Mediators of Discrimination in Primary Care Appointment Access.

We examine how differences in questions asked and information provided by physicians' offices contribute to differences in new-patient appointment offers. Data is from a 2013-16 field experiment involving calls to a random sample of US primary care physicians on behalf of simulated new patients differentiated by race/ethnicity (Black, Hispanic, White), sex, and insurance. We find that the rates and stated reasons for denial of appointment offers differ substantially across patient groups.

Access to US primary care physicians for new patients concerned about smoking or weight.

Tobacco smoking and obesity are leading causes of preventable morbidity and mortality in the US, and primary care physicians are the main source of preventive care. However, it is not known whether access for new patients is affected by an expression of interest in preventive care. In a 2015 audit, we called US primary care physicians' offices to request appointment information regarding new patient physicals for simulated patients. Simulated patients were differentiated by smoking concerns (N = 907), weight concerns (N = 867), or no health concerns ("healthy" patients; N = 3561). Additionally, patient profiles varied by race/ethnicity, sex, and insurance type. We also examined whether access differed in states that expanded Medicaid under the Affordable Care Act. We found that physicians' offices were no more likely to offer appointments to patients with smoking concerns than to healthy patients (54% vs. 55%; p-value = 0.56), and patients with smoking concerns were offered fewer appointments than patients with weight concerns (54% vs. 62%, p-value < 0.01). In analyses adjusted for covariates, smoking concerns did not improve appointment offers for any patient group, and reduced Medicare patients' offers in Medicaid expansion states by 9 percentage points relative to healthy patients (95% CI: -16, -2). Health concerns did not statistically significantly affect waits-to-appointment. Our results suggest that patients with smoking concerns are no more likely to be offered new patient appointments than those with no health concerns. The greater likelihood of appointment offers for some patients with weight concerns is encouraging for obesity prevention and management.

State Medicaid fees and access to primary care physicians.

Medicaid and uninsured patients are disadvantaged in access to care and are disproportionately Black and Hispanic. Using a national audit of primary care physicians, we examine the relationship between state Medicaid fees for primary care services and access for Medicaid, Medicare, uninsured, and privately insured patients who differ by race/ethnicity and sex. We found that states with higher Medicaid fees had higher probabilities of appointment offers and shorter wait times for Medicaid patients, and lower probabilities of appointment offers and longer wait times for uninsured patients. Appointment offers and wait times for Medicare and privately insured patients were unaffected by Medicaid fees. At mean state Medicaid fees, our analysis predicts a 27-percentage-point disadvantage for Medicaid versus Medicare in appointment offers. This decreases to 6 percentage points when Medicaid and Medicare fees are equal, suggesting that permanent fee parity with Medicare could eliminate most of the disparity in appointment offers for Medicaid patients. The predicted decrease in the disparity is smaller for Black and Hispanic patients than for White patients. Our research highlights the importance of considering the effects of policy on nontarget patient groups, and the consequences of seemingly race-neutral policies on racial/ethnic and sex-based disparities.

Disparities in access to appointments for contraceptive services among Black, Hispanic, White, and recently incarcerated women in Alabama, Louisiana, and Mississippi.

OBJECTIVE: To measure differences in access to contraceptive services based on history of incarceration and its intersections with race/ethnicity and insurance status. DATA SOURCES AND STUDY SETTING: Primary data were collected from telephone calls to physician offices in Alabama, Louisiana, and Mississippi in 2021. STUDY DESIGN: We deployed a field experiment. The outcome variables were appointment offers, wait days, and questions asked of the caller. The independent variables were callers' incarceration history, race/ethnicity, and insurance. DATA COLLECTION METHODS: Using standardized scripts, Black, Hispanic, and White female research assistants called actively licensed primary care physicians and Obstetrician/Gynecologists asking for the next available appointment for a contraception prescription. Physicians were randomly selected and randomly assigned to callers. In half of calls, callers mentioned recent incarceration. We also varied insurance status. PRINCIPAL FINDINGS: Appointment offer rates were five percentage points lower (95% CI: -0.10 to 0.01) for patients with a history of incarceration and 11 percentage points lower (95% CI: -0.15 to -0.06) for those with Medicaid. We did not find significant differences in appointment offer rates or wait days when incarceration status was interacted with race or insurance. Schedulers asked questions about insurance significantly more often to recently incarcerated Black patients and recently incarcerated patients who had Medicaid. CONCLUSIONS: Women with a history of incarceration have less access to medical appointments; this access did not vary by race or insurance status among women with a history of incarceration.

Is Venous Thromboembolism Prophylaxis Needed in Patients Undergoing Knee Arthroscopy? A Prospective Observational Study.

BACKGROUND: Although rare, deep vein thrombosis is a potentially life-threatening complication of knee arthroscopy. There are scanty literature analysing deep vein thrombosis after arthroscopy in Nepal. This study aimed to identify the prevalence of deep vein thrombosis in patients undergoing knee arthroscopy without chemoprophylaxis postoperatively at 2 weeks and 6 weeks, respectively. The study also aimed to estimate the risk of deep vein thrombosis in these patients by using Caprini Risk Assessment Model. METHODS: This prospective observational study was conducted at AKB center, B and B Hospital, Gwarko, Lalitpur, over a period of 16 months. All patients who underwent arthroscopy knee surgeries fulfilling the inclusion criteria were included in the study. The primary outcome measure was the prevalence of deep vein thrombosis as diagnosed by compression color-coded ultrasonography of the popliteal vein and calf vein at 2 weeks and 6 weeks postoperatively. The secondary outcome measure was the prevalence of deep vein thrombosis in the risk groups according to Caprini Risk Assessment Model. RESULTS: Out of 612 patients who underwent arthroscopic knee surgeries during the study period, 2 patients (0.33%) developed deep vein thrombosis at 6 weeks follow-up as diagnosed with ultrasonography of the popliteal and calf veins. The prevalence rate in high-risk group was 0.33% (1 in 307) and in very high-risk group was 5.88% (1 in 17). CONCLUSIONS: There was a low prevalence of deep vein thrombosis without chemoprophylaxis following knee arthroscopy in our study. There was higher prevalence of deep vein thrombosis in very high-risk group patients, so close monitoring of such patients during follow-up is recommended.

Disparities in Access to Primary Care Appointments Among Asian American Subgroups, and the Impact of Concordance.

While Asian Americans experience disparate access to health services, little is known about the extent to which providers discriminate against Asian American patients. Further, research on Asian American health disparities tends to group Asian American ethnicities together, overlooking potential within-group differences. We deployed a field experiment to assess whether Asian American ethnic sub-groups experience discrimination in appointment scheduling. We further explored the impact of racial concordance between Asian patients and physicians. Overall, we did not detect significant differences in appointment offer rates between White and Asian American patients. However, we found that Asian Americans experienced longer wait times driven primarily by the treatment of patients of Chinese and Korean descent. Physician offices, surprisingly, offered concordant Asian patients appointments at significantly lower rates. The disparities Asian Americans experience relative to White Americans through longer waits for primary care appointments are not consistent across sub-groups. Increased attention to the unique experiences of people of Asian descent in accessing health services is warranted.

Functional Outcome and Quality of Life Following Total Hip Replacement Surgery.

BACKGROUND: Total hip replacement surgeries are popular treatment modality for degenerative and traumatic hip condition which provides high degree of patient satisfaction and are mainly described in literatures among patient residing in western world. However activities of daily living of people in hilly area of developing country are different from western country but there are paucity of literature describing outcome of these people. METHODS: Retrospective observational study was carried out in a university teaching hospital in Nepal. Patients residing in hilly region of Nepal who underwent total joint replacement of hip joint between 2017 to 2019 AD were included in the study. The functional outcome was measured using Harris Hip Score and the quality of life was assessed using SF-12 Patient Questionnaire preoperatively , 3 months , 6 months and 1 year follow up. RESULTS: More than two-thirds of the patients were male. The mean age group of patients was 45.71 years. The most common indication of surgery was avascular necrosis of femoral head. There was significant improvement in Harris Hip Score upto 6 months postoperatively. Quality of life including both physical and mental component of SF-12 improved significantly upto 6 months. CONCLUSIONS: Total hip replacement surgery significantly improves functional outcome and quality of life of patients residing in hilly region of Nepal. However, long term follow up still is request to find out effect of joint replacement in activities of daily living in these group of people.

Offers of appointments with nurse practitioners if a requested physician is unavailable.

BACKGROUND AND PURPOSE: Access to primary care remains a problem for a substantial portion of the U.S. population, and is predicted to worsen due to an aging population and the increasing burden of chronic diseases. Better integration of nurse practitioners (NPs) into the primary care workforce is a possible solution. We examine offers of appointments with NPs if a requested primary care physician is unavailable. METHODS: Data are from a 2013 audit (simulated patient) study requesting appointment information from a national random sample of primary care physicians. Outcome variables include appointment offers, wait-to-appointment times, and appointment offers with alternate providers, including NPs. CONCLUSIONS: Of 922 calls to primary care physicians serving the general adult population, 378 (41%) offered appointments with the requested physician. Alternate providers were offered by 63 (7%), including nine offers with NPs (<1%). Mean wait-to-appointment for NPs (3.6 days) was statistically significantly shorter (p-values < .01) than for requested physicians (22.5 days) or non-NP alternate providers (23.9 days). IMPLICATIONS FOR PRACTICE: NPs are an important part of the primary care workforce, and new patients seeking primary care physicians may substantially reduce their wait times if an NP is offered.

Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain.

OBJECTIVES: To identify relative provider costs, clinical outcomes, and patient satisfaction for the treatment of low back pain (LBP). METHODS: This was a practice-based, nonrandomized, comparative study of patients self-referring to 60 doctors of chiropractic and 111 medical doctors in 51 chiropractic and 14 general practice community clinics over a 2-year period. Patients were included if they were at least 18 years old, ambulatory, and had low back pain of mechanical origin (n = 2780). Outcomes were (standardized) office costs, office costs plus referral costs for office-based care and advanced imaging, pain, functional disability, patient satisfaction, physical health, and mental health evaluated at 3 and 12 months after the start of care. Multiple regression analysis was used to correct for baseline differences between provider types. RESULTS: Chiropractic office costs were higher for both acute and chronic patients (P < .01). When referrals were included, there were no significant differences in either group between provider types (P > .20). Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction (P < .01); clinically important differences in pain and disability improvement were found for chronic patients only. CONCLUSIONS: Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain.

Repetitive transcranial magnetic stimulation versus electroconvulsive therapy for major depression: preliminary results of a randomized trial.

BACKGROUND: Many severely depressed patients do not benefit from or tolerate existing treatments. Repetitive transcranial magnetic stimulation (rTMS) has been reported to benefit depression. We compared rTMS to electroconvulsive therapy (ECT) in severely ill, depressed patients. METHODS: Twenty-five patients with a major depression (unipolar or bipolar) deemed clinically appropriate for ECT were randomly assigned to rTMS (10-20 treatments, 10 Hz, 110% motor threshold applied to the left dorsolateral prefrontal cortex for a total of 10,000-20,000 stimulations) or a course of bitemporal ECT (4-12 treatments). The primary outcome measure was the 24-item Hamilton Depression Rating Scale (HDRS). The Brief Psychiatric Rating Scale (BPRS), Young Mania Rating Scale (YMS), and Clinical Global Impression scale (CGI) were secondary measures. Minimal rescue medications were utilized. RESULTS: Mean percent improvement on the baseline HDRS score did not significantly differ between the two treatments (i.e., 55% for the rTMS group vs. 64% for the ECT group [p = ns]). With response defined as a 50% reduction from baseline and a final score < or = 8 on the HDRS, there was also no significant difference between the two groups. We did not observe any differences between groups on the secondary measures. CONCLUSIONS: A 2-4 week randomized, prospective trial comparing rTMS to ECT produced comparable therapeutic effects in severely depressed patients.

Migrating foreign body in mediastinum--intravascular Steinman pin.

We report a case of migration of a Steinman pin to the innominate vein. A pin was used to fix a shoulder separation but a broken piece was left unattended at the time of removal of the pin. How this piece made its way in to innominate vein is puzzling. To our knowledge migration of fixation wires to the innominate vein has not been reported previously.