Preferences for self-management support: findings from a survey of diabetes patients in safety-net health systems.

OBJECTIVE: We sought to identify interest in different modes of self-management support among diabetes patients cared for in public hospitals, and to assess whether demographic or disease-specific factors were associated with patient preferences. We explored the possible role of a perceived communication need in influencing interest in self-management support. METHODS: Telephone survey of a random sample of 796 English and Spanish-speaking diabetes patients (response rate 47%) recruited from four urban US public hospital systems. In multivariate models, we measured the association of race/ethnicity, primary language, self-reported health literacy, self-efficacy, and diabetes-related factors on patients' interest in three self-management support strategies (telephone support, group medical visits, and Internet-based support). We explored the extent to which patients believed that better communication with providers would improve their diabetes control, and whether this perception altered the relationship between patient factors and self-management support acceptance. RESULTS: Sixty-nine percent of respondents reported interest in telephone support, 55% in group medical visits, and 42% in Internet. Compared to Non-Hispanic Whites, Spanish-speaking Hispanics were more interested in telephone support (OR 3.45, 95% CI 1.97-6.05) and group medical visits (OR 2.45, 95% CI 1.49-4.02), but less interested in Internet self-management support (OR 0.56, 95% CI 0.33-0.93). African-Americans were more interested than Whites in all three self-management support strategies. Patients with limited self-reported health literacy were more likely to be interested in telephone support than those not reporting literacy deficits. Forty percent reported that their diabetes would be better controlled if they communicated better with their health care provider. This perceived communication benefit was independently associated with interest in self-management support (p<0.001), but its inclusion in models did not alter the strengths of the main associations between patient characteristics and self-management support preferences. CONCLUSION: Many diabetes patients in safety-net settings report an interest in receiving self-management support, but preferences for modes of delivery of self-management support vary by race/ethnicity, language proficiency, and self-reported health literacy. PRACTICE IMPLICATIONS: Public health systems should consider offering a range of self-management support services to meet the needs of their diverse patient populations. More broad dissemination and implementation of self-management support may help address the unmet need for better provider communication among diabetes patients in these settings.

Glycemic and lipid control among patients with diabetes at six U.S. public hospitals.

OBJECTIVE: Public hospital systems share a mission to provide access to healthcare regardless of ability to pay. While public hospital systems care for large numbers of socioeconomically vulnerable and ethnically diverse populations who have diabetes, little is known about the quality of diabetes care provided in these sites. METHODS: We assessed the measurement and control of hemoglobin A1c (HbA1c) and lipids (LDL) in a sample of patients with diabetes with > or =2 outpatient visits per year in two consecutive years at one of 6 public hospitals (N=14,222). RESULTS: High proportions of patients had at least one HbA1c and LDL measurement within 2 years (89% and 88%, respectively). Thirty-five percent had HbA1c < 7.0%; 21% had HbA1c > or =9.5%; 36% had LDL<100 mg/dl; 10% had LDL>160 mg/dl. Non-White patients and patients who were never insured were most at risk for poor glycemic and lipid control. CONCLUSIONS: The quality of care, as measured by glycemic and lipid monitoring and control among ongoing users of public hospital systems, was similar to that of other health systems, but disparities exist across race/ethnicity and insurance status. Because of the critical role these institutions play in providing care to the underserved, research is needed to explore factors contributing to differences in glycemic and lipid control and develop strategies to improve chronic disease management in these systems.

A proposal for the development of national certification standards for patient decision aids in the US.

Efforts to implement the use of patient decision aids to stimulate shared decision making are gaining prominence. Patient decision aids have been designed to help patients participate in making specific choices among health care options. Because these tools clearly influence decisions, poor quality, inaccurate or unbalanced presentations or misleading tools are a risk to patients. As payer interest in these tools increases, so does the risk that patients are harmed by the use of tools that are described as patient decision aids yet fail to meet established standards. To address this problem, the National Quality Forum (NQF) in the USA convened a multi-stakeholder expert panel in 2016 to propose national standards for a patient decision aid certification process. In 2017, NQF established an Action Team to foster shared decision making, and to call for a national certification process as one recommendation among others to stimulate improvement. A persistent barrier to the setup of a national patient decision aids certification process is the lack of a sustainable financial model to support the work.

Junior faculty's perspectives on mentoring.

The prevalence and characteristics of mentorship among junior faculty in clinician-scientist and clinician-educator tracks were evaluated. Comprehensive improvement strategies are needed.

Colorectal cancer screening among African Americans: the importance of physician recommendation.

INTRODUCTION: African Americans have higher colorectal cancer incidence and mortality rates than whites. They are also more likely to be diagnosed with late-stage disease and less likely to survive for at least five years after diagnosis. Lack of adherence to colorectal cancer screening recommendations has previously been found to be associated with lower income, lower educational level, and racial/ethnic minority status. METHODS: One hundred-fifty African-American patients (aged 50-79 years) of an inner city hospital, were surveyed by mail and telephone in early 2002. Seventy-six patients completed the survey, and data from 74 surveys were analyzed. RESULTS: Approximately one-half (55%) of the respondents reported having received a fecal occult blood test (FOBT) in the last 12 months, sigmoidoscopy in the last five years, or colonoscopy in the last 10 years. Thirty-nine percent of the survey participants reported never having received a physician recommendation for FOBT, 60% reported never having received a recommendation for sigmoidoscopy, and 57% reported never having received a recommendation for colonoscopy. Previous physician recommendation was strongly associated (p < 0.001) with levels of FOBT, sigmoidoscopy, and colonoscopy use. DISCUSSION: Future studies should examine factors that influence primary care physicians' decision-making about ordering colorectal cancer screening tests, as well as patients' decision-making regarding adherence to physician recommendations.

In search of mixed anxiety-depressive disorder: a primary care study.

The diagnosis of mixed anxiety-depressive disorder, as proposed in DSM-IV, is intended to be useful in settings such as primary care, where low-level anxiety and depressive symptoms may cause clinically significant impairment but are undiagnosable using current criteria. Evidence of the prevalence of this diagnosis is, however, lacking, particularly since the publication of the proposed diagnostic criteria in DSM-IV. Our study examined symptoms of anxiety and depression in 65 primary care patients screened for anxiety and depression while visiting their doctor. Results indicated that of the 37 patients without a diagnosable anxiety or depressive disorder, none had symptoms of depression and anxiety accompanied by interference that the patient deemed significant and attributable to his or her symptoms. These data dispute the need for a mixed anxiety-depression category (beyond mood and anxiety syndromes currently in DSM-IV) in future editions of the DSM.

Utilization management: issues, effects, and future prospects.

Utilization management encompasses a diverse set of activities designed to influence the use of health care services and thereby constrain health care resource consumption. Utilization management, which has become one of the most widely used cost-containment approaches, has engendered debate and controversy. Physicians have been outspoken critics of utilization management because it has limited their clinical autonomy and has contributed to an intolerable administrative burden. Insurance carriers, managed care plans, and third-party payers have defended the use of utilization management as an imperfect-but necessary-practice that is needed to reduce consumption of unnecessary or inappropriate health care services. This review examines the operation and effects of three widely used utilization management procedures: prospective utilization review, case management, and physician gatekeeping programs. In addition, it explores the future role of utilization management in the health care system and outlines a set of principles that we believe should be used to guide the development of utilization management strategies in the future.

Undertreatment of panic disorder in primary care: role of patient and physician characteristics.

BACKGROUND: In contrast with many studies describing the usual care for major depression in the primary care setting, there are few data on treatment received by primary care patients with panic disorder. METHODS: This prospective cohort study describes the self-reported medication use, at 3-month intervals for 1 year, of 58 patients with panic disorder and predictors of the use of appropriate (type, dose, and duration) medication. RESULTS: Approximately one half the patients received some type of antipanic medication at each interval, with selective serotonin reuptake inhibitors (SSRIs) the most common. Pharmacy records indicate that about 40% of patients not taking medication had received an initial physician prescription. Adequacy of dose and duration was achieved in only two thirds of the medication trials, usually with an SSRI. Patient characteristics (agoraphobia and low neuroticism) but not physician characteristics (eg, specialty, level of training, or years in practice) predicted those patients who had an adequate trial during at least one time interval. The relation between adequacy of medication and outcome was minimal. CONCLUSION: These findings highlight the continued undertreatment of panic disorder in primary care but suggest that focused efforts at physician education about diagnosis and treatment are less likely to increase rates of treatment compared with efforts to educate patients and improve the care process with more frequent visits and monitoring.

Self-management support in a web-based medical record: a pilot randomized controlled trial.

Physicians were much less likely than other primary care team members to use a Web-based application to counsel patients with diabetes about behavior change.