Showing papers by "Marshall H. Chin published in 2013"

Patient Trust in Physicians and Shared Decision-Making Among African-Americans With Diabetes

Abstract: This study explores patient trust in physicians and its relationship to shared decision-making (SDM) among African-Americans with diabetes (types 1 and 2). We conducted a series of focus groups (n = 27) and in-depth interviews (n = 24). Topic guides were developed utilizing theoretical constructs. Each interview was audiotaped and transcribed verbatim. Each transcript was independently coded by two randomly assigned members of the research team; codes and themes were identified in an iterative fashion utilizing Atlas.ti software. The mean age of study participants was 62 years and 85% were female. We found that (1) race as a social construct has the potential to influence key domains of patient trust (interpersonal/relationship aspects and medical skills/technical competence), (2) the relationship between patient trust and shared decision-making is bidirectional in nature, and (3) enhancing patient trust may potentially increase or decrease SDM among African-Americans with diabetes. Mistrust of physicians among African-Americans with diabetes may partially be addressed through (1) patient education efforts, (2) physician training in interpersonal skills and cultural competence, and (3) physician efforts to engage patients in SDM. To help enhance patient outcomes among African-Americans with diabetes, physicians might consider incorporating strategies to simultaneously engender their patients' trust and encourage shared decision-making.

Improving the effectiveness of health care innovation implementation: middle managers as change agents.

Abstract: The rate of successful health care innovation implementation is dismal. Middle managers have a potentially important yet poorly understood role in health care innovation implementation. This study used self-administered surveys and interviews of middle managers in health centers that implemented an innovation to reduce health disparities to address the questions: Does middle managers' commitment to health care innovation implementation influence implementation effectiveness? If so, in what ways does their commitment influence implementation effectiveness? Although quantitative survey data analysis results suggest a weak relationship, qualitative interview data analysis results indicate that middle managers' commitment influences implementation effectiveness when middle managers are proactive. Scholars should account for middle managers' influence in implementation research, and health care executives may promote implementation effectiveness by hiring proactive middle managers and creating climates in which proactivity is rewarded, supported, and expected.

Thirty years of disparities intervention research: what are we doing to close racial and ethnic gaps in health care?

Abstract: Over the past 30 years, disparities researchers have shifted focus from documenting racial and ethnic disparities to identifying interventions that close the gap in care.1 The Patient Protection and Affordable Care Act will institutionalize the collection of clinical performance data stratified by race, ethnicity, and language, providing promising opportunities for organizations to identify health disparities in their patient populations.2 However, stratified data alone are insufficient to reduce disparities.3 There remains a critical need for evidence-based interventions that improve outcomes for minority patients.4 Existing reviews of disparities interventions focus on specific diseases, care settings, or priority populations. Several reviews have developed taxonomies of intervention studies to organize their findings; however, to our knowledge, none focus specifically on efforts to improve minority health.5–8 The Agency for Healthcare Research and Quality's Taxonomy of Quality Improvement, for example, does not include equity-specific approaches, such as cultural competency training or enhanced interpreter services.9 It is important to assess the disparities literature specifically, because generic quality improvement efforts are insufficient to close the gap in care.10 Even quality improvement initiatives that improve outcomes for all patients can inadvertently widen the difference in outcomes between White and minority patients.11 Equity-specific approaches that are tailored for minority patients show promise for reducing disparities,12 as do nonclinical services that complement and enhance care delivery for priority populations.1 Therefore, we developed a taxonomy of disparities interventions in the healthcare setting and used this taxonomy to systematically categorize 391 intervention articles from the peer-reviewed literature. Our taxonomy organizes the disparities literature so that researchers, providers, funders, and policymakers can easily identify the available evidence and target areas for further study. It breaks down multi-faceted interventions into their essential parts, guiding healthcare organizations to identify the approaches that best fit their context and settings. The tool also helps patients and patient advocates understand the variety of programs available to them. Overall, the disparities taxonomy allows readers to identify studies relevant to their own work and target approaches for reducing disparities in care.

Undergoing transformation to the patient centered medical home in safety net health centers: perspectives from the front lines.

Abstract: OBJECTIVES : Safety net health centers (SNHCs), which include federally qualified health centers (FQHCs) provide primary care for underserved, minority and low income patients. SNHCs across the country are in the process of adopting the patient centered medical home (PCMH) model, based on promising early implementation data from demonstration projects. However, previous demonstration projects have not focused on the safety net and we know little about PCMH transformation in SNHCs. DESIGN : This qualitative study characterizes early PCMH adoption experiences at SNHCs. SETTING AND PARTICIPANTS : We interviewed 98 staff (administrators, providers, and clinical staff) at 20 of 65 SNHCs, from five states, who were participating in the first of a five-year PCMH collaborative, the Safety Net Medical Home Initiative. MAIN MEASURES : We conducted 30-45 minute, semi-structured telephone interviews. Interview questions addressed benefits anticipated, obstacles encountered, and lessons learned in transition to PCMH. RESULTS : Anticipated benefits for participating in the PCMH included improved staff satisfaction and patient care and outcomes. Obstacles included staff resistance and lack of financial support for PCMH functions. Lessons learned included involving a range of staff, anticipating resistance, and using data as frequent feedback. CONCLUSIONS : SNHCs encounter unique challenges to PCMH implementation, including staff turnover and providing care for patients with complex needs. Staff resistance and turnover may be ameliorated through improved health care delivery strategies associated with the PCMH. Creating predictable and continuous funding streams may be more fundamental challenges to PCMH transformation. ( Ethn Dis. 2013;23[3]:356–362)

Relationship Between Persistent Pain and 5-year Mortality: a Population-Based Prospective Cohort Study.

Abstract: Objectives: To assess the association between self-reported noncancer pain and 5-year mortality. Design: Cohort. Setting: Community-dwelling older adults. Participants: Canadian Study of Health and Aging 1996 wave. Measurements: Registrar of Vital Statistics�established 5-year mortality. Noncancer pain was assessed using the 5-point verbal descriptor scale, dichotomized into no or very mild versus moderate, severe, or very severe pain. Frailty was the accumulation of health deficits. Cognitive status (Modified Mini-Mental State Examination) and depressed mood (five-item mental health screening questionnaire) were also assessed. Multivariable logistic regression and Cox proportional hazards were used to analyze the relationship between pain and 5-year mortality. Results: Of 5,703 participants, 4,694 (82.3%) had complete data for analysis; 1,663 of these (35.4%) reported moderate, severe, or very severe pain, and 1,343 (28.6%) had died at 5-year follow-up. Four hundred ninety-six of those who died (29.8%) reported moderate, severe, or very severe pain and 847 (27.9%) no or very mild pain. Multivariate logistic analysis found that individuals with moderate, severe, or very severe pain had lower odds of 5-year mortality than those with no or very mild pain (odds ratio = 0.78, 95% confidence interval (CI) = 0.66�0.92; P < .001). The risk of death was lower in persons reporting moderate or greater pain than in those with no or very mild pain (HR = 0.85, 95% CI = 0.75�0.96; P = .01). An interaction between pain and sex explained this effect. Men with pain were not significantly more likely than men without pain to die (HR = 1.00, 95% CI = 0.84�1.19; P = .99), whereas women without pain (HR = 0.54, 95% CI = 0.47�0.63; P < 0.01) and women with pain (HR = 0.40; CI = 0.33�0.47; P < .01) had less risk of death than men without and with pain, respectively. Conclusion: Older women with pain were less likely to die within 5 years than older women without pain, men in pain, or men without pain.

Variation in dialysis quality measures by facility, neighborhood, and region.

Abstract: Background: We examined whether dialysis facility characteristics, neighborhood demographics, and region are associated with Centers for Medicare and Medicaid Services (CMS) dialysis facility quality measures in order to determine the most important targets for intervention. Methods: We linked US census data to the CMS Dialysis Compare File which contains information for facility outcomes for all CMScertified dialysis facilities in 2007 (n=5616). We then used linear and logistic regression to characterize the association between dialysis facility quality—worse than expected patient survival, and the proportion of individuals in a facility achieving dialysis adequacy (urea reduction rate >65) or target hemoglobin (10

Ethnic differences in quality of life in insured older adults with diabetes mellitus in an integrated delivery system.

Abstract: Objectives: To explore racial and ethnic (ethnic hereafter) differences in health-related quality of life (HRQL) in older adults with diabetes mellitus in an integrated delivery system. Design: Observational cross-sectional study. Setting: Kaiser Permanente Northern California. Participants: Ethnic-stratified, random sample of 6,096 adults with diabetes mellitus aged 60 to 75 who completed a HRQL questionnaire. Measurements: Physical and mental HRQL were measured based on the Medical Outcomes Study 8-item Short Form Survey (range 0�100, mean 50). Age- and sex-adjusted weighted linear regression models estimated associations between ethnicity and HRQL and evaluated potential mediators (socioeconomic status, acculturation, health behaviors, diabetes mellitus�related conditions). Differences in ethnic-specific, adjusted mean HRQL scores were tested (reference whites). Results: Physical HRQL was better for Filipinos (48.3, 95% confidence interval (CI) = 47.0�49.6, P < .001), Asians (48.1, 95% CI = 46.8�49.3, P < .001), Hispanics (45.1, 95% CI = 44.2�46.0, P < .001), and blacks (44.2, 95% CI = 43.3�45.1, P = .04) than whites (42.9, 95% CI = 42.6�43.2). Adjusting for potential mediators did not change these relationships. Mental HRQL was better only for Asians (52.7, 95% CI = 51.6�53.7, P = .01) than for whites (51.0, 95% CI = 50.7�51.3), but this difference was small and became nonsignificant after adjustment for socioeconomic status, acculturation, health behaviors, and diabetes mellitus�related conditions. Conclusion: In older adults with diabetes mellitus in a well-established integrated healthcare delivery system, ethnic minorities had better physical HRQL than whites. Equal access to care in an integrated delivery system may hold promise for reducing health disparities in diabetes mellitus-related patient-reported outcomes.

Combating Obesity at Community Health Centers (COACH): a quality improvement collaborative for weight management programs.

Abstract: Community health centers (CHCs) seek effective strategies to address obesity. MidWest Clinicians' Network partnered with [an academic medical center] to test feasibility of a weight management quality improvement (QI) collaborative. MidWest Clinicians' Network members expressed interest in an obesity QI program. This pilot study aimed to determine whether the QI model can be feasibly implemented with limited resources at CHCs to improve weight management programs. Five health centers with weight management programs enrolled with CHC staff as primary study participants; this study did not attempt to measure patient outcomes. Participants attended learning sessions and monthly conference calls to build QI skills and share best practices. Tailored coaching addressed local needs. Topics rated most valuable were patient recruitment/retention strategies, QI techniques, evidence-based weight management, motivational interviewing. Challenges included garnering provider support, high staff turnover, and difficulty tracking patient-level data. This paper reports practical lessons about implementing a weight management QI collaborative in CHCs.