Use of Interpreters by Physicians for Hospitalized Limited English Proficient Patients and Its Impact on Patient Outcomes

BACKGROUND

Few studies have examined the impact of inpatient interpreter use for limited English proficient (LEP) patients on length of stay (LOS), 30-day post discharge emergency department (ED) visits and 30-day hospital readmission rates for LEP patients.

METHODS

A retrospective cohort analysis was conducted of all hospitalized patients admitted to the general medicine service at a large academic center. For patients self-reported as LEP, use of interpreters during each episode of hospitalization was categorized as: 1) interpreter used by non-MD (i.e., nurse); 2) interpreter used by a non-Hospitalist MD; 3) interpreter used by Hospitalist; and 4) no interpreter used during hospitalization. We examined the association of English proficiency and interpreter use on outcomes utilizing Poisson and logistic regression models.

RESULTS

Of 4,224 patients, 564 (13 %) were LEP. Of these LEP patients, 65.8 % never had a documented interpreter visit, 16.8 % utilized an interpreter with a non-MD, 12.6 % utilized an interpreter with a non-Hospitalist MD and 4.8 % utilized an interpreter with a hospitalist present. In adjusted models, compared to English speakers, LEP patients with no interpreters had significantly shorter LOS. There were no differences in readmission rates and ED utilization between LEP and English-speaking patients. Compared to LEP patients with no interpreter use, those who had a physician use an interpreter had odds for a longer LOS, but there was no difference in odds of readmission or ED utilization.

CONCLUSION

Academic hospital clinician use of interpreters remains highly variable and physicians may selectively be using interpreters for the sickest patients.KEY WORDS: limited English proficiency, interpreter use, length of stay, thirty-day readmissions     

Professional Language Interpretation and Inpatient Length of Stay and Readmission Rates

Background

The population of persons seeking medical care is linguistically diverse in the United States. Language barriers can adversely affect a patient’s ability to explain their symptoms. Among hospitalized patients, these barriers may lead to higher readmission rates and longer hospitalizations. Trained interpreters help overcome communication barriers; however, interpreter usage among patients is suboptimal.

Objective

To investigate differences among patients with limited English proficiency (LEP) in their length of stay (LOS) and 30-day readmission rate associated with their receiving professional interpretation at admission or discharge.

Design

We analyzed the rates of interpretation at admission and discharge of all LEP patients admitted to a tertiary care hospital over a three-year period. We calculated length of stay in days and as log of LOS. We also examined 30-day readmission. Using multivariable regression models, we explored differences among patients who received interpretation at admission, discharge, or both, controlling for patient characteristics, including age, illness severity, language, and gender.

Participants

All LEP patients admitted between May 1, 2004 and April 30, 2007.

Main Measures

Length of hospital stay as related to use of professional interpreters; readmission to the hospital within 30 days.

Key Results

Of the 3071 patients included in the study, 39 % received language interpretation on both admission and discharge date. Patients who did not receive professional interpretation at admission or both admission/discharge had an increase in their LOS of between 0.75 and 1.47 days, compared to patients who had an interpreter on both day of admission and discharge (P < 0.02). Patients receiving interpretation at admission and/or discharge were less likely than patients receiving no interpretation to be readmitted with 30 days.

Conclusions

The length of a hospital stay for LEP patients was significantly longer when professional interpreters were not used at admission or both admission/discharge.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-012-2041-5) contains supplementary material, which is available to authorized users.Key Words: low English proficient (LEP), interpreters, length of stay (LOS)People living in the United States speak over 300 different languages according to the 2008 US census estimates and over 24 million individuals speak English less than very well, representing 8.6 % of the US population.¹ Low English proficient (LEP) patients seeking medical care often have a difficult time explaining their illness and understanding their doctor’s instructions and treatment plan. Language problems impact multiple aspects of health care including access, patient-physician communication, satisfaction with care and patient safety.² This results in LEP patients being more likely to experience adverse medical events of a serious nature and having difficulty adhering to their treatment plan.³ LEP patients receiving care without qualified interpreters have a poor self-reported understanding of their diagnosis and treatment plan and frequently wish their doctors had explained things better.⁴To avoid these problems, it is imperative that LEP patients be provided with qualified, professional interpreters to help them navigate our health care system. Kaliner et al. described a professional interpreter as one who is paid by a hospital or health system to interpreter.⁵ Training can vary between institutions. Research has shown that the use of untrained, ad hoc interpreters or family members can result in disastrous mistakes. Ad hoc interpreters can misinterpret or omit up to half of physicians’ questions, are more likely to commit errors with clinical significance, have a higher risk of not mentioning medication side effects, and may ignore embarrassing issues (especially when children are used to interpret).^3,6,7From an economical standpoint, it has been found that LEP patients stay in the hospital between 0.7 and 4.3 days longer than English speaking patients with similar conditions.⁸ In addition non-English speaking patient have a higher 30-day readmission rate compared to their English speaking counterparts.⁹ This research did not address the use of professional interpreters though and its effect on LOS or readmission. More recently it’s been shown that providing LEP inpatients with trained medical interpreters throughout their hospital stay can reduce their LOS by almost a day.¹⁰Our objective was to examine hospital length of stay (LOS) and 30-day readmission rates among LEP patients and compare those rates with a patient’s access to professional interpretation. We tried to determine if the timing of interpretation, at admission, discharge or some other time during a patient’s stay was associated was LOS and readmission.     

Disparities in the Use of Internet and Telephone Medication Refills among Linguistically Diverse Patients

Background

Health systems are increasingly implementing remote telephone and Internet refill systems to enhance patient access to medication refills. Remote refill systems may provide an effective approach for improving medication non-adherence, but more research is needed among patients with limited English proficiency with poor access to remote refill systems.

Objective

To compare the use of remote medication refill systems among limited-English-proficiency (LEP) and English-proficient (EP) patients with chronic conditions.

Methods

Cross-sectional survey in six languages/dialects (English, Cantonese, Mandarin, Korean, Vietnamese, and Spanish) of 509 adults with diabetes, hypertension, or hyperlipidemia. Primary study outcomes were self-reported use of 1) Internet refills, 2) telephone refills, and 3) any remote refill system. LEP was measured by patient self-identification of a primary language other than English and a claims record of use of an interpreter. Other measures were age, gender, education, years in the U.S., insurance, health status, chronic conditions, and number of prescribed medications. Analyses included multivariable logistic regression weighted for survey non-response.

Results

Overall, 33.1 % of patients refilled their medications by telephone and 31.6 % by Internet. Among LEP patients (n = 328), 31.5 % refilled by telephone and 21.2 % by Internet, compared with 36.7 % by telephone and 52.7 % by Internet among EP patients (n = 181). Internet refill by language groups were as follows: English (52.7 %), Cantonese (34.9 %), Mandarin (17.4 %), Korean (16.7 %), Vietnamese (24.4 %), and Spanish (12.6 %). Compared to EP patients, LEP patients had lower use of any remote refill system (adjusted odds ratio [AOR] 0.18; p < 0.001),

Conclusions

LEP patients are significantly less likely than EP patients to use any remote medication refill system. Increased reliance on current systems for remote medication refills may increase disparities in health outcomes affecting LEP patients with poor access to telephone and Internet medication refills.Key Words: language barriers, minority health, survey research, disparities, adherence     

Enhancing Care for Hospitalized Older Adults with Cognitive Impairment: A Randomized Controlled Trial

Background

Approximately 40% of hospitalized older adults have cognitive impairment (CI) and are more prone to hospital-acquired complications. The Institute of Medicine suggests using health information technology to improve the overall safety and quality of the health care system.

Objective

Evaluate the efficacy of a clinical decision support system (CDSS) to improve the quality of care for hospitalized older adults with CI.

Design

A randomized controlled clinical trial.

Setting

A public hospital in Indianapolis.

Population

A total of 998 hospitalized older adults were screened for CI, and 424 patients (225 intervention, 199 control) with CI were enrolled in the trial with a mean age of 74.8, 59% African Americans, and 68% female.

Intervention

A CDSS alerts the physicians of the presence of CI, recommends early referral into a geriatric consult, and suggests discontinuation of the use of Foley catheterization, physical restraints, and anticholinergic drugs.

Measurements

Orders of a geriatric consult and discontinuation orders of Foley catheterization, physical restraints, or anticholinergic drugs.

Results

Using intent-to-treat analyses, there were no differences between the intervention and the control groups in geriatric consult orders (56% vs 49%, P = 0.21); discontinuation orders for Foley catheterization (61.7% vs 64.6%, P = 0.86); physical restraints (4.8% vs 0%, P = 0.86), or anticholinergic drugs (48.9% vs 31.2%, P = 0.11).

Conclusion

A simple screening program for CI followed by a CDSS did not change physician prescribing behaviors or improve the process of care for hospitalized older adults with CI.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-012-1994-8) contains supplementary material, which is available to authorized users.KEY WORDS: cognitive impairment, clinical trial, decision support, hospitalized elders     

A Randomized Trial of Peer Coach and Office Staff Support to Reduce Coronary Heart Disease Risk in African-Americans with Uncontrolled Hypertension

OBJECTIVE

Adopting features of the Chronic Care Model may reduce coronary heart disease risk and blood pressure in vulnerable populations. We evaluated a peer and practice team intervention on reduction in 4-year coronary heart disease risk and systolic blood pressure.

DESIGN AND SUBJECTS

A single blind, randomized, controlled trial in two adjacent urban university-affiliated primary care practices. Two hundred eighty African-American subjects aged 40 to 75 with uncontrolled hypertension.

INTERVENTION

Three monthly calls from trained peer patients with well-controlled hypertension and, on alternate months, two practice staff visits to review a personalized 4-year heart disease risk calculator and slide shows about heart disease risks. All subjects received usual physician care and brochures about healthy cooking and heart disease.

MAIN MEASURES

Change in 4-year coronary heart disease risk (primary) and change in systolic blood pressure, both assessed at 6 months.

KEY RESULTS

At baseline, the 136 intervention and 144 control subjects’ mean 4-year coronary heart disease risk did not differ (intervention = 5.8 % and control = 6.4 %, P = 0.39), and their mean systolic blood pressure was the same (140.5 mmHg, p = 0.83). Endpoint data for coronary heart disease were obtained for 69 % of intervention and 82 % of control subjects. After multiple imputation for missing endpoint data, the reduction in risk among all 280 subjects favored the intervention, but was not statistically significant (difference −0.73 %, 95 % confidence interval: -1.54 % to 0.09 %, p = 0.08). Among the 247 subjects with a systolic blood pressure endpoint (85 % of intervention and 91 % of control subjects), more intervention than control subjects achieved a >5 mmHg reduction (61 % versus 45 %, respectively, p = 0.01). After multiple imputation, the absolute reduction in systolic blood pressure was also greater for the intervention group (difference −6.47 mmHg, 95 % confidence interval: −10.69 to −2.25, P = 0.003). One patient died in each study arm.

CONCLUSIONS

Peer patient and office-based behavioral support for African-American patients with uncontrolled hypertension did not result in a significantly greater reduction in coronary heart disease risk but did significantly reduce systolic blood pressure.KEY WORDS: coronary heart disease, hypertension, African American, peer support     

Association of Sweetened Beverage Intake with Incident Hypertension

BACKGROUND

Consumption of sugar-sweetened beverages (SSBs) is associated with an increased risk of hypertension in cross-sectional studies. However, prospective data are limited.

OBJECTIVE

To examine the associations between SSBs and artificially sweetened beverages (ASBs) with incident hypertension.

DESIGN AND SETTING

Prospective analysis using Cox proportional hazards regression to examine the association between SSBs and ASBs with incident hypertension in three large, prospective cohorts, the Nurses'' Health Studies I (n = 88,540 women) and II (n = 97,991 women) and the Health Professionals'' Follow-Up Study (n = 37,360 men).

MEASUREMENTS

Adjusted hazard ratios for incident clinically diagnosed hypertension.

RESULTS

Higher SSB and ASB intake was associated with an increased risk of developing hypertension in all three cohorts. In a pooled analysis, participants who consumed at least one SSB daily had an adjusted HR for incident hypertension of 1.13 (95 % CI, 1.09–1.17) compared with those who did not consume SSBs; for persons who drank at least one ASB daily, the adjusted HR was 1.14 (95 % CI, 1.09–1.18). The association between sweetened beverage intake and hypertension was stronger for carbonated beverages versus non-carbonated beverages, and for cola-containing versus non-cola beverages in the NHS I and NHS II cohorts only. Higher fructose intake from SSBs as a percentage of daily calories was associated with increased hypertension risk in NHS I and NHS II (p-trend = 0.001 in both groups), while higher fructose intake from sources other than SSBs was associated with a decrease in hypertension risk in NHS II participants (p-trend = 0.006).

LIMITATIONS

Residual confounding factors may interfere with the interpretation of results.

CONCLUSIONS

SSBs and ASBs are independently associated with an increased risk of incident hypertension after controlling for multiple potential confounders. These associations may be mediated by factors common to both SSBs and ASBs (e.g., carbonation or cola), but are unlikely to be due to fructose.KEY WORDS: sweetened beverages, fructose, hypertension, artificial sweetener, risk     

Differences in Patient–Provider Communication for Hispanic Compared to Non-Hispanic White Patients in HIV Care

Background

Hispanic Americans with HIV/AIDS experience lower quality care and worse outcomes than non-Hispanic whites. While deficits in patient–provider communication may contribute to these disparities, no studies to date have used audio recordings to examine the communication patterns of Hispanic vs. non-Hispanic white patients with their health care providers.

Objective

To explore differences in patient–provider communication for English-speaking, HIV-infected Hispanic and non-Hispanic white patients.

Design

Cross-sectional analysis.

Setting

Two HIV care sites in the United States (New York and Portland) participating in the Enhancing Communication and HIV Outcomes (ECHO) study.

Subjects

Nineteen HIV providers and 113 of their patients.

Measurements

Patient interviews, provider questionnaires, and audio-recorded, routine, patient–provider encounters coded with the Roter Interaction Analysis System (RIAS).

Results

Providers were mostly non-Hispanic white (68%) and female (63%). Patients were Hispanic (51%), and non-Hispanic white (49%); 20% were female. Visits with Hispanic patients were less patient-centered (0.75 vs. 0.90, p = 0.009), with less psychosocial talk (80 vs. 118 statements, p < 0.001). This pattern was consistent among Hispanics who spoke English very well and those with less English proficiency. There was no association between patient race/ethnicity and visit length, patients’ or providers’ emotional tone, or the total number of patient or provider statements categorized as socioemotional, question-asking, information-giving, or patient activating. Hispanic patients gave higher ratings than whites (AOR 3.05 Hispanic vs. white highest rating of providers’ interpersonal style, 95% CI 1.20-7.74).

Conclusion

In this exploratory study, we found less psychosocial talk in patient–provider encounters with Hispanic compared to white patients. The fact that Hispanic patients rated their visits more positively than whites raises the possibility that these differences in patient–provider interactions may reflect differences in patient preferences and communication style rather than “deficits” in communication. If these findings are replicated in future studies, efforts should be undertaken to understand the reasons underlying them and their impact on the quality and equity of care.KEY WORDS: HIV/AIDS, patient–physician relations, patient–physician communication, health disparities     

National Survey of Medical Spanish Curriculum in U.S. Medical Schools

Background

Patients with limited English proficiency (LEP) may be at risk for medical errors and worse health outcomes. Language concordance between patient and provider has been shown to improve health outcomes for Spanish-speaking patients. Nearly 40 % of Hispanics, a growing population in the United States, are categorized as having limited English proficiency. Many medical schools have incorporated a medical Spanish curriculum to prepare students for clinical encounters with LEP patients.

Objective

To describe the current state of medical Spanish curricula at United States medical schools.

Methods

The Latino Medical Student Association distributed an e-mail survey comprising 39 items to deans from each U.S. medical school from July 2012 through July 2014. This study was IRB-exempt.

Results

Eighty-three percent (110/132) of the U.S. medical schools completed the survey. Sixty-six percent (73/110) of these schools reported offering a medical Spanish curriculum. In addition, of schools with no curriculum, 32 % (12/37) planned to incorporate the curriculum within the next two years. Most existing curricula were elective, not eligible for course credit, and taught by faculty or students. Teaching modalities included didactic instruction, role play, and immersion activities. Schools with the curriculum reported that the diverse patient populations in their respective service areas and/or student interest drove course development. Barriers to implementing the curriculum included lack of time in students’ schedules, overly heterogeneous student language skill levels, and a lack of financial resources. Few schools reported the use of validated instruments to measure language proficiency after completion of the curriculum.

Conclusions

Growing LEP patient populations and medical student interest have driven the implementation of medical Spanish curricula at U.S. medical schools, and more schools have plans to incorporate this curriculum in the near future. Studies are needed to reveal best practices for developing and evaluating the curriculum.     

Empathy Training for Resident Physicians: A Randomized Controlled Trial of a Neuroscience-Informed Curriculum

Background

Physician empathy is an essential attribute of the patient–physician relationship and is associated with better outcomes, greater patient safety and fewer malpractice claims.

Objective

We tested whether an innovative empathy training protocol grounded in neuroscience could improve physician empathy as rated by patients.

Design

Randomized controlled trial.

Intervention

We randomly assigned residents and fellows from surgery, medicine, anesthesiology, psychiatry, ophthalmology, and orthopedics (N = 99, 52% female, mean age 30.6 ± 3.6) to receive standard post-graduate medical education or education augmented with three 60-minute empathy training modules.

Main Measure

Patient ratings of physician empathy were assessed within one-month pre-training and between 1–2 months post-training with the use of the Consultation and Relational Empathy (CARE) measure. Each physician was rated by multiple patients (pre-mean = 4.6 ± 3.1; post-mean 4.9 ± 2.5), who were blinded to physician randomization. The primary outcome was change score on the patient-rated CARE.

Key Results

The empathy training group showed greater changes in patient-rated CARE scores than the control (difference 2.2; P = 0.04). Trained physicians also showed greater changes in knowledge of the neurobiology of empathy (difference 1.8; P < 0.001) and in ability to decode facial expressions of emotion (difference 1.9; P < 0.001).

Conclusions

A brief intervention grounded in the neurobiology of empathy significantly improved physician empathy as rated by patients, suggesting that the quality of care in medicine could be improved by integrating the neuroscience of empathy into medical education.KEY WORDS: empathy, randomized controlled trial, communication skills, graduate medical education, patient–physician relationship     

Do First Opinions Affect Second Opinions?

Background

Second medical opinions have become commonplace and even mandatory in some health-care systems, as variations in diagnosis, treatment or prognosis may emerge among physicians.

Objective

To evaluate whether physicians’ judgment is affected by another medical opinion given to a patient.

Design

Orthopedic surgeons and neurologists filled out questionnaires presenting eight hypothetical clinical scenarios with suggested treatments. One group of physicians (in each specialty) was told what the other physician’s opinion was (study group), and the other group was not told what it was (control group).

Participants

A convenience sample of 332 physicians in Israel: 172 orthopedic surgeons (45.9% of their population) and 160 neurologists (64.0% of their population).

Measurements

Scoring was by choice of less or more interventional treatment in the scenarios. We used χ² tests and repeated measures ANOVA to compare these scores between the two groups. We also fitted a cumulative ordinal regression to account for the dependence within each physician’s responses.

Results

Orthopedic surgeons in the study group chose a more interventionist treatment when the other physician suggested an intervention than those in the control group [F (1, 170) = 4.6, p = 0.03; OR = 1.437, 95% CI 1.115-1.852]. Evaluating this effect separately in each scenario showed that in four out of the eight scenarios, they chose a more interventional treatment when the other physician suggested an intervention (scenario 1, p = 0.039; scenario 2, p < 0.001; scenario 3, p = 0.033; scenario 6, p < 0.001). These effects were insignificant among the neurologists [F (1,158) = 0.44, p = 0.51; OR = 1.087, 95% CI 0.811-1.458]. In both specialties there were no differences in responses by level of clinical experience [orthopedic surgeons: F (2, 166) = 0.752, p = 0.473; neurologists: F (2,154) = 1.951, p = 0.146].

Conclusions

The exploratory survey showed that in some cases physicians’ judgments may be affected by other physicians’ opinions, but unaffected in other cases. Weighing previous opinions may yield a more informed clinical decision, yet physicians may be unintentionally influenced by previous opinions. Second opinion has the potential to improve the clinical decision-making processes, and mechanisms are needed to reconcile discrepant opinions.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-012-2056-y) contains supplementary material, which is available to authorized users.KEY WORDS: second-opinion, differential diagnosis, diagnostic reasoning, medical decision-making, health policy, surgery, orthopedics, neurology, surveys, consultation     

Moving Forward in GME Reform: A 4 + 1 Model of Resident Ambulatory Training

BACKGROUND

Traditional ambulatory training models have limitations in important domains, including opportunities for residents to learn, fragmentation of care delivery experience, and satisfaction with ambulatory experiences. New models of ambulatory training are needed.

AIM

To compare the impact of a traditional ambulatory training model with a templated 4 + 1 model.

SETTING

A large university-based internal medicine residency using three different training sites: a patient-centered medical home, a hospital-based ambulatory clinic, and community private practices.

PARTICIPANTS

Residents, faculty, and administrative staff.

PROGRAM DESCRIPTION

Development of a templated 4 + 1 model of residency where trainees do not attend to inpatient and outpatient responsibilities simultaneously.

PROGRAM EVALUATION

A mixed-methods analysis of survey and nominal group data measuring three primary outcomes: 1) Perception of learning opportunities and quality of faculty teaching; 2) Reported fragmentation of care delivery experience; 3) Satisfaction with ambulatory experiences. Self-reported empanelment was a secondary outcome. Residents’ learning opportunities increased (p = 0.007) but quality of faculty teaching was unchanged. Participants reported less fragmentation in the care residents provide patients in the inpatient and outpatient setting (p < 0.0001). Satisfaction with ambulatory training improved (p < 0.0001). Self-reported empanelment also increased (p < 0.0001). Results held true for residents, faculty, and staff at all three ambulatory training sites (p < 0.0001).

DISCUSSION

A 4 + 1 model increased resident time in ambulatory continuity clinic, enhanced learning opportunities, reduced fragmentation of care residents provide, and improved satisfaction with ambulatory experiences. More studies of similar models are needed to evaluate effects on additional trainee and patient outcomes.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-013-2387-3) contains supplementary material, which is available to authorized users.KEY WORDS: ambulatory training, 4 + 1 model     

Association Between Race, Depression, and Antiretroviral Therapy Adherence in a Low-Income Population with HIV Infection

Background

Racial disparities exist in many aspects of HIV/AIDS. Comorbid depression adds to the complexity of disease management. However, prior research does not clearly show an association between race and antiretroviral therapy (ART) adherence, or depression and adherence. It is also not known whether the co-existence of depression modifies any racial differences that may exist.

Objective

To examine racial differences in ART adherence and whether the presence of comorbid depression moderates these differences among Medicaid-enrolled HIV-infected patients.

Design

Retrospective cohort study.

Setting

Multi-state Medicaid database (Thomson Reuters MarketScan®).

Participants

Data for 7,034 HIV-infected patients with at least two months of antiretroviral drug claims between 2003 and 2007 were assessed.

Main Measures

Antiretroviral therapy adherence (90 % days covered) were measured for a 12-month period. The main independent variables of interest were race and depression. Other covariates included patient variables, clinical variables (comorbidity and disease severity), and therapy-related variables.

Key Results

In this study sample, over 66 % of patients were of black race, and almost 50 % experienced depression during the study period. A significantly higher portion of non-black patients were able to achieve optimal adherence (≥90 %) compared to black patients (38.6 % vs. 28.7 %, p < 0.001). In fact, black patients had nearly 30 % decreased odds of being optimally adherent to antiretroviral drugs compared to non-black patients (OR = 0.70, 95 % CI: 0.63–0.78), and was unchanged regard less of whether the patient had depression. Antidepressant treatment nearly doubled the odds of optimal ART adherence among patients with depression (OR = 1.92, 95 % CI: 1.12–3.29).

Conclusions

Black race was significantly associated with worse ART adherence, which was not modified by the presence of depression. Under-diagnosis and under-treatment of depression may hinder ART adherence among HIV-infected patients of all races.KEY WORDS: HIV, adherence, depression, race, Medicaid     

Asthma Beliefs Are Associated with Medication Adherence in Older Asthmatics

BACKGROUND

Empirical research and health policies on asthma have focused on children and young adults, even though asthma morbidity and mortality are higher among older asthmatics.

OBJECTIVE

To explore the relationship of asthma-related beliefs and self-reported controller medication adherence in older asthmatics.

DESIGN

An observational study of asthma beliefs and self-management among older adults.

PARTICIPANTS

Asthmatics ages ≥60 years (N = 324, mean age 67.4 ± 6.8, 28 % white, 32 % black, 30 % Hispanic) were recruited from primary care practices in New York City and Chicago.

MAIN MEASURES

Self-reported controller medication adherence was assessed using the Medication Adherence Report Scale. Based on the Common Sense Model of Self-Regulation, patients were asked if they believe they only have asthma with symptoms, their physician can cure their asthma, and if their asthma will persist. Beliefs on the benefit, necessity and concerns of treatment use were also assessed. Multivariate logistic regression was used to examine the association of beliefs with self-reported medication adherence.

KEY RESULTS

The majority (57.0 %) of patients reported poor adherence. Poor self-reported adherence was more common among those with erroneous beliefs about asthma illness and treatments, including the “no symptoms, no asthma” belief (58.7 % vs. 31.7 %, respectively, p < 0.001), “will not always have asthma” belief (34.8 % vs. 12.5 %, p < 0.001), and the “MD can cure asthma” belief (21.7 % vs. 9.6 %, p = 0.01). Adjusting for illness beliefs, treatment beliefs and demographics, patients with a “no symptoms, no asthma” belief had lower odds of having good self-reported adherence (odds ratio [OR] 0.45, 95 % confidence interval [CI] 0.23-0.86), as did those with negative beliefs about the benefits (OR 0.73, 95 % CI 0.57-0.94) and necessity (OR 0.89, 95 % CI 0.83-0.96) of treatment.

CONCLUSIONS

Illness and treatment beliefs have a strong influence on self-reported medication adherence in older asthmatics. Interventions to improve medication adherence in older asthmatics by modifying illness and treatment beliefs warrant study.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-012-2160-z) contains supplementary material, which is available to authorized users.KEY WORDS: asthma, disease management, medication adherence, aging, health beliefs.     

Randomized controlled trial of health maintenance reminders provided directly to patients through an electronic PHR

BACKGROUND

Provider and patient reminders can be effective in increasing rates of preventive screenings and vaccinations. However, the effect of patient-directed electronic reminders is understudied.

OBJECTIVE

To determine whether providing reminders directly to patients via an electronic Personal Health Record (PHR) improved adherence to care recommendations.

DESIGN

We conducted a cluster randomized trial without blinding from 2005 to 2007 at 11 primary care practices in the Partners HealthCare system.

PARTICIPANTS

A total of 21,533 patients with access to a PHR were invited to the study, and 3,979 (18.5%) consented to enroll.

INTERVENTIONS

Patients in the intervention arm received health maintenance (HM) reminders via a secure PHR “eJournal,” which allowed them to review and update HM and family history information. Patients in the active control arm received access to an eJournal that allowed them to input and review information related to medications, allergies and diabetes management.

MAIN MEASURES

The primary outcome measure was adherence to guideline-based care recommendations.

KEY RESULTS

Intention-to-treat analysis showed that patients in the intervention arm were significantly more likely to receive mammography (48.6% vs 29.5%, p = 0.006) and influenza vaccinations (22.0% vs 14.0%, p = 0.018). No significant improvement was observed in rates of other screenings. Although Pap smear completion rates were higher in the intervention arm (41.0% vs 10.4%, p < 0.001), this finding was no longer significant after excluding women’s health clinics. Additional on-treatment analysis showed significant increases in mammography (p = 0.019) and influenza vaccination (p = 0.015) for intervention arm patients who opened an eJournal compared to control arm patients, but no differences for any measure among patients who did not open an eJournal.

CONCLUSIONS

Providing patients with HM reminders via a PHR may be effective in improving some elements of preventive care.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-011-1859-6) contains supplementary material, which is available to authorized users.KEY WORDS: health maintenance reminders, personal health record, preventive care, clinical decision support, Patient Gateway     

Medical Home Features of VHA Primary Care Clinics and Avoidable Hospitalizations

Background

As the Veterans Health Administration (VHA) reorganizes providers into the patient-centered medical home, questions remain whether this model of care can demonstrate improved patient outcomes and cost savings.

Objective

We measured adoption of medical home features by VHA primary care clinics prior to widespread implementation of the patient-centered medical home and examined if they were associated with lower risk and costs of potentially avoidable hospitalizations.

Design

Secondary patient data was linked to clinic administrative and survey data. Patient and clinic factors in the baseline year (FY2009) were used to predict patient outcomes in the follow-up year.

Participants

2,853,030 patients from 814 VHA primary care clinics

Main Measures

Patient outcomes were measured by hospitalizations for an ambulatory care sensitive condition (ACSC) and their costs and identified through diagnosis and procedure codes from inpatient records. Clinic adoption of medical home features was obtained from the American College of Physicians Medical Home Builder®.

Key Results

The overall mean home builder score in the study clinics was 88 (SD = 13) or 69 %. In adjusted analyses an increase of 10 points in the medical home adoption score in a clinic decreased the odds of an ACSC hospitalization for patients by 3 % (P = 0.032). By component, higher access and scheduling (P = 0.004) and care coordination and transitions (P = 0.020) component scores were related to lower risk of an ACSC hospitalization, and higher population management was related to higher risk (P = 0.023). Total medical home features was not related to ACSC hospitalization costs among patients with at least one (P = 0.074).

Conclusion

Greater adoption of medical home features by VHA primary care clinics was found to be significantly associated with lower risk of avoidable hospitalizations with access and scheduling and care coordination/transitions in care as key factors.KEY WORDS: medical home, avoidable hospitalizations, access, care coordination     

Outcomes of Anticoagulation Therapy in Patients with Mental Health Conditions

Background

Patients with mental health conditions (MHCs) experience poor anticoagulation control when using warfarin, but we have limited knowledge of the association between specific mental illness and warfarin treatment outcomes.

Objective

To examine the relationship between the severity of MHCs and outcomes of anticoagulation therapy.

Design

Retrospective cohort analysis.

Participants

We studied 103,897 patients on warfarin for 6 or more months cared for by the Veterans Health Administration during fiscal years 2007–2008. We identified 28,216 patients with MHCs using ICD-9 codes: anxiety disorders, bipolar disorder, depression, post-traumatic stress disorder, schizophrenia, and other psychotic disorders.

Main Measures

Outcomes included anticoagulation control, as measured by percent time in the therapeutic range (TTR), as well as major hemorrhage. Predictors included different categories of MHC, Global Assessment of Functioning (GAF) scores, and psychiatric hospitalizations.

Key Results

Patients with bipolar disorder, depression, and other psychotic disorders experienced TTR decreases of 2.63 %, 2.26 %, and 2.92 %, respectively (p < 0.001), after controlling for covariates. Patients with psychotic disorders other than schizophrenia experienced increased hemorrhage after controlling for covariates [hazard ratio (HR) 1.24, p = 0.03]. Having any MHC was associated with a slightly increased hazard for hemorrhage (HR 1.19, p < 0.001) after controlling for covariates.

Conclusion

Patients with specific MHCs (bipolar disorder, depression, and other psychotic disorders) experienced slightly worse anticoagulation control. Patients with any MHC had a slightly increased hazard for major hemorrhage, but the magnitude of this difference is unlikely to be clinically significant. Overall, our results suggest that appropriately selected patients with MHCs can safely receive therapy with warfarin.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-2784-2) contains supplementary material, which is available to authorized users.KEY WORDS: anticoagulation, mental health, veterans, warfarin therapy, psychiatric conditions     

Usual Source of Care and Outcomes Following Acute Myocardial Infarction

Background

The quality of the relationship between a patient and their usual source of care may impact outcomes, especially after an acute clinical event requiring regular follow-up.

Objective

To examine the association between the presence and strength of a usual source of care with mortality and readmission after hospitalization for acute myocardial infarction (AMI).

Design

Prospective Registry Evaluating Myocardial Infarction: Event and Recovery (PREMIER), an observational, 19-center study.

Patients

AMI patients discharged between January 2003 and June 2004.

Main Measures

The strength of the usual source of care was categorized as none, weak, or strong based upon the duration and familiarity of the relationship. Main outcome measures were readmissions and mortality at 6 months and 12 months post-AMI, examined in multivariable analysis adjusting for socio-demographic characteristics, access and barriers to care, financial status, baseline risk factors, and AMI severity.

Key Results

Among 2,454 AMI patients, 441 (18.0 %) reported no usual source of care, whereas 247 (10.0 %) and 1,766 (72.0 %) reported weak and strong usual sources of care, respectively. When compared with a strong usual source of care, adults with no usual source of care had higher 6-month mortality rates [adjusted hazard ratio (aHR) = 3.15, 95 % CI, 1.79–5.52; p < 0.001] and 12-month mortality rates (aHR = 1.92, 95 % CI, 1.19–3.12; p = 0.01); adults with a weak usual source of care trended toward higher mortality at 6 months (aHR = 1.95, 95 % CI, 0.98–3.88; p = 0.06), but not 12 months (p = 0.23). We found no association between the usual source of care and readmissions.

Conclusions

Adults with no or weak usual sources of care have an increased risk for mortality following AMI, but not for readmission.

Electronic supplementary material

The online version of this article (doi:10.1007/s11606-014-2794-0) contains supplementary material, which is available to authorized users.KEY WORDS: doctor and patient relationship, usual source of care, myocardial infarction     

Improving Medication Adherence through Graphically Enhanced Interventions in Coronary Heart Disease (IMAGE-CHD): A Randomized Controlled Trial

Background

Up to 50 % of patients do not take medications as prescribed. Interventions to improve adherence are needed, with an understanding of which patients benefit most.

Objective

To test the effect of two low-literacy interventions on medication adherence.

Design

Randomized controlled trial, 2 × 2 factorial design.

Participants

Adults with coronary heart disease in an inner-city primary care clinic.

Interventions

For 1 year, patients received usual care, refill reminder postcards, illustrated daily medication schedules, or both interventions.

Main Measures

The primary outcome was cardiovascular medication refill adherence, assessed by the cumulative medication gap (CMG). Patients with CMG < 0.20 were considered adherent. We assessed the effect of the interventions overall and, post-hoc, in subgroups of interest.

Key Results

Most of the 435 participants were elderly (mean age = 63.7 years), African-American (91 %), and read below the 9th-grade level (78 %). Among the 420 subjects (97 %) for whom CMG could be calculated, 138 (32.9 %) had CMG < 0.20 during follow-up and were considered adherent. Overall, adherence did not differ significantly across treatments: 31.2 % in usual care, 28.3 % with mailed refill reminders, 34.2 % with illustrated medication schedules, and 36.9 % with both interventions. In post-hoc analyses, illustrated medication schedules led to significantly greater odds of adherence among patients who at baseline had more than eight medications (OR = 2.2; 95 % CI, 1.21 to 4.04) or low self-efficacy for managing medications (OR = 2.15; 95 % CI, 1.11 to 4.16); a trend was present among patients who reported non-adherence at baseline (OR = 1.89; 95 % CI, 0.99 to 3.60).

Conclusions

The interventions did not improve adherence overall. Illustrated medication schedules may improve adherence among patients with low self-efficacy, polypharmacy, or baseline non-adherence, though this requires confirmation.KEY WORDS: coronary heart disease, medical adherence, medication management     

The Effects of Guided Care on the Perceived Quality of Health Care for Multi-morbid Older Persons: 18-Month Outcomes from a Cluster-Randomized Controlled Trial

BACKGROUND

The quality of health care for older Americans with chronic conditions is suboptimal.

OBJECTIVE

To evaluate the effects of “Guided Care” on patient-reported quality of chronic illness care.

DESIGN

Cluster-randomized controlled trial of Guided Care in 14 primary care teams.

PARTICIPANTS

Older patients of these teams were eligible to participate if, based on analysis of their recent insurance claims, they were at risk for incurring high health-care costs during the coming year. Small teams of physicians and their at-risk older patients were randomized to receive either Guided Care (GC) or usual care (UC).

INTERVENTION

“Guided Care” is designed to enhance the quality of health care by integrating a registered nurse, trained in chronic care, into a primary care practice to work with 2–5 physicians in providing comprehensive chronic care to 50–60 multi-morbid older patients.

MEASUREMENTS

Eighteen months after baseline, interviewers blinded to group assignment administered the Patient Assessment of Chronic Illness Care (PACIC) survey by telephone. Logistic and linear regression was used to evaluate the effect of the intervention on patient-reported quality of chronic illness care.

RESULTS

Of the 13,534 older patients screened, 2,391 (17.7%) were eligible to participate in the study, of which 904 (37.8%) gave informed consent and were cluster-randomized. After 18 months, 95.3% and 92.2% of the GC and UC recipients who remained alive and eligible completed interviews. Compared to UC recipients, GC recipients had twice greater odds of rating their chronic care highly (aOR = 2.13, 95% CI = 1.30–3.50, p = 0.003).

CONCLUSION

Guided Care improves self-reported quality of chronic health care for multi-morbid older persons.KEY WORDS: quality of care, chronic illness, older