[Show abstract][Hide abstract] ABSTRACT: We evaluated a quality improvement program with a pay-for-performance (P4P) incentive in a population-focused, integrated care program for safety-net patients in 29 community health clinics.
We used a quasi-experimental design with 1673 depressed adults before and 6304 adults after the implementation of the P4P program. Survival analyses examined the time to improvement in depression before and after implementation of the P4P program, with adjustments for patient characteristics and clustering by health care organization.
Program participants had high levels of depression, other psychiatric and substance abuse problems, and social adversity. After implementation of the P4P incentive program, participants were more likely to experience timely follow-up, and the time to depression improvement was significantly reduced. The hazard ratio for achieving treatment response was 1.73 (95% confidence interval=1.39, 2.14) after the P4P program implementation compared with pre-program implementation.
Although this quasi-experiment cannot prove that the P4P initiative directly caused improved patient outcomes, our analyses strongly suggest that when key quality indicators are tracked and a substantial portion of payment is tied to such quality indicators, the effectiveness of care for safety-net populations can be substantially improved.
American Journal of Public Health 04/2012; 102(6):e41-5. · 3.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study evaluated a mail and telephone intervention to improve breast health behaviors while maintaining quality of life. Women recruited from the general public were randomized to a stepped-intensity intervention consisting of mailings, telephone calls, and counseling (if requested or appropriate given a woman's genetic risk for breast cancer) or to a delayed treatment control group. Outcomes (mammography screening and quality of life) were measured at baseline in a telephone survey and again at a 12-month follow-up period. Women in the intervention group significantly increased screening mammography uptake by 12% and quality of life by 5.3 scale points compared to control participants. Changes in knowledge of breast cancer, genetic testing, and cancer worry all significantly predicted intervention changes. This successful intervention can help women make better breast health choices without causing increased worry.
Health Education & Behavior 02/2010; 37(4):479-89. · 1.54 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To establish the feasibility of and to generate preliminary evidence for the efficacy of a care management program addressing both physical and emotional pain associated with late-life depression and osteoarthritis.
Treatment development pilot study in three university affiliated primary care clinics. Participants were patients 60 years or older with depression and osteoarthritis pain. The intervention entailed a nurse administered care management program supporting depression and arthritis treatment by primary care physicians. Outcomes include depression, pain severity and functional impairment from pain assessed at baseline and 6 months.
Fourteen patients participated in the pilot program. Between baseline and 6 months, mean HSCL-20 depression scores dropped from 1.78 (SD 0.56) to 1.06 (SD 0.59), a standardized effect size of 1.27 (p = 0.004). Pain intensity scores dropped from 5.67 (SD 1.69) to 4.18 (SD 1.98), an effect size of 0.88 (p = 0.021) and pain interference scores dropped from 4.91 (SD 1.75) to 3.49 (SD 2.14), an effect size of 0.81 (p = 0.013). Patients also experienced improvements in self efficacy, in satisfaction with depression care, and in timed 8-m walk and transfer tests.
The combined intervention was feasible and well-received by patients. Preliminary outcomes are promising and comparisons to an earlier trial of care management for depression alone suggest that the combined program may be equally effective for depression but more effective for pain.
International Journal of Geriatric Psychiatry 05/2008; 23(11):1166-71. · 3.09 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To determine the long-term effects on total healthcare costs of the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) program for late-life depression compared with usual care.
Randomized controlled trial with enrollment from July 1999 through August 2001. The IMPACT trial, conducted in primary care practices in 8 delivery organizations across the United States, enrolled 1801 depressed primary care patients 60 years or older. Data are from the 2 IMPACT sites for which 4-year cost data were available. Trial enrollment across these 2 health maintenance organizations was 551 patients.
Participants were randomly assigned to the IMPACT intervention (n = 279) or to usual primary care (n = 272). Intervention patients had access to a depression care manager who provided education, behavioral activation, support of antidepressant medication management prescribed by their regular primary care provider, and problem-solving treatment in primary care for up to 12 months. Care managers were supervised by a psychiatrist and a primary care provider. The main outcome measures were healthcare costs during 4 years.
IMPACT participants had lower mean total healthcare costs ($29 422; 95% confidence interval, $26 479-$32 365) than usual care patients ($32 785; 95% confidence interval, $27 648-$37 921) during 4 years. Results of a bootstrap analysis suggested an 87% probability that the IMPACT program was associated with lower healthcare costs than usual care.
Compared with usual primary care, the IMPACT program is associated with a high probability of lower total healthcare costs during a 4-year period.
The American journal of managed care 03/2008; 14(2):95-100. · 2.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The health of sexual minority women (SMW) has recently received research attention. Previous research into the health of SMW (e.g., lesbians, bisexuals, transgendered women) used a mixture of sampling methods, many of which were poorly documented and difficult to understand. The results of these previous studies do not present a consistent pattern of findings, possibly due to differences in sampling methods. The present study compared the characteristics ofSMWacross four survey sampling methods, three in the same geographic area. Differences were found among groups of SMW by sampling method, including in demographic data (e.g., level of education) and personal health data (e.g., rates of regular mammography screening). These findings provided a possible explanation for the variety of findings in the published literature and identified rigorous sampling methods that can be used in future research.
Women & Health 02/2006; 44(2):121-34. · 1.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Sexual minority women (lesbian and bisexual) represent a vulnerable group regarding their breast health. The participants in this study were 150 women aged 18-74 recruited via public announcements in mainstream and sexual minority communities in the greater Seattle metropolitan area. Potential participants were recruited to participate in a randomized trial of a breast cancer risk counseling intervention for sexual minority women. The counseling intervention produced significant reductions in perceived risk of breast cancer, anxieties and fears about breast cancer at 6 and 24 months, and increases in breast screening rates at 24 months in the intervention arm, compared with the control arm participants. These data add to the growing body of knowledge on sexual minority women's health and point to areas of community action and future research.
Health Care For Women International 02/2006; 27(1):59-74. · 0.63 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Area probability sampling was used to conduct a women's health survey in Boston, MA. Sexual minority women (SMW) and heterosexual adult women were compared on a variety of health-related measures.
SMW-rich census tracts were identified and mapped onto zip code boundaries. Eligible respondents were women 18 and older who lived within the defined area, who were able to complete a personal interview or self-administered questionnaire in English. Differences in significant health-related outcomes by sexual orientation were examined.
SMW and heterosexual women differed on access to health care and utilization of screening tests. There were no significant differences in smoking rates, eating less calories or fat, and intentions to follow mammography recommendations.
In certain respects, study results are congruent with previous non-probability surveys, while in others the results are different. It is likely that real differences exist in some health-related variables by sexual orientation category.
Women & Health 02/2004; 40(3):19-34. · 1.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Alternative options for medical care are rapidly growing choices in our current health care system, yet we lack a full understanding of the motivators and predictors of this trend. Lesbians may represent a cultural group that uses alternate health care options more frequently and therefore can provide valuable insights into this growing trend. Objective: The purpose of this paper is to describe and identify predictors of interest in alternative methods of health care among a group of lesbians. Subject: Sexual-minority women (n = 150) were recruited through community channels and were screened via telephone. Measures: Participants completed a survey of health behaviors and key variables related to use of alternative and traditional health care providers. Results: Over half the sample (68%) reported that they wanted access to an alternative provider. Participants reported equal and high levels of trust in both traditional and alternative providers. The most desired alternative providers are massage therapists (87%) and acupuncturists (56%). Positive predictors of interest in alternative providers included anxiety and trust in alternative providers, whereas trust in traditional providers negatively predicted interest. Conclusion: These data generated hypotheses for predicting uptake of alternative care in more-mainstream populations.
Journal of the Gay and Lesbian Medical Association 02/2002; 6(1):3-7.
[Show abstract][Hide abstract] ABSTRACT: Lesbians may be at risk for poorer health outcomes than heterosexual women because of differential health behaviors and risk factors for disease. Difficulty recruiting representative lesbian populations and a lack of simple, accurate measures of sexual orientation have hindered research about the differential health risks and outcomes faced by lesbian and heterosexual women. The purpose of this article was to (1) examine the relationship between self-chosen sexual orientation labels and other sexual orientation measures and (2) compare the health related behaviors of women of diverse sexual orientations based on simple sexual orientation measures. The participants in this study were women aged 18 to 74 recruited via public announcements in mainstream and minority communities to participate in a randomized trial of breast cancer risk counseling strategies. Sexual orientation, relevant health behaviors and other outcomes related to breast cancer risk and screening were measured. No single measure of sexual behavior or desire appears to accurately measure lesbian sexual orientation. Lesbians were found to participate in mammography and Pap testing at significantly lower levels than bisexuals and heterosexuals. These data add to the growing body of knowledge on lesbian health and point to areas of community action and future research.
Journal of Prevention & Intervention Community 01/2001; 22(2):43-60.
[Show abstract][Hide abstract] ABSTRACT: This article describes women who called a research line to quit smoking and identifies correlates of confidence in quitting among the callers. Approximately 4,000 women called the study line to participate after a single press release, indicating intensive interest in quitting. Overall, the randomized sample of women was aged 26 to 65 years, reported smoking just over one pack per day, was mostly White, predominantly employed, and had quit an average of two times the past year before joining the study. Standard background variables, such as age, income, body weight and smoking history variables did not predict baseline self-efficacy or confidence in quitting. However, level of stress, cognitive restraint, and weight gain concerns did predict self-efficacy. These data indicate strong interest in quitting among women and highlight the role of affect and weight concerns in quitting confidence.
Women & Health 02/2000; 31(4):41-58. · 1.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Recent scientific breakthroughs in the genetics of breast cancer may have had effects on women's perceptions of risk and subsequent worry about breast cancer. Here, we present the rates of interest in counseling among women identified from diverse sources, their levels of cancer worry and perceived risk, and predictors of their agreement to participate in breast cancer risk counseling. Women were identified through breast cancer cases and through media offers. They completed a telephone survey and were ultimately either entered or not entered into a counseling trial. Overall, almost half (46%) of cases who were approached responded to the contact letter asking for information about potentially interested relatives. A total of 588 women responded to the brief media solicitations over a 15-week period. Participants recruited from media contacts reported slightly but significantly higher levels of worry about getting cancer, compared to case-recruited participants. Cancer worry negatively and significantly predicted entry into the counseling project. The results presented here may have implications for recruiting women in the general population with a family history of breast cancer for counseling about their risk for the disease.
[Show abstract][Hide abstract] ABSTRACT: Improving breast screening behaviors in African American women is an important public health goal. To increase participation in screening, it is necessary to identify factors that contribute to reduced screening, including perceived risk and cancer worry. This paper presents predictors of changes perceived in risk and worry among African American women of differing ethnic identities as they undergo breast cancer risk counseling. Participants (n = 113) were recruited from community sources to a study of counseling for breast cancer risk. They completed a baseline assessment, randomly received breast cancer risk counseling or served as a control group, and completed a follow-up assessment. Counseling produced significant differences in perceived risk and cancer worry. Predictors of risk and worry changes, as a result of counseling, included income and ethnic identity. These data can guide better services for African American women and research into the complexity of the effects of ethnic identity on health.
Journal of Clinical Psychology in Medical Settings 08/1998; 5(3):365-379. · 1.49 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: African American women are less likely than white women to receive and perform adequate breast screening, and represent a group that has not been thoroughly researched in the area of breast cancer risk. In general, perceptions of risk and worry about cancer are both related to obtaining mammography and possibly other screening activities. We examine African American women's worry and beliefs about breast cancer, and their intentions to perform breast and genetic screening behaviors, using the self-regulatory model. Participants were recruited via media announcements; they completed questionnaires addressing several aspects of the self-regulatory model. Forty-one percent of participants were underestimators, 23% were overestimators, and 37% were extreme overestimators of their own personal risk for breast cancer. Several variables were significant predictors of willingness to undergo mammography and genetic screening, including ethnic identity, attitudes toward the physician, emotional distress, and risk overestimation. These data highlight the importance of psychological variables in understanding screening in African American women and hold promise for intervention design.