Low Income Suburban Residents Perceive a Greater Lack of Specialty But not Primary Care Physicians than Those with Higher Incomes.

As the number of low income residents in suburban areas increases, they may present new healthcare delivery challenges. We compared residents' perceptions of access to primary care (PCP) and specialty (SCP) physicians by income categories in two adjacent counties of New York, which differ in physician density and public healthcare delivery models. Telephone interviews of 812 residents of Nassau (NC, 6.9 physicians/1000) and Suffolk (SC, 3.5 physicians/1000) counties were conducted, assessing perceptions of whether there were "too few," or "about the right number" of PCPs and SCPs. Counties were compared using bivariate analysis; multivariate analyses examined the association of perceptions of PCP and SCP access with demographic variables, including income. Twice as many SC respondents perceived too few SCPs compared to NC (35.31 vs. 18.27%, p = .001) and 50% more perceived too few PCPs (32.56 vs. 23.85%, p = .06). Thus, physician access was a perceived problem for many in SC despite a supply greater than the national average. For both counties combined, those with household incomes less than $35,000/year were twice as likely to perceive too few SCPs (p = .05), while in SC, this group was more than three times as likely to perceive too few SCPs (p = .02). There were no significant associations between income and perception of PCP availability. Thus, both counties have eliminated income-related differences in perceived access to PCPs. However, this is not the case for SCPs, especially in SC, which, unlike NC, has no publically supported specialty care. As the number of low income suburban residents increases, access to specialty care presents an important challenge for some areas.

Chronic stress and associated coping strategies among volunteer EMS personnel.

OBJECTIVE: This study assessed the chronic (everyday) stress experiences and coping strategies among volunteer Emergency Medical Services personnel. METHODS: An anonymous, self-report survey using standardized measures of burnout (the Maslach Burnout Inventory) and coping (the Coping Mechanisms Checklist) was completed by a convenience sample of volunteer Emergency Medical Services personnel serving one of six participating ambulance companies in Suffolk County, New York. RESULTS: Survey responders included 139 of 175 volunteers who were recruited to participate (response rate = 79%). Alarming percentages of participants scored high on emotional exhaustion (92%) and depersonalization (99%); however, 75% also reported high levels of personal accomplishment. The use of several coping strategies were concerning. Significant differences were found in coping strategies used between genders and number of years served; women were more likely to talk with significant others (97% vs. 81.7%, chi-square = 6.849, p < 0.001), whereas men were more likely to indicate that they pick and choose calls to go on (67% vs. 49%, chi-square = 4.062, p = 0.044). Participants with 6+ years were more likely than those with fewer years to "keep thoughts/feelings to self" (95.6% vs. 81.2%, chi-square = 5.72, p = 0.017) and "engage in risky behaviors" (47.82% vs. 30.43%, chi-square = 3.68, p = 0.055). Approximately half of responders indicted that they do the bare minimum required to stay an active member of their ambulance company (53%). ANOVAs revealed that use of several coping strategies were significantly associated with depersonalization and personal accomplishment scores. CONCLUSION: Gender, years of experience, the types of coping strategies used, and high levels of depersonalization and emotional exhaustion must be considered when developing mental health programs for chronic stress among volunteer Emergency Medical Services personnel.

The effect of message frames and CVD risk factors on behavioral outcomes.

OBJECTIVES: To examine the interactive effects of message frames and CVD risk factors on women's knowledge, beliefs, efficacy, and behavioral intentions. METHODS: In a randomized experiment, women (n = 395) read either a loss- or gain-framed heart disease prevention message to test differential effects by risk factor status. RESULTS: Messages significantly increased knowledge, self-efficacy and intervention efficacy beliefs, and behavioral intentions. Frames had significantly different effects on self-efficacy and behavioral intent to engage in detection behaviors by parental risk factor status. CONCLUSIONS: Further study is warranted to assess effects of frames on behavioral outcomes among women at elevated CVD risk.

Sex bias in referral of women to outpatient cardiac rehabilitation? A meta-analysis.

BACKGROUND: Cardiovascular disease continues to be among the leading causes of morbidity and mortality among men and women globally. However, research suggests that women are significantly underrepresented in cardiac rehabilitation (CR), programmes which are shown to reduce recurrent cardiac events and related premature death. However, sex differences in referral rates have not been systematically and quantitatively reviewed. Hence, the objective of the study was to assess whether a significant sex difference exists. METHODS: We searched Scopus, MEDLINE, CINAHL, PsycINFO, PubMed, and The Cochrane Library databases for studies reporting CR referral rates in women and men published between July 2000 and July 2011. Titles and abstracts were screened, and the selected full-text articles were independently screened based on predefined inclusion/exclusion criteria. Included articles were assessed for quality using STROBE. RESULTS: Of 623 screened articles, 19 observational studies reporting data for 241,613 participants (80,505 women) met the inclusion criteria. In the pooled analysis, women (39.6%) were significantly less likely to be referred to CR compared to men (49.4%; odds ratio 0.68, 95% confidence interval 0.62-0.74). Heterogeneity was considered significant (I (2 )= 90%). There was no change in significant findings when subgroup analyses were conducted, examining fee for service vs. no fee, high-quality studies vs. others, or studies pooled by different study methodologies. CONCLUSIONS: CR referral remains low for all patients, but is significantly lower for women than men. Evidence-based interventions to increase referral for all patients, including women, need to be instituted. It is time to ensure broader implementation of these strategies.

Can a brief video intervention improve breast cancer clinical trial knowledge and beliefs?

A total of 262 women in the USA (161 breast cancer survivors and 101 controls) were exposed to a video vignette using modeling in which a physician discussed the concept of a clinical trial (CT) with a woman who was in the process of making a treatment decision. A pretest-post-test design was used and improvements in clinical trial knowledge and beliefs were assessed. Results indicate that video modeling is a powerful tool for increasing CT knowledge (pretest mean=41.5% correct, post-test mean=77.5% correct) but not for improving CT beliefs. Increased clinical trial knowledge, as measured by change scores, was associated with white race, lower levels of education and pretest breast cancer knowledge, more negative pretest CT beliefs, and a higher estimate of the lifetime probability that a woman will have breast cancer. When pretest CT knowledge was added to the analysis using hierarchical multiple regression, all variables except white race became nonsignificant; an increase in CT knowledge was associated with having lower pretest CT knowledge. Results indicate that the effects of low education, low breast cancer knowledge, and biased probability assessment were mediated through the pretest score. An increase in post-test positive CT beliefs was associated with older age, thinking about breast cancer less often, and having lower pretest CT knowledge in the total sample. When pretest CT beliefs was added to the analysis using hierarchical multiple regression, all other variables became nonsignificant; an increase in CT beliefs was associated with having lower pretest CT beliefs, again indicating mediation of the effects of other variables.

Awareness of the 2010 guidelines implemented by the New York State Education Department for respiratory therapists in their role as clinical preceptors.

BACKGROUND: In 1993, the New York State (NYS) legislature and governor signed into law the Respiratory Therapy Guide to Practice Education Law to guide and regulate the profession of respiratory care under the auspices of the New York State Education Department. New guidelines were implemented by the New York State Education Department for respiratory therapists (RTs) in 2010 to provide the opportunity for RTs to receive continuing education units (CEUs) when participating as clinical preceptors. This study was conducted in June 2012 to determine the extent to which the NYS RTs are aware of the new licensing guidelines and amendments. METHODS: In June 2012, a web-based survey was e-mailed to 2,503 NYS members of the New York State Society for Respiratory Care, 14% of which (n= 360) completed the survey. The survey included 21 items to assess RTs' awareness of the licensing guidelines that were implemented in 2010, and these respondents were analyzed using basic descriptive statistics. RESULTS: The study showed that 50% of the respondents were not aware of eligibility to earn CEUs as a clinical preceptor in NYS. Twenty-eight percent responded correctly that licensed RTs were eligible to earn CEUs as a clinical preceptor in NYS. In addition, 67% of those who responded were unaware of how many CEUs could be earned for each renewal period for clinical precepting. Finally, 70% of the respondents indicated that they would be inclined to seek employment at a facility that has a clinical affiliation with a university or college respiratory care program. CONCLUSIONS: The findings indicate that more education is needed in NYS to make licensed RTs aware of the 2010 guidelines. Practitioners may require incentives to become actively involved in the clinical education of respiratory care students as their clinical preceptors.

Sex differences in cardiac rehabilitation enrollment: a meta-analysis.

BACKGROUND: The present systematic review and meta-analysis examines studies published in the past 10 years that described cardiac rehabilitation (CR) enrollment among women and men, to determine whether a significant sex difference persists despite the evidence supporting the benefits of CR to women as well as men. METHODS: Scopus, MEDLINE, CINAHL, PsycINFO, PubMed, and The Cochrane Library databases were systematically searched for peer-reviewed articles published from July 2000 to July 2011. Titles and abstracts were screened, and the 623 selected full-text articles were independently screened based on predefined inclusion/exclusion criteria (guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses; PRISMA) and assessed for quality using the Strengthening the Reporting of Observational studies in Epidemiology (STROBE) statement form. The meta-analysis was undertaken using Review Manager software. RESULTS: Twenty-six eligible observational studies reporting data for 297,719 participants (128,499 [43.2%] women) were included. On average, 45.0% of men and 38.5% of women enrolled in CR. In the pooled analysis, men were more likely to be enrolled in CR compared with women (female enrollment vs male enrollment odds ratio, 0.64; 95% confidence interval, 0.57-0.72; P < 0.00001). Heterogeneity was considered high (I(2) = 78%). In the subgroup analyses, systematic CR referral during inpatient tertiary care resulted in significantly greater enrollment among women than nonsystematic referral. CONCLUSIONS: Overall, rates of CR enrollment among women are significantly lower compared with men, with women being 36% less likely to enroll in a rehabilitation program.

Examining the effect of a patient navigation intervention on outpatient cardiac rehabilitation awareness and enrollment.

PURPOSE: Awareness of and enrollment in outpatient cardiac rehabilitation (OCR) following a cardiac event or procedure remain suboptimal. Thus, it is important to identify new approaches to improve these outcomes. The objectives of this study were to identify (1) the contributions of a patient navigation (PN) intervention and other patient characteristics on OCR awareness; and (2) the contributions of OCR awareness and other patient characteristics on OCR enrollment among eligible cardiac patients up to 12 weeks posthospitalization. METHODS: In this randomized controlled study, 181 eligible and consenting patients were assigned to either PN (n = 90) or usual care (UC; n = 91) prior to hospital discharge. Awareness of OCR was assessed by telephone interview at 12 weeks posthospitalization, and OCR enrollment was confirmed by staff at collaborating OCR programs. Of the 181 study participants, 3 died within 1 month of hospital discharge and 147 completed the 12-week telephone interview. RESULTS: Participants in the PN intervention arm were nearly 6 times more likely to have at least some awareness of OCR than UC participants (OR = 5.99; P = .001). Moreover, participants who reported at least some OCR awareness were more than 9 times more likely to enroll in OCR (OR = 9.27, P = .034) and participants who were married were less likely to enroll (P = .031). CONCLUSIONS: Lay health advisors have potential to improve awareness of outpatient rehabilitation services among cardiac patients, which, in turn, can yield greater enrollment rates in a program.

Referral to outpatient cardiac rehabilitation: intervention research at the patient, provider, and health system levels.

This article sets out the clinical context of the research presented by Grace et al. in an accompanying article in this journal. Secondary preventive measures against cardiovascular disease, such as outpatient cardiac rehabilitation (OCR), can greatly reduce associated burden on health systems. Here, I discuss the study carried out by Grace and colleagues--a multilevel study of the contribution of patient and physician factors to cardiac rehabilitation referral. Grace et al. demonstrate that both physician and patient factors have key roles in OCR referral. In this commentary I explore the limitations of studying the factors that contribute to referral alone as a final end point given the lower-than-desired rates of enrollment among referred patients.

Physical therapists as providers of care: exercise prescriptions and resultant outcomes in cardiac and pulmonary rehabilitation programs in new york state.

PURPOSE: Physical therapists have engaged in cardiac rehabilitation (CR) and pulmonary rehabilitation (PR) for decades, but the extent of their current involvement in this practice area is unclear. This study surveyed directors of CR and PR programs on a statewide level to ascertain what type of provider is writing the prescription, which methods of exercise formulation are used, which outcome measures are used and their congruency with established guidelines. METHODS: A convenience sample of outpatient CR and PR directors (n=31) representing 38 CR and/or PR programs located in New York completed a survey in spring 2005 (29 CR and 9 PR). RESULTS: RESULTS showed that only 2 physical therapists were responsible for writing exercise prescriptions in CR and PR programs. Most program directors were registered nurses (53%), who also wrote the majority of CR exercise prescriptions. Exercise intensity was most frequently determined using formulae and data that were highly patient-specific. Clinical outcomes most frequently included Quality of Life scales and stress tests. CONCLUSIONS: Physical therapists are minimally involved in directing programs and writing exercise prescriptions. Exercise prescriptions are individualized to the patient. Outcome measures most frequently used by participating CR and PR program directors are consistent with nationally-recognized best practice.

The role of physician characteristics in clinical trial acceptance: testing pathways of influence.

Eight videotaped vignettes were developed that assessed the effects of three physician-related experimental variables (in a 2 x 2 x 2 factorial design) on clinical trial (CT) knowledge, video knowledge, information processing, CT beliefs, affective evaluations (attitudes), and CT acceptance. It was hypothesized that the physician variables (community versus academic-based affiliation, enthusiastic versus neutral presentation of the trial, and new versus previous relationship with the patient) would serve as communication cues that would interrupt message processing, leading to lower knowledge gain but more positive beliefs, attitudes, and CT acceptance. A total of 262 women (161 survivors and 101 controls) participated in the study. The manipulated variables primarily influenced the intermediary variables of post-test CT beliefs and satisfaction with information rather than knowledge or information processing. Multiple regression results indicated that CT acceptance was associated with positive post-CT beliefs, a lower level of information processing, satisfaction with information, and control status. Based on these results, CT acceptance does not appear to be based on a rational decision-making model; this has implications for both the ethics of informed consent and research conceptual models.

Alternative models in the delivery of primary and secondary prevention programs.

Despite the strong scientific evidence supporting the effectiveness of cardiovascular risk reduction interventions, their application is inconsistent across medical care settings and patient groups. Traditional approaches have been largely ineffective. Thus, there is an urgent need to develop and implement innovative approaches that provide persons with or at risk for coronary heart disease effective risk reduction interventions that are accessible and affordable. Advanced practice nurses and community health workers providing care as members of multidisciplinary teams have been successful strategies for improving outcomes. This paper describes the evidence supporting these alternative models and suggests strategies for the delivery of such programs for the primary and secondary prevention of coronary heart disease.

Disparities in women's referral to and enrollment in outpatient cardiac rehabilitation.

OBJECTIVE: The purpose of this study was to determine the predictors of referral and enrollment, including racial differences, in phase 2 cardiac rehabilitation programs among African-American and white women who are eligible for such programs. DESIGN: Prospective longitudinal design. SETTING: One large academic medical center and two large community hospitals. PATIENTS: A total of 253 women (108 African American, 145 white) were surveyed within the first month of discharge from the hospital for a percutaneous coronary intervention, coronary artery bypass surgery, or myocardial infarction without revascularization. A total of 234 (99 African American, 135 white) completed the 6-month follow-up. MAIN RESULTS: The rate of referral to outpatient phase 2 cardiac rehabilitation was significantly lower for African-American women compared with white women, 12 (12%) versus 33 (24%) (P=.03). Only 35 (15%) of women in the study reported enrollment in phase 2 cardiac rehabilitation programs, with fewer African-American women reporting enrollment compared with white women, 9 (9%) versus 26 (19%) (P=.03). Controlling for age, education, angina class, and comorbidities, women with annual incomes <20,000 dollars were 66% less likely to be referred to cardiac rehabilitation (P=.01) and 60% less likely to enroll compared to women with incomes >20,000 dollars (P=.01). Although borderline significant, African-American women were 55% less likely to be referred (P=.059) and 58% less likely to enroll (P=.059) than white women. CONCLUSIONS: We found disparities in cardiac rehabilitation program participation, with women with lower incomes less likely to be referred and to have lower enrollment rates in cardiac rehabilitation and a strong trend for African-American women to be less likely to be referred and enroll. Because almost all patients who have had an acute coronary event, with or without revascularization procedures, will benefit from cardiac rehabilitation, automatic referral systems should be considered to increase utilization and reduce disparities.

Community-based cancer screening programs in older populations: making progress but can we do better?

BACKGROUND: Older individuals have higher rates of most types of cancer. Community-based cancer screening programs offer one avenue for addressing the need to prevent or detect cancers in early stages in this population. Identifying characteristics of successful interventions can assist researchers in the development of future studies. METHODS: A comprehensive literature review of community-based cancer screening interventions was undertaken and 114 behavioral interventions for breast, cervical and colorectal cancer screening published prior to 2000 and 42 studies published during 2000-2003 were identified. From these, 17 studies were identified as model interventions that were effective in significantly increasing screening rates among older populations. RESULTS: Effective interventions employed a variety of strategies including the use of social networks and lay health care workers, mass media, community-based education, reminder notices/behavioral cues, and health care provider assistance. CONCLUSION: Although subgroups of individuals still have lower rates of screening, the results indicate that older populations can be encouraged to engage in appropriate cancer screening behaviors through community-based interventions. The next round of interventions could be strengthened by evaluating intervention components, integrating theory and community participation into designs, focusing on those most at need, and considering program sustainability and costs.