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1.
Siobhan M. Phillips Russell E. Glasgow Ghalib Bello Marcia G. Ory Beth A. Glenn Sherri N. Sheinfeld-Gorin Roy T. Sabo Suzanne Heurtin-Roberts Sallie Beth Johnson Alex H. Krist 《Annals of family medicine》2014,12(6):iii-513
PURPOSE
To describe the frequency and patient-reported readiness to change, desire to discuss, and perceived importance of 13 health risk factors in a diverse range of primary care practices.METHODS
Patients (n = 1,707) in 9 primary care practices in the My Own Health Report (MOHR) trial reported general, behavioral, and psychosocial risk factors (body mass index [BMI], health status, diet, physical activity, sleep, drug use, stress, anxiety or worry, and depression). We classified responses as “at risk” or “healthy” for each factor, and patients indicated their readiness to change and/or desire to discuss identified risk factors with providers. Patients also selected 1 of the factors they were ready to change as most important. We then calculated frequencies within and across these factors and examined variation by patient characteristics and across practices.RESULTS
On average, patients had 5.8 (SD = 2.12; range, 0–13) unhealthy behaviors and mental health risk factors. About 55% of patients had more than 6 risk factors. On average, patients wanted to change 1.2 and discuss 0.7 risks. The most common risks were inadequate fruit/vegetable consumption (84.5%) and overweight/obesity (79.6%). Patients were most ready to change BMI (33.3%) and depression (30.7%), and most wanted to discuss depression (41.9%) and anxiety or worry (35.2%). Overall, patients rated health status as most important.CONCLUSIONS
Implementing routine comprehensive health risk assessments in primary care will likely identify a high number of behavioral and psychosocial health risks. By soliciting patient priorities, providers and patients can better manage counseling and behavior change. 相似文献2.
Felicity Goodyear-Smith Jim Warren Minja Bojic Angela Chong 《Annals of family medicine》2013,11(5):460-466
PURPOSE
Early detection and management of unhealthy behaviors and mental health issues in primary care has the potential to prevent or ameliorate many chronic diseases and increase patients’ well-being. This study aimed to assess the feasibility and acceptability of the systematic use of a Web-based eCHAT (electronic Case-finding and Help Assessment Tool) screening patients for problematic drinking, smoking, and other drug use, gambling, exposure to abuse, anxiety, depression, anger control, and physical inactivity, and whether they want help with these issues. Patients self-administered eCHAT on an iPad in the waiting room and received summarized results, including relevant scores and interpretations, which could be by a family physician on the website and in the electronic health record (EHR) at the point of care.METHODS
We conducted a mixed method feasibility and acceptability study in 2 general practices in Auckland, New Zealand. Participants were consecutive adult patients attending the practice during a 2-week period, as well as all practice staff. Patients completed eCHAT, doctors accessed the summarized reports. Outcome measures were patients’ responses to eCHAT, and patients’ written and staff recorded interview feedback.RESULTS
Of the 233 invited patients, 196 (84%) completed eCHAT and received feedback. Domains where patients wanted immediate help were anxiety (9%), depression (7%), physical activity (6%), and smoking (5%), which was not overwhelming for physicians to address. Most patients found the iPad easy to use, and the questions easy to understand and appropriate; they did not object to questions. Feedback from 7 doctors, 2 practice managers, 4 nurses, and 5 receptionists was generally positive. Practices continue to use eCHAT regularly since the research was completed.CONCLUSIONS
eCHAT is an acceptable and feasible means of systemic screening patients for unhealthy behaviors and negative mood states and is easily integrated into the primary care electronic health record. 相似文献3.
Benjamin Lê Cook Ph.D. M.P.H. Colleen L. Barry Ph.D. M.P.P. Susan H. Busch Ph.D. 《Health services research》2013,48(1):129-149
Objective
To examine trends in disparities in children''s mental health care.Data
2002–2007 Medical Expenditure Panel Survey.Study Design
We used the Institute of Medicine (IOM) definition of health care disparities and estimated two-part expenditure models to examine disparity trends in any mental health care use, any outpatient care, and psychotropic drug use, as well as expenditures in these three categories, conditional on use. We used 2-year longitudinal panel data to determine disparities in care initiation among children with unmet need.Principal Findings
Assessing trends over time between 2002 and 2007, we identified that disparities persist for blacks and Latinos in receipt of any mental health care, any outpatient care, and any psychotropic drug use. Among those with positive mental health care expenditures, Latino–white disparities in overall mental health care expenditures increased over time. Among children with unmet need, significant disparities in initiation of an episode of mental health care were found, with whites approximately twice as likely as blacks and Latinos to initiate care.Conclusions
Disparities in children''s mental health care use are persistent and driven by disparities in initiation, suggesting policies to improve detection or increase initial access to care may be critical to reducing disparities. 相似文献4.
5.
Alex H. Krist Steven H. Woolf Ghalib A. Bello Roy T. Sabo Daniel R. Longo Paulette Kashiri Rebecca S. Etz John Loomis Stephen F. Rothemich J. Eric Peele Jeffrey Cohn 《Annals of family medicine》2014,12(5):418-426
PURPOSE
Health care leaders encourage clinicians to offer portals that enable patients to access personal health records, but implementation has been a challenge. Although large integrated health systems have promoted use through costly advertising campaigns, other implementation methods are needed for small to medium-sized practices where most patients receive their care.METHODS
We conducted a mixed methods assessment of a proactive implementation strategy for a patient portal (an interactive preventive health record [IPHR]) offered by 8 primary care practices. The practices implemented a series of learning collaboratives with practice champions and redesigned workflow to integrate portal use into care. Practice implementation strategies, portal use, and factors influencing use were assessed prospectively.RESULTS
A proactive and customized implementation strategy designed by practices resulted in 25.6% of patients using the IPHR, with the rate increasing 1.0% per month over 31 months. Fully 23.5% of IPHR users signed up within 1 day of their office visit. Older patients and patients with comorbidities were more likely to use the IPHR, but blacks and Hispanics were less likely. Older age diminished as a factor after adjusting for comorbidities. Implementation by practice varied considerably (from 22.1% to 27.9%, P <.001) based on clinician characteristics and workflow innovations adopted by practices to enhance uptake.CONCLUSIONS
By directly engaging patients to use a portal and supporting practices to integrate use into care, primary care practices can match or potentially surpass the usage rates achieved by large health systems. 相似文献6.
Lydie A. Lebrun‐Harris Travis P. Baggett Darlene M. Jenkins Alek Sripipatana Ravi Sharma A. Seiji Hayashi Charles A. Daly Quyen Ngo‐Metzger 《Health services research》2013,48(3):992-1017
Objective
To examine health status and health care experiences of homeless patients in health centers and to compare them with their nonhomeless counterparts.Data Sources/Study Setting
Nationally representative data from the 2009 Health Center Patient Survey.Study Design
Cross-sectional analyses were limited to adults (n = 2,683). We compared sociodemographic characteristics, health conditions, access to health care, and utilization of services among homeless and nonhomeless patients. We also examined the independent effect of homelessness on health care access and utilization, as well as factors that influenced homeless patients'' health care experiences.Data Collection
Computer-assisted personal interviews were conducted with health center patients.Principal Findings
Homeless patients had worse health status—lifetime burden of chronic conditions, mental health problems, and substance use problems—compared with housed respondents. In adjusted analyses, homeless patients had twice the odds as housed patients of having unmet medical care needs in the past year (OR = 1.98, 95 percent CI: 1.24–3.16) and twice the odds of having an ED visit in the past year (OR = 2.00, 95 percent CI: 1.37–2.92).Conclusions
There is an ongoing need to focus on the health issues that disproportionately affect homeless populations. Among health center patients, homelessness is an independent risk factor for unmet medical needs and ED use. 相似文献7.
Context
Health care delivery systems are becoming increasingly consolidated in urban areas of the United States. While this consolidation could increase efficiency and improve quality, it also could raise the cost of health care for payers. This article traces the consolidation trajectory in a single community, focusing on factors influencing recent acquisitions of physician practices by integrated delivery systems.Methods
We used key informant interviews, supplemented by document analysis.Findings
The acquisition of physician practices is a process that will be difficult to reverse in the current health care environment. Provider revenue uncertainty is a key factor driving consolidation, with public and private attempts to control health care costs contributing to that uncertainty. As these efforts will likely continue, and possibly intensify, community health care systems now are less consolidated than they will be in the future. Acquisitions of multispecialty and primary care practices by integrated delivery systems follow a common process, with relatively predictable issues relating to purchase agreements, employment contracts, and compensation. Acquisitions of single-specialty practices are less common, with motivations for acquisitions likely to vary by specialty type, group size, and market structure. Total cost of care contracting could be an important catalyst for practice acquisitions in the future.Conclusions
In the past, market and regulatory forces aimed at controlling costs have both encouraged and rewarded the consolidation of providers, with important new developments likely to create momentum for further consolidation, including acquisitions of physician practices. 相似文献8.
Marina Serper Rachel E. Patzer Ph.D. M.P.H. Laura M. Curtis M.S. Samuel G. Smith B.Sc. M.Sc. Ph.D. Rachel O'Conor M.P.H. David W. Baker M.D. M.P.H. Michael S. Wolf Ph.D. M.P.H. 《Health services research》2014,49(4):1249-1267
Objective
To investigate whether previously noted associations between health literacy and functional health status might be explained by cognitive function.Data Sources/Study Setting
Health Literacy and Cognition in Older Adults (“LitCog,” prospective study funded by National Institute on Aging). Data presented are from interviews conducted among 784 adults, ages 55–74 years receiving care at an academic general medicine clinic or one of four federally qualified health centers in Chicago from 2008 to 2010.Study Design
Study participants completed structured, in-person interviews administered by trained research assistants.Data Collection
Health literacy was measured using the Test of Functional Health Literacy in Adults, Rapid Estimate of Adult Literacy in Medicine, and Newest Vital Sign. Cognitive function was assessed using measures of long-term and working memory, processing speed, reasoning, and verbal ability. Functional health was assessed with SF-36 physical health summary scale and Patient Reported Outcomes Measurement Information System short form subscales for depression and anxiety.Principal Findings
All health literacy measures were significantly correlated with all cognitive domains. In multivariable analyses, inadequate health literacy was associated with worse physical health and more depressive symptoms. After adjusting for cognitive abilities, associations between health literacy, physical health, and depressive symptoms were attenuated and no longer significant.Conclusions
Cognitive function explains a significant proportion of the associations between health literacy, physical health, and depression among older adults. Interventions to reduce literacy disparities in health care should minimize the cognitive burden in behaviors patients must adopt to manage personal health. 相似文献9.
10.
Total Cost of Care Lower among Medicare Fee‐for‐Service Beneficiaries Receiving Care from Patient‐Centered Medical Homes
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Martijn van Hasselt Ph.D. Nancy McCall Sc.D. Vince Keyes M.A. Suzanne G. Wensky Ph.D. Kevin W. Smith M.A. 《Health services research》2015,50(1):253-272
Objective
To compare health care utilization and payments between NCQA-recognized patient-centered medical home (PCMH) practices and practices without such recognition.Data Sources
Medicare Part A and B claims files from July 1, 2007 to June 30, 2010, 2009 Census, 2007 Health Resources and Services Administration and CMS Utilization file, Medicare''s Enrollment Data Base, and the 2005 American Medical Association Physician Workforce file.Study Design
This study used a longitudinal, nonexperimental design. Three annual observations (July 1, 2008–June 30, 2010) were available for each practice. We compared selected outcomes between practices with and those without NCQA PCMH recognition.Data Collection Methods
Individual Medicare fee-for-service (FFS) beneficiaries and their claims and utilization data were assigned to PCMH or comparison practices based on where they received the plurality of evaluation and management services between July 1, 2007 and June 30, 2008.Principal Findings
Relative to the comparison group, total Medicare payments, acute care payments, and the number of emergency room visits declined after practices received NCQA PCMH recognition. The decline was larger for practices with sicker than average patients, primary care practices, and solo practices.Conclusions
This study provides additional evidence about the potential of the PCMH model for reducing health care utilization and the cost of care. 相似文献11.
Objectives:
The suicide rate in Korea is increasing every year, and is the highest among the Organization for Economic Cooperation and Development countries. Psychiatric patients in particular have a higher risk of suicide than other patients. This study was performed to evaluate determinants of mental health care utilization among individuals at high risk for suicide.Methods:
Korea Health Panel data from 2009 to 2011 were used. Subjects were individuals at high risk of suicide who had suicidal ideation, a past history of psychiatric illness, or had utilized outpatient services for a psychiatric disorder associated with suicidal ideation within the past year. The chi-square test and hierarchical logistic regression were used to identify significant determinants of mental health care utilization.Results:
The total number of subjects with complete data on the variables in our model was 989. Individuals suffering from three or more chronic diseases used mental health care more frequently. Mental health care utilization was higher in subjects who had middle or high levels of educational attainment, were receiving Medical Aid, or had a large family size.Conclusions:
It is important to control risk factors in high-risk groups as part of suicide prevention strategies. The clinical approach, which includes community-based intervention, entails the management of reduction of suicidal risk. Our study identified demographic characteristics that have a significant impact on mental health care utilization and should be considered in the development of suicide prevention strategies. Further studies should examine the effect of mental health care utilization on reducing suicidal ideation. 相似文献12.
13.
Lisa A. Cooper M.D M.P.H Bri K. Ghods Dinoso M.P.H. M.B.A. Daniel E. Ford M.D M.P.H Debra L. Roter DrPH Annelle B. Primm M.D M.P.H Susan M. Larson M.S James M. Gill M.D M.P.H Gary J. Noronha M.D Elias K. Shaya M.D Nae‐Yuh Wang Ph.D 《Health services research》2013,48(1):150-174
Objective
To compare the effectiveness of standard and patient-centered, culturally tailored collaborative care (CC) interventions for African American patients with major depressive disorder (MDD) over 12 months of follow-up.Data Sources/Study Setting
Twenty-seven primary care clinicians and 132 African American patients with MDD in urban community-based practices in Maryland and Delaware.Study Design
Cluster randomized trial with patient-level, intent-to-treat analyses.Data Collection/Extraction Methods
Patients completed screener and baseline, 6-, 12-, and 18-month interviews to assess depression severity, mental health functioning, health service utilization, and patient ratings of care.Principal Findings
Patients in both interventions showed statistically significant improvements over 12 months. Compared with standard, patient-centered CC patients had similar reductions in depression symptom levels (−2.41 points; 95 percent confidence interval (CI), −7.7, 2.9), improvement in mental health functioning scores (+3.0 points; 95 percent CI, −2.2, 8.3), and odds of rating their clinician as participatory (OR, 1.48, 95 percent CI, 0.53, 4.17). Treatment rates increased among standard (OR = 1.8, 95 percent CI 1.0, 3.2), but not patient-centered (OR = 1.0, 95 percent CI 0.6, 1.8) CC patients. However, patient-centered CC patients rated their care manager as more helpful at identifying their concerns (OR, 3.00; 95 percent CI, 1.23, 7.30) and helping them adhere to treatment (OR, 2.60; 95 percent CI, 1.11, 6.08).Conclusions
Patient-centered and standard CC approaches to depression care showed similar improvements in clinical outcomes for African Americans with depression; standard CC resulted in higher rates of treatment, and patient-centered CC resulted in better ratings of care. 相似文献14.
Bruckner TA Scheffler RM Shen G Yoon J Chisholm D Morris J Fulton BD Dal Poz MR Saxena S 《Bulletin of the World Health Organization》2011,89(3):184-194
Objective
To estimate the shortage of mental health professionals in low- and middle-income countries (LMICs).Methods
We used data from the World Health Organization’s Assessment Instrument for Mental Health Systems (WHO-AIMS) from 58 LMICs, country-specific information on the burden of various mental disorders and a hypothetical core service delivery package to estimate how many psychiatrists, nurses and psychosocial care providers would be needed to provide mental health care to the total population of the countries studied. We focused on the following eight problems, to which WHO has attached priority: depression, schizophrenia, psychoses other than schizophrenia, suicide, epilepsy, dementia, disorders related to the use of alcohol and illicit drugs, and paediatric mental disorders.Findings
All low-income countries and 59% of the middle-income countries in our sample were found to have far fewer professionals than they need to deliver a core set of mental health interventions. The 58 LMICs sampled would need to increase their total mental health workforce by 239 000 full-time equivalent professionals to address the current shortage.Conclusion
Country-specific policies are needed to overcome the large shortage of mental health-care staff and services throughout LMICs. 相似文献15.
Peer Reviewed: Promising Practices in Promotion of Healthy Weight at Small and Medium-Sized US Worksites
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Pamela Williams-Piehota James Hersey Jennifer Alexander Karen Bandel Isenberg Adrienne Rooks Phillip B Sparling Mary D Hill Diane O Dunet 《Preventing chronic disease》2008,5(4)
Introduction
We developed a new evaluation method to identify promising practices for promoting healthy weight among employees at small and medium-sized worksites.Methods
We used a structured rating and selection process to select 9 worksites with approximately 100 to 3,000 employees from a pool of worksites with health promotion programs reputed to be exemplary. A site visit over 2 sequential half-days at each site included interviews with senior management, program staff, vendors, and wellness committees; observation guided by a written environmental assessment; and structured review of program data on health outcomes of wellness program participants. The team corroborated findings from interviews, observations, and reviews of aggregate data on health outcomes of participants. Using the site visit reports, the project team and a separate panel of experts identified worksite health promotion practices that were promising, innovative, feasible to implement in a variety of settings, sustainable, and relevant for public health.Results
Innovative practices included peer coaching, wellness screening coupled with motivational interviewing and follow-up, free access to fitness facilities, and incentives such as days of paid leave for participation in wellness programs. Introduction of incentives was associated with higher participation rates. To build the business case for their programs, staff at several worksites used aggregate data on decreases in high blood pressure, serum cholesterol concentrations, and body weight in longitudinal samples of program participants.Conclusion
The evaluation method identified promising practices implemented at small and medium-sized worksites to promote healthy weight and related favorable health outcomes. 相似文献16.
Sanghamitra Pati Subhashisa Swain Mohammad Akhtar Hussain Shridhar Kadam Chris Salisbury 《Annals of family medicine》2015,13(5):446-450
PURPOSE
Little information is available on multimorbidity in primary care in India. Because primary care is the first contact of health care for most of the population and important for coordinating chronic care, we wanted to examine the prevalence and correlates of multimorbidity in India and its association with health care utilization.METHODS
Using a structured multimorbidity assessment protocol, we conducted a cross-sectional study, collecting information on 22 self-reported chronic conditions in a representative sample of 1,649 adult primary care patients in Odisha, India.RESULTS
The overall age- and sex-adjusted prevalence of multimorbidity was 28.3% (95% CI, 24.3–28.6) ranging from 5.8% in patients aged 18 to 29 years to 45% in those aged older than 70 years. Older age, female sex, higher education, and high income were associated with significantly higher odds of multimorbidity. After adjusting for age, sex, socioeconomic status (SES), education, and ethnicity, the addition of each chronic condition, as well as consultation at private hospitals, was associated with significant increase in the number of medicines intake per person per day. Increasing age and higher education status significantly raised the number of hospital visits per person per year for patients with multiple chronic conditions.CONCLUSION
Our findings of higher prevalence of multimorbidity and hospitalizations in higher SES individuals contrast with findings in Western countries, where lower SES is associated with a greater morbidity burden. 相似文献17.
Michael K. Magill David Ehrenberger Debra L. Scammon Julie Day Tatiana Allen Andreu J. Reall Rhonda W. Sides Jaewhan Kim 《Annals of family medicine》2015,13(5):429-435
PURPOSE
As medical practices transform to patient-centered medical homes (PCMHs), it is important to identify the ongoing costs of maintaining these “advanced primary care” functions. A key required input is personnel effort. This study’s objective was to assess direct personnel costs to practices associated with the staffing necessary to deliver PCMH functions as outlined in the National Committee for Quality Assurance Standards.METHODS
We developed a PCMH cost dimensions tool to assess costs associated with activities uniquely required to maintain PCMH functions. We interviewed practice managers, nurse supervisors, and medical directors in 20 varied primary care practices in 2 states, guided by the tool. Outcome measures included categories of staff used to perform various PCMH functions, time and personnel costs, and whether practices were delivering PCMH functions.RESULTS
Costs per full-time equivalent primary care clinician associated with PCMH functions varied across practices with an average of $7,691 per month in Utah practices and $9,658 in Colorado practices. PCMH incremental costs per encounter were $32.71 in Utah and $36.68 in Colorado. The average estimated cost per member per month for an assumed panel of 2,000 patients was $3.85 in Utah and $4.83 in Colorado.CONCLUSIONS
Identifying costs of maintaining PCMH functions will contribute to effective payment reform and to sustainability of transformation. Maintenance and ongoing support of PCMH functions require additional time and new skills, which may be provided by existing staff, additional staff, or both. Adequate compensation for ongoing and substantial incremental costs is critical for practices to sustain PCMH functions. 相似文献18.
Objective
To examine racial/ethnic disparities in medical and oral health status, access to care, and use of services in U.S. adolescents.Data Source
Secondary data analysis of the 2003 National Survey of Children''s Health. The survey focus was children 0–17 years old.Study Design
Bivariate and multivariable analyses were conducted for white, African American, Latino, Asian/Pacific Islander, American Indian/Alaskan Native, and multiracial adolescents 10–17 years old (n = 48,742) to identify disparities in 40 measures of health and health care.Principal Findings
Certain disparities were especially marked for specific racial/ethnic groups and multiracial youth. These disparities included suboptimal health status and lack of a personal doctor or nurse for Latinos; suboptimal oral health and not receiving all needed medications in the past year for African Americans; no physician visit or mental health care in the past year for Asian/Pacific Islanders; overweight/obesity, uninsurance, problems getting specialty care, and no routine preventive visit in the past year for American Indian/Alaska Natives; and not receiving all needed dental care in multiracial youth.Conclusions
U.S. adolescents experience many racial/ethnic disparities in health and health care. These findings indicate a need for ongoing identification and monitoring of and interventions for disparities for all five major racial/ethnic groups and multiracial adolescents. 相似文献19.
20.
Man Hung Weiping Zhang Wei Chen Jerry Bounsanga Christine Cheng Jeremy D Franklin Anthony B Crum Maren W Voss Shirley D Hon 《JMIR Public Health and Surveillance》2015,1(2)