Differences in the Patterns of Health Care System Distrust Between Blacks and Whites

Context  Although health care-related distrust may contribute to racial disparities in health and health care in the US, current evidence about racial differences in distrust is often conflicting, largely limited to measures of physician trust, and rarely linked to multidimensional trust or distrust. Objective  To test the hypothesis that racial differences in health care system distrust are more closely linked to values distrust than to competence distrust. Design  Cross-sectional telephone survey. Participants  Two hundred fifty-five individuals (144 black, 92 white) who had been treated in primary care practices or the emergency department of a large, urban Mid-Atlantic health system. Primary measures  Race, scores on the overall health care system distrust scale and on the 2 distrust subscales, values distrust and competence distrust. Results  In univariate analysis, overall health care system distrust scores were slightly higher among blacks than whites (25.8 vs 24.1, p = .05); however, this difference was driven by racial differences in values distrust scores (15.4 vs 13.8, p = .003) rather than in competence distrust scores (10.4 vs 10.3, p = .85). After adjustment for socioeconomic status, health/psychological status, and health care access, individuals in the top quartile of values distrust were significantly more likely to be black (odds ratio = 2.60, 95% confidence interval = 1.03–6.58), but there was no significant association between race and competence distrust. Conclusions  Racial differences in health care system distrust are complex with far greater differences seen in the domain of values distrust than in competence distrust. This framework may be useful for explaining the mixed results of studies of race and health care-related distrust to date, for the design of future studies exploring the causes of racial disparities in health and health care, and for the development and testing of novel strategies for reducing these disparities.     

Distrust of the health care system and self-reported health in the United States

CONTEXT: Despite theoretical concerns that health care related distrust may lead to poor health outcomes by interfering with effective health care, little is currently known about the prevalence or outcomes of distrust of the health care system in the United States.
OBJECTIVE: To investigate the association between distrust of the health care system and self-reported health status among the general population in the United States.
DESIGN: Random-digit-dialing telephone survey.
PARTICIPANTS: Nine hundred and sixty-one adult residents of the continental U.S.
PRIMARY MEASURES: Distrust of the health care system and self-reported health status.
RESULTS: Distrust of the health care system is relatively high in the United States, with between 20% and 80% of respondents reporting distrust for each item on the Health Care System Distrust scale and a median scale score of 31 (potential range from 10 to 50). Distrust of the health care system is strongly associated with self-reported fair/poor health (odds ratio [OR] 1.40%, 95% confidence interval [CI] 1.12 to 1.75 for each standard deviation increase in distrust), even after adjusting for sociodemographic characteristics, access to health care and trust in primary physicians. In contrast, low trust in one's primary physician is much lower (only 10% to 20% of respondents reported distrust for each item) and is not associated with health status.
CONCLUSIONS: Distrust of the health care system is relatively high in the general population in the United States and is strongly associated with worse self-reported health. Further studies are needed to assess the direction of this association and the mechanisms involved.     

Development and testing of the health care system distrust scale

BACKGROUND: Distrust of the health care system may be a significant barrier to seeking medical care, adhering to preventive health care and treatment regimens, and participating in medical research. OBJECTIVE: To describe the development and psychometric testing of an instrument (the Health Care System Distrust Scale) to measure distrust of the health care system. METHODS: Scale development involved 2 phases. In Phase 1, a pilot instrument was developed based on a conceptual model of health care-related distrust. Draft items were created using focus group sessions with members of the general public, literature review, and expert opinion. Draft items were pilot tested with 55 individuals waiting to be assigned to jury duty at the Municipal Court of Philadelphia. A priori, candidate items for elimination or revision included those with >5% missing data, extremely low or high interitem or item-total correlations, or those having a negative effect on the scale's internal consistency. In Phase 2, we conducted a survey of 400 prospective jurors to assess the reliability and validity of the final scale scores. RESULTS: In Phase 1, a 10-item scale was constructed that included 4 items measuring honesty, 2 items measuring confidentiality, 2 items measuring competence, and 2 items measuring fidelity. The participants in Phase 2 had a mean age of 41 years. Forty-three percent were African-American, 45% white, and 4% Hispanic. Scores on the Health Care System Distrust scale ranged from 12 to 46 with a possible range from 10 to 50. The mean score was 29.4 with a standard deviation of 6.33. No item had over 5% missing data. Internal consistency (Cronbach's alpha) was 0.75. Item-total correlations ranged from 0.27 to 0.57. Principal components analysis revealed 1 general component accounting for 32% of the variance. Nine of the variables had loadings higher than 0.40. As predicted, distrust of the health care system was higher among African Americans than whites and was inversely correlated with trust in personal physicians. CONCLUSIONS: Initial testing suggests that we developed an instrument with valid and reliable scores in order to measure distrust of the health care system. Future research is needed to evaluate the validity and reliability of the Health Care System Distrust scale among diverse populations. This instrument can facilitate the investigation of the prevalence, causes, and effects of health care system distrust in the United States.     

Development and Testing of the Multidimensional Trust in Health Care Systems Scale

Objective  To describe the development and psychometric testing of the Multidimensional Trust in Health Care Systems Scale (MTHCSS). Methods  Scale development occurred in 2 phases. In phase 1, a pilot instrument with 70 items was generated from the review of the trust literature, focus groups, and expert opinion. The 70 items were pilot tested in a sample of 256 students. Exploratory factor analysis was used to derive an orthogonal set of correlated factors. In phase 2, the final scale was administered to 301 primary care patients to assess reliability and validity. Phase 2 participants also completed validated measures of patient-centered care, health locus of control, medication nonadherence, social support, and patient satisfaction. Results  In phase 1, a 17-item scale (MTHCSS) was developed with 10 items measuring trust in health care providers, 4 items measuring trust in health care payers, and 3 items measuring trust in health care institutions. In phase 2, the 17-item MTHCSS had a mean score of 63.0 (SD 8.8); the provider subscale had a mean of 40.0 (SD 6.2); the payers subscale had a mean of 12.8 (SD 3.0); and the institutions subscale had a mean of 10.3 (SD 2.1). Cronbach’s α for the MTHCSS was 0.89 and 0.92, 0.74, and 0.64 for the 3 subscales. The MTHCSS was significantly correlated with patient-centered care (r = .22 to .62), locus of control—chance (r = .42), medication nonadherence (r = −.22), social support (r = .25), and patient satisfaction (r = .67). Conclusions  The MTHCSS is a valid and reliable instrument for measuring the 3 objects of trust in health care and is correlated with patient-level health outcomes.     

Co-ordination of Diabetes Care in the Primary and the Secondary Health Care System in Denmark

In Denmark the co-operation between the primary and secondary health care system is organized through referrals. Recommendations for improving interaction between the diabetes team (diabetologists, diabetes nurses, dietitians, chiropodists etc.) at the diabetes clinic, and general practice have been prepared by a working party for the Danish National Board of Health. General recommendations: (a) Appointment of a liaison committee in each county consisting of general practitioners (GPs), diabetologists, administrators, etc. (b) Employment of a GP at the diabetes clinic to take care of improving communication, teaching, research, quality assessment, etc. (c) Referral of all newly diagnosed patients with Type 1 diabetes and younger or complicated patients with Type 2 diabetes to the diabetes clinic. More far-reaching forms of co-operation to be discussed in the liaison committees include: (a) Based upon his own knowledge of where to look for help to solve a specific health problem, the diabetic patient may on his own initiative consult either the diabetes clinic or general practice. (b) Provision of access to consult the diabetes nurse/dietitian at the diabetes clinic for instruction without a formal referral. (c) Patients treated solely in general practice and thus unknown to the diabetes clinic may be referred or reported systematically to the diabetes clinic.     

Using Complexity Theory to Build Interventions that Improve Health Care Delivery in Primary Care

Previous observational research confirms abundant variation in primary care practice. While variation is sometimes viewed as problematic, its presence may also be highly informative in uncovering ways to enhance health care delivery when it represents unique adaptations to the values and needs of people within the practice and interactions with the local community and health care system. We describe a theoretical perspective for use in developing interventions to improve care that acknowledges the uniqueness of primary care practices and encourages flexibility in the form of intervention implementation, while maintaining fidelity to its essential functions.     

The Age‐Friendly Health System Imperative

The unprecedented changes happening in the American healthcare system have many on high alert as they try to anticipate legislative actions. Significant efforts to move from volume to value, along with changing incentives and alternative payment models, will affect practice and the health system budget. In tandem, growth in the population aged 65 and older is celebratory and daunting. The John A. Hartford Foundation is partnering with the Institute for Healthcare Improvement to envision an age‐friendly health system of the future. Our current prototyping for new ways of addressing the complex and interrelated needs of older adults provides great promise for a more‐effective, patient‐directed, safer healthcare system. Proactive models that address potential health needs, prevent avoidable harms, and improve care of people with complex needs are essential. The robust engagement of family caregivers, along with an appreciation for the value of excellent communication across care settings, is at the heart of our work. Five early‐adopter health systems are testing the prototypes with continuous improvement efforts that will streamline and enhance our approach to geriatric care.     

Employing the Electronic Health Record to Improve Diabetes Care: A Multifaceted Intervention in an Integrated Delivery System

INTRODUCTION Type 2 diabetes is one of the nation’s most prevalent chronic diseases. Although well-known practice guidelines exist, real-life clinical performance often falls short of benchmarks. AIM Employ an electronic registry derived from a fully integrated electronic health record (EHR) as the cornerstone of an intervention to improve compliance with recommended diabetes performance measures in an integrated practice network. SETTING Geisinger Health System’s network of 38 practice sites providing care to over 20,000 persons with diabetes located in a 40-county region of central and northeastern Pennsylvania. PROGRAM DESCRIPTION A multidisciplinary group of physicians worked to create a “bundle” of best practice measures for diabetes. This measurement tool was then used as part of a multifaceted intervention to improve physician performance in diabetes care, including audit and feedback, computerized reminders, and financial incentives. Changes in performance of individual measures and the total “bundle” were tracked monthly over 1 year. PROGRAM EVALUATION Significant increases were seen in all measures of diabetes care over the 12-month period of the study. Vaccination for pneumococcal disease and influenza improved from 56.5% to 80.8% (p < .0001) and 55.1% to 71.0% (p < .0001), respectively. The percentage of patients with ideal glucose control (HBA1c < 7.0) increased from 32.2% to 34.8% (p < .001), and blood pressure control (<130/80) improved from 39.7% to 43.9% (p < .0001). The overall number of patients receiving all 9 “bundled” measurements improved from 2.4% to 6.5% (p < .0001). DISCUSSION Diabetes care improved significantly in response to a multifaceted intervention featuring the use of an EHR-derived registry in an integrated delivery system. More work is needed to demonstrate that such improvements will translate into improved patient health outcomes.     

Interest in Long-Term Care Among Health Services Administration Students

The aging of the population has created increased opportunities for health administrators in long-term care. This study consisted of a cross-sectional survey of 68 undergraduate health services administration students to explore factors related to interest in a career in long-term care administration. One third expressed interest working in the field. Experience in long-term care settings, quality of contact with unrelated older adults, satisfaction working with the elderly, and confidence in the ability to work in the field were positively associated with interest in long-term care administration. The findings have important implications for experiential learning in health administration programs.     

Impact of Home Health Care on Health Care Resource Utilization Following Hospital Discharge: A Cohort Study

Background

As healthcare costs rise, home health care represents an opportunity to reduce preventable adverse events and costs following hospital discharge. No studies have investigated the utility of home health care within the context of a large and diverse patient population.

Barriers to Veterans Health Administration Care in a Nationally Representative Sample of Women Veterans

BACKGROUND: Women veterans are generally less healthy than their nonveteran female counterparts or male veterans. Accumulating evidence suggests there may be barriers to women veterans' access to and use of Veterans Health Administration (VHA) care.
OBJECTIVE: To document perceived and/or actual barriers to care in a nationally representative sample of women veterans and examine associations with VHA use.
DESIGN: Cross-sectional telephone survey.
PARTICIPANTS: Women who are current and former users of VHA from VA's National Registry of Women Veterans.
MEASUREMENTS: Assessments of perceptions of VHA care, background characteristics, and health service use.
RESULTS: Perceptions of VHA care were most positive regarding facility/physical environment characteristics and physician skill and sensitivity and least positive regarding the availability of needed services and logistics of receiving VHA care ( M =0.05 and M =−0.10; M =−0.23 and M =−0.25, respectively). The most salient barrier to the use of VHA care was problems related to ease of use. Moreover, each of the barriers constructs contributed unique variance in VHA health care use above and beyond background characteristics known to differentiate current users from former VHA users (Odds ratio [OR]=4.03 for availability of services; OR=2.63 for physician sensitivity and skill: OR=2.70 for logistics of care; OR=2.30 for facility/physical environment). Few differences in barriers to care and their association with VHA health care use emerged for women with and without service-connected disabilities.
CONCLUSIONS: Findings highlight several domains in which VHA decisionmakers can intervene to enhance the care available to women veterans and point to a number of areas for further investigation.     

Accuracy of the Pain Numeric Rating Scale as a Screening Test in Primary Care

BACKGROUND Universal pain screening with a 0–10 pain intensity numeric rating scale (NRS) has been widely implemented in primary care. OBJECTIVE To evaluate the accuracy of the NRS as a screening test to identify primary care patients with clinically important pain. DESIGN Prospective diagnostic accuracy study PARTICIPANTS 275 adult clinic patients were enrolled from September 2005 to March 2006. MEASUREMENTS We operationalized clinically important pain using two alternate definitions: (1) pain that interferes with functioning (Brief Pain Inventory interference scale ≥ 5) and (2) pain that motivates a physician visit (patient-reported reason for the visit). RESULTS 22% of patients reported a pain symptom as the main reason for the visit. The most common pain locations were lower extremity (21%) and back/neck (18%). The area under the receiver operator characteristic curve for the NRS as a test for pain that interferes with functioning was 0.76, indicating fair accuracy. A pain screening NRS score of 1 was 69% sensitive (95% CI 60–78) for pain that interferes with functioning. Multilevel likelihood ratios for scores of 0, 1–3, 4–6, and 7–10 were 0.39 (0.29–0.53), 0.99 (0.38–2.60), 2.67 (1.56–4.57), and 5.60 (3.06–10.26), respectively. Results were similar when NRS scores were evaluated against the alternate definition of clinically important pain (pain that motivates a physician visit). CONCLUSIONS The most commonly used measure for pain screening may have only modest accuracy for identifying patients with clinically important pain in primary care. Further research is needed to evaluate whether pain screening improves patient outcomes in primary care. Earlier versions of this work were presented at the 2005 national meeting of the Robert Wood Johnson Clinical Scholars Program and the 2006 national meeting of the Society of General Internal Medicine.