[show abstract][hide abstract] ABSTRACT: To assess the effect of survey distribution protocol (mail versus handout) on data quality and measurement of patient care experiences.
Multisite randomized trial of survey distribution protocols. Analytic sample included 2,477 patients of 15 clinicians at three practice sites in New York State.
Mail and handout distribution modes were alternated weekly at each site for 6 weeks.
Handout protocols yielded an incomplete distribution rate (74 percent) and lower overall response rates (40 percent versus 58 percent) compared with mail. Handout distribution rates decreased over time and resulted in more favorable survey scores compared with mailed surveys. There were significant mode-physician interaction effects, indicating that data cannot simply be pooled and adjusted for mode.
In-office survey distribution has the potential to bias measurement and comparison of physicians and sites on patient care experiences. Incomplete distribution rates observed in-office, together with between-office differences in distribution rates and declining rates over time suggest staff may be burdened by the process and selective in their choice of patients. Further testing with a larger physician and site sample is important to definitively establish the potential role for in-office distribution in obtaining reliable, valid assessment of patient care experiences.
Health Services Research 10/2010; 45(5 Pt 1):1345-59. · 2.29 Impact Factor
[show abstract][hide abstract] ABSTRACT: Although different types of gender-based violence (GBV) have been documented in disaster-affected populations, no studies have documented a quantitative increase in rates of GBV among populations living in protracted displacement after a disaster. We aimed to assess the change in rates of GBV after Hurricane Katrina among internally displaced people (IDPs) living in travel trailer parks in Mississippi.
The study design included successive cross-sectional randomized surveys, conducted in 2006 and 2007, among IDPs in Mississippi using a structured questionnaire. We sampled 50 travel trailer parks in 9 counties in Mississippi in 2006, and 69 parks in 20 counties in 2007. A total of 420 female respondents comprised the final sample. We measured respondent demographics, forms of GBV including sexual and physical violence further subtyped by perpetrator, suicidal ideation, suicide attempt, and Patient Health Questionnaire-9-assessed depression.
Respondents had a mean age of 42.7 years. The crude rate of new cases of GBV among women increased from 4.6/100,000 per day to 16.3/100,000 per day in 2006, and remained elevated at 10.1/100,000 per day in 2007. The increase was primarily driven by the increase in intimate partner violence. GBV experience was significantly associated with increased risk for poor mental health outcomes.
Overall, the rate of GBV, particularly intimate partner violence, increased within the year following Hurricane Katrina and did not return to baseline during the protracted phase of displacement. Disaster planning efforts should incorporate plans to decrease the incidence of GBV following a disaster, and to ensure adequate services to people with postdisaster GBV experience.
Disaster Medicine and Public Health Preparedness 04/2009; 3(1):18-26. · 1.14 Impact Factor
[show abstract][hide abstract] ABSTRACT: Assessment of gender-based violence (GBV) among internally displaced persons (IDPs) is at best difficult. In complex humanitarian disasters, GBV inquiry can sometimes be dangerous and may lead to underestimation of the true prevalence. We developed a method of identifying women who have greater odds of having been exposed to postdisaster GBV (PDGBV) using mental health indicators.
We systematically random sampled IDPs living in travel trailer parks in Louisiana and Mississippi and interviewed respondents using a health needs assessment survey during an 8-week period in April and May 2006. Women (n = 194) were screened for GBV and symptoms of depression.
Women were on average 43.3 years old (range 18-85). Of the nine symptoms assessed with the Patient Health Questionnaire-9 (PHQ-9), four were associated with PDGBV. Among women with sleep dysregulation, the odds of PDGBV were 2.5 times higher in comparison with women without sleep dysregulation (95% CI 1.2-5.1). Appetite dysregulation increased the odds by 3.8 (95% CI 1.4-10.3), low self-esteem increased the odds by 2.3 (95% CI 1.2-4.6), and suicidal ideation increased the odds by 2.7 (95% CI 1.1-6.7). The internal consistency reliability of this symptom cluster was higher among women with PDGBV. Women screening positive on all four symptoms were 2.7 times more likely to have experienced PDGBV (95% CI 1.03-7.1).
Several but not all symptoms of depression indicated exposure to PDGBV. Sleeping dysregulation, appetite dysregulation, low self-esteem, and suicidal ideation should be considered secondary indicators useful for identifying the prevalence of PDGBV exposure among female IDPs. This model may be useful for identifying women with exposure to PDGBV in settings where direct questioning may not be safe and reliable.
Journal of Women s Health 11/2008; 17(9):1437-44. · 1.42 Impact Factor
[show abstract][hide abstract] ABSTRACT: Physicians are increasingly asked to improve the delivery of clinical services and patient experiences of care.
We evaluated the association between clinical performance and patient experiences in a statewide sample of physician practice sites and a sample of physicians within a large physician group.
We separately identified 373 practice sites and 119 individual primary care physicians in Massachusetts.
Using Health Plan Employer Data and Information Set data, we produced two composites addressing processes of care (prevention, disease management) and one composite addressing outcomes. Using Ambulatory Care Experiences Survey data, we produced seven composite measures summarizing the quality of clinical interactions and organizational features of care. For each sample (practice site and individual physician), we calculated adjusted Spearman correlation coefficients to assess the relationship between the composites summarizing patient experiences of care and those summarizing clinical performance.
Among 42 possible correlations (21 correlations involving practice sites and 21 involving individual physicians), the majority were positive in site level (71%) and physician level (67%) analyses. For the 28 possible correlations involving patient experiences and clinical process composites, 8 (29%) were significant and positive, and only 2 (7%) were significant and negative. The magnitude of the significant positive correlations ranged from 0.13 to 0.19 at the site level and from 0.28 to 0.51 at the physician level. There were no significant correlations between patient experiences and the clinical outcome composite.
The modest correlations suggest that clinical quality and patient experience are distinct, but related domains that may require separate measurement and improvement initiatives.
Journal of General Internal Medicine 09/2008; 23(11):1784-90. · 3.28 Impact Factor
[show abstract][hide abstract] ABSTRACT: Virus-specific CD8(+) T lymphocytes play a key role in the initial reduction of peak viremia during acute viral infections, but display signs of increasing dysfunction and exhaustion under conditions of chronic antigen persistence. It has been suggested that virus-specific CD8(+) T cells with a "polyfunctional" profile, defined by the capacity to secrete multiple cytokines or chemokines, are most competent in controlling viral replication in chronic HIV-1 infection. We used HIV-1 infection as a model of chronic persistent viral infection to investigate the process of exhaustion and dysfunction of virus-specific CD8(+) T cell responses on the single-epitope level over time, starting in primary HIV-1 infection.
We longitudinally analyzed the polyfunctional epitope-specific CD8(+) T cell responses of 18 patients during primary HIV-1 infection before and after therapy initiation or sequence variation in the targeted epitope. Epitope-specific CD8(+) T cells responded with multiple effector functions to antigenic stimulation during primary HIV-1 infection, but lost their polyfunctional capacity in response to antigen and up-regulated programmed death 1 (PD-1) expression with persistent viremic infection. This exhausted phenotype significantly decreased upon removal of stimulation by antigen, either in response to antiretroviral therapy or by reduction of epitope-specific antigen load in the presence of ongoing viral replication, as a consequence of in vivo selection of cytotoxic T lymphocyte escape mutations in the respective epitopes. Monofunctionality increased in CD8(+) T cell responses directed against conserved epitopes from 49% (95% confidence interval 27%-72%) to 76% (56%-95%) (standard deviation [SD] of the effect size 0.71), while monofunctionality remained stable or slightly decreased for responses directed against escaped epitopes from 61% (47%-75%) to 56% (42%-70%) (SD of the effect size 0.18) (p < 0.05).
These data suggest that persistence of antigen can be the cause, rather than the consequence, of the functional impairment of virus-specific T cell responses observed during chronic HIV-1 infection, and underscore the importance of evaluating autologous viral sequences in studies aimed at investigating the relationship between virus-specific immunity and associated pathogenesis.
PLoS Medicine 05/2008; 5(5):e100. · 15.25 Impact Factor
[show abstract][hide abstract] ABSTRACT: Physicians and medical educators have repeatedly acknowledged the inadequacy of communication skills training in the medical school curriculum and opportunities to improve these skills in practice. This study of a controlled intervention evaluates the effect of teaching practicing physicians the skill of "agenda-setting" on patients' experiences with care. The agenda-setting intervention aimed to engage clinicians in the practice of initiating patient encounters by eliciting the full set of concerns from the patient's perspective and using that information to prioritize and negotiate which clinical issues should most appropriately be dealt with and which (if any) should be deferred to a subsequent visit.
Ten physicians from a large physician organization in California with baseline patient survey scores below the statewide 25th percentile participated in the agenda-setting intervention. Eleven physicians matched on baseline scores, geography, specialty, and practice size were selected as controls. Changes in survey summary scores from pre- and post-intervention surveys were compared between the two groups. Multilevel regression models that accounted for the clustering of patients within physicians and controlled for respondent characteristics were used to examine the effect of the intervention on survey scale scores.
There was statistically significant improvement in intervention physicians' ability to "explain things in a way that was easy to understand" (p = 0.02) and marginally significant improvement in the overall quality of physician-patient interactions (p = 0.08) compared to control group physicians. Changes in patients' experiences with organizational access, care coordination, and office staff interactions did not differ by experimental group.
A simple and modest behavioral training for practicing physicians has potential to positively affect physician-patient relationship interaction quality. It will be important to evaluate the effect of more extensive trainings, including those that work with physicians on a broader set of communication techniques.
BMC Medical Education 02/2008; 8:3. · 1.41 Impact Factor
[show abstract][hide abstract] ABSTRACT: The health care needs of Gulf Coast residents displaced by Hurricane Katrina in 2005 who remain in travel trailer parks nearly three years later have not been evaluated. We conducted a population-based assessment of the health care access of residents of these travel trailer parks in Mississippi. Our findings indicate a worsening of chronic disease, mental illness, and barriers to health care access since displacement. Meeting both the chronic disease and the mental health needs of people displaced by the hurricanes of 2005 is essential for ensuring their full recovery and that of the region.
Health Affairs 01/2008; 27(5):w416-29. · 4.64 Impact Factor
[show abstract][hide abstract] ABSTRACT: By studying time allocation, a factor implicitly linked to health by structuring individuals' physical exercise, leisure, sleep, and access to care, we can better understand behavioral mechanisms to improve health in minority populations. We piloted the time diary method in a Honduran immigrant community to assess time spent in personal and interpersonal responsibilities, and we examined how these patterns varied by gender. In the context of participatory ethnography, 34 urban Honduran immigrants were recruited and followed over 7 days. Respondents reported activities by 30-min periods for seven 24-h days. Observed respondent-level reliability exceeded 0.7 for time spent in commuting, care work, family responsibility, and individual leisure, showing better results than 3- or 10-day tracking schemes. Gender differences in time allocation patterns were also observed. We argue that understanding time use patterns will elucidate gendered disparities in health outcomes associated with physical mobility, and in access to health care.
Journal of Immigrant and Minority Health 01/2008; 10(5):437-43. · 1.16 Impact Factor
[show abstract][hide abstract] ABSTRACT: We used a global humanitarian aid perspective to assess basic needs, women's health, mental health, and opinions about the status of internally displaced persons living in travel trailer parks to inform recovery efforts for this population.
This was a systematic randomized survey of 366 internally displaced persons, conducted with structured questionnaires. The study setting was commercial and group travel trailer parks in Louisiana and Mississippi. Information was gathered about respondent demographics, food security, basic needs, domestic and sexual violence, security concerns, reproductive health, mental health, morbidity, mortality, health care assessment, substance use, and opinions about internally displaced persons and social status.
Respondents were 45.9 (standard deviation 0.8) years of age on average and were mostly white (62%) in Mississippi and mostly black (65%) in Louisiana. Shelter, transportation, security, and lack of financial means were listed as the worst problems since displacement. Sixteen percent of respondents reported not having enough drinking water, and only 13% of those living in counties and parishes under boil orders were doing so. More than half of households reported an ill adult or child in the previous 2 months. The number of parents reporting problems getting children to school more than tripled after displacement. Intimate partner violence rates postdisplacement were 3 times higher than US baseline rates. Fifty percent of respondents met criteria for major depression. Suicide completion rates after displacement were more than 14 times the baseline rates, and attempt rates were more than 78 times baseline.
The health burdens identified present a formidable challenge for the health infrastructures in Louisiana and Mississippi without outside assistance. Those planning and leading recovery efforts must understand internally displaced persons in a more global context and tailor programming that follows well-developed international models of rights-based care.
Annals of emergency medicine 05/2007; 49(5):590-601, 601.e1-12. · 4.23 Impact Factor