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1.
Turner BJ Hollenbeak CS Liang Y Pandit K Joseph S Weiner MG 《Journal of general internal medicine》2012,27(10):1258-1264
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 相似文献2.
Jed D. Gonzalo MD Cynthia H. Chuang MD MSc Grace Huang MD Christopher Smith MD 《Journal of general internal medicine》2010,25(8):792-798
Background
Bedside rounds have decreased in frequency on teaching services. Perceived barriers toward bedside rounds are inefficiency and patient and house staff lack of preference for this mode of rounding.Objectives
To evaluate the impact of a bedside rounding intervention on the frequency of bedside rounding, duration of patient encounters and rounding sessions, and patient and resident attitudes toward bedside rounds.Design
A pre- and postintervention design, with a bedside rounding workshop midway through two consecutive internal medicine rotations, with daily resident interviews, patient surveys, and an end-of-the-year survey given to all Medicine house staff.Participants
Medicine house staff and medicine patients.Measures
Frequency of bedside rounds, duration of new patient encounters and rounding sessions, and patient and house staff attitudes regarding bedside rounds.Results
Forty-four residents completed the bedside rounding workshop. Comparing the preintervention and postintervention phases, bedside rounds increased from <1% to 41% (p < 0.001). The average duration of walk rounding encounters was 16 min, and average duration of bedside rounding encounters was 15 min (p = 0.42). Duration of rounds was 95 and 98 min, respectively (p = 0.52). Patients receiving bedside rounds preferred bedside rounds (99% vs. 83%, p = 0.03) and perceived more time spent at the bedside by their team (p < 0.001). One hundred twelve house staff (71%) responded, with 73% reporting that bedside rounds are better for patient care. House staff performing bedside rounds were less likely to believe that bedside rounds were more educational (53% vs. 78%, p = 0.01).Conclusions
Bedside rounding increased after an educational intervention, and the time to complete bedside rounding encounters was similar to alternative forms of rounding. Patients preferred bedside rounds and perceived more time spent at the bedside when receiving bedside rounds. Medicine residents performing bedside rounds were less likely to believe bedside rounds were more educational, but all house staff valued the importance of bedside rounding for the delivery of patient care.KEY WORDS: bedside rounds, medical education, patient care 相似文献3.
Collet TH Salamin S Zimmerli L Kerr EA Clair C Picard-Kossovsky M Vittinghoff E Battegay E Gaspoz JM Cornuz J Rodondi N 《Journal of general internal medicine》2011,26(7):724-730
BACKGROUND
Standard indicators of quality of care have been developed in the United States. Limited information exists about quality of care in countries with universal health care coverage.OBJECTIVE
To assess the quality of preventive care and care for cardiovascular risk factors in a country with universal health care coverage.DESIGN AND PARTICIPANTS
Retrospective cohort of a random sample of 1,002 patients aged 50–80 years followed for 2 years from all Swiss university primary care settings.MAIN MEASURES
We used indicators derived from RAND’s Quality Assessment Tools. Each indicator was scored by dividing the number of episodes when recommended care was delivered by the number of times patients were eligible for indicators. Aggregate scores were calculated by taking into account the number of eligible patients for each indicator.KEY RESULTS
Overall, patients (44% women) received 69% of recommended preventive care, but rates differed by indicators. Indicators assessing annual blood pressure and weight measurements (both 95%) were more likely to be met than indicators assessing smoking cessation counseling (72%), breast (40%) and colon cancer screening (35%; all p < 0.001 for comparisons with blood pressure and weight measurements). Eighty-three percent of patients received the recommended care for cardiovascular risk factors, including >75% for hypertension, dyslipidemia and diabetes. However, foot examination was performed only in 50% of patients with diabetes. Prevention indicators were more likely to be met in men (72.2% vs 65.3% in women, p < 0.001) and patients <65 years (70.1% vs 68.0% in those ≥65 years, p = 0.047).CONCLUSIONS
Using standardized tools, these adults received 69% of recommended preventive care and 83% of care for cardiovascular risk factors in Switzerland, a country with universal coverage. Prevention indicator rates were lower for women and the elderly, and for cancer screening. Our study helps pave the way for targeted quality improvement initiatives and broader assessment of health care in Continental Europe.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-011-1674-0) contains supplementary material, which is available to authorized users.KEY WORDS: quality of health care, insurance coverage, primary health care, primary prevention 相似文献4.
Cynthia M. Boyd MD MPH Lisa Reider MHS Katherine Frey MPH Daniel Scharfstein ScD Bruce Leff MD Jennifer Wolff PhD Carol Groves RN MPA Lya Karm MD Stephen Wegener PhD Jill Marsteller MPP PhD Chad Boult MD MPH MBA 《Journal of general internal medicine》2010,25(3):235-242
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 相似文献5.
Tang JW Kushner RF Cameron KA Hicks B Cooper AJ Baker DW 《Journal of general internal medicine》2012,27(8):933-939
Background
Physicians often do not recognize when their patients are overweight and infrequently counsel them about weight loss.Objective
To evaluate a set of electronic health record (EHR)-embedded tools to assist with identification and counseling of overweight patients.Design
Randomized controlled trial.Participants
Physicians at an academic general internal medicine clinic were randomized to activation of the EHR tools (n = 15) or to usual care (n = 15). Patients of these physicians were included in analyses if they had a body mass index (BMI) between 27 and 29.9 kg/m2.Intervention
The EHR tool set included: a physician point-of-care alert for overweight (BMI 27–29. 9 kg/m2); a counseling template to help physicians counsel patients on action plans; and an order set to facilitate entry of overweight as a diagnosis and to order relevant patient handouts.Main Measures
Physician documentation of overweight as a problem; documentation of weight-specific counseling; physician perceptions of the EHR tools; patient self-reported progress toward their goals and perspectives about counseling received.Key Results
Patients of physicians receiving the intervention were more likely than those of usual care physicians to receive a diagnosis of overweight (22% vs. 7%; p = 0.02) and weight-specific counseling (27% vs. 15%; p = 0.02). Most patients receiving counseling in the intervention group reported increased motivation to lose weight (90%) and taking steps toward their goal (93%). Most intervention physicians agreed that the tool alerted them to patients they did not realize were overweight (91%) and improved the effectiveness of their counseling (82%); more than half (55%) reported counseling overweight patients more frequently (55%). However, most physicians used the tool infrequently because of time barriers.Conclusions
EHR-based alerts and management tools increased documentation of overweight and counseling frequency; the majority of patients for whom the tools were used reported short-term behavior change.KEY WORDS: overweight, counseling, electronic health record 相似文献6.
Vashitz G Pliskin JS Parmet Y Kosashvili Y Ifergane G Wientroub S Davidovitch N 《Journal of general internal medicine》2012,27(10):1265-1271
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 相似文献7.
Sunil Kripalani MD MSc Brian Schmotzer MS Terry A. Jacobson MD 《Journal of general internal medicine》2012,27(12):1609-1617
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 相似文献8.
Anastasia Sofianou MS Melissa Martynenko MPA MPH Michael S. Wolf PhD MPH Juan P. Wisnivesky MD DrPH Katherine Krauskopf MD MPH Elizabeth A. H. Wilson PhD Mita Sanghavi Goel MD MPH Howard Leventhal PhD Ethan A. Halm MD MPH Alex D. Federman MD MPH 《Journal of general internal medicine》2013,28(1):67-73
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. 相似文献9.
Mary Catherine Beach MD MPH Somnath Saha MD MPH P. Todd Korthuis MD Victoria Sharp MD Jonathon Cohn MD Ira Wilson MD Susan Eggly PhD Lisa A. Cooper MD MPH Debra Roter DrPH Andrea Sankar PhD Richard Moore MD MHS 《Journal of general internal medicine》2010,25(7):682-687
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 相似文献10.
Michael S. Wolf PhD MPH Jennifer King MPH Elizabeth A. H. Wilson PhD Laura M. Curtis MS Stacy Cooper Bailey PhD MPH James Duhig PhD Allison Russell BA Ashley Bergeron MPH Amanda Daly BA Ruth M. Parker MD Terry C. Davis PhD William H. Shrank MD MSHS Bruce Lambert PhD 《Journal of general internal medicine》2012,27(12):1714-1720
11.
Amber T. Pincavage MD Shana Ratner MD Megan L. Prochaska MD Meryl Prochaska BA Julie Oyler MD Andrew M. Davis MD Vineet M. Arora MD MAPP 《Journal of general internal medicine》2012,27(11):1438-1444
BACKGROUND
Many patients nationwide change their primary care physician (PCP) when internal medicine (IM) residents graduate. Few studies have examined this handoff.OBJECTIVE
To assess patient outcomes and resident perspectives after the year-end continuity clinic handoffDESIGN
Retrospective cohortPARTICIPANTS
Patients who underwent a year-end clinic handoff in July 2010 and a comparison group of all other resident clinic patients from 2009–2011. PGY2 IM residents surveyed from 2010–2011.MEASUREMENTS
Percent of high-risk patients after the clinic handoff scheduled for an appointment, who saw their assigned PCP, lost to follow-up, or had an acute visit (ED or hospitalization). Perceptions of PGY2 IM residents surveyed after receiving a clinic handoff.RESULTS
Thirty graduating residents identified 258 high-risk patients. While nearly all patients (97 %) were scheduled, 29 % missed or cancelled their first new PCP visit. Only 44 % of patients saw the correct PCP and six months later, one-fifth were lost to follow-up. Patients not seen by a new PCP after the handoff were less likely to have appropriate follow-up for pending tests (0 % vs. 63 %, P < 0.001). A higher mean no show rate (NSR) was observed among patients who missed their first new PCP visit (22 % vs. 16 % NSR, p < 0.001) and those lost to follow-up (21 % vs. 17 % NSR, p = 0.019). While 47 % of residents worried about missing important data during the handoff, 47 % reported that they do not perceive patients as “theirs” until they are seen by them in clinic.CONCLUSIONS
While most patients were scheduled for appointments after a clinic handoff, many did not see the correct resident and one-fifth were lost to follow-up. Patients who miss appointments are especially at risk of poor clinic handoff outcomes. Future efforts should improve patient attendance to their first new PCP visit and increase PCP ownership.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2100-y) contains supplementary material, which is available to authorized users.KEY WORDS: outpatient handoffs, signout, resident continuity clinic, year-end transfer, transitions of care 相似文献12.
David A. Haggstrom MD MAS Carrie N. Klabunde PhD Judith Lee Smith PhD Gigi Yuan MS 《Journal of general internal medicine》2013,28(1):18-24
BACKGROUND
Screening patterns among primary care physicians (PCPs) may be influenced by patient age and comorbidity. Colorectal cancer (CRC) screening has little benefit among patients with limited life expectancy.OBJECTIVE
To characterize the extent to which PCPs modify their recommendations for CRC screening based upon patients’ increasing age and/or worsening comorbidityDESIGN
Cross-sectional, nationally representative survey.PARTICIPANTS
The study comprised primary care physicians (n = 1,266) including general internal medicine, family practice, and obstetrics-gynecology physicians.MAIN MEASURES
Physician CRC screening recommendations among patients of varying age and comorbidity were measured based upon clinical vignettes. Independent variables in adjusted models included physician and practice characteristics.KEY RESULTS
For an 80-year-old patient with unresectable non-small cell lung cancer (NSCLC), 25 % of PCPs recommended CRC screening. For an 80-year-old patient with ischemic cardiomyopathy (New York Heart Association, Class II), 71 % of PCPs recommended CRC screening. PCPs were more likely to recommend fecal occult blood testing than colonoscopy as the preferred screening modality for a healthy 80-year-old, compared to healthy 50- or 65-year-old patients (19 % vs. 5 % vs. 2 % p < 0.001). For an 80-year-old with unresectable NSCLC, PCPs who were an obstetrics-gynecology physician were more likely to recommend CRC screening, while those with a full electronic medical record were less likely to recommend screening.CONCLUSIONS
PCPs consider comorbidity when screening older patients for CRC and may change the screening modality from colonoscopy to FOBT. However, a sizable proportion of PCPs would recommend screening for patients with advanced cancer who would not benefit. Understanding the mechanisms underlying these patterns will facilitate the design of future medical education and policy interventions to reduce unnecessary care.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2093-6) contains supplementary material, which is available to authorized users.KEY WORDS: cancer screening, health services, colorectal cancer, primary care physicians 相似文献13.
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15.
Kong MC Nahata MC Lacombe VA Seiber EE Balkrishnan R 《Journal of general internal medicine》2012,27(9):1159-1164
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 相似文献16.
Craig Evan Pollack MD MHS Gary E. Weissman MD Klaus W. Lemke PhD Peter S. Hussey PhD Jonathan P. Weiner DrPH 《Journal of general internal medicine》2013,28(3):459-465
BACKGROUND
Improving care coordination is a national priority and a key focus of health care reforms. However, its measurement and ultimate achievement is challenging.OBJECTIVE
To test whether patients whose providers frequently share patients with one another—what we term ‘care density’—tend to have lower costs of care and likelihood of hospitalization.DESIGN
Cohort studyPARTICIPANTS
9,596 patients with congestive heart failure (CHF) and 52,688 with diabetes who received care during 2009. Patients were enrolled in five large, private insurance plans across the US covering employer-sponsored and Medicare Advantage enrolleesMAIN MEASURES
Costs of care, rates of hospitalizationsKEY RESULTS
The average total annual health care cost for patients with CHF was $29,456, and $14,921 for those with diabetes. In risk adjusted analyses, patients with the highest tertile of care density, indicating the highest level of overlap among a patient’s providers, had lower total costs compared to patients in the lowest tertile ($3,310 lower for CHF and $1,502 lower for diabetes, p < 0.001). Lower inpatient costs and rates of hospitalization were found for patients with CHF and diabetes with the highest care density. Additionally, lower outpatient costs and higher pharmacy costs were found for patients with diabetes with the highest care density.CONCLUSION
Patients treated by sets of physicians who share high numbers of patients tend to have lower costs. Future work is necessary to validate care density as a tool to evaluate care coordination and track the performance of health care systems.Electronic supplementary material
The online version of this article (doi:10.1007/s11606-012-2104-7) contains supplementary material, which is available to authorized users.KEY WORDS: care coordination, performance measure, provider social networks, care density 相似文献17.
Jean Yoon PhD MHS Danielle E. Rose PhD MPH Ismelda Canelo MPA Anjali S. Upadhyay MS Gordon Schectman MD Richard Stark MD Lisa V. Rubenstein MD MSPH Elizabeth M. Yano PhD MSPH 《Journal of general internal medicine》2013,28(9):1188-1194
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 clinicsMain 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 相似文献18.
Erica S. Spatz MD MHS Sameer D. Sheth MD Kensey L. Gosch MS Mayur M. Desai PhD MPH John A. Spertus MD MPH Harlan M. Krumholz MD SM Joseph S. Ross MD MHS 《Journal of general internal medicine》2014,29(6):862-869
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 相似文献19.
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Saima I. Chaudhry MD MSHS Sandy Balwan MD Karen A. Friedman MD FACP Suzanne Sunday PhD Basit Chaudhry MD PhD Deborah DiMisa Alice Fornari EdD 《Journal of general internal medicine》2013,28(8):1100-1104