[show abstract][hide abstract] ABSTRACT: In a nationally representative sample of United States Medicare beneficiaries, we examined the extent of chiropractic use, factors associated with seeing a chiropractor, and predictors of the volume of chiropractic use among those having seen one.
We performed secondary analyses of baseline interview data on 4,310 self-respondents who were 70 years old or older when they first participated in the Survey on Assets and Health Dynamics Among the Oldest Old (AHEAD). The interview data were then linked to their Medicare claims. Multiple logistic and negative binomial regressions were used.
The average annual rate of chiropractic use was 4.6%. During the four-year period (two years before and two years after each respondent's baseline interview), 10.3% had one or more visits to a chiropractor. African Americans and Hispanics, as well as those with multiple depressive symptoms and those who lived in counties with lower than average supplies of chiropractors were much less likely to use them. The use of chiropractors was much more likely among those who drank alcohol, had arthritis, reported pain, and were able to drive. Chiropractic services did not substitute for physician visits. Among those who had seen a chiropractor, the volume of chiropractic visits was lower for those who lived alone, had lower incomes, and poorer cognitive abilities, while it was greater for the overweight and those with lower body limitations.
Chiropractic use among older adults is less prevalent than has been consistently reported for the United States as a whole, and is most common among Whites, those reporting pain, and those with geographic, financial, and transportation access.
[show abstract][hide abstract] ABSTRACT: There is now widespread agreement that geographic identifiers (geocodes) should be assigned to cancer records, but little agreement on their form and how they should be assigned, reported, and used. This paper reviews geocoding practice in relation to major purposes and discusses methods to improve the accuracy of geocoded cancer data. Differences in geocoding methods and materials introduce errors of commission and omission into geocoded data. A common source of error comes from the practice of using digital boundary files of dubious quality to place addresses into areas of interest. Geocoded data are linked to demographic, environmental, and health services data, and each data type has unique accuracy considerations. In health services applications, the accuracy of distances computed from geocodes can differ markedly. Privacy and confidentiality issues are important in the use and release of geocoded cancer data. When masking methods are used for disclosure limitation purposes, statistical methods must be adjusted for the locational uncertainty of geocoded data. We conclude that selection of one particular type of geographic area as the geocode may unnecessarily constrain future work. Therefore, the longitude and latitude of each case is the superior basic geocode; all other geocodes of interest can be constructed from this basic identifier.
American Journal of Preventive Medicine 03/2006; 30(2 Suppl):S16-24. · 3.95 Impact Factor
[show abstract][hide abstract] ABSTRACT: Despite the increasing usage and popularity of chiropractic care, there has been limited research conducted to examine the professional relationships between conventional trained primary care physicians (PCPs) and chiropractors (DCs). The objectives of our study were to contrast the intra-professional referral patterns among PCPs with referral patterns to DCs, and to identify predictors of PCP referral to DCs.
We mailed a survey instrument to all practicing PCPs in the state of Iowa. Descriptive statistics were used to summarize their responses. Multivariable logistic regression analyses were conducted to identify demographic factors associated with inter-professional referral behaviors.
A total of 517 PCPs (33%) participated in the study. PCPs enjoyed strong intra-professional referral relationships with other PCPs. Although patients exhibited a great deal of interest in chiropractic care, PCPs were unlikely themselves to make formal referral relationships with DCs. PCPs in a private practice arrangement were more likely to exhibit positive referral attitudes towards DCs (p = 0.01).
PCPs enjoy very good professional relationships with other PCPs. However, the lack of direct formalized referral relationships between PCPs and chiropractors has implications for efficiency, continuity, quality, and patient safety in the health care delivery system. Future research must focus on identifying facilitators and barriers for developing positive relationships between PCPs and chiropractors.
BMC Complementary and Alternative Medicine 02/2006; 6:5. · 2.08 Impact Factor
[show abstract][hide abstract] ABSTRACT: With the increasing popularity of chiropractic care in the United States, inter-professional relationships between conventional trained physicians (MDs and DOs) and chiropractors (DCs) will have an expanding impact on patient care. The objectives of this study are to describe the intra-professional referral patterns amongst DCs, describe the inter-professional referral patterns between DCs and conventional trained medical primary care physicians (MDPCPs), and to identify provider characteristics that may affect these referral behaviors.
A survey instrument to assess the attitudes and patterns of referral and consultation between MD primary care physicians (MDPCPs) and DCs was developed and sent to all DCs in the state of Iowa. Multivariable logistic regression models were built to assess the impact of provider characteristics on intra-professional and inter-professional referral patterns.
Of all DCs contacted, 452 (40.7%) participated in the study. Close to 8% of DCs reported that they never send a case report when referring a patient to another DC, while 13% never send a case report to a MDPCP. About 10% of DCs never send follow-up clinical information to referring doctors. DCs that perform differential diagnosis were significantly more likely to have engaged in inter-professional referral than DCs who did not perform differential diagnosis.
The tendency toward informality, in both referral practices and sharing of clinical documentation for referred patients between MDPCPs and DCs, is an explicit marker of concerns that need to be addressed in order to improve coordination and continuity of care for patients shared between these provider types.
[show abstract][hide abstract] ABSTRACT: The Upper Midwest offers a distinct environment for identifying and addressing threat and preparedness scenarios. The population is often scattered, with residents using urban centers periodically. This has also led to the challenge of providing specific skills and cross-disciplinary awareness and coordination to the public health community. The Upper Midwest Center for Public Health Preparedness was established by a grant from the Centers for Disease Control and Prevention to assist in meeting the challenge of adding capacity to develop the preparedness workforce in the Upper Midwest. Project Public Health Ready (PPHR) provides an example of the role academic preparedness centers can play in partnering with local public health agencies to strengthen the public health workforce. The purpose of this article is to present the Iowa Systems Model for Workforce Development being utilized for workforce training and education, describe how the model has been applied in the example of PPHR, and discuss lessons learned from the PPHR experience.
Journal of public health management and practice: JPHMP 12/2005; Suppl:S106-12. · 0.96 Impact Factor
[show abstract][hide abstract] ABSTRACT: This study compares the financial and productivity performance of hospital- versus physician-owned medical group practices. Nineteen hospital-owned and twenty-three physician-owned family practices were matched by location (state) and size (full-time equivalent providers). The data were obtained from the 1998 Medical Group Management Association (MGMA) Cost Survey database. The focus of this study is on the "bottom-line" performance of the organizations as well as the production costs of the different type of practices. Analyses of these data consider staffing differences, charge and revenue differentials, productivity factors, and differences in patient volume and procedure volume. When comparing the hospital-owned and physician-owned family practice groups, the statistical analysis of these data suggest that the underlying distinctions are driven by differences in the volume of patients and volume of procedures.
The Journal of ambulatory care management 11/2002; 25(4):26-36.
[show abstract][hide abstract] ABSTRACT: High and increasing consumer demand for complementary and alternative medicine (CAM) services necessitates a concerted focus to determine the effectiveness of such practices and to ensure that future possible integration of CAM with conventional medicine is founded on sound evidence-based principles of quality health care delivery. The example of chiropractic provides useful insights to guide further research and integration of evidence-based CAM into mainstream health care in the United States. A critical point of departure for this area of inquiry is identifying and addressing barriers to conducting scientifically sound and meaningful cross-disciplinary, practice-based research.
The Journal of ambulatory care management 05/2002; 25(2):1-16.
[show abstract][hide abstract] ABSTRACT: The terrorist acts during the fall of 2001 triggered renewed concern about the capacity of the nation's public health system to deal with crisis. A critical element of the response ability of the public health system is a prepared workforce. Based on a pre-existing concern about emerging infectious disease, the Centers for Disease Control (CDC), working with the Association of Schools of Public Health, had established a network of university-based Centers for Public Health Preparedness. The events of September 11 accelerated, expanded, and focused this effort. This article discusses this national program, details the activities of the based Center for Public Health Preparedness located at the University of Iowa, and suggests preparedness issues deserving future development.
Journal of public health management and practice: JPHMP 9(5):418-26. · 0.96 Impact Factor
[show abstract][hide abstract] ABSTRACT: The objective of our study is to document how often MD/DOs and doctors of chiropractic (DCs) receive patient information from referring MD/DOs and DCs and highlight to what extent there is a lack of formal intraprofessional and interprofessional referral relationships between MD/DOs and DCs. A total of 517 MD/DOs and 452 DCs participated in this study. The study results suggest that patient information is not regularly provided by either MD/DOs or DCs, even when making formal referrals to a provider of the same type. This was more pronounced when MDs made formal referrals to DCs.
The Journal of ambulatory care management 30(4):344-6.
[show abstract][hide abstract] ABSTRACT: This article recommends that the content of traditional continuing medical education be changed significantly to include the concepts and skills necessary to enable practice teams to feedback information into the practice, which would result in the creation of a learning organization with the ability to plan for and anticipate future activities. The primary role in this new organization would be called a care pilot who would have as a primary responsibility, the successful navigation and improvement of the 6 aims as spelled out in the Institute of Medicine report Crossing the Quality Chasm.
The Journal of ambulatory care management 30(4):283-90.
[show abstract][hide abstract] ABSTRACT: Findings from recent studies suggest that there are poor interprofessional referral relationships between primary care physicians (MDs) and chiropractors (DCs) and this can lead to fragmentation of care. The objective of this study is to identify potential facilitators and barriers to developing positive interprofessional referrals relationships between MDs and DCs.
We conducted 2 rounds of focus group interviews on a convenience sample of MDs and DCs. The focus groups were audiotaped, and transcripts were prepared for each focus group interaction. These data were analyzed through content analysis by 2 independent evaluators to determine the key themes and concepts provided by the focus groups.
Both MDs and DCs suggested that good communication, openness to discussion by providers, and patient interest are key factors for developing positive interprofessional referral relationships and implementing interprofessional practice-based research networks. Barriers to interprofessional relationships include lack of good communication between the 2 provider types, bias toward alternative medicine, lack of knowledge or understanding of chiropractic care, geographic constraints, and economic considerations.
This study identified several facilitators and barriers for developing positive referral relationships between primary care physicians and chiropractors. Future studies must focus on demonstrating the role of these factors on developing positive interprofessional relationships.
The Journal of ambulatory care management 30(4):347-54.
[show abstract][hide abstract] ABSTRACT: The patient-centered medical home provides an operational framework for implementing the Institute of Medicine's 6 quality aims within primary care. Successful implementation of the patient-centered medical home necessitates transformation at the group practice level. This article describes a conceptual model for transformational clinical leadership, based on the paradigm of the care pilot and the tools and training for effective implementation of this role within primary care group practice. In addition, we propose an innovative academically based system to train and support the care pilot and practice transformation in primary care and rural practice settings.
The Journal of ambulatory care management 33(2):97-107.