Improving Health Care for the Future Uninsured in Los Angeles County: A Community-Partnered Dialogue.

OBJECTIVE: To understand the health care access issues faced by Los Angeles (LA) County's uninsured and residually uninsured after implementation of the Affordable Care Act (ACA) and to identify potential solutions using a community-partnered dialogue. DESIGN: Qualitative study using a community-partnered participatory research framework. SETTING: Community forum breakout discussion. DISCUSSANTS: Representatives from LA County health care agencies, community health care provider organizations, local community advocacy and service organizations including uninsured individuals, and the county school district. MAIN OUTCOME MEASURES: Key structural and overarching value themes identified through community-partnered pile sort, c-coefficients measuring overlap between themes. RESULTS: Five overarching value themes were identified - knowledge, trust, quality, partnership, and solutions. Lack of knowledge and misinformation were identified as barriers to successful enrollment of the eligible uninsured and providing health care to undocumented individuals. Discussants noted dissatisfaction with the quality of traditional sources of health care and a broken cycle of trust and disengagement. They also described inherent trust by the uninsured in "outsider" community-based providers not related to quality. CONCLUSIONS: Improving health care for the residually uninsured after ACA implementation will require addressing dissatisfaction in safety-net providers, disseminating knowledge and providing health care through trusted nontraditional sources, and using effective and trusted partnerships between community and health care agencies with mutual respect. Community-academic partnerships can be a trusted conduit to discuss issues related to the health care of vulnerable populations.

Language concordance, interpersonal care, and diabetes self-care in rural Latino patients.

BACKGROUND: Interpersonal care (IPC) is increasingly emphasized as health care systems focus on implementing patient-centered care. Language barriers may be a particularly important influence on IPC ratings among rural Spanish-speaking Latinos. OBJECTIVE: To examine the associations between provider Spanish fluency and Spanish-speaking patients' ratings of IPC and between patient-provider language concordance and patient engagement in diabetes self-care activities. DESIGN: Cross-sectional survey combined with chart reviews. SETTING/PARTICIPANTS: Two hundred fifty Latino adults with diabetes receiving care at safety-net community health centers in two rural California counties. MAIN MEASURES: Using a validated questionnaire, we assessed patient ratings of IPC in three areas: communication, decision-making, and interpersonal style. Patient-provider language concordance was measured by physician self-reported fluency in Spanish. We measured participation in diabetes self-care activities by patient self-report. The survey response rate was 68%. KEY RESULTS: Patients with language-concordant providers had more favorable IPC ratings (20% to 41% of language-discordant patients had optimal scores for IPC scales vs. 35% to 69% of language-concordant patients, p < 0.05), except with respect to discrimination. Patients with language-concordant providers reported higher levels of participation in diabetic foot care (1.4 days vs. 0.7 days per week, p value 0.01) compared to patients with language discordance. There was no association between language concordance and participation in other self-care activities. CONCLUSION: This study provides evidence that language concordance is independently associated with high IPC scores in rural Latino adults with diabetes. Moreover, this study suggests that language concordance may contribute to improved participation diabetes self-care activities.

Long-term doctor-patient relationships: patient perspective from online reviews.

BACKGROUND: Continuity of patient care is one of the cornerstones of primary care. OBJECTIVE: To examine publicly available, Internet-based reviews of adult primary care physicians, specifically written by patients who report long-term relationships with their physicians. METHODS: This substudy was nested within a larger qualitative content analysis of online physician ratings. We focused on reviews reflecting an established patient-physician relationship, that is, those seeing their physicians for at least 1 year. RESULTS: Of the 712 Internet reviews of primary care physicians, 93 reviews (13.1%) were from patients that self-identified as having a long-term relationship with their physician, 11 reviews (1.5%) commented on a first-time visit to a physician, and the remainder of reviews (85.4%) did not specify the amount of time with their physician. Analysis revealed six overarching domains: (1) personality traits or descriptors of the physician, (2) technical competence, (3) communication, (4) access to physician, (5) office staff/environment, and (6) coordination of care. CONCLUSIONS: Our analysis shows that patients who have been with their physician for at least 1 year write positive reviews on public websites and focus on physician attributes.

Signal and noise: applying a laboratory trigger tool to identify adverse drug events among primary care patients.

BACKGROUND: The extent of outpatient adverse drug events (ADEs) remains unclear. Trigger tools are used as a screening method to identify care episodes that may be ADEs, but their value in a population with high chronic-illness burden remains unclear. METHODS: The authors used six abnormal laboratory triggers for detecting ADEs among adults in outpatient care. Eligible patients were included if they were >18 years, sought primary or urgent care between November 2008 and November 2009 and were prescribed at least one medication. The authors then used the clinical / administrative database to identity patients with these triggers. Two physicians conducted in-depth chart review of any medical records with identified triggers. RESULTS: The authors reviewed 1342 triggers representing 622 unique episodes among 516 patients. The trigger tool identified 91 (15%) ADEs. Of the 91 ADEs included in the analysis, 49 (54%) occurred during medication monitoring, 41 (45%) during patient self-administration, and one could not be determined. 96% of abnormal international normalised ratio triggers were ADEs, followed by 12% of abnormal blood urea nitrogen triggers, 9% of abnormal alanine aminotransferase triggers, 8% of abnormal serum creatinine triggers and 3% of aspartate aminotransferase triggers. CONCLUSIONS: The findings imply that other tools such as text triggers or more complex automated screening rules, which combine data hierarchically are needed to effectively screen for ADEs in chronically ill adults seen in primary care.

What patients say about their doctors online: a qualitative content analysis.

BACKGROUND: Doctor rating websites are a burgeoning trend, yet little is known about their content. OBJECTIVE: To explore the content of Internet reviews about primary care physicians. DESIGN: Qualitative content analysis of 712 online reviews from two rating websites. We purposively sampled reviews of 445 primary care doctors (internists and family practitioners) from four geographically dispersed U.S. urban locations. We report the major themes, and because this is a large sample, the frequencies of domains within our coding scheme. RESULTS: Most reviews (63%) were positive, recommending the physician. We found a major distinction between global reviews, "Dr. B is a great doctor." vs. specific descriptions which included interpersonal manner, "She always listens to what I have to say and answers all my questions."; technical competence "No matter who she has recommended re: MD specialists, this MD has done everything right."; and/or systems issues such as appointment and telephone access. Among specific reviews, interpersonal manner "Dr. A is so compassionate." and technical competence "He is knowledgeable, will research your case before giving you advice." comments tended to be more positive (69% and 80%, respectively), whereas systems-issues comments "Staff is so-so, less professional than should be…" were more mixed (60% positive, 40% negative). CONCLUSIONS: The majority of Internet reviews of primary care physicians are positive in nature. Our findings reaffirm that the care encounter extends beyond the patient-physician dyad; staff, access, and convenience all affect patient's reviews of physicians. In addition, negative interpersonal reviews underscore the importance of well-perceived bedside manner for a successful patient-physician interaction.

Synergy between activin A and gonadotropin-releasing hormone in transcriptional activation of the rat follicle-stimulating hormone-beta gene.

Both activin and GnRH can independently stimulate expression of the FSHbeta subunit gene. In this study, we used the gonadotrope-derived LbetaT2 cell line to investigate the potential interaction between activin and GnRH in regulating the transcriptional activity of the rat FSHbeta gene promoter. Activin A and GnRH synergistically enhanced rat FSHbeta transcriptional activity. Overexpression of SMAD3 (mediator of decapentaplegic-related protein 3), but not of SMAD2, increased transcriptional activation of the rat (r) FSHbeta gene promoter, which was further enhanced by the combined overexpression of SMAD3 and 4 (3+4). The stimulatory effects of SMAD3 overexpression were localized to -472/-256 of the rFSHbeta gene promoter, and activin- and GnRH-responsive proteins were shown to bind to region -284/-252. Sequence analysis identified a consensus palindromic SMAD-binding site at -266/-259 of the rFSHbeta gene promoter. Mutation of two bases located in the center of this palindrome effectively abrogated SMAD4 binding, markedly reduced SMAD3 and 3+4 stimulation of the rFSHbeta gene promoter, and significantly decreased the synergistic enhancement of promoter activity by both activin A and GnRH, and SMAD3 and GnRH. Blockade of the MAPK-signaling pathway did not significantly affect the response to combined stimulation with activin and GnRH. In contrast, interference with SMAD3 signaling caused a significant reduction in activin and GnRH synergy. The results indicate that SMAD3 plays an important role in the synergistic effects of activin and GnRH and demonstrate that this synergy is mediated by a palindromic cis-element located at -266/-259 of the rFSHbeta gene promoter.