Third Year of Survey Data Shows Continuing Benefits of Medicaid Expansions for Low-Income Childless Adults in the U.S.

Background

The Affordable Care Act (ACA) of 2010 incentivized states to expand eligibility for their Medicaid programs. Many did so in 2014, and there has been great interest in understanding the effects of these expansions on access to health care, health care utilization, and population health.

Objective

To estimate the longer-term (three-year) impact of Medicaid expansions on insurance coverage, access to care, preventive care, self-assessed health, and risky health behaviors.

Design

A difference-in-differences model, exploiting variation across states and over time in Medicaid expansion, was estimated using data from the Behavioral Risk Factor Surveillance System (BRFSS) for 2010–2016.

Participants

Low-income childless adults aged 19–64 years in the BRFSS.

Main Measures

Outcomes included insurance coverage, access to care, several forms of preventive care (e.g., routine checkups, flu shots, HIV tests, dental visits, and cancer screening), risky health behaviors (e.g., smoking, alcohol abuse, obesity), and self-assessed health.

Key Results

The previously documented benefits of Medicaid expansions on insurance coverage, access to care, preventive care, and self-assessed health have persisted 3 years after expansion. There was no detectable effect on risky health behaviors.

Conclusions

The Affordable Care Act was motivated in part by a desire to increase health insurance coverage, improve access to care, and increase use of preventive care. The Medicaid expansions facilitated by the ACA are helping to achieve those objectives, and the benefits have persisted 3 years after expansion.

     

Collaborating Across the Departments of Veterans Affairs and Defense to Integrate Mental Health and Chaplaincy Services

BACKGROUND

Recognizing that clergy and spiritual care providers are a key part of mental health care systems, the Department of Veterans Affairs (VA) and Department of Defense (DoD) jointly examined chaplains’ current and potential roles in caring for veterans and service members with mental health needs.

OBJECTIVE

Our aim was to evaluate the intersection of chaplain and mental health care practices in VA and DoD in order to determine if improvement is needed, and if so, to develop actionable recommendations as indicated by evaluation findings.

DESIGN

A 38-member multidisciplinary task group partnered with researchers in designing, implementing, and interpreting a mixed methods study that included: 1) a quantitative survey of VA and DoD chaplains; and 2) qualitative interviews with mental health providers and chaplains.

PARTICIPANTS

Quantitative: the survey included all full-time VA chaplains and all active duty military chaplains (n?=?2,163 completed of 3,464 invited; 62 % response rate). Qualitative: a total of 291 interviews were conducted with mental health providers and chaplains during site visits to 33 VA and DoD facilities.

MAIN MEASURES

Quantitative: the online survey assessed intersections between chaplaincy and mental health care and took an average of 37 min to complete. Qualitative: the interviews assessed current integration of mental health and chaplain services and took an average of 1 h to complete.

KEY RESULTS

When included on interdisciplinary mental health care teams, chaplains feel understood and valued (82.8–100 % of chaplains indicated this, depending on the team). However, findings from the survey and site visits suggest that integration of services is often lacking and can be improved.

CONCLUSIONS

Closely coordinating with a multidisciplinary task group in conducting a mixed method evaluation of chaplain-mental health integration in VA and DoD helped to ensure that researchers assessed relevant domains and that findings could be rapidly translated into actionable recommendations.

     

Care coordination and provider stress in primary care management of high-risk patients

Background

Care coordination is a critical component of managing high-risk patients, who tend to have complex and multiple medical and psychosocial problems and are typically at high risk for increased hospitalization and incur high health care expenditures. Primary care models such as the patient-centered medical homes (PCMHs) are designed to improve care coordination and reduce care fragmentation. However, little is known about how the burden of care coordination for high-risk patients influences PCMH team members’ stress.

Objective

To evaluate the relationship between provider stress and care coordination time in high-risk patient care and whether availability of help is associated with reduced stress.

Study design

Multivariable regression analysis of a cross-sectional survey of PCMH primary care providers (PCPs) and nurses.

Participants

A total of 164 PCPs and 272 nurses in primary care practices at five geographically diverse Veteran Health Administration (VA) medical center health systems.

Main measures

The main outcome variable was provider stress due to high-risk patient care. Independent variables were the reported proportion of high-risk patients in PCP/nurse patient panels, time spent coordinating care for these patients, and provider satisfaction with help received in caring for them.

Key results

The response rate was 44%. Spending more than 8 h per week coordinating care was significantly associated with a 0.21-point increase in reported provider stress compared to spending 8 h or less per week (95% CI: 0.04–0.39; p = 0.015). The magnitude of the association between stress and care coordination time was diminished when provider satisfaction with help received was included in the model.

Conclusions

Perceived provider stress from care of high-risk patients may arise from challenges related to coordinating their care. Our findings suggest that the perception of receiving help for high-risk patient care may be valuable in reducing provider stress.

     

Prediction Model for Two-Year Risk of Opioid Overdose Among Patients Prescribed Chronic Opioid Therapy

Background

Naloxone is a life-saving opioid antagonist. Chronic pain guidelines recommend that physicians co-prescribe naloxone to patients at high risk for opioid overdose. However, clinical tools to efficiently identify patients who could benefit from naloxone are lacking.

Objective

To develop and validate an overdose predictive model which could be used in primary care settings to assess the need for naloxone.

Design

Retrospective cohort.

Setting

Derivation site was an integrated health system in Colorado; validation site was a safety-net health system in Colorado.

Participants

We developed a predictive model in a cohort of 42,828 patients taking chronic opioid therapy and externally validated the model in 10,708 patients.

Main Measures

Potential predictors and outcomes (nonfatal pharmaceutical and heroin overdoses) were extracted from electronic health records. Fatal overdose outcomes were identified from state vital records. To match the approximate shelf-life of naloxone, we used Cox proportional hazards regression to model the 2-year risk of overdose. Calibration and discrimination were assessed.

Key Results

A five-variable predictive model showed good calibration and discrimination (bootstrap-corrected c-statistic?=?0.73, 95% confidence interval [CI] 0.69–0.78) in the derivation site, with sensitivity of 66.1% and specificity of 66.6%. In the validation site, the model showed good discrimination (c-statistic?=?0.75, 95% CI 0.70–0.80) and less than ideal calibration, with sensitivity and specificity of 82.2% and 49.5%, respectively.

Conclusions

Among patients on chronic opioid therapy, the predictive model identified 66–82% of all subsequent opioid overdoses. This model is an efficient screening tool to identify patients who could benefit from naloxone to prevent overdose deaths. Population differences across the two sites limited calibration in the validation site.

     

A Model for Interprofessional Health Disparities Education: Student-Led Curriculum on Chronic Hepatitis B Infection

BACKGROUND

Although health disparities are commonly addressed in preclinical didactic curricula, direct patient care activities with affected communities are more limited.

PURPOSE

To address this problem, health professional students designed a preclinical service-learning curriculum on hepatitis B viral (HBV) infection, a major health disparity affecting the Asian/Pacific Islander (API) population, integrating lectures, skills training, and direct patient care at student-run clinics.

SETTING

An urban health professions campus.

METHODS

Medical and other health professional students at University of California, San Francisco, organized a preclinical didactic and experiential elective, and established two monthly clinics offering HBV screening, vaccination, and education to the community.

RESULTS

Between 2004 and 2009, 477 students enrolled in the student-led HBV curriculum. Since the clinics’ inception in 2007, 804 patients have been screened for chronic HBV; 87% were API immigrants, 63% had limited English proficiency, and 46% were uninsured. Serologically, 10% were found to be chronic HBV carriers, 44% were susceptible to HBV, and 46% were immune.

DISCUSSION

Our student-led didactic and experiential elective can serve as an interprofessional curricular model for learning about specific health disparities while providing important services to the local community.

     

Effect of Pharmacist Counseling Intervention on Health Care Utilization Following Hospital Discharge: A Randomized Control Trial

Background

Reduction in 30-day readmission rates following hospitalization for acute coronary syndrome (ACS) and acute decompensated heart failure (ADHF) is a national goal.

Objective

The aim of this study was to determine the effect of a tailored, pharmacist-delivered, health literacy intervention on unplanned health care utilization, including hospital readmission or emergency room (ER) visit, following discharge.

Design

Randomized, controlled trial with concealed allocation and blinded outcome assessors

Setting

Two tertiary care academic medical centers

Participants

Adults hospitalized with a diagnosis of ACS and/or ADHF

Intervention

Pharmacist-assisted medication reconciliation, inpatient pharmacist counseling, low-literacy adherence aids, and individualized telephone follow-up after discharge

Main Measures

The primary outcome was time to first unplanned health care event, defined as hospital readmission or an ER visit within 30 days of discharge. Pre-specified analyses were conducted to evaluate the effects of the intervention by academic site, health literacy status (inadequate versus adequate), and cognition (impaired versus not impaired). Adjusted hazard ratios (aHR) and 95 % confidence intervals (CI) are reported.

Key Results

A total of 851 participants enrolled in the study at Vanderbilt University Hospital (VUH) and Brigham and Women’s Hospital (BWH). The primary analysis showed no statistically significant effect on time to first unplanned hospital readmission or ER visit among patients who received interventions compared to controls (aHR?=?1.04, 95 % CI 0.78-1.39). There was an interaction of treatment effect by site (p?=?0.04 for interaction); VUH aHR?=?0.77, 95 % CI 0.51-1.15; BWH aHR?=?1.44 (95 % CI 0.95-2.12). The intervention reduced early unplanned health care utilization among patients with inadequate health literacy (aHR 0.41, 95 % CI 0.17-1.00). There was no difference in treatment effect by patient cognition.

Conclusion

A tailored, pharmacist-delivered health literacy-sensitive intervention did not reduce post-discharge unplanned health care utilization overall. The intervention was effective among patients with inadequate health literacy, suggesting that targeted practice of pharmacist intervention in this population may be advantageous.

     

Performance of Health Literacy Tests Among Older Adults with Diabetes

BACKGROUND

Knowing a patient’s health literacy can help clinicians and researchers anticipate a patient’s ability to understand complex health regimens and deliver better patient-centered instructions and information. Poor health literacy has been linked with lower ability to function adequately in health care systems.

OBJECTIVE

We evaluated and compared three measures of health literacy and performance among older patients with diabetes.

DESIGN

Cross-sectional study utilizing in-person interviews conducted in participants’ homes.

PARTICIPANTS

A tri-ethnic sample (

MAIN MEASURE

Participants completed interviews and health literacy assessments using the Short-Form Test of Functional Health Literacy in Adults (S-TOFHLA), the Rapid Estimates of Adult Literacy in Medicine Short-Form (REALM-SF), or the Newest Vital Signs (NVS). Scores for reading comprehension and numeracy were calculated.

RESULTS

Over 90% completed the S-TOFHLA numeracy and approximately 85% completed the S-TOFHLA reading and REALM-SF. Only 73% completed the NVS. The correlation of S-TOFHLA total scores with REALM-SF and NVS were 0.48 and 0.54, respectively. Age, gender, ethnic, educational and income differences in health literacy emerged for several instruments, but the pattern of results across the instruments was highly variable.

CONCLUSIONS

A large segment of older adults is unable to complete short-form assessments of health literacy. Among those who were able to complete assessments, the REALM-SF and NVS performed comparably, but their relatively low convergence with the S-TOFHLA raises questions about instrument selection when studying health literacy of older adults.

     

Early Integration of Advance Care Planning (ACP) into Cirrhosis Care: Why We Need It

Purpose of Review

Patients with cirrhosis are largely unaware of the disease trajectory. This review emphasizes the importance of early advance care planning (ACP) and provides practitioners with a framework to apply these concepts.

Recent Findings

Literature is arising describing the importance of ACP and application of palliative principles (symptom management, quality of life, social, spiritual, and emotional care) in cirrhosis care. Understanding illness trajectories can promote symptom control, promote appropriate location of care, and ease care transitions. Our group of practitioners has spent time reviewing literature on ACP and has published tools to educate patients, surrogates, and health practitioners regarding the importance of these principles. In addition, work is ongoing to integrate this very important aspect of care into the daily practice of practitioners who managed end-stage-liver disease.

Summary

Early ACP and integration of palliative principles into cirrhosis care is critical. Provided is an action plan for implementing early ACP into end-stage liver disease (ESLD) care.

     

Cancer Risk Communication with Low Health Literacy Patients: A Continuing Medical Education Program

BACKGROUND

Low health literacy (HL) is an important risk factor for cancer health disparities.

OBJECTIVE

Describe a continuing medical education (CME) program to teach primary care physicians (PCP) cancer risk communication and shared decision-making (SDM) with low HL patients and baseline skills assessment.

DESIGN

Cluster randomized controlled trial in five primary care clinics in New Orleans, LA.

PARTICIPANTS

Eighteen PCPs and 73 low HL patients overdue for cancer screening.

INTERVENTION

Primary care physicians completed unannounced standardized patient (SP) encounters at baseline. Intervention physicians received SP verbal feedback; academic detailing to review cancer screening guidelines, red flags for identifying low HL, and strategies for effective counseling; and web-based tutorial of SP comments and checklist items hyperlinked to reference articles/websites.

MAIN MEASURES

Baseline PCP self-rated proficiency, SP ratings of physician general cancer risk communication and SDM skills, patient perceived involvement in care.

RESULTS

Baseline assessments show physicians rated their proficiency in discussing cancer risks and eliciting patient preference for treatment/decision-making as “very good”. SPs rated physician exploration of perceived cancer susceptibility, screening barriers/motivators, checking understanding, explaining screening options and associated risks/benefits, and eliciting preferences for screening as “satisfactory”. Clinic patients rated their doctor’s facilitation of involvement in care and information exchange as “good”. However, they rated their participation in decision-making as “poor”.

DISCUSSION

The baseline skills assessment suggests a need for physician training in cancer risk communication and shared decision making for patients with low HL. We are determining the effectiveness of teaching methods, required resources and long-term feasibility for a CME program.

     

Social Media and Allergy

Purpose of Review

Social media services dominate online consumption of information and play an ever expanding role in our lives. They are not only used to connect with friends and family but also to educate and recruit colleagues and patients, and to stay up-to-date with the new developments in the field of allergy and immunology.

Recent Findings

There are known risks to social media user by health care professionals mostly related to breaches of patient confidentiality, professionalism, and privacy. Malpractice and liability risks have been linked to irresponsible use of social media.

Summary

This review provides a comprehensive overview of the current social media tools in allergy. We recommend a pragmatic approach to maximize social media tools for the allergy practice.

     

Using the Teamlet Model to Improve Chronic Care in an Academic Primary Care Practice

Background

Team care can improve management of chronic conditions, but implementing a team approach in an academic primary care clinic presents unique challenges.

Objectives

To implement and evaluate the Teamlet Model, which uses health coaches working with primary care physicians to improve care for patients with diabetes and/or hypertension in an academic practice.

Design

Process and outcome measures were compared before and during the intervention in patients seen with the Teamlet Model and in a comparison patient group.

Participants

First year family medicine residents, medical assistants, health workers, and adult patients with either type 2 diabetes or hypertension in a large public health clinic.

Intervention

Health coaches, in coordination with resident primary care physicians, met with patients before and after clinic visits and called patients between visits.

Measurements

Measurement of body mass index, assessment of smoking status, and formulation of a self-management plan prior to and during the intervention period for patients in the Teamlet Model group. Testing for LDL and HbA1C and the proportion of patients at goal for blood pressure, LDL, and HbA1C in the Teamlet Model and comparison groups in the year prior to and during implementation.

Results

Teamlet patients showed improvement in all measures, though improvement was significant only for smoking, BMI, and self-management plan documentation and testing for LDL (p?=?0.02), with a trend towards significance for LDL at goal (p?=?0.07). Teamlet patients showed a greater, but non-significant, increase in the proportion of patients tested for HbA1C and proportion reaching goal for blood pressure, HgbA1C, and LDL compared to the comparison group patients. The difference for blood pressure was marginally significant (p?=?0.06). In contrast, patients in the comparison group were significantly more likely to have had testing for LDL (P?=?0.001).

Conclusions

The Teamlet Model may improve chronic care in academic primary care practices.

     

Primary Language and Receipt of Recommended Health Care Among Hispanics in the United States

Background

Disparities in health care services between Hispanics and whites in the United States are well documented.

Objective

The objective of the study was to determine whether language spoken at home identifies Hispanics at risk for not receiving recommended health care services.

Design

The design of the study was cross-sectional, nationally representative survey of households.

Patients

The patients were non-Hispanic white and Hispanic adults participating in the 2003 Medical Expenditure Panel Survey.

Measurements

We compared receipt of ten recommended health care services by ethnicity and primary language adjusting for demographic and socioeconomic characteristics, health status, and access to care.

Results

The sample included 12,706 whites and 5,500 Hispanics. In bivariate comparisons, 57.0% of whites received all eligible health care services compared to 53.6% for Hispanics who spoke English at home, 44.9% for Hispanics who did not speak English at home but who were comfortable speaking English, and 35.0% for Hispanics who did not speak English at home and were uncomfortable speaking English (p?<?.001). In multivariate logistic models, compared to non-Hispanic whites, Hispanics who did not speak English at home were less likely to receive all eligible health care services, whether they were comfortable speaking English (risk ratio [RR] 0.88, 95% confidence interval [CI] 0.74–0.97) or not (RR 0.84, 95% CI 0.68–0.95).

Conclusions

Speaking a language other than English at home identified Hispanics at risk for not receiving recommended health care services, whether they were comfortable in speaking English or not. Identifying the mechanism for disparities by language usage may lead to interventions to reduce ethnic disparities.

     

Training Primary Care Physicians to Employ Self-Efficacy-Enhancing Interviewing Techniques: Randomized Controlled Trial of a Standardized Patient Intervention

Background

Primary care providers (PCPs) have few tools for enhancing patient self-efficacy, a key mediator of myriad health-influencing behaviors.

Objective

To examine whether brief standardized patient instructor (SPI)-delivered training increases PCPs’ use of self-efficacy-enhancing interviewing techniques (SEE IT).

Design

Randomized controlled trial.

Participants

Fifty-two family physicians and general internists from 12 primary care offices drawn from two health systems in Northern California.

Interventions

Experimental arm PCPs received training in the use of SEE IT training during three outpatient SPI visits scheduled over a 1-month period. Control arm PCPs received a single SPI visit, during which they viewed a diabetes treatment video. All intervention visits (experimental and control) were timed to last 20 min. SPIs portrayed patients struggling with self-care of depression and diabetes in the first 7 min, then delivered the appropriate intervention content during the remaining 13 min.

Main Measures

The primary outcome was provider use of SEE IT (a count of ten behaviors), coded from three audio-recorded standardized patient visits at 1–3 months, again involving depression and diabetes self-care. Two five-point scales measured physician responses to training: Value (7 items: quality, helpfulness, understandability, relevance, feasibility, planned use, care impact), and Hassle (2 items: personal hassle, flow disruption).

Key Results

Pre-intervention, study PCPs used a mean of 0.7 behaviors/visit, with no significant between-arm difference (P?=?0.23). Post-intervention, experimental arm PCPs used more of the behaviors than controls (mean 2.7 vs. 1.0 per visit; adjusted difference 1.7, 95 % CI 1.1–2.2; P?<?0.001). Experimental arm PCPs had higher training Value scores than controls (mean difference 1.05, 95 % CI 0.68–1.42; P?<?0.001), and similarly low Hassle scores.

Conclusions

Primary care physicians receiving brief SPI-delivered training increased their use of SEE IT and found the training to be of value. Whether patients visiting SEE IT-trained physicians experience improved health behaviors and outcomes warrants study.

ClinicalTrials.gov Identifier

NCT01618552

     

Providing High-Quality Care for Limited English Proficient Patients: The Importance of Language Concordance and Interpreter Use

Background

Provider–patient language discordance is related to worse quality care for limited English proficient (LEP) patients who speak Spanish. However, little is known about language barriers among LEP Asian-American patients.

Objective

We examined the effects of language discordance on the degree of health education and the quality of interpersonal care that patients received, and examined its effect on patient satisfaction. We also evaluated how the presence/absence of a clinic interpreter affected these outcomes.

Design

Cross-sectional survey, response rate 74%.

Participants

A total of 2,746 Chinese and Vietnamese patients receiving care at 11 health centers in 8 cities.

Measurements

Provider–patient language concordance, health education received, quality of interpersonal care, patient ratings of providers, and the presence/absence of a clinic interpreter. Regression analyses were used to adjust for potential confounding.

Results

Patients with language-discordant providers reported receiving less health education (β?=?0.17, p?<?0.05) compared to those with language-concordant providers. This effect was mitigated with the use of a clinic interpreter. Patients with language-discordant providers also reported worse interpersonal care (β?=?0.28, p?<?0.05), and were more likely to give low ratings to their providers (odds ratio [OR]?=?1.61; CI?=?0.97–2.67). Using a clinic interpreter did not mitigate these effects and in fact exacerbated disparities in patients’ perceptions of their providers.

Conclusion

Language barriers are associated with less health education, worse interpersonal care, and lower patient satisfaction. Having access to a clinic interpreter can facilitate the transmission of health education. However, in terms of patients’ ratings of their providers and the quality of interpersonal care, having an interpreter present does not serve as a substitute for language concordance between patient and provider.

     

Access to Mental Health Treatment by English Language Proficiency and Race/Ethnicity

Background

Limited English proficiency (LEP) may contribute to mental health care disparities, yet empirical data are limited.

Objective

To quantify the language barriers to mental health care by race/ethnicity using a direct measure of LEP is the objective of the study.

Design

Cross-sectional analysis of the 2001 California Health Interview Survey is the study’s design.

Participants

Adults aged 18 to 64 who provided language data (n?=?41,984) were the participants of the study.

Measurement

Participants were categorized into three groups by self-reported English proficiency and language spoken at home: (1) English-speaking only, (2) Bilingual, and (3) Non-English speaking. Mental health treatment was measured by self-reported use of mental health services by those reporting a mental health need.

Results

Non-English speaking individuals had lower odds of receiving needed services (OR: 0.28; 95% CI: 0.17–0.48) than those who only spoke English, when other factors were controlled. The relationship was even more dramatic within racial/ethnic groups: non-English speaking Asian/PIs (OR?=?0.15; 95% CI: 0.30–0.81) and non-English speaking Latinos (OR: 0.19; 95% CI: 0.09–0.39) had significantly lower odds of receiving services compared to Asian/PIs and Latinos who spoke only English.

Conclusions

LEP is associated with lower use of mental health care. Since LEP is concentrated among Asian/PIs and Latinos, it appears to contribute to racial/ethnic disparities in mental health care. Heightened attention to LEP is warranted in both mental health practice and policy.

     

Effects of Health Insurance on Perceived Quality of Care Among Latinos in the United States

BACKGROUND

There is suggestive evidence that lower rates of health insurance coverage increases the gaps in quality and access to care among Latinos as compared with non-Latino whites. In order to examine these potential disparities, we assessed the effects of insurance coverage and multiple covariates on perceived quality of care.

OBJECTIVE

To assess the distribution of perceived quality of care received in a national Latino population sample, and the role of insurance in different patient subgroups.

DESIGN

Telephone interviews conducted between 2007 and 2008 using the Pew Hispanic Center/Robert Wood Johnson Foundation Latino Health Surveys (Waves 1 and 2).

PARTICIPANTS

Randomly selected Latino adults aged ≥18 years living in the United States.

MEASUREMENTS

Pearson χ² tests identified associations among various demographic variables by quality of care ratings (poor, fair, good, excellent) for the insured and uninsured (Wave 1: N?=?3545). Subgroup analyses were conducted among Wave 2 participants reporting chronic conditions (N?=?1067). Bivariate and multivariate analyses were conducted to estimate the effects of insurance, demographic variables and consumer characteristics on quality of care.

RESULTS

Insurance availability had an odds ratio of 1.47 (95% CI, 1.22–1.76) net of confounders in predicting perceived quality of care among Latinos. The largest gap in rates of excellent/good ratings occurred among the insured with eight or more doctor visits compared to the uninsured (76.2% vs. 54.6%, P?<?.05).

CONCLUSIONS

Future research can gain additional insights by examining the impact of health insurance on processes of care with a refined focus on specific transactions between consumers and providers’ support staff and physicians guided by the principles of patient-centered care.

     

Effects of the Wars on Smoking Among Veterans

BACKGROUND

Educating medical students about health disparities may be one step in diminishing the disparities in health among different populations. According to adult learning theory, learners’ opinions are vital to the development of future curricula.

DESIGN

Qualitative research using focus group methodology.

OBJECTIVES

Our objectives were to explore the content that learners value in a health disparities curriculum and how they would want such a curriculum to be taught.

PARTICIPANTS

Study participants were first year medical students with an interest in health disparities (n?=?17).

APPROACH

Semi-structured interviews consisting of 12 predetermined questions, with follow-up and clarifying questions arising from the discussion. Using grounded theory, codes were initially developed by the team of investigators, applied, and validated through an iterative process.

MAIN RESULTS

The students perceived negative attitudes towards health disparities education as a potential barrier towards the development of a health disparities curriculum and proposed possible solutions. These solutions centered around the learning environment and skill building to combat health disparities.

CONCLUSIONS

While many of the students’ opinions were corroborated in the literature, the most striking differences were their opinions on how to develop good attitudes among the student body. Given the impact of the provider on health disparities, how to develop such attitudes is an important area for further research.

     

Interventions to Improve Veterans’ Access to Care: A Systematic Review of the Literature

Objectives

To conduct a systematic review to address the following key questions: (1) what interventions have been successful in improving access for veterans with reduced health care access? (2) Have interventions that have improved health care access led to improvements in process and clinical outcomes?

Data Sources

OVID MEDLINE, CINAHL, PsychINFO.

Study Eligibility Criteria, Participants, and Interventions

English language articles published in peer-reviewed journals from 1990 to June 2010. All interventions designed to improve access to health care for US veterans that reported the impact of the intervention on perceived (e.g., satisfaction with access) or objective (e.g., travel time, wait time) access were included.

Appraisal and Synthesis Methods

Investigators abstracted data on study design, study quality, intervention, and impact of the intervention on access, process outcomes, and clinical outcomes.

Results

Nineteen articles (16 unique studies) met the inclusion criteria. While there were a small number of studies in support of any one intervention, all showed a positive impact on either perceived or objective measures of access. Implementation of Community Based Outpatient Clinics (n?=?5 articles), use of Telemedicine (n?=?5 articles), and Primary Care Mental Health Integration (n?=?6 articles) improved access. All 16 unique studies reported process outcomes, most often satisfaction with care and utilization. Four studies reported clinical outcomes; three found no differences.

Limitations

Included studies were largely of poor to fair methodological quality.

Conclusions and Implications of Key Findings

Interventions can improve access to health care for veterans. Increased access was consistently linked to increased primary care utilization. There was a lack of data regarding the link between access and clinical outcomes; however, the limited data suggest that increased access may not improve clinical outcomes. Future research should focus on the quality and appropriateness of care and clinical outcomes.