Separate But Not Equal? A Cross-Sectional Study of Segregation by Payor Mix in Academic Primary Care Clinics.

BACKGROUND: At some US Academic Health Centers (AHCs), patients with predominantly Medicaid insurance are seen in one clinic and patients with other insurance are seen in another. The extent of this practice and implications are unknown. OBJECTIVE: To estimate the proportion of AHCs that have at least two primary care internal medicine clinics that differ substantially in proportion of patients with Medicaid and to compare patient demographic, staffing, and operational features. PARTICIPANTS: General internal medicine chiefs and clinic directors at 40 randomly selected US AHCs plus the top 10 AHCs in terms of NIH funding. MAIN MEASURE: An AHC was classified as maintaining clinics that differed substantially in the proportion of patients with Medicaid if any two differed by ≥ 40% (absolute). Other criteria were used for pre-specified secondary analyses (e.g., ≥ 30%). KEY RESULTS: Thirty-nine of 50 AHCs (78%) participated. Four of 39 (10%; 95% CI, 3 to 24%) had two clinics differing by ≥ 40% in the proportion of patients with Medicaid, eight (21%; 95% CI, 9 to 36%) had clinics differing by ≥ 30%, and 15 (38%; 95% CI, 23 to 55%) had clinics differing by ≥ 20%. Clinics with more patients with Medicaid by any of the three criteria were more likely to employ resident physicians as providers of longitudinal care (with faculty supervision) and more likely to have patients who were Black or Hispanic. CONCLUSIONS: Some US AHCs maintain separate clinics defined by the proportion of patients with Medicaid. Clinics with a higher proportion of patients insured by Medicaid are more likely to employ residents (with faculty oversight), feature residents as providers of longitudinal care, and serve patients who are Black and Hispanic. Further research is needed to understand why some AHCs have primary care clinics distinguishable by insurance mix with the goal of ensuring that racism and discrimination are not root causes.

Behavioral and psychosocial responses to genomic testing for colorectal cancer risk.

We conducted a translational genomic pilot study to evaluate the impact of genomic information related to colorectal cancer (CRC) risk on psychosocial, behavioral and communication outcomes. In 47 primary care participants, 96% opted for testing of three single nucleotide polymorphisms (SNPs) related to CRC risk. Participants averaged 2.5 of 6 possible SNP risk alleles (10% lifetime risk). At 3-months, participants did not report significant increases in cancer worry/distress; over half reported physical activity and dietary changes. SNP risk scores were unrelated to behavior change at 3-months. Many participants (64%) shared their SNP results, including 28% who shared results with a physician. In this pilot, genomic risk education, including discussion of other risk factors, appeared to impact patients' health behaviors, regardless of the level of SNP risk. Future work can compare risk education with and without SNP results to evaluate if SNP information adds value to existing approaches.

"Is it really worth it to get tested?": primary care patients' impressions of predictive SNP testing for colon cancer.

Despite significant progress in genomics research over the past decade, we remain years away from the integration of genomics into routine clinical care. As an initial step toward the implementation of genomic-based medicine, we explored primary care patients' ideas about genomic testing for common complex diseases to help develop future patient education materials and interventions to communicate genomic risk information. We conducted a mixed-methods study with participants from a large primary care clinic. Within four focus groups, we used a semi-structured discussion guide and administered brief pre- and post- discussion quantitative surveys to assess participants' interest, attitudes, and preferences related to testing and receipt of test results. Prior to the discussion, moderators presented a plain-language explanation of DNA and genetics, defined "SNP", and highlighted what is known and unknown about the risks associated with testing for SNPs related to colorectal cancer risk. We used the NVIVO 8 software package to analyze the transcripts from the focus group discussions. The majority of participants (75 %) were "very" or "somewhat interested" in receiving information from a colon cancer SNP test, even after learning about and discussing the small and still clinically uncertain change in risk conferred by SNPs. Reported interest in testing was related to degree of risk conferred, personal risk factors, family history, possible implications for managing health /disease prevention and curiosity about genetic results. Most people (85 %) preferred that genetic information be delivered in person by a healthcare or genetics professional rather than through print materials or a computer. These findings suggest that patients may look to genetic counselors, physicians or other healthcare professionals as gatekeepers of predictive genomic risk information.

Men's use of an Internet-based decision aid for prostate cancer screening.

Most medical organizations recommend informed decision making before undergoing prostate cancer screening. The authors conducted a detailed evaluation of men's use of an interactive, Web-based prostate cancer screening decision aid. Participants (N = 531) were 57 years old (SD = 6.8), 37% were African American, and 92% had Internet access. Men completed 2 telephone interviews, pre- and 1-month post-Web site availability. Half of the sample (n = 256) accessed the Web site. Multivariate analysis revealed that users were more likely than nonusers to be White (OR = 2.37, CI 1.6-3.6), previously screened (OR = 2.13, CI 1.07-4.26), have Internet access (OR = 3.66, CI 1.15-11.58), and to report daily Internet use (OR = 2.58, CI 1.47-4.55). Agreement between self-reported and actual Web site use was moderate (κ = .67). Tracking software revealed a mean of 1.3 (SD = 0.5) log-ons and a median of 38 min per log-on. Of participants, 84% used the values clarification tool, and more than 50% viewed each video testimonial. Baseline screening preference was associated with values clarification tool responses and Web site feedback. This study revealed that, beyond the digital divide, Web site use depended on more than Internet access. Further, electronic tracking of Web site use demonstrated overestimation of self-reported use, high use of interactive features, and effect of baseline screening preference on men's response to the Web site.

The development of a web- and a print-based decision aid for prostate cancer screening.

BACKGROUND: Whether early detection and treatment of prostate cancer (PCa) will reduce disease-related mortality remains uncertain. As a result, tools are needed to facilitate informed decision making. While there have been several decision aids (DAs) developed and tested, very few have included an exercise to help men clarify their values and preferences about PCa screening. Further, only one DA has utilized an interactive web-based format, which allows for an expansion and customization of the material. We describe the development of two DAs, a booklet and an interactive website, each with a values clarification component and designed for use in diverse settings. METHODS: We conducted two feasibility studies to assess men's (45-70 years) Internet access and their willingness to use a web- vs. a print-based tool. The booklet was adapted from two previous versions evaluated in randomized controlled trials (RCTs) and the website was created to closely match the content of the revised booklet. Usability testing was conducted to obtain feedback regarding draft versions of the materials. The tools were also reviewed by a plain language expert and the interdisciplinary research team. Feedback on the content and presentation led to iterative modifications of the tools. RESULTS: The feasibility studies confirmed that the Internet was a viable medium, as the majority of men used a computer, had access to the Internet, and Internet use increased over time. Feedback from the usability testing on the length, presentation, and content of the materials was incorporated into the final versions of the booklet and website. Both the feasibility studies and the usability testing highlighted the need to address men's informed decision making regarding screening. CONCLUSIONS: Informed decision making for PCa screening is crucial at present and may be important for some time, particularly if a definitive recommendation either for or against screening does not emerge from ongoing prostate cancer screening trials. We have detailed our efforts at developing print- and web-based DAs to assist men in determining how to best meet their PCa screening preferences. Following completion of our ongoing RCT designed to test these materials, our goal will be to develop a dissemination project for the more effective tool. TRIAL REGISTRATION: NCT00623090.

How well do second-year students learn physical diagnosis? Observational study of an Objective Structured Clinical Examination (OSCE).

BACKGROUND: Little is known about using the Objective Structured Clinical Examination (OSCE) in physical diagnosis courses. The purpose of this study was to describe student performance on an OSCE in a physical diagnosis course. METHODS: Cross-sectional study at Harvard Medical School, 1997-1999, for 489 second-year students. RESULTS: Average total OSCE score was 57% (range 39-75%). Among clinical skills, students scored highest on patient interaction (72%), followed by examination technique (65%), abnormality identification (62%), history-taking (60%), patient presentation (60%), physical examination knowledge (47%), and differential diagnosis (40%) (p <.0001). Among 16 OSCE stations, scores ranged from 70% for arthritis to 29% for calf pain (p <.0001). Teaching sites accounted for larger adjusted differences in station scores, up to 28%, than in skill scores (9%) (p <.0001). CONCLUSIONS: Students scored higher on interpersonal and technical skills than on interpretive or integrative skills. Station scores identified specific content that needs improved teaching.

Decision making in prostate cancer screening using decision aids vs usual care: a randomized clinical trial.

IMPORTANCE: The conflicting recommendations for prostate cancer (PCa) screening and the mixed messages communicated to the public about screening effectiveness make it critical to assist men in making informed decisions. OBJECTIVE: To assess the effectiveness of 2 decision aids in helping men make informed PCa screening decisions. DESIGN, SETTING, AND PARTICIPANTS: A racially diverse group of male outpatients aged 45 to 70 years from 3 sites were interviewed by telephone at baseline, 1 month, and 13 months, from 2007 through 2011. We conducted intention-to-treat univariate analyses and multivariable linear and logistic regression analyses, adjusting for baseline outcome measures. INTERVENTION: Random assignment to print-based decision aid (n = 628), web-based interactive decision aid (n = 625), or usual care (UC) (n = 626). MAIN OUTCOMES AND MEASURES: Prostate cancer knowledge, decisional conflict, decisional satisfaction, and whether participants underwent PCa screening. RESULTS: Of 4794 eligible men approached, 1893 were randomized. At each follow-up assessment, univariate and multivariable analyses indicated that both decision aids resulted in significantly improved PCa knowledge and reduced decisional conflict compared with UC (all P <.001). At 1 month, the standardized mean difference (Cohen's d) in knowledge for the web group vs UC was 0.74, and in the print group vs UC, 0.73. Decisional conflict was significantly lower for web vs UC (d = 0.33) and print vs UC (d = 0.36). At 13 months, these differences were smaller but remained significant. At 1 month, high satisfaction was reported by significantly more print (60.4%) than web participants (52.2%; P = .009) and significantly more web (P = .001) and print (P = .03) than UC participants (45.5%). At 13 months, differences in the proportion reporting high satisfaction among print (55.7%) compared with UC (49.8%; P = .06) and web participants (50.4%; P = .10) were not significant. Screening rates at 13 months did not differ significantly among groups. CONCLUSIONS AND RELEVANCE: Both decision aids improved participants' informed decision making about PCa screening up to 13 months later but did not affect actual screening rates. Dissemination of these decision aids may be a valuable public health tool. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00196807.