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Ochoa-Dominguez CY, Pickering TA, Navarro S, Rodriguez C, Farias AJ. Healthcare Experiences Are Associated with Colorectal Cancer Mortality but only for Specific Racial Groups: a SEER-CAHPS Study. J Racial Ethn Health Disparities 2024; 11:2224-2235. [PMID: 37369914 PMCID: PMC11236924 DOI: 10.1007/s40615-023-01690-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 06/01/2023] [Accepted: 06/18/2023] [Indexed: 06/29/2023]
Abstract
BACKGROUND The objective of this study was to determine whether racial/ethnic disparities exist in patient-reported experiences with care after colorectal cancer diagnosis and whether they are associated with mortality. METHODS We conducted a retrospective cohort study of colorectal cancer patients diagnosed from 1997 to 2011, ≥ 65 years, and completed a Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey at least 6 months after a cancer diagnosis. We leverage the National Cancer Institute's SEER-CAHPS dataset of Medicare beneficiaries. CAHPS survey responses were used to generate four composite measures of patient experiences with 1) getting needed care, 2) getting needed prescription drugs, 3) getting care quickly, and 4) physician communication. We used multivariable linear regression models to examine racial differences in patient experiences with aspects of their care and multivariable Cox proportional hazards models to identify the risk of mortality associated with each composite score by racial group. RESULTS Of the 5135 patients, 76.86% were non-Hispanic White, 7.58% non-Hispanic Black, 8.30% Hispanic, and 7.26% non-Hispanic Asian. Overall, patients reported the highest scores for composite measures regarding "getting all needed prescriptions" and the lowest score for "getting care quickly." In our adjusted models, we found that Hispanics, non-Hispanic Black, and non-Hispanic Asian patients reported significantly lower scores for getting needed prescription drugs (B = - 4.34, B = - 4.32, B = - 5.66; all p < 0.001) compared to non-Hispanic Whites. Moreover, non-Hispanic Black patients also reported lower scores for getting care quickly (B = - 3.44, p < 0.05). We only found one statistically significant association between composite scores of patient experience and mortality. For non-Hispanic Black patients, a 3-unit increase in getting needed care was associated with 0.97 times the hazard of mortality (p = 0.003). CONCLUSION Our research underscores that CAHPS patient experiences with care are an important patient-centered quality-of-care metric that may be associated with cancer outcomes and that there may be differences in these relationships by race and ethnicity. Thus, highlighting how patients' perceptions of their healthcare experiences can contribute to disparities in colorectal cancer outcomes.
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Affiliation(s)
- Carol Y Ochoa-Dominguez
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, 2001 N. Soto St., Suite 318B, Los Angeles, CA, 90032, USA
- Department of Radiation Medicine and Applied Sciences, University of California San Diego, San Diego, CA, USA
| | - Trevor A Pickering
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, 2001 N. Soto St., Suite 318B, Los Angeles, CA, 90032, USA
| | - Stephanie Navarro
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, 2001 N. Soto St., Suite 318B, Los Angeles, CA, 90032, USA
| | - Claudia Rodriguez
- Dornsife College of Letters, Arts, and Sciences, University of Southern California, Los Angeles, CA, USA
| | - Albert J Farias
- Department of Population and Public Health Sciences, Keck School of Medicine of the University of Southern California, 2001 N. Soto St., Suite 318B, Los Angeles, CA, 90032, USA.
- Gehr Family Center for Health System Science, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.
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Krishnamurthy S, Li Y, Sileanu F, Essien UR, Vanneman ME, Mor M, Fine MJ, Thorpe CT, Radomski T, Suda K, Gellad WF, Roberts ET. Racial and Ethnic Differences in Health Care Experiences for Veterans Receiving VA Community Care from 2016 to 2021. J Gen Intern Med 2024:10.1007/s11606-024-08818-3. [PMID: 38822210 DOI: 10.1007/s11606-024-08818-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Accepted: 05/13/2024] [Indexed: 06/02/2024]
Abstract
BACKGROUND Prior research documented racial and ethnic disparities in health care experiences within the Veterans Health Administration (VA). Little is known about such differences in VA-funded community care programs, through which a growing number of Veterans receive health care. Community care is available to Veterans when care is not available through the VA, nearby, or in a timely manner. OBJECTIVE To examine differences in Veterans' experiences with VA-funded community care by race and ethnicity and assess changes in these experiences from 2016 to 2021. DESIGN Observational analyses of Veterans' ratings of community care experiences by self-reported race and ethnicity. We used linear and logistic regressions to estimate racial and ethnic differences in community care experiences, sequentially adjusting for demographic, health, insurance, and socioeconomic factors. PARTICIPANTS Respondents to the 2016-2021 VA Survey of Healthcare Experiences of Patients-Community Care Survey. MEASURES Care ratings in nine domains. KEY RESULTS The sample of 231,869 respondents included 24,306 Black Veterans (mean [SD] age 56.5 [12.9] years, 77.5% male) and 16,490 Hispanic Veterans (mean [SD] age 54.6 [15.9] years, 85.3% male). In adjusted analyses pooled across study years, Black and Hispanic Veterans reported significantly lower ratings than their White and non-Hispanic counterparts in five of nine domains (overall rating of community providers, scheduling a recent appointment, provider communication, non-appointment access, and billing), with adjusted differences ranging from - 0.04 to - 0.13 standard deviations (SDs) of domain scores. Black and Hispanic Veterans reported higher ratings with eligibility determination and scheduling initial appointments than their White and non-Hispanic counterparts, and Black Veterans reported higher ratings of care coordination, with adjusted differences of 0.05 to 0.21 SDs. Care ratings improved from 2016 to 2021, but differences between racial and ethnic groups persisted. CONCLUSIONS This study identified small but persistent racial and ethnic differences in Veterans' experiences with VA-funded community care, with Black and Hispanic Veterans reporting lower ratings in five domains and, respectively, higher ratings in three and two domains. Interventions to improve Black and Hispanic Veterans' patient experience could advance equity in VA community care.
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Affiliation(s)
- Sudarshan Krishnamurthy
- Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Yaming Li
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Florentina Sileanu
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Utibe R Essien
- VA Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, West Los Angeles, CA, USA
- David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Megan E Vanneman
- Decision Enhancement and Analytic Sciences Center, VA Informatics, VA Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
- Department of Population Health Sciences, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Maria Mor
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Michael J Fine
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Carolyn T Thorpe
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - Thomas Radomski
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Katie Suda
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Walid F Gellad
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Eric T Roberts
- VA Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Division of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.
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Shannon EM, Jones KT, Moy E, Steers WN, Toyama J, Washington DL. Evaluation of regional variation in racial and ethnic differences in patient experience among Veterans Health Administration primary care users. Health Serv Res 2024. [PMID: 38808495 DOI: 10.1111/1475-6773.14328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024] Open
Abstract
OBJECTIVE To evaluate racial and ethnic differences in patient experience among VA primary care users at the Veterans Integrated Service Network (VISN) level. DATA SOURCE AND STUDY SETTING We performed a secondary analysis of the VA Survey of Healthcare Experiences of Patients-Patient Centered Medical Home for fiscal years 2016-2019. STUDY DESIGN We compared 28 patient experience measures (six each in the domains of access and care coordination, 16 in the domain of person-centered care) between minoritized racial and ethnic groups (American Indian or Alaska Native [AIAN], Asian, Black, Hispanic, Multi-Race, Native Hawaiian or Other Pacific Islander [NHOPI]) and White Veterans. We used weighted logistic regression to test differences between minoritized and White Veterans, controlling for age and gender. DATA COLLECTION/EXTRACTION METHODS We defined meaningful difference as both statistically significant at two-tailed p < 0.05 with a relative difference ≥10% or ≤-10%. Within VISNs, we included tests of group differences with adequate power to detect meaningful relative differences from a minimum of five comparisons (domain agnostic) per VISN, and separately for a minimum of two for access and care coordination and four for person-centered care domains. We report differences as disparities/large disparities (relative difference ≥10%/≥ 25%), advantages (experience worse or better, respectively, than White patients), or equivalence. PRINCIPAL FINDINGS Our analytic sample included 1,038,212 Veterans (0.6% AIAN, 1.4% Asian, 16.9% Black, 7.4% Hispanic, 0.8% Multi-Race, 0.8% NHOPI, 67.7% White). Across VISNs, the greatest proportion of comparisons indicated disparities for three of seven eligible VISNs for AIAN, 6/10 for Asian, 3/4 for Multi-Race, and 2/6 for NHOPI Veterans. The plurality of comparisons indicated advantages or equivalence for 17/18 eligible VISNs for Black and 12/14 for Hispanic Veterans. AIAN, Asian, Multi-Race, and NHOPI groups had more comparisons indicating disparities by VISN in the access domain than person-centered care and care coordination. CONCLUSIONS We found meaningful differences in patient experience measures across VISNs for minoritized compared to White groups, especially for groups with lower population representation.
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Affiliation(s)
- Evan Michael Shannon
- VA HSR Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, California, USA
| | - Kenneth T Jones
- Office of Health Equity, Veterans Health Administration, Washington, DC, USA
| | - Ernest Moy
- Office of Health Equity, Veterans Health Administration, Washington, DC, USA
| | - W Neil Steers
- VA HSR Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Joy Toyama
- VA HSR Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Donna L Washington
- VA HSR Center for the Study of Healthcare Innovation, Implementation & Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Division of General Internal Medicine and Health Services Research, UCLA David Geffen School of Medicine, Los Angeles, California, USA
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Wheat CL, Wong ES, Gray KE, Stockdale SE, Nelson KM, Reddy A. Factors Associated With Use of the Preventive Health Inventory in US Veterans. JAMA Netw Open 2024; 7:e242717. [PMID: 38497962 PMCID: PMC10949100 DOI: 10.1001/jamanetworkopen.2024.2717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/24/2024] [Indexed: 03/19/2024] Open
Abstract
Importance The COVID-19 pandemic caused significant declines in the quality of preventive and chronic disease care. The Veterans Health Administration (VHA) used the Preventive Health Inventory (PHI), a multicomponent care management intervention, to catch up on care disrupted by the pandemic. Objective To identify key factors associated with PHI use. Design, Setting, and Participants This cohort study of veterans receiving primary care used administrative data from national VHA primary care clinics for February 1, 2021, through February 1, 2022. Exposure Patient PHI receipt. Main Outcomes and Measures The main outcomes were patient, practitioner, and clinic factors associated with PHI receipt. Binomial generalized linear models with fixed effects for clinic were used to analyze factors associated with receipt of PHI. Least absolute shrinkage and selection operator procedures were used for variable selection. Results A total of 4 358 038 veterans (mean [SD] age, 63.7 [16.0] years; 90% male; 76% non-Hispanic White) formed the study cohort, of whom 389 757 (9%) received the PHI. Veterans who received the PHI had higher mean Care Assessment Need (CAN) scores, which indicate the likelihood of hospitalization or death within 1 year (mean [SD], 51.9 [28.6] vs 47.2 [28.6]; standardized mean difference [SMD], -0.16). They were also more likely to live in urban areas (77% vs 64%; SMD, 0.28) and have a shorter drive distance to primary care (mean [SD], 13.2 [12.4] vs 15.7 [14.6] miles; SMD, 0.19). The mean outpatient use was higher among PHI recipients compared with non-PHI recipients (mean [SD], 18.4 [27.8] vs 15.1 [24.1] visits; SMD, -0.13). In addition, veterans with primary care practitioners with higher caseloads were more likely to receive the PHI (mean [SD], 778 [231] vs 744 [249] patients; SMD, -0.14), and they were more likely to be seen at larger clinics (mean [SD], 9670 [6876] vs 8786 [6892] patients; SMD, -0.13). Prior outpatient use and CAN score were associated with PHI receipt in the final model. Conclusions and Relevance In this cohort study of the VHA's PHI, patients with higher CAN scores and more outpatient use in the previous year were more likely to receive the PHI. This study identifies potential intervention points to improve care coordination for veterans.
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Affiliation(s)
- Chelle L. Wheat
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
| | - Edwin S. Wong
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Kristen E. Gray
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
| | - Susan E. Stockdale
- VA Greater Los Angeles Healthcare System, Center for the Study of Healthcare Innovation, Implementation and Policy (CSHIIP), Los Angeles, California
- David Geffen School of Medicine, Department of Medicine, Division of General Internal Medicine, University of California at Los Angeles, Los Angeles
| | - Karin M. Nelson
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
| | - Ashok Reddy
- Center for Veteran-Centered and Value-Driven Care, Veterans Affairs (VA) Puget Sound Health Care System, Seattle, Washington
- Department of Health Systems and Population Health, University of Washington, Seattle
- Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle
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Lee NS, Keddem S, Sorrentino AE, Jenkins KA, Long JA. Health Equity in the Veterans Health Administration From Veterans' Perspectives by Race and Sex. JAMA Netw Open 2024; 7:e2356600. [PMID: 38373000 PMCID: PMC10877456 DOI: 10.1001/jamanetworkopen.2023.56600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024] Open
Abstract
Importance Advancing equitable patient-centered care in the Veterans Health Administration (VHA) requires understanding the differential experiences of unique patient groups. Objective To inform a comprehensive strategy for improving VHA health equity through the comparative qualitative analysis of care experiences at the VHA among veterans of Black and White race and male and female sex. Design, Setting, and Participants This qualitative study used a technique termed freelisting, an anthropologic technique eliciting responses in list form, at an urban academic VHA medical center from August 2, 2021, to February 9, 2022. Participants included veterans with chronic hypertension. The length of individual lists, item order in those lists, and item frequency across lists were used to calculate a salience score for each item, allowing comparison of salient words and topics within and across different groups. Participants were asked about current perceptions of VHA care, challenges in the past year, virtual care, suggestions for change, and experiences of racism. Data were analyzed from February 10 through September 30, 2022. Main Outcomes and Measures The Smith salience index, which measures the frequency and rank of each word or phrase, was calculated for each group. Results Responses from 49 veterans (12 Black men, 12 Black women, 12 White men, and 13 White women) were compared by race (24 Black and 25 White) and sex (24 men and 25 women). The mean (SD) age was 64.5 (9.2) years. Some positive items were salient across race and sex, including "good medical care" and telehealth as a "comfortable/great option," as were some negative items, including "long waits/delays in getting care," "transportation/traffic challenges," and "anxiety/stress/fear." Reporting "no impact" of racism on experiences of VHA health care was salient across race and sex; however, reports of race-related unprofessional treatment and active avoidance of race-related conflict differed by race (present among Black and not White participants). Experiences of interpersonal interactions also diverged. "Impersonal/cursory" telehealth experiences and the need for "more personal/attentive" care were salient among women and Black participants, but not men or White participants, who associated VHA care with courtesy and respect. Conclusions and Relevance In this qualitative freelist study of veteran experiences, divergent experiences of interpersonal care by race and sex provided insights for improving equitable, patient-centered VHA care. Future research and interventions could focus on identifying differences across broader categories both within and beyond race and sex and bolstering efforts to improve respect and personalized care to diverse veteran populations.
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Affiliation(s)
- Natalie S. Lee
- Division of General Internal Medicine, The Ohio State University Wexner Medical Center, Columbus
- Center for the Advancement of Team Science, Analytics, and Systems Thinking in Health Services and Implementation Science Research, The Ohio State University, Columbus
| | - Shimrit Keddem
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Department of Family Medicine and Community Health, University of Pennsylvania Perelman School of Medicine, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Anneliese E. Sorrentino
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
| | - Kevin Ahmaad Jenkins
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Judith A. Long
- Center for Health Equity Research and Promotion, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
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Shannon EM, Steers WN, Washington DL. Investigation of the role of perceived access to primary care in mediating and moderating racial and ethnic disparities in chronic disease control in the veterans health administration. Health Serv Res 2024; 59:e14260. [PMID: 37974469 PMCID: PMC10771907 DOI: 10.1111/1475-6773.14260] [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] [Indexed: 11/19/2023] Open
Abstract
OBJECTIVE To examine the role of patient-perceived access to primary care in mediating and moderating racial and ethnic disparities in hypertension control and diabetes control among Veterans Health Administration (VA) users. DATA SOURCE AND STUDY SETTING We performed a secondary analysis of national VA user administrative data for fiscal years 2016-2019. STUDY DESIGN Our primary exposure was race or ethnicity and primary outcomes were binary indicators of hypertension control (<140/90 mmHg) and diabetes control (HgbA1c < 9%) among patients with known disease. We used the inverse odds-weighting method to test for mediation and logistic regression with race and ethnicity-by-perceived access interaction product terms to test moderation. All models were adjusted for age, sex, socioeconomic status, rurality, education, self-rated physical and mental health, and comorbidities. DATA COLLECTION/EXTRACTION METHODS We included VA users with hypertension and diabetes control data from the External Peer Review Program who had contemporaneously completed the Survey of Healthcare Experience of Patients-Patient-Centered Medical Home. Hypertension (34,233 patients) and diabetes (23,039 patients) samples were analyzed separately. PRINCIPAL FINDINGS After adjustment, Black patients had significantly lower rates of hypertension control than White patients (75.5% vs. 78.8%, p < 0.01); both Black (81.8%) and Hispanic (80.4%) patients had significantly lower rates of diabetes control than White patients (85.9%, p < 0.01 for both differences). Perceived access was lower among Black, Multi-Race and Native Hawaiian and Other Pacific Islanders compared to White patients in both samples. There was no evidence that perceived access mediated or moderated associations between Black race, Hispanic ethnicity, and hypertension or diabetes control. CONCLUSIONS We observed disparities in hypertension and diabetes control among minoritized patients. There was no evidence that patients' perception of access to primary care mediated or moderated these disparities. Reducing racial and ethnic disparities within VA in hypertension and diabetes control may require interventions beyond those focused on improving patient access.
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Affiliation(s)
- Evan Michael Shannon
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Division of General Internal Medicine and Health Services ResearchUCLA David Geffen School of MedicineLos AngelesCaliforniaUSA
| | - W. Neil Steers
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
| | - Donna L. Washington
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation & PolicyVA Greater Los Angeles Healthcare SystemLos AngelesCaliforniaUSA
- Division of General Internal Medicine and Health Services ResearchUCLA David Geffen School of MedicineLos AngelesCaliforniaUSA
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Hausmann LR, Lamorte C, Estock JL. Understanding the Context for Incorporating Equity into Quality Improvement Throughout a National Health Care System. Health Equity 2023; 7:312-320. [PMID: 37284535 PMCID: PMC10240324 DOI: 10.1089/heq.2023.0009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/25/2023] [Indexed: 06/08/2023] Open
Abstract
Purpose Although health care systems aspire to deliver equitable care, practical tools that empower the health care workforce to weave equity throughout quality improvement (QI) processes are lacking. In this article, we report findings from context of use interviews that informed the development of a user-centered tool to support equity-focused QI. Methods Semistructured interviews were conducted from February to April of 2019. Participants included 14 medical center administrators, departmental or service line leaders, and clinical staff involved in direct patient care from three Veterans Affairs (VA) Medical Centers within a single region. Interviews covered existing practices for monitoring health care quality (i.e., priorities, tasks, workflow, and resources) and explored how equity data might fit into current processes. Themes extracted through rapid qualitative analysis were used to draft initial functional requirements for a tool to support equity-focused QI. Results Although the potential value of examining disparities in health care quality was clearly recognized, the data necessary for examining disparities were lacking for most quality measures. Interviewees also desired guidance on how inequities could be addressed through QI. The ways in which QI initiatives were selected, carried out, and supported also had important design implications for tools to support equity-focused QI. Discussion The themes identified in this work guided the development of a national VA Primary Care Equity Dashboard to support equity-focused QI within VA. Understanding the ways in which QI was carried out across multiple levels of the organization provided a successful foundation upon which to build functional tools to support thoughtful engagement around equity in clinical settings.
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Affiliation(s)
- Leslie R.M. Hausmann
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Carolyn Lamorte
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Jamie L. Estock
- Center for Health Equity Research and Promotion (CHERP), Veterans Affairs (VA) Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
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Callegari LS, Mahorter SS, Benson SK, Zhao X, Schwarz EB, Borrero S. Perceived Contraceptive Counseling Quality Among Veterans Using VA Primary Care: Data from the ECUUN Study. J Gen Intern Med 2022; 37:698-705. [PMID: 36042079 PMCID: PMC9481768 DOI: 10.1007/s11606-022-07586-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 04/01/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND High-quality contraceptive counseling is critical to support Veterans' reproductive autonomy and promote healthy outcomes. OBJECTIVE To describe perceived quality of contraceptive counseling in Veterans Health Administration (VA) primary care and assess factors associated with perceived high- and low-quality contraceptive counseling. DESIGN Cross-sectional study using data from the Examining Contraceptive Use and Unmet Need in women Veterans (ECUUN) national telephone survey. PARTICIPANTS Veterans aged 18-44 who received contraceptive services from a VA primary care clinic in the past year (N=506). MAIN MEASURES Perceived quality of contraceptive counseling was captured by assessing Veterans' agreement with 6 statements regarding provider counseling adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. High-quality counseling was defined as a top score of strongly agreeing on all 6 items; low-quality counseling was defined as not agreeing (neutral, disagreeing, or strongly disagreeing) with >3 items. We constructed two multivariable models to assess associations between patient-, provider-, and system-level factors and perceived high-quality (Model 1) and perceived low-quality counseling (Model 2). KEY RESULTS Most participants strongly agreed that their providers listened carefully (74%), explained things clearly (77%), and spent enough time discussing things (71%). Lower proportions strongly agreed that their provider discussed more than one option (54%), discussed pros/cons of various methods (44%), or asked which choice they thought was best for them (62%). In Model 1, Veterans who received care in a Women's Health Clinic (WHC) had twice the odds of perceiving high-quality counseling (aOR=1.99; 95%CI=1.24-3.22). In Model 2, Veterans who received care in a WHC (aOR=0.49; 95%CI=0.25-0.97) or from clinicians who provide cervical cancer screening (aOR=0.49; 95%CI=0.26-0.95) had half the odds of perceiving low-quality counseling. CONCLUSIONS Opportunities exist to improve the quality of contraceptive counseling within VA primary care settings, including more consistent efforts to seek patients' perspectives with respect to contraceptive decisions.
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Affiliation(s)
- Lisa S Callegari
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way S-152, Seattle, WA, 98108, USA. .,Department of Obstetrics & Gynecology, University of Washington School of Medicine, Seattle, USA. .,Department of Health Services, University of Washington School of Public Health, Seattle, USA.
| | - Siobhan S Mahorter
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way S-152, Seattle, WA, 98108, USA
| | - Sam K Benson
- Health Services Research and Development, Department of Veterans Affairs (VA) Puget Sound Health Care System, 1660 S. Columbian Way S-152, Seattle, WA, 98108, USA
| | - Xinhua Zhao
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, USA
| | | | - Sonya Borrero
- Center for Health Equity, Research, and Promotion, VA Pittsburgh Health Care System, Pittsburgh, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
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Wyte-Lake T, Levy C, Hovsepian S, Mudoh Y, Schmitz C, Dobalian A. COVID-19 vaccine adoption and hesitancy among older Veterans. BMC Public Health 2022; 22:1532. [PMID: 35953851 PMCID: PMC9366126 DOI: 10.1186/s12889-022-13882-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 07/25/2022] [Indexed: 11/10/2022] Open
Abstract
Background Older adults are particularly at risk for severe illness or death from COVID-19. Accordingly, the Veterans Health Administration (VA) has prioritized this population group in its COVID-19 vaccination strategy. This study examines the receptivity of Veterans enrolled in the VA’s Geriatric Patient Aligned Care Team (GeriPACT) to receiving the COVID-19 vaccine. GeriPACT is an outpatient primary care program that utilizes multi-disciplinary teams to provide health services to older Veterans. Methods We conducted semistructured interviews with 42 GeriPACT-enrolled Veterans from five states. Participants were asked to identify barriers to vaccine acceptance. We gathered data from January-March 2021 and analyzed them using qualitative methods. Results Both White and African American GeriPACT Veterans had minimal vaccine hesitancy towards the COVID-19 vaccine. On-line registration and ineligibility of a spouse/caregiver for vaccination were primary barriers to early vaccination. Conclusions As the first wave of early adopters of the COVID-19 vaccination effort nears completion, targeted strategies are needed to understand and respond to vaccine hesitancy to lower the risk of subsequent waves of infections. The 2021 SAVE LIVES Act, begins to address identified vaccination barriers by permitting vaccination of Veteran spouses and caregivers, but consideration must be given to creating alternatives to on-line registration and allowing spouses and caregivers to register for appointments together.
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Affiliation(s)
- Tamar Wyte-Lake
- Veterans Emergency Management Evaluation Center (VEMEC), Office of Patient Care Services (Population Health), US Department of Veterans Affairs, Veterans Health Administration, 16111 Plummer St. MS-152, Bldg 22, Rm 113, North Hills, CA, 91343, USA. .,Department of Family Medicine, Oregon Health & Science University, Portland, OR, USA.
| | - Cari Levy
- US Department of Veterans Affairs, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA.,Denver School of Medicine, University of Colorado, Aurora, OR, USA
| | - Sona Hovsepian
- Veterans Emergency Management Evaluation Center (VEMEC), Office of Patient Care Services (Population Health), US Department of Veterans Affairs, Veterans Health Administration, 16111 Plummer St. MS-152, Bldg 22, Rm 113, North Hills, CA, 91343, USA.,Veterans Emergency Management Evaluation Center, Office of Patient Care Services (Population Health), US Department of Veterans Affairs, Veterans Health Administration, North Hills, CA, USA
| | - Yvonne Mudoh
- Veterans Emergency Management Evaluation Center (VEMEC), Office of Patient Care Services (Population Health), US Department of Veterans Affairs, Veterans Health Administration, 16111 Plummer St. MS-152, Bldg 22, Rm 113, North Hills, CA, 91343, USA.,Veterans Emergency Management Evaluation Center, Office of Patient Care Services (Population Health), US Department of Veterans Affairs, Veterans Health Administration, North Hills, CA, USA
| | - Cheryl Schmitz
- US Department of Veterans Affairs, Office of Geriatrics and Extended Care, Washington, DC, USA
| | - Aram Dobalian
- Veterans Emergency Management Evaluation Center (VEMEC), Office of Patient Care Services (Population Health), US Department of Veterans Affairs, Veterans Health Administration, 16111 Plummer St. MS-152, Bldg 22, Rm 113, North Hills, CA, 91343, USA.,Veterans Emergency Management Evaluation Center, Office of Patient Care Services (Population Health), US Department of Veterans Affairs, Veterans Health Administration, North Hills, CA, USA.,Division of Health Services Management and Policy, The Ohio State University College of Public Health, Columbus, OH, USA
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10
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Lung Cancer Mortality Racial/Ethnic Disparities in Patient Experiences with Care: a SEER-CAHPS Study. J Racial Ethn Health Disparities 2022:10.1007/s40615-022-01358-8. [PMID: 35767217 DOI: 10.1007/s40615-022-01358-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2022] [Revised: 06/16/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND To determine whether there are racial/ethnic disparities in patient experiences with care among lung cancer survivors, whether they are associated with mortality. METHODS A retrospective cohort study of lung cancer survivors > 65 years old who completed a CAHPS survey > 6 months after the date of diagnosis. We used data from the SEER-Consumer Assessment of Healthcare Providers Systems (SEER-CAHPS®) database from 2000 to 2013 to assess racial/ethnic differences in patient experiences with care multivariable Cox proportional hazards models to assess the association between patient experience with care scores mortality in each racial/ethnic group. RESULTS Within our cohort of 2603 lung cancer patients, Hispanic patients reported lower adjusted mean score with their ability to get needed care compared to white patients (B: - 5.21, 95% CI: - 9.03, - 1.39). Asian patients reported lower adjusted mean scores with their ability to get care quickly (- 4.25 (- 8.19, - 0.31)), get needed care (- 7.06 (- 10.51, - 3.61)), get needed drugs (- 9.06 (- 13.04, - 5.08)). For Hispanic patients, a 1-unit score increase in their ability to get all needed care (HR: 1.02, 1.00-1.03) care coordination (1.06, 1.02-1.09) was associated with higher risk of mortality. Among black patients, a 1-unit score increase in their ability to get needed care (HR: 0.99, 95% CI 0.98-0.99) care coordination (0.97, 0.94-0.99) was associated with lower risk mortality. CONCLUSIONS There are racial/ethnic disparities in lung cancer patient experiences with care that may impact mortality. Patient experiences with care are important risk factors of mortality for certain racial/ethnic groups.
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11
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Essien UR, Kim N, Magnani JW, Good CB, Litam TMA, Hausmann LRM, Mor MK, Gellad WF, Fine MJ. Association of Race and Ethnicity and Anticoagulation in Patients with Atrial Fibrillation Dually Enrolled in VA and Medicare: Effects of Medicare Part D on Prescribing Disparities. Circ Cardiovasc Qual Outcomes 2021; 15:e008389. [PMID: 34779655 DOI: 10.1161/circoutcomes.121.008389] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Racial and ethnic disparities in anticoagulation exist in atrial fibrillation (AF) management in Medicare and the Veterans Health Administration (VA), but the influence of dual VA and Medicare enrollment is unclear. We compared anticoagulant initiation by race and ethnicity in dually enrolled patients and assessed the role of Medicare Part D enrollment on anticoagulation disparities. Methods: We identified patients with incident AF (2014-2018) dually enrolled in VA and Medicare. We assessed any anticoagulant initiation (warfarin or direct-acting oral anticoagulants, DOACs) within 90 days of AF diagnosis and DOAC use among anticoagulant initiators. We modeled anticoagulant initiation, adjusting for patient, provider, and facility factors, including main effects for race and ethnicity and Medicare Part D enrollment and an interaction term for these variables. Results: In 43,789 patients, 8.9% were Black, 3.6% Hispanic, and 87.5% White; 10.9% participated in Medicare Part D. Overall, 29,680 (67.8%) patients initiated any anticoagulant, of which 17,568 (59.2%) initiated DOACs. Lower proportions of Black (65.2%) than Hispanic (67.6%) or White (68.0%) patients initiated any anticoagulant (p= 0.001), and lower proportions of Black (56.3%) and Hispanic (55.9%) than White (59.6%) patients (p=0.001) initiated DOACs. Compared to White patients, Black patients had significantly lower initiation of any anticoagulant, adjusted odds ratio (aOR) 0.89; 95% CI 0.82-0.97. The aORs for DOAC initiation were significantly lower for Black (0.72; 95% CI, 0.65-0.81) and Hispanic (0.84; 95% CI, 0.70-1.00) than White patients.The interaction between race and ethnicity and Medicare Part D enrollment was non-significant for any anticoagulant (p=0.99) and DOAC (p=0.27) therapies. Conclusions: In dually enrolled VA and Medicare patients with AF, Black patients were less likely to initiate any anticoagulant and Black and Hispanic patients were less likely to initiate DOACs. Medicare Part D enrollment did not moderate the associations between race and ethnicity and anticoagulant therapies.
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Affiliation(s)
- Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA; Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, PA
| | - Terrence M A Litam
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA; Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
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12
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Ochoa CY, Toledo G, Iyawe-Parsons A, Navarro S, Farias AJ. Multilevel Influences on Black Cancer Patient Experiences With Care: A Qualitative Analysis. JCO Oncol Pract 2021; 17:e645-e653. [PMID: 33974829 DOI: 10.1200/op.21.00011] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE Black patients with cancer report worse experiences with health care compared with White patients; however, little is known about what influences these ratings. The objective of this study is to explore the multilevel factors that influence global ratings of care for Black cancer survivors. METHODS We conducted semistructured in-depth interviews with 18 Black cancer survivors. We assessed the global ratings of their personal doctor, specialist, health plan, prescription drug plan, and overall health care, and asked patients to elaborate on their rating. We analyzed the interviews with a deductive grounded theory approach using the socioecologic model to identify the individual, interpersonal, organizational, and environmental influences on Black cancer patient experiences with global ratings of care. We used an inductive constant comparison approach to identify additional themes that emerged. Two coauthors separately coded a set of transcripts and met to refine the codebook. RESULTS On average, participants reported the highest mean rating for their specialist (9.39/10) and the lowest mean rating for their personal doctor (7.33/10). Emerging themes that influenced patient ratings were perceptions about their interaction with medical providers, physician communication, the doctor's expertise, and aspects of the physical facilities. Global ratings of care measures were widely influenced by patient interactions with their providers that were empathetic, nondiscriminatory, and where the doctors addressed all concerns. CONCLUSION This grounded theory study identifies multiple aspects of health care that intervention researchers, health care administrators, and providers may target to improve Black cancer patient experiences with care.
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Affiliation(s)
- Carol Y Ochoa
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA
| | - Gabriela Toledo
- UCL Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Aisa Iyawe-Parsons
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA.,Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Stephanie Navarro
- Department of Preventive Medicine, University of Southern California, Los Angeles, CA.,Keck School of Medicine of the University of Southern California, Los Angeles, CA
| | - Albert J Farias
- Department of Preventive Medicine, The Gehr Family Center for Health Systems Science, University of Southern California, Los Angeles, CA
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13
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Essien UR, Kim N, Hausmann LRM, Mor MK, Good CB, Magnani JW, Litam TMA, Gellad WF, Fine MJ. Disparities in Anticoagulant Therapy Initiation for Incident Atrial Fibrillation by Race/Ethnicity Among Patients in the Veterans Health Administration System. JAMA Netw Open 2021; 4:e2114234. [PMID: 34319358 PMCID: PMC8319757 DOI: 10.1001/jamanetworkopen.2021.14234] [Citation(s) in RCA: 46] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
IMPORTANCE Atrial fibrillation is a common cardiac rhythm disturbance causing substantial morbidity and mortality that disproportionately affects racial/ethnic minority groups. Anticoagulation reduces stroke risk in atrial fibrillation, yet studies show it is underprescribed in racial/ethnic minority patients. OBJECTIVE To compare initiation of anticoagulant therapy by race/ethnicity for patients in the Veterans Health Administration (VA) system with atrial fibrillation. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study included 111 666 patients within the VA system with incident atrial fibrillation between January 1, 2014, and December 31, 2018. Data were analyzed between December 1, 2019, and March 31, 2020. EXPOSURES Any anticoagulation was defined as receipt of warfarin or direct-acting oral anticoagulants, apixaban, dabigatran, edoxaban, or rivaroxaban. MAIN OUTCOMES AND MEASURES Initiation of any anticoagulation (or direct-acting oral anticoagulant therapy in those who initiated any anticoagulation) was examined within 90 days of an index atrial fibrillation diagnosis. RESULTS Our final cohort comprised 111 666 patients (109 386 men [98.0%] and 95 493 White patients [85.5%]; mean [SD] age, 72.9 [10.4] years). A total of 69 590 patients (62.3%) initiated any anticoagulant therapy, varying 10.5 percentage points by race/ethnicity (P < .001); initiation was lowest in Asian (52.2% [n = 676]) and Black (60.3% [n = 6177]) patients and highest in White patients (62.7% [n = 59 881]). Among anticoagulant initiators, 45 381 (65.2%) used direct-acting oral anticoagulants, varying 7.2 percentage points by race/ethnicity (P < .001); initiation was lowest in Hispanic (58.3% [n = 1470]), American Indian/Alaska Native (59.8% [n = 201]), and Black (60.9% [n = 3763]) patients and highest in White patients (66.0% [n = 39 502). Compared with White patients, the odds of initiating any anticoagulant therapy were significantly lower for Asian (adjusted odds ratio [aOR], 0.82; 95% CI, 0.72-0.94) and Black (aOR, 0.90; 95% CI 0.85-0.95) patients. Among initiators, the adjusted odds of direct-acting oral anticoagulant initiation were significantly lower for Hispanic (aOR, 0.79; 95% CI, 0.70-0.89), American Indian/Alaska Native (aOR, 0.75; 95% CI, 0.57-0.99), and Black (aOR, 0.74; 95% CI 0.69-0.80) patients. CONCLUSIONS AND RELEVANCE This cohort study found that in patients with incident atrial fibrillation managed in the VA system, race/ethnicity was independently associated with initiating any anticoagulant therapy and direct-acting oral anticoagulant use among anticoagulant initiators. Understanding the reasons for these treatment disparities is essential to improving equitable atrial fibrillation management and outcomes among racial/ethnic minority patients treated in the VA system.
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Affiliation(s)
- Utibe R Essien
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Nadejda Kim
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Maria K Mor
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Chester B Good
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Centers for Value-Based Pharmacy Initiatives and High-Value Health Care, UPMC Health Plan, Pittsburgh, Pennsylvania
| | - Jared W Magnani
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Terrence M A Litam
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
| | - Walid F Gellad
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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14
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Hernandez SE, Sylling PW, Mor MK, Fine MJ, Nelson KM, Wong ES, Liu CF, Batten AJ, Fihn SD, Hebert PL. Developing an Algorithm for Combining Race and Ethnicity Data Sources in the Veterans Health Administration. Mil Med 2021; 185:e495-e500. [PMID: 31603222 DOI: 10.1093/milmed/usz322] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION Racial/ethnic disparities exist in the Veterans Health Administration (VHA), despite financial barriers to care being largely mitigated and Veterans Administration's (VA) organizational commitment to health equity. Accurately identifying minority veterans is critical to monitoring progress toward equity as the VHA treats an increasingly racially and ethnically diverse veteran population. Although the VHA's completeness of race and ethnicity data is generally better than its public sector and private counterparts, the accuracy of the race and ethnicity in the various databases available to VHA is variable, as is the accuracy in identifying specific minority groups. The purpose of this article was to develop an algorithm for constructing race and ethnicity variables from data sources available to VHA researchers, to present demographic differences cross the data sources, and to apply the algorithm to one study year. MATERIALS AND METHODS We used existing VHA survey data from the Survey of Healthcare Experiences of Patients (SHEP) and three commonly used administrative databases from 2003 to 2015: the VA Corporate Data Warehouse (CDW), VA Defense Identity Repository (VADIR), and Medicare. Using measures of agreement such as sensitivity, specificity, positive and negative predictive values, and Cohen kappa, we compared self-reported race and ethnicity from the SHEP and each of the other data sources. Based on these results, we propose an algorithm for combining data on race and ethnicity from these datasets. We included VHA patients who completed a SHEP and had race/ethnicity recorded in CDW, VADIR, and/or Medicare. RESULTS Agreement between SHEP and other sources was high for Whites and Blacks and substantially lower for other minority groups. The CDW demonstrated better agreement than VADIR or Medicare. CONCLUSIONS We developed an algorithm of data source precedence in the VHA that improves the accuracy of the identification of historically under-identified minorities: (1) SHEP, (2) CDW, (3) Department of Defense's VADIR, and (4) Medicare.
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Affiliation(s)
- Susan E Hernandez
- Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660.,Assessment, Policy Development & Evaluation Unit, Public Health-Seattle & King County, 401 5th Ave, Suite #1300, Seattle, WA 98104
| | - Philip W Sylling
- King County Department of Community and Human Services, Performance Measurement and Evaluation, 401 5th Ave, Suite #500, Seattle, WA 98104
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System University Drive (151C), Pittsburgh, PA 15240.,Biostatistics, Informatics, and Computing Core (BICC), Pittsburgh CHERP, VA Pittsburgh Healthcare System, University Drive (151C), Pittsburgh, PA 15240.,Pitt Public Health, University of Pittsburgh, 130 De Soto Street, Pittsburgh, PA 15261
| | - Michael J Fine
- VA Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System University Drive (151C), Pittsburgh, PA 15240.,Center for Research on Health Care, School of Medicine, University of Pittsburgh, Pittsburgh, PA.,School of Medicine, University of Pittsburgh, Pittsburgh, PA 15213
| | - Karin M Nelson
- PACT Demonstration Laboratory Initiative, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108.,School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195
| | - Edwin S Wong
- Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660.,Health Sciences Research & Development, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108
| | - Chuan-Fen Liu
- Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660.,Health Sciences Research & Development, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108
| | - Adam J Batten
- PACT Demonstration Laboratory Initiative, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108
| | - Stephan D Fihn
- School of Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195.,VHA Office of Clinical Systems Development and Evaluation, 1700 N Wheeling St, Aurora, CO 80045
| | - Paul L Hebert
- Department of Health Services, School of Public Health, University of Washington, 1959 NE Pacific St, Magnuson Health Sciences Center, Room H-680, Box 357660, Seattle, WA 98195-7660.,Health Sciences Research & Development, VA Puget Sound Health Care System, 1660 S. Columbian Way, Seattle, WA 98108
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15
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Liao L, Chung S, Altamirano J, Garcia L, Fassiotto M, Maldonado B, Heidenreich P, Palaniappan L. The association between Asian patient race/ethnicity and lower satisfaction scores. BMC Health Serv Res 2020; 20:678. [PMID: 32698825 PMCID: PMC7374891 DOI: 10.1186/s12913-020-05534-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/13/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patient satisfaction is increasingly being used to assess, and financially reward, provider performance. Previous studies suggest that race/ethnicity (R/E) may impact satisfaction, yet few practices adjust for patient R/E. The objective of this study is to examine R/E differences in patient satisfaction ratings and how these differences impact provider rankings. METHODS Patient satisfaction survey data linked to electronic health records from two large outpatient centers in northern California - a non-profit organization of community-based clinics (Site A) and an academic medical center (Site B) - was collected and analyzed. Participants consisted of adult patients who received outpatient care at Site A from December 2010 to November 2014 and Site B from March 2013 to August 2014, and completed Press-Ganey Medical Practice Survey questionnaires (N = 216,392 (Site A) and 30,690 (Site B)). Self-reported non-Hispanic white (NHW), Black, Latino, and Asian patients were studied. For six questions each representing a survey subdomain, favorable ratings were defined as top-box ("very good") compared to all other categories ("very poor," "poor," "fair," and "good"). Using multivariable logistic regression with provider random effects, we assessed whether the likelihood of giving favorable ratings differed by patient R/E, adjusting for patient age and sex. RESULTS Asian, younger and female patients provided less favorable ratings than other R/E, older and male patients. After adjustment, Asian patients were less likely than NHW patients to provide top-box ratings to the overall assessment question "likelihood of recommending this practice to others" (Site A: Asian predicted probability (PP) 0.680, 95% confidence interval (CI): 0.675-0.685 compared to NHW PP 0.820, 95% CI: 0.818-0.822; Site B: Asian PP 0.734, 95% CI: 0.733-0.736 compared to NHW PP 0.859, 95% CI: 0.859-0.859). The effect sizes for Asian R/E were greater than the effect sizes for older age and female sex. An absolute 3% decrease in mean composite score between providers serving different percentages of Asian patients translated to an absolute 40% drop in national ranking. CONCLUSIONS Patient satisfaction scores may need to be adjusted for patient R/E, particularly for providers caring for high panel percentages of Asian patients.
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Affiliation(s)
- Lillian Liao
- Department of Health Research and Policy, Stanford University School of Medicine, Stanford, USA
- Department of Medicine, Stanford University School of Medicine, Stanford, USA
- Columbia University Vagelos College of Physicians and Surgeons, 50 Haven Avenue Box #B-26, New York, NY10032 USA
| | - Sukyung Chung
- Palo Alto Medical Foundation Research Institute, Palo Alto, USA
| | - Jonathan Altamirano
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, USA
| | - Luis Garcia
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, USA
| | - Magali Fassiotto
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, USA
| | - Bonnie Maldonado
- Office of Faculty Development and Diversity, Stanford University School of Medicine, Stanford, USA
| | - Paul Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, USA
| | - Latha Palaniappan
- Department of Medicine, Stanford University School of Medicine, Stanford, USA
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16
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Jones AL, Kertesz SG, Hausmann LRM, Mor MK, Suo Y, Pettey WBP, Schaefer JH, Gundlapalli AV, Gordon AJ. Primary care experiences of veterans with opioid use disorder in the Veterans Health Administration. J Subst Abuse Treat 2020; 113:107996. [PMID: 32359670 DOI: 10.1016/j.jsat.2020.02.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 01/16/2020] [Accepted: 02/25/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND While patients with substance use disorders (SUDs) are thought to encounter poor primary care experiences, the perspectives of patients with opioid use disorder (OUD), specifically, are unknown. This study compares the primary care experiences of patients with OUD, other SUDs and no SUD in the Veterans Health Administration. METHODS The sample included Veterans who responded to the national Patient-Centered Medical Home Survey of Healthcare Experiences of Patients, 2013-2015. Respondents included 3554 patients with OUD, 36,175 with other SUDs, and 756,386 with no SUD; 742 OUD-diagnosed patients received buprenorphine. Multivariable multinomial logistic regressions estimated differences in the probability of reporting positive and negative experiences (0-100 scale) for patients with OUD, compared to patients with other SUDs and no SUD, and for OUD-diagnosed patients treated versus not treated with buprenorphine. RESULTS Of all domains, patients with OUD reported the least positive experiences with access (31%) and medication decision-making (35%), and the most negative experiences with self-management support (35%) and provider communication (23%). Compared to the other groups, patients diagnosed with OUD reported fewer positive and/or more negative experiences with access, communication, office staff, provider ratings, comprehensiveness, care coordination, and self-management support (adjusted risk differences[aRDs] range from |2.9| to |7.0|). Among OUD-diagnosed patients, buprenorphine was associated with more positive experiences with comprehensiveness (aRD = 8.3) and self-management support (aRD = 7.1), and less negative experiences with care coordination (aRD = -4.9) and medication shared decision-making (aRD = -5.4). CONCLUSIONS In a national sample, patients diagnosed with OUD encounter less positive and more negative experiences than other primary care patients, including those with other SUDs. Buprenorphine treatment relates positively to experiences with care comprehensiveness, medication decisions, and care coordination. As stakeholders encourage more primary care providers to manage OUD, it will be important for healthcare systems to attend to patient access and experiences with care in these settings.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Stefan G Kertesz
- Birmingham VA Medical Center, Birmingham, AL, USA; University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA.
| | - Leslie R M Hausmann
- Center for Health Equity and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
| | - Maria K Mor
- Center for Health Equity and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA; Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA.
| | - Ying Suo
- Informatics, Decision Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Warren B P Pettey
- Informatics, Decision Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - James H Schaefer
- Department of Veterans Affairs Office of Reporting, Analytics, Performance, Improvement and Deployment, Durham, NC, USA.
| | - Adi V Gundlapalli
- Informatics, Decision Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Adam J Gordon
- Informatics, Decision Enhancement and Analytic Sciences Center (IDEAS), VA Salt Lake City Health Care System, Salt Lake City, UT, USA; Division of Epidemiology, Department of Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA; Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT, USA.
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17
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Batten AJ, Augustine MR, Nelson KM, Kaboli PJ. Development of a novel metric of timely care access to primary care services. Health Serv Res 2020; 55:301-309. [PMID: 31943208 DOI: 10.1111/1475-6773.13255] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE To develop a model for identifying clinic performance at fulfilling next-day and walk-in requests after adjusting for patient demographics and risk. DATA SOURCE Using Department of Veterans Affairs (VA) administrative data from 160 VA primary care clinics from 2014 to 2017. STUDY DESIGN Using a retrospective cohort design, we applied Bayesian hierarchical regression models to predict provision of timely care, with clinic-level random intercept and slope while adjusting for patient demographics and risk status. Timely care was defined as the provision of an appointment within 48 hours of any patient requesting the clinic's next available appointment or walking in to receive care. DATA COLLECTION/EXTRACTION METHODS We extracted 1 841 210 timely care requests from 613 263 patients. PRINCIPAL FINDINGS Across 160 primary care clinics, requests for timely care were fulfilled 86 percent of the time (range 83 percent-88 percent). Our model of timely care fit the data well, with a Bayesian R2 of .8. Over the four years of observation, we identified 25 clinics (16 percent) that were either struggling or excelling at providing timely care. CONCLUSION Statistical models of timely care allow for identification of clinics in need of improvement after adjusting for patient demographics and risk status. VA primary care clinics fulfilled 86 percent of timely care requests.
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Affiliation(s)
- Adam J Batten
- Primary Care Analytics Team, Veterans Health Administration, Seattle, Washington
| | - Matthew R Augustine
- Department of Medicine, James J Peters VA Medical Center, Bronx, New York.,Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Karin M Nelson
- Primary Care Analytics Team, Veterans Health Administration, Seattle, Washington.,Department of Medicine, VA Puget Sound Healthcare System, Seattle, Washington.,Department of Medicine, University of Washington, Seattle, Washington
| | - Peter J Kaboli
- Veterans Rural Health Resource Center-Iowa City, VA Office of Rural Health and Center for Access and Delivery Research and Evaluation (CADRE), Iowa City VA Healthcare System, Iowa City, Iowa.,Department of Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa
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How Are Patients Accessing Primary Care Within the Patient-Centered Medical Home? Results From the Veterans Health Administration. J Ambul Care Manage 2019; 41:194-203. [PMID: 29847406 DOI: 10.1097/jac.0000000000000241] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The patient-centered medical home (PCMH) expands access by providing care same-day, by phone, and after hours; however, little is known about which patients seek these services. We examined the association of patient, clinical, and local economic characteristics with the self-reported use of 5 routine and nonroutine ways to access primary care within the Veterans Health Administration. We identified sets of characteristics, including gender- and age-specific, racial and ethnic, and socioeconomic differences of how veterans report seeking primary care. As the PCMH model develops, it will be important to further understand the differential demand for these services to optimize patient-centered access.
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19
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Patient-Reported Access in the Patient-Centered Medical Home and Avoidable Hospitalizations: an Observational Analysis of the Veterans Health Administration. J Gen Intern Med 2019; 34:1546-1553. [PMID: 31161568 PMCID: PMC6667567 DOI: 10.1007/s11606-019-05060-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Revised: 11/27/2018] [Accepted: 03/27/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The Patient-Centered Medical Home (PCMH) has emphasized timely access to primary care, often by using non-traditional modes of delivery, such as care in person after-hours or by phone during or after normal hours. Limited data exists on whether improving patient-reported access with these service types reduces hospitalization. OBJECTIVE To examine the association of patient-reported access to primary care within the Veteran Health Administration (VHA) via five service types and hospitalizations for ambulatory care sensitive conditions (ACSCs). DESIGN Retrospective cohort study, using multivariable logistic regression adjusting for patient demographics, comorbidity, characteristics of patients' area of residence, and clinic-level random effects. PARTICIPANTS A total of 69,710 VHA primary care patients who responded to the 2012 Survey of Healthcare Experiences of Patients (SHEP), PCMH module. MAIN MEASURES Survey questions captured patients' ability to obtain care from VHA for five service types: routine care, immediate care, after-hours care, care by phone during regular office hours, and care by phone after normal hours. Outcomes included binary measures of hospitalization for overall, acute, and chronic ACSCs in 2013, identified in VHA administrative data and Medicare fee-for-service claims. KEY RESULTS Patients who reported "always" able to obtain after-hours care compared to "never" were less likely to be hospitalized for chronic ACSCs (OR 0.62, 95% CI 0.44-0.89, p = 0.009). Patients reporting "usually" getting care by phone during regular hours were more likely have a hospitalization for chronic ACSC (OR 1.49, 95% CI 1.03-2.17, p = 0.034). Experiences with routine care, immediate care, and care by phone after-hours demonstrated no significant association with hospitalization for ACSCs. CONCLUSIONS Improving patients' ability to obtain after-hours care was associated with fewer hospitalizations for chronic ACSCs, while access to care by phone during regular hours was associated with more hospitalizations. Health systems should consider the benefits, including reduced hospitalizations for chronic ACSCs, against the costs of implementing each of these PCMH services.
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20
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Chung S, Huang Q, LaMori J, Doshi D, Romanelli RJ. Patient-Reported Experiences in Discussing Prescribed Medications with a Health Care Provider: Evidence for Racial/Ethnic Disparities in a Large Health Care Delivery System. Popul Health Manag 2019; 23:78-84. [PMID: 31013464 DOI: 10.1089/pop.2018.0206] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
The objective was to understand patient-reported experiences in communicating with a health care provider about prescribed medications in a health care setting serving diverse racial/ethnic groups. Adult patients who completed a patient-experience survey and received a prescription for a hypertension, hyperlipidemia, or diabetes medication at the surveyed encounter were studied (N = 19,006). Data were collected in a large mixed-payer outpatient health care system in northern California between 2011 and 2014. Surveys were linked to the electronic health records of the office visit to which the survey refers, with detailed information on visit content, provider, and patient characteristics. The focus was on 2 survey questions asking about providers' efforts to include patients in treatment decisions and the information received about medications. Logistic regression was used to assess factors associated with survey responses, which were dichotomized as very good or not (ie, good, fair, poor, very poor). Chinese (OR: 0.59; 95% CI: 0.50-0.70), Asian Indians (0.68; 0.54-0.84), Japanese (0.74; 0.57-0.98), Koreans (0.46; 0.25-0.83), Vietnamese (0.51; 0.27-0.98), and African Americans (0.74; 0.55-0.99) vs. non-Hispanic whites (NHWs) reported poorer experiences of involvement in treatment decisions. Similarly, Chinese (0.59; 0.49-0.70), Asian Indians (0.67; 0.54-0.83), Koreans (0.38; 0.21-0.70), Vietnamese (0.46; 0.25-0.87), African Americans (0.65; 0.49-0.87), and Mexicans (0.77; 0.61-0.98) vs. NHWs reported poorer experiences for information received about medications. Almost all racial/ethnic groups report poorer experiences with involvement in treatment decisions and information received about medications than NHWs in the same clinical setting, which may contribute to poorer adherence and outcomes among racial/ethnic minority groups.
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Affiliation(s)
- Sukyung Chung
- Palo Alto Medical Foundation Research Institute, Sutter Health, Palo Alto, California
| | - Qiwen Huang
- Palo Alto Medical Foundation Research Institute, Sutter Health, Palo Alto, California
| | - Joyce LaMori
- Janssen Scientific Affairs, LLC, Titusville, New Jersey
| | - Dilesh Doshi
- Janssen Scientific Affairs, LLC, Titusville, New Jersey
| | - Robert J Romanelli
- Palo Alto Medical Foundation Research Institute, Sutter Health, Palo Alto, California
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21
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Jones AL, Hausmann LRM, Kertesz SG, Suo Y, Cashy JP, Mor MK, Pettey WBP, Schaefer JH, Gordon AJ, Gundlapalli AV. Providing Positive Primary Care Experiences for Homeless Veterans Through Tailored Medical Homes: The Veterans Health Administration's Homeless Patient Aligned Care Teams. Med Care 2019; 57:270-278. [PMID: 30789541 PMCID: PMC7773035 DOI: 10.1097/mlr.0000000000001070] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND In 2012, select Veterans Health Administration (VHA) facilities implemented a homeless-tailored medical home model, called Homeless Patient Aligned Care Teams (H-PACT), to improve care processes and outcomes for homeless Veterans. OBJECTIVE The main aim of this study was to determine whether H-PACT offers a better patient experience than standard VHA primary care. RESEARCH DESIGN We used multivariable logistic regressions to estimate differences in the probability of reporting positive primary care experiences on a national survey. SUBJECTS Homeless-experienced survey respondents enrolled in H-PACT (n=251) or standard primary care in facilities with H-PACT available (n=1527) and facilities without H-PACT (n=10,079). MEASURES Patient experiences in 8 domains from the Consumer Assessment of Healthcare Provider and Systems surveys. Domain scores were categorized as positive versus nonpositive. RESULTS H-PACT patients were less likely than standard primary care patients to be female, have 4-year college degrees, or to have served in recent military conflicts; they received more primary care visits and social services. H-PACT patients were more likely than standard primary care patients in the same facilities to report positive experiences with access [adjusted risk difference (RD)=17.4], communication (RD=13.9), office staff (RD=13.1), provider ratings (RD=11.0), and comprehensiveness (RD=9.3). Standard primary care patients in facilities with H-PACT available were more likely than those from facilities without H-PACT to report positive experiences with communication (RD=4.7) and self-management support (RD=4.6). CONCLUSIONS Patient-centered medical homes designed to address the social determinants of health offer a better care experience for homeless patients, when compared with standard primary care approaches. The lessons learned from H-PACT can be applied throughout VHA and to other health care settings.
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Affiliation(s)
- Audrey L. Jones
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - Leslie R. M. Hausmann
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Stefan G. Kertesz
- Birmingham VA Medical Center, Birmingham, AL; and Department of Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL
| | - Ying Suo
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - John P. Cashy
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
| | - Maria K. Mor
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA
| | - Warren B. P. Pettey
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
| | - James H. Schaefer
- Department of Veterans Affairs Office of Reporting, Analytics, Performance, Improvement and Deployment, Durham, NC
| | - Adam J. Gordon
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
- Department of Psychiatry, University of Utah School of Medicine, Salt Lake City, UT
| | - Adi V. Gundlapalli
- Informatics, Decision-Enhancement and Analytic Sciences (IDEAS 2.0) Center, Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT; and Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT
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22
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Differences in Experiences With Care Between Homeless and Nonhomeless Patients in Veterans Affairs Facilities With Tailored and Nontailored Primary Care Teams. Med Care 2019; 56:610-618. [PMID: 29762272 DOI: 10.1097/mlr.0000000000000926] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Homeless patients describe poor experiences with primary care. In 2012, the Veterans Health Administration (VHA) implemented homeless-tailored primary care teams (Homeless Patient Aligned Care Team, HPACTs) that could improve the primary care experience for homeless patients. OBJECTIVE To assess differences in primary care experiences between homeless and nonhomeless Veterans receiving care in VHA facilities that had HPACTs available (HPACT facilities) and in VHA facilities lacking HPACTs (non-HPACT facilities). RESEARCH DESIGN We used multivariable multinomial regressions to estimate homeless versus nonhomeless patient differences in primary care experiences (categorized as negative/moderate/positive) reported on a national VHA survey. We compared the homeless versus nonhomeless risk differences (RDs) in reporting negative or positive experiences in 25 HPACT facilities versus 485 non-HPACT facilities. SUBJECTS Survey respondents from non-HPACT facilities (homeless: n=10,148; nonhomeless: n=309,779) and HPACT facilities (homeless: n=2022; nonhomeless: n=20,941). MEASURES Negative and positive experiences with access, communication, office staff, provider rating, comprehensiveness, coordination, shared decision-making, and self-management support. RESULTS In non-HPACT facilities, homeless patients reported more negative and fewer positive experiences than nonhomeless patients. However, these patterns of homeless versus nonhomeless differences were reversed in HPACT facilities for the domains of communication (positive experience RDs in non-HPACT versus HPACT facilities=-2.0 and 2.0, respectively); comprehensiveness (negative RDs=2.1 and -2.3), shared decision-making (negative RDs=1.2 and -1.8), and self-management support (negative RDs=0.1 and -4.5; positive RDs=0.5 and 8.0). CONCLUSIONS VHA facilities with HPACT programs appear to offer a better primary care experience for homeless versus nonhomeless Veterans, reversing the pattern of relatively poor primary care experiences often associated with homelessness.
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23
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Martino SC, Mathews M, Agniel D, Orr N, Wilson‐Frederick S, Ng JH, Ormson AE, Elliott MN. National racial/ethnic and geographic disparities in experiences with health care among adult Medicaid beneficiaries. Health Serv Res 2019; 54 Suppl 1:287-296. [PMID: 30628052 PMCID: PMC6341217 DOI: 10.1111/1475-6773.13106] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To investigate whether health care experiences of adult Medicaid beneficiaries differ by race/ethnicity and rural/urban status. DATA SOURCES A total of 270 243 respondents to the 2014-2015 Nationwide Adult Medicaid Consumer Assessment of Healthcare Providers and Systems Survey. STUDY DESIGN Linear regression was used to estimate case mix adjusted differences in patient experience between racial/ethnic minority and non-Hispanic white Medicaid beneficiaries, and between beneficiaries residing in small urban areas, small towns, and rural areas vs large urban areas. Dependent measures included getting needed care, getting care quickly, doctor communication, and customer service. PRINCIPAL FINDINGS Compared with white beneficiaries, American Indian/Alaska Native (AIAN) and Asian/Pacific Islander (API) beneficiaries reported worse experiences, while black beneficiaries reported better experiences. Deficits for AIAN beneficiaries were 6-8 points on a 0-100 scale; deficits for API beneficiaries were 13-22 points (P's < 0.001); advantages for black beneficiaries were 3-5 points (P's < 0.001). Hispanic white differences were mixed. Beneficiaries in small urban areas, small towns, and isolated rural areas reported significantly better experiences (2-3 points) than beneficiaries in large urban areas (P's < 0.05), particularly regarding access to care. Racial/ethnic differences typically did not vary by geography. CONCLUSIONS Improving experiences for racial/ethnic minorities and individuals living in large urban areas should be high priorities for policy makers exploring approaches to improve the value and delivery of care to Medicaid beneficiaries.
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Affiliation(s)
| | | | | | - Nate Orr
- RAND CorporationSanta MonicaCalifornia
| | | | - Judy H. Ng
- National Committee for Quality AssuranceWashingtonDistrict of Columbia
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Chung S, Mujal G, Liang L, Palaniappan LP, Frosch DL. Racial/ethnic differences in reporting versus rating of healthcare experiences. Medicine (Baltimore) 2018; 97:e13604. [PMID: 30558033 PMCID: PMC6320096 DOI: 10.1097/md.0000000000013604] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Asians are reported to have poorer healthcare experience than non-Hispanic Whites (NHWs), but the sources of the differences are not understood. One explanation is Asian's reluctance to choose extreme responses in survey. We thus sought to compare NHW-Asian differences in responses to healthcare experience surveys when asked to report versus rate their experiences. Patients of an outpatient care system in 2013 to 2014 in the United States were studied. Patient experience surveys were sent after randomly selected clinic visits. Responses from 6 major Asian subgroups and NHWs were included (N = 61,115). The surveys used a combined questionnaire of Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) and Press Ganey surveys. CG-CAHPS questions are framed as "reporting" and Press Ganey questions as "rating" of experiences. We compared the proportion of favorable (or top box) responses to 2 related questions, one from CG-CAHPS and another from Press Ganey, and assessed racial/ethnic differences when using each of the 2 related questions, using a Pearson chi-squared test for independence. All Asian subgroups were less likely to select top box than NHWs for all questions. The Asian-NHW differences in 'rating" questions were larger than the difference in related "reporting" questions. Of those who chose top box to CG-CAHPS questions (e.g., "Yes" on a question asking "Waited < 15 minutes"), their responses to related Press Ganey questions varied widely: 47% to 57% of Asian subgroups versus 67% of NHWs rated wait time as "Very good." The extent of racial/ethnic differences in patient-reported experiences varies based on how questions are framed. The observed poorer experiences by Asians are in part explained by their worse rating of similar objectively measurable experiences.
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Affiliation(s)
- Sukyung Chung
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | - Gabriella Mujal
- Department of Health Administration, Saint Louis University, St Louis, MO
| | - Lily Liang
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA
| | | | - Dominick L. Frosch
- Palo Alto Medical Foundation Research Institute, Palo Alto, CA
- Department of Medicine, University of California Los Angeles, Los Angeles, CA
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25
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Jackson GL, Stechuchak KM, Weinberger M, Bosworth HB, Coffman CJ, Kirshner MA, Edelman D. How Views of the Organization of Primary Care Among Patients with Hypertension Vary by Race or Ethnicity. Mil Med 2018; 183:e583-e588. [PMID: 29672720 DOI: 10.1093/milmed/usx111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION We assessed potential racial or ethnic differences in the degree to which veterans with pharmaceutically treated hypertension report experiences with their primary care system that are consistent with optimal chronic illness care as suggested by Wagner's Chronic Care Model (CCM). MATERIALS AND METHODS A cross-sectional analysis of the results of the Patient Assessment of Chronic Illness Care (PACIC), which measured components of the care system suggested by the CCM and was completed at baseline by participants in a hypertension disease management clinical trial. Participants had a recent history of uncontrolled systolic blood pressure. RESULTS Among 377 patients, non-Hispanic African American veterans had almost twice the odds of indicating that their primary care experience is consistent with CCM features when compared with non-Hispanic White patients (odds ratio (OR) = 1.86; 95% confidence interval (CI) = 1.16-2.98). Similar statistically significant associations were observed for follow-up care (OR = 2.59; 95% CI = 1.49-4.50), patient activation (OR = 1.80; 95% CI = 1.13-2.87), goal setting (OR = 1.65; 95% CI = 1.03-2.64), and help with problem solving (OR = 1.62; 95% CI = 1.00-2.60). CONCLUSIONS Non-Hispanic African Americans with pharmaceutically treated hypertension report that the primary care system more closely approximates the Wagner CCM than non-Hispanic White patients.
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Affiliation(s)
- George L Jackson
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Karen M Stechuchak
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC
| | - Morris Weinberger
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC.,Department of Health Policy and Management, University of North Carolina at Chapel Hill, CB #7411, Chapel Hill, NC
| | - Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC.,Department of Population Health Sciences, Duke University School of Medicine, Durham, NC.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Cynthia J Coffman
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC.,Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Miriam A Kirshner
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC
| | - David Edelman
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, 508 Fulton St., Durham, NC.,Division of General Internal Medicine, Duke University School of Medicine, Durham, NC
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Jones AL, Mor MK, Haas GL, Gordon AJ, Cashy JP, Schaefer JH, Hausmann LRM. The Role of Primary Care Experiences in Obtaining Treatment for Depression. J Gen Intern Med 2018; 33:1366-1373. [PMID: 29948804 PMCID: PMC6082202 DOI: 10.1007/s11606-018-4522-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Revised: 04/03/2018] [Accepted: 05/24/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Managing depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown. OBJECTIVE In a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression. DESIGN AND PARTICIPANTS We conducted a lagged cross-sectional study of depression treatment among Veterans with depression diagnoses (n = 27,362) in the years before (Y1) and after (Y2) they completed the Veterans Health Administration's national 2013 PCMH Survey of Healthcare Experiences of Patients. MAIN MEASURES We assessed patient experiences in four domains, each categorized as positive/moderate/negative. Depression treatment, determined from administrative records, was defined annually as 90 days of antidepressant medications or six psychotherapy visits. Multivariable logistic regressions measured associations between PCMH experiences and receipt of depression treatment in Y2, accounting for treatment in Y1. KEY RESULTS Among those who did not receive depression treatment in Y1 (n = 4613), positive experiences in three domains (comprehensiveness, shared decision-making, self-management support) predicted greater initiation of treatment in Y2. Among those who received depression treatment in Y1 (n = 22,749), positive or moderate experiences in four domains (comprehensiveness, care coordination, medication decision-making, self-management support) predicted greater continuation of treatment in Y2. CONCLUSIONS In a national PCMH setting, patient experiences with integrated care, including care coordination, comprehensiveness, involvement in shared decision-making, and self-management support predicted patients' subsequent initiation and continuation of depression treatment over time-a relationship that could affect physical and mental health outcomes.
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Affiliation(s)
- Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation (IDEAS 2.0), Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA.
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Maria K Mor
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Gretchen L Haas
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- VISN4 Mental Illness Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Adam J Gordon
- Informatics, Decision-Enhancement and Analytic Sciences Center of Innovation (IDEAS 2.0), Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT, USA
- Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - John P Cashy
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - James H Schaefer
- Department of Veterans Affairs Office of Reporting, Analytics, Performance, Improvement and Deployment, Durham, NC, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Bailey C, Sattar Z, Akhtar P. Older south Asian women sharing their perceptions of health and social care services and support: A participatory inquiry. Health Sci Rep 2018; 1:e55. [PMID: 30623091 PMCID: PMC6266364 DOI: 10.1002/hsr2.55] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/16/2018] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The needs of older people in Black Minority and Ethnic (BAME) communities require culturally appropriate services provision, but little is known about how BAME older people support themselves and others, what they perceive to be their "needs", and, critically, the extent to which they feel such needs are being appropriately met. OBJECTIVE To enable older women from a BAME community to work with health and social care professionals and organisations, to support independent living. METHODS In 2016, all 15 members of a BAME older women's social group attached to a Women's Centre in the North East of England, approached the research team to support achieving this objective. They did not wish to be co-researchers. A collaborative participatory inquiry was carried out. The research team and the older social group designed, together, 4 workshops that explored (1) health and well-being; (2) home and housing; and (3) services and support. There was also an evaluative session with stakeholders, and the research team managed research processes. FINDINGS Most of the women described living with mobility and health challenges requiring change and adaptation. Language and literacy might be barriers to building confidential professional relationships with primary care professionals. The women emphasised needing a "little bit of help" in the home, that is affordable, culturally appropriate, and on their terms. They stressed such help would make them less reliant on busy family members and restore status, purpose, and standing. CONCLUSION Findings do not address all BAME older people's needs. They do, however, have implications for how health and social care services can work with older people from BAME communities, to promote and maintain meaningful independence, on their terms.
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Affiliation(s)
- Cathy Bailey
- Health and Life SciencesNorthumbria UniversityUK
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28
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Jones AL, Hausmann LRM, Haas GL, Mor MK, Cashy JP, Schaefer JH, Gordon AJ. A national evaluation of homeless and nonhomeless veterans' experiences with primary care. Psychol Serv 2018; 14:174-183. [PMID: 28481602 DOI: 10.1037/ser0000116] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Persons who are homeless, particularly those with mental health and/or substance use disorders (MHSUDs), often do not access or receive continuous primary care services. In addition, negative experiences with primary care might contribute to homeless persons' avoidance and early termination of MHSUD treatment. The patient-centered medical home (PCMH) model aims to address care fragmentation and improve patient experiences. How homeless persons with MHSUDs experience care within PCMHs is unknown. This study compared the primary care experiences of homeless and nonhomeless veterans with MHSUDs receiving care in the Veterans Health Administration's medical home environment, called Patient Aligned Care Teams. The sample included VHA outpatients who responded to the national 2013 PCMH-Survey of Health Care Experiences of Patients (PCMH-SHEP) and had a past-year MSHUD diagnosis. Veterans with evidence of homelessness (henceforth "homeless") were identified through VHA administrative records. PCMH-SHEP survey respondents included 67,666 veterans with MHSUDs (9.2% homeless). Compared with their nonhomeless counterparts, homeless veterans were younger, more likely to be non-Hispanic Black and nonmarried, had less education, and were more likely to live in urban areas. Homeless veterans had elevated rates of most MHSUDs assessed, indicating significant co-occurrence. After controlling for these differences, homeless veterans reported more negative and fewer positive experiences with communication; more negative provider ratings; and more negative experiences with comprehensiveness, care coordination, medication decision-making, and self-management support than nonhomeless veterans. Homeless persons with MHSUDs may need specific services that mitigate negative care experiences and encourage their continuation in longitudinal primary care services. (PsycINFO Database Record
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Affiliation(s)
- Audrey L Jones
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - Leslie R M Hausmann
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - Gretchen L Haas
- VISN 4 Mental Illness Research, Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - John P Cashy
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System
| | - James H Schaefer
- Department of Veterans Affairs Office of Analytics and Business Intelligence
| | - Adam J Gordon
- VA Center for Health Equity Research and Promotion, VISN4 Mental Illness Research, Education and Clinical Center, Veterans Affairs Pittsburgh Healthcare System
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Zickmund SL, Burkitt KH, Gao S, Stone RA, Jones AL, Hausmann LRM, Switzer GE, Borrero S, Rodriguez KL, Fine MJ. Racial, Ethnic, and Gender Equity in Veteran Satisfaction with Health Care in the Veterans Affairs Health Care System. J Gen Intern Med 2018; 33:305-331. [PMID: 29313226 PMCID: PMC5834960 DOI: 10.1007/s11606-017-4221-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Revised: 10/05/2017] [Accepted: 11/02/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patient satisfaction is an important dimension of health care quality. The Veterans Health Administration (VA) is committed to providing high-quality care to an increasingly diverse patient population. OBJECTIVE To assess Veteran satisfaction with VA health care by race/ethnicity and gender. DESIGN AND PARTICIPANTS We conducted semi-structured telephone interviews with gender-specific stratified samples of black, white, and Hispanic Veterans from 25 predominantly minority-serving VA Medical Centers from June 2013 to January 2015. MAIN MEASURES Satisfaction with health care was assessed in 16 domains using five-point Likert scales. We compared the proportions of Veterans who were very satisfied, somewhat satisfied, and less than satisfied (i.e., neither satisfied nor dissatisfied, somewhat dissatisfied, or very dissatisfied) in each domain, and used random-effects multinomial regression to estimate racial/ethnic differences by gender and gender differences by race/ethnicity. KEY RESULTS Interviews were completed for 1222 of the 1929 Veterans known to be eligible for the interview (63.3%), including 421 white, 389 black, and 396 Hispanic Veterans, 616 of whom were female. Veterans were less likely to be somewhat satisfied or less than satisfied versus very satisfied with care in each of the 16 domains. The highest satisfaction ratings were reported for costs, outpatient facilities, and pharmacy (74-76% very satisfied); the lowest ratings were reported for access, pain management, and mental health care (21-24% less than satisfied). None of the joint tests of racial/ethnic or gender differences in satisfaction (simultaneously comparing all three satisfaction levels) was statistically significant (p > 0.05). Pairwise comparisons of specific levels of satisfaction revealed racial/ethnic differences by gender in three domains and gender differences by race/ethnicity in five domains, with no consistent directionality across demographic subgroups. CONCLUSIONS Our multisite interviews of a diverse sample of Veterans at primarily minority-serving sites showed generally high levels of health care satisfaction across 16 domains, with few quantitative differences by race/ethnicity or gender.
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Affiliation(s)
- Susan L Zickmund
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), VA Salt Lake City Health Care System, Salt Lake City, UT, USA. .,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA.
| | - Kelly H Burkitt
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Shasha Gao
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Roslyn A Stone
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Audrey L Jones
- Informatics, Decision-Enhancement and Analytic Sciences Center (IDEAS 2.0), VA Salt Lake City Health Care System, Salt Lake City, UT, USA.,Division of Epidemiology, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Leslie R M Hausmann
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Galen E Switzer
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Sonya Borrero
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Keri L Rodriguez
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael J Fine
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA.,Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Kimerling R, Pavao J, Wong A. Patient Activation and Mental Health Care Experiences Among Women Veterans. ADMINISTRATION AND POLICY IN MENTAL HEALTH AND MENTAL HEALTH SERVICES RESEARCH 2018; 43:506-13. [PMID: 25917224 DOI: 10.1007/s10488-015-0653-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
We utilized a nationally representative survey of women veteran primary care users to examine associations between patient activation and mental health care experiences. A dose-response relationship was observed, with odds of high quality ratings significantly greater at each successive level of patient activation. Higher activation levels were also significantly associated with preference concordant care for gender-related preferences (use of female providers, women-only settings, and women-only groups as often as desired). Results add to the growing literature documenting better health care experiences among more activated patients, and suggest that patient activation may play an important role in promoting engagement with mental health care.
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Affiliation(s)
- Rachel Kimerling
- National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, PTSD-324, Menlo Park, CA, 94025, USA. .,Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152 MPD), Menlo Park, CA, 94025, USA.
| | - Joanne Pavao
- National Center for PTSD, VA Palo Alto Health Care System, 795 Willow Road, PTSD-324, Menlo Park, CA, 94025, USA
| | - Ava Wong
- Center for Innovation to Implementation, VA Palo Alto Health Care System, 795 Willow Road (152 MPD), Menlo Park, CA, 94025, USA
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Chen LM, Epstein AM, Orav EJ, Filice CE, Samson LW, Joynt Maddox KE. Association of Practice-Level Social and Medical Risk With Performance in the Medicare Physician Value-Based Payment Modifier Program. JAMA 2017; 318:453-461. [PMID: 28763549 PMCID: PMC5817610 DOI: 10.1001/jama.2017.9643] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
IMPORTANCE Medicare recently launched the Physician Value-Based Payment Modifier (PVBM) Program, a mandatory pay-for-performance program for physician practices. Little is known about performance by practices that serve socially or medically high-risk patients. OBJECTIVE To compare performance in the PVBM Program by practice characteristics. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional observational study using PVBM Program data for payments made in 2015 based on performance of large US physician practices caring for fee-for-service Medicare beneficiaries in 2013. EXPOSURES High social risk (defined as practices in the top quartile of proportion of patients dually eligible for Medicare and Medicaid) and high medical risk (defined as practices in the top quartile of mean Hierarchical Condition Category risk score among fee-for-service beneficiaries). MAIN OUTCOMES AND MEASURES Quality and cost z scores based on a composite of individual measures. Higher z scores reflect better performance on quality; lower scores, better performance on costs. RESULTS Among 899 physician practices with 5 189 880 beneficiaries, 547 practices were categorized as low risk (neither high social nor high medical risk) (mean, 7909 beneficiaries; mean, 320 clinicians), 128 were high medical risk only (mean, 3675 beneficiaries; mean, 370 clinicians), 102 were high social risk only (mean, 1635 beneficiaries; mean, 284 clinicians), and 122 were high medical and social risk (mean, 1858 beneficiaries; mean, 269 clinicians). Practices categorized as low risk performed the best on the composite quality score (z score, 0.18 [95% CI, 0.09 to 0.28]) compared with each of the practices categorized as high risk (high medical risk only: z score, -0.55 [95% CI, -0.77 to -0.32]; high social risk only: z score, -0.86 [95% CI, -1.17 to -0.54]; and high medical and social risk: -0.78 [95% CI, -1.04 to -0.51]) (P < .001 across groups). Practices categorized as high social risk only performed the best on the composite cost score (z score, -0.52 [95% CI, -0.71 to -0.33]), low risk had the next best cost score (z score, -0.18 [95% CI, -0.25 to -0.10]), then high medical and social risk (z score, 0.40 [95% CI, 0.23 to 0.57]), and then high medical risk only (z score, 0.82 [95% CI, 0.65 to 0.99]) (P < .001 across groups). Total per capita costs were $9506 for practices categorized as low risk, $13 683 for high medical risk only, $8214 for high social risk only, and $11 692 for high medical and social risk. These patterns were associated with fewer bonuses and more penalties for high-risk practices. CONCLUSIONS AND RELEVANCE During the first year of the Medicare Physician Value-Based Payment Modifier Program, physician practices that served more socially high-risk patients had lower quality and lower costs, and practices that served more medically high-risk patients had lower quality and higher costs.
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Affiliation(s)
- Lena M. Chen
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
- Center for Healthcare Outcomes and Policy, University of Michigan, Ann Arbor
- Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, Washington, DC
| | - Arnold M. Epstein
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Clara E. Filice
- Atrius Health, Newton, Massachusetts
- Now with Commonwealth Medicine, University of Massachusetts Medical School, Shrewsbury
| | - Lok Wong Samson
- Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, Washington, DC
| | - Karen E. Joynt Maddox
- Office of the Assistant Secretary for Planning and Evaluation, US Department of Health and Human Services, Washington, DC
- Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Now with Washington University School of Medicine, St Louis, Missouri
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Hausmann LR, Canamucio A, Gao S, Jones AL, Keddem S, Long JA, Werner R. Racial and Ethnic Minority Concentration in Veterans Affairs Facilities and Delivery of Patient-Centered Primary Care. Popul Health Manag 2017; 20:189-198. [DOI: 10.1089/pop.2016.0053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Leslie R.M. Hausmann
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion (CHERP), Pittsburgh, Pennsylvania
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Anne Canamucio
- Veterans Integrated Service Network 4 Center to Evaluate Patient Aligned Care Teams (CEPACT), Philadelphia, Pennsylvania
| | - Shasha Gao
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion (CHERP), Pittsburgh, Pennsylvania
| | - Audrey L. Jones
- Veterans Affairs Pittsburgh Healthcare System, Center for Health Equity Research and Promotion (CHERP), Pittsburgh, Pennsylvania
| | - Shimrit Keddem
- Veterans Integrated Service Network 4 Center to Evaluate Patient Aligned Care Teams (CEPACT), Philadelphia, Pennsylvania
| | - Judith A. Long
- Veterans Integrated Service Network 4 Center to Evaluate Patient Aligned Care Teams (CEPACT), Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Center for Health Equity Research and Promotion (CHERP), Philadelphia, Pennsylvania
- Divison of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Rachel Werner
- Veterans Integrated Service Network 4 Center to Evaluate Patient Aligned Care Teams (CEPACT), Philadelphia, Pennsylvania
- Corporal Michael J. Crescenz Veterans Affairs Medical Center, Center for Health Equity Research and Promotion (CHERP), Philadelphia, Pennsylvania
- Divison of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Jones AL, Mor MK, Cashy JP, Gordon AJ, Haas GL, Schaefer JH, Hausmann LRM. Racial/Ethnic Differences in Primary Care Experiences in Patient-Centered Medical Homes among Veterans with Mental Health and Substance Use Disorders. J Gen Intern Med 2016; 31:1435-1443. [PMID: 27325318 PMCID: PMC5130946 DOI: 10.1007/s11606-016-3776-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2016] [Revised: 05/12/2016] [Accepted: 06/07/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Patient-Centered Medical Homes (PCMH) may be effective in managing care for racial/ethnic minorities with mental health and/or substance use disorders (MHSUDs). How such patients experience care in PCMH settings is relatively unknown. OBJECTIVE We aimed to examine racial/ethnic differences in experiences with primary care in PCMH settings among Veterans with MHSUDs. DESIGN We used multinomial regression methods to estimate racial/ethnic differences in PCMH experiences reported on a 2013 national survey of Veterans Affairs patients. PARTICPANTS Veterans with past-year MHSUD diagnoses (n = 65,930; 67 % White, 20 % Black, 11 % Hispanic, 1 % American Indian/Alaska Native[AI/AN], and 1 % Asian/Pacific Island[A/PI]). MAIN MEASURES Positive and negative experiences from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) PCMH Survey. RESULTS Veterans with MHSUDs reported the lowest frequency of positive experiences with access (22 %) and the highest frequency of negative experiences with self-management support (30 %) and comprehensiveness (16 %). Racial/ethnic differences (as compared to Whites) were observed in all seven healthcare domains (p values < 0.05). With access, Blacks and Hispanics reported more negative (Risk Differences [RDs] = 2 .0;3.6) and fewer positive (RDs = -2 .3;-2.3) experiences, while AI/ANs reported more negative experiences (RD = 5.7). In communication, Blacks reported fewer negative experiences (RD = -1.3); AI/ANs reported more negative (RD = 3.6) experiences; and AI/ANs and APIs reported fewer positive (RD = -6.5, -6.7) experiences. With office staff, Hispanics reported fewer positive experiences (RDs = -3.0); AI/ANs and A/PIs reported more negative experiences (RDs = 3.4; 3.7). For comprehensiveness, Blacks reported more positive experiences (RD = 3.6), and Hispanics reported more negative experiences (RD = 2.7). Both Blacks and Hispanics reported more positive (RDs = 2.3; 4.2) and fewer negative (RDs = -1.8; -1.9) provider ratings, and more positive experiences with decision making (RDs = 2.4; 3.0). Blacks reported more positive (RD = 3.9) and fewer negative (RD = -5.1) experiences with self-management support. CONCLUSIONS In a national sample of Veterans with MHSUDs, potential deficiencies were observed in access, self-management support, and comprehensiveness. Racial/ethnic minorities reported worse experiences than Whites with access, comprehensiveness, communication, and office staff helpfulness/courtesy.
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Affiliation(s)
- Audrey L Jones
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA.
- Center for Health Equity Research and Promotion (CHERP), VA Pittsburgh Healthcare System, University Drive (151C), Building 30, Pittsburgh, PA, 15240-1001, USA.
| | - Maria K Mor
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - John P Cashy
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Adam J Gordon
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Gretchen L Haas
- VISN4 Mental Illness Research, Education, and Clinical Center, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - James H Schaefer
- Department of Veterans Affairs Office of Analytics and Business Intelligence, Durham, NC, USA
| | - Leslie R M Hausmann
- VA Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
- Division of General Internal Medicine, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Jackson GL, Weinberger M, Kirshner MA, Stechuchak KM, Melnyk SD, Bosworth HB, Coffman CJ, Neelon B, Van Houtven C, Gentry PW, Morris IJ, Rose CM, Taylor JP, May CL, Han B, Wainwright C, Alkon A, Powell L, Edelman D. Open-label randomized trial of titrated disease management for patients with hypertension: Study design and baseline sample characteristics. Contemp Clin Trials 2016; 50:5-15. [PMID: 27417982 PMCID: PMC5035600 DOI: 10.1016/j.cct.2016.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Revised: 07/06/2016] [Accepted: 07/10/2016] [Indexed: 01/21/2023]
Abstract
Despite the availability of efficacious treatments, only half of patients with hypertension achieve adequate blood pressure (BP) control. This paper describes the protocol and baseline subject characteristics of a 2-arm, 18-month randomized clinical trial of titrated disease management (TDM) for patients with pharmaceutically-treated hypertension for whom systolic blood pressure (SBP) is not controlled (≥140mmHg for non-diabetic or ≥130mmHg for diabetic patients). The trial is being conducted among patients of four clinic locations associated with a Veterans Affairs Medical Center. An intervention arm has a TDM strategy in which patients' hypertension control at baseline, 6, and 12months determines the resource intensity of disease management. Intensity levels include: a low-intensity strategy utilizing a licensed practical nurse to provide bi-monthly, non-tailored behavioral support calls to patients whose SBP comes under control; medium-intensity strategy utilizing a registered nurse to provide monthly tailored behavioral support telephone calls plus home BP monitoring; and high-intensity strategy utilizing a pharmacist to provide monthly tailored behavioral support telephone calls, home BP monitoring, and pharmacist-directed medication management. Control arm patients receive the low-intensity strategy regardless of BP control. The primary outcome is SBP. There are 385 randomized (192 intervention; 193 control) veterans that are predominately older (mean age 63.5years) men (92.5%). 61.8% are African American, and the mean baseline SBP for all subjects is 143.6mmHg. This trial will determine if a disease management program that is titrated by matching the intensity of resources to patients' BP control leads to superior outcomes compared to a low-intensity management strategy.
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Affiliation(s)
- George L Jackson
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA; Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC 27710, USA.
| | - Morris Weinberger
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA; Department of Health Policy and Management, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599, USA
| | - Miriam A Kirshner
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA
| | - Karen M Stechuchak
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA
| | - Stephanie D Melnyk
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA
| | - Hayden B Bosworth
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA; Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC 27710, USA
| | - Cynthia J Coffman
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA; Department of Biostatistics & Bioinformatics, Duke University, Durham, NC 27710, USA
| | - Brian Neelon
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC 29425, USA
| | - Courtney Van Houtven
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA; Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC 27710, USA
| | - Pamela W Gentry
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA; Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC 27710, USA
| | - Isis J Morris
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA
| | - Cynthia M Rose
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA; Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC 27710, USA
| | - Jennifer P Taylor
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA
| | - Carrie L May
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA
| | - Byungjoo Han
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA
| | - Christi Wainwright
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA
| | - Aviel Alkon
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA; Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC 27710, USA
| | - Lesa Powell
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA
| | - David Edelman
- Center for Health Services Research in Primary Care, Durham Veterans Affairs Medical Center, Durham, NC 27705, USA; Department of Medicine, Division of General Internal Medicine, Duke University, Durham, NC 27710, USA
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Tsai J, Rosenheck RA. US Veterans’ Use Of VA Mental Health Services And Disability Compensation Increased From 2001 To 2010. Health Aff (Millwood) 2016; 35:966-73. [DOI: 10.1377/hlthaff.2015.1555] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Jack Tsai
- Jack Tsai ( ) is a core investigator for the Veterans Affairs (VA) New England Mental Illness, Research, Education, and Clinical Center and an assistant professor of psychiatry at the Yale University School of Medicine, both in West Haven, Connecticut
| | - Robert A. Rosenheck
- Robert A. Rosenheck is a senior investigator for the VA New England Mental Illness, Research, Education, and Clinical Center and a professor of psychiatry at the Yale University School of Medicine
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Abstract
The annual National Healthcare Quality and Disparities Reports document widespread and persistent racial and ethnic disparities. These disparities result from complex interactions between patient factors related to social disadvantage, clinicians, and organizational and health care system factors. Separate and unequal systems of health care between states, between health care systems, and between clinicians constrain the resources that are available to meet the needs of disadvantaged groups, contribute to unequal outcomes, and reinforce implicit bias. Recent data suggest slow progress in many areas but have documented a few notable successes in eliminating these disparities. To eliminate these disparities, continued progress will require a collective national will to ensure health care equity through expanded health insurance coverage, support for primary care, and public accountability based on progress toward defined, time-limited objectives using evidence-based, sufficiently resourced, multilevel quality improvement strategies that engage patients, clinicians, health care organizations, and communities.
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Affiliation(s)
- Kevin Fiscella
- Departments of Family Medicine and Public Health Sciences, University of Rochester Medical Center, Rochester, New York 14620;
| | - Mechelle R Sanders
- Departments of Family Medicine and Public Health Sciences, University of Rochester Medical Center, Rochester, New York 14620;
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Abstract
BACKGROUND High-quality communication and a positive patient-provider relationship are aspects of patient-centered care, a crucial component of quality. We assessed racial/ethnic disparities in patient-reported communication problems and perceived discrimination in maternity care among women nationally and measured racial/ethnic variation in the correlates of these outcomes. METHODS Data for this analysis came from the Listening to Mothers III survey, a national sample of women who gave birth to a singleton baby in a US hospital in 2011-2012. Outcomes were reluctance to ask questions and barriers to open discussion in prenatal care, and perceived discrimination during the birth hospitalization, assessed using multinomial and logistic regression. We also estimated models stratified by race/ethnicity. RESULTS Over 40% of women reported communication problems in prenatal care, and 24% perceived discrimination during their hospitalization for birth. Having hypertension or diabetes was associated with higher levels of reluctance to ask questions and higher odds of reporting each type of perceived discrimination. Black and Hispanic (vs. white) women had higher odds of perceived discrimination due to race/ethnicity. Higher education was associated with more reported communication problems among black women only. Although having diabetes was associated with perceptions of discrimination among all women, associations were stronger for black women. CONCLUSIONS Race/ethnicity was associated with perceived racial discrimination, but diabetes and hypertension were consistent predictors of communication problems and perceptions of discrimination. Efforts to improve communication and reduce perceived discrimination are an important area of focus for improving patient-centered care in maternity services.
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Affiliation(s)
- Laura Attanasio
- Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis, MN
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Women Veterans' Pathways to and Perspectives on Veterans Affairs Health Care. Womens Health Issues 2015; 25:658-65. [PMID: 26341566 DOI: 10.1016/j.whi.2015.06.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 06/22/2015] [Accepted: 06/26/2015] [Indexed: 11/24/2022]
Abstract
BACKGROUND We examined Veterans Affairs (VA) health care experiences among contemporary women veteran patients receiving care at a VA medical center. Specifically, we examined women veteran patients' satisfaction with VA care along dimensions in line with patient-centered medical home (patient-aligned care teams [PACT] in VA) priorities, and pathways through which women initially accessed VA care. METHODS We used a mixed methods research design. First, 249 racially diverse women (ages 22-64) who were past-year users of primary care at a VA medical center completed interviewer-administered surveys in 2012 assessing ratings of satisfaction with care in the past year. We then conducted in-depth qualitative interviews of a subset of women surveyed (n = 25) to gain a deeper understanding of perspectives and experiences that shaped satisfaction with care and to explore women's initial pathways to VA care. RESULTS Ratings of satisfaction with VA care were generally high, with some variation by demographic characteristics. Qualitative interviews revealed perceptions of care centered on the following themes: 1) barriers to care delay needed medical care, while innovative care models facilitate access, 2) women value communication and coordination of care, and 3) personalized context of VA care, including gender sensitive care shapes women's perceptions. Pathways to VA care were characterized by initial delays, often attributable to lack of knowledge or negative perceptions of VA care. Informal social networks were instrumental in helping women to overcome barriers. CONCLUSIONS Findings highlight convergence of women's preferences with PACT priorities of timely access to care, provider communication, and coordination of care, and suggest areas for improvement. Outreach is needed to address gaps in knowledge and negative perceptions. Initiatives to enhance women veterans' social networks may provide an information-sharing resource.
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Reddy A, Pollack CE, Asch DA, Canamucio A, Werner RM. The Effect of Primary Care Provider Turnover on Patient Experience of Care and Ambulatory Quality of Care. JAMA Intern Med 2015; 175:1157-62. [PMID: 25985320 PMCID: PMC5561428 DOI: 10.1001/jamainternmed.2015.1853] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Primary care provider (PCP) turnover is common and can disrupt patient continuity of care. Little is known about the effect of PCP turnover on patient care experience and quality of care. OBJECTIVE To measure the effect of PCP turnover on patient experiences of care and ambulatory care quality. DESIGN, SETTING, AND PARTICIPANTS Observational, retrospective cohort study of a nationwide sample of primary care patients in the Veterans Health Administration (VHA). We included all patients enrolled in primary care at the VHA between 2010 and 2012 included in 1 of 2 national data sets used to measure our outcome variables: 326,374 patients in the Survey of Healthcare Experiences of Patients (SHEP; used to measure patient experience of care) associated with 8441 PCPs and 184,501 patients in the External Peer Review Program (EPRP; used to measure ambulatory care quality) associated with 6973 PCPs. EXPOSURES Whether a patient experienced PCP turnover, defined as a patient whose provider (physician, nurse practitioner, or physician assistant) had left the VHA (ie, had no patient encounters for 12 months). MAIN OUTCOMES AND MEASURES Five patient care experience measures (from SHEP) and 11 measures of quality of ambulatory care (from EPRP). RESULTS Nine percent of patients experienced a PCP turnover in our study sample. Primary care provider turnover was associated with a worse rating in each domain of patient care experience. Turnover was associated with a reduced likelihood of having a positive rating of their personal physician of 68.2% vs 74.6% (adjusted percentage point difference, -5.3; 95% CI, -6.0 to -4.7) and a reduced likelihood of getting care quickly of 36.5% vs 38.5% (adjusted percentage point difference, -1.1; 95% CI, -2.1 to -0.1). In contrast, PCP turnover was not associated with lower quality of ambulatory care except for a lower likelihood of controlling blood pressure of 78.7% vs 80.4% (adjusted percentage point difference, -1.44; 95% CI, -2.2 to -0.7). In 9 measures of ambulatory care quality, the difference between patients who experienced no PCP turnover and those who had a PCP turnover was less than 1 percentage point. These effects were moderated by the patients' continuity with their PCP prior to turnover, with a larger detrimental effect of PCP turnover among those with higher continuity prior to the turnover. CONCLUSIONS AND RELEVANCE Primary care provider turnover was associated with worse patient experiences of care but did not have a major effect on ambulatory care quality.
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Affiliation(s)
- Ashok Reddy
- VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center, Philadelphia, Pennsylvania2Perelman School of Medicine at the University of Pennsylvania, Philadelphia3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelp
| | | | - David A Asch
- VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center, Philadelphia, Pennsylvania2Perelman School of Medicine at the University of Pennsylvania, Philadelphia3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelp
| | - Anne Canamucio
- VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center, Philadelphia, Pennsylvania
| | - Rachel M Werner
- VISN 4 Center for Evaluation of PACT, Philadelphia VA Medical Center, Philadelphia, Pennsylvania2Perelman School of Medicine at the University of Pennsylvania, Philadelphia3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelp
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Satisfaction with social care services among South Asian and White British older people: the need to understand the system. AGEING & SOCIETY 2015. [DOI: 10.1017/s0144686x15000422] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
ABSTRACTNational surveys show that people from minority ethnic groups tend to be less satisfied with social care services compared with the white population, but do not show why. Research indicates that barriers to accessing services include lack of information, perceptions of cultural inappropriateness and normative expectations of care. Less research has examined the experience of minority ethnic service users after they access services. This study conducted in-depth interviews with 82 South Asian and White British service users and family carers, the majority of whom were older people. Thematic analysis was used. The key theme was understanding the social care system. Participants with a good understanding of the system were more able to adapt and achieve control over their care. Participants with a poor understanding were uncertain about how to access further care, or why a service had been refused. More White British than South Asian participants had a good understanding of the system. There was more in common between the South Asian and White British participants' experiences than might have been expected. Language was an important facilitator of care for South Asian participants, but ethnic matching with staff was less important. Recommendations include better communication throughout the care process to ensure service users and carers have a clear understanding of social care services and hence a better experience.
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Zickmund SL, Burkitt KH, Gao S, Stone RA, Rodriguez KL, Switzer GE, Shea JA, Bayliss NK, Meiksin R, Walsh MB, Fine MJ. Racial Differences in Satisfaction with VA Health Care: A Mixed Methods Pilot Study. J Racial Ethn Health Disparities 2015; 2:317-29. [PMID: 26863462 DOI: 10.1007/s40615-014-0075-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 10/24/2014] [Accepted: 11/24/2014] [Indexed: 10/24/2022]
Abstract
INTRODUCTION As satisfied patients are more adherent and play a more active role in their own care, a better understanding of factors associated with patient satisfaction is important. PURPOSE In response to a United States Veterans Administration (VA) Hospital Report Card that revealed lower levels of satisfaction with health care for African Americans compared to Whites, we conducted a mixed methods pilot study to obtain preliminary qualitative and quantitative information about possible underlying reasons for these racial differences. METHODS We conducted telephone interviews with 30 African American and 31 White veterans with recent inpatient and/or outpatient health care visits at three urban VA Medical Centers. We coded the qualitative interviews in terms of identified themes within defined domains. We summarized racial differences using ordinal logistic regression for Likert scale outcomes and used random effects logistic regression to assess racial differences at the domain level. RESULTS Compared to Whites, African Americans were younger (p < 0.001) and better educated (p = 0.04). Qualitatively, African Americans reported less satisfaction with trust/confidence in their VA providers and healthcare system and less satisfaction with patient-provider communication. Quantitatively, African Americans reported less satisfaction with outpatient care (odds ratio = 0.28; 95 % confidence interval (CI) 0.10-0.82), but not inpatient care. At the domain level, African Americans were significantly less likely than Whites to express satisfaction themes in the domain of trust/confidence (odds ratio = 0.36; 95 % CI 0.18-0.73). CONCLUSION The current pilot study demonstrates racial differences in satisfaction with outpatient care and identifies some specific sources of dissatisfaction. Future research will include a large national cohort, including Hispanic veterans, in order to gain further insight into the sources of racial and ethnic differences in satisfaction with VA care and inform future interventions.
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Affiliation(s)
- Susan L Zickmund
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA. .,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA.
| | - Kelly H Burkitt
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA
| | - Shasha Gao
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA
| | - Roslyn A Stone
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, 15261, USA
| | - Keri L Rodriguez
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
| | - Galen E Switzer
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA.,Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15213, USA
| | - Judy A Shea
- Philadelphia VA Medical Center, Center for Health Equity Research and Promotion, Philadelphia, PA, 19104, USA
| | - Nichole K Bayliss
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Psychology, Chatham University, Pittsburgh, PA, 15232, USA
| | - Rebecca Meiksin
- Gender Violence and Health Centre, London School of Hygiene and Tropical Medicine, London, England
| | - Mary B Walsh
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
| | - Michael J Fine
- VA Pittsburgh Healthcare System, Center for Health Equity Research and Promotion, University Drive (151C), Building 30, Pittsburgh, PA, 15240, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 15261, USA
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