Distance is Relative: Unpacking a Principal Barrier in Rural Healthcare

Background

Distance to healthcare services is a known barrier to access. However, the degree to which distance is a barrier is not well described. Distance may impact different patients in different ways and be mediated by the context of medical need.

Objective

Identify factors related to distance that impede access to care for rural veterans.

Approach

Mixed-methods approach including surveys, in-depth interviews, and focus groups at 15 Veterans Health Administration (VHA) primary care clinics in 8 Midwestern states. Survey data were compiled and interviews transcribed and coded for thematic content.

Participants

Surveys were completed by 96 patients and 88 providers/staff. In-depth interviews were completed by 42 patients and 64 providers/staff. A total of 7 focus groups were convened consisting of providers and staff.

Key results

Distance was identified by patients, providers, and staff as the most important barrier for rural veterans seeking healthcare. In-depth interviews revealed specific examples of barriers to care such as long travel for common diagnostic services, routine specialty care, and emergency services. Patient factors compounding the impact of these barriers were health status, functional impairment, travel cost, and work or family obligations. Providers and staff reported challenges to healthcare delivery due to distance.

Conclusions

Distance as a barrier to healthcare was not uniformly defined. Rather, its importance was relative to the health status and resources of patients, complexity of service provided, and urgency of service needed. Improved transportation, flexible fee-based services, more structured communication mechanisms, and integration with community resources will improve access to care and overall health status for rural veterans.

     

The Challenges of Multimorbidity from the Patient Perspective

Background

Although multiple co-occurring chronic illnesses within the same individual are increasingly common, few studies have examined the challenges of multimorbidity from the patient perspective.

Objective

The aim of this study is to examine the self-management learning needs and willingness to see non-physician providers of patients with multimorbidity compared to patients with single chronic illnesses.

Design

This research is designed as a cross-sectional survey.

Participants

Based upon ICD-9 codes, patients from a single VHA healthcare system were stratified into multimorbidity clusters or groups with a single chronic illness from the corresponding cluster. Nonproportional sampling was used to randomly select 720 patients.

Measurements

Demographic characteristics, functional status, number of contacts with healthcare providers, components of primary care, self-management learning needs, and willingness to see nonphysician providers.

Results

Four hundred twenty-two patients returned surveys. A higher percentage of multimorbidity patients compared to single morbidity patients were “definitely” willing to learn all 22 self-management skills, of these only 2 were not significant. Compared to patients with single morbidity, a significantly higher percentage of patients with multimorbidity also reported that they were “definitely” willing to see 6 of 11 non-physician healthcare providers.

Conclusions

Self-management learning needs of multimorbidity patients are extensive, and their preferences are consistent with team-based primary care. Alternative methods of providing support and chronic illness care may be needed to meet the needs of these complex patients.

     

Administering a Telemedicine Program

Purpose of Review

The purpose of this review is to describe the process of administering a telemedicine program including reviewing telemedicine guidelines; discussing licensing, credentialing, and privileging of providers; outlining scheduling and recruitment of patients; and measuring outcomes of a telemedicine program.

Recent Findings

Recent literature findings suggest that telemedicine in specialty clinics continues to grow at a rapid pace. Medical specialty programs should prepare to adopt a practice that includes telemedicine to better serve their patients and families who have expressed significant satisfaction with the delivery of healthcare in this manner.

Summary

With the appropriate support, any specialty clinic can provide their patients with a telemedicine option which has shown to be highly successful for Children’s Mercy Allergy, Asthma, & Immunology Department.

     

The Development and Evaluation of an Online Healthcare Toolkit for Autistic Adults and their Primary Care Providers

Background

The healthcare system is ill-equipped to meet the needs of adults on the autism spectrum.

Objective

Our goal was to use a community-based participatory research (CBPR) approach to develop and evaluate tools to facilitate the primary healthcare of autistic adults.

Design

Toolkit development included cognitive interviewing and test–retest reliability studies. Evaluation consisted of a mixed-methods, single-arm pre/post-intervention comparison.

Participants

A total of 259 autistic adults and 51 primary care providers (PCPs) residing in the United States.

Interventions

The AASPIRE Healthcare toolkit includes the Autism Healthcare Accommodations Tool (AHAT)—a tool that allows patients to create a personalized accommodations report for their PCP—and general healthcare- and autism-related information, worksheets, checklists, and resources for patients and healthcare providers.

Main Measures

Satisfaction with patient–provider communication, healthcare self-efficacy, barriers to healthcare, and satisfaction with the toolkit’s usability and utility; responses to open-ended questions.

Key Results

Preliminary testing of the AHAT demonstrated strong content validity and adequate test–retest stability. Almost all patient participants (>94 %) felt that the AHAT and the toolkit were easy to use, important, and useful. In pre/post-intervention comparisons, the mean number of barriers decreased (from 4.07 to 2.82, p?<?0.0001), healthcare self-efficacy increased (from 37.9 to 39.4, p?=?0.02), and satisfaction with PCP communication improved (from 30.9 to 32.6, p?=?0.03). Patients stated that the toolkit helped clarify their needs, enabled them to self-advocate and prepare for visits more effectively, and positively influenced provider behavior. Most of the PCPs surveyed read the AHAT (97 %), rated it as moderately or very useful (82 %), and would recommend it to other patients (87 %).

Conclusions

The CBPR process resulted in a reliable healthcare accommodation tool and a highly accessible healthcare toolkit. Patients and providers indicated that the tools positively impacted healthcare interactions. The toolkit has the potential to reduce barriers to healthcare and improve healthcare self-efficacy and patient–provider communication.

     

Promoting Access Through Complementary eHealth Technologies: Recommendations for VA’s Home Telehealth and Personal Health Record Programs

BACKGROUND

Many healthcare organizations have embraced eHealth technologies in their efforts to promote patient-centered care, increase access to services, and improve outcomes.

OBJECTIVE

Using the Department of Veterans Affairs (VA) as a case study, this paper presents two specific eHealth technologies, the Care Coordination Home Telehealth (CCHT) Program and the My HealtheVet (MHV) personal health record (PHR) portal with integrated secure messaging, and articulates a vision of how they might be implemented as part of a patient-centric healthcare model and used in a complementary manner to enhance access to care and to support patient-centered care.

METHODS

Based on our experience and ongoing work with both programs, we offer a series of recommendations for pursuing and ultimately achieving this vision.

CONCLUSION

VA’s CCHT and MHV programs are examples of an expanding repertoire of eHealth applications available to patients and healthcare teams. VA’s new patient-centric healthcare model represents a significant shift in the way that services are delivered and a profound opportunity to incorporate eHealth technologies like the CCHT and MHV programs into clinical practice to increase access to care, and to ensure the responsiveness of such technologies to the preferences and circumstances of patients.

     

Setting Up a Heart Failure Program in 2018: Moving Towards New Paradigm(s)

Purpose of Review

Heart failure (HF) is the first cause of hospitalization in the elderly in Western countries, generating tremendous healthcare costs. Despite the spread of multidisciplinary post-discharge programs, readmission rates have remained unchanged over time. We review the recent developments in this setting.

Recent Findings

Recent data plead for global reorganization of HF care, specifically targeting patients at high risk for further readmission, as well as a stronger involvement of primary care providers (PCP) in patients’ care plan. Besides, tools, devices, and new interdisciplinary expertise have emerged to support and be integrated into those programs; they have been greeted with great enthusiasm, but their routine applicability remains to be determined.

Summary

HF programs in 2018 should focus on pragmatic assessments of patients that will benefit the most from the multidisciplinary care; delegating the management of low-risk patients to trained PCP and empowering the patient himself, using the newly available tools as needed.

     

Systematic Reviews and Meta-analysis in Rhinosinusitis: a Critical Review of the Reviews

Purpose of Review

There has been an explosion in the number of published systematic reviews on chronic rhinosinusitis in the last decade.

Recent Findings

While the aim of these reviews in facilitating evidence-based practice is laudable, poor quality reviews may contain significant bias that can mislead a non-discerning reader.

Summary

Attention therefore must be given to review methodology before implanting findings. Organisations such as the Cochrane Collaboration promote high-quality reviews, but are limited in chronic sinus disease by heterogeneous outcomes and a paucity of randomised trials.

     

Objective Differences in Colonoscopy Technique Between Trainee and Expert Endoscopists Using the Colonoscopy Force Monitor

Background

Learning to perform colonoscopy safely and effectively is central to gastroenterology fellowship programs. The application of force to the colonoscope is an important part of colonoscopy technique.

Aims

We compared force application during colonoscopy between novice and expert endoscopists using a novel device to determine differences in colonoscopy technique.

Methods

This is an observational cohort study designed to compare force application during colonoscopy between novice and experienced trainees, made up of gastroenterology fellows from two training programs, and expert endoscopists from both academic and private practice settings.

Results

Force recordings were obtained for 257 colonoscopies by 37 endoscopists, 21 of whom were trainees. Experts used higher average forward forces during insertion compared to all trainees and significantly less clockwise torque compared to novice trainees.

Conclusions

We present significant, objective differences in colonoscopy technique between novice trainees, experienced trainees, and expert endoscopists. These findings suggest that the colonoscopy force monitor is an objective tool for measuring proficiency in colonoscopy. Furthermore, the device may be used as a teaching tool in training and continued medical education programs.

     

Increased Rates of Documented Alcohol Counseling in Primary Care: More Counseling or Just More Documentation?

Background

Clinical performance measures often require documentation of patient counseling by healthcare providers. Little is known about whether such measures encourage delivery of counseling or merely its documentation.

Objective

To assess changes in provider documentation of alcohol counseling and patient report of receiving alcohol counseling in the Veterans Administration (VA) from 2009 to 2012.

Design

Retrospective time-series analysis.

Participants

A total of 5413 men who screened positive for unhealthy alcohol use at an outpatient visit and responded to a confidential mailed survey regarding alcohol counseling from a VA provider in the prior year.

Main Measures

Rates of provider documentation of alcohol counseling in the electronic health record and patient report of such counseling on the survey were assessed over 4 fiscal years. Annual rates were calculated overall and with patients categorized into four mutually exclusive groups based on their own reports of alcohol counseling (yes/no) and whether alcohol counseling was documented by a provider (yes/no).

Key Results

Provider documentation of alcohol counseling increased 23.6% (95% CI: 17.0, 30.2), from 59.4% to 83.0%, while patient report of alcohol counseling showed no significant change (4.0%, 95% CI: ?2.3, 10.3), increasing from 66.1% to 70.1%. An 18.7% (95% CI: 11.7, 25.7) increase in the proportion of patients who reported counseling that was documented by a provider largely reflected a 14.7% decline (95% CI: 8.5, 20.8) in the proportion of patients who reported alcohol counseling that was not documented by a provider. The proportion of patients who did not report counseling but whose providers documented it did not show a significant change (4.9%, 95%CI: 0.0, 9.9).

Conclusions

If patient report is accurate, increased rates of documented alcohol counseling in the VA from 2009 to 2012 predominantly reflected improved documentation of previously undocumented counseling rather than delivery of additional counseling or increased documentation of counseling that did not meaningfully occur.

     

Provider Recommendations in the Face of Scientific Uncertainty: An Analysis of Audio-Recorded Discussions about Vitamin D

BACKGROUND

Little is known about how providers communicate recommendations when scientific uncertainty exists.

OBJECTIVES

To compare provider recommendations to those in the scientific literature, with a focus on whether uncertainty was communicated.

DESIGN

Qualitative (inductive systematic content analysis) and quantitative analysis of previously collected audio-recorded provider–patient office visits.

PARTICIPANTS

Sixty-one providers and a socio-economically diverse convenience sample of 603 of their patients from outpatient community- and academic-based primary care, integrative medicine, and complementary and alternative medicine provider offices in Southern California.

MAIN MEASURES

Comparison of provider information-giving about vitamin D to professional guidelines and scientific information for which conflicting recommendations or insufficient scientific evidence exists; certainty with which information was conveyed.

RESULTS

Ninety-two (15.3 %) of 603 visit discussions touched upon issues related to vitamin D testing, management and benefits. Vitamin D deficiency screening was discussed with 23 (25 %) patients, the definition of vitamin D deficiency with 21 (22.8 %), the optimal range for vitamin D levels with 26 (28.3 %), vitamin D supplementation dosing with 50 (54.3 %), and benefits of supplementation with 46 (50 %). For each of the professional guidelines/scientific information examined, providers conveyed information that deviated from professional guidelines and the existing scientific evidence. Of 166 statements made about vitamin D in this study, providers conveyed 160 (96.4 %) with certainty, without mention of any equivocal or contradictory evidence in the scientific literature. No uncertainty was mentioned when vitamin D dosing was discussed, even when recommended dosing was higher than guideline recommendations.

CONCLUSIONS AND RELEVANCE

Providers convey the vast majority of information and recommendations about vitamin D with certainty, even though the scientific literature contains inconsistent recommendations and declarations of inadequate evidence. Not communicating uncertainty blurs the contrast between evidence-based recommendations and those without evidence. Providers should explore best practices for involving patients in decision-making by acknowledging the uncertainty behind their recommendations.

     

Providing High-Quality Care for Limited English Proficient Patients: The Importance of Language Concordance and Interpreter Use

Background

Provider–patient language discordance is related to worse quality care for limited English proficient (LEP) patients who speak Spanish. However, little is known about language barriers among LEP Asian-American patients.

Objective

We examined the effects of language discordance on the degree of health education and the quality of interpersonal care that patients received, and examined its effect on patient satisfaction. We also evaluated how the presence/absence of a clinic interpreter affected these outcomes.

Design

Cross-sectional survey, response rate 74%.

Participants

A total of 2,746 Chinese and Vietnamese patients receiving care at 11 health centers in 8 cities.

Measurements

Provider–patient language concordance, health education received, quality of interpersonal care, patient ratings of providers, and the presence/absence of a clinic interpreter. Regression analyses were used to adjust for potential confounding.

Results

Patients with language-discordant providers reported receiving less health education (β?=?0.17, p?<?0.05) compared to those with language-concordant providers. This effect was mitigated with the use of a clinic interpreter. Patients with language-discordant providers also reported worse interpersonal care (β?=?0.28, p?<?0.05), and were more likely to give low ratings to their providers (odds ratio [OR]?=?1.61; CI?=?0.97–2.67). Using a clinic interpreter did not mitigate these effects and in fact exacerbated disparities in patients’ perceptions of their providers.

Conclusion

Language barriers are associated with less health education, worse interpersonal care, and lower patient satisfaction. Having access to a clinic interpreter can facilitate the transmission of health education. However, in terms of patients’ ratings of their providers and the quality of interpersonal care, having an interpreter present does not serve as a substitute for language concordance between patient and provider.

     

Diabetes Awareness and Knowledge Among Latinos: Does a Usual Source of Healthcare Matter?

Objective

To provide national prevalence estimates of usual source of healthcare (USHC), and examine the relationship between USHC and diabetes awareness and knowledge among Latinos using a modified Andersen model of healthcare access.

Participants

Three thousand eight hundred and ninety-nine Latino (18-years or older) participants of the Pew Hispanic Center/Robert Wood Johnson Foundation Hispanic/Latino Health survey from the 48 contiguous United States.

Design

Cross-sectional, stratified, random sample telephone interviews.

Methods

Self-reported healthcare service use was examined in regression models that included a past-year USHC as the main predictor of diabetes awareness and knowledge. Anderson model predisposing and enabling factors were included in additional statistical models.

Results

Significant differences in USHC between Latino groups were found with Mexican Americans having the lowest rates (59.7%). USHC was associated with significantly higher diabetes awareness and knowledge (OR=1.24; 95%CI=1.05-1.46) after accounting for important healthcare access factors. Men were significantly (OR=0.64; 95%CI=0.52-0.75) less informed about diabetes than women.

Conclusion

We found important and previously unreported differences between Latinos with a current USHC provider, where the predominant group, Mexican Americans, are the least likely to have access to a USHC. USHC was associated with Latinos being better informed about diabetes; however, socioeconomic barriers limit the availability of this potentially valuable tool for reducing the risks and burden of diabetes, which is a major public health problem facing Latinos.

     

Innovative Care Models in Liver Disease: the Role of Multidisciplinary Teams

Purpose of Review

Patients with chronic liver disease have diverse healthcare and psychosocial needs across a multitude of care domains. Incorporation of multidisciplinary teams (MDT) enhances care coordination between physician, patient, and other healthcare providers.

Recent Findings

A MDT approach may be beneficial to provide comprehensive care for all cirrhotics. MDT are successfully used for management of hepatocellular carcinoma and evaluating candidacy for liver transplantation (LT). Among patients with alcoholic liver disease, lower rates of post LT recidivism are observed with MDT. The Practice Guide on Obesity and Weight Management, Education and Resources program, a comprehensive care model developed to increase collaboration and patient-centered care may help in patients with non-alcoholic fatty liver disease. Furthermore, telemedicine and telemonitoring may help expand a MDT approach.

Summary

The MDT model benefits many stakeholders, including the patient, physician, as well as the broader healthcare system. Further studies are needed to identify its long-term benefits.

     

Cost of Transformation among Primary Care Practices Participating in a Medical Home Pilot

Background

Medical home initiatives encourage primary care practices to invest in new structural capabilities such as patient registries and information technology, but little is known about the costs of these investments.

Objectives

To estimate costs of transformation incurred by primary care practices participating in a medical home pilot.

Design

We interviewed practice leaders in order to identify changes practices had undertaken due to medical home transformation. Based on the principles of activity-based costing, we estimated the costs of additional personnel and other investments associated with these changes.

Setting

The Pennsylvania Chronic Care Initiative (PACCI), a statewide multi-payer medical home pilot.

Participants

Twelve practices that participated in the PACCI.

Measurements

One-time and ongoing yearly costs attributed to medical home transformation.

Results

Practices incurred median one-time transformation-associated costs of $30,991 per practice (range, $7694 to $117,810), equivalent to $9814 per clinician ($1497 to $57,476) and $8 per patient ($1 to $30). Median ongoing yearly costs associated with transformation were $147,573 per practice (range, $83,829 to $346,603), equivalent to $64,768 per clinician ($18,585 to $93,856) and $30 per patient ($8 to $136). Care management activities accounted for over 60% of practices’ transformation-associated costs. Per-clinician and per-patient transformation costs were greater for small and independent practices than for large and system-affiliated practices.

Limitations

Error in interviewee recall could affect estimates. Transformation costs in other medical home interventions may be different.

Conclusions

The costs of medical home transformation vary widely, creating potential financial challenges for primary care practices—especially those that are small and independent. Tailored subsidies from payers may help practices make these investments.

Primary Funding Source

Agency for Healthcare Research and Quality

     

The Impact of an Enhanced Interpreter Service Intervention on Hospital Costs and Patient Satisfaction

BACKGROUND

Many health care providers do not provide adequate language access services for their patients who are limited English-speaking because they view the costs of these services as prohibitive. However, little is known about the costs they might bear because of unaddressed language barriers or the costs of providing language access services.

OBJECTIVE

To investigate how language barriers and the provision of enhanced interpreter services impact the costs of a hospital stay.

DESIGN

Prospective intervention study.

SETTING

Public hospital inpatient medicine service.

PARTICIPANTS

Three hundred twenty-three adult inpatients: 124 Spanish-speakers whose physicians had access to the enhanced interpreter intervention, 99 Spanish-speakers whose physicians only had access to usual interpreter services, and 100 English-speakers matched to Spanish-speaking participants on age, gender, and admission firm.

MEASUREMENTS

Patient satisfaction, hospital length of stay, number of inpatient consultations and radiology tests conducted in the hospital, adherence with follow-up appointments, use of emergency department (ED) services and hospitalizations in the 3 months after discharge, and the costs associated with provision of the intervention and any resulting change in health care utilization.

RESULTS

The enhanced interpreter service intervention did not significantly impact any of the measured outcomes or their associated costs. The cost of the enhanced interpreter service was $234 per Spanish-speaking intervention patient and represented 1.5% of the average hospital cost. Having a Spanish-speaking attending physician significantly increased Spanish-speaking patient satisfaction with physician, overall hospital experience, and reduced ED visits, thereby reducing costs by $92 per Spanish-speaking patient over the study period.

CONCLUSION

The enhanced interpreter service intervention did not significantly increase or decrease hospital costs. Physician–patient language concordance reduced return ED visit and costs. Health care providers need to examine all the cost implications of different language access services before they deem them too costly.