Showing papers in "Journal of Primary Care & Community Health in 2012"
TL;DR: Education about warfarin in older patients is currently suboptimal and may in part contribute to poor therapeutic outcomes, according to a comprehensive review of the literature.
Abstract: Objective: To review the challenges of warfarin education for older patients (aged 65 years or older) in terms of knowledge, access to warfarin education, and education resources. Methods: A quasi-...
51 citations
TL;DR: The findings point to a changing population of patients for primary care physicians that will require treatment of multiple chronic conditions as well as increased burden of disease, which could likely lead to inefficient care and possibly inadequate payment for the required level of management.
Abstract: Background: As the United States population ages, chronic conditions are becoming more prevalent and our healthcare system is faced with increasing costs. This aging population with increased multi...
42 citations
TL;DR: Good patient care and communication are similarly important to all patients, regardless of race, and practices should maintain focus on these qualities, as well as on patient education regarding the relevant differences between FM and IM physicians.
Abstract: Background and Aims: Studies have identified factors important to patients in consideration of a primary care physician (PCP) Few have explored relevant differences in choosing between family medi
37 citations
TL;DR: Policy that promotes mental health education for primary care providers, provides reimbursement for mental health screening, and encourages better service integration could increase suicide screening and save healthcare costs and patients’ lives.
Abstract: Objective: To determine primary care providers’ rates of screening for suicide and mental health problems in adolescents and the factors that promote or discourage this practice. Patients and Metho...
37 citations
TL;DR: It is suggested that increasing the intake of fruits and vegetables may be an effective dietary strategy to control weight and mitigate the risk of obesity.
Abstract: Background: Empirical evidence on the relationship between consumption of fruits and vegetables and body weight is inconclusive. Previous studies mostly use linear regression methods to study the c...
35 citations
TL;DR: In this study of adolescents who already have primary care providers and are seemingly well-connected to the health care system, there remained significant reported barriers to accessing necessary health services.
Abstract: Objectives: To determine from adolescents using health care their: 1) perceptions of barriers to obtaining health services, 2) views on how to overcome the barriers and 3) views on how to create an adolescent-friendly primary care practice. Design: Six focus group interviews. Methods: Adolescents 11-21 years old from three health centers in the Bronx were recruited. Main Outcome Measures: 1) barriers to accessing health care such as insurance, language barriers, transportation, making an appointment; 2) identifying barriers related to issues of consent and confidentiality; 3) exploring barriers to accessing mental health and related issues; and 4) their visions of an adolescent-friendly office. Results: Thirty-one adolescents, aged 11-21 years old, participated. The majority were Hispanic and 52% were female. Fifty percent of adolescents had a routine visit within the past month. Most adolescents reported experiencing barriers to making an appointment. Additionally, they complained about long waiting time...
29 citations
TL;DR: Improvements in health care services have been made, including better continuity, emphasis on top chief complaints, and provider education in medical Spanish.
Abstract: Purpose: To identify the chief complaints and demographics at Clinica Esperanza, a student-run free clinic for an underserved Hispanic population. Methods: A retrospective chart review of patient f...
20 citations
TL;DR: Dementia status and medical burden were independent predictors of emergency department (ED) visits and death in patients with clinically diagnosed dementia followed from the early stage of disease.
Abstract: Studies that assess health care use in older adults with and without dementia face several major challenges. These include ascertaining dementia status, measuring health care use, and adjusting for comorbidities. Most studies rely either on patient and informant reports or on medical claims data. Claims-based studies show that older adults with dementia use more medical care and incur higher medical costs than older adults without dementia.1–3 In these studies, the use of medical claims data to establish dementia cases creates at least two methodological issues. First, use of claims data likely underestimates true dementia-related utilization, as such data cannot capture undiagnosed dementia or the prodromal states preceding frank dementia. Second, because the same data are used to capture dementia cases and to measure outcomes, persons with higher costs may be preferentially ascertained, resulting in ascertainment bias.4 Studies using claims-based data are therefore vulnerable to the twin problems of underestimating total utilization and cost, while overestimating the health care costs per person.
Studies that rely on patient and informant reports often use research quality evaluations to determine dementia status, which generally provide more consistent ascertainment of dementia status.5,6 However, these studies may need to rely on informants to obtain medical history and determine patterns of health care use. Abundant evidence suggests that such informant-based reporting is subject to bias, often failing to report utilization.7,8
Assessing the role of comorbidities is a third challenge. Serious medical conditions that are common in people with dementia increase the use and cost of health care services.9 If comorbidites increase utilization independent of dementia status, any estimate of dementia burden should adjust for them. On the other hand, if comorbid disease is mediated by dementia status, then adjusting may lead to underestimates of dementia-attributable utilization.
To address these challenges, we systematically screened and diagnosed dementia in older adults participating in a longitudinal cohort study of dementia screening strategies in an urban geriatrics practice. To capture the range in severity of comorbidities, we then used the Cumulative Illness Rating Scale-Geriatrics (CIRS-G) a well validated measure of chronic medical burden for geriatric patients that indicates number and severity of comorbid disease.10,11 We avoided reliance on informant reports by reviewing medical charts to compile the CIRS-G. Finally, we used hospital-based claims data to assess utilization, focusing on emergency department (ED) visits and hospital admissions for 5 years following our initial assessment.
We expected that patients with very mild dementia would have more ED visits and hospitalizations than patients without dementia. This is because very mild dementia, which often goes unrecognized in primary care,12–14 may lead to poor adherence to medication and lifestyle management and a failure to optimally manage medical comorbidities.15 This, in turn, may increase the use of acute care services and exacerbate cognitive impairment.1,5,16 Medical burden was expected to be a powerful predictor of both ED visits and hospital admissions as it is in most studies of dementia. 9 Finally, we sought to determine whether dementia status and medical burden were independent predictors of ED visits and hospitalizations.
19 citations
TL;DR: The results show that 44.6% of convenient care clinic visits occurred on weekdays, 5 pm or later, or on weekends, and savings from avoided encounters with the emergency room, urgent care, and primary care physician were $135.53 million.
Abstract: This study examines the utilization of convenient care clinic services outside of typical physician office hours and estimates the cost savings from potentially avoided visits to the emergency room, urgent care center, and primary care physician associated with convenient care clinic encounters. The results show that 44.6% of convenient care clinic visits occurred on weekdays, 5 pm or later, or on weekends. Savings from avoided encounters with the emergency room, urgent care, and primary care physician were estimated at $135.53 million.
18 citations
TL;DR: Older drivers support mandatory age-based testing but appear more likely to follow recommendations from physicians or family members, thereby supporting a role for physician counseling, driver evaluations, and advanced driving directives.
Abstract: Objectives: To describe older adults’ opinions about driving cessation and driver retesting. Methods: Older adult (≥ 65 years) patients visiting the emergency department or geriatric clinic at a university hospital completed a confidential survey regarding attitudes toward driving tests and restrictions. Results: The response rate was 50% (N = 169). The median age was 75 years (range, 65-98); 53% were women. Most reported driving at least occasionally (78%; 95% confidence interval [95% CI], 72-84). Twelve percent (95% CI, 7-18) reported a crash in the prior year; most (84%; 95% CI, 78-90) reported at least 1 medical diagnosis possibly linked to increased crash risk. Most participants (74%; 95% CI, 67-81) supported mandatory, age-based driver retesting but thought family (73%; 95% CI, 68-81) or physicians (60%; 95% CI, 54-69) should determine license revocation for an unsafe driver rather than the Department of Motor Vehicles (34%; 95% CI, 28-42) or the police (30%; 95% CI, 23-37). Almost all reported they...
17 citations
TL;DR: Factors that predict plans to retire differ from those associated with plans to leave practices for other reasons, and the strongest predictor concerned problems regarding time spent coordinating care for patients, possibly reflecting dissatisfaction with tasks that do not require medical expertise and are not generally paid for in fee-for-service medicine.
Abstract: The status of the primary care workforce is a major health policy concern. It is affected not only by the specialty choices of young physicians but also by decisions of physicians to leave their pr...
TL;DR: Early signs of cognitive decline may be an indicator of greater use of primary care and more PCPs are likely to be needed to meet the increasing needs of the older population.
Abstract: Objective: To assess the relationship between cognitive decline of older patients (≥ 65 y) and use of primary care physician (PCP) services over 24 months. Design: Retrospective analysis of prospec...
TL;DR: Acculturation, insurance, and performance of breast self-examination were key correlates of recent cervical cancer screening among Midwest Latina farmworkers.
Abstract: Background: While cancer control and prevention efforts are well documented, limited information on this topic exists for Latina farmworkers in the rural Midwest This study sought to examine corre
TL;DR: As primary care delivery systems are redesigned in ways that rely on new roles to deliver care, understanding how to effectively add or change staff roles is essential and requires attention to patients’, practice members’ and institutions’ support for new roles.
Abstract: Purpose: While experts suggest that primary care needs far-reaching transformation that includes adding or reconfiguring roles to improve patient care, little is known about how role change occurs in practice settings. Methods This was a cross-case comparative analysis of 3 projects designed to improve health behavior counseling in primary care practices by adding to or changing clinical support staff roles. Qualitative data (site visits notes, grantee reports, interviews with grantees, and online diary entries) were analyzed to examine instances of role change in depth, using role change theory as an organizing framework. Results Practice team members had greater success taking on new roles when patients valued the services provided. Often, it was easier to a hire a new person into a new role rather than have an existing practice member shift responsibilities. This was because new personnel had the structural autonomy, credibility, and organizational support needed to develop new responsibilities and rou...
TL;DR: Although physicians were knowledgeable about CRC screening guidelines, 25% mistakenly believed that single-sample in-office fecal testing was appropriate, and there was a striking lack of office systems for identifying eligible patients and facilitating CRC screening.
Abstract: Patients generally access colorectal cancer (CRC) screening through primary care physicians. National guidelines recommend CRC screening for adults beginning at age 50, yet one-third of Americans are not up to date. Methods: A self-administered questionnaire was administered to family physicians from 16 practices in a Midwestern state who attended an information session for a randomized study to improve CRC screening. The questionnaire assessed CRC screening practices, knowledge of CRC screening guidelines, and office strategies for improving screening. Results: Of 131 health care providers, 85 (65%) completed the questionnaire. Two-thirds were aware of the CRC screening guidelines; 91% knew that the follow-up interval for screening depends on the test chosen. Twenty-five percent incorrectly stated that a single-sample in-office fecal occult blood test is an acceptable screening test. Only 8% had a written policy regarding CRC screening; 18% had offices that used chart reminders; and 32% had charts organi...
TL;DR: Evidence is found showing that eating behavior is an important determinant of obesity prevalence, and the findings suggest that improving the eating behavior of individuals would help reduce excessive body weight and its induced health risks.
Abstract: Background: Although a growing body of research has examined the association between food prices and the availability of fast food restaurants on weight outcomes, there is limited empirical evidenc...
TL;DR: In general, primary health care provided a better quality of care to diabetic patients compared to that of hospitals, and primary care patients had a better satisfaction score towards diabetes care.
Abstract: Objective: To assess the quality of diabetes care provided to patients attending primary care settings and hospitals in the State of Qatar. Design: Observational cohort study. Setting: The survey w...
TL;DR: In a medical culture that provides only limited time for physician and patient interactions, physician-patient communication using electronic health record-tethered patient portals may provide a time-efficient, low-cost mechanism for effective ACP.
Abstract: In the last 20 years, progress has been made to develop resources for advance care planning (ACP). Several ACP delivery tools have demonstrated progress, but more are needed to improve ACP delivery systems. Providers continue to indicate that increasing patient volume, increasing patient complexity, and an increasing paperwork burden have adversely affected quality ACP delivery. An increasing and ubiquitous use of health information technology, such as electronic health records and electronic health record-tethered patient portals, affords opportunities for innovation to streamline communication methods between providers and patients. In a medical culture that provides only limited time for physician and patient interactions, physician-patient communication using electronic health record-tethered patient portals may provide a time-efficient, low-cost mechanism for effective ACP.
TL;DR: Outreach to male patients and additional supports for primary care providers, especially in the first years of practice, may improve screening and treatment for depression among Alaska Native and American Indian people.
Abstract: Introduction: The US Preventive Services Task Force recommends routine depression screening in primary care, yet regular screening does not occur in most health systems serving Alaska Native and Am...
TL;DR: The results of the study showed the need to attract and retain physicians in rural health clinics, and the positive relationship between rural location and quality of care reflects more on the limited access to hospitals in remote areas.
Abstract: Purpose: To identify organizational and environmental correlates to rural health clinics’ preventive quality of care in the United States. Design: A retrospective observational cohort study design was applied under Donabedian’s Structure-Process-Outcome framework. Three structure measures of care (proportion of nonphysicians, absence of physicians, and provider affiliation) and three measures of process (total clinical visits, prevention use for congestive heart failure and diabetes) were used as explanatory variables. Five environmental correlates were included. The Centers for Medicare and Medicaid Services National Medicare Chronic Care Condition Data Warehouse for 2007 was used to obtain clinical data. Preventive quality of care outcomes were measured through Agency for Healthcare Research and Quality prevention quality indicators. The indicators were risk adjusted for age, sex, race, severity, and comorbidity of patients. Methods: Structural equation modeling with maximum likelihood estimation was us...
TL;DR: The need to improve infrastructure for pediatric PCPs to receive and request infant hearing screening results to facilitate reporting and coordinate follow-up services for infants identified with hearing loss is highlighted.
Abstract: Objective: Approximately 2 to 3 out of 1000 infants are born with hearing loss in the United States each year. Pediatric primary care physicians (PCPs) can play an important role in ensuring that infants with hearing loss are identified early and provided appropriate services. In this study, pediatric PCPs were surveyed about their practices regarding early hearing detection and intervention. Methods: Responses from the 2008 DocStyles survey were used to examine patient, physician, and practice variables associated with actions consistent with the 2007 Joint Committee on Infant Hearing position statement, which includes follow-up protocols for medical home providers. Results: Pediatricians working in a group setting were more likely to receive hearing screening results than were those in individual practices or hospitals and clinics. Family/general physicians with heavier caseloads were more likely to receive hearing screening results for their pediatric patients than were those with lighter caseloads. Fe...
TL;DR: The findings of this study showed that activity limitation and cost of medical care are associated with FMD in the US elderly population.
Abstract: Objectives: Poor mental health is a major source of distress, disability, and social burden in older adults The objective of this study was to determine if activity limitation and healthcare access are associated with frequent mental distress (FMD) in adults 65 years and older Methods: Of the 123 427 study participants aged 65 years or older, 120 445 participants responded to the Behavioral Risk Factors Surveillance System (BRFSS) survey question on number of mentally unhealthy days Participants who reported having 14 or more mentally unhealthy days during the past 30 days were considered as having FMD Activity limitation, avoidance of medical care due to cost, and availability of personal doctor were examined for their association with FMD in multivariable logistic regression analysis Age, sex, race/ethnicity, marital and employment status, emotional support, and life satisfaction were included as potential confounders Results: The prevalence of FMD in this study population was 65% (95% CI = 63-68) with estimates significantly greater among women (72%, 95% CI = 69-76) as compared to men (55%, 95% CI = 51-60) The odds of FMD were more than 2-fold elevated for those who reported activity limitations due to physical, mental, or emotional problems (adjusted OR = 259, 95% CI = 233-287), and among those who reported health care cost as a barrier to see a doctor (adjusted OR = 214, 95% CI = 175-261) There was no significant relationship between availability of personal doctor and FMD observed in the study Conclusions: The findings of this study showed that activity limitation and cost of medical care are associated with FMD in the US elderly population Language: en
TL;DR: Using the self-management guide and action plan framework, particularly during the initial clinic visit, helped focus patients on behavior change and provides insight into initiating brief diabetes self- management strategies in resource-poor community clinics.
Abstract: Purpose: To evaluate the implementation of a brief diabetes self-management support intervention designed for resource-poor community clinics. Methods: The authors conducted a pilot study among pat...
TL;DR: The aim of this study was to highlight the expectations that patients with type 2-diabetes have of the health advice conversation with the nurse practitioner and to motivate the informants about lifestyle changes and to gain the ability to manage the disease.
Abstract: Type 2-diabetes usually makes its first appearance in adult age. In order for patients to feel in control of the disease, they need support and information that can easily be understood and which is relevant for the individual. By educating and supporting them, patients can conduct self-care and take control. The aim of this study was to highlight the expectations that patients with type 2-diabetes have of the health advice conversation with the nurse practitioner. A qualitative method using interviews was conducted and the data material was analysed according to manifest and latent content analysis. Three categories emerged in the results. Firstly, providing good accessibility to the diabetes nurse practitioner is of importance. Secondly, there is a demand for group activities in which patients have the opportunity to talk with other individuals who have diabetes. Finally, knowledge about self-care means that the patients themselves are able to change the intake of medication, their eating habits, and ex...
TL;DR: Future research is needed to explore innovative health education strategies that improve knowledge and subsequent CRC screening behaviors among low-income, low-literacy, unacculturated Latinos.
Abstract: Objective: Colorectal cancer (CRC) is the third leading cause of cancer death for Latino men and women; and Latinos are more likely to be diagnosed at a later stage, which is most likely due to underutilization of CRC preventive screening. The purpose of this study was to determine whether a brief, clinic-based intervention by a community health advisor (CHA) would increase CRC knowledge compared with traditional educational methodologies (eg, use of print materials). Methods: Latino adults 50 years and older attending a San Diego community health center were recruited while waiting for their primary care provider routine visit and were randomly assigned to receive 1 of 3 CRC educational interventions: community health advisor (CHA) plus CRC educational brochure (CHA intervention group), CRC educational brochure (minimal intervention group), or 5-a-day nutrition brochure (usual care). CRC knowledge was assessed before and after the primary care provider visit for 130 participants. Results: Results demonst...
TL;DR: This study demonstrates attending an AMS for primary care predicted earlier return to the primary care provider after an index PED visit, demonstrating Elements of adolescent specialty care producing such outcomes are worthy of further study.
Abstract: Background: Many of the 18 million emergency department visits by adolescents annually in the United States are for nonurgent problems that might be addressed in a primary care setting. Methods: As part of a larger randomized controlled intervention, 1023 adolescents aged 12 to 21 years registering in an urban pediatric emergency department (PED) were tracked over the subsequent 365 days to record all visits to the PED. Adolescents identifying an adolescent medicine service (AMS) as the primary care source were compared with adolescents receiving primary care elsewhere in an integrated urban medical system (non-AMS) to determine how often after the index PED visit they revisited the PED, returned to primary care (PC), visited a subspecialist (SS), or were hospitalized. Mean values and odds ratios of each type of visit were compared between AMS and non-AMS patients using multivariate logistic and ordinary least squares regressions to control for covariates. Results: AMS patients (n = 124, 12%), compared to...
TL;DR: As Web-based Ix increases in frequency, the evaluation of patient and clinician communication is important and should be expanded to increase the benefits for both patients and clinicians.
Abstract: Background: Recently, experts have included information therapy (Ix) as a method for increasing clinician-patient communication, patient adherence, patient understanding of diagnosis and treatment options, and reduction in hospitalizations. Methods: This study, a secondary, retrospective analysis of survey data, independently examined participating patient perceptions of an Ix program between two Mid-western employers. Surveys were administered through the online platform from January 1, 2006 through December 31, 2009 for Employer 1 (N = 4105) and from June 1, 2007 through December 31, 2009 for Employer 2 (N = 8123). Results: Preliminary findings indicate the majority of patients were adherent to recommended treatment(s) and highly rated their physician’s performance. Additionally, patients indicated that their physician’s access to their questionnaire responses motivated them to improve their health literacy and change their health behaviors. Secondary data analysis indicated a positive relationship betw...
TL;DR: Oral gargles and sprays have been shown to be significantly better than are oral rinses if the oropharynx is the targeted site, and the size of the oral airway does not impede their efficacy.
Abstract: Introduction and Aims: Patients with sore throats are often treated with oral gargles or oral sprays. Some may rinse instead of gargle, leading to unsatisfactory outcome. The authors studied the efficacy of oral rinses, gargles, and sprays and the effect of Friedman palate position on the outcome. Methods: Ten subjects used specially prepared solutions to rinse, gargle, and then spray their oral cavities at 2-hour intervals. The blue dye indicated the areas stained by the solution, which were scored. Results: Although there was no difference in reaching the oropharynx between the gargles and sprays, they were both better than were the oral rinses (P < .001). The difference in Friedman palate position did not have an effect on the efficacy of the different modalities. Conclusion: Oral gargles and sprays have been shown to be significantly better than are oral rinses if the oropharynx is the targeted site, and the size of the oral airway does not impede their efficacy.
TL;DR: Clinicians and health care professionals should be encouraged to emphasize the importance of consumption of fruits and vegetables in their routine practice to the patients with chronic disease(s), especially to those who are unmarried and male.
Abstract: Objective: The objective of this study was to examine the factors associated with fruits and vegetables consumption pattern among persons with doctor-diagnosed chronic diseases. Method: The authors...
TL;DR: Self-medication for arthritis is common and often does not follow clinical guidelines, and efforts to improve the quality of osteoarthritis care that focus solely on health care providers are unlikely to ensure optimal arthritis care.
Abstract: Background: Although arthritis is disabling, highly prevalent, and often treated without health professional input, little is known about the treatments selected by affected individuals. Such information is important because of the toxicity associated with some arthritis treatments. Objective: To describe the pattern of drug treatment use in a sample of persons with arthritis. Method: The authors distributed an 11-item survey to veterans attending veterans’ organization post meetings in southeastern Wisconsin during November and December 2009. Of 32 posts, 26 (81%) returned surveys from 446 persons; survey count and attendance figures suggest that the majority of attendees completed surveys at participating posts. Most respondents were older (75% aged 60 years or older) men (90%). Respondents with arthritis reported whether they had used each of seven drug therapies in the past year. Results: Almost all members of participating posts responded to the survey, increasing the likelihood that this was a repre...