Social disadvantage: Its impact on the use of Medicare services related to diabetes in NSW

Objective: To use Medicare data to examine the impact of social disadvantage on the use of health services related to diabetes.
Method: Information on number of diabetic individuals and number of services for select Medicare item codes were retrieved by New South Wales postcodes using a Health Insurance Commission data file. The postcodes were graded into quintiles of social disadvantage.
Results: People at most social disadvantage were significantly less likely to be under the care of a general practitioner (adjusted OR 0.41; 95% CI 0.40–0.41) or consultant physician (adjusted OR 0.50; 95% CI 0.48–0.53), despite this group having the highest prevalence of diabetes. The difference in attendance to other specialists was less marked but nevertheless significant (adjusted OR 0.71; 95% CI 0.68–0.75). Once under a doctor's care, patients at most disadvantage were slightly more likely to undergo HbA1c or microalbuminuria estimation (adjusted OR 1.04; 95% CI 1.00–1.10 and adjusted OR 1.22; 95% CI 1.12–1.33, respectively) but were less likely to undergo lipid or HDL cholesterol estimation (adjusted OR 0.81; 95% CI 0.48–0.53 and adjusted OR 0.85; 95% CI 0.79–0.90, respectively).
Conclusion: While access to medical care is decreased for people at most social disadvantage, once under a doctor's care they receive a level of monitoring that is relatively equal to that provided to people less disadvantaged.
Implication: Strategies are required to ensure equal access to medical services for all persons with diabetes, especially for persons who are at most social and medical disadvantage.     

A cross-sectional study of secondary cardiac care in general practice: impact of personal and practice characteristics

OBJECTIVE: To determine the impact of patient (age, gender, type of and time since diagnosis) and practice (rurality, number of partners, availability of practice nurse) characteristics on secondary cardiac care in general practice in a country without universal registration. METHODS: Medical and demographic data were gathered from the medical charts of 1611 eligible patients from 35 randomly selected practices. Eligible patients were aged under 80 years with a recorded history of acute myocardial infarction, percutaneous trans coronary arteriogram or angina. Self-report data about diet, exercise, smoking and alcohol consumption were provided from postal questionnaire (1084 patients responded; 69% response rate). RESULTS: Having an angina only diagnosis significantly decreased the likelihood of patients being prescribed aspirin (OR = 0.53; 95% CI = 0.40-0.69), lipid-lowering medication (OR = 0.55; 95% CI = 0.43-0.69) or ACE inhibitors (OR = 0.62; 95% CI = 0.48-0.81). Younger patients (OR = 1.05; 95% CI = 1.04-1.06) were also more likely to be prescribed lipid-lowering medication. Cholesterol was predicted by gender only, with females having significantly higher cholesterol (B = -0.41; 95% CI = -0.54 to -0.27). The number of missed opportunities for secondary cardiac care was greater among patients with angina only (B = 0.39; 95% CI = 0.19-0.60). The amount of variance explained by practice and patient variables overall for each of the measures was small, ranging from 2 to 6%. CONCLUSIONS: Practice size or location appears to have little impact on secondary cardiac care. The most consistent significant personal characteristic finding was that patients with a diagnosis of angina only were significantly less likely to receive aspirin, statins or ACE inhibitors and more likely to have more missed opportunities for secondary cardiac care.     

Competing priorities as a barrier to medical care among homeless adults in Los Angeles.

OBJECTIVES: The role of competing priorities as a barrier to the utilization of physical health services was assessed in a subset (n = 363) of a probability sample of homeless adults in Los Angeles. METHODS: Unadjusted odds of four measures of health services utilization were calculated for those with frequent difficulty in meeting their subsistence needs. These odds were then adjusted for a range of characteristics assumed to affect the utilization of health services among the homeless. RESULTS: Before and after adjustment, those with frequent subsistence difficulty were less likely to have a regular source of care (odds ratio [OR] = 0.30, 95% confidence interval [CI] = 0.16, 0.53) and more likely to have gone without needed medical care (OR = 1.77, 95% CI = 1.04, 3.00). Subsistence difficulty had no impact on the likelihood of having an outpatient visit or having been hospitalized. Conclusions remained the same after adjustment. CONCLUSIONS: Frequent subsistence difficulty appears to be an important nonfinancial barrier to the utilization of health services perceived as discretionary among homeless adults.     

Use of Social Services by Pregnant Medicaid Eligible Women in Baltimore

Objectives: To use linked health and social service databases to determine differences in the use of social services by pregnant women in different managed care systems. Methods: Comparison of service use by women enrolled in a fee-for-service primary care case management program (Maryland Access to Care or MAC), in a capitated health maintenance organization (HMO), or not assigned to managed care using six state databases. Participants included 5181 women receiving Medical Assistance (MA) and delivering in Baltimore City in 1993. Outcome measures were receipt of WIC, AFDC, and Food Stamps. Results: The overall proportions of women receiving WIC, AFDC, and Food Stamps at delivery were 52.7%, 89.2%, and 62.7%, respectively. Women enrolled in an HMO at delivery were less likely to be receiving WIC (adjusted odds ratios, 0.8, 95% CI, 0.69 to 0.93), AFDC (OR, 0.20; CI, 0.03 to 0.43 for women with prior children and OR 0.13; CI, 0.09 to 0.20 for women without prior children), and Food Stamps (OR 0.77; CI, 0.59 to 0.95 for women with prior children and OR, 0.49; CI, 0.35 to 0.67 for women without prior children) than their MAC counterparts. Women not assigned to managed care also generally were less likely than their MAC counterparts to receive WIC (OR 0.55; CI, 0.46, 0.66), AFDC (OR 1.07; CI 0.83,1.30 for women with prior children and OR 0.24; CI 0.18,0.34 for women without prior children), and Food Stamps (OR 0.31; CI 0.08, 0.55 for women with prior children and OR 0.31; CI 0.23, 0.41 for women without prior children). Conclusions: Although many low-income pregnant women qualify for select social services, receipt of WIC and Food Stamps was low. Increasing efforts are needed by managed care systems and public health agencies to ensure delivery of appropriate services for women.     

Distance, Use of Resources, and Mortality Among Rural Missouri Residents With Acute Myocardial Infarction

Abstract: Prompt access to medical services is considered critical in managing acute myocardial infarction (AMI). Several socioeconomic and geographic factors affect access to such care in rural areas. This study measured the effect of geographic distance from care on utilization of cardiovascular technology and death after AMI. The records of 1,658 rural Missouri residents age 65 or older with a discharge diagnosis of AMI in 1991 were obtained from Medicare data. The rate of use of cardiovascular technology and rate of post-AMI mortality for rural Missouri residents who live far from emergency departments and cardiac referral centers (CRC) were compared with those who live nearest such services. Those living 60 miles or more from a CRC were less likely to have cardiac catheterization (odds ratio [OR]=0.55; 95% confidence interval [CI]=0.40 to 0.75) or angioplasty (OR=0.68; 95% CI=0.47 to 0.98), compared with those living fewer than 30 miles from a CRC. There were no differences in 30-day, 90-day, or one-year mortality rates. After adjusting for distance to a CRC, those living 20 miles or more from emergency services were more likely to have coronary artery bypass grafting (OR=1.92; 95% CI=1.18 to 3.15) than those living fewer than 10 miles from such services, but there was no difference in mortality. Distance from services strongly predicts utilization of cardiovascular resources, but it does not predict mortality among rural Missouri Medicare beneficiaries hospitalized with AMI.     

Relationship of diabetes-specific knowledge to self-management activities, ambulatory preventive care, and metabolic outcomes

BACKGROUND: Educational interventions increase diabetes patients' knowledge and self-care activities, but their impact on the use of health services to prevent diabetes complications is unclear. We sought to determine the relationship of patients' diabetes-specific knowledge with self-management behaviors, use of ambulatory preventive care, and metabolic outcomes. METHODS: We surveyed 670 adults with diabetes from three managed care plans to assess diabetes knowledge (using an eight-item scale) and self-management activities. With chart review, we assessed five processes of care--retinal and foot examinations, low-density lipoprotein cholesterol (LDL-C) testing, hemoglobin A1c (HbA1c) testing, and urine microalbumin testing--and three metabolic outcomes--HbA1c < or = 9.5%, LDL-C <130 mg/dL (3.36 mmol/L), and last blood pressure <140/90 mm Hg. RESULTS: In adjusted analyses, a one-point increase on the knowledge scale was associated with following a diabetes diet (OR 1.23, 95% CI 1.10-1.38), blood glucose self-measurement (OR 1.29, 95% CI 1.13-1.48), and regular exercise (OR 1.15, 95% CI 1.03-1.28) but not with processes of care or metabolic outcomes. CONCLUSIONS: Knowledgeable patients were more likely to perform self-management activities but not to receive recommended ambulatory care or reach metabolic outcome goals. Providing patient education about diabetes care processes should be tested as a means of increasing ambulatory care to prevent diabetes complications.     

Hospice enrollment and evaluation of its causal effect on hospitalization of dying nursing home patients

OBJECTIVE: To examine the patient, nursing home (NH), hospice provider, and local market factors associated with the selection of the Medicare hospice benefit by eligible NH residents, and evaluate the causal effect of hospice on end-of-life hospitalization rates. DATA SOURCES/STUDY SETTING: Secondary data for 1995-1997 for NH residents. STUDY DESIGN: This retrospective cohort study includes NH residents in five states (Kansa, Maine, New York, Ohio, South Dakota) who died in the years 1995-1997. Medicare claims identified hospice enrollment and hospitalizations. Geocoding of NHs, hospice providers, and hospitals was used to identify local markets. The two outcome measures are hospice enrollment and hospitalization of NH residents in their last 30 days of life. DATA COLLECTION/EXTRACTION METHOD: A file was constructed linking MDS assessments to Medicare claims and denominator files, NH provider files (OSCAR), hospice provider of service files, and the area resource file. PRINCIPAL FINDINGS: Twenty-six percent of hospice and 44 percent of nonhospice residents were hospitalized in their last 30 days of life (odds ratio [OR] 0.45; 95 percent confidence interval [CI]: 0.42-0.48). Adjusting for confounders, hospice patients were less likely than nonhospice residents to be hospitalized (OR 0.47; 95 percent CI: 0.45-0.50). Adding inverse propensity score weighting, hospice patients were still less likely than nonhospice residents to be hospitalized (OR 0.56; 95 percent CI: 0.53-0.61). CONCLUSIONS: Hospice selection introduces some bias in the evaluation of the causal effect of hospice on end-of-life hospitalization rates. However, even after adjusting for selection bias, hospice does have a powerful effect in reducing end-of-life hospitalization rates.     

Socio-economic position and the use of preventive health care in older British women: a cross-sectional study using data from the British Women's Heart and Health Study cohort

BACKGROUND: Socio-economic inequalities in health may be due to differential uptake of preventive and therapeutic medical services. OBJECTIVES: To examine socio-economic position and self-reported use of six preventive services in a cohort of older British women. METHODS: Women randomly selected from general practice age/sex registers in 23 towns were examined from 1998 to 2001. Of all, 3652 women aged 62-83 years completed a questionnaire in 2003 assessing preventive service use. RESULTS: Women from manual social classes were less likely to have recent flu vaccinations [odds ratio (OR) 0.85, 95% confidence interval (CI) 0.74, 0.98] and dental (OR 0.42, 95% CI 0.36, 0.49), eye (OR 0.77, 95% CI 0.67, 0.88) or chiropody examinations (OR 0.88, 95% CI 0.77, 1.01). Manual social class was not related to having recent blood pressure or cholesterol checks. CONCLUSIONS: Among older British women, preventive services for cardiovascular disease are not socially patterned. However, those from lower socio-economic groups are less likely to have recent flu vaccinations and dental, eye and chiropody examinations.     

Racial and ethnic disparities in the prevalence and management of cardiovascular risk factors in the United States workforce

OBJECTIVE: To assess racial or ethnic differences in workers with respect to awareness, treatment, and control of hypertension, diabetes, and dyslipidemia, and to identify factors associated with these disparities. METHODS: Analysis of nationally representative data collected from employed persons participating in the National Health and Nutrition Examination Survey 1999 to 2002, with sub-analyses by race and ethnicity. RESULTS: Mexican-American workers are less likely than non-Hispanic whites to be aware of their hypertension (odds ratio [OR] = 0.60; 95% confidence interval [CI] = 0.39-0.94) and less likely to be treated (OR = 0.45; 95% CI = 0.23-0.85); less likely to be aware (OR = 0.56; 95% CI = 0.33-0.93) and treated (OR = 0.33; 95% CI = 0.14-0.78) for dyslipidemia; and more likely to be aware of diabetes (OR = 3.01; 95% CI = 1.14-7.95). Non-Hispanic blacks treated for hypertension are less likely than whites to reach blood pressure goal (OR = 0.47; 95% CI = 0.33-0.66). Having a usual place of care is independently associated with awareness and treatment for hypertension, and treatment for dyslipidemia. CONCLUSION: Understanding cardiovascular health disparities in the workforce can help employers structure appropriate workplace screening and prevention programs.     

Is it necessary that some patients come to see us so often? Factors associated with primary care use in pediatrics

OBJECTIVES: To analyze the relationship between pediatric patients morbidity and their level of primary health care services use; and to establish if the patients level of use affects the health promotion and immunization schedule completion. METHODS: All patients assigned to a pediatric practice of the Basque National Health Service in Astrabudua (Bizkaia, Spain) over a 6-year period were categorized into different utilization patterns according to their age and number of primary care visits (whose principal reason for encounter was different from health promotion activities). Bivariate and multivariate analyses were performed comparing three groups of subjects: 116 consistently high users, 115 consistently low users and 123 patients classified as consistently medium or erratic users. Ambulatory care Groups (ACGs) case-mix system was used to manage pathologies. RESULTS: High use patients experienced several morbidity types most frequently than low use ones: asthma (OR = 44.7; 95% CI = 5.5-206.1), diseases likely to recurr (OR = 33.5; 95% CI = 8.5-131.6), specialty unstable chronic conditions (OR = 10.8; 95% CI = 2.2-52.8), psychosocial conditions (OR = 5.7; 95% CI = 2.1-15.2), chronic medical stable conditions (OR = 4.0; 95% CI = 1.9-8.6), eye/dental diseases (OR = 3.5; 95% CI = 1.5-8.1). On the other hand, low users were more likely to be lacking completion of the immunization (OR = 3.0; 95% CI = 1.1-8.8) and the well-child care program visits schedules (OR = 4.3; 95% CI = 2.3-8.0). CONCLUSION: Our data confirm that high utilization, far from being inadequate behavior, is an adequate response to the higher health care needs showed by such patients. Primary care pediatricians should assess preventive care needs of the children who consult them infrequently.     

After a stroke,ability with daily tasks of living improves after therapy based rehabilitation services

QuestionDo post-discharge rehabilitation services change recovery after stroke?Study designSystematic review with meta-analysis.Main resultsFourteen trials met inclusion criteria; 12 trials comparing therapy-based rehabilitation services were included in the meta-analysis (occupational therapy = 6 trials, physiotherapy = 2 trials and mixed services = 4 trials). At a median follow-up of 6 months, therapy-based rehabilitation services reduced the risk of deterioration in ability to undertake daily living tasks compared with control, (OR 0.72, 95% CI 0.57 to 0.92). Ability to carry out extended activities of daily living significantly improved in people undergoing therapy-based rehabilitation services compared with control (mean difference 0.17 95% CI 0.04 to 0.30). When similar categories of therapy were compared, only occupational therapy significantly reduced deterioration rate (occupational therapy: OR 0.73, 95% CI 0.55 to 0.96; physiotherapy OR 0.67, 95% CI 0.24 to 1.89; mixed services OR 0.72, 95% CI 0.41 to 1.27). Data were inconclusive with respect to mood, quality of life, need for long-term care and hospital readmission.Authors’ conclusionsPeople discharged to their homes after stroke are less likely to deteriorate if therapy-based rehabilitation services are provided compared with usual care or no routine intervention.     

Exposure to environmental tobacco smoke in the nonsmoking population of Cambodia

OBJECTIVE: To estimate the extent of environmental tobacco smoke (ETS) exposure among nonsmokers in the adult population of Cambodia. METHODS: A cross-sectional survey was conducted on a nationally representative sample of 13,988 Cambodian adults in 2005. Information on smoking and exposure to ETS was obtained by trained interviewers using a standard questionnaire. RESULTS: Overall, 37.4% of the 10,263 nonsmoking responders, or an estimated 1,629,700 nonsmoking Cambodians, were exposed to ETS. One third of pregnant women (31.4%) were exposed to ETS at home. In both unadjusted and adjusted models, men were less likely to be exposed to ETS at home (OR=0.34; 95% CI=0.29-0.41) and more likely to be exposed to ETS at work and in public places (OR=3.08; 95% CI=2.14-4.43 and OR=2.17; 95% CI=1.82-2.59, respectively). Education was inversely related to ETS exposure at home (OR=0.51; 95% CI=0.27-0.96 for 10 years of education vs 5 years or less). Legislators, senior officials, and managers were less likely to be exposed to ETS at home than professionals (OR=0.13; 95% CI=0.04-0.46), but more likely to be exposed at work or in public places. Rural residence was associated with higher ETS exposure in the home (OR=2.52; 95% CI=1.71-3.71) and lower ETS exposure at work (OR=0.42; 95% CI=0.24-0.76) compared to urban residence. CONCLUSIONS: The high prevalence of ETS exposure among adult Cambodians indicates an urgent need for specific measures such as public awareness campaigns, policies, and regulations to protect nonsmokers in Cambodia.     

Maternity care with the women's business service at the Mildura Aboriginal Health Service

OBJECTIVE: To assess and contrast views and experiences of women attending the Women's Business Service at the Mildura Aboriginal Health Service with those of rural women attending public maternity services who participated in a Victorian statewide survey conducted in 2000. METHODS: Face-to-face interviews were conducted with clients of the Women's Business Service (n=25) using a structured interview schedule based on the Victorian Survey of Recent Mothers 2000. Comparisons were made with rural women who had participated in the 2000 survey and had received public care for their pregnancy (n=333). RESULTS: Compared with rural participants in the 2000 survey, women who attended the Women's Business Service were significantly more likely to say care providers kept them informed (OR 20.63, 95% CI 3.27-853.75), midwives were never rushed during check-ups (OR 22.24, 95% CI 3.50-921.47), and to say they were happy with medical care (OR 5.79, 95% CI 1.68-30.67). Eighty per cent of interview participants described their antenatal care as 'very good'. Fewer women rated intrapartum care (64%) or postnatal hospital care (43%) as 'very good'. Compared with rural participants in the statewide survey, women attending the Women's Business Service were significantly more confident about looking after their baby in the first week at home (OR 9.08, 95% CI 2.95-37.01), and less likely to want additional help or advice (OR 0.21, 95% CI 0.04-0.73). CONCLUSIONS: Women using the Women's Business Service were significantly more positive about many aspects of their care than women attending other rural public maternity services. The study lends support to the view that Aboriginal community-controlled health services are well placed to provide appropriate and accessible care to Indigenous women.     

The effect of caregiving on preventive care for people with disabilities

BackgroundOverall, disparities exist in preventive health care services for people with disabilities compared with other Americans. Little is known about the effects of caregiving on preventive services use. This study examines caregiver characteristics and influence on the use of preventive services for people with disabilities.MethodsThe 2000-2001 Behavioral Risk Factor Surveillance System of 25 states included 5486 self-reported respondents with disabilities who were surveyed for preventive care use. Multivariate logistic regression adjusted for demographic and functional status of these respondents.ResultsAmong the subset of the respondents with caregivers, those with paid caregivers were significantly more likely to receive an influenza vaccination (adjusted odds ratio [OR], 1.49; 95% confidence interval [CI], 1.08-1.93). Among those with a caregiver, those with a spouse/partner caregiver were also significantly more likely to receive an influenza vaccination (adjusted OR, 1.33; 95% CI, 1.05-1.69) or PPV (adjusted OR, 1.59; 95% CI, 1.41-2.38) compared with those with “other” as their caregiver. Women with disabilities with a spouse/partner caregiver were significantly more likely to have ever had a Pap test (adjusted OR, 3.13; 95% CI, 1.41-6.67) or mammogram (adjusted OR, 1.85; 95% CI, 1.23-2.70) than those with “other” relative caregiver. Those respondents who reported “rarely adequate” caregiver satisfaction were significantly more likely to have self-reported ever having colon cancer screening compared with those with a usually adequate caregiver. The majority of results did not show consistent evidence of caregiver benefit, and a fair number of the associations were not statistically significant.ConclusionThe findings suggest that having a caregiver is not consistently associated with self-report of ever using preventive services. However, this study suggests that caregiver characteristics are associated with preventive care for people with disabilities. For influenza vaccination, our results showed that paid caregivers were more likely to provide preventive care to individuals with disability than a spouse or partner, which were more likely to provide more preventive care than those with “other” caregiver. Given the number of comparisons, we consider these results to be preliminary and require more confirmation in other population data.     

Physician Assistants and Nurse Practitioners as a Usual Source of Care

ABSTRACT:  Purpose: To identify characteristics and outcomes of patients who use physician assistants and nurse practitioners (PA/NPs) as a usual source of care. Methods: Cross sectional analysis using the telephone and mail surveys of the Wisconsin Longitudinal Study (WLS), a prospective cohort study of Wisconsin high school graduates and selected siblings (n = 6,803). Findings: Individuals from metropolitan (OR = 0.40, 95% CI = 0.29-0.54) and micropolitan (OR = 0.65, 95% CI = 0.44-0.95) areas were less likely to utilize PA/NPs than participants from rural locations. Participants without insurance or with public insurance other than Medicare were more likely than those with private insurance to utilize PA/NPs (OR = 1.71, 95% CI = 1.02-2.86). Patients of PA/NPs were more likely to be women (OR = 1.77, 95% CI = 1.34-2.34), younger (OR = 0.95, 95% CI = 0.92-0.98) and have lower extroversion scores (OR = 0.81, 95% CI = 0.68-0.96). Participants utilizing PA/NPs reported lower perceived access (β=−0.22, 95% CI =−0.35-0.09) than those utilizing doctors. PA/NP utilization was associated with an increased likelihood of chiropractor visits (OR = 1.57, 95% CI = 1.15-2.15) and decreased likelihood of a complete health exams (OR = 0.74, 95% CI = 0.55-0.99) or mammograms (OR = 0.65, 95% CI = 0.45-0.93). There were no significant differences in self-rated health or difficulties/delays in receiving care. Conclusions: Populations served by PA/NPs and doctors differ demographically but not in complexity. Though perceived access to care was lower for patients of PA/NPs, there were few differences in utilization and no differences in difficulties/delays in care or outcomes. This suggests that PA/NPs are acting as primary care providers to underserved patients with a range of disease severity, findings which have important implications for policy, including clinician workforce and reimbursement issues.     

Racial differences in colorectal cancer test use by Medicare consumers

BACKGROUND: Lower use of colorectal cancer (CRC) screening has been suggested as a factor in higher rates of CRC incidence and mortality among African Americans. Racial differences in colorectal cancer test use are not well understood. METHODS: The study sample included respondents aged 50 to 80 to a 2001 telephone survey of Medicare consumers from two states. The analyses, initiated in 2004, were limited to respondents with no history of CRC (n = 1901). Three CRC tests were examined: fecal occult blood tests (FOBTs), sigmoidoscopy, and colonoscopy. Type of testing and testing according to Medicare coverage intervals by race were compared. Odds ratios (ORs) and 95% confidence intervals (CIs) were obtained from unadjusted and adjusted models to assess the independent associations between race and test use. RESULTS: Adherence to the Medicare-covered intervals for CRC tests was low (56.8% for whites, 39.1% for African Americans), and did not significantly differ by race after adjustment. African Americans were, however, significantly less likely to have ever been tested (OR = 0.48, 95% CI = 0.33-0.70) and more likely to have had an endoscopic test than an FOBT (OR = 3.06, 95% CI = 1.70-5.51). CONCLUSIONS: The type of test used to screen for colorectal cancer has important implications for compliance with recommended screening intervals. Understanding reasons for racial differences in CRC test use may help identify approaches to increasing test use in the Medicare population.     

Teamwork Is Associated with Reduced Hospital Staff Burnout at Military Treatment Facilities: Findings from the 2019 Department of Defense Patient Safety Culture Survey

BackgroundA National Academy of Medicine report emphasizes the importance of creating positive work environments to address the negative effects of burnout on health care workers. The purpose of this investigation was to determine the scope of burnout among military hospital personnel and explore the relationship between teamwork, burnout, and patient safety culture.MethodsA logistic regression analysis investigated the relationship between teamwork and burnout using the 2019 US Department of Defense Patient Safety Culture Survey data from 15,838 military hospital workers. Additional regressions investigated teamwork/burnout relationships among individual work areas and staff positions.ResultsAbout one third of respondents (34.4%) reported experiencing burnout. Work areas most likely to report burnout included many different/other work areas (43.4%), pharmacy (41.8%), and labor and delivery/obstetrics (41.8%). Staff positions most likely to report burnout included pharmacy/pharmacists (39.7%), assistants/technicians/therapists (38.1%), and nurses/nursing (37.6%). Analysis revealed an association between lower burnout and high teamwork, both within (odds ratio [OR] 0.54, 95% confidence interval [CI] 0.48–0.60) and across (OR 0.64, 95% CI 0.57–0.72) units. Within-unit teamwork was associated with reduced odds of burnout across almost all work areas and staff positions, with the greatest odds reduction among personnel working in emergency (OR 0.25, 95% CI 0.14–0.43), radiology (OR 0.41, 95% CI 0.20–0.83), and labor and delivery/obstetrics (OR 0.42, 95% CI 0.27–0.65); and physicians/medical staff (OR = 0.44, 95% CI: 0.28–0.69), other staff positions (OR 0.48, 95% CI 0.28–0.81), and assistants/technicians/therapists (OR 0.58, 95% CI 0.46–0.73).ConclusionEffective teamwork may reduce burnout in hospital workers. This association between teamwork (particularly teamwork within units) and burnout was found in all work areas, even in those with the highest levels of self-reported workplace chaos. Greater adoption of workplace interventions focused on improving teamwork, such as TeamSTEPPS, is warranted.     

Full disclosure of financial costs and options to patients: the roles of race, age, health insurance, and usual source for care

The objective was to identify factors associated with financial discussions and financial disclosure of medical costs within a low-income urban community. The method used was a cross-sectional community-based survey in Allegheny County, Pennsylvania. The survey was conducted door-to-door and at area food pantries. Two hundred and twenty six adults were interviewed. Overall, 76.1% reported having a usual source for care and 73.0% had health insurance. Thirty nine and four tenths percent reported having been asked about their ability to pay for health services; this was more common among African Americans (OR 5.2; 95% CI 1.73-15.84), those with no health insurance (OR 4.3; 95% CI 1.01-17.89), and those less than 45 years old (OR:2.9; 95% CI 1.03-8.28). Only 10.6% reported being told how much a health visit would cost. Overall, 30.1% reported their provider made payment allowances for medical bills, with white respondents 2.5 times more likely and those persons identifying an ambulatory site for care 2.6 times more likely to report this. Overall, 30.5% reported being referred to a collection agency for unpaid medical bills; this was 2.4 times more common among those individuals identifying a non-ambulatory usual site for care. Significant race and socio-economic disparities exist in discussions about and access to financial resources to pay for medical care. Expanding the availability of financial assistance is critical to improving access to health care.     

Frequency of patient-physician contact in chronic kidney disease care and achievement of clinical performance targets.

OBJECTIVE: To examine whether the frequency of physician contact is associated with accepted quality of care measures reflecting clinical performance in chronic kidney disease patients. DESIGN: Prospective cohort study of end-stage renal disease patients begun in 1995, followed for 2.5 years. SETTING: 76 not-for-profit US dialysis clinics. STUDY PARTICIPANTS: 678 incident hemodialysis patients for whom we had information on average frequency of patient-physician contact at each clinic (low, monthly or less frequent; intermediate, between monthly and weekly; high, more than weekly), determined by clinic survey. MAIN OUTCOME MEASURES: Achievement of accepted 6 month clinical performance targets of albumin (> or =3.5 g/dl), calcium-phosphate (Ca-P) product (<60 mg(2)/dl(2)), dialysis dose (Kt/V > or = 1.2), vascular access type (fistula), and hemoglobin (> or =11 g/dl). RESULTS: By logistic regression, patients treated at clinics reporting less frequent physician contact had lower odds of achieving most targets, statistically significantly for albumin [low, adjusted odds ratio (OR) = 0.83, 95% confidence interval (CI), 0.55-1.25; intermediate, adjusted OR = 0.62, 95% CI, 0.42-0.93; reference, high] and dialysis dose (low, adjusted OR = 0.26, 95% CI, 0.08-0.89; intermediate, adjusted OR = 0.67, 95% CI, 0.20-2.27); however, they had greater odds of achieving the hemoglobin target (low, adjusted OR = 1.94, 95% CI, 1.24-3.04; intermediate, adjusted OR = 1.89, 95% CI, 1.27-2.83). Additionally, the number of targets reached was statistically significantly lower in the monthly or less group (adjusted OR = 0.43, 95% CI, 0.20-0.94). CONCLUSIONS: More frequent patient-physician contact is positively associated with the achievement of clinical performance targets in chronic kidney disease care.