Measuring a Critical Component of Contraceptive Decision Making: The Contraceptive Concerns and Beliefs Scale.

INTRODUCTION: Concerns about safety and side effects from contraceptives are widespread and related to reluctance to use them. Measuring these concerns is an essential component of understanding contraceptive decision-making and guiding contraceptive and interpregnancy clinical care. METHODS: We used qualitative research and item response theory to develop and test a psychometric instrument to measure contraceptive concerns and beliefs. We developed 55 candidate scale items and tested them among 572 adolescents and adults across nine California healthcare facilities in 2019-2020. We derived a 6-item scale and assessed differences by age and social determinants of health with multivariable regression. RESULTS: In qualitative data, participants voiced both concerns and positive beliefs about contraception. Quantitative survey respondents were aged 21 years on average, and 24% were parous. Over half (54%) worried contraception has dangerous side effects, and 39% worried it is unnatural. The mean Contraceptive Concerns score, increasing with higher concerns, was 1.85 (SD: 1.00, range 0-4, α = 0.81). Items fit a partial credit item response model and met prespecified criteria for internal structure validity. Contraceptive use declined with increasing Concerns score (adjusted prevalence ratio [aPR] = 0.81 [0.72-0.92]). Scores were elevated among Black (mean: 2.06; aß = 0.34 [0.09, 0.59]) and Multiracial or other race (2.11; aß = 0.34 [0.02, 0.66]) respondents vs. White (1.66), but not Latinx respondents (1.81; aß = 0.11 [- 0.11, 0.33]). Scores were also elevated among participants with lower maternal education (high school/Associate's 1.89 versus college 1.60; aß = 0.28 [0.04, 0.53]). DISCUSSION: The psychometrically robust Concerns instrument can be used in research to measure autonomous contraceptive decision-making and to design person-centered care.

Effect of Social Needs Case Management on Hospital Use Among Adult Medicaid Beneficiaries : A Randomized Study.

BACKGROUND: Case management programs assisting patients with social needs may improve health and avoid unnecessary health care use, but little is known about their effectiveness. OBJECTIVE: This large-scale study assessed the population-level impact of a case management program designed to address patients' social needs. DESIGN: Single-site randomized encouragement design with administrative enrollment from an eligible population and intention-to-treat analysis. Study participants were enrolled between August 2017 and December 2018 and followed for 1 year. (ClinicalTrials.gov: NCT04000074). SETTING: Contra Costa County, an economically and culturally diverse community in the San Francisco Bay Area. PARTICIPANTS: 57 972 randomized enrollments of adult Medicaid patients at elevated risk for health care use (top 15%) to the intervention or control group. INTERVENTION: Enrollees were offered 12 months of social needs case management, which provided more intensive services to patients with higher demonstrated needs. MEASUREMENTS: Medical use was measured via emergency department (ED) visits and inpatient admissions, some of which were classified as avoidable. RESULTS: Participants in the intervention group visited the ED at ratios of 0.96 (95% CI, 0.91 to 1.00) for all visits and 0.97 (CI, 0.92 to 1.03) for avoidable visits relative to the control group. The intervention group was hospitalized at ratios of 0.89 (CI, 0.81 to 0.98) for all admissions and 0.72 (CI, 0.55 to 0.88) for avoidable admissions. LIMITATIONS: Only 40% of the intervention group engaged with the program. The program was in continual development during the trial period. CONCLUSION: Although social needs case management programs may reduce health care use, these savings may not cover full program costs. More work is needed to identify ways to increase patient uptake and define characteristics of successful programs. PRIMARY FUNDING SOURCE: Contra Costa Health Services via the Medicaid waiver program.

Intersecting systemic and personal barriers to accessing social services: qualitative interviews in northern California.

BACKGROUND: Addressing social risks in the clinical setting can increase patient confidence in the availability of community resources and may contribute to the development of a therapeutic alliance which has been correlated with treatment adherence and improved quality of life in mental health contexts. It is not well understood what barriers patients face when trying to connect to community resources that help address social risks. This paper aims to describe patient-reported barriers to accessing and using social needs-related resources to which they are referred by a program embedded in a safety net primary care clinic. METHODS: This is a qualitative assessment of patient-reported barriers to accessing and using social needs assistance programs. We conducted over 100 in-depth interviews with individuals in Northern California who participated in a navigation and referral program to help address their social needs and describe a unique framework for understanding how policies and systems intersect with an individual's personal life circumstances. RESULTS: Individuals described two distinct domains of barriers: 1) systems-level barriers that were linked to the inequitable distribution of and access to resources, and 2) personal-level barriers that focused on unique limitations experienced by each patient and impacted the way that they accessed services in their communities. While these barriers often overlapped or manifested in similar outcomes, this distinction was key because the systems barriers were not things that individuals could control or overcome through their own initiative or by increasing individual capacity. CONCLUSIONS: Respondents describe intersecting systemic and personal barriers that compound patients' challenges to getting their social needs met; this includes both a picture of the inequitable distribution of and access to social services and a profile of the limitations created by individual life histories. These results speak to the need for structural changes to improve adequacy, availability, and accessibility of social needs resources. These findings highlight the need for advocacy to address systems barriers, especially the stigma that is faced by people who struggle with a variety of health and social issues, and investment in incentives to strengthen relationships between health care settings and social service agencies.

Patient Perspectives on Addressing Social Needs in Primary Care Using a Screening and Resource Referral Intervention.

BACKGROUND: Interest is growing in interventions to address social needs in clinical settings. However, little is known about patients' perceptions and experiences with these interventions. OBJECTIVE: To evaluate patients' experiences and patient-reported outcomes of a primary care-based intervention to help patients connect with community resources using trained volunteer advocates. DESIGN: Qualitative telephone interviews with patients who had worked with the volunteer advocates. Sample and recruitment targets were equally distributed between patients who had at least one reported success in meeting an identified need and those who had no reported needs met, based on the database used to document patient encounters. PARTICIPANTS: One hundred two patients. INTERVENTIONS: Patients at the study clinic were periodically screened for social needs. If needs were identified, they were referred to a trained volunteer advocate who further assessed their needs, provided them with resource referrals, and followed up with them on whether their need was met. APPROACH: Thematic analysis was used to code the data. KEY RESULTS: Interviewed patients appreciated the services offered, especially the follow-up. Patients' ability to access the resource to which they were referred was enhanced by assistance with filling out forms, calling community resources, and other types of navigation. Patients also reported that interacting with the advocates made them feel listened to and cared for, which they perceived as noteworthy in their lives. CONCLUSIONS: This patient-reported information provides key insights into a human-centered intervention in a clinical environment. Our findings highlight what works in clinical interventions addressing social needs and provide outcomes that are difficult to measure using existing quantitative metrics. Patients experienced the intervention as a therapeutic relationship/working alliance, a type of care that correlates with positive outcomes such as treatment adherence and quality of life. These insights will help design more patient-centered approaches to providing holistic patient care.

Adherence to planned risk management interventions in Swedish forensic care: What is said and done according to patient records.

Both structured and unstructured clinical risk assessments within forensic care aim to prevent violence by informing risk management, but research about their preventive role is inconclusive. The aim of this study was to investigate risk management interventions that were planned and realized during forensic care by analysing patient records. Records from a forensic clinic in Sweden, covering 14 patients and 526 months, were reviewed. Eight main types of risk management interventions were evaluated by content analysis: monitoring, supervision, assessment, treatment, victim protection, acute coercion, security level and police interventions. Most planned risk management interventions were realized, both in structured and clinical risk assessments. However, most realized interventions were not planned, making them more open to subjective decisions. Analysing risk management interventions actually planned and realized in clinical settings can reveal the preventive role of structured risk assessments and how different interventions mediate violence risk.

Personal home care workers' role in hospital: a qualitative study.

OBJECTIVES: Unlike in most high-income countries, in Israel personal (social) care of elderly patients in hospitals is provided either by relatives or friends, or, for those patients with live-in assistance at home, by their home care workers. Our aim was to understand the explicit and implicit roles of live-in carers and whether any difficulties occurred. METHODS: Interviews in the internal medicine unit of Hadassah Hospital with 17 patients, 16 relatives, 20 home care workers and 20 nurses. Data were subjected to categorical content analysis. RESULTS: Three major themes emerged: the development of teamwork with relatives and nurses; the varied roles of home care workers including nursing care, emotional care, and monitoring and supervision of the patient; and the conflicts and challenges associated with having a care worker related to their physical presence and the care worker's own social needs. CONCLUSIONS: Israel partially addresses its nursing shortage by allowing paid home care workers to take an active role in the care of hospitalized older adults. This can have both a positive and a negative impact on the role and perception of nursing.

Family caregiving at the intersection of private care by migrant home care workers and public care by nursing staff.

BACKGROUND: This study evaluated private family caregiving at the intersection of private migrant home care and public nursing care on the hospitalization of an older patient. METHODS: Seventy-three individuals were interviewed, including older hospitalized patients, their family members, accompanying migrant home care workers, and nursing personnel. RESULTS: There was no clear consensus concerning the role of family members. Although family members emphasized care management as their main role, the other three groups emphasized that the family members' mere physical presence was their main role. All four groups identified potential barriers to family caregiving, rather than motives for family caregiving, hence pointing to a potential discrepancy between expected and performed family caregiving roles. CONCLUSIONS: An indication of the lack of clarity concerning family caregiving roles stems from the finding that family members were frequently viewed as unengaged and neglectful, yet at times they were criticized for being overly involved in patient care. Implications for the care of hospitalized older adults are discussed.

C-reactive protein testing does not decrease antibiotic use for acute cough illness when compared to a clinical algorithm.

BACKGROUND: Antibiotics are commonly overused in adults seeking emergency department (ED) care for acute cough illness. OBJECTIVE: To evaluate the effect of a point-of-care C-reactive protein (CRP) blood test on antibiotic treatment of acute cough illness in adults. METHODS: A randomized controlled trial was conducted in a single urban ED in the United States. The participants were adults (age ≥ 18 years) seeking care for acute cough illness (≤ 21 days duration); 139 participants were enrolled, and 131 completed the ED visit. Between November 2005 and March 2006, study participants had attached to their medical charts a clinical algorithm with recommendations for chest X-ray study or antibiotic treatment. For CRP-tested patients, recommendations were based on the same algorithm plus the CRP level. RESULTS: There was no difference in antibiotic use between CRP-tested and control participants (37% [95% confidence interval (CI) 29-45%] vs. 31% [95% CI 23-39%], respectively; p = 0.46) or chest X-ray use (52% [95% CI 43-61%] vs. 48% [95% CI 39-57%], respectively; p = 0.67). Among CRP-tested participants, those with normal CRP levels received antibiotics much less frequently than those with indeterminate CRP levels (20% [95% CI 7-33%] vs. 50% [95% CI 32-68%], respectively; p = 0.01). CONCLUSIONS: Point-of-care CRP testing does not seem to provide any additional value beyond a point-of-care clinical decision support for reducing antibiotic use in adults with acute cough illness.

Physician champions are key to improving antibiotic prescribing quality.

BACKGROUND: The previously reported IMPAACT study was a cluster randomized controlled trial of a patient and physician educational intervention designed to reduce antibiotic prescribing for acute respiratory tract infections (ARIs) in emergency departments (EDs) in the United States. On average, the intervention resulted in a modest improvement in antibiotic prescribing behavior at the end of Year 1 and further improvement after Year 2. Yet the intervention's impact was large at some sites but minimal or even negative at others. A study was undertaken to identify organizational factors that influenced the effectiveness (Organizational Effect Modifiers [OEMs]) of the intervention. METHODS: Focus groups of nurses and ED staff and semistructured interviews of local project leaders, nurse managers, and quality improvement (QI) officers were performed at seven EDs across the United States. Effectiveness of the local project leader, institutional emphasis on patient satisfaction ratings, and institutional history with and approach to QI were initially identified as key potential OEMs. Two investigators independently read the transcripts for each site and, using prespecified rating scales, rated the presence of each OEM. FINDINGS: The perceived effectiveness of the local project leader was most strongly linked to the effectiveness of the intervention. Perceived institutional emphasis on patient satisfaction and institutional history of and approach to QI (top down or bottom up) did not appear to be closely linked with intervention effectiveness. DISCUSSION: An effective local leader to serve as a physician champion was key to the success of this project. Organizational factors modify the effectiveness of QI interventions targeting individual physician performance and should be addressed during program implementation.

Perceived social support among adults seeking care for acute respiratory tract infections in US EDs.

Emergency departments (EDs) provide a disproportionate amount of care to disenfranchised and vulnerable populations. We examined social support levels among a diverse population of adults seeking ED care for acute respiratory tract infections. A convenience sample of adults seeking care in 1 of 15 US EDs was telephone interviewed 1 to 6 weeks postvisit. The Multidimensional Scale of Perceived Social Support (7-point Likert) assessed social support across 3 domains: friends, family, and significant others. Higher scores indicate higher support. Of 1104 subjects enrolled, 704 (64%) completed the follow-up interview. Factor analysis yielded 3 factors. Mean social support score was 5.54 (SD 1.04). Female sex, greater household income, and better health status were independently associated with higher levels of social support. Social support levels among adults seeking care in the ED for acute respiratory tract infections are similar to general population cohorts, suggesting that social support is not a strong determinant of health care seeking in EDs.

The context of caregiving, kinship tie and health: a comparative study of caregivers and non-caregivers.

The present study aimed to compare caregiving appraisal and psychological and physical health between caregivers and non-caregivers and between wives or daughters, and to examine the associations of caregiving context variables (intensity, duration, and co-residence) with health. The sample included 201 individually matched pairs of caregivers and non-caregivers, wives and daughters of older patients discharged from the three Internal Medicine wards at Hadassah Medical Centre in Jerusalem, Israel, during 2003. Caregivers reported significantly more negative appraisal and poorer health compared with non-caregivers, wives differed from daughters in burden appraisal and had significantly poorer health. Almost no significant interactions of caregiving status by kinship tie were observed, suggesting that caregivers differed from non-caregivers irrespective of kinship tie. The multivariate analyses of health measures by caregiving context revealed that high-intensity caregivers and co-residing daughter caregivers were most vulnerable to poor health. Health services providers need to develop ways for early identification of vulnerable caregivers, providing support and care programs and targeting resources.

Cluster-randomized trial to improve antibiotic use for adults with acute respiratory infections treated in emergency departments.

STUDY OBJECTIVE: We evaluate the effectiveness of an educational program in hospital emergency departments (EDs) targeting reduction in antibiotic overuse for acute respiratory tract infections. METHODS: Sixteen hospitals participated in the cluster randomized trial, selecting a Veterans Administration (VA) and non-VA hospital within each of 8 metropolitan regions. Intervention sites received performance feedback, clinician education, and patient educational materials, including an interactive computer kiosk located in the waiting room. Medical records were reviewed at each site during the baseline year 1 and intervention year 2. The primary measure of effect was the percentage of visits for upper respiratory tract infections and acute bronchitis that were treated with antibiotics. Secondary outcomes, including return visits and visit satisfaction, were assessed by follow-up telephone interviews of patients. Alternating logistic regression models were used to adjust for baseline treatment rates, case mix differences, and provider characteristics. RESULTS: The adjusted antibiotic prescription level for upper respiratory tract infection/acute bronchitis visits was 47% for control sites and 52% for intervention sites in year 1. Antibiotic prescriptions at control sites increased by 0.5% between year 1 and year 2 (95% confidence interval -3% to 5%) and at intervention sites decreased by 10% (95% confidence interval -18% to -2%). There were no significant differences between control and intervention sites in the proportions of upper respiratory tract infection/bronchitis patients with return ED visits or in overall visit satisfaction. CONCLUSION: Multidimensional educational interventions can reduce antibiotic overuse in the treatment of patients with upper respiratory tract infections and acute bronchitis in EDs. However, substantial antibiotic overuse persists despite this educational intervention.

Caregiving stressors and psychological distress among veteran resident and immigrant family caregivers in Israel.

The study compared caregiving stressors and psychological distress between Israeli veteran resident and immigrant family caregivers. It examined whether psychosocial variables (appraisal of caregiving, mastery, social support and coping) mediate the differences in psychological distress between these two groups. A total of 213 veteran resident and 206 immigrant (from the former Soviet Union) caregivers of chronically ill elderly were recruited from health services. The comparisons between the two groups were examined separately for spouse and adult child caregivers. The immigrant spouse and adult child caregivers reported significantly higher levels of caregiving stressors than veteran resident caregivers, but psychological distress was significantly higher only among the immigrant adult child caregivers. In multivariate analyses, the difference in psychological distress disappeared when caregiving stressors and mediating psychosocial variables were included in the regression models. Different caregiving stressors and psychosocial variables were associated with psychological distress among the spouses and among the adult child caregivers. The findings suggest that the caregiving stressors and psychosocial variables explain differences in psychological health outcomes between veteran resident and immigrant caregivers. Social work interventions should address these factors among caregivers, take into account the relationship to the care recipient, be culturally adapted to the immigrant caregivers, and target immigrant adult child caregivers in particular.

Antibiotic treatment of acute respiratory infections in acute care settings.

OBJECTIVES: To examine the patterns of antibiotic use for acute respiratory tract infections (ARIs) in acute care settings. METHODS: Chart reviews were performed retrospectively on a random sample of adult ARI visits to seven Veterans Affairs (VA) and seven non-VA emergency departments (EDs) for the period of November 2003 to February 2004. Visits were limited to those discharged to home and those with primary diagnoses of antibiotic-responsive (pneumonia, acute exacerbation of chronic bronchitis, pharyngitis, sinusitis) and antibiotic-nonresponsive conditions (acute bronchitis, nonspecific upper respiratory tract infection [URI]). Results are expressed as adjusted odds ratios with 95% confidence intervals. RESULTS: Of 2,270 ARI visits, 62% were for antibiotic-nonresponsive diagnoses. Seventy-two percent of acute bronchitis and 38% of URI visits were treated with antibiotics (p < 0.001). Stratified analyses show that antibiotic prescription rates were similar among attending-only and housestaff-associated visits for antibiotic-responsive diagnoses (p = 0.11), and acute bronchitis (76% vs. 59%; p = 0.31). However, the antibiotic prescription rate for URIs was greater for attending-only visits compared with housestaff-associated visits (48% vs. 15%; p = 0.01). Antibiotic prescription rates for total ARIs varied between sites, ranging from 42% to 89%. Patient age, gender, race and ethnicity, smoking status, comorbidities, and clinical setting (VA vs. non-VA) were not independently associated with antibiotic prescribing. CONCLUSIONS: Acute care settings are important targets for reducing inappropriate antibiotic prescribing. The mechanisms accounting for lower antibiotic prescription rates observed with housestaff-associated visits merit further study.

Randomized clinical trial of the efficacy of bupropion combined with nicotine patch in the treatment of adolescent smokers.

Adolescent smokers (N = 211) were randomized to 1 of 2 groups: (a) nicotine patch plus bupropion SR (sustained release; 150 mg per day) or (b) nicotine patch plus placebo. Group skills training sessions were conducted each week by research staff. Abstinence rates at Weeks 10 and 26 were as follows: (a) patch plus bupropion, 23% and 8%, (b) patch plus placebo, 28% and 7%. Despite the lack of a treatment effect, a large majority of adolescents in both treatment groups reduced their consumption to a few cigarettes per day or less and maintained this reduction over time. Similarly, an examination of survival curves revealed that by the end of treatment many had managed to avoid a return to daily smoking. These findings are encouraging and suggest new avenues for research. For example, treatments of the kind examined in this report, augmented by extended maintenance therapies, may yield higher long-term success rates.