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Parzuchowski A, Oronce C, Guo R, Tseng CH, Fendrick AM, Mafi JN. Evaluating the accessibility and value of U.S. ambulatory care among Medicaid expansion states and non-expansion states, 2012-2015. BMC Health Serv Res 2023; 23:723. [PMID: 37400793 PMCID: PMC10318663 DOI: 10.1186/s12913-023-09696-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 06/07/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND While the Affordable Care Act's Medicaid expansion improved healthcare coverage and access for millions of uninsured Americans, less is known about its effects on the overall accessibility and quality of care across all payers. Rapid volume increases of newly enrolled Medicaid patients might have unintentionally strained accessibility or quality of care. We assessed changes in physician office visits and high- and low-value care associated with Medicaid expansion across all payers. METHODS Prespecified, quasi-experimental, difference-in-differences analysis pre and post Medicaid expansion (2012-2015) in 8 states that did and 5 that did not choose to expand Medicaid. Physician office visits sampled from the National Ambulatory Medical Care Survey, standardized with U.S. Census population estimates. Outcomes included visit rates per state population and rates of high or low-value service composites of 10 high-value measures and 7 low-value care measures respectively, stratified by year and insurance. RESULTS We identified approximately 143 million adults utilizing 1.9 billion visits (mean age 56; 60% female) during 2012-2015. Medicaid visits increased in expansion states post-expansion compared to non-expansion states by 16.2 per 100 adults (p = 0.031 95% CI 1.5-31.0). New Medicaid visits increased by 3.1 per 100 adults (95% CI 0.9-5.3, p = 0.007). No changes were observed in Medicare or commercially-insured visit rates. High or low-value care did not change for any insurance type, except high-value care during new Medicaid visits, which increased by 4.3 services per 100 adults (95% CI 1.1-7.5, p = 0.009). CONCLUSIONS Following Medicaid expansion, the U.S. healthcare system increased access to care and use of high-value services for millions of Medicaid enrollees, without observable reductions in access or quality for those enrolled in other insurance types. Provision of low-value care continued at similar rates post-expansion, informing future federal policies designed to improve the value of care.
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Affiliation(s)
- Aaron Parzuchowski
- Department of Veteran Affairs, National Clinician Scholars Program, Ann Arbor, MI, USA
- Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Carlos Oronce
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
- VA Greater Los Angeles Healthcare System, Los Angeles, CA, USA
| | - Rong Guo
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA
| | - A Mark Fendrick
- Division of General Medicine, University of Michigan, Ann Arbor, MI, USA
| | - John N Mafi
- Division of General Internal Medicine and Health Services Research, University of California Los Angeles, Los Angeles, CA, USA.
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Du M, Li P, Tang L, Xu M, Chen X, Long H. Cognition, attitude, practice toward health checkup and associated factors among urban residents in southwest China, Sichuan province, 2022: a community-based study. ZEITSCHRIFT FUR GESUNDHEITSWISSENSCHAFTEN = JOURNAL OF PUBLIC HEALTH 2023; 32:1-12. [PMID: 37361297 PMCID: PMC10023997 DOI: 10.1007/s10389-023-01883-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/02/2023] [Indexed: 06/28/2023]
Abstract
Aim Research on the health checkup status of urban residents in Southwest China is limited. In this study, we aimed to investigate the current status of health checkups and explore their influencing factors by analyzing the cognition, attitudes, and practices of urban residents in Southwest China. Methods We sampled 1200 urban residents for a questionnaire survey. Statistical analysis was performed using SPSS 23, and logistic regression analysis was used to analyze the factors affecting cognition, attitudes, and practices regarding health checkups. A P value < 0.05 was used to identify variables significantly associated with the outcome variable. Results Overall, 29% of the residents understood the importance of health checkups. The main ways urban residents acquire health-related knowledge are through the use of mobile media and medical staff health education. Only 40% of residents had undergone a regular checkup. Health self-assessment, economic reasons, and time are the factors that interfere with urban residents' health checkups. Logistic regression analysis showed that occupation status, educational background, self-assessed health status, exercise status, and monthly income level were the common influencing factors of health checkup cognition and planning. Whether residents had participated in a medical checkup program was also related to sex and age. Conclusions Urban residents in Southwest China generally had a high willingness to undergo physical examinations, but there were differences in knowledge and practice; at the same time, residents lacked understanding of respiratory assessments. Improving the health literacy of medical staff, strengthening urban residents' health education, and enhancing the utilization rate of health checkups in urban residents are necessary and urgent.
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Affiliation(s)
- Min Du
- North Sichuan Medical College, Nanchong, Sichuan People’s Republic of China
- Geriatric intensive care unit, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, UESTC, Chengdu, Sichuan People’s Republic of China
| | - Pingyang Li
- University of Electronic Science and Technology of China, Chengdu, China
| | - Ling Tang
- North Sichuan Medical College, Nanchong, Sichuan People’s Republic of China
| | - Min Xu
- University of Electronic Science and Technology of China, Chengdu, China
| | - Xinzhu Chen
- University of Electronic Science and Technology of China, Chengdu, China
| | - Huaicong Long
- Geriatric intensive care unit, Sichuan Academy of Medical Sciences & Sichuan Provincial People’s Hospital, School of Medicine, UESTC, Chengdu, Sichuan People’s Republic of China
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Hernandez R. "It's Always among Us. I Can't Act Like It's Not.": Women College Students' Perceptions of Physicians' Implicit Bias. HEALTH COMMUNICATION 2023; 38:50-60. [PMID: 34036850 DOI: 10.1080/10410236.2021.1932107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Physicians have an opportunity to provide accurate and timely information about sexual behavior to individuals in their care. However, many young people, and in particular college women, are reticent to talk to their physicians about sexual behavior. One explanation for this reticence may be the fact that physicians' implicit bias has the potential to denigrate communication between physicians and patients. However, little is known about how patients perceive physicians' implicit bias, or to what extent it shapes a patient's beliefs about communicating with their physician. Qualitative analysis of in-depth, semi-structured interviews was used to describe and explain the way women college students perceive issues concerning physicians' implicit bias. Results were interpreted through the lens of Communication Privacy Management theory and revealed that participants either avoided or limited communication with a physician as a result of anticipating implicit bias. Major themes included "untangling identity and the effects of physicians' implicit bias" and "seeking to understand physicians' cognition and emotion." These findings have the potential to improve communication interventions both for women college students and healthcare professionals by introducing evidence of patients' perceptions of implicit biases along the intersection of race, young age, sexuality, and female gender in physician-patient communication about sexual behavior.
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Sheiman I, Shishkin S, Sazhina S. Vertical program of screenings and check-ups in the Russian Federation: design, implementation and lessons learnt. Arch Public Health 2022; 80:123. [PMID: 35428312 PMCID: PMC9012158 DOI: 10.1186/s13690-022-00878-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 04/01/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
The Russian Federation has introduced a vertical large-scale program of ‘dispensarization’ (Program) that includes health check-ups and screenings for the entire adult population. It is expected to improve the results of medical interventions and ensure health gains at a relatively low cost. The major research question: Does the design and implementation of the program meet the expectations?
Methods
We analyze regulatory acts and the literature on the design and the outcomes of the Program. Physicians’ surveys and interviews are conducted to understand the capacity of primary care providers to meet the requirements of the Program, as well as the link between the early identification of new illnesses and their follow-up management, administration of the program, the barriers to its successful implementation.
Results
There is a substantial progress in the coverage of the population and increase in the number of identified illnesses. Some specific instruments of the Program implementation work well, others require more careful design and additional integrative and managerial activities. The capacity of primary care providers does not allow to provide high quality preventive services, as well as to ensure a continuum of preventive and curative work. The pattern of the Program administration facilitates its nation-wide implementation according to the unified rules, but makes it more difficult to account for the local conditions and limits the autonomy of professionals to choose specific population risk groups and a list of services. The interaction of providers in preventive activities is inadequate.
Conclusion
The expectations of the Program are too high due to the inconsistencies in its design and implementation. The major lesson learnt is that the program like this should meet the capacity of primary care and be designed as a complex of interrelated activities to identify illnesses and provide their follow-up management.
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Obi IR, Obi KM, Seer-Uke EN, Onuorah SI, Okafor NP. Preventive health care services utilization and its associated factors among older adults in rural communities in Anambra State, Nigeria. Pan Afr Med J 2021; 39:83. [PMID: 34466185 PMCID: PMC8379407 DOI: 10.11604/pamj.2021.39.83.26997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 05/15/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction quality of life and life expectancy of people are improved when preventive health care services are utilized because these identify treatable health problems and puts life-threatening diseases in check. Morbidity and mortality associated with age-related chronic disease among the older adults is on the increase, therefore, this study aims at determining preventive health care services utilization among older adults in rural communities in Anambra State. Methods a cross sectional design adopted for this study was carried out on older adults from the ages of 65 years and above in rural communities in Anambra State from October 2019 to January 2020. Data were collected through researcher-administered structured questionnaire. Data were analysed using univariable and multivariable regression analysis. Results a total of 1944 older adults participated with an overall cluster percentage of 40.6% older adults utilizing investigated preventive health care services. The results of the multivariable analysis indicates that the following factors were associated with utilization of preventive healthcare services: male gender (aOR: 0.443, 95%CI: 0.281 - 5.472, p=0.47), level of education; primary (aOR: 1.536, 95%CI: 1.201 - 5.261, p=0.00), secondary (aOR: 4.516, 95%CI: 3.192 - 6.242, p=0.00), and tertiary (aOR: 3.407, 95%CI: 3.199 - 5.666, p=0.00)], income of N50,000-N100,000 (aOR: 2.754, 95%CI: 1.066 - 10.766, p=0.01), and N100,000 and above (aOR: 4.233, 95%CI: 1.846 - 12.811, p=0.00)], and health insurance [aOR: 0.691, 95%CI: 0.422 - 1.945, p=0.03]. Conclusion preventive health care services were under-utilized. Creating awareness on the importance of utilizing preventive health care services is highly recommended since most age-related chronic diseases once established may last a lifetime and affect quality of life and wellbeing.
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Affiliation(s)
- Ifunanya Rosemary Obi
- Department of Physical and Health Education, Federal College of Education (Technical), Umunze, Nigeria
| | | | | | | | - Nonye Peculiar Okafor
- Department of Human Kinetics and Sports Studies, Alvan Ikoku College of Education, Owerri, Nigeria
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Smith MP. Self-estimated BMI, but not self-perceived body size, accurately identifies unhealthy weight in US adults. BMC Public Health 2021; 21:253. [PMID: 33516202 PMCID: PMC7847588 DOI: 10.1186/s12889-021-10316-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 01/24/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Self-perceptions of health and disease can be a major driver of health behaviors. Improving accuracy of self-ascertainment of obesity may prompt uptake of weight-control behaviors in those with obesity. METHODS We assess performance of self-perceived body size ('too small', 'about right' or 'too large'), self-estimated BMI in kg/m2, and sociodemographics in detecting measured BMI category (under-, normal-, overweight and obese; BMI cutpoints 18.5, 25 and 30) in first bivariate and then multivariable models. RESULTS Of 37,281 adults in the US from NHANES, 2, 34, 33 and 32% were under-, normal-, overweight and obese. Respectively 56, 73, 60 and 91% self-perceived as 'too small', 'about right', 'too large' and 'too large.' Of those who self-perceived as 'too small', 22% were underweight and 10% were overweight or obese. 99.7% of obese participants self-estimated a BMI in the overweight/obese range, including many who did not self-perceive as 'too large'. Among obese participants, self-perception as either 'about right' or 'too small' was more likely for those who were younger (OR for perception as 'too large' 1.01 per year, 95% confidence interval 1.00-1.01) male (OR 0.33, (0.28-0.39)) nonwhite (ORs 0.36-0.79 for different ethnicities), low-income (ORs 0.61 and 1.8 for the lowest and highest of six categories, vs. the third) or measured recently (OR 0.98 (0.96-1.0) per year since 1999). Misperception was less common, but still existed, for participants with moderate or severe obesity (ORs 2.9 (2.3-3.5) and 7.9 (5.4-12), vs. 'mild.') (all p < 0.01.) CONCLUSIONS: A tenth of adults in the US with obesity, especially those from overweight peer groups, self-perceive as normal or underweight and thus may not be motivated to control their weight. However, virtually all self-estimate an overweight or obese BMI. If measured BMI is not available, self-estimates are sufficiently accurate that interventions may rely on it to identify obesity.
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Affiliation(s)
- Maia Phillips Smith
- St. George's University School of Medicine, PO Box 7, True Blue, West Indies, Grenada.
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Ganguli I, Lupo C, Mainor AJ, Wang Q, Orav EJ, Rosenthal MB, Sequist TD, Colla CH. Assessment of Prevalence and Cost of Care Cascades After Routine Testing During the Medicare Annual Wellness Visit. JAMA Netw Open 2020; 3:e2029891. [PMID: 33306120 PMCID: PMC7733154 DOI: 10.1001/jamanetworkopen.2020.29891] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
IMPORTANCE For healthy adults, routine testing during annual check-ups is considered low value and may trigger cascades of medical services of unclear benefit. It is unknown how often routine tests are performed during Medicare annual wellness visits (AWVs) or whether they are associated with cascades of care. OBJECTIVE To estimate the prevalence of routine electrocardiograms (ECGs), urinalyses, and thyrotropin tests and of cascades (further tests, procedures, visits, hospitalizations, and new diagnoses) that might follow among healthy adults receiving AWVs. DESIGN, SETTING, AND PARTICIPANTS Observational cohort study using fee-for-service Medicare claims data from beneficiaries aged 66 years and older who were continuously enrolled in fee-for-service Medicare between January 1, 2013, and March 31, 2015; received an AWV in 2014; had no test-relevant prior conditions; did not receive 1 of the 3 tests in the 6 months before the AWV; and had no test-relevant symptoms or conditions in the AWV testing period. Data were analyzed from February 13, 2019, to June 8, 2020. EXPOSURE Receipt of a given test within 1 week before or after the AWV. MAIN OUTCOMES AND MEASURES Prevalence of routine tests during AWVs and cascade-attributable event rates and associated spending in the 90 days following the AWV test period. Patient, clinician, and area-level characteristics associated with receiving routine tests were also assessed. RESULTS Among 75 275 AWV recipients (mean [SD] age, 72.6 [6.1] years; 48 107 [63.9%] women), 18.6% (14 017) received at least 1 low-value test including an ECG (7.2% [5421]), urinalysis (10.0% [7515]), or thyrotropin test (8.7% [6534]). Patients were more likely to receive a low-value test if they were younger (adjusted odds ratio [aOR], 1.69 for ages 66-74 years vs ages ≥85 years [95% CI, 1.53-1.86]), White (aOR, 1.32 compared with Black [95% CI, 1.16-1.49]), lived in urban areas (aOR, 1.29 vs rural [95% CI, 1.15-1.46]), and lived in high-income areas (aOR, 1.26 for >400% of the federal poverty level vs <200% of the federal poverty level [95% CI, 1.16-1.37]). A total of 6.1 (95% CI, 4.8-7.5) cascade-attributable events per 100 beneficiaries occurred in the 90 days following routine ECGs and 5.4 (95% CI, 4.2-6.5) following urinalyses, with cascade-attributable cost per beneficiary of $9.62 (95% CI, $6.43-$12.80) and $7.46 (95% CI, $5.11-$9.81), respectively. No cascade-attributable events or costs were found to be associated with thyrotropin tests. CONCLUSIONS AND RELEVANCE In this study, 19% of healthy Medicare beneficiaries received routine low-value ECGs, urinalyses, or thyrotropin tests during their AWVs, more often those who were younger, White, and lived in urban, high-income areas. ECGs and urinalyses were associated with cascades of modest but notable cost.
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Affiliation(s)
- Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Claire Lupo
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Alexander J. Mainor
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Qianfei Wang
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - E. John Orav
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Meredith B. Rosenthal
- Department of Health Care Policy and Management, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas D. Sequist
- Harvard Medical School, Boston, Massachusetts
- Division of General Internal Medicine and Primary Care, Brigham and Women’s Hospital, Boston, Massachusetts
- Mass General Brigham, Boston, Massachusetts
| | - Carrie H. Colla
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Norris Cotton Cancer Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
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Affiliation(s)
- Carl Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kamal R Mahtani
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Coroiu A, Moran C, Bergeron C, Thombs BD, Geller AC, Kingsland E, Körner A. Operationalization of skin self-examination in randomized controlled trials with individuals at increased risk for melanoma: A systematic review. PATIENT EDUCATION AND COUNSELING 2020; 103:1013-1026. [PMID: 31917011 DOI: 10.1016/j.pec.2019.12.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 11/25/2019] [Accepted: 12/11/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate how skin self-examination was operationalized and the psychometric properties of the scales used to assess this behavior in randomized controlled trials (RCTs) testing interventions that promote SSE among individuals at increased risk for melanoma. METHOD Eight scientific databases (e.g., Medline, EMBASE, CINAHL, PsycINFO) and four trial registries (e.g., Clinicaltrials.gov, UK Clinical Trails Gateway) were searched from inception through April 2, 2019. Three reviewers carried out the selection of relevant trials and conducted data extraction. RESULTS The review identified 13 unique RCT's. The definition of skin self-exams, extrapolated from instructions provided to participants during the trials and reported in only 6/13 trials, included periodically checking the skin of the entire body, individually or with partners/mirrors, with or without tracking or monitoring tools, and using the ABCDE criteria to identify early signs of melanoma. There was variability in how skin self-examination behavior was measured with respect to item content, number of items, response format, and type of outcome variable used: continuous or binary). No validity evidence and minimal reliability evidence for the measures were identified. CONCLUSIONS AND PRACTICE IMPLICATIONS Future studies are needed to establish the psychometric properties of measures assessing skin self-examination.
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Affiliation(s)
- Adina Coroiu
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Department of Educational and Counselling Psychology, McGill University, Montréal, Quebec, Canada.
| | - Chelsea Moran
- Department of Psychology, University of Calgary, Calgary, Alberta, Canada
| | - Catherine Bergeron
- Department of Educational and Counselling Psychology, McGill University, Montréal, Quebec, Canada
| | - Brett D Thombs
- Department of Educational and Counselling Psychology, McGill University, Montréal, Quebec, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Quebec, Canada; Department of Psychiatry, McGill University, Montréal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montréal, Quebec, Canada; Department of Medicine, McGill University, Montréal, Quebec, Canada; Department of Psychology, McGill University, Montréal, Quebec, Canada
| | - Alan C Geller
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, United States
| | - Emily Kingsland
- McGill Library and Archives, McGill University, Montréal, Canada
| | - Annett Körner
- Department of Social and Behavioral Sciences, Harvard T.H. Chan School of Public Health, Boston, MA, United States; Lady Davis Institute for Medical Research, Jewish General Hospital, Montréal, Quebec, Canada; Louise Granofsky Psychosocial Oncology Program, Segal Cancer Center, Montreal, Canada; Psychosocial Oncology Program, McGill University Health Centre, Montreal, Canada
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Oronce CIA, Fortuna RJ. Differences in Rates of High-Value and Low-Value Care Between Community Health Centers and Private Practices. J Gen Intern Med 2020; 35:994-1000. [PMID: 31745849 PMCID: PMC7174534 DOI: 10.1007/s11606-019-05544-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 09/17/2019] [Accepted: 10/08/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Community health centers (CHCs) are an integral part of the health care safety net. As health systems seek to improve value, it is important to understand the quality of care provided by CHCs. OBJECTIVE To evaluate the performance of CHCs compared with private practices on a comprehensive set of high-value and low-value care measures. DESIGN This cross-sectional study used data from the National Ambulatory Medical Care Survey from 2010 through 2012. We compared CHCs with private practices using logistic regression models that adjusted for age, sex, race/ethnicity, insurance, number of chronic illnesses, rural versus urban location, region of country, and survey year. SETTING/PARTICIPANTS We included outpatient visits to generalist physicians at either CHCs or private practices by patients 18 years and older. MAIN MEASURES We examined 12 measures of high-value care and 7 measures of low-value care. RESULTS A total of 29,155 physician visits, representing 584,208,173 weighted visits, from 2010 through 2012 were included. CHCs were more likely to provide high-value care by ordering beta-blockers in CHF (46.9% vs. 36.5%; aOR 2.56; 95%CI 1.18-5.56), statins in diabetes (37.0% vs 35.5%; aOR 1.35; 95%CI 1.02-1.79), and providing treatment for osteoporosis (35.7% vs 23.2%; aOR 1.77; 95%CI 1.05-3.00) compared with private practices. CHCs were more likely to avoid low-value screening EKGs (98.7% vs. 88.0%; aOR 11.03; 95%CI 2.67-45.52), CBCs (75.9% vs. 65.7%; aOR 1.72; 95%CI 1.18-2.53), or urinalyses (86.0% vs. 80.5%; aOR 1.87; 95%CI 1.11-3.14) during a general medical exam. CHCs were also less likely to prescribe antibiotics for a URI (48.3% vs. 63.1%; aOR 0.59; 95%CI 0.40-0.88). CONCLUSIONS On a number of high-value and low-value measures of care, CHCs performed similar to or better than private practices. As healthcare delivery reforms continue to progress, CHCs are well positioned to provide high-value healthcare.
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Affiliation(s)
- Carlos Irwin A Oronce
- VA Greater Los Angeles Healthcare System, 1100 Glendon Ave. Ste. 900, Los Angeles, CA, 90034, USA. .,National Clinician Scholars Program and the Division of General Internal Medicine and Health Services Research, University of California, 1100 Glendon Ave. Ste. 900, Los Angeles, CA, 90034, USA.
| | - Robert J Fortuna
- Department of Medicine, University of Rochester Medical Center, 913 Culver Rd, Rochester, NY, 14609, USA. .,Department of Pediatrics, University of Rochester Medical Center, 913 Culver Rd, Rochester, NY, 14609, USA. .,Center for Primary Care, Culver Medical Group, University of Rochester Medical Center, 913 Culver Rd, Rochester, NY, 14609, USA.
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Effects of Routine Checkups and Chronic Conditions on Middle-Aged Patients with Diabetes. Adv Prev Med 2020; 2020:4043959. [PMID: 32181018 PMCID: PMC7063879 DOI: 10.1155/2020/4043959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 08/28/2019] [Indexed: 11/17/2022] Open
Abstract
Purpose. Middle-aged males and females with diabetes are more likely to have poor physical (PH) and mental health (MH); however, there is limited research determining the relationship between MH and PH and routine check-up in diabetic middle-aged adults, especially by gender. The purpose of this study was to determine whether PH and MH status differ by routine check-up in middle-aged (age 45-64) adults with diabetes in the general population. Methods. This cross-sectional analysis used data from the 2017 BRFSS conducted by the CDC for adults aged 45-64 who reported having diabetes in Florida (N = 1183), Kentucky (N = 617), Maryland (N = 731), New York (N = 593), and Ohio (N = 754). Multiple logistic regression by state and gender was used to determine the relationship between MH and PH status and routine check-up while controlling for health-related, socioeconomic, and demographic factors. Results. Across states, up to one-half reported good PH (32-50%), over one-half reported good MH (46-67%), and most reported having a routine check-up (87-93%). Adjusted analysis indicated that MH and PH were not significantly related to routine check-up, but both were inversely related to having diabetes plus two other health conditions. Conclusions. Overall, routine check-up was not related to good PH and MH in this target population; however, a number of health conditions were inversely related to good PH and MH status. In a primary care setting for this target population, there may be a low to moderate prevalence of good PH and MH and a high prevalence of having a routine check-up and having multiple health conditions. It is recommended to automatically screen this target population for PH, MH, other chronic conditions, and physical activity and treat concurrently.
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Lillie M, Lema I, Kaaya S, Steinberg D, Baumgartner JN. Nutritional status among young adolescents attending primary school in Tanzania: contributions of mid-upper arm circumference (MUAC) for adolescent assessment. BMC Public Health 2019; 19:1582. [PMID: 31775700 PMCID: PMC6882207 DOI: 10.1186/s12889-019-7897-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/05/2019] [Indexed: 12/20/2022] Open
Abstract
Background Adolescence is a critical time of development and nutritional status in adolescence influences both current and future adult health outcomes. However, data on adolescent nutritional status is limited in low-resource settings. Mid-upper arm circumference (MUAC) has the potential to offer a simple, low-resource alternative or supplement to body mass index (BMI) in assessing nutrition in adolescent populations. Methods This is secondary data analysis, from a cross-sectional pilot study, which analyses anthropometric data from a sample of young adolescents attending their last year of primary school in Pwani Region and Dar es Salaam Region, Tanzania (n = 154; 92 girls & 62 boys; mean age 13.2 years). Results The majority of adolescents (75%) were of normal nutritional status defined by BMI. Significantly more males were stunted than females, while significantly more females were overweight than males. Among those identified as outside the normal nutrition ranges, there was inconsistency between MUAC and BMI cut-offs. Bivariate analyses indicate that BMI and MUAC show a positive correlation for both female and male participants, and the relationship between BMI and MUAC was more strongly correlated among adolescent females. Conclusions Further studies are needed with more nutritionally and demographically diverse populations to better understand the nutritional status of adolescents and the practical contribution of MUAC cut-offs to measure adolescent nutrition.
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Affiliation(s)
| | - Isaac Lema
- School of Medicine, Muhimbili University of Health & Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Sylvia Kaaya
- School of Medicine, Muhimbili University of Health & Allied Sciences (MUHAS), Dar es Salaam, Tanzania
| | - Dori Steinberg
- Duke Global Health Institute, Duke University, Durham, USA.,School of Nursing, Duke University, Durham, USA
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Rao A, Shi Z, Ray KN, Mehrotra A, Ganguli I. National Trends in Primary Care Visit Use and Practice Capabilities, 2008-2015. Ann Fam Med 2019; 17:538-544. [PMID: 31712292 PMCID: PMC6846275 DOI: 10.1370/afm.2474] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2019] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Recent evidence shows a national decline in primary care visit rates over the last decade. It is unclear how changes in practice-including the use and content of primary care visits-may have contributed. METHODS We analyzed nationally representative data of adult visits to primary care physicians (PCPs) and physician practice characteristics from 2007-2016 (National Ambulatory Medical Care Survey). United States census estimates were used to calculate visits per capita. Measures included visit rates per person year; visit duration; number of medications, diagnoses, and preventive services per visit; percentage of visits with scheduled follow-up; and percentage of physicians with practice capabilities including an electronic medical record (EMR). RESULTS Our weighted sample represented 3.2 billion visits (83,368 visits, unweighted). Visits per capita declined by 20% (-0.25 visits per person, 95% CI, -0.32 to -0.19) during this time, while visit duration increased by 2.4 minutes per visit (95% CI, 1.1-3.8). Per visit, PCPs addressed 0.30 more diagnoses (95% CI, 0.16-0.43) and 0.82 more medications (95% CI, 0.59-1.1), and provided 0.24 more preventive services (95% CI, 0.12-0.36). Visits with scheduled PCP followup declined by 6.0% (95% CI, -12.4 to 0.46), while PCPs reporting use of EMR increased by 44.3% (95% CI, 39.1-49.5) and those reporting use of secure messaging increased by 60.9% (95% CI, 27.5-94.3). CONCLUSION From 2008 to 2015, primary care visits were longer, addressed more issues per visit, and were less likely to have scheduled follow-up for certain patients and conditions. Meanwhile, more PCPs offered non-face-to-face care. The decline in primary care visit rates may be explained in part by PCPs offering more comprehensive in-person visits and using more non-face-to-face care.
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Affiliation(s)
- Aarti Rao
- Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Zhuo Shi
- Harvard Medical School, Boston, Massachusetts
| | - Kristin N Ray
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ateev Mehrotra
- Harvard Medical School, Boston, Massachusetts.,Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Ishani Ganguli
- Harvard Medical School, Boston, Massachusetts .,Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
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Hoang PT, Hodgkin D, Thomas JP, Ritter G, Chilingerian J. Effect of periodic health exam on provider management of preventive services. J Eval Clin Pract 2019; 25:827-833. [PMID: 30488532 DOI: 10.1111/jep.13083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Accepted: 11/05/2018] [Indexed: 11/30/2022]
Abstract
RATIONALE AND OBJECTIVE To evaluate the relationship between receipt of annual physicals and the receipt of provider recommendation for preventive services, during a period when Medicare did not cover annual physicals (before 2011). METHODS Electronic medical records of patients aged 65 years and older from a US health care system were extracted for the 2001 to 2007 period. A fixed-effects logistic model was used to assess the relationship between receipt of periodic health examination (PHE) and receipt of provider recommendation for mammogram screening for 6466 female Medicare beneficiaries. Logistic regression models were used to assess the relationship between receipt of PHE and receipt of provider recommendation for colonoscopy screening and pneumococcal vaccination for 10 318 Medicare beneficiaries. Nine primary care providers from the network were also interviewed, selected by random sampling stratified by care model. RESULTS Electronic medical record analyses suggest that patients with a PHE were more likely to obtain provider recommendations for mammogram screening (OR = 2.17, P < 0.0001), colonoscopy screening (OR = 1.54, P < 0.0001), and pneumococcal vaccination (OR = 1.10, P < 0.0001). Providers suggested that prevention care quality improves with the PHE because certain screening measures (eg, skin cancer screening, breast exam) would be neglected without it, and healthy patients could miss recommended preventive services entirely. Without the PHE, some providers reported having tried to incorporate discussions of preventive services by scheduling more frequent follow-up chronic care visits than they would have otherwise, and some routinely charged Medicare for a more complex follow-up visit than they would have charged without the preventive service discussions. CONCLUSION Periodic health examination is important in connecting patients to recommended preventive services. Provider interviews suggested that, indirectly, Medicare ended up paying for the PHE via greater frequency of follow-up visits or higher visit charges from providers integrating the services with other visits.
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Affiliation(s)
- Phuong T Hoang
- The Heller School for Social Policy and Management, Brandeis University, 415 South St, Waltham, MA, 02453, USA
| | - Dominic Hodgkin
- The Heller School for Social Policy and Management, Brandeis University, 415 South St, Waltham, MA, 02453, USA
| | - John P Thomas
- Elliot Family Medicine at Glen Lake, 89 South Mast Rd, Goffstown, NH, 03045, USA
| | - Grant Ritter
- The Heller School for Social Policy and Management, Brandeis University, 415 South St, Waltham, MA, 02453, USA
| | - Jon Chilingerian
- The Heller School for Social Policy and Management, Brandeis University, 415 South St, Waltham, MA, 02453, USA
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Evans D, Goldstein S, Loewy A, Altman AD. No 385 - Indications de l'examen pelvien. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1235-1250. [DOI: 10.1016/j.jogc.2019.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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16
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Evans D, Goldstein S, Loewy A, Altman AD. No. 385-Indications for Pelvic Examination. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1221-1234. [DOI: 10.1016/j.jogc.2018.12.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Garcia Mosqueira A, Rosenthal M, Barnett ML. The Association Between Primary Care Physician Compensation and Patterns of Care Delivery, 2012-2015. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2019; 56:46958019854965. [PMID: 31179800 PMCID: PMC6558535 DOI: 10.1177/0046958019854965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
As health systems seek to incentivize physicians to deliver high-value care, the relationship between physician compensation and health care delivery is an important knowledge gap. To examine physician compensation nationally and its relationship with care delivery, we examined 2012-2015 cross-sectional data on ambulatory primary care physician visits from the National Ambulatory Medical Care Survey. Among 175 762 office visits with 3826 primary care physicians, 15.4% of primary care physicians reported salary-based, 4.5% productivity-based, and 12.9% "mixed" compensation, while 61.4% were practice owners. After adjustment, delivery of out-of-visit/office care was more common for practice owners and "mixed" compensation primary care physicians, while there was little association between compensation type and rates of high- or low-value care delivery. Despite early health reform efforts, the overall landscape of physician compensation has remained strongly tethered to fee-for-service. The lack of consistent association between compensation and care delivery raises questions about the potential impact of payment reform on individual physicians' behavior.
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Affiliation(s)
- Adrian Garcia Mosqueira
- 1 Department of Health Policy and Managment, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Meredith Rosenthal
- 1 Department of Health Policy and Managment, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Michael L Barnett
- 1 Department of Health Policy and Managment, Harvard T.H. Chan School of Public Health, Boston, MA, USA.,2 Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, MA, USA
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Matulis JC, Schilling JJ, North F. Primary Care Provider Continuity Is Associated With Improved Preventive Service Ordering During Brief Visits for Acute Symptoms. Health Serv Res Manag Epidemiol 2019; 6:2333392819826262. [PMID: 30793012 PMCID: PMC6376498 DOI: 10.1177/2333392819826262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2019] [Accepted: 01/05/2019] [Indexed: 11/25/2022] Open
Abstract
Background: If a patient presents for an acute care visit and sees their assigned primary care provider (PCP), they may be more likely to receive preventive and other services than a patient not seeing their assigned PCP. Methods: After exclusion of 2 visits with insufficient information, we reviewed 98 consecutive, outpatient internal medicine 15-minute acute care visits comparing patients seeing their assigned PCP with those seeing a non-PCP provider. The primary outcome, preventive service ordering, was measured in 2 ways: percentage of patient visits with any preventive service ordered and the total number of preventive services ordered as a proportion of all preventive service items due for each entire cohort. The secondary outcome of other work completed was assessed by comparing tests and consults ordered, and by counting the number of physical examination elements and discrete medical diagnoses documented. Results: The PCPs were significantly more likely than non-PCPs to order any preventive service 45% versus 17% (P = .005; odds ratio [OR]: 4.16, 95% confidence interval [CI]: 1.45-12.0). The PCP cohort ordered a higher proportion of the total number of preventive services due compared with the non-PCP cohort (30% vs 11%; P = .002; OR: 3.4, CI: 1.5-7.7). The PCPs also addressed more medical diagnoses (2.3 vs 1.4; P = .008) and more frequently ordered tests outside the reason for that visit (40% vs 13%; P = .003; OR: 4.27, CI: 1.5-11.8). Conclusion: Patients seeing their assigned PCP in brief, acute visits have higher rates of preventive and other service ordering compared to those not seeing their assigned PCP.
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Affiliation(s)
- John C Matulis
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | | | - Frederick North
- Division of Primary Care Internal Medicine, Mayo Clinic, Rochester, MN, USA
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Cipriano LE, Goldhaber-Fiebert JD, Liu S, Weber TA. Optimal Information Collection Policies in a Markov Decision Process Framework. Med Decis Making 2018; 38:797-809. [PMID: 30179585 DOI: 10.1177/0272989x18793401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
BACKGROUND The cost-effectiveness and value of additional information about a health technology or program may change over time because of trends affecting patient cohorts and/or the intervention. Delaying information collection even for parameters that do not change over time may be optimal. METHODS We present a stochastic dynamic programming approach to simultaneously identify the optimal intervention and information collection policies. We use our framework to evaluate birth cohort hepatitis C virus (HCV) screening. We focus on how the presence of a time-varying parameter (HCV prevalence) affects the optimal information collection policy for a parameter assumed constant across birth cohorts: liver fibrosis stage distribution for screen-detected diagnosis at age 50. RESULTS We prove that it may be optimal to delay information collection until a time when the information more immediately affects decision making. For the example of HCV screening, given initial beliefs, the optimal policy (at 2010) was to continue screening and collect information about the distribution of liver fibrosis at screen-detected diagnosis in 12 years, increasing the expected incremental net monetary benefit (INMB) by $169.5 million compared to current guidelines. CONCLUSIONS The option to delay information collection until the information is sufficiently likely to influence decisions can increase efficiency. A dynamic programming framework enables an assessment of the marginal value of information and determines the optimal policy, including when and how much information to collect.
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Affiliation(s)
- Lauren E Cipriano
- Ivey Business School, Western University, London, ON, Canada (LEC).,Center for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA (JDG-F).,Industrial & Systems Engineering, College of Engineering, University of Washington, Seattle, WA (SL).,Operations, Economics and Strategy, College of Management of Technology, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland (TAW)
| | - Jeremy D Goldhaber-Fiebert
- Ivey Business School, Western University, London, ON, Canada (LEC).,Center for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA (JDG-F).,Industrial & Systems Engineering, College of Engineering, University of Washington, Seattle, WA (SL).,Operations, Economics and Strategy, College of Management of Technology, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland (TAW)
| | - Shan Liu
- Ivey Business School, Western University, London, ON, Canada (LEC).,Center for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA (JDG-F).,Industrial & Systems Engineering, College of Engineering, University of Washington, Seattle, WA (SL).,Operations, Economics and Strategy, College of Management of Technology, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland (TAW)
| | - Thomas A Weber
- Ivey Business School, Western University, London, ON, Canada (LEC).,Center for Health Policy and Primary Care and Outcomes Research, Stanford University, Stanford, CA (JDG-F).,Industrial & Systems Engineering, College of Engineering, University of Washington, Seattle, WA (SL).,Operations, Economics and Strategy, College of Management of Technology, École Polytechnique Fédérale de Lausanne, Lausanne, Switzerland (TAW)
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Rotarou ES, Sakellariou D. Determinants of utilisation rates of preventive health services: evidence from Chile. BMC Public Health 2018; 18:839. [PMID: 29976166 PMCID: PMC6034328 DOI: 10.1186/s12889-018-5763-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 06/26/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Preventive health services play a vital role in population health. However, access to such services is not always equitably distributed. In this article, we examine the barriers affecting utilisation rates of preventive health services, using Chile as a case study. METHODS We conducted a cross-sectional study analysing secondary data from 206,132 Chilean adults, taken from the 2015 National Socioeconomic Characterisation Survey of the Government of Chile. We carried out logistic regressions to explore the relationship between the dependent variable use of preventive services and various demographic and socioeconomic variables. RESULTS Categories more likely to use preventive services were women (OR=1.16; 95%CI: 1.11-1.21) and inactive people (OR=1.41; 95%CI: 1.33-1.48). By contrast, single individuals (OR= 0.85 ; 95%CI: 0.80-0.91) and those affiliated with the private healthcare provider (OR= 0.89; 95%CI: 0.81-0.96) had fewer odds of undertaking preventive exams. CONCLUSIONS The findings underline the necessity of better information campaigns on the availability and necessity of preventive health services, addressing health inequality in accessing health services, and tackling lifestyle-related health risks. This is particularly important in countries - such as Chile - characterised by high income inequality and low utilisation rates of preventive health services.
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Affiliation(s)
- Elena S. Rotarou
- Department of Economics, University of Chile, Diagonal Paraguay 257, Office 1506, 8330015 Santiago, Chile
| | - Dikaios Sakellariou
- Cardiff University, School of Healthcare Sciences, Eastgate House, Newport Road 35-43, Cardiff, CF24 0AB UK
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Abstract
The physical examination in the outpatient setting is a valuable tool. Even in settings where there is lack of evidence, such as the annual physical examination of an asymptomatic adult, the physical examination is beneficial for the physician-patient relationship. When a patient has specific symptoms, the physical examination-in addition to a thorough history-can help narrow down, or in many cases establish, a diagnosis. In a time where imaging and laboratory tests are easily available, but are expensive and can be invasive, a skilled physical examination remains an important component of patient evaluation.
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Affiliation(s)
- Maja K Artandi
- Department of Medicine, Stanford University, 211 Quarry Road, Hoover Pavilion, Suite 301, Palo Alto, CA 94304, USA
| | - Rosalyn W Stewart
- Department of Medicine, Johns Hopkins University, 601 North Caroline Street, JHOC 7143, Baltimore, MD 21287, USA; Department of Pediatrics, Johns Hopkins University, 601 North Caroline Street, JHOC 7143, Baltimore, MD 21287, USA.
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Cipriano LE, Weber TA. Population-level intervention and information collection in dynamic healthcare policy. Health Care Manag Sci 2017; 21:604-631. [PMID: 28887763 PMCID: PMC6208882 DOI: 10.1007/s10729-017-9415-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 08/10/2017] [Indexed: 12/09/2022]
Abstract
We develop a general framework for optimal health policy design in a dynamic setting. We consider a hypothetical medical intervention for a cohort of patients where one parameter varies across cohorts with imperfectly observable linear dynamics. We seek to identify the optimal time to change the current health intervention policy and the optimal time to collect decision-relevant information. We formulate this problem as a discrete-time, infinite-horizon Markov decision process and we establish structural properties in terms of first and second-order monotonicity. We demonstrate that it is generally optimal to delay information acquisition until an effect on decisions is sufficiently likely. We apply this framework to the evaluation of hepatitis C virus (HCV) screening in the general population determining which birth cohorts to screen for HCV and when to collect information about HCV prevalence.
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Affiliation(s)
- Lauren E Cipriano
- Ivey Business School, Western University, 1255 Western Road, London, ON, N6G 0N1, Canada.
| | - Thomas A Weber
- Ecole Polytechnique Fédérale de Lausanne, CDM-ODY 3.01, Station 5, CH-1015, Lausanne, Switzerland
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24
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Alpert JS. Will Physicians Stop Performing Physical Examinations? Am J Med 2017; 130:759-760. [PMID: 28373113 DOI: 10.1016/j.amjmed.2017.03.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Accepted: 03/22/2017] [Indexed: 10/19/2022]
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Abstract
IMPORTANCE National patterns of low-value and high-value care delivered to patients without insurance or with Medicaid could inform public policy but have not been previously examined. OBJECTIVE To measure rates of low-value care and high-value care received by patients without insurance or with Medicaid, compared with privately insured patients, and provided by safety-net physicians vs non-safety-net physicians. DESIGN, SETTING, AND PARTICIPANTS This multiyear cross-sectional observational study included all patients ages 18 to 64 years from the National Ambulatory Medical Care Survey (2005-2013) and the National Hospital Ambulatory Medical Care Survey (2005-2011) eligible for any of the 21 previously defined low-value or high-value care measures. All measures were analyzed with multivariable logistic regression and adjusted for patient and physician characteristics. EXPOSURES Comparison of patients by insurance status (uninsured/Medicaid vs privately insured) and safety-net physicians (seeing >25% uninsured/Medicaid patients) vs non-safety-net physicians (seeing 1%-10%). MAIN OUTCOMES AND MEASURES Delivery of 9 low-value or 12 high-value care measures, based on previous research definitions, and composite measures for any high-value or low-value care delivery during an office visit. RESULTS Overall, 193 062 office visits were eligible for at least 1 measure. Mean (95% CI) age for privately insured patients (n = 94 707) was 44.7 (44.5-44.9) years; patients on Medicaid (n = 45 123), 39.8 (39.3-40.3) years; and uninsured patients (n = 19 530), 41.9 (41.5-42.4) years. Overall, low-value and high-value care was delivered in 19.4% (95% CI, 18.5%-20.2%) and 33.4% (95% CI, 32.4%-34.3%) of eligible encounters, respectively. Rates of low-value and high-value care delivery were similar across insurance types for the majority of services examined. Among Medicaid patients, adjusted rates of use were no different for 6 of 9 low-value and 9 of 12 high-value services compared with privately insured beneficiaries, whereas among the uninsured, rates were no different for 7 of 9 low-value and 9 of 12 high-value services. Safety-net physicians provided similar care compared with non-safety-net physicians, with no difference for 8 out of 9 low-value and for all 12 high-value services. CONCLUSIONS AND RELEVANCE Overuse of low-value care is common among patients without insurance or with Medicaid. Rates of low-value and high-value care were similar among physicians serving vulnerable patients and other physicians. Overuse of low-value care is a potentially important focus for state Medicaid programs and safety-net institutions to pursue cost savings and improved quality of health care delivery.
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Affiliation(s)
- Michael L Barnett
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts2Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jeffrey A Linder
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Cheryl R Clark
- Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Benjamin D Sommers
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts2Division of General Internal Medicine and Primary Care, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Associations of Undergoing a Routine Medical Examination or Not with Prevalence Rates of Hypertension and Diabetes Mellitus: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:ijerph13070628. [PMID: 27347985 PMCID: PMC4962169 DOI: 10.3390/ijerph13070628] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 06/13/2016] [Accepted: 06/20/2016] [Indexed: 12/05/2022]
Abstract
Background: Undergoing a routine medical examination may be associated with the prevalence rate of chronic diseases from a population-based household interview survey. However, this important issue has not been examined so far. Methods: Data came from the first health service household interview of Hunan province, China, in 2013. A Rao–Scott chi-square test was performed to examine the difference in prevalence rates between subgroups. Adjusted odds ratio (OR) was calculated using the PROC SURVEYLOGISTIC procedure of SAS9.1 statistical software. Results: In total, 24,282 residents of 8400 households were surveyed. A higher proportion of elderly adults had undergone a medical examination within the prior 12 months compared with young adults (≥65 years, 60%; 45–64 years, 46%; 18–44 years, 37%). After controlling for location, sex, and household income per capita, undergoing a medical examination was significantly associated with high prevalence rates of hypertension (adjusted OR: 2.0, 95% CI: 1.1–3.5) and of diabetes mellitus (adjusted OR: 3.3, 95% CI: 1.7–6.5) for young adults aged 18–44 years. The associations were not statistically significant for age groups 45–64 years and 65 years or older. Conclusion: The prevalence rates of hypertension and diabetes mellitus may be seriously underestimated for young adults not undergoing a routine medical examination in a health household interview survey.
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Affiliation(s)
- Ateev Mehrotra
- From the Department of Health Care Policy, Harvard Medical School, and the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center - both in Boston (A.M.); and the Division of General Internal Medicine, University of Colorado Health Sciences Center, Denver (A.P.)
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Burns RB, Potter JE, Ricciotti HA, Reynolds EE. Screening Pelvic Examinations in Adult Women: Grand Rounds Discussion From the Beth Israel Deaconess Medical Center. Ann Intern Med 2015; 163:537-47. [PMID: 26436618 DOI: 10.7326/m15-1220] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Pelvic examinations have historically been a part of regular preventive care. However, because women can now be screened for cervical cancer at intervals up to every 5 years, the question of whether women need to be seen annually for routine pelvic examinations has arisen. In July 2014, the American College of Physicians (ACP) issued a guideline presenting the available evidence on screening for pathologic conditions using pelvic examination in adult, asymptomatic women at average risk. The American College of Obstetricians and Gynecologists (ACOG) Committee on Gynecologic Practice had previously issued a committee opinion in August 2012 on the need for annual examinations and provided guidelines on important elements of this procedure, including when to examine asymptomatic women. ACOG reaffirmed its initial position after publication of the ACP guideline. The guidelines differ-the ACP guideline recommends against and the ACOG committee opinion recommends in favor of routine annual pelvic examination. This paper summarizes a discussion between an internist and a gynecologist on how they would balance these recommendations in general and what they would suggest for an individual patient.
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Brown JD, Barrett A, Hourihan K, Caffery E, Ireys HT. State Variation in the Delivery of Comprehensive Services for Medicaid Beneficiaries with Schizophrenia and Bipolar Disorder. Community Ment Health J 2015; 51:523-34. [PMID: 25786723 DOI: 10.1007/s10597-015-9857-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Accepted: 02/27/2015] [Indexed: 11/28/2022]
Abstract
Medicaid beneficiaries with schizophrenia and bipolar disorder require a range of services and supports. This descriptive study used 2007 Medicaid claims data from 21 states and the District of Columbia to examine the extent to which this population received guideline-concordant medications, medication monitoring, outpatient mental health care, and preventive physical health care. More than 80 % of beneficiaries in each state filled at least one prescription for a guideline-concordant medication during the year but, on average, only 57 % of those with schizophrenia and 45 % of those with bipolar disorder maintained a continuous supply of medications. Roughly 25 % did not have an outpatient mental health visit during the year (excluding case management and some other services); in some states more than half did not have such a visit. Only 11 % of beneficiaries received a physical health examination or health behavior counseling when claims codes were used to identify these services rather than all primary care physician visits. Less than 5 % of beneficiaries maintained their supply of medications, received medication monitoring and had an outpatient mental health visit, physical health examination or received health behavior counseling during the year. Although these rates of service utilization are likely conservative and the data predate recent efforts to integrate care, the findings underscore the need for quality improvement efforts targeted to this population and may provide a baseline for monitoring progress.
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Affiliation(s)
- Jonathan D Brown
- Mathematica Policy Research, 1100 First Street, 12th Floor, Washington, DC, 20002, USA,
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Makridakis S, Moleskis A. The costs and benefits of positive illusions. Front Psychol 2015; 6:859. [PMID: 26175698 PMCID: PMC4485033 DOI: 10.3389/fpsyg.2015.00859] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2015] [Accepted: 06/10/2015] [Indexed: 11/13/2022] Open
Abstract
Positive illusions are associated with unrealistic optimism about the future and an inflated assessment of one’s abilities. They are prevalent in normal life and are considered essential for maintaining a healthy mental state, although, there are disagreements to the extent to which people demonstrate these positive illusions and whether they are beneficial or not. But whatever the situation, it is hard to dismiss their existence and their positive and/or negative influence on human behavior and decision making in general. Prominent among illusions is that of control, that is “the tendency for people to overestimate their ability to control events.” This paper describes positive illusions, their potential benefits but also quantifies their costs in five specific fields (gambling, stock and other markets, new firms and startups, preventive medicine and wars). It is organized into three parts. First the psychological reasons giving rise to positive illusions are described and their likely harm and benefits stated. Second, their negative consequences are presented and their costs are quantified in five areas seriously affected with emphasis to those related to the illusion of control that seems to dominate those of unrealistic optimism. The costs involved are huge and serious efforts must be undertaken to understand their enormity and steps taken to avoid them in the future. Finally, there is a concluding section where the challenges related to positive illusions are noted and directions for future research are presented.
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Affiliation(s)
- Spyros Makridakis
- Economics and Business, Neapolis University of Pafos, Pafos Cyprus ; Decisions Sciences, INSEAD, Fontainebleau France ; Decision Sciences, INSEAD, Singapore Singapore
| | - Andreas Moleskis
- Economics and Business, Neapolis University of Pafos, Pafos Cyprus
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Backonja U, Royer HR, Lauver DR. Young women's reasons to seek sexually transmitted infection screening. Public Health Nurs 2014; 31:395-404. [PMID: 24766580 DOI: 10.1111/phn.12125] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe young women's reasons to seek and not to seek sexually transmitted infection (STI) screening; to explore whether reasons differed by age and STI screening history. DESIGN AND SAMPLE Cross-sectional, descriptive. Female students (N = 216) at a university in the Midwestern United States. MEASURES An anonymous online survey was designed based on the Theory of Care Seeking Behavior and literature regarding STI screening among young women. RESULTS The most common reason to seek STI screening was to start treatment promptly (85%); the most common reason not to seek screening was being asymptomatic (54%). Participants' reasons differed by age and screening history. Women under 25 were more likely than women 25 and older to seek screening because of encouragement from female role models (p < .01). Women who had never been screened were more likely than women who had been screened to avoid screening because of embarrassment (p < .05). Novel findings included seeking STI screening because it "should be done" if sexually active and because of encouragement from female role models. CONCLUSIONS Health care and public health professionals can use these findings to develop strategies to improve STI screening rates among young women.
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Affiliation(s)
- Uba Backonja
- University of Wisconsin-Madison School of Nursing
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Ports KA, Barnack-Tavlaris JL, Syme ML, Perera RA, Lafata JE. Sexual health discussions with older adult patients during periodic health exams. J Sex Med 2014; 11:901-908. [PMID: 24517714 PMCID: PMC4657130 DOI: 10.1111/jsm.12448] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Sexual health is an integral part of overall health across the lifespan. In order to address sexual health issues, such as sexually transmitted infections (STIs) and sexual functioning, the sexual history of adult patients should be incorporated as a routine part of the medical history throughout life. Physicians and health-care professionals cite many barriers to attending to and assessing the sexual health needs of older adult patients, underscoring the importance of additional research to improve sexual history taking among older patients. AIM The purpose of this article is to explore the content and context of physician-patient sexual health discussions during periodic health exams (PHEs) with adults aged 50-80 years. METHODS Patients completed a pre-visit telephone survey and attended a scheduled PHE with their permission to audio-record the exam. Transcribed audio recordings of 483 PHEs were analyzed according to the principles of qualitative content analysis. MAIN OUTCOME MEASURES Frequency of sexual history taking components as observed in transcripts of PHEs. Physician characteristics were obtained from health system records and patient characteristics were obtained from the pre-visit survey. RESULTS Analyses revealed that approximately one-half of the PHEs included some discussion about sexual health, with the majority of those conversations initiated by physicians. A two-level logistic regression model revealed that patient-physician gender concordance, race discordance, and increasing physician age were significantly associated with sexual health discussions. CONCLUSION Interventions should focus on increasing physician self-efficacy for assessing sexual health in gender discordant and race/ethnicity concordant patient interactions. Interventions for older adults should increase education about sexual health and sexual risk behaviors, as well as empower individuals to seek information from their health-care providers.
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Affiliation(s)
- Katie A. Ports
- Department of Social and Behavioral Health, Virginia Commonwealth University/School of Medicine, PO Box 980149, 830 E Main Street, Richmond, Virginia 23298-0149, The United States of America, Phone: 001-804-628-4631/Fax: 001-804-828-5440,
| | | | - Maggie L. Syme
- Cancer Center Comprehensive Partnership, San Diego State University/ University of California, San Diego,
| | - Robert A. Perera
- Department of Biostatistics, Virginia Commonwealth University/ School of Medicine,
| | - Jennifer Elston Lafata
- Department of Social and Behavioral Health, Virginia Commonwealth University/School of Medicine,
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Abstract
Predicted primary care shortages have spurred action to increase the number of primary care physicians. However, simply increasing the number of primary care providers is not the only solution to resolving the imbalance between the supply of primary care physicians and the demand for primary care services. In this point-counterpoint, we highlight the limitations of existing primary care shortage predictions and discuss strategies to deliver primary care services without necessarily increasing the number of primary care physicians for a given population. Innovative solutions can be used to reduce or even eliminate projected primary care shortages while changing the prevailing paradigm of primary care.
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The influence of deductible health plans on receipt of the human papillomavirus vaccine series. J Adolesc Health 2014; 54:275-81. [PMID: 24560035 PMCID: PMC4142695 DOI: 10.1016/j.jadohealth.2013.12.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 10/18/2013] [Accepted: 12/01/2013] [Indexed: 11/23/2022]
Abstract
PURPOSE To evaluate whether enrollment in deductible health plans (DHP) with higher patient cost-sharing requirements than traditional health maintenance organization plans (HMP) decreased initiation and completion of the human papillomavirus (HPV) vaccine series recommended for prevention of cervical cancer. METHODS This was a retrospective observational study of 9- to 26-year-old females at Kaiser Permanente Georgia and Kaiser Permanente Colorado who were HPV vaccine naive at time of enrollment in a self-pay DHP or HMP in 2007. Estimates of rates of initiation and completion of the HPV vaccine series from plan enrollment in 2007 through December 2009 were obtained using Cox proportional hazards regressions (accounting for censoring) on samples matched on the propensity to enroll in a DHP versus HMP. RESULTS Initiation of the HPV vaccine series was 22.2% and 24.4% in the DHP and HMP groups, respectively, at Kaiser Permanente Georgia; completion was 12.3% and 14.4% in the DHP and HMP groups, respectively. Human papillomavirus vaccine series initiation was higher at Kaiser Permanente Colorado, but completion was lower. In the Cox proportional hazards regressions, rates of initiation and completion of the HPV vaccine series did not differ significantly (p ≤ .05) by plan type (DHP vs. HMP) at both sites. The primary care visit rate included in these regressions had a significant, positive association with initiation and completion of the HPV vaccine series. CONCLUSIONS Enrollment in a DHP versus an HMP did not directly affect initiation or completion of the HPV vaccine series among age-eligible females. Independent of plan type, more frequent primary care visits increased initiation and completion rates.
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Preventive services for adults: how have differences across subgroups changed over the past decade? Med Care 2013; 51:999-1007. [PMID: 24036996 DOI: 10.1097/mlr.0b013e3182a97bc0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND A large literature documents cross-sectional differences in adult preventive services across population subgroups. Less is known, however, about how these differences have changed over time. OBJECTIVES This study tracks changes over time in the distribution of preventive services use across groups defined by poverty status, race/ethnicity, insurance coverage, Census region, and urbanicity. METHODS Data from the 1996-2008 Medical Expenditure Panel Survey are used to examine 5 preventive services: general checkups, blood pressure screening, blood cholesterol screening, Pap smears, and mammograms. Multivariate logistic regression models of preventive services use are used to compute adjusted utilization for each subgroup of adults aged 19-64 in 1996/1998, 2002/2003, and 2007/2008. We then examine the extent to which percentage point gaps in utilization rates across subgroups have changed between 1996/1998 and 2007/2008. RESULTS Our analysis of utilization rates across subgroups and over time identified only rare cases in which subgroup differences narrowed or widened between 1996/1998 and 2007/2008. Rather, differences across subgroups tended to persist over time. Some of the largest (adjusted) gaps are between adults with and without coverage, and only for blood cholesterol screening do we observe significant narrowing of the gap between the uninsured and the privately insured. Regional differences persisted or widened over the study period. CONCLUSIONS On the eve of health reform implementation, a key challenge facing the Affordable Care Act will be to address persistent differences in preventive services use within the US population.
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Brunner-Ziegler S, Rieder A, Stein KV, Koppensteiner R, Hoffmann K, Dorner TE. Predictors of participation in preventive health examinations in Austria. BMC Public Health 2013; 13:1138. [PMID: 24308610 PMCID: PMC3866300 DOI: 10.1186/1471-2458-13-1138] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 11/27/2013] [Indexed: 12/19/2022] Open
Abstract
Background Preventive health check-ups in Austria are offered free of charge to all insured adults (98% of the population) and focus on early detection of chronic diseases, primary prevention, and health counseling. The study aims to explore predictors of compliance with the recommended interval of preventive health check-up performance. Methods Source of data was the Austrian Health Interview Survey 2006/07 (15,474 subjects). Participation in a preventive health examination during the last three years was used as dependent variable. Socio-demographic and health-related characteristics were used as independent variables in a multivariate logistic regression analysis. Results Results show that 41.6% of men and 41.8% of women had attended a preventive health check-up within the last three years. In multivariate analysis, subjects ≥40 years, with higher education, higher income or born in Austria were significantly more likely to attend a preventive health check-up. Furthermore, a chronic disease was associated with a higher attendance rate (OR: 1.21; CI: 1.07-1.36 in men; OR: 1.19; CI: 1.06-1.33 in women). Conclusions Attendance rates for health check-ups in the general Austrian population are comparatively high but not equally distributed among subgroups. Health check-ups must increase among people at a young age, with a lower socio-economic status, migration background and in good health.
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Affiliation(s)
- Sophie Brunner-Ziegler
- Department for Internal Medicine, Division of Angiology, Medical University of Vienna, Währinger Gürtel 18-20, Vienna, Austria.
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Yu Y, Li J, Liu J. M-HELP: a miniaturized total health examination system launched on a mobile phone platform. Telemed J E Health 2013; 19:857-65. [PMID: 24050610 DOI: 10.1089/tmj.2013.0031] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND A timely health examination is of great significance for incipient disease detection and prevention. However, conventional examinations generally rely heavily on bulky and expensive instrumentation, which is not easily available. To address technical barriers, an innovative, highly miniaturized, and integrated health examination system-Mobile Health Examination Launched on the Phone (M-HELP)-was developed. MATERIALS AND METHODS Based on the design of a multifunctional Android® (Google, Mountain View, CA) application and the development of different wireless biomedical sensor modules, a mobile phone was incorporated into a central terminal for personal health examination. More than 12 parameters, including electrocardiogram, heart sound, and eye test, as well as others, covered the majority of the crucial parameters in a total health examination and have been successfully established and incorporated into the system. Unlike the conventional examination, the M-HELP system could generate electronic health records and send them to physicians via e-mails or multimedia messages. This significantly simplifies the general health examination with much lower cost and fewer temporal and spatial restrictions. RESULTS For proof of concept, a bench-scale test recruiting 11 volunteer subjects showed that the average time spent on a total health examination with M-HELP system was about 28 min. CONCLUSIONS This article clarifies the basic concept of a total health examination on the platform of a mobile phone, demonstrates the basic features of the M-HELP system with group tests, and suggests the practical future application of the new system and the scientific issues thus raised.
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Affiliation(s)
- Yang Yu
- 1 Department of Biomedical Engineering, School of Medicine, Tsinghua University , Beijing, China
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Electronic tools to assist with identification and counseling for overweight patients: a randomized controlled trial. J Gen Intern Med 2012; 27:933-9. [PMID: 22402982 PMCID: PMC3403149 DOI: 10.1007/s11606-012-2022-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2011] [Revised: 01/24/2012] [Accepted: 02/09/2012] [Indexed: 10/28/2022]
Abstract
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/m(2). INTERVENTION The EHR tool set included: a physician point-of-care alert for overweight (BMI 27-29. 9 kg/m(2)); 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.
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Shires DA, Stange KC, Divine G, Ratliff S, Vashi R, Tai-Seale M, Lafata JE. Prioritization of evidence-based preventive health services during periodic health examinations. Am J Prev Med 2012; 42:164-73. [PMID: 22261213 PMCID: PMC3262983 DOI: 10.1016/j.amepre.2011.10.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Revised: 09/20/2011] [Accepted: 10/14/2011] [Indexed: 01/12/2023]
Abstract
BACKGROUND Delivery of preventive services sometimes falls short of guideline recommendations. PURPOSE To evaluate the multilevel factors associated with evidence-based preventive service delivery during periodic health examinations (PHEs). METHODS Primary care physicians were recruited from an integrated delivery system in southeast Michigan. Audio recordings of PHE office visits conducted from 2007 to 2009 were used to ascertain physician recommendation for or delivery of 19 guideline-recommended preventive services. Alternating logistic regression was used to evaluate factors associated with service delivery. Data analyses were completed in 2011. RESULTS Among 484 PHE visits to 64 general internal medicine and family physicians by insured patients aged 50-80 years, there were 2662 services for which patients were due; 54% were recommended or delivered. Regression analyses indicated that the likelihood of service delivery decreased with patient age and with each concern the patient raised, and it increased with increasing BMI and with each additional minute after the scheduled appointment time the physician first presented. The likelihood was greater with patient-physician gender concordance and less if the physician used the electronic medical record in the exam room or had seen the patient in the past 12 months. CONCLUSIONS A combination of patient, patient-physician relationship, and visit contextual factors are associated with preventive service delivery. Additional studies are warranted to understand the complex interplay of factors that support and compromise preventive service delivery.
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Affiliation(s)
- Deirdre A Shires
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, Michigan, USA
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Smith AK, Ayanian JZ, Covinsky KE, Landon BE, McCarthy EP, Wee CC, Steinman MA. Conducting high-value secondary dataset analysis: an introductory guide and resources. J Gen Intern Med 2011; 26:920-9. [PMID: 21301985 PMCID: PMC3138974 DOI: 10.1007/s11606-010-1621-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2010] [Revised: 12/09/2010] [Accepted: 12/17/2010] [Indexed: 11/18/2022]
Abstract
Secondary analyses of large datasets provide a mechanism for researchers to address high impact questions that would otherwise be prohibitively expensive and time-consuming to study. This paper presents a guide to assist investigators interested in conducting secondary data analysis, including advice on the process of successful secondary data analysis as well as a brief summary of high-value datasets and online resources for researchers, including the SGIM dataset compendium ( www.sgim.org/go/datasets ). The same basic research principles that apply to primary data analysis apply to secondary data analysis, including the development of a clear and clinically relevant research question, study sample, appropriate measures, and a thoughtful analytic approach. A real-world case description illustrates key steps: (1) define your research topic and question; (2) select a dataset; (3) get to know your dataset; and (4) structure your analysis and presentation of findings in a way that is clinically meaningful. Secondary dataset analysis is a well-established methodology. Secondary analysis is particularly valuable for junior investigators, who have limited time and resources to demonstrate expertise and productivity.
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Affiliation(s)
- Alexander K Smith
- Department of Medicine, University of California, San Francisco, CA, USA.
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Hunziker S, Schläpfer M, Langewitz W, Kaufmann G, Nüesch R, Battegay E, Zimmerli LU. Open and hidden agendas of "asymptomatic" patients who request check-up exams. BMC FAMILY PRACTICE 2011; 12:22. [PMID: 21504617 PMCID: PMC3094231 DOI: 10.1186/1471-2296-12-22] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 04/19/2011] [Indexed: 01/28/2023]
Abstract
Background Current guidelines for a check-up recommend routine screening not triggered by specific symptoms for some known risk factors and diseases in the general population. Patients' perceptions and expectations regarding a check-up exam may differ from these principles. However, quantitative and qualitative data about the discrepancy between patient- and provider expectations for this type of clinic consultation is lacking. Methods For a year, we prospectively enrolled 66 patients who explicitly requested a "check-up" at our medical outpatient division. All patients actively denied upon prompting having any symptoms or specific health concerns at the time they made their appointment. All consultations were videotaped and analysed for information about spontaneously mentioned symptoms and reasons for the clinic consultation ("open agendas") and for cues to hidden patient agendas using the Roter interaction analysis system (RIAS). Results All patients initially declared to be asymptomatic but this was ultimately the case in only 7 out of 66 patients. The remaining 59 patients spontaneously mentioned a mean of 4.2 ± 3.3 symptoms during their first consultation. In 23 patients a total of 31 hidden agendas were revealed. The primary categories for hidden agendas were health concerns, psychosocial concerns and the patient's concept of disease. Conclusions The majority of patients requesting a general check-up tend to be motivated by specific symptoms and health concerns and are not "asymptomatic" patients who primarily come for preventive issues. Furthermore, physicians must be alert for possible hidden agendas, as one in three patients have one or more hidden reasons for requesting a check-up.
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Affiliation(s)
- Sabina Hunziker
- Medical Outpatient Division/Ambulatory Internal Medicine, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
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Mehrotra A, Wang MC, Lave JR, Adams JL, McGlynn EA. Retail clinics, primary care physicians, and emergency departments: a comparison of patients' visits. Health Aff (Millwood) 2011; 27:1272-82. [PMID: 18780911 DOI: 10.1377/hlthaff.27.5.1272] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In this study we compared the demographics of and reasons for visits in national samples of visits to retail clinics, primary care physicians (PCPs), and emergency departments (EDs). We found that retail clinics appear to be serving a patient population that is underserved by PCPs. Ten clinical problems such as sinusitis and immunizations encompass more than 90 percent of retail clinic visits. These same ten clinical problems make up 13 percent of adult PCP visits, 30 percent of pediatric PCP visits, and 12 percent of ED visits. Whether there will be a future shift of care from EDs or PCPs to retail clinics is unknown.
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Wu HY, Yang LL, Zhou S. Impact of periodic health examination on surgical treatment for uterine fibroids in Beijing: a case-control study. BMC Health Serv Res 2010; 10:329. [PMID: 21134290 PMCID: PMC3002351 DOI: 10.1186/1472-6963-10-329] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2010] [Accepted: 12/07/2010] [Indexed: 11/21/2022] Open
Abstract
Background During the past 2 decades, there has been a rapid proliferation of "health examination center (HEC)" across China. The effects of their services on public's health have not been systemically investigated. This study aimed to assess the impact of periodic health examination (PHE) at HEC on surgical treatment for uterine fibroids in Beijing residents. Methods We identified 224 patients with a primary diagnosis of uterine fibroids who had surgical treatment at four Level-1 general hospitals in Beijing, from June 1, 2009 to October 20, 2009. Controls were women who did not have surgery for uterine fibroids, matched (1:1 ratio) for age (within 2 years). A standard questionnaire was used to inquire about whether participants had PHE at HEC during the previous 2 years. Results PHE at HEC within 2 years were associated with surgical treatment for uterine fibroids. Odds ratios was 4.05 (95% CI, 2.61-6.29 P < 0.001), after adjustment for marital status, whether have children, annual family income, health insurance, education level and self-rated uterine fibroids-related symptom severity. Conclusions Our study showed PHE currently provided at HEC in China were associated with significantly increased use of surgical treatment for uterine fibroids in women. Further studies are needed to assess the effects of PHE on clinical as well as on broad societal outcomes in Chinese in contemporary medical settings.
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Affiliation(s)
- Hai-Yun Wu
- Institute of Geriatric Cardiology, Chinese PLA General Hospital, Beijing, P R China.
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Akers AY, Gold MA, Borrero S, Santucci A, Schwarz EB. Providers' perspectives on challenges to contraceptive counseling in primary care settings. J Womens Health (Larchmt) 2010; 19:1163-70. [PMID: 20420508 PMCID: PMC2940510 DOI: 10.1089/jwh.2009.1735] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although three quarters of reproductive-age women see a health provider annually, less than half receive recommended contraceptive counseling services. We sought to explore providers' perspectives on the challenges to contraceptive counseling in primary care clinics to develop strategies to improve counseling services. METHODS A qualitative, focus group (n = 8) study was conducted in November and December 2007; 48 of 90 providers practicing in four primary care clinics at the University of Pittsburgh Medical Center participated. Providers included physicians, nurses, and pharmacists working in these clinics' multidisciplinary teams. Discussions explored perceived barriers to the provision of counseling services. All groups were audiorecorded, transcribed, and entered into Atlas.Ti, a qualitative data management software. The data were analyzed using a grounded theory approach to content analysis. RESULTS Perceived patient, provider, and health system barriers to contraceptive counseling were identified. Perceived patient barriers included infrequent sexual activity, familiarity with a limited number of methods, desire for pregnancy despite medical contraindications, and religious beliefs. Provider barriers included lack of knowledge, training, and comfort; assumptions about patient pregnancy risk; negative beliefs about contraceptive methods; reliance on patients to initiate discussions; and limited communication between primary care providers (PCPs) and subspecialists. Health system barriers included limited time and competing medical priorities. CONCLUSIONS PCPs vary widely in their knowledge, perceived competence, and comfort in providing contraceptive counseling. General efforts to improve integration of contraceptive counseling into primary care services in addition to electronic reminders and efficient delivery of contraceptive information are needed.
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Affiliation(s)
- Aletha Y Akers
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh School of Medicine, 300 Halket Street, Pittsburgh, PA 15213-3180, USA.
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Sack GH. Comprehensive outpatient health assessment: a case-finding tool in 500 consecutive asymptomatic individuals. Medicine (Baltimore) 2009; 88:268-278. [PMID: 19745685 DOI: 10.1097/md.0b013e3181b9512b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
This study appraises the case-finding efficiency of a single-day outpatient program of a broad-based clinical evaluation and laboratory studies in asymptomatic adults. The same protocol, varied only according to age and sex, was used for 500 individuals encountered consecutively over 15 months, and an unanticipated new diagnosis or important clinical or laboratory finding was established for one-third of them. The diagnoses varied widely, consistent with the breadth of the observations, and most led to specific recommendations for care. These findings confirm the case-finding efficacy of comprehensive clinical assessments supported by basic laboratory studies and counter the notion that specific tests and/or portions of the review of systems and physical examination can be eliminated in establishing a reliable medical database for asymptomatic adults. In addition, such comprehensive data provide essential reference material for later comparisons.
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Affiliation(s)
- George H Sack
- From Departments of Medicine and Biological Chemistry, The Johns Hopkins University School of Medicine, Baltimore, Maryland
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Effect of Uniform Consensus Recommendations for PCa Screening in Older Population: Differential Effects and Perceptions of Healthcare Providers and Patients. Urology 2009; 73:603-8; discussion 608-9. [DOI: 10.1016/j.urology.2008.08.518] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2008] [Revised: 08/13/2008] [Accepted: 08/25/2008] [Indexed: 11/22/2022]
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Harrison J. Doctors' health and fitness to practise: assessment models. Occup Med (Lond) 2008; 58:318-22. [DOI: 10.1093/occmed/kqn078] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Preventive services use among women seen by gynecologists, general medical physicians, or both. Obstet Gynecol 2008; 111:945-52. [PMID: 18378755 DOI: 10.1097/aog.0b013e318169ce3e] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To estimate how preventive services and counseling differ for women seen by general medical physicians and gynecologists, and whether seeing both types of physicians had a greater impact on delivery of gender-specific and gender-neutral preventive care than by either type of physician alone. METHODS Using data from the 2000 National Health Interview Survey, we studied the association of provider type with Pap tests, tobacco use screening, and exercise and diet counseling among women 18-64 years (n=7,317), and these services along with clinical breast examinations, mammograms, and colon cancer screening among women aged 50-64 years (n=1,551). We modeled care using multivariable logistic regression and used propensity score techniques to limit selection bias from choice of provider. RESULTS In the study sample, 15% were seen by general medical physicians, 62% by gynecologists, and 23% by both. Overall rates of gender-specific services (Pap test, clinical breast examination, mammography) were high (88-95%), whereas gender-neutral services were low (23-53%). Patients of gynecologists only were more likely to have Pap tests (adjusted relative risk [RR] 1.26, 95% confidence interval [CI] 1.24-1.27), tobacco use screening (adjusted RR 1.08, 95% CI 1.02-1.14), mammography (adjusted RR 1.25, 95% CI 1.20-1.28), and clinical breast examination (adjusted RR 1.25, 95% CI 1.19-1.29). In general, combined gynecologist and general care did not increase the likelihood of preventive care. Propensity score analyses confirmed these results. CONCLUSION Patients of gynecologists receive more preventive services compared with patients of general medical physicians, although rates of gender-neutral services were low regardless of provider type. These findings validate gynecologists' roles as providers of basic preventive care services but demonstrate that considerable room exists to improve delivery of preventive care to women.
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