Ghali, for the IMECCHI Investigators
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  ABSTRACT: Background: The United States is about to make a major nationwide transition from ICD-9-CM coding of hospital discharges to ICD-10-CM, a country-specific modification of the World Health Organization's ICD-10. As this transition occurs, the WHO is already in the midst of developing ICD-11. Given this context, we undertook this review to discuss: (1) the history of the International Classification of Diseases (a core information “building block” for health systems everywhere) from its introduction to the current era of ICD-11 development; (2) differences across country-specific ICD-10 clinical modifications and the challenges that these differences pose to the international comparability of morbidity data; (3) potential strategic approaches to achieving better international ICD-11 comparability. Literature Review and Discussion: A literature review and stakeholder consultation was carried out. The various ICD-10 clinical modifications (ICD-10-AM [Australia], ICD-10-CA [Canada], ICD-10-GM [Germany], ICD-10-TM [Thailand], ICD-10-CM [United States]) were compared. These ICD-10 modifications differ in their number of codes, chapters, and subcategories. Specific conditions are present in some but not all of the modifications. ICD-11, with a similar structure to ICD-10, will function in an electronic health records environment and also provide disease descriptive characteristics (eg, causal properties, functional impact, and treatment). Conclusion: The threat to the comparability of international clinical morbidity is growing with the development of many country-specific ICD-10 versions. One solution to this threat is to develop a meta-database including all country-specific modifications to ensure more efficient use of people and resources, decrease omissions and errors but most importantly provide a platform for future ICD updates.
  Medical Care 11/2010; 48(12):1105-1110.
• Article: Response to Letter to the Editor Regarding, Quality Variation and Its Impact on Costs and Satisfaction: Evidence From the QIDS Study

  John W. Peabody, Riti Shimkhada, Jhiedon Florentino, Orville Solon, Stella Quimbo
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  ABSTRACT: An abstract is unavailable. This article is available as HTML full text and PDF.
  Medical Care 05/2010; 48(6):570-571.
• Article: Differences in the Diagnosis and Management of Type 2 Diabetes in 3 Countries (US, UK, and Germany): Results From a Factorial Experiment

  Olaf von dem Knesebeck, Eric Gerstenberger, Carol Link, Lisa Marceau, Martin Roland, Stephen Campbell, Johannes Siegrist, Werner de Cruppé, John McKinlay
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  ABSTRACT: Objectives: This article examines the diagnosis and management of type-2 diabetes when exactly the same “patient” is encountered by 192 randomly selected primary care doctors in 3 different health care systems—the United States, United Kingdom, and Germany. Methods: We conducted a factorial experiment, employing 2 clinically authentic filmed scenarios, to examine country differences in the treatment of diabetes, while controlling the effects of selected characteristics of patients and physicians. The patient in the first scenario presented with (undiagnosed) signs and symptoms strongly suggestive of diabetes, while the second scenario presented an already diagnosed patient with an emerging foot neuropathy. Physicians were asked how they would diagnose and manage the patients after watching the video vignettes using a questionnaire with standardized and open-ended questions. Results: Regarding the first (undiagnosed) case, US doctors would ask significantly more questions than physicians from the UK and Germany (P < 0.001). German physicians would give less advice but would want to see the patient again much sooner (P < 0.001). Regarding the diagnosed case with an emerging foot neuropathy, US physicians would be most active in terms of questioning, testing, prescribing, and advice giving. Again, physicians from Germany would be less active in terms of therapeutic strategies but they would like to see the patient again sooner (P = 0.005). Conclusions: Although physicians in the 3 countries encountered exactly the same patient, differences in diagnostic and management decisions were evident. The experimental design provides unconfounded estimates of health system differences while simultaneously controlling for the effects of selected patient attributes and physician characteristics.
  Medical Care 03/2010; 48(4):321-326.
• Article: Measuring and Comparing Safety Climate in Intensive Care Units

  Daniel J. France, Robert A. Jr Greevy, Xulei Liu, Hayley Burgess, Robert S. Dittus, Matthew B. Weinger, Theodore Speroff
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  ABSTRACT: Background: Learning about the factors that influence safety climate and improving the methods for assessing relative performance among hospital or units would improve decision-making for clinical improvement. Objectives: To measure safety climate in intensive care units (ICU) owned by a large for-profit integrated health delivery systems; identify specific provider, ICU, and hospital factors that influence safety climate; and improve the reporting of safety climate data for comparison and benchmarking. Research Design: We administered the Safety Attitudes Questionnaire (SAQ) to clinicians, staff, and administrators in 110 ICUs from 61 hospitals. Subjects: A total of 1502 surveys (43% response) from physicians, nurses, respiratory therapists, pharmacists, mangers, and other ancillary providers. Measures: The survey measured safety climate across 6 domains: teamwork climate; safety climate; perceptions of management; job satisfaction; working conditions; and stress recognition. Percentage of positive scores, mean scores, unadjusted random effects, and covariate-adjusted random effect were used to rank ICU performance. Results: The cohort was characterized by a positive safety climate. Respondents scored perceptions of management and working conditions significantly lower than the other domains of safety climate. Respondent job type was significantly associated with safety climate and domain scores. There was modest agreement between ranking methodologies using raw scores and random effects. Conclusions: The relative proportion of job type must be considered before comparing safety climate results across organizational units. Ranking methodologies based on raw scores and random effects are viable for feedback reports. The use of covariate-adjusted random effects is recommended for hospital decision-making.
  Medical Care 02/2010; 48(3):279-284.
• Article: Coordinating Cancer Care: Patient and Practice Management Processes Among Surgeons Who Treat Breast Cancer

  Steven J. Katz, Sarah T. Hawley, Monica Morrow, Jennifer J. Griggs, Reshma Jagsi, Ann S. Hamilton, John J. Graff, Christopher R. Friese, Timothy P. Hofer
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  ABSTRACT: Objectives: The Institute of Medicine has called for more coordinated cancer care models that correspond to initiatives led by cancer providers and professional organizations. These initiatives parallel those underway to integrate the management of patients with chronic conditions. Methods: We developed 5 breast cancer patient and practice management process measures based on the Chronic Care Model. We then performed a survey to evaluate patterns and correlates of these measures among attending surgeons of a population-based sample of patients diagnosed with breast cancer between June 2005 and February 2007 in Los Angeles and Detroit (N = 312; response rate, 75.9%). Results: Surgeon practice specialization varied markedly with about half of the surgeons devoting 15% or less of their total practice to breast cancer, whereas 16.2% of surgeons devoted 50% or more. There was also large variation in the extent of the use of patient and practice management processes with most surgeons reporting low use. Patient and practice management process measures were positively associated with greater levels of surgeon specialization and the presence of a teaching program. Cancer program status was weakly associated with patient and practice management processes. Conclusion: Low uptake of patient and practice management processes among surgeons who treat breast cancer patients may indicate that surgeons are not convinced that these processes matter, or that there are logistical and cost barriers to implementation. More research is needed to understand how large variations in patient and practice management processes might affect the quality of care for patients with breast cancer.
  Medical Care 12/2009; 48(1):45-51.
• Article: Prolonged Hospital Stay and the Resident Duty Hour Rules of 2003

  Jeffrey H. Silber, Paul R. Rosenbaum, Amy K. Rosen, Patrick S. Romano, Kamal M. F. Itani, Liyi Cen, Lanyu Mi, Michael J. Halenar, Orit Even-Shoshan, Kevin G. Volpp
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  ABSTRACT: Background: Resident duty hour reforms of 2003 had the potential to create a major impact on the delivery of inpatient care. Objective: We examine whether the reforms influenced the probability of a patient experiencing a prolonged hospital length of stay (PLOS), a measure reflecting either inefficiency of care or the development of complications that may slow the rate of discharge. Research Design: Conditional logistic models to compare PLOS in more versus less teaching-intensive hospitals before and after the reform, adjusting for patient comorbidities, common time trends, and hospital site. Subjects: Medicare (N = 6,059,015) and Veterans Affairs (VA) (N = 210,276) patients admitted for medical conditions (acute myocardial infarction, heart failure, stroke, or gastrointestinal bleeding) or surgical procedures (general, orthopedic, and vascular) from July 2000 to June 2005. Measures: Prolonged length of stay. Results: Modeling all medical conditions together, the odds of prolonged stay in the first year post reform at more versus less teaching intensive hospitals was 1.01 (95% CI: 0.97-1.05) for Medicare and 1.07 (0.94-1.20) for the VA. Results were similarly negative in the second year post reform. For combined surgery the post year 1 odds ratios were 1.04 (0.98-1.09) and 0.94 (0.78-1.14) for Medicare and the VA respectively, and similarly unchanged in post year 2. Isolated increases in the probability of prolonged stay did occur for some vascular surgery procedures. Conclusions: Hospitals generally found ways to cope with duty hour reform without increasing the prevalence of prolonged hospital stays, a marker of either inefficient care or complications.
  Medical Care 11/2009; 47(12):1191-1200.
• Article: Medicare Managed Care Enrollment by Disability-Eligible and Age-Eligible Veterans

  Matthew L. Maciejewski, Sarah Birken, Mark Perkins, James F. Jr Burgess, Nancy Sharp, Chuan-Fen Liu
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  ABSTRACT: Objective: To assess factors associated with enrollment in a Medicare advantage (MA) plan versus Medicare fee-for-service plan in 2000-2004 by Medicare-eligible veterans. We also assessed whether these factors differed between disability-eligible veterans and age-eligible veterans. Methods: Medicare claims data, VA administrative data, and 2000 census data were constructed in a retrospective cohort study of 20,581 age-eligible veterans and 7541 disability-eligible veterans. MA enrollment in 2000-2004 was estimated in a logistic regression in a pooled sample of age-eligible and disability-eligible veterans that controlled for demographic, socioeconomic, and disease risk factors. Separate logistic regressions also were estimated for age-eligible and disability-eligible veterans. Results: Minority veterans and veterans with lower disease risk scores were more likely to be enrolled in an MA plan in 2000-2004 than white veterans or veterans with higher risk scores. Age-eligible veterans were more likely to be enrolled if aged 75 or older, female, able to receive free VA care, or not enrolled in Medicaid. Disability-eligible veterans were more likely to be enrolled if they were married or elderly. Conclusions: Medicare Advantage plans appeared to benefit from favorable selection of Medicare-eligible veterans.
  Medical Care 10/2009; 47(11):1180-1185.
• Article: Racial and Ethnic Disparities in Pneumonia Treatment and Mortality

  Leslie R. M. Hausmann, Said A. Ibrahim, Ateev Mehrotra, Wato Nsa, Dale W. Bratzler, Maria K. Mor, Michael J. Fine
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  ABSTRACT: Background: The extent to which racial/ethnic disparities in pneumonia care occur within or between hospitals is unclear. Objective: Examine within and between-hospital racial/ethnic disparities in quality indicators and mortality for patients hospitalized for pneumonia. Research Design: Retrospective cohort study. Subjects: A total of 1,183,753 non-Hispanic white, African American, and Hispanic adults hospitalized for pneumonia between January 2005 and June 2006. Measures: Eight pneumonia care quality indicators and in-hospital mortality. Results: Performance rates for the 8 quality indicators ranged from 99.4% (oxygenation assessment within 24 hours) to 60.2% (influenza vaccination). Overall hospital mortality was 4.1%. African American and Hispanic patients were less likely to receive pneumococcal and influenza vaccinations, smoking cessation counseling, and first dose of antibiotic within 4 hours than white patients at the same hospital (ORs = 0.65-0.95). Patients at hospitals with the racial composition of those attended by average African Americans and Hispanics were less likely to receive all indicators except blood culture within 24 hours than patients at hospitals with the racial composition of those attended by average whites. Hospital mortality was higher for African Americans (OR = 1.05; 95% CI = 1.02, 1.09) and lower for Hispanics (OR = 0.85; 95% CI = 0.81, 0.89) than for whites within the same hospital. Mortality for patients at hospitals with the racial composition of those attended by average African Americans (OR = 1.21; 95% CI = 1.18, 1.25) or Hispanics (OR = 1.18; 95% CI = 1.14, 1.23) was higher than for patients at hospitals with the racial composition of those attended by average whites. Conclusions: Racial/ethnic disparities in pneumonia treatment and mortality are larger and more consistent between hospitals than within hospitals.
  Medical Care 08/2009; 47(9):1009-1017.
• Article: Treatment Intensification and Risk Factor Control: Toward More Clinically Relevant Quality Measures

  Joseph V. Selby, Connie S. Uratsu, Bruce Fireman, Julie A. Schmittdiel, Tiffany Peng, Nicolas Rodondi, Andrew J. Karter, Eve A. Kerr
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  ABSTRACT: Background: Intensification of pharmacotherapy in persons with poorly controlled chronic conditions has been proposed as a clinically meaningful process measure of quality. Objective: To validate measures of treatment intensification by evaluating their associations with subsequent control in hypertension, hyperlipidemia, and diabetes mellitus across 35 medical facility populations in Kaiser Permanente, Northern California. Design: Hierarchical analyses of associations of improvements in facility-level treatment intensification rates from 2001 to 2003 with patient-level risk factor levels at the end of 2003. Patients: Members (515,072 and 626,130; age >20 years) with hypertension, hyperlipidemia, and/or diabetes mellitus in 2001 and 2003, respectively. Measurements: Treatment intensification for each risk factor defined as an increase in number of drug classes prescribed, of dosage for at least 1 drug, or switching to a drug from another class within 3 months of observed poor risk factor control. Results: Facility-level improvements in treatment intensification rates between 2001 and 2003 were strongly associated with greater likelihood of being in control at the end of 2003 (P ≤ 0.05 for each risk factor) after adjustment for patient-and facility-level covariates. Compared with facility rankings based solely on control, addition of percentages of poorly controlled patients who received treatment intensification changed 2003 rankings substantially: 14%, 51%, and 29% of the facilities changed ranks by 5 or more positions for hypertension, hyperlipidemia, and diabetes, respectively. Conclusions: Treatment intensification is tightly linked to improved control. Thus, it deserves consideration as a process measure for motivating quality improvement and possibly for measuring clinical performance.
  Medical Care 03/2009; 47(4):395-402.
• Article: Proxy Assessment of Health-Related Quality of Life in African American and White Respondents With Prostate Cancer: Perspective Matters

  A Simon Pickard, Hsiang-Wen Lin, Sara J. Knight, Roohollah Sharifi, Zhigang Wu, Shih-Ying Hung, Whitney P. Witt, Chih-Hung Chang, Charles L. Bennett
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  ABSTRACT: Objectives: An emerging issue in the proxy literature is whether specifying different proxy viewpoints contributes to different health-related quality of life (HRQL) assessments, and if so, how might each perspective be informative in medical decision making. The aims of this study were to determine if informal caregiver assessments of patients with prostate cancer differed when prompted from both the patient perspective (proxy-patient) and their own viewpoint (proxy-proxy), and to identify factors associated with differences in proxy perspectives (ie, the intraproxy gap). Research Design and Methods: Using a cross-sectional design, prostate cancer patients and their informal caregivers were recruited from urology clinics in the Jesse Brown Veterans Affairs Healthcare System in Chicago. Dyads assessed HRQL using the EQ-5D visual analog scale (VAS) and EORTC QLQ-C30. Results: Of 87 dyads, most caregivers were female (83%) and were spouses/partners (58%). Mean difference scores between proxy-patient and proxy-proxy perspectives were statistically significant for QLQ-C30 physical and emotional functioning, and VAS (all P < 0.05), with the proxy-patient perspective closer to patient self-report. Emotional functioning had the largest difference, mean 6.0 (SD 12.8), an effect size = 0.47. Factors weakly correlated with the intraproxy gap included relationship (spouse) and proxy gender for role functioning, and health literacy (limited/functional) for physical functioning (all P < 0.05, 0.20 < r < 0.35). Conclusions: Meaningful differences between proxy-patient and proxy-proxy perspectives on mental health were consistent with a conceptual framework for understanding proxy perspectives. Prompting different proxy viewpoints on patient health could help clinicians identify patients who may benefit from clinical intervention.
  Medical Care 01/2009; 47(2):176-183.
• Article: Patient Safety Climate in 92 US Hospitals: Differences by Work Area and Discipline

  Sara J. Singer, David M. Gaba, Alyson Falwell, Shoutzu Lin, Jennifer Hayes, Laurence Baker
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  ABSTRACT: Background: Concern about patient safety has promoted efforts to improve safety climate. A better understanding of how patient safety climate differs among distinct work areas and disciplines in hospitals would facilitate the design and implementation of interventions. Objectives: To understand workers' perceptions of safety climate and ways in which climate varies among hospitals and by work area and discipline. Research Design: We administered the Patient Safety Climate in Healthcare Organizations survey in 2004-2005 to personnel in a stratified random sample of 92 US hospitals. Subjects: We sampled 100% of senior managers and physicians and 10% of all other workers. We received 18,361 completed surveys (52% response). Measures: The survey measured safety climate perceptions and worker and job characteristics of hospital personnel. We calculated and compared the percent of responses inconsistent with a climate of safety among hospitals, work areas, and disciplines. Results: Overall, 17% of responses were inconsistent with a safety climate. Patient safety climate differed by hospital and among and within work areas and disciplines. Emergency department personnel perceived worse safety climate and personnel in nonclinical areas perceived better safety climate than workers in other areas. Nurses were more negative than physicians regarding their work unit's support and recognition of safety efforts, and physicians showed marginally more fear of shame than nurses. For other dimensions of safety climate, physician-nurse differences depended on their work area. Conclusions: Differences among and within hospitals suggest that strategies for improving safety climate and patient safety should be tailored for work areas and disciplines.
  Medical Care 12/2008; 47(1):23-31.
• Article: An interview with Ronald Andersen, PhD by Carol M Ashton.

  Ronald Andersen
  Medical Care 08/2008; 46(7):645-6.
• Source

  Available from: washington.edu

  Article: Physician implicit attitudes and stereotypes about race and quality of medical care.

  Janice A Sabin, Frederick P Rivara, Anthony G Greenwald
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  ABSTRACT: Recent reports speculate that provider implicit attitudes about race may contribute to racial/ethnic health care disparities. We hypothesized that implicit racial bias exists among pediatricians, implicit and explicit measures would differ and implicit measures may be related to quality of care. A single-session, Web survey of academic pediatricians in an urban university measured implicit racial attitudes and stereotypes using a measure of implicit social cognition, the Implicit Association Test (IAT). Explicit (overt) attitudes were measured by self-report. Case vignettes were used to assess quality of care. We found an implicit preference for European Americans relative to African Americans, which was weaker than implicit measures for others in society (mean IAT score = 0.18; P = 0.01; Cohen's d = 0.41). Physicians held an implicit association between European Americans relative to African Americans and the concept of "compliant patient" (mean IAT score = 0.25; P = 0.001; Cohen's d = 0.60) and for African Americans relative to European Americans and the concept of "preferred medical care" (mean IAT score =-0.21; P = 0.001; Cohen's d = 0.64). Medical care differed by patient race in 1 of 4 case vignettes. No significant relationship was found between implicit and explicit measures, or implicit measures and treatment recommendations. Pediatricians held less implicit race bias compared with other MDs and others in society. Among pediatricians we found evidence of a moderate implicit "perceived patient compliance and race" stereotype. Further research is needed to explore whether physician implicit attitudes and stereotypes about race predict quality of care.
  Medical Care 08/2008; 46(7):678-85.
• Article: Racial and ethnic disparities in detection and treatment of depression and anxiety among psychiatric and primary health care visits, 1995-2005.

  Susan E Stockdale, Isabel T Lagomasino, Juned Siddique, Thomas McGuire, Jeanne Miranda
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  ABSTRACT: Recent evidence questions whether formerly documented disparities in care for common mental disorders among African Americans and Hispanics still remain. Also, whether disparities exist mainly in psychiatric settings or primary health care settings is unknown. To comprehensively examine time trends in outpatient diagnosis and treatment of depression and anxiety among ethnic groups in primary care and psychiatric settings. Analyses of office-based outpatient visits from the National Ambulatory Medical Care Study from 1995-2005 (n = 96,075). Visits to office-based primary care physicians and psychiatrists in the United States. Diagnosed with depression or anxiety, received counseling or a referral for counseling, received an antidepressant prescription, and any counseling or antidepressant care. In these analyses of 10-year trends in treatment of common mental disorders, disparities in counseling/referrals for counseling, antidepressant medications, and any care vastly improved or were eliminated over time in psychiatric visits. Continued disparities in diagnoses, counseling/referrals for counseling, antidepressant medication, and any care are found in primary care visits. Disparities in care for depression and anxiety among African Americans and Hispanics remain in primary care. Quality improvement efforts are needed to address cultural and linguistic barriers to care.
  Medical Care 08/2008; 46(7):668-77.
• Article: Do financial incentives linked to ownership of specialty hospitals affect physicians' practice patterns?

  Jean M Mitchell
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  ABSTRACT: Although physician-owned specialty hospitals have become increasingly prevalent in recent years, little research has examined whether the financial incentives linked to ownership influence physicians' referral rates for services performed at the specialty hospital. We compared the practice patterns of physician owners of specialty hospitals in Oklahoma, before and after ownership, to the practice patterns of physician nonowners who treated similar cases over the same time period in Oklahoma markets without physician-owned specialty hospitals. We constructed episodes of care for injured workers with a primary diagnosis of back/spine disorders. We used pre-post comparisons and difference-in-differences analysis to evaluate changes in practice patterns for physician owners and nonowners over the time period spanned by the entry of the specialty hospital. Findings suggest the introduction of financial incentives linked to ownership coincided with a significant change in the practice patterns of physician owners, whereas such changes were not evident among physician nonowners. After physicians established ownership interests in a specialty hospital, the frequency of use of surgery, diagnostic, and ancillary services used in the treatment of injured workers with back/spine disorders increased significantly. Physician ownership of specialty hospitals altered the frequency of use for an array of procedures rendered to patients treated at these hospitals. Given the growth in physician-owned specialty hospitals, these findings suggest that health care expenditures will be substantially greater for patients treated at these institutions relative to persons who obtain care from nonself-referral providers.
  Medical Care 08/2008; 46(7):732-7.
• Article: Influence of patient-provider communication on colorectal cancer screening.

  Patricia Carcaise-Edinboro, Cathy J Bradley
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  ABSTRACT: Screening reduces incidence and mortality from colorectal cancer (CRC). Despite improved access, screening is suboptimal and disparate among minority groups. Quality of patient-provider communication may impact CRC screening. We examined the relationship between patient-provider communication and socioeconomic variables on the receipt of CRC screening using data from the Medical Expenditure Panel Survey. All persons age 50 years or older (N = 8488). Dependent measures were receipt of CRC screening, fecal occult blood testing, and colonoscopy or sigmoidoscopy. Independent variables included demographic characteristics, patient language, and patient-provider communication measures from the Consumer Assessment of Health Plan survey. Patients who felt they had sufficient time with their healthcare provider were more likely to be screened for CRC. Receiving adequate explanation of healthcare needs from provider was a significant predictor of fecal occult blood testing screening. In addition, persons with less than a high school education, the uninsured, or those with low income were associated with reduced likelihood of receiving CRC screening. Asians and Hispanics had a significantly reduced likelihood of receiving screening in comparison with whites; however, after adjusting for language, no significant differences for race or ethnicity were observed. Adequate time with a healthcare provider and receiving sufficient explanation of the healthcare processes by providers may improve screening rates. Patient-provider communication may be improved by addressing language needs of non-English speaking patients. Overall improved communication may increase CRC screening rates in underserved populations.
  Medical Care 08/2008; 46(7):738-45.
• Article: An assessment of the quality of mammography care at facilities treating medically vulnerable populations.

  L Elizabeth Goldman, Sebastien J-P A Haneuse, Diana L Miglioretti, Karla Kerlikowske, Diana S M Buist, Bonnie Yankaskas, Rebecca Smith-Bindman
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  ABSTRACT: Women in medically vulnerable populations, including racial and ethnic minorities, socioeconomically disadvantaged, and residents of rural areas, experience higher breast cancer mortality than do others. Whether mammography facilities that treat vulnerable women demonstrate lower quality of care than other facilities is unknown. To assess the quality of mammography women receive at facilities characterized as serving a high proportion of medically vulnerable populations. We prospectively collected self-reported breast cancer risk factor information, mammography interpretations, and cancer outcomes on 1,579,929 screening mammography examinations from 750,857 women, aged 40-80 years, attending any of 151 facilities in the Breast Cancer Surveillance Consortium between 1998 and 2004. To classify facilities as serving medically vulnerable populations, we used 4 criteria: educational attainment, racial/ethnic minority, household income, and rural/urban residence. After adjustment for patient-level factors known to affect mammography accuracy, facilities serving vulnerable populations had significantly higher mammography specificity than did other facilities: ie, those serving a higher proportion of women who were minorities [odds ratio (OR): 1.32; 95% confidence interval (CI): 1.01-1.73], living in rural areas (1.45; 1.15-1.73), and with lower household income (1.33; 1.05-1.68). We observed no statistically significant differences between facilities in mammography sensitivity. Facilities serving high proportions of vulnerable populations provide screening mammography with equal or better quality (as reflected in higher specificity with no corresponding decrease in sensitivity) than other facilities. Further research is needed to understand the mechanisms underlying these findings.
  Medical Care 08/2008; 46(7):701-8.
• Article: The effectiveness of guideline implementation strategies on improving antipsychotic medication management for schizophrenia.

  Richard R Owen, Teresa Hudson, Carol Thrush, Purushottam Thapa, Tracey Armitage, Reid D Landes
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  ABSTRACT: To compare the effectiveness of a conceptually-based, multicomponent "enhanced" strategy with a "basic" strategy for implementing antipsychotic management recommendations of VA schizophrenia guidelines. Two VA medical centers in each of 3 Veterans Integrated Service Networks were randomized to either a basic educational implementation strategy or the enhanced strategy, in which a trained nurse promoted provider guideline adherence and patient compliance. Patients with acute exacerbation of schizophrenia were enrolled and assessed at baseline and 6 months and their medical records were abstracted; 291 participants were included in analyses. Logistic regression models were developed for rates of: (1) switching patients from first-generation antipsychotics (FGA) to second-generation antipsychotics (SGA), and (2) guideline-concordant antipsychotic dose. Of participants prescribed FGAs at baseline, those at enhanced sites were significantly more likely than participants at basic sites to have an SGA added to the FGA during the study (29% vs. 8%; adjusted OR = 7.7; 95% CI: 2.0-30.1), but were not significantly more likely to be switched to monotherapy with an SGA (29% vs. 23%). Guideline-concordant antipsychotic dosing was not significantly affected by the intervention. The enhanced guideline implementation strategy increased addition of SGAs to FGA therapy, but did not significantly increase guideline-recommended switching from FGA to SGA monotherapy. Antipsychotic dosing was not significantly altered. The study illustrates the challenges of changing clinical behavior. Strategies to improve medication management for schizophrenia are needed, and must incorporate recommendations likely to emerge from recent research suggesting comparable effectiveness of SGAs and FGAs.
  Medical Care 08/2008; 46(7):686-91.