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Gertner AK, Grove LR, Swietek KE, Lin CCC, Ray N, Malone TL, Rosen DL, Zarzar TR, Domino ME, Steiner BD. Enhanced Primary Care for People With Serious Mental Illness: A Propensity Weighted Cohort Study. J Clin Psychiatry 2023; 84:22m14496. [PMID: 37022757 PMCID: PMC10113019 DOI: 10.4088/jcp.22m14496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
Objective: People with serious mental illness (SMI) have high rates of cardiometabolic illness, receive low quality care, and experience poor outcomes. Nevertheless, studies of existing integrated care models have not consistently shown improvements in cardiometabolic health for people with SMI. This study assessed the effect of a novel model of enhanced primary care for people with SMI on cardiometabolic outcomes. Enhanced primary care is a model of integrated care wherein comprehensive primary care delivery is adapted to the needs of people with SMI in coordination with behavioral care. Methods: We conducted a propensity-weighted cohort study comparing 234 patients with SMI receiving enhanced primary care to 4,934 patients with SMI receiving usual primary care using electronic health data from a large academic medical system covering the years 2014-2018. The propensity-weighted models controlled for baseline differences in outcome measures and patient characteristics between groups. Results: Compared to usual primary care, enhanced primary care increased hemoglobin A1c (HbA1c) screening by 18 percentage points (95% confidence interval [CI], 10 to 25), low-density lipoprotein (LDL) screening by 16 percentage points (CI, 8.8 to 24), and blood pressure screening by 7.8 percentage points (CI, 5.8 to 9.9). Enhanced primary care reduced HbA1c by 0.27 percentage points (CI, -0.47 to -0.060) and systolic blood pressure by 3.9 mm Hg (CI, -5.2 to -2.5) compared to usual primary care. We did not find evidence that enhanced primary care consistently affected glucose screening, LDL values, or diastolic blood pressure. Conclusions: Enhanced primary care can achieve clinically meaningful improvements in cardiometabolic health compared to usual primary care.
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Affiliation(s)
- Alex K Gertner
- School of Medicine, Chapel Hill, University of North Carolina at Chapel Hill, North Carolina
- Corresponding author: Alex K. Gertner, MD, PhD, 321 S Columbia St, Chapel Hill, NC 27516
| | - Lexie R Grove
- Dell Medical School, University of Texas at Austin, Austin, Texas
| | | | - Ching-Ching Claire Lin
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Neepa Ray
- Center for Medication Optimization, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Tyler L Malone
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - David L Rosen
- Institute for Global Health and Infectious Diseases, Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Theodore R Zarzar
- Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Marisa Elena Domino
- Center for Health Information and Research, College of Health Solutions, Arizona State University, Phoenix, Arizona
| | - Beat D Steiner
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Lin CCC, Lee H, Snyder JE. Rural-Urban Differences in the Utilization of Hospital-Based Care for Women of Reproductive Age. Womens Health Rep (New Rochelle) 2022; 3:20-30. [PMID: 35136873 PMCID: PMC8812499 DOI: 10.1089/whr.2021.0061] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Accepted: 12/07/2021] [Indexed: 11/13/2022]
Abstract
Background: To investigate rural-urban differences in hospital-based care utilization among women of reproductive age (18-44 years). Methods: Rural-urban differences were estimated for hospital outpatient visits, emergency department (ED) visits, hospitalizations, and associated expenditures both overall and by insurance status, by analyzing a nationally representative sample of women of reproductive age from the Medical Expenditure Panel Survey (2006-2015). Results: The study sample consisted of 48,114 women of reproductive age. Unadjusted results showed that rural women reported higher likelihood of hospital outpatient visits (rural vs. urban: 17.10% vs. 13.34%) although, among those using such care, fewer average visits (rural vs. urban: 2.00 vs. 2.56 visits). Rural women reported higher likelihood of ED visits (rural vs. urban: 18.13% vs. 15.11%) and more hospital stays (rural vs. urban: 0.13 vs. 0.11 stays). Adjusted results showed rural women had higher likelihood of outpatient care use (+2.5 percentage points; 95% confidence interval [CI] = 0.002-0.049) but fewer visits (-0.314 visits, 95% CI = -0.566 to -0.062). For the privately insured, rural women had greater likelihood of outpatient care (+3.1 percentage points, 95% CI = 0.001-0.060) and fewer ED visits (-0.031 visits, 95% CI = -0.061 to -0.003); for the publicly insured, rural women had more hospital stays (+0.045 stays, 95% CI = 0.009-0.083); for the uninsured, rural women had fewer outpatient visits among those using such care (-1.118 visits, 95% CI = -1.865 to -0.372) and shorter hospital stays overall (-0.093 nights, 95% CI = -0.181 to -0.005). Rural-urban expenditure differences were not significant between any insurance grouping. Conclusions: Rural-urban differences in hospital-based care utilization were observed, although somewhat heterogeneous by insurance status. Strengthening outpatient and preventive service access, particularly for publicly insured and uninsured rural women of reproductive age, is important for shifting care to lower cost settings and improving population health.
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Affiliation(s)
- Ching-Ching Claire Lin
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan. Formally Office of Planning, Analysis, and Evaluation (OPAE), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS), Rockville, Maryland, USA
| | - Hyunjung Lee
- Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, Tennessee, USA.,Office of Health Equity (OHE), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS), Rockville, Maryland, USA
| | - John E Snyder
- Office of Planning, Analysis, and Evaluation (OPAE), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services (HHS), Rockville, Maryland, USA
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Grove LR, Gertner AK, Swietek KE, Lin CCC, Ray N, Malone TL, Rosen DL, Zarzar TR, Domino ME, Sheitman B, Steiner BD. Effect of Enhanced Primary Care for People with Serious Mental Illness on Service Use and Screening. J Gen Intern Med 2021; 36:970-977. [PMID: 33506397 PMCID: PMC8041990 DOI: 10.1007/s11606-020-06429-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 12/09/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Strategies are needed to better address the physical health needs of people with serious mental illness (SMI). Enhanced primary care for people with SMI has the potential to improve care of people with SMI, but evidence is lacking. OBJECTIVE To examine the effect of a novel enhanced primary care model for people with SMI on service use and screening. DESIGN Using North Carolina Medicaid claims data, we performed a retrospective cohort analysis comparing healthcare use and screening receipt of people with SMI newly receiving enhanced primary care to people with SMI newly receiving usual primary care. We used inverse probability of treatment weighting to estimate average differences in outcomes between the treatment and comparison groups adjusting for observed baseline characteristics. PARTICIPANTS People with SMI newly receiving primary care in North Carolina. INTERVENTIONS Enhanced primary care that includes features tailored for individuals with SMI. MAIN MEASURES Outcome measures included outpatient visits, emergency department (ED) visits, inpatient stays and days, and recommended screenings 18 months after the initial primary care visit. KEY RESULTS Compared to usual primary care, enhanced primary care was associated with an increase of 1.2 primary care visits (95% confidence interval [CI]: 0.31 to 2.1) in the 18 months after the initial visit and decreases of 0.33 non-psychiatric inpatient stays (CI: - 0.49 to - 0.16) and 3.0 non-psychiatric inpatient days (CI: - 5.3 to - 0.60). Enhanced primary care had no significant effect on psychiatric service and ED use. Enhanced primary care increased the probability of glucose and HIV screening, decreased the probability of lipid screening, and had no effect on hemoglobin A1c and colorectal cancer screening. CONCLUSIONS Enhanced primary care for people with SMI can increase receipt of some preventive screening and decrease use of non-psychiatric inpatient care compared to usual primary care.
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Affiliation(s)
- Lexie R Grove
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr., Chapel Hill, NC, 27599-7411, USA.
| | - Alex K Gertner
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr., Chapel Hill, NC, 27599-7411, USA
| | | | | | - Neepa Ray
- Center for Medication Optimization, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Tyler L Malone
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr., Chapel Hill, NC, 27599-7411, USA
| | - David L Rosen
- Institute for Global Health and Infectious Diseases, Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Theodore R Zarzar
- Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Marisa Elena Domino
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 135 Dauer Dr., Chapel Hill, NC, 27599-7411, USA
- Department of Psychiatry, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, USA
| | - Brian Sheitman
- North Carolina Department of Public Safety-Prisons, Raleigh, USA
| | - Beat D Steiner
- Department of Family Medicine, School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, USA
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Lee H, Hirai AH, Lin CCC, Snyder JE. Determinants of rural-urban differences in health care provider visits among women of reproductive age in the United States. PLoS One 2020; 15:e0240700. [PMID: 33301492 PMCID: PMC7728245 DOI: 10.1371/journal.pone.0240700] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 10/01/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Rural health disparities and access gaps may contribute to higher maternal and infant morbidity and mortality. Understanding and addressing access barriers for specialty women's health services is important in mitigating risks for adverse childbirth events. The objective of this study was to investigate rural-urban differences in health care access for women of reproductive age by examining differences in past-year provider visit rates by provider type, and quantifying the contributing factors to these findings. METHODS AND FINDINGS Using a nationally-representative sample of reproductive age women (n = 37,026) from the Medical Expenditure Panel Survey (2010-2015) linked to the Area Health Resource File, rural-urban differences in past-year office visit rates with health care providers were examined. Blinder-Oaxaca decomposition analysis quantified the portion of disparities explained by individual- and county-level sociodemographic and provider supply characteristics. Overall, there were no rural-urban differences in past-year visits with women's health providers collectively (65.0% vs 62.4%), however differences were observed by provider type. Rural women had lower past-year obstetrician-gynecologist (OB-GYN) visit rates than urban women (23.3% vs. 26.6%), and higher visit rates with family medicine physicians (24.3% vs. 20.9%) and nurse practitioners/physician assistants (NPs/PAs) (24.6% vs. 16.1%). Lower OB-GYN availability in rural versus urban counties (6.1 vs. 13.7 providers/100,000 population) explained most of the rural disadvantage in OB-GYN visit rates (83.8%), and much of the higher family physician (80.9%) and NP/PA (50.1%) visit rates. Other individual- and county-level characteristics had smaller effects on rural-urban differences. CONCLUSION Although there were no overall rural-urban differences in past-year visit rates, the lower OB-GYN availability in rural areas appears to affect the types of health care providers seen by women. Whether rural women are receiving adequate specialized women's health care services, while seeing a different cadre of providers, warrants further investigation and has particular relevance for women experiencing high-risk pregnancies and deliveries.
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Affiliation(s)
- Hyunjung Lee
- Oak Ridge Institute for Science and Education (ORISE), Oak Ridge, Tennessee, United States of America
- Office of Health Equity (OHE), Health Resources and Services Administration (HRSA), Rockville, Maryland, United States of America
| | - Ashley H. Hirai
- Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA), Rockville, Maryland, United States of America
| | - Ching-Ching Claire Lin
- Office of Planning, Analysis, and Evaluation (OPAE), Health Resources and Services Administration (HRSA), Rockville, Maryland, United States of America
| | - John E. Snyder
- Office of Planning, Analysis, and Evaluation (OPAE), Health Resources and Services Administration (HRSA), Rockville, Maryland, United States of America
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Affiliation(s)
- Ching-Ching Claire Lin
- Health Resources and Services Administration, U.S. Department of Health and Human Services Rockville, Maryland (C.C.L., A.H.H., S.K.F.)
| | - Ashley H Hirai
- Health Resources and Services Administration, U.S. Department of Health and Human Services Rockville, Maryland (C.C.L., A.H.H., S.K.F.)
| | - Rui Li
- Centers for Disease Control and Prevention, U.S. Department of Health and Human Services Atlanta, Georgia (R.L., E.V.K.)
| | - Elena V Kuklina
- Centers for Disease Control and Prevention, U.S. Department of Health and Human Services Atlanta, Georgia (R.L., E.V.K.)
| | - Sylvia K Fisher
- Health Resources and Services Administration, U.S. Department of Health and Human Services Rockville, Maryland (C.C.L., A.H.H., S.K.F.)
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Lee H, Lin CCC, Snyder JE. Rural-Urban Differences in Health Care Access Among Women of Reproductive Age: A 10-Year Pooled Analysis. Ann Intern Med 2020; 173:S55-S58. [PMID: 33253026 DOI: 10.7326/m19-3250] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Hyunjung Lee
- Oak Ridge Institute for Science and Education, Oak Ridge, Tennessee (H.L.)
| | - Ching-Ching Claire Lin
- Office of Planning, Analysis, and Evaluation, Health Resources and Services Administration Rockville, Maryland (C.L., J.S.)
| | - John E Snyder
- Office of Planning, Analysis, and Evaluation, Health Resources and Services Administration Rockville, Maryland (C.L., J.S.)
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Affiliation(s)
- Gopal K Singh
- Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland (G.K.S., C.C.L.)
| | - Ching-Ching Claire Lin
- Health Resources and Services Administration, U.S. Department of Health and Human Services, Rockville, Maryland (G.K.S., C.C.L.)
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Lin CCC, Dievler A, Robbins C, Sripipatana A, Quinn M, Nair S. Telehealth In Health Centers: Key Adoption Factors, Barriers, And Opportunities. Health Aff (Millwood) 2019; 37:1967-1974. [PMID: 30633683 DOI: 10.1377/hlthaff.2018.05125] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Telehealth services have the potential to improve access to care, especially in rural or urban areas with scarce health care resources. Despite the potential benefits, telehealth has not been fully adopted by health centers. This study examined factors associated with and barriers to telehealth use by federally funded health centers. We analyzed data for 2016 from the Uniform Data System using a mixed-methods approach. Our findings suggest that rural location, operational factors, patient demographic characteristics, and reimbursement policies influence health centers' decisions about using telehealth. Cost, reimbursement, and technical issues were described as major barriers. Medicaid reimbursement policies promoting live video and store-and-forward services were associated with a greater likelihood of telehealth adoption. Many health centers were implementing telehealth or exploring its use. Our findings identified areas that policy makers can address to achieve greater telehealth adoption by health centers.
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Affiliation(s)
- Ching-Ching Claire Lin
- Ching-Ching Claire Lin ( ) is a health economist in the Office of Planning, Analysis, and Evaluation, Health Resources and Services Administration (HRSA), in Rockville, Maryland
| | - Anne Dievler
- Anne Dievler is a senior advisor in the Office of Planning, Analysis, and Evaluation, HRSA
| | - Carolyn Robbins
- Carolyn Robbins is a public health analyst in the Office of Planning, Analysis, and Evaluation, HRSA
| | - Alek Sripipatana
- Alek Sripipatana is director of the Data and Evaluation Division in the Bureau of Primary Health Care, HRSA
| | - Matt Quinn
- Matt Quinn is a senior advisor in the Office of Planning, Analysis, and Evaluation, HRSA
| | - Suma Nair
- Suma Nair is director of the Office of Quality Improvement, Bureau of Primary Health Care, HRSA
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Domino ME, Lin CCC, Morrissey JP, Ellis AR, Fraher E, Richman EL, Thomas KC, Prinstein MJ. Training Psychologists for Rural Practice: Exploring Opportunities and Constraints. J Rural Health 2018; 35:35-41. [PMID: 29664202 DOI: 10.1111/jrh.12299] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 01/09/2018] [Accepted: 02/08/2018] [Indexed: 11/27/2022]
Abstract
PURPOSE To examine trends in the psychologist workforce and training opportunities, including factors that may influence the decision of clinical psychologists to practice in rural settings. METHODS We use a mixed-methods approach to examine the psychologist workforce nationally and in North Carolina (NC), including (1) an analysis of the location of programs awarding doctoral degrees; (2) an analysis of the practice, demographic, and educational characteristics of the psychologist workforce; and (3) interviews with directors of doctoral programs in clinical psychology to understand where current graduates are getting jobs and why they may or may not be choosing to practice in rural communities. FINDINGS Fewer than 1% of programs and institutions awarding doctoral degrees in psychology in the United States are located in rural areas. In NC, approximately 80% of practicing psychologists have out-of-state degrees and about 80% of recent NC graduates are not currently licensed in the state. This juxtaposition undermines the utility of adding more in-state degree programs. While expansion of training programs within rural areas could help alleviate the shortages of mental health providers, adding new degree-granting programs alone will not necessarily increase supply. We discuss complementary recruitment and retention strategies, including greater incentives for rural training and practice as well as training in emerging technologies that don't require providers to be physically located in underserved areas, such as telemedicine. CONCLUSIONS Increasing the supply of psychologists practicing in rural areas will require a thoughtful, multipronged approach to training this critical part of the behavioral health workforce.
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Affiliation(s)
- Marisa Elena Domino
- Department of Health Policy and Management, The Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Ching-Ching Claire Lin
- Department of Health Policy and Management, The Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Joseph P Morrissey
- Department of Health Policy and Management, The Gillings School of Global Public Health, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Alan R Ellis
- Department of Social Work, North Carolina State University, Raleigh, North Carolina
| | - Erin Fraher
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina.,Department of Family Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Erica L Richman
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Kathleen C Thomas
- Cecil G. Sheps Center for Health Services Research, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mitchell J Prinstein
- Department of Psychology, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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