State funding of comprehensive primary medical care service programs for medically underserved populations

Caring for the disadvantaged: the role of physician assistants

OBJECTIVE

We investigated community health centers (CHCs) and the roles of physician assistants (PAs) within them. Our goals were to broadly describe PA practice characteristics within CHCs, to explore why PAs work in CHCs, and to understand patient perspectives of PAs.

METHODS

We evaluated 10 CHCs in Texas (5 urban and 5 rural), using an ethnographic approach to examine attitudes and beliefs of PAs, medical staff, and patients.

RESULTS

Nine of the 10 clinics used PAs interchangeably with physicians, and most medical staff and patients perceived few differences between them. Patients view all providers as highly effective and genuinely concerned for their patients.

CONCLUSIONS

We found that clinicians and staff believe in the work they do, report that they function as a team, and seem to like their roles. It appears that working with the medically underserved and economically disadvantaged enables PAs to thrive.

MODULE TWO: INFORMED CONSENT

The objective of this module is to familiarise you with the concept of informed consent, its ethical basis, its elements, and typical problems that are encountered even by the most well intentioned researchers when trying to achieve genuine informed consent.

State-Funded Comprehensive Primary Medical Care Service Programs for Medically Underserved Populations: 1995 vs 2000

Objectives. We analyzed responses to the 2000 Comprehensive Primary Medical Care programs for Medically Underserved Populations Survey and compared them with the 1995 survey results to identify trends.

Methods. Surveys were mailed to all primary care program offices. State primary care program associations reviewed primary care program offices’ responses and completed surveys for offices that did not respond.

Results. We identified 30 qualified primary care programs in 24 states that had an overall funding level of $215 million. Most states allowed funds to be spent on expanding service areas, buying equipment, and hiring and training staff.

Conclusions. Although state funding has increased overall, many states do not have comprehensive primary care programs, and an increasing number of states are experiencing budget deficits that may lead to reductions in existing programs.

Racial and ethnic disparities in the purchase of nongroup health insurance: the roles of community and family-level factors

OBJECTIVE

To evaluate the influence of community- and family-level factors on racial/ethnic disparities in the uptake of nongroup (individual) health insurance.

DATA SOURCES

Responses to the 1996-1997 Community Tracking Study Household Survey plus community-level descriptors from several sources including census data, the Area Resource File, and community and migrant health center Medicare cost reports.

STUDY DESIGN

Logistic regression was used to compare families in which at least one person had nongroup health insurance to families without nongroup insurance in which at least one person was uninsured. Sequential models were constructed examining family- and community-level factors.

RESULTS

Twenty-three percent of families with otherwise-uninsured persons purchased nongroup insurance, ranging from 11% to 41% among the 60 communities sampled. Disadvantaged minority group members, especially Spanish-speaking Hispanics, had half or less the odds of whites of purchasing nongroup insurance. Education had a weaker association with purchasing nongroup insurance among minority group members than among whites. Community-level factors had minimal effect on disparities in uptake, although greater housing segregation was associated with lower uptake among blacks.

CONCLUSIONS

Minority group members are much less likely to purchase nongroup insurance than whites. Family income and community factors do not explain this gap. Programs aimed at stimulating voluntary insurance purchase will continue to underenroll disadvantaged minorities if nonfinancial barriers to acquiring insurance coverage, including the interplay between race/ethnicity and education, are not better understood and addressed.

To decentralize or not to decentralize, is that the question? Nicaraguan health policy under structural adjustment in the 1990s

Since 1990, health services decentralization in Nicaragua has been accompanied by structural adjustment, resulting in reduced equity and accountability. Sandinista efforts in the 1980s to extend access to primary care and reduce class and regional disparities in the delivery of health services were accompanied by modest attempts to increase local-level accountability and responsiveness. The escalation of war in the late 1980s transformed this effort into greater de facto decentralization. Over the past decade, Nicaragua has used decentralization policy to restructure the health system through health spending cuts and the favoring of curative over preventive services; privatization and the promotion of user fees; and confusion of lines of accountability. The authors analyze the 1990s' health policies in Nicaragua, paying particular attention to the blending of decentralization policy with the fiscal and administrative reforms advanced by the International Monetary Fund, World Bank, and other international agencies. They conclude that analyzing decentralization as a sector-specific reform that can be ameliorated through technocratic modifications is insufficient. A full understanding of the problems and possibilities of decentralization requires an analysis of the political and economic context that conditions these policies.

Quality of diabetes care in community health centers

OBJECTIVES

This study assessed the quality of diabetes care in community health centers.

METHODS

In 55 midwestern community health centers, we reviewed the charts of 2865 diabetic adults for American Diabetes Association measures of quality.

RESULTS

On average, 70% of the patients in each community health center had measurements of glycosylated hemoglobin, 26% had dilated eye examinations, 66% had diet intervention, and 51% received foot care. The average glycosylated hemoglobin value per community health center was 8.6%. Practice guidelines were independently associated with higher quality of care.

CONCLUSIONS

Rates of adherence to process measures of quality were relatively low among community health centers, compared with the targets established by the American Diabetes Association.

Evaluation of outreach clinics held by specialists in general practice in England

OBJECTIVES

To measure the processes of care, health benefits and costs of outreach clinics held by hospital specialists in primary care settings.

DESIGN

The study was designed as a case-referent (comparative) study in which the features of 19 outreach clinics (cases) were compared with matched outpatient clinics (controls). The measuring instruments were self administered questionnaires. Patients were followed up at six months to reassess health status. The specialties included in the study were cardiology, ENT, general medicine, general surgery, gynaecology and rheumatology.

SETTING

Specialist outreach clinics in general practice in England, with matched outpatient clinic controls.

SUBJECTS

Consecutive patient attenders in the outreach and outpatient clinics, their specialists, the outreach patients' general practitioners, practice managers and trust accountants. Patients' response rate at baseline: 78% (1420).

MAIN OUTCOME MEASURES

Patient satisfaction, doctors' attitudes, processes and health outcomes, costs.

RESULTS

Outreach patients were more satisfied with the processes of their care than outpatients, their access to specialist care was better than that for outpatients and they were more likely to be discharged. Doctors reported that the main advantages of the outreach clinic were improved patient access to specialists and convenience for patients, in comparison with outpatients, and most GPs and specialists felt the outreach clinic was "worthwhile". At six month follow up, the health status of the outreach sample had significantly improved more than that of the outpatients on all eight sub-scales of the HSQ-12, but this was probably because of their better starting point at baseline. The impact of outreach on health outcomes was small. The NHS costs of outreach were significantly higher than outpatients. An increase in outreach clinic size would reduce cost per patient, but would lead to the loss of most of the clinics' benefits.

CONCLUSIONS

While the process of care was of higher quality in outreach than in outpatients, and the efficiency of care was also greater in the latter, the effect on patients' health outcomes was small. Responsiveness to patients' views and preferences is an essential component of good quality service provision. However, the greater cost of outreach raises the issue of whether improvements in the quality and efficiency of health care, without a substantial impact on health outcomes, is money well spent in a publicly funded health service. On the other hand, the real costs of outreach in comparison with outpatients clinics can probably only be truly estimated in a longitudinal study with a resource based costing model derived from documented patient attendances and treatment costs over time in relation to longer term outcome (for example, at a two year end point).