Health and Ambulatory Care Use Among Native American Veterans

In 1995, the Veterans Health Administration reorganized its health services structure to emphasize ambulatory care. Successful health care planning and improving access to ambulatory care services now depends upon a better understanding of health care needs and outpatient services. Because the veteran population is heterogeneous, it is important to understand the health, access issues, and utilization of ambulatory care services in order to develop effective strategies and interventions to ensure access to and utilization of ambulatory care. Drawing on a focus group methodology with 86 Native American veterans, representing 34 tribes, this study is a qualitative examination of the health, access, use of the Department of Veterans Affairs Health Care services, barriers to health care, and satisfaction with care experienced by Native American veterans. Results reveal problems in accessing care, receiving appropriate care, and coordinating care within the VA health care system. Policy and program recommendations include increasing outreach and education efforts regarding the availability of benefits and services, improving coordination of services between the Indian Health Service and the VA, and reemphasizing the importance of patient-centered care.     

School Disrepair and Substance Use Among Regular and Alternative High School Students

BACKGROUND: The physical environment influences adolescent health behavior and personal development. This article examines the relationship between level of school disrepair and substance use among students attending regular high school (RHS) and alternative high school (AHS). METHODS: Data were collected from students (N = 7058) participating in 2 randomized controlled trials of a school-based substance abuse prevention program implemented across the United States. Students provided substance use and demographic information on a self-reported survey. Data for the physical disrepair of schools were collected from individual rater observations of each school environment. We hypothesized that school disrepair would be positively associated with substance use controlling for individual characteristics and a socioeconomic status proxy. Multilevel mixed modeling was used to test the hypothesized association and accounted for students nested within schools. RESULTS: Findings indicated that students attending AHS with greater school disrepair were more likely to report the use of marijuana and other illicit drugs (ie, cocaine, heroin). Students attending RHS with greater school disrepair were less likely to report smoking cigarettes. CONCLUSIONS: Differences in findings between RHS and AHS students are discussed, and implications for substance use prevention programming are offered. Students attending AHS with greater school disrepair may require more substance abuse prevention programming, particularly to prevent illicit substance use.     

Methamphetamine Use Is Independently Associated With Recent Risky Sexual Behaviors and Adolescent Pregnancy

BACKGROUND: Lifetime methamphetamine use among adolescents is estimated to be between 5% and 10%. Youth substance use in general is known to be associated with risky sexual behaviors, but the effect of methamphetamine use on recent risky sexual behaviors and adolescent pregnancy has received little attention. The purpose of this analysis was to evaluate the association between lifetime methamphetamine use and recent (past 3 months) risky sexual behaviors and lifetime adolescent pregnancy, adjusting for other substance use. METHODS: We analyzed data from the 2003 National Youth Risk Behavior Survey, a school‐based paper‐and‐pencil survey that assesses risky health behaviors among a nationally representative sample of 9th‐ to 12th‐grade students. Multivariable logistic regression was used to calculate adjusted odds ratios (AORs) to examine the association between methamphetamine use and being recently sexually active, having 2 or more recent sex partners, and ever being pregnant or getting someone pregnant. RESULTS: Lifetime methamphetamine use was reported by 7.6% of students. After adjustment for demographic covariates and lifetime use of cigarettes, alcohol, marijuana, and other illicit drugs, lifetime methamphetamine use was associated with recent sexual intercourse (AOR = 1.8, 95% confidence interval [CI] = 1.5‐2.3), having 2 or more recent sex partners (AOR = 3.0, 95% CI = 2.2‐4.2), and ever being pregnant or getting someone pregnant (AOR = 2.9, 95% CI = 2.1‐3.9). CONCLUSIONS: Adolescent methamphetamine use is common and is associated with recent risky sexual behaviors and adolescent pregnancy. Prevention strategies for high school students should integrate education on substance abuse, pregnancy, sexually transmitted infections, and human immunodeficiency virus.     

男性生殖健康热线使用情况分析

探索为男性参与计划生育/生殖健康提供咨询服务的途径,2000年3月设立“避孕套和生殖健康热线—加强生殖健康中男性的责任”人工台和自动台。热线开通以来,通过宣传干预共接听咨询电话3 724次。对其使用结果、咨询对象性别、咨询内容等进行统计分析。人工台接听咨询电话826个,自动台接听2 898个,男性咨询对象占70.1％。人工台咨询较多的问题依次为避孕节育知识、生殖系统疾病诊治、性卫生与性传播疾病,而自动台咨询避孕套使用和性卫生与性传播疾病较多。实践证明,热线是一种保密性强、文明便捷的服务方式,为男性参与生殖健康开辟了新途径。     

Relationship between Clinical Conditions and Use of Veterans Affairs Health Care among Medicare-Enrolled Veterans

Objective. To determine how reliance on Veterans Affairs (VA) for medical care among veterans enrolled in Medicare is affected by medical conditions, access, and patient characteristics. Data Sources/Study Setting. Department of Veterans Affairs. Study Design. We examined reliance on the VA for inpatient, outpatient, and overall medical care among all VA users in fiscal years 2003 and 2004 who were also enrolled in Medicare. We calculated the marginal effects of patient factors on VA reliance using fractional logistic regression; we also analyzed overall VA reliance separately for under‐65 and age‐65+ groups. The primary focus of this analysis was the relationship between aggregated condition categories (ACCs), which represent medical conditions, and reliance on the VA. Principal Findings. Mean VA reliance was significantly higher in the under‐65 population than in the age‐65+ group (0.800 versus 0.531). Lower differential distance to the VA, and higher VA‐determined priority for health care, predicted higher VA reliance. Most individual ACCs were negatively associated with VA reliance, though substance abuse and mental health disorders were significantly associated with increased reliance on VA care. Conditions of the eyes and ears/nose/throat had positive marginal effect on VA reliance for the under 65, while diabetes was positive for age 65+. Among inpatients, veterans with ACCs for mental health conditions, eye conditions, amputations, or infectious and parasitic conditions had higher likelihood of a VA hospitalization than inpatients without these conditions. Conclusions. Many dually enrolled Veterans use both Medicare and VA health care. Age, accessibility, and priority level for VA services have a clear relationship with VA reliance. Because dual use is common, coordination of care among health care settings for such patients should be a policy priority.     

Effective Methods to Improve Recruitment and Retention in School-Based Substance Use Prevention Studies

BACKGROUND: Poor recruitment and high attrition may invalidate results of research studies. This paper describes successful recruitment and retention strategies in a school-based substance use prevention trial and explores factors associated with intervention attendance and retention.
METHODS: A total of 384 parent-child dyads from 15 schools in the New York Metropolitan area participated in a control trial, testing the efficacy of parent-training to prevent youth substance use. Assessments were completed immediately post-intervention and 6-, 12-, and 24-month postintervention. Logistic regression analyses were used to determine which familial and study characteristics predicted attendance in the intervention and retention by parents and youth.
RESULTS: 84% of intervention parents attended 4 of the 5 workshops; 83% of control parents attended their single workshop. Intervention attendance was predicted by parent job status, but this was not significant after controlling for other family factors. Retention rates ranged from 87% to 91% over the 2 years. No family characteristics predicted retention, but time since baseline and attendance at treatment workshops and the control workshop did. For children, age at baseline and ethnicity predicted retention, but this did not remain significant in the adjusted model.
CONCLUSION: Intervention attendance was high and retention rates far exceeded the minimum standard of 70% retention in behavioral studies. Recruitment and retention strategies were effective for different family constellations. Efforts to maximize participation in both treatment and control interventions are critical to retention in longitudinal trials.     

美国区域卫生信息化及有效使用电子健康档案的启示

通过介绍美国区域卫生信息化发展、有效使用EHR计划、区域卫生信息化组织等,探讨推进区域卫生信息化和电子健康档案应用过程中的问题和挑战,包括公共医学术语和技术标准、电子健康档案及区域卫生信息化潜在经济效益、电子健康档案应用保障机制、区域卫生信息化水平评价及区域卫生信息化组织可持续运营等,以提供借鉴。     

The Conceptual and Empirical Link Between Health Behaviors,Self Reported Health,and the Use of Home Health Care in Later Life

ABSTRACT

The primary qualification for Medicare's home health care benefit is being homebound, typically by a chronic disability. Disability and functional ability in late-life are heavily influenced by the long-term practice of health behaviors. One of the goals of Healthy People 2000 is to increase the years of healthy life which are measured, in part, by self reported health status. This compression of morbidity would, in effect, reduce the need for long term care. This paper examines three conceptual models linking health behaviors to self reported health in a unique sample of older adults who have chosen to participate in a corporate sponsored wellness program. It is hoped that these findings will encourage further research on formulating empirical pathways from health behaviors to reduced need for home health care.     

Tobacco Use in Silent Film: Precedents of Modern-Day Substance Use Portrayals

Much research has been done into tobacco use portrayals in film since the mid-twentieth century, but the earlier years of Hollywood history have been overlooked. Yet the first decades of the twentieth century saw annual per capita cigarette consumption increase from under 100 in 1900 upto 1,500 in 1930. The current study looks at frequency and context (gender, age range, socioeconomic status, type of portrayal) of tobacco use in 20 top-grossing silent films spanning the silent feature era (1915-1928). The sample averaged 23.31 tobacco uses per hour. Tobacco use was most often associated with positive characterizations, working/middle class status, masculinity, and youth. Previous research has verified the influence of the film industry on tobacco consumption in modern years, and this potential connection should not be ignored for the silent film era. Top-grossing silent films set a precedent for positive media portrayals of substance use that have persisted to the present day.     

Engaging Primary Care Patients to Use a Patient-Centered Personal Health Record

PURPOSE

Health care leaders encourage clinicians to offer portals that enable patients to access personal health records, but implementation has been a challenge. Although large integrated health systems have promoted use through costly advertising campaigns, other implementation methods are needed for small to medium-sized practices where most patients receive their care.

METHODS

We conducted a mixed methods assessment of a proactive implementation strategy for a patient portal (an interactive preventive health record [IPHR]) offered by 8 primary care practices. The practices implemented a series of learning collaboratives with practice champions and redesigned workflow to integrate portal use into care. Practice implementation strategies, portal use, and factors influencing use were assessed prospectively.

RESULTS

A proactive and customized implementation strategy designed by practices resulted in 25.6% of patients using the IPHR, with the rate increasing 1.0% per month over 31 months. Fully 23.5% of IPHR users signed up within 1 day of their office visit. Older patients and patients with comorbidities were more likely to use the IPHR, but blacks and Hispanics were less likely. Older age diminished as a factor after adjusting for comorbidities. Implementation by practice varied considerably (from 22.1% to 27.9%, P <.001) based on clinician characteristics and workflow innovations adopted by practices to enhance uptake.

CONCLUSIONS

By directly engaging patients to use a portal and supporting practices to integrate use into care, primary care practices can match or potentially surpass the usage rates achieved by large health systems.     

Social Determinants and Health Service Use Among Racial and Ethnic Minorities: Findings From a Community Sample

Multiple models conceptualizing the relationship between social determinants and health exist, but little research has examined the relationship between social determinants and health service use. Using previously collected survey data from racial and linguistic minorities from high-crime communities in a Midwestern urban area, this study uses the Commission on Social Determinants of Health framework to test the structural and intermediary determinants of health service use. The results indicate that perceived discrimination and neighborhood cohesion increase the likelihood of a person using health services. Implications for social work practice, advocacy, and research to address intermediary social determinants are discussed.     

Use of medical emergency services

Background

In the Wesel District (North Rhine-Westphalia), emergency ambulances have been called out with increasing frequency and clinics report that their emergency departments (ED) are increasingly being used outside the consultation hours of panel doctors/compulsory health insurance (CHI) physicians. Therefore, the District Health Conference put this issue on its agenda.

Aims of the study

The aims were to obtain data on the following questions: 1. What do people do when they need medical help outside consultation hours of panel doctors? 2. Do people know that there is a duty panel doctor on call? Do they know how to contact this service? Do people know about the medical emergency service and phone number 112, and the new phone number 19222 for patient transport ambulances?

Material and methods

The study comprised all residents of the District of Wesel between 18 and 87 years of age (approximately 385,000 people). The sample contained 1089 persons drawn in accordance with the Gabler-Häder method and in a second step with the “birthday method”. The survey was carried out by the CATI (computer-assisted telephone interviews) laboratory at the Institute of Public Health (LÖGD, Bielefeld) between 18 February and 28 March 2002.

Results

On being asked “how would you act in case of a non-life-threatening disease outside consultation hours of panel doctors”, 48.6% of respondents were “correct” (i.e. on-call CHI duty physicians), while 51.5% of respondents were “incorrect”, for example “I go to the hospital/emergency department” (24.3%) or “I call the number 112” (13%). About 80% of respondents said they knew about on-call CHI duty physicians. More than 95% of respondents stated they knew about the emergency service of the fire department, and 86% of these respondents were able to recall the correct number 112. About 4% of the respondents said they knew the national telephone number for patient transport, and 58% of these respondents mentioned the correct number (19222).

Discussion

The tiered medical emergency system should be used properly. This aim could be achieved by: (1) informing the public about the 24-hour on-call service provided by panel doctors, that the majority of medical conditions can be treated by panel doctors, and in severe cases a professional and quick referral will be done, and that self-referral to hospital may reduce or even obstruct professional resources for the treatment of “real” emergency patients; (2) informing target groups (elderly people) about the emergency number 112; and (3) informing the public about the national number 19222 for patient transport. Structural measures include: (1) Specific on-call services, and (2) improvement in the transparency and reachability of panel doctors’ on-call services.