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Fuehrer S, Weil A, Osterberg LG, Zulman DM, Meunier MR, Schwartz R. Building Authentic Connection in the Patient-Physician Relationship. J Prim Care Community Health 2024; 15:21501319231225996. [PMID: 38281122 PMCID: PMC10823846 DOI: 10.1177/21501319231225996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 12/20/2023] [Accepted: 12/22/2023] [Indexed: 01/29/2024] Open
Abstract
INTRODUCTION/OBJECTIVES Delivering optimal patient care is impacted by a physician's ability to build trusting relationships with patients. Identifying techniques for rapport building is important for promoting patient-physician collaboration and improved patient outcomes. This study sought to characterize the approaches highly skilled primary care physicians (PCPs) use to effectively connect with diverse patients. METHODS Using an inductive thematic analysis approach, we analyzed semi-structured interview transcripts with 10 PCPs identified by leadership and/or colleagues for having exceptional patient communication skills. PCPs practiced in 3 diverse clinic settings: (1) academic medical center, (2) Veterans Affairs clinic, and (3) safety-net community clinic. RESULTS AND CONCLUSIONS The thematic analysis yielded 5 themes that enable physicians to establish connections with patients: Respect for the Patient, Engaged Curiosity, Focused Listening, Mutual Participation, and Self-Awareness. Underlying all of these themes was a quality of authenticity, or a state of symmetry between one's internal experience and external words and actions. Adopting these communication techniques while allowing for adaptability in order to remain authentic in one's interactions with patients may facilitate improved connection and trust with patients. Encouraging physician authenticity in the patient-physician relationship supports a shift toward relationship-centered care. Additional medical education training is needed to facilitate authentic connection between physicians and patients.
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Affiliation(s)
| | - Amy Weil
- University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Lars G. Osterberg
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Donna M. Zulman
- Stanford University School of Medicine, Palo Alto, CA, USA
- VA Palo Alto Health Care System, Menlo Park, CA, USA
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Ghazi L, Oakes JM, MacLehose RF, Luepker RV, Osypuk TL, Drawz PE. Neighborhood Socioeconomic Status and Identification of Patients With CKD Using Electronic Health Records. Am J Kidney Dis 2021; 78:57-65.e1. [PMID: 33359151 PMCID: PMC10156131 DOI: 10.1053/j.ajkd.2020.10.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 10/24/2020] [Indexed: 01/29/2023]
Abstract
RATIONALE & OBJECTIVE Screening for chronic kidney disease (CKD) is recommended for patients with diabetes and hypertension as stated by the respective professional societies. However, CKD, a silent disease usually detected at later stages, is associated with low socioeconomic status (SES). We assessed whether adding census tract SES status to the standard screening approach improves our ability to identify patients with CKD. STUDY DESIGN Screening test analysis. SETTINGS & PARTICIPANTS Electronic health records (EHR) of 256,162 patients seen at a health care system in the 7-county Minneapolis/St. Paul area and linked census tract data. EXPOSURE The first quartile of census tract SES (median value of owner-occupied housing units <$165,200; average household income <$35,935; percentage of residents >25 years of age with a bachelor's degree or higher <20.4%), hypertension, and diabetes. OUTCOMES CKD (eGFR <60 mL/min/1.73 m2, or urinary albumin-creatinine ratio >30mg/g, or urinary protein-creatinine ratio >150mg/g, or urinary analysis [albuminuria] >30 mg/d). ANALYTICAL APPROACH Sensitivity, specificity, and number needed to screen (NNS) to detect CKD if we screened patients who had hypertension and/or diabetes and/or who lived in low-SES tracts (belonging to the first quartile of any of the 3 measures of tract SES) versus the standard approach. RESULTS CKD was prevalent in 13% of our cohort. Sensitivity, specificity, and NNS of detecting CKD after adding tract SES to the screening approach were 67% (95% CI, 66.2%-67.2%), 61% (95% CI, 61.1%-61.5%), and 5, respectively. With the standard approach, sensitivity of detecting CKD was 60% (95% CI, 59.4%-60.4%), specificity was 73% (95% CI, 72.4%-72.7%), and NNS was 4. LIMITATIONS One health care system and selection bias. CONCLUSIONS Leveraging patients' addresses from the EHR and adding tract-level SES to the standard screening approach modestly increases the sensitivity of detecting patients with CKD at a cost of decreased specificity. Identifying further factors that improve CKD detection at an early stage are needed to slow the progression of CKD and prevent cardiovascular complications.
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Affiliation(s)
- Lama Ghazi
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN; Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN.
| | - J Michael Oakes
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Richard F MacLehose
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Russell V Luepker
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Theresa L Osypuk
- Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, Minneapolis, MN
| | - Paul E Drawz
- Division of Renal Diseases and Hypertension, University of Minnesota, Minneapolis, MN
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Riordan F, McHugh SM, O'Donovan C, Mtshede MN, Kearney PM. The Role of Physician and Practice Characteristics in the Quality of Diabetes Management in Primary Care: Systematic Review and Meta-analysis. J Gen Intern Med 2020; 35:1836-1848. [PMID: 32016700 PMCID: PMC7280455 DOI: 10.1007/s11606-020-05676-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 12/03/2019] [Accepted: 01/19/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Despite evidence-based guidelines, high-quality diabetes care is not always achieved. Identifying factors associated with the quality of management in primary care may inform service improvements, facilitating the tailoring of quality improvement interventions to practice needs and resources. METHODS We searched MEDLINE, EMBASE, CINAHL and Web of Science from January 1990 to March 2019. Eligible studies were cohort studies, cross-sectional studies and randomised controlled trials (baseline data) conducted among adults with diabetes, which examined the relationship between any physician and/or practice factors and any objective measure(s) of quality. Studies which examined patient factors only were ineligible. Where possible, data were pooled using random-effects meta-analysis. RESULTS In total, 82 studies were included. The range of individual quality measures and the construction of composite measures varied considerably. Female physicians compared with males ((odds ratio (OR) = 1.07, 95% CI: 1.04, 1.10), 8 studies), physicians with higher diabetes volume compared with lower volume (OR = 1.24, 95% CI: 1.05-1.47, 4 studies) and practices with Electronic Health Records (EHR) versus practices without (OR = 1.43, 95% CI: 1.11-1.84, 4 studies) were associated with a higher quality of care. There was no association between physician experience, practice location and type of practice and quality. Based on the narrative synthesis, increasing physician age and higher practice socio-economic deprivation may be associated with lower quality of care. DISCUSSION Identification of physician- and practice-level factors associated with the quality of care (female gender, younger age, physician-level diabetes volume, practice deprivation and EHR use) may explain differences across practices and physicians, provide potential targets for quality improvement interventions and indicate which practices need specific supports to deliver improvements in diabetes care.
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Affiliation(s)
- F Riordan
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland.
| | - S M McHugh
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | | | - Mavis N Mtshede
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
| | - P M Kearney
- School of Public Health, University College Cork, Western Gateway Building, Western Rd, Cork, Ireland
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Markovitz AR, Alexander JA, Lantz PM, Paustian ML. Patient-centered medical home implementation and use of preventive services: the role of practice socioeconomic context. JAMA Intern Med 2015; 175:598-606. [PMID: 25686468 PMCID: PMC4860609 DOI: 10.1001/jamainternmed.2014.8263] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The patient-centered medical home (PCMH) model of primary care is being implemented in a wide variety of socioeconomic contexts, yet there has been little research on whether its effects differ by context. Clinical preventive service use, including cancer screening, is an important outcome to assess the effectiveness of the PCMH within and across socioeconomic contexts. OBJECTIVE To determine whether the relationship between the PCMH and cancer screening is conditional on the socioeconomic context in which a primary care physician practice operates. DESIGN, SETTING, AND PARTICIPANTS A longitudinal study spanning July 1, 2009, through June 30, 2012, using data from the Blue Cross Blue Shield of Michigan Physician Group Incentive Program was conducted. Michigan nonpediatric primary care physician practices that participated in the Physician Group Incentive Program (5452 practice-years) were included. Sample size and outlier exclusion criteria were applied to each outcome. We examined the interaction between practices' PCMH implementation scores and their socioeconomic context. The implementation of a PCMH was self-reported by the practice's affiliated physician organizations and was measured as a continuous score ranging from 0 to 1. Socioeconomic context was calculated using a market-based approach based on zip code characteristics of the practice's patients and by combining multiple measures using principal components analysis. MAIN OUTCOMES AND MEASURES Breast, cervical, and colorectal cancer screening rates for practices' Blue Cross Blue Shield of Michigan patients. RESULTS The implementation of a PCMH was associated with higher breast, cervical, and colorectal cancer screening rates across most market socioeconomic contexts. In multivariable models, the PCMH was associated with a higher rate of screening for breast cancer (5.4%; 95% CI, 1.5% to 9.3%), cervical cancer (4.2%; 95% CI, 1.4% to 6.9%), and colorectal cancer (7.0%; 95% CI, 3.6% to 10.5%) in the lowest socioeconomic group but nonsignificant differences in screening for breast cancer (2.6%; 95% CI, -0.1% to 5.3%) and cervical cancer (-0.5%; 95% CI, -2.7% to 1.7%) and a higher rate of colorectal cancer (4.5%; 95% CI, 1.8% to 7.3%) screening in the highest socioeconomic group. Because PCMH implementation was associated with larger increases in screening in lower socioeconomic practice settings, models suggest reduced disparities in screening rates across these contexts. For example, the model-predicted disparity in breast cancer screening rates between the highest and lowest socioeconomic contexts was 6% (77.9% vs 72.2%) among practices with no PCMH implementation and 3% (80.3% vs. 77.0%) among practices with full PCMH implementation. CONCLUSIONS AND RELEVANCE In our study, the PCMH model was associated with improved cancer screening rates across contexts but may be especially relevant for practices in lower socioeconomic areas.
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Affiliation(s)
- Amanda R Markovitz
- Department of Clinical Epidemiology and Biostatistics, Blue Cross Blue Shield of Michigan, Ann Arbor2Department of Epidemiology, Harvard School of Public Health, Harvard University, Boston, Massachusetts
| | - Jeffrey A Alexander
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | - Paula M Lantz
- Department of Health Policy, Milken Institute School of Public Health, George Washington University, Washington, DC
| | - Michael L Paustian
- Department of Clinical Epidemiology and Biostatistics, Blue Cross Blue Shield of Michigan, Ann Arbor
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Anderson SG, Malipatil NS, Roberts H, Dunn G, Heald AH. Socioeconomic deprivation independently predicts symptomatic painful diabetic neuropathy in type 1 diabetes. Prim Care Diabetes 2014; 8:65-69. [PMID: 24211151 DOI: 10.1016/j.pcd.2013.08.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Revised: 07/30/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
Abstract
INTRODUCTION Painful peripheral neuropathy in people with type 1 diabetes is a disabling and costly complication. A greater understanding of predisposing factors and prescribing may facilitate more effective resource allocation. METHODS The Townsend index of deprivation (numerically higher for greater disadvantage) was examined in the pseudonymised records of 1621 (684 females) individuals with type 1 diabetes and related to prevalence of drug treated severe diabetes related neuropathic pain. RESULTS Treatment for neuropathic pain was initiated in 280 patients, who were older at 57.1 vs 45.6 years and had greater BMI (29.8 vs 27.8kg/m(2); p<0.0001). HbA1C was similar between groups, whilst eGFR was lower in the neuropathic pain group. Amitriptyline was the most commonly prescribed agent (46.8% of total prescriptions). Duloxetine (60mg daily) was prescribed in 9.3% of cases. There were significant differences between the groups for the Townsend index, with a greater proportion (34.3% vs 21.7%) of patients with treated neuropathic pain having a score of ≥1 (X(2)=19.9, p<0.001). Multivariate logistic regression analyses indicated that each unit increment in Townsend index was associated with a 11% increased odds of requiring neuropathic pain treatment [odds ratio (95% CI) 1.11 (1.05-1.17), p<0.001]. This was independent of age: 1.04 (1.02-1.05), BMI: 1.03 (1.01-1.05), HbA1C: 1.15 (1.05-1.24), male gender: 0.74 (0.55-0.98), systolic BP and eGFR. Inclusion of depression and mixed anxiety/depressive disorder did not change the risk estimates. CONCLUSION Amitriptyline was the most commonly used agent for treatment of diabetes related neuropathic pain with Duloxetine much less used. A higher level of socioeconomic deprivation may predispose to severe neuropathic pain in diabetes. Differential allocation of resources may benefit this group.
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Affiliation(s)
- Simon G Anderson
- Cardiovascular Sciences Research Group, Core Technology Facility (3rd Floor), University of Manchester, 46 Grafton Street, Manchester, United Kingdom
| | | | - Hugh Roberts
- Department of Medicine, Leighton Hospital, Crewe, United Kingdom
| | - George Dunn
- Podiatry, East Cheshire NHS Trust, Macclesfield, United Kingdom
| | - Adrian H Heald
- Department of Medicine, Leighton Hospital, Crewe, United Kingdom; School of Medicine and Manchester Academic Health Sciences Centre, University of Manchester, Manchester, United Kingdom.
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Elam AR, Lee PP. High-risk populations for vision loss and eye care underutilization: a review of the literature and ideas on moving forward. Surv Ophthalmol 2013; 58:348-58. [PMID: 23664105 DOI: 10.1016/j.survophthal.2012.07.005] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Revised: 07/24/2012] [Accepted: 07/31/2012] [Indexed: 10/26/2022]
Abstract
Much work has been done to highlight and understand the significant disparities in the use of eye care services, but they continue to exist. We review the existing literature on utilization in high-risk populations to provide a context for understanding what "high-risk" means, to understand the utilization patterns among high-risk populations, and to highlight barriers to appropriate eye care utilization. We also discuss potential approaches to reduce these disparities.
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Affiliation(s)
- Angela R Elam
- Department of Ophthalmology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania 15213, USA.
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Timbie JW, Hussey PS, Adams JL, Ruder TW, Mehrotra A. Impact of socioeconomic adjustment on physicians' relative cost of care. Med Care 2013; 51:454-60. [PMID: 23552439 PMCID: PMC4045113 DOI: 10.1097/mlr.0b013e31828d1251] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Ongoing efforts to profile physicians on their relative cost of care have been criticized because they do not account for differences in patients' socioeconomic status (SES). The importance of SES adjustment has not been explored in cost-profiling applications that measure costs using an episode of care framework. OBJECTIVES We assessed the relationship between SES and episode costs and the impact of adjusting for SES on physicians' relative cost rankings. RESEARCH DESIGN We analyzed claims submitted to 3 Massachusetts commercial health plans during calendar years 2004 and 2005. We grouped patients' care into episodes, attributed episodes to individual physicians, and standardized costs for price differences across plans. We accounted for differences in physicians' case mix using indicators for episode type and a patient's severity of illness. A patient's SES was measured using an index of 6 indicators based on the zip code in which the patient lived. We estimated each physician's case mix-adjusted average episode cost and percentile rankings with and without adjustment for SES. RESULTS Patients in the lowest SES quintile had $80 higher unadjusted episode costs, on average, than patients in the highest quintile. Nearly 70% of the variation in a physician's average episode cost was explained by case mix of their patients, whereas the contribution of SES was negligible. After adjustment for SES, only 1.1% of physicians changed relative cost rankings >2 percentiles. CONCLUSIONS Accounting for patients' SES has little impact on physicians' relative cost rankings within an episode cost framework.
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Impact of a pay for performance program to improve diabetes care in the safety net. Prev Med 2012; 55 Suppl:S80-5. [PMID: 23046985 DOI: 10.1016/j.ypmed.2012.05.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Revised: 03/06/2012] [Accepted: 05/03/2012] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the impact of a "piece-rate" pay for performance (P4P) program aimed at improving diabetes care processes, outcomes and related healthcare utilization for patients enrolled in a not-for-profit Medicaid-focused managed care plan. METHODS To evaluate Hudson Health Plan's P4P program in New York (2003-2007), we conducted: (1) a case-comparison difference-in-difference study using plan-level administrative data; (2) a patient-level claims data analysis; and (3) a cross-sectional survey. RESULTS The case-comparison study found that diabetes care processes (e.g., HbA1c, lipid, and dilated eye exam rates) and outcomes (e.g., LDL-C<100mg/dL) did not improve significantly over the study period. Claims analysis showed that younger adults had significantly increased odds (OR 3.50-3.56, p<0.001) of using emergency and hospital-based services and similarly decreased odds of receiving recommended care process (OR 0.22-0.36, p<0.01-0.001). Survey study indicated that practices lack fundamental quality improvement infrastructures and training. CONCLUSIONS Recent health legislation mandates the use of P4P incentives in government programs that disproportionately care for patients with lower socioeconomic or minority backgrounds (e.g., Medicaid, Veterans Health Administration, and Tricare). More research is needed in order to understand how to tailor P4P programs for vulnerable care settings.
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Plowman E, Hentz B, Ellis C. Post-stroke aphasia prognosis: a review of patient-related and stroke-related factors. J Eval Clin Pract 2012; 18:689-94. [PMID: 21395923 DOI: 10.1111/j.1365-2753.2011.01650.x] [Citation(s) in RCA: 126] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Recovery of language function in individuals with post-stroke aphasia is associated with a variety of patient and stroke-related indices. Amidst a complex interaction of a multitude of variables, clinicians are faced with the arduous challenge of predicting aphasia recovery patterns and subsequently, long-term outcomes in these individuals. Unfortunately, predictive factors are highly variable making prognosis of aphasia recovery difficult. Therefore, the objective of this review was to assess the influence of patient-related and stroke-related factors on language recovery in individuals with post-stroke aphasia. METHODS We completed a literature review to assess and identify evidence-based patient and stroke-related variables shown to be influential in aphasia recovery. RESULTS A range of patient-related (gender, handedness, age, education, socio-economic status and intelligence) and stroke-related indices (initial severity, lesion site and lesion size) were identified as potential influential factors to post-stroke aphasia recovery. Initial severity of aphasia emerged as the factor most predictive of long-term aphasia recovery. Other influential factors of post-stroke language recovery included lesion site and size. CONCLUSIONS Stroke-related factors, including aphasia severity, lesion site and lesion size, appear most critical to post-stroke aphasia recovery. The findings presented in this review offer clinicians an evidenced-based framework to assist in prediction of post-stroke aphasia recovery patterns and subsequent long-term functional communication outcomes.
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Affiliation(s)
- Emily Plowman
- Department of Communication Sciences and Disorders, College of Behavioral and Community Sciences, University of South Florida, Tampa, FL, USA
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Chien AT, Wroblewski K, Damberg C, Williams TR, Yanagihara D, Yakunina Y, Casalino LP. Do physician organizations located in lower socioeconomic status areas score lower on pay-for-performance measures? J Gen Intern Med 2012; 27:548-54. [PMID: 22160817 PMCID: PMC3326117 DOI: 10.1007/s11606-011-1946-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 10/18/2011] [Accepted: 10/31/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Physician organizations (POs)--independent practice associations and medical groups--located in lower socioeconomic status (SES) areas may score poorly in pay-for-performance (P4P) programs. OBJECTIVE To examine the association between PO location and P4P performance. DESIGN Cross-sectional study; Integrated Healthcare Association's (IHA's) P4P Program, the largest non-governmental, multi-payer program for POs in the U.S. PARTICIPANTS 160 POs participating in 2009. MAIN MEASURES We measured PO SES using established methods that involved geo-coding 11,718 practice sites within 160 POs to their respective census tracts and weighting tract-specific SES according to the number of primary care physicians at each site. P4P performance was defined by IHA's program and was a composite mainly representing clinical quality, but also including measures of patient experience, information technology and registry use. KEY RESULTS The area-based PO SES measure ranged from -11 to +11 (mean 0, SD 5), and the IHA P4P performance score ranged from 23 to 86 (mean 69, SD 15). In bivariate analysis, there was a significant positive relationship between PO SES and P4P performance (p < 0.001). In multivariate analysis, a one standard deviation increase in PO SES was associated with a 44% increase (relative risk 1.44, 95%CI, 1.22-1.71) in the likelihood of a PO being ranked in the top two quintiles of performance (p < 0.001). CONCLUSIONS Physician organizations' performance scores in a major P4P program vary by the SES of the areas in which their practice sites are located. P4P programs that do not account for this are likely to pay higher bonuses to POs in higher SES areas, thus increasing the resource gap between these POs and POs in lower SES areas, which may increase disparities in the care they provide.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Children's Hospital Boston, and Department of Pediatrics, Harvard Medical School, 21 Autumn Street-Room 223, Boston, MA 02215, USA.
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Breland HL, Ellis C. Is Reporting Race and Ethnicity Essential to Occupational Therapy Evidence? Am J Occup Ther 2012; 66:115-9. [DOI: 10.5014/ajot.2012.002246] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Affiliation(s)
- Hazel L. Breland
- Hazel L. Breland, PhD, OTR/L, is Assistant Professor, Division of Occupational Therapy, Department of Health Professions, College of Health Professions, Medical University of South Carolina, 151B Rutledge Avenue, MSC 962, Charleston, SC 29425-9620;
| | - Charles Ellis
- Charles Ellis, Jr., PhD, CCC-SLP, is Associate Professor, Department of Health Sciences and Research, College of Health Professions, Medical University of South Carolina, Charleston
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Ben-Morderchai B, Herman A, Kerzman H, Irony A. Structured discharge education improves early outcome in orthopedic patients. Int J Orthop Trauma Nurs 2010. [DOI: 10.1016/j.joon.2009.02.001] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Ellis C. Does race/ethnicity really matter in adult neurogenics? AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2009; 18:310-314. [PMID: 19332522 DOI: 10.1044/1058-0360(2009/08-0039)] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
PURPOSE Recent evidence suggests that race/ethnicity is a variable that is critical to outcomes in neurological disorders. The purpose of this article was to examine the proportion of studies published in the American Journal of Speech-Language Pathology (AJSLP) and the Journal of Speech, Language, and Hearing Research (JSLHR) that were designed to examine neurologically based disorders of communication in adults and that reported the race/ethnicity of the participants. METHOD A review of articles in AJSLP and JSLHR from 1997 through 2007 was completed to determine what proportion of articles in the area of adult neurogenic communication disorders reported the race/ethnicity of the participants. RESULTS Between 1997 and 2007, less than 15% of the 116 articles published in the 2 journals reported the race/ethnicity of the participants. The review of studies indicates that the reporting of the race/ethnicity of participants in studies of adult neurogenic communication disorders remains inconsistent. CONCLUSIONS Because few studies report race/ethnicity or consider how race/ethnicity has the potential to confound the results and conclusions drawn, the generalization of the reported findings may be limited. Reporting race/ethnicity is likely critical to the external validity of studies in adult neurogenic communication disorders and when available can enhance the relevance of the findings reported.
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Affiliation(s)
- Charles Ellis
- Medical University of South Carolina, College of Health Professions, Department of Health Professions, Charleston, SC 29425, USA.
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Karathanasi I, Kamposioras K, Cortinovis I, Karampoiki V, Alevizaki P, Dambrosio M, Zorba E, Panou C, Pantazi E, Bristianou M, Kouiroukidou P, Bouiatiotis E, Xilomenos A, Zavou D, Casazza G, Mauri D. Moving ahead in diabetics' cancer screening; food for thought from the Hellenic experience. Eur J Cancer Care (Engl) 2009; 18:255-63. [PMID: 19175670 DOI: 10.1111/j.1365-2354.2007.00858.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Although data from literature suggest that diabetic women are frequently under screened for gynaecological cancers little is known about screening implementation for other cancers for both genders. This study investigates comprehensive cancer screening practices of diabetics as compared with non-diabetics; analyses screening patterns both by gender and level of evidence and reveals target subgroups that should be paid more attention for screening implementation. 675 diabetics vs. 5772 non-diabetic Greek individuals entered the PACMeR 02 cancer screening study. Diabetic women reported significantly lower performance for the sex-specific evidence-based cancer screening tests and digital rectal examination (DRE) as compared with non-diabetics (P < 0.05). Diabetic women older than 60 years old, of elementary education, housewives and farmers showed the lowest performance rates (P < 0.01). Prostate cancer screening was higher among diabetic men with ultrasound and DRE reaching statistical significance (P < 0.05). Subgroups analysis did not reveal a hidden relationship. Both genders of diabetics reported never performing skin examination at higher rates (P < 0.001), although screening intent is extremely low in both diabetics and non-diabetics (<1%). Evidence-based screening coverage was inconsistent in both genders independently by the diabetic status. Primary care efforts should be provided to implement presymptomatic cancer control.
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Affiliation(s)
- I Karathanasi
- Department Of Endocrinology, Polykliniki General Hospital, Athens, Greece
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Boykin MJ, Gilbert GH, Tilashalski KR, Litaker MS. Racial differences in baseline treatment preference as predictors of receiving a dental extraction versus root canal therapy during 48 months of follow-up. J Public Health Dent 2009; 69:41-7. [PMID: 18662253 PMCID: PMC2815351 DOI: 10.1111/j.1752-7325.2008.00091.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study aimed to test hypotheses that: a) treatment preference as stated at baseline predicts subsequent receipt of extraction (EXT) versus root canal treatment; and b) racial differences in treatment preference at baseline account for racial differences in receipt of these treatments during follow-up. METHODS Data were taken from the Florida Dental Care Study This stratified random sample included at baseline 873 subjects, all of whom were 45-years-old or older, reported race as non-Hispanic African American or non-Hispanic white, and had at least one tooth. At baseline, participants were asked about past dental care characteristics, history of or current presence of various dental diseases and conditions, and sociodemographic circumstance. An EXT/root canal treatment "CHOICE" scenario was also queried at baseline. Predisposing, enabling, and need factors were tested as predictors of EXT/root canal treatment received during follow-up. Bivariate multivariable logistic regression analyses quantified associations between the outcomes (EXT/root canal) and the predictors. RESULTS Receipt of EXT or root canal treatment during follow-up was strongly related to race even after people with mobile teeth at baseline were excluded from the analysis. Certain baseline factors (tooth mobility, periodontal attachment level, and ability to pay an unexpected dental bill) strongly predicted EXT/root canal treatment receipt during follow-up, although significant race effects remained; however, including "CHOICE" removed the race effect. CONCLUSIONS Baseline treatment preference strongly predicts subsequent receipt of EXT versus root canal treatment. Racial differences in treatment received during follow-up were explained by baseline racial differences in treatment preference, tooth mobility, and periodontal status.
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Affiliation(s)
| | - Gregg H. Gilbert
- Professor and Chair, Department of Diagnostic Sciences, School of Dentistry, University of Alabama at Birmingham
| | - Ken R. Tilashalski
- Associate Professor, Department of Diagnostic Sciences, School of Dentistry, University of Alabama at Birmingham
| | - Mark S. Litaker
- Associate Professor, Department of Diagnostic Sciences, School of Dentistry, University of Alabama at Birmingham
- Director of Biostatistics, School of Dentistry, University of Alabama at Birmingham
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16
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Exploring Socioeconomic Variations in Diabetes Control Strategies: Impact of Outcome Expectations. J Natl Med Assoc 2009; 101:18-23. [DOI: 10.1016/s0027-9684(15)30806-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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17
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Abstract
OBJECTIVE We assessed the frequency that patients are incorrectly used as the unit of analysis among studies of physicians' patient care behavior in articles published in high impact journals. METHODS We surveyed 30 high-impact journals across 6 medical fields for articles susceptible to unit of analysis errors published from 1994 to 2005. Three reviewers independently abstracted articles using previously published criteria to determine the presence of analytic errors. RESULTS One hundred fourteen susceptible articles were found published in 15 journals, 4 journals published the majority (71 of 114 or 62.3%) of studies, 40 were intervention studies, and 74 were noninterventional studies. The unit of analysis error was present in 19 (48%) of the intervention studies and 31 (42%) of the noninterventional studies (overall error rate 44%). The frequency of the error decreased between 1994-1999 (N = 38; 65% error) and 2000-2005 (N = 76; 33% error) (P = 0.001). CONCLUSIONS Although the frequency of the error in published studies is decreasing, further improvement remains desirable.
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Bernheim SM, Ross JS, Krumholz HM, Bradley EH. Influence of patients' socioeconomic status on clinical management decisions: a qualitative study. Ann Fam Med 2008; 6:53-9. [PMID: 18195315 PMCID: PMC2203396 DOI: 10.1370/afm.749] [Citation(s) in RCA: 114] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Little is known about how patients' socioeconomic status (SES) influences physicians' clinical management decisions, although this information may have important implications for understanding inequities in health care quality. We investigated physician perspectives on how patients' SES influences care. METHODS The study consisted of in-depth semistructured interviews with primary care physicians in Connecticut. Investigators coded interviews line by line and refined the coding structure and interview guide based on successive interviews. Recurrent themes emerged through iterative analysis of codes and tagged quotations. RESULTS We interviewed 18 physicians from varied practice settings, 6 female, 9 from minority racial backgrounds, and 3 of Hispanic ethnicity. Four themes emerged from our interviews: (1) physicians held conflicting views about the effect of patient SES on clinical management, (2) physicians believed that changes in clinical management based on the patient's SES were made in the patient's interest, (3) physicians varied in the degree to which they thought changes in clinical management influenced patient outcomes, and (4) physicians faced personal and financial strains when caring for patients of low SES. CONCLUSIONS Physicians indicated that patient SES did affect their clinical management decisions. As a result, physicians commonly undertook changes to their management plan in an effort to enhance patient outcomes, but they experienced numerous strains when trying to balance what they believed was feasible for the patient with what they perceived as established standards of care.
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Affiliation(s)
- Susannah M Bernheim
- Department of Internal Medicine, Yale University School of Medicine, 333 Cedar St, PO Box 208025, New Haven, CT 208088, USA.
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19
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Stone PW, Mooney-Kane C, Larson EL, Horan T, Glance LG, Zwanziger J, Dick AW. Nurse working conditions and patient safety outcomes. Med Care 2007; 45:571-8. [PMID: 17515785 DOI: 10.1097/mlr.0b013e3180383667] [Citation(s) in RCA: 227] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND System approaches, such as improving working conditions, have been advocated to improve patient safety. However, the independent effect of many working condition variables on patient outcomes is unknown. OBJECTIVE To examine effects of a comprehensive set of working conditions on elderly patient safety outcomes in intensive care units. DESIGN Observational study, with patient outcome data collected using the National Nosocomial Infection Surveillance system protocols and Medicare files. Several measures of health status and fixed setting characteristics were used to capture distinct dimensions of patient severity of illness and risk for disease. Working condition variables included organizational climate measured by nurse survey; objective measures of staffing, overtime, and wages (derived from payroll data); and hospital profitability and magnet accreditation. SETTING AND PATIENTS The sample comprised 15,846 patients in 51 adult intensive care units in 31 hospitals depending on the outcome analyzed; 1095 nurses were surveyed. MAIN OUTCOME MEASURES Central line associated bloodstream infections (CLBSI), ventilator-associated pneumonia, catheter-associated urinary tract infections, 30-day mortality, and decubiti. RESULTS Units with higher staffing had lower incidence of CLBSI, ventilator-associated pneumonia, 30-day mortality, and decubiti (P <or= 0.05). Increased overtime was associated with higher rates of catheter-associated urinary tract infections and decubiti, but slightly lower rates of CLBSI (P <or= 0.05). The effects of organizational climate and profitability were not consistent. CONCLUSIONS Nurse working conditions were associated with all outcomes measured. Improving working conditions will most likely promote patient safety. Future researchers and policymakers should consider a broad set of working condition variables.
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Affiliation(s)
- Patricia W Stone
- Columbia University School of Nursing, New York, New York 10032, USA.
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20
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Abstract
To maximise benefits and minimise harm, equity must be built in from the start
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21
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Chagpar AB, McMasters KM. Trends in Mammography and Clinical Breast Examination: A Population-Based Study. J Surg Res 2007; 140:214-9. [PMID: 17418862 DOI: 10.1016/j.jss.2007.01.034] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Revised: 01/08/2007] [Accepted: 01/30/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND There are well-accepted clinical guidelines for early detection of breast cancer through mammography and clinical breast examination. The purpose of this study was to determine trends in the utilization of these techniques over the past 5 years. METHODS The National Health Interview Survey is a population-based computer survey of noninstitutionalized civilian Americans conducted annually by the National Center for Health Statistics, Centers for Disease Control and Prevention. We evaluated the reported use of mammography and clinical breast examination in women 40 years of age and older between 2000 and 2005. Data were evaluated using SAS and SAS-callable SUDAAN software. RESULTS Surveyed were 10,994 and 11,128 women over age 40 in 2000 and 2005, respectively. Between these years, there was a decline in women >or=40 years old who reported ever having a mammogram (80.79% versus 79.52%, P<0.0001) and in those who had a mammogram within the preceding 2 years (87.98% versus 86.30%, P=0.0040). In addition, there was a drop in women reporting ever having a clinical breast exam (82.12% versus 75.91%, P<0.0001) and in those reporting having had a clinical breast exam in the 2 years prior to the survey (89.24% versus 87.63%, P=0.0012). Similar results were found in the population aged 50-69. CONCLUSIONS Despite well-established clinical guidelines for early detection of breast cancer, there has been a decline in the rates of annual mammography and clinical breast exam in women over the age of 40 over the past 5 years.
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Affiliation(s)
- Anees B Chagpar
- Division of Surgical Oncology, Department of Surgery, University of Louisville, Louisville, Kentucky 40202, USA.
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22
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van Vliet EPM, Eijkemans MJC, Steyerberg EW, Kuipers EJ, Tilanus HW, van der Gaast A, Siersema PD. The role of socio-economic status in the decision making on diagnosis and treatment of oesophageal cancer in The Netherlands. Br J Cancer 2006; 95:1180-5. [PMID: 17031405 PMCID: PMC2360583 DOI: 10.1038/sj.bjc.6603374] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In the United States (USA), a correlation has been demonstrated between socio-economic status (SES) of patients on the one hand, and tumour histology, stage of the disease and treatment modality of various cancer types on the other hand. It is unknown whether such correlations are also involved in patients with oesophageal cancer in The Netherlands. Between 1994 and 2003, 888 oesophageal cancer patients were included in a prospective database with findings on the diagnostic work-up and treatment of oesophageal cancer. Socio-economic status of patients was defined as the average net yearly income. Linear-by-linear association testing revealed that oesophageal adenocarcinoma was more frequently observed in patients with higher SES and squamous cell carcinoma in patients with lower SES (P=0.02). Multivariable logistic regression analysis showed no correlation between SES and staging procedures and preoperative TNM stage. The adjusted odds ratio (OR) for stent placement was 0.82 (95% CI 0.71–0.95), indicating that with an increase in SES by 1200 €, the likelihood that a stent was placed declined by 18%. Patients with a higher SES more frequently underwent resection or were treated with chemotherapy (OR: 1.15; 95% CI 1.01–1.32 and OR: 1.16; 95% CI 1.02–1.32, respectively). Socio-economic factors are involved in oesophageal cancer in The Netherlands, as patients with a higher SES are more likely to have an adenocarcinoma and patients with a lower SES a squamous cell carcinoma. Moreover, the correlations between SES and different treatment modalities suggest that both patient and doctor determinants contribute to the decision on the most optimal treatment modality in patients with oesophageal cancer.
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Affiliation(s)
- E P M van Vliet
- Department of Gastroenterology and Hepatology, Erasmus MC – University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - M J C Eijkemans
- Department of Public Health, Erasmus MC – University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - E W Steyerberg
- Department of Public Health, Erasmus MC – University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - E J Kuipers
- Department of Gastroenterology and Hepatology, Erasmus MC – University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - H W Tilanus
- Department of Surgery, Erasmus MC – University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - A van der Gaast
- Department of Oncology, Erasmus MC – University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - P D Siersema
- Department of Gastroenterology and Hepatology, Erasmus MC – University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, The Netherlands
- E-mail:
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23
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Gilbert GH, Weems RA, Litaker MS, Shelton BJ. Practice characteristics associated with patient-specific receipt of dental diagnostic radiographs. Health Serv Res 2006; 41:1915-37. [PMID: 16987308 PMCID: PMC1955302 DOI: 10.1111/j.1475-6773.2006.00537.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To quantify the role of practice characteristics in patient-specific receipt of dental diagnostic radiographic services. DATA SOURCE/STUDY SETTING Florida Dental Care Study (FDCS). Study Design. The FDCS was a 48-month prospective observational cohort study of community-dwelling adults. Participants' dentists were asked to complete a questionnaire about their practice characteristics. DATA COLLECTION/EXTRACTION METHODS In-person interviews and clinical examinations were conducted at baseline, 24, and 48 months, with 6-monthly telephone interviews in between. A single multivariate (four radiographic service outcomes) multivariable (multiple explanatory covariates) logistic regression was used to model service receipts. PRINCIPAL FINDINGS These practice characteristics were significantly associated with patient-specific receipt of radiographic services: number of different practices attended during follow-up; dentist's rating of how busy the practice was; typical waiting time for a new patient examination; practice size; percentage of patients that the dentist reported as interested in details about the condition of their mouths; percentage of African American patients in the practice; percentage of patients in the practice who do not have dental insurance; and dentist's agreement with a statement regarding whether patients should be dismissed from the practice. Effects had differential magnitudes and directions of effect, depending upon radiograph type. CONCLUSIONS Practice characteristics were significantly associated with patient-specific receipt of services. These effects were independent of patient-specific disease level and patient-specific sociodemographic characteristics, suggesting that practitioners do influence receipt of these diagnostic services. These findings are consistent with the conclusion that practitioners act in response to a mix of patients' interests, economic self-interests, and their own treatment preferences.
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Affiliation(s)
- Gregg H Gilbert
- Department of Diagnostic Sciences, UAB School of Dentistry, SDB Room 109, 1530 3rd Avenue South, Birmingham, AL 35294-0007, USA
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24
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Springer D, Dziura J, Tamborlane WV, Steffen AT, Ahern JH, Vincent M, Weinzimer SA. Optimal control of type 1 diabetes mellitus in youth receiving intensive treatment. J Pediatr 2006; 149:227-32. [PMID: 16887440 DOI: 10.1016/j.jpeds.2006.03.052] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2004] [Revised: 02/01/2006] [Accepted: 03/31/2006] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To investigate the impact of factors that might interfere with optimal glycemic control in youth with type 1 diabetes mellitus (T1DM) in the current era of intensive management, including the interplay of race/ethnicity and socioeconomic status (SES) on HbA1c levels. STUDY DESIGN This study comprised a database review of all patients under age 18 years with T1DM for at least 6 months duration. Sex, age, race/ethnicity, duration of diabetes, mode of insulin administration (pump vs injection), body mass index, SES, and HbA1c level were recorded at each patient's most recent visit between January and September 2003. RESULTS Mean HbA1c level for the 455 patients was 7.6% +/- 1.4%; only 31% of patients failed to meet the therapeutic goal of < 8.0%. Multiple linear regression analysis identified female sex (P = .02), older age (P = .001), longer duration of diabetes (P < .001), injection therapy (P < .001), and lower SES (P = .001) as significantly associated with higher HbA1c level. After adjustment for SES, race/ethnicity was not a determinant of HbA1c level. CONCLUSIONS Low SES had a greater association with poor metabolic control than did race/ethnicity, which was not associated with differences in HbA1c level after controlling for SES. Most children were able to attain glycemic targets at least as good as the Diabetes Control and Complications Trial recommendations in a large clinical practice.
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Affiliation(s)
- Dena Springer
- Department of Pediatrics and the General Clinical Research Center, Yale University School of Medicine, New Haven, Connecticut, USA
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25
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Epstein RM, Franks P, Shields CG, Meldrum SC, Miller KN, Campbell TL, Fiscella K. Patient-centered communication and diagnostic testing. Ann Fam Med 2005; 3:415-21. [PMID: 16189057 PMCID: PMC1466928 DOI: 10.1370/afm.348] [Citation(s) in RCA: 225] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2005] [Revised: 05/06/2005] [Accepted: 05/09/2005] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Although patient-centered communication is associated with improved health and patient trust, information about the impact of patient-centered communication on health care costs is limited. We studied the relationship between patient-centered communication and diagnostic testing expenditures. METHODS We undertook an observational cross-sectional study using covert standardized patient visits to study physician interaction style and its relationship to diagnostic testing costs. Participants were 100 primary care physicians in the Rochester, NY, area participating in a large managed care organization (MCO). Audio recordings of 2 standardized patient encounters for each physician were rated using the Measure of Patient-Centered Communication (MPCC). Standardized diagnostic testing and other expenditures, adjusted for patient demographics and case-mix, were derived from the MCO claims database. Analyses were adjusted for demographics and standardized patient detection. RESULTS Compared with other physicians, those who had MPCC scores in the lowest tercile had greater standardized diagnostic testing expenditures (11.0% higher, 95% confidence interval [CI], 4.5%-17.8%) and greater total standardized expenditures (3.5% higher, 95% CI, 1.0%-6.1%). Whereas lower MPCC scores were associated with shorter visits, adjustment for visit length and standardized patient detection did not affect the relationship with expenditures. Total (testing, ambulatory and hospital care) expenditures were also greater for physicians who had lower MPCC scores, an effect primarily associated with the effect on testing expenditures. CONCLUSIONS Patient-centered communication is associated with fewer diagnostic testing expenditures but also with increased visit length. Because costs and visit length may affect physicians' and health systems' willingness to endorse and practice a patient-centered approach, these results should be confirmed in future randomized trials.
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Affiliation(s)
- Ronald M Epstein
- Department of Family Medicine, University of Rochester Medical Center, Rochester, NY, USA.
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26
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Franks P, Jerant AF, Fiscella K, Shields CG, Tancredi DJ, Epstein RM. Studying physician effects on patient outcomes: physician interactional style and performance on quality of care indicators. Soc Sci Med 2005; 62:422-32. [PMID: 15993531 DOI: 10.1016/j.socscimed.2005.05.027] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2005] [Indexed: 10/25/2022]
Abstract
Many prior studies which suggest a relationship between physician interactional style and patient outcomes may have been confounded by relying solely on patient reports, examining very few patients per physician, or not demonstrating evidence of a physician effect on the outcomes. We examined whether physician interactional style, measured both by patient report and objective encounter ratings, is related to performance on quality of care indicators. We also tested for the presence of physician effects on the performance indicators. Using data on 100 US primary care physician (PCP) claims data on 1,21,606 of their managed care patients, survey data on 4746 of their visiting patients, and audiotaped encounters of 2 standardized patients with each physician, we examined the relationships between claims-based quality of care indicators and both survey-derived patient perceptions of their physicians and objective ratings of interactional style in the audiotaped standardized patient encounters. Multi-level models examined whether physician effects (variance components) on care indicators were mediated by patient perceptions or objective ratings of interactional style. We found significant physician effects associated with glycohemoglobin and cholesterol testing. There was also a clinically significant association between better patient perceptions of their physicians and more glycohemoglobin testing. Multi-level analyses revealed, however, that the physician effect on glycohemoglobin testing was not mediated by patient perceived physician interaction style. In conclusion, similar to prior studies, we found evidence of an apparent relationship between patient perceptions of their physician and patient outcomes. However, the apparent relationships found in this study between patient perceptions of their physicians and patient care processes do not reflect physician style, but presumably reflect unmeasured patient confounding. Multi-level modeling may contribute to better understanding of the relationships between physician style and patient outcomes.
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Affiliation(s)
- Peter Franks
- Department of Family and Community Medicine, Universtiy of California Davis, UC Davis Medical Center, Sacramento, 95817, USA.
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