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This cohort study assesses the performance of International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) Z59 codes for identifying housing instability during health care encounters.
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Classificação Internacional de Doenças , Humanos , Habitação , Masculino , Feminino , Pessoas Mal Alojadas/estatística & dados numéricos , Adulto , Pessoa de Meia-IdadeRESUMO
INTRODUCTION: There are high rates of substance use disorder (SUD) among people released from carceral settings and, upon release, many of these people also face unstable housing situations, posing challenges to connecting with resources to facilitate SUD recovery. Recovery homes provide a temporary sober living environment for those seeking both SUD recovery and transition back to the community after carceral release. However, successful recovery home placement for this population can prove difficult, and there is a need for research to identify ways to overcome them. METHODS: The current qualitative study seeks to understand barriers to recovery home access for people leaving carceral settings and identify potential best practices for overcoming these barriers from the perspective of recovery home directors. The study conducted semi-structured interviews at two data collection points with eight recovery home directors from sites participating in a housing linkage and placement intervention pilot. The research team used qualitative software to identify and organize directors' experiences and practices in housing and supporting this population. RESULTS: Recovery home directors identified significant barriers to linkage from carceral settings, including difficulties communicating and coordinating placement with potential residents while still incarcerated. Interviews also revealed approaches recovery home directors take to improve recovery home placement, such as sharing information and resources with carceral settings prior to release and helping residents avoid reincarceration by managing relationships with court agents and parole. CONCLUSION: Recovery resident directors have considerable insight into the most significant placement challenges faced by recovery homes upon carceral release as well as experience with potential solutions for overcoming them. Directors can be the key to direct seamless support and continuity of care for criminal legal system involved individuals through coordination with jails, prisons, and other community resources. Directors can also play a significant role in the successful completion of probation and parole by helping residents avoid further issues with the legal system. These directors view working cooperatively with residents as an effective approach to ensuring clients adhere to court orders and are successful in recovery and reentry.
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Although bail reform reduces jail census, whether or not its effects extend to incarcerated individuals with mental illness is unknown. Using a novel high-sensitivity measure of serious mental illness (SMI) from jail-based electronic health records, we conducted an interrupted time series analysis assessing the impact of Illinois bail reform on total jail registrations and the nested subset with SMI ± co-occurring substance use disorder (SUD). Compared with a decline in total jail registrations, admission of individuals with SMI ± SUD showed no decline. Consequently, the proportion of admissions involving SMI increased between 2015 and 2019 from 26% to 35%. Intentional efforts involving cooperation by the health, social services, and justice sectors are needed to translate the impact of bail reform onto the population experiencing SMI.
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Transtornos Mentais , Prisioneiros , Transtornos Relacionados ao Uso de Substâncias , Humanos , Prisões Locais , Transtornos Mentais/epidemiologia , Transtornos Mentais/terapia , Saúde Pública , Transtornos Relacionados ao Uso de Substâncias/epidemiologiaRESUMO
BACKGROUND: Medical legal partnerships provide an opportunity to help address various social determinants of health; however, the traditional practice of screening patients during clinical encounters is limited by the capacity of busy clinicians. Our medical legal partnership utilized care coordinators trained by the legal service attorneys to screen patients outside of clinical encounters for health harming legal needs. The goal of our study was to demonstrate that our novel model could successfully identify and refer patients of a safety-net healthcare system to appropriate legal services. METHODS: We conducted a mixed methods evaluation of the program. Data was collected during the implementation period of the program from March 2017 to August 2018. Operational data collected included number of patients screened, number of referrals to the legal partner, source and reason for referrals. Return on investment was calculated by subtracting program costs from the total reimbursement to the health system from clients' insurance benefits secured through legal services. RESULTS: During the 18-month study, 29,268 patients were screened by care coordinators for health harming legal needs, with 492 patients (1.7%) referred for legal assistance. Of the 133 cases closed in 2017, all clients were invited to participate in a telephone interview; 63 pre-consented to contact, 33 were successfully contacted and 23 completed the interview. The majority (57%) reported a satisfactory resolution of their legal barrier to health. This was accompanied by an improvement in self-reported health with a decrease of patients reporting less than optimal health from 16 (89%) prior to intervention to 8 (44%) after intervention [risk ratio (95% confidence interval): 0.20 (0.04, 0.91)]. Patients also reported improvements in general well-being for themselves and their family. The healthcare system recorded a 263% return on investment. CONCLUSIONS: In our medical legal partnership, screening for health harming legal needs by care coordinators outside of a clinical encounter allowed for efficient screening in a high risk population. The legal services intervention was associated with improvements in self-reported health and family well-being when compared to previous models. The return on investment was substantial.
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Atenção à Saúde , Serviços Jurídicos , Humanos , Advogados , Programas de Rastreamento , Encaminhamento e ConsultaRESUMO
INTRODUCTION: Substance use disorder researchers and treatment professionals have long recognized that risk of opioid-related mortality (ORM) is elevated after release from jail and prison. However, there are gaps in knowledge around ORM among people on probation and the relationship of ORM to drug testing and treatment referral while under supervision. Understanding this relationship is critical for probation officers who are often tasked with referring clients to treatment and monitoring compliance with treatment, without having a clinical background. In this cross-sectional study we estimate the prevalence and risk factors for ORM in a large, urban probation department. METHODS: We joined mortality records and probation records for 2018 and 2019 to determine the rate of ORM for the probation population. We stratified ORM rates by risk factors, including demographics, drug testing results, and treatment placements. RESULTS: Individuals on probation were fifteen times more likely to die from ORM (361 per 100,000) than the general county population (23 per 100,000), largely driven by fentanyl (detected in 86.8% of deaths). Risk was elevated for clients over age 45 (838 per 100,000; 95% CI [655-1057]), clients with at least one positive drug test for opioids (1995 per 100,000; 95% CI [1419-2727]) or cocaine (1200 per 100,000; 95% CI [841-1661]), and clients with previous placements in drug treatment (692 per 100,000; 95% CI [503-929]). Positive urine tests for opioids were associated with 80 times greater risk of ORM than the general population. Although Black clients experienced ORM in greater numbers, white clients had relatively greater ORM risk. CONCLUSIONS: Elevated risk for ORM among the probation population justifies urgent and data-driven partnerships between public health and community corrections to train probation staff; to identify high-risk clients for evidence-based treatment and overdose prevention strategies; and to institute policies to support and sustain these activities.
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Analgésicos Opioides , Overdose de Drogas , Analgésicos Opioides/efeitos adversos , Estudos Transversais , Humanos , Pessoa de Meia-Idade , Prevalência , Prisões , Fatores de Risco , Estados UnidosRESUMO
Cook County Health partnered with the Chicago Departments of Public Health and Family & Support Services and several dozen community-based organizations to rapidly establish a temporary medical respite shelter during the spring 2020 COVID-19 peak for individuals experiencing homelessness in Chicago and Cook County, Illinois. This program provided low-barrier isolation housing to medically complex adults until their safe return to congregate settings. We describe strategies used by the health care agency, which is not a Health Resource and Services Administration Health Care for the Homeless grantee, to provide medical services and care coordination.
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COVID-19/reabilitação , Redes Comunitárias/organização & administração , Pessoas Mal Alojadas/estatística & dados numéricos , Relações Interinstitucionais , Serviço Social/organização & administração , COVID-19/epidemiologia , Chicago , Doenças Transmissíveis Emergentes/prevenção & controle , Humanos , Illinois , Comunicação Interdisciplinar , Habitação Popular/estatística & dados numéricos , Populações Vulneráveis/estatística & dados numéricosRESUMO
BACKGROUND: Homelessness is associated with substantial morbidity. Data linkages between homeless and health systems are important to understand unique needs across homeless populations, identify homeless individuals not registered in homeless databases, quantify the impact of housing services on health-system use, and motivate health systems and payers to contribute to housing solutions. METHODS: We performed a cross-sectional survey including six health systems and two Homeless Management Information Systems (HMIS) in Cook County, Illinois. We performed privacy-preserving record linkage to identify homelessness through HMIS or ICD-10 codes captured in electronic medical records. We measured the prevalence of health conditions and health-services use across the following typologies: housing-service utilizers stratified by service provided (stable, stable plus unstable, unstable) and non-utilizers (i.e., homelessness identified through diagnosis codes-without receipt of housing services). RESULTS: Among 11,447 homeless recipients of healthcare, nearly 1 in 5 were identified by ICD10 code alone without recorded homeless services (n = 2177; 19%). Almost half received homeless services that did not include stable housing (n = 5444; 48%), followed by stable housing (n = 3017; 26%), then receipt of both stable and unstable services (n = 809; 7%). Setting stable housing recipients as the referent group, we found a stepwise increase in behavioral-health conditions from stable housing to those known as homeless solely by health systems. Compared to those in stable housing, prevalence rate ratios (PRR) for those without homeless services were as follows: depression (PRR = 2.2; 95% CI 1.9 to 2.5), anxiety (PRR = 2.5; 95% CI 2.1 to 3.0), schizophrenia (PRR = 3.3; 95% CI 2.7 to 4.0), and alcohol-use disorder (PRR = 4.4; 95% CI 3.6 to 5.3). Homeless individuals who had not received housing services relied on emergency departments for healthcare-nearly 3 of 4 visited at least one and many (24%) visited multiple. CONCLUSIONS: Differences in behavioral-health conditions and health-system use across homeless typologies highlight the particularly high burden among homeless who are disconnected from homeless services. Fragmented and high use of emergency departments for care should motivate health systems and payers to promote housing solutions, especially those that incorporate substance use and mental health treatment.
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Pessoas Mal Alojadas , Estudos Transversais , Atenção à Saúde , Habitação , Humanos , Illinois , Armazenamento e Recuperação da InformaçãoRESUMO
Background: Synthetic opioids, including fentanyl analogs, contribute to an increasing proportion of opioid-related deaths. Highly potent analogs pose an increased risk for fatal overdose. The prevalence of fentanyl analog exposures in patients with known opioid exposure is unknown.Objective: The purpose of this study was to determine the exposure prevalence for fentanyl analogs in living patients with positive urine screens for opiates or fentanyl.Methods: This was a cross-sectional analysis of urine high performance liquid chromatography/tandem mass spectroscopy (HPLC-MS/MS) results from patients with a positive urine screen for opiates or fentanyl at a large public healthcare system in Chicago, Illinois. Samples with positive screens were non-continuously tested by HPLC-MS/MS for 5 selected months in 2018 and 2019.Results: A total of 219 urine samples which screened positive for fentanyl or opiates underwent HPLC-MS/MS testing. At least one fentanyl analog was detected in 65.3% (n = 143) of samples with 26.0% (n = 57) testing positive for multiple analogs. The most common analogs, intermediates, or metabolites were: 4-ANPP (n = 131); 2-furanylfentanyl (n = 22); acryl fentanyl (n = 21); butyrylfentanyl (n = 15); cyclopropylfentanyl (n = 15); and carfentanil (n = 13). Of samples which screened positive for fentanyl (n = 188), 70.2% (132) tested positive for at least one fentanyl analog. Of samples which screened negative for fentanyl but positive for opiates (n = 31), 35.5% (n = 11) tested positive for fentanyl analogsConclusion: Fentanyl analog exposure is common in patients with positive urine screens for fentanyl or opiates. Screening living patient samples for synthetic opioids has future toxicosurveillance implications and these data underscore the increased risks from illicit opioid use.
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Fentanila/análise , Transtornos Relacionados ao Uso de Opioides/urina , Detecção do Abuso de Substâncias/métodos , Adulto , Idoso , Chicago , Cromatografia Líquida de Alta Pressão , Estudos Transversais , Feminino , Fentanila/análogos & derivados , Furanos/análise , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Espectrometria de Massas em TandemRESUMO
There have been improvements nationally in teenagers' self-reported health risk since the 1990s. This study provides an overview of trends in substance use, sexual health, violence and victimization, and suicide risk among Chicago Public High School (CPS) students over a 20-year period. We compared responses to 29 identically worded items from the 1997, 2007, and 2017 Chicago Youth Risk Behavior Survey (YRBS) in the four domains. We show changes in responses across individual items, mean changes across the four domains, and change in the proportion of students with highest risk exposure (≥10 affirmative responses). Analyses control for CPS students' grade, sex, and race/ethnicity. Reductions in substance use, sexual health risk, and violence and victimization (30, 40% and 40% in the mean number of affirmative responses, respectively) were observed. Suicide risk showed an initial improvement from 1997 to 2007, only to worsen by 2017 and show little difference from 1997. There was an approximate 70% decrease in the likelihood of being in the high multiple risk category (≥10 affirmative responses) in 2017 compared to 1997 (OR 0.33; CI 0.22-0.49). In alignment with national trends, our study documents significant improvement in Chicago public high school students' long-term health risk exposure over the 20-year study period, with the notable exception of suicide risk. This study emphasizes the need to invest in strategies both inside and outside of the classroom to mitigate the effect of adversity and promote protective factors, which are at the root of academic success and overall wellbeing.
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BACKGROUND: It is unknown if targeted risk reduction counseling in the health care setting, after documented exposure to fentanyl, can affect behavior change to reduce risks and increase utilization of evidence-based overdose prevention strategies. METHODS: We conducted a retrospective analysis of results (7/2018-6/2019) from questionnaire-facilitated counseling by recovery coaches in the emergency department (ED) and primary care settings following disclosure of a urine toxicology positive for fentanyl. RESULTS: Seventy-five percent of N = 101 respondents were neither aware of nor expecting fentanyl in their substances of use. Fifty-three (70 %) of those initially unaware answered that learning about exposure to and the risks from fentanyl changed their thoughts about reducing or abstaining from use. A greater proportion of patients seen in the ED expressed desire to stop or reduce opioid use as compared to ambulatory clinic patients (91 % vs. 46 %, p < 0.001). Of those not already engaged in treatment, 18 % and 15 % were interested in medication and behavioural health treatment, respectively, and each of them indicated a change in thought based on the counseling. Forty-five percent of individuals not yet receiving naloxone endorsed interest in receiving it, and 22 % of all respondents were somewhat or very interested in access to safe consumption sites. CONCLUSION: This study suggests a novel clinical utility in toxicology screens to inform behavior in the setting of illicit fentanyl exposure. In addition to linkages to evidence-based treatment, linkages to harm-mitigating strategies associated with ongoing substance use may be critical to a comprehensive overdose prevention strategy in the clinical setting.
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Fentanila/urina , Conhecimentos, Atitudes e Prática em Saúde , Dependência de Heroína/psicologia , Dependência de Heroína/urina , Adulto , Analgésicos Opioides/efeitos adversos , Analgésicos Opioides/urina , Overdose de Drogas/prevenção & controle , Overdose de Drogas/psicologia , Overdose de Drogas/urina , Serviço Hospitalar de Emergência/tendências , Feminino , Fentanila/análise , Heroína/análise , Heroína/urina , Dependência de Heroína/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Naloxona/uso terapêutico , Transtornos Relacionados ao Uso de Opioides/prevenção & controle , Transtornos Relacionados ao Uso de Opioides/psicologia , Transtornos Relacionados ao Uso de Opioides/urina , Estudos Retrospectivos , Comportamento de Redução do Risco , Inquéritos e Questionários , Adulto JovemRESUMO
BACKGROUND: The continued rise in fatalities from opioid analgesics despite a steady decline in the number of individual prescriptions directing ≥ 90 morphine milligram equivalents (MME)/day may be explained by patient exposures to redundant prescriptions from multiple prescribers. OBJECTIVES: We evaluated prescribers' specialty and social network characteristics associated with high-risk opioid exposures resulting from single-prescriber high-daily dose prescriptions or multi-prescriber discoordination. DESIGN: Retrospective cohort study. PARTICIPANTS: A cohort of prescribers with opioid analgesic prescription claims for non-cancer chronic opioid users in an Illinois Medicaid managed care program in 2015-2016. MAIN MEASURES: Per prescriber rates of single-prescriber high-daily-dose prescriptions or multi-prescriber discoordination. KEY RESULTS: For 2280 beneficiaries, 36,798 opioid prescription claims were submitted by 3532 prescribers. Compared to 3% of prescriptions (involving 6% of prescribers and 7% of beneficiaries) that directed ≥ 90 MME/day, discoordination accounted for a greater share of high-risk exposures-13% of prescriptions (involving 23% of prescribers and 24% of beneficiaries). The following specialties were at highest risk of discoordinated prescribing compared to internal medicine: dental (incident rate ratio (95% confidence interval) 5.9 (4.6, 7.5)), emergency medicine (4.7 (3.8, 5.8)), and surgical subspecialties (4.2 (3.0, 5.8)). Social network analysis identified 2 small interconnected prescriber communities of high-volume pain management specialists, and 3 sparsely connected groups of predominantly low-volume primary care or emergency medicine clinicians. Using multivariate models, we found that the sparsely connected sociometric positions were a risk factor for high-risk exposures. CONCLUSION: Low-volume prescribers in the social network's periphery were at greater risk of intended or discoordinated prescribing than interconnected high-volume prescribers. Interventions addressing discoordination among low-volume opioid prescribers in non-integrated practices should be a priority. Demands for enhanced functionality and integration of Prescription Drug Monitoring Programs or referrals to specialized multidisciplinary pain management centers are potential policy implications.
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Analgésicos Opioides/administração & dosagem , Padrões de Prática Médica/estatística & dados numéricos , Medicina de Emergência , Humanos , Transtornos Relacionados ao Uso de Opioides/epidemiologia , Programas de Monitoramento de Prescrição de Medicamentos/estatística & dados numéricos , Atenção Primária à Saúde , Estudos Retrospectivos , Rede SocialRESUMO
OBJECTIVES: Concurrent diabetic ketoacidosis (DKA) is highly prevalent in patients with hypertriglyceridemia-induced pancreatitis (HP). Diabetic ketoacidosis could potentially complicate the diagnosis, management, and prognosis of HP. This study aimed to directly compare the clinical course of HP with and without DKA and assess the outcomes of frequently used severity-prediction scores in such population. METHODS: We retrospectively analyzed 140 patients with HP; 37 patients (26.4%) had concurrent DKA. We compared epidemiologic characteristics, initial laboratory values, and clinical courses between the DKA and non-DKA groups. Bedside Index for Severity in Acute Pancreatitis score, Sequential Organ Failure Assessment score, Ranson criteria, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and Marshall score were calculated and compared between groups. RESULTS: We observed more acute kidney injury in the DKA group. Patients with DKA more likely required intensive care unit admission, received intravenous insulin, and were discharged on subcutaneous insulin. Ranson criteria and APACHE II score were significantly higher with DKA. CONCLUSIONS: Concurrent DKA does not affect length of stay, in-hospital mortality, and readmission rate in patients with HP. Higher Ranson criteria and APACHE II score likely reflected derangement of clinical parameters secondary to DKA rather than true severity of pancreatitis in such population.
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Cetoacidose Diabética/complicações , Hipertrigliceridemia/complicações , Pâncreas/patologia , Pancreatite/complicações , APACHE , Doença Aguda , Adulto , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Pancreatite/etiologia , Pancreatite/terapia , Prognóstico , Estudos Retrospectivos , Índice de Gravidade de DoençaRESUMO
PURPOSE: The main study objective was to assess the predictive value of selected physical symptoms for screening obstructive sleep apnea and major cardiac conditions in adults with obesity, thus providing the evidence for routine symptom screening of obesity complications endorsed by obesity management clinical practice guidelines. METHODS: We performed a retrospective cohort study using patient-reported outcomes data including the physical symptoms severity component of the Memorial Symptom Assessment Scale administered through Audio Computer-Assisted Self-Interviews combined with data from the electronic medical records of an urban safety-net primary care clinic. Non-underweight ambulatory patients completing the standardized survey assessment were included. The prevalence of pre-selected symptoms and the diagnostic characteristics at various severity cut-points were determined for obstructive sleep apnea or major cardiac conditions separately for patients with and without obesity. RESULTS: Of the 1399 patients included in this analysis, most (77%) were non-hispanic black or hispanic. Step-wise increases in positive likelihood ratios ranging between 1.2 and 4.6 with greater severity cough, dyspnea, fatigue, bloating, dizziness, and nausea were observed for both obstructive sleep apnea and major cardiac complications. Likelihood ratio estimates for both obese and non-obese patients were statistically significant. CONCLUSIONS: Our findings provide a basis to support current guideline recommendations for routine symptom screening to identify medical complications among patients with BMI 30 kg/m2 or greater.
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Doenças Cardiovasculares/etiologia , Pneumopatias/etiologia , Obesidade/complicações , Medidas de Resultados Relatados pelo Paciente , Qualidade de Vida/psicologia , Autorrelato/estatística & dados numéricos , Estudos de Coortes , Computadores , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Inquéritos e QuestionáriosRESUMO
Excitement about mobile health (mHealth) for improving care transitions is fueled by widespread adoption of smartphones across all social segments, but new disparities can emerge around nonadopters of technology-based communications. We conducted a cross-sectional survey of urban low-income adults to assess inadequate reading health literacy and limited English proficiency as factors affecting access to and engagement with mHealth. Although the proportion owning smartphones were comparable to national figures, adjusted analysis showed fewer patients with inadequate reading health literacy having Internet access (odds ratio [95% confidence interval]: 0.50 [0.26-0.95]), e-mail (0.43 [0.24-0.79]), and interest in using e-mail (0.34 [0.18-0.65]) for healthcare communications. Fewer patients with limited English proficiency were interested in using mobile apps (0.2 [0.09-0.46]). Inpatient status was independently associated with less interest in text messaging (0.46 [0.25-0.87]). mHealth exclusions around literacy and language proficiency threaten equity, and innovative solutions are needed to realize mHealth's potential for reducing disparities. Journal of Hospital Medicine 2017;12:90-93.
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Disparidades em Assistência à Saúde , Provedores de Redes de Segurança/estatística & dados numéricos , Telemedicina/métodos , Envio de Mensagens de Texto/estatística & dados numéricos , Adulto , Idoso , Estudos Transversais , Correio Eletrônico , Feminino , Letramento em Saúde , Humanos , Internet/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , População UrbanaRESUMO
BACKGROUND: Itch is a well-established symptom in cutaneous disease. However, little is known about the burden of itch outside the dermatology setting. PURPOSE: To determine the prevalence and impact of itch on quality of life (QOL) in the general internal medicine setting. METHODS: We performed a cross-sectional study of 2076 adults from an outpatient general internal medicine clinic, using an audio computer-assisted self-administered interview. A history of itch (acute or chronic) and other physical symptoms in the past week, Patient-Reported Outcomes Measurement Information System (PROMIS) 10-item Global Health Questionnaire scores, and Patient Health Questionnaire-2 scores were assessed. RESULTS: The prevalence of itch was 39.9 % and increased with age from 33.1 % at age 19-39 years to 45.9 % at age ≥80 years. In multivariable models controlled for socio-demographics, even feeling "a little" or "some" distress from itch was significantly associated with lower PROMIS global physical and mental health T-scores and estimated health utility scores (P ≤ 0.01). Further, feeling "quite a lot" of distress or "very much" distress from itch was associated with higher adjusted odds ratios for depressed mood (4.91 [95 % confidence interval (CI) 3.36-7.18]) and anhedonia (4.46 [95 % CI 3.07-6.47]). The patient burden of itch was similar to those of pain, constipation, sexual dysfunction, cough, and weight loss. CONCLUSIONS: Itch occurs commonly in the primary care setting and is associated with poor QOL. Physicians should inquire about itch and its associations during review of systems. Future studies are needed to distinguish between the effects of acute and chronic itch.
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Prurido/epidemiologia , Qualidade de Vida , Dermatopatias/complicações , Adulto , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Instituições de Assistência Ambulatorial , Estudos Transversais , Feminino , Medicina Geral , Humanos , Masculino , Pessoa de Meia-Idade , Prevalência , Prurido/etiologia , Inquéritos e Questionários , Adulto JovemRESUMO
PURPOSE: Standardized measures of physical symptoms predict mortality and healthcare utilization, but clinicians remain uncertain about how to apply them in routine clinical care. Recognizing the tendency for physician documentations to routinely underestimate symptom burden, we assessed whether or not severity was an important dimension of symptom assessments that may determine their usefulness in clinical encounters. METHODS: Retrospective cohort study using data from audio computer-assisted self-interviews augmented by chart review of patients from a primary care clinic of an urban health system. RESULTS: We sampled 145 patients who completed the Memorial Symptom Assessment Scale (MSAS) short form-physical symptom severity measurement-before their primary care visit. Most were women (60 %), and non-Hispanic black (59 %), and many responded in Spanish (19 %). All but three reported > 1 symptom. Overall, 79 % of elicited symptoms were not documented in physician notes from the same day. Severe symptoms were more likely to be documented [MSAS mean (95 % confidence interval): documented 2.2 (1.9, 2.4) vs. undocumented 1.8 (1.7, 1.9)]. CONCLUSION: Documentations reflect usual patient-clinician communications that prioritize severe symptoms, while standardized instruments target their comprehensive assessments. Among the many validated instruments, those eliciting the severity of physical symptoms may simultaneously help clinicians with prioritization and risk assessments.
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Medidas de Resultados Relatados pelo Paciente , Avaliação de Sintomas/métodos , Idoso , Registros Eletrônicos de Saúde , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Exame Físico , Atenção Primária à Saúde , Qualidade de Vida , Estudos Retrospectivos , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Gender earnings disparities among physicians exist even after considering differences in specialty, part-time status, and practice type. Little is known about the role of job satisfaction priorities on earnings differences. OBJECTIVE: To examine gender differences in work characteristics and job satisfaction priorities, and their relationship with gender earnings disparities among hospitalists. DESIGN: Observational cross-sectional survey study. PARTICIPANTS: US hospitalists in 2010. MEASUREMENTS: Self-reported income, work characteristics, and priorities among job satisfaction domains. RESULTS: On average, women compared to men hospitalists were younger, less likely to be leaders, worked fewer full-time equivalents, worked more nights, reported fewer daily billable encounters, more were pediatricians, worked in university settings, worked in the Western United States, and were divorced. More hospitalists of both genders prioritized optimal workload among the satisfaction domains. However, substantial pay ranked second in prevalence by men and fourth by women. Women hospitalists earned $14,581 less than their male peers in an analysis adjusting for these differences. CONCLUSIONS: The gender earnings gap persists among hospitalists. A portion of the disparity is explained by the fewer women hospitalists compared to men who prioritize pay.
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Medicina Hospitalar/economia , Salários e Benefícios/economia , Sexismo/economia , Adulto , Estudos Transversais , Feminino , Medicina Hospitalar/normas , Humanos , Masculino , Pessoa de Meia-Idade , Inquéritos e QuestionáriosRESUMO
OBJECTIVE: To characterize changes in patient-reported outcome measures from hospital discharge to assess when they best inform risk of utilization as defined by readmissions or emergency department use. PARTICIPANTS: Patients discharged from an urban safety-net hospital. DESIGN: Longitudinal cohort study. MAIN MEASURES: We serially administered the Memorial Symptom Assessment Scale (MSAS) and the PROMIS Global Health short form assessing General Self-Rated Health (GSRH), Global Physical (GPH), and Mental (GMH) Health at 0, 30, 90, and 180 days from hospital discharge. Time to first utilization from each survey was plotted by dichotomizing our sample on each patient-reported measure, and equivalence of the time-to-event curves was assessed using the log-rank test. Cox proportional hazard models were used to control for available covariates including prior utilization during the study, Charlson score, age, gender, and race/ethnicity. We assessed each measure's effect on the fit of the predictive models using the likelihood ratio test. KEY RESULTS: We recruited 196 patients, of whom 100%, 98%, 90%, and 88% completed each respective survey wave. Participants' mean age was 52 years, 51% were women, 60% were non-Hispanic black, and 21% completed the questionnaires in Spanish. In-hospital assessments revealed high symptom burden and poor health status. In-hospital assessments of GMH and GSRH predicted 14-day reutilization, whereas posthospitalization assessments of MSAS and GPH predicted subsequent utilizations. Each measure selectively improved predictive model fit. CONCLUSIONS: Routine measurement of patient-reported outcomes can help identify patients at higher risk for utilizations. At different time points, MSAS, GPH, GMH, and GSRH all informed utilization risk.
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Nível de Saúde , Alta do Paciente , Avaliação de Resultados da Assistência ao Paciente , Readmissão do Paciente/estatística & dados numéricos , Autorrelato , Adulto , Fatores Etários , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Hospitalização , Hospitais Urbanos/estatística & dados numéricos , Humanos , Estudos Longitudinais , Masculino , Saúde Mental , Pessoa de Meia-Idade , Modelos de Riscos Proporcionais , Grupos Raciais , Fatores de Risco , Provedores de Redes de Segurança/estatística & dados numéricos , Índice de Gravidade de Doença , Fatores SexuaisRESUMO
Quality improvement (QI) efforts hold great promise for improving care delivery. However, hospitals often struggle with QI implementation and fail to sustain improvement in either process changes or patient outcomes. Physician mentored implementation (PMI) is a novel approach that promotes the success and sustainability of QI initiatives at hospitals. It leverages the expertise of external physician mentors who coach QI teams to implement interventions at their local hospitals. The PMI model includes five core components: (1) a hospital self-assessment tool, (2) a face-to-face training session including direct interaction with a physician mentor, (3) a guided continuous quality improvement and systems approach, (4) yearlong individual physician mentoring, and (5) a learning community supported by a resource center, listserv, and webinars. Mentors provide content and process expertise, rather than offering "one-size-fits-all" technical assistance that might not be sustained after the mentoring year ends. Mentors support and motivate QI teams throughout the planning and implementation phases of their interventions, help to engage hospital leadership, garner local physician buy-in, and address institutional barriers. Mentors also guide hospitals to identify opportunities for the adaptation and customization of original evidence-based models of care while ensuring the fidelity of those models. More than 350 hospitals have used the PMI model to implement successful national and statewide QI initiatives. Academic medical centers are charged with improving the health of patients and reengineering care delivery; thus, they serve as the ideal source for physician mentors and can act as leaders in implementing QI projects using the PMI model.