Measuring Access to Mental Health Services Among Primary Care Patients.

BACKGROUND: The lifetime risk of mental health disorders is almost 50% and, in any year, about 25% of the population have a psychiatric disorder. Many of those people are cared for in primary care settings. RESEARCH OBJECTIVE: Measure access to mental health services, such as getting counselling or prescription mental health medications, using new patient survey questions that can be added to Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys. STUDY DESIGN: Surveys were conducted with a stratified probability sample of patients receiving primary care services in a single state in 2018-2019. Medicaid and privately insured patients were surveyed by mail or telephone, respectively. RESULTS: Approximately 14% of sampled patients responded to a survey. More than 10% of privately insured respondents and about 20% of Medicaid respondents got or tried to get appointments for mental health care. About 15% of privately insured respondents and 11% of Medicaid respondents reported problems getting appointments with counselors. Only 8%-9% of respondents seeking mental health medicines reported problems getting appointments for prescriptions. A composite measure combining access to counselors and prescribers of mental health medicines evidenced adequate internal consistency reliability. Group level reliability estimates were low. CONCLUSIONS: Many respondents got or tried to get mental health services and a substantial number reported problems getting appointments or getting mental health prescriptions. The tested questions can be combined into an Access to Mental Health Care measure, which can be included in patient experience surveys for ambulatory care to monitor access to behavioral health care.

A Systematic Review of Strategies to Enhance Response Rates and Representativeness of Patient Experience Surveys.

BACKGROUND: Data from surveys of patient care experiences are a cornerstone of public reporting and pay-for-performance initiatives. Recently, increasing concerns have been raised about survey response rates and how to promote equity by ensuring that responses represent the perspectives of all patients. OBJECTIVE: Review evidence on survey administration strategies to improve response rates and representativeness of patient surveys. RESEARCH DESIGN: Systematic review adhering to the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. STUDY SELECTION: Forty peer-reviewed randomized experiments of administration protocols for patient experience surveys. RESULTS: Mail administration with telephone follow-up provides a median response rate benefit of 13% compared with mail-only or telephone-only. While surveys administered only by web typically result in lower response rates than those administered by mail or telephone (median difference in response rate: -21%, range: -44%, 0%), the limited evidence for a sequential web-mail-telephone mode suggests a potential response rate benefit over sequential mail-telephone (median: 4%, range: 2%, 5%). Telephone-only and sequential mixed modes including telephone may yield better representation across patient subgroups by age, insurance type, and race/ethnicity. Monetary incentives are associated with large increases in response rates (median increase: 12%, range: 7%, 20%). CONCLUSIONS: Sequential mixed-mode administration yields higher patient survey response rates than a single mode. Including telephone in sequential mixed-mode administration improves response among those with historically lower response rates; including web in mixed-mode administration may increase response at lower cost. Other promising strategies to improve response rates include in-person survey administration during hospital discharge, incentives, minimizing survey language complexity, and prenotification before survey administration.

Comparing Web and Mail Protocols for Administering Hospital Consumer Assessment of Healthcare Providers and Systems Surveys.

OBJECTIVE: The objective of this study was to compare results of using web-based and mail (postal) Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) data collection protocols. RESEARCH DESIGN: Patients who had been hospitalized in a New England Hospital were surveyed about their hospital experience. Patients who provided email addresses were randomized to 1 of 3 data collection protocols: web-alone, web with postal mail follow-up, and postal mail only. Those who did not provide email addresses were surveyed using postal mail only. Analyses compared response rates, respondent characteristics, and patient-reported experiences. SUBJECTS: For an 8-week period, patients were discharged from the study hospital to home. MEASURES: Measures included response rates, characteristics of respondents, 6 composite measures of their patient experiences, and 2 ratings of the hospital. RESULTS: Response rates were significantly lower for the web-only protocol than the mail or combined protocols, and those who had not provided email addresses had lower response rates. Those over 65 were more likely than others to respond to all protocols, especially for the mail-only protocols. Respondents without email addresses were older, less educated, and reported worse health than those who provided email addresses. After adjusting for respondent differences, those in the combined protocol differed significantly from the mail (postal) only respondents on 2 measures of patient experience; those in the web-only protocol differed on one. Those not providing an email address differed from those who did on one measure. CONCLUSION: If web-based protocols are used for HCAHPS surveys, adjustments for a mode of data collection are needed to make results comparable.

A longitudinal study of electronic cigarette use among a population-based sample of adult smokers: association with smoking cessation and motivation to quit.

AIMS: Increasingly popular electronic cigarettes (e-cigarettes) may be the most promising development yet to end cigarette smoking. However, there is sparse evidence that their use promotes cessation. We investigated whether e-cigarette use increases smoking cessation and/or has a deleterious effect on quitting smoking and motivation to quit. METHODS: Representative samples of adults in 2 US metropolitan areas were surveyed in 2011/2012 about their use of novel tobacco products. In 2014, follow-up interviews were conducted with 695 of the 1,374 baseline cigarette smokers who had agreed to be re-contacted (retention rate: 51%). The follow-up interview assessed their smoking status and history of electronic cigarette usage. Respondents were categorized as intensive users (used e-cigarettes daily for at least 1 month), intermittent users (used regularly, but not daily for more than 1 month), and non-users/triers (used e-cigarettes at most once or twice). RESULTS: At follow-up, 23% were intensive users, 29% intermittent users, 18% had used once or twice, and 30% had not tried e-cigarettes. Logistic regression controlling for demographics and tobacco dependence indicated that intensive users of e-cigarettes were 6 times more likely than non-users/triers to report that they quit smoking (OR: 6.07, 95% CI = 1.11, 33.2). No such relationship was seen for intermittent users. There was a negative association between intermittent e-cigarette use and 1 of 2 indicators of motivation to quit at follow-up. CONCLUSIONS: Daily use of electronic cigarettes for at least 1 month is strongly associated with quitting smoking at follow-up. Further investigation of the underlying reasons for intensive versus intermittent use will help shed light on the mechanisms underlying the associations between e-cigarette use, motivation to quit, and smoking cessation.

Changes in Antidementia Medications upon Admission to the Nursing Home: Who Decides and Why? Results From a National Survey of Nursing Home Administrators.

OBJECTIVE: Little is known about who is involved and what factors influence changes in antidementia medications for older adults living in nursing homes. The study sought to describe factors associated with initiation and discontinuation of antidementia medications in nursing home residents with dementia. DESIGN: National survey of nursing homes with ≥30 beds; homes with dementia units were oversampled. SETTINGS AND PARTICIPANTS: Nursing home administrators [eg, Directors of Nursing (DoNs)]. METHODS: In 2022, 1293 homes were surveyed (response rate: 26.6%, n = 340). Weighted analyses provided nationally representative results corrected for nonresponse (n = 14,455). RESULTS: DoNs reported that people always/almost always involved in antidementia medication decisions included nursing home prescriber (84.4%), nursing staff (33.2%), family (23.4%), resident (13.8%), community primary care provider (12.1%), and dementia specialist (5.8%). DoNs reported that antidementia medications were much more likely to be initiated if residents (55.8%) and family members (53.2%) wanted antidementia medications, a dementia specialist was involved (51.9%), resident had aggressive behaviors (44.8%), resisted care (31.6%), or had severe physical/cognitive impairment (22.3%). DoNs reported that antidementia medications were much more likely to be discontinued with dementia specialist involvement (46.5%), progression to severe impairment (39.2%), hospice involvement (31.5%), <6 months' prognosis (28.5%), emergence of aggressive behaviors (25.2%), or resisting care (19.0%) and much less likely to be discontinued if residents (30.2%) and family (27.3%) were reluctant to discontinue. One in 6 homes reported that residents had no immediate family/caregivers usually or almost always/always. CONCLUSIONS AND IMPLICATIONS: DoNs report that family/caregivers and dementia specialists have significant influence on antidementia medication decisions in nursing homes, but many residents lack their involvement. Real-world evidence on the risks and benefits of antidementia medications in nursing homes is needed to inform clinical guidance about appropriate use of antidementia medications in nursing homes.

Reported racial discrimination, trust in physicians, and medication adherence among inner-city African Americans with hypertension.

OBJECTIVES: We sought to determine if reported racial discrimination was associated with medication nonadherence among African Americans with hypertension and if distrust of physicians was a contributing factor. METHODS: Data were obtained from the TRUST project conducted in Birmingham, Alabama, 2006 to 2008. All participants were African Americans diagnosed with hypertension and receiving care at an inner city, safety net setting. Three categories of increasing adherence were defined based on the Morisky Medication Adherence Scale. Trust in physicians was measured with the Hall General Trust Scale, and discrimination was measured with the Experiences of Discrimination Scale. Associations were quantified by ordinal logistic regression, adjusting for gender, age, education, and income. RESULTS: The analytic sample consisted of 227 African American men and 553 African American women, with a mean age of 53.7 ± 9.9 years. Mean discrimination scores decreased monotonically across increasing category of medication adherence (4.1, 3.6, 2.9; P = .025), though the opposite was found for trust scores (36.5, 38.5, 40.8; P < .001). Trust mediated 39% (95% confidence interval = 17%, 100%) of the association between discrimination and medication adherence. CONCLUSIONS: Within our sample of inner city African Americans with hypertension, racial discrimination was associated with lower medication adherence, and this association was partially mediated by trust in physicians. Patient, physician and system approaches to increase "earned" trust may enhance existing interventions for promoting medication adherence.

Rising to the Occasion: A National Nursing Home Study Documenting Attempts to Address Social Isolation During the COVID-19 Pandemic.

OBJECTIVES: COVID-19-related policies introduced extraordinary social disruption in nursing homes. In response, nursing facilities implemented strategies to alleviate their residents' loneliness. This study sought to describe interventions nursing homes used, document the perceived effectiveness of efforts, and determine barriers to implementing strategies to mitigate social isolation and loneliness. DESIGN: National survey of nursing homes sampled in strata defined by facility size (beds: 30-99, 100+) and quality ratings (1, 2-4, 5). SETTINGS AND PARTICIPANTS: US Nursing Home Directors of Nursing/Administrators (n = 1676). METHODS: The survey was conducted between February and May 2022 (response rate: 30%; n = 504, weighted n = 14,506). Weighted analyses provided nationally representative results. RESULTS: One-third were extremely concerned about their home's ability to meet residents' medical and social needs during COVID-19 before vaccines were available and 13% after vaccines. Nearly all reported trying to mitigate residents' social isolation during the pandemic. Efforts tried, and perceived as most useful, included using technology (tablets, phones, emails), assigning staff as a family contact, and more staff time with residents. Most frequently cited barriers to implementation were related to staffing issues. CONCLUSIONS AND IMPLICATIONS: Despite multiple challenges, nearly all nursing homes tried to implement many different approaches to address residents' social needs, with some (eg, having an assigned family contact, use of tablets and phones) perceived as more useful than others. Staffing issues presented barriers for addressing the social needs of nursing home residents. Many strategies for addressing social isolation placed more demands on a workforce already stretched to the limit. While concerns about resident social isolation reduced after vaccine availability, administrators remained extremely concerned about staff burnout and mental health.

Professional language interpretation and inpatient length of stay and readmission rates.

BACKGROUND: The population of persons seeking medical care is linguistically diverse in the United States. Language barriers can adversely affect a patient's ability to explain their symptoms. Among hospitalized patients, these barriers may lead to higher readmission rates and longer hospitalizations. Trained interpreters help overcome communication barriers; however, interpreter usage among patients is suboptimal. OBJECTIVE: To investigate differences among patients with limited English proficiency (LEP) in their length of stay (LOS) and 30-day readmission rate associated with their receiving professional interpretation at admission or discharge. DESIGN: We analyzed the rates of interpretation at admission and discharge of all LEP patients admitted to a tertiary care hospital over a three-year period. We calculated length of stay in days and as log of LOS. We also examined 30-day readmission. Using multivariable regression models, we explored differences among patients who received interpretation at admission, discharge, or both, controlling for patient characteristics, including age, illness severity, language, and gender. PARTICIPANTS: All LEP patients admitted between May 1, 2004 and April 30, 2007. MAIN MEASURES: Length of hospital stay as related to use of professional interpreters; readmission to the hospital within 30 days. KEY RESULTS: Of the 3071 patients included in the study, 39 % received language interpretation on both admission and discharge date. Patients who did not receive professional interpretation at admission or both admission/discharge had an increase in their LOS of between 0.75 and 1.47 days, compared to patients who had an interpreter on both day of admission and discharge (P<0.02). Patients receiving interpretation at admission and/or discharge were less likely than patients receiving no interpretation to be readmitted with 30 days. CONCLUSIONS: The length of a hospital stay for LEP patients was significantly longer when professional interpreters were not used at admission or both admission/discharge.

Community health worker encounter forms: a tool to guide and document patient visits and worker performance.

OBJECTIVES: We explored the benefits of using community health worker (CHW) encounter forms to collect data on patient interactions and assessed the effectiveness of these forms in guiding and directing interactions. METHODS: A 1-page standardized encounter form was developed to document topics discussed during visits with diabetes patients. A portion of the form was designed to be used as a script to guide the interaction and assist patients in setting appropriate self-management goals. Data were also collected via CHW work logs and interviews with CHWs and their supervisors to validate findings. RESULTS: Data were collected for 1198 interactions with 540 patients at 6 community health centers. Self-management goals were set during 62% of encounters. With respect to the most recent self-management goal set, patients who had set a challenging goal were more likely to be in the action stage of change than in other stages. Work logs revealed that CHWs engaged in a number of activities not involving direct patient interactions and thus not captured on encounter forms. CONCLUSIONS: Evaluating and monitoring CHWs' daily activities has been challenging. Encounter forms have great potential for documenting the work of CHWs with patients.

Exploring the association between reported discrimination and hypertension among African Americans: a systematic review.

BACKGROUND: The experience of racial discrimination among African Americans may contribute to an increased risk of developing hypertension and having poor hypertension control once diagnosed. Although it is a commonly held belief that experiences of discrimination may exert lasting effects on health behavior and physiology, the existing evidence is mixed. OBJECTIVE: The objective of this review was to identify evidence linking the experience of discrimination with hypertension among African Americans and to provide an updated synthesis of the literature. DESIGN: Articles for the review were identified through an electronic search of PubMed, OVID, and other pertinent journals. The review was augmented with a manual search of references. We assessed the quality of included articles using modified Downs and Black criteria. RESULTS: In total, 15 articles were selected for the review, 12 cross-sectional studies and 3 cohort studies. The preponderance of evidence (9 of 15 articles) indicated that discrimination was associated with an increased risk of developing hypertension, difficulty obtaining control of existing hypertension, and/or elevated blood pressure among those without a diagnosis of hypertension. CONCLUSIONS: This systematic review supports the association of racial discrimination with an increased risk of developing hypertension; however, the picture is not uniform. Methodological challenges, such as floor or ceiling effects of reported discrimination and low sample size, may have prevented researchers from detecting important associations. A better understanding of the emerging but complex relationship between discrimination and hypertension among African Americans is needed, as we seek to resolve existing cardiovascular health disparities.

Developing a Storytelling Study for African Americans with Hypertension:: A Study Protocol.

Objective: Storytelling is an engaging approach for promoting health and wellness among individuals with health conditions including type 2 diabetes (TTDM), breast cancer, and hypertension. Storytelling interventions are an evidence-based approach that has been effective in promoting behavioral change such as increasing physical activity, medication adherence, and making dietary changes. The use of storytelling to convey health information and promote behavior change is associated with increased engagement in self-management particularly in communities of color. The primary objective of this paper was to describe our process for developing the storytelling study; specifically, recruitment, screening, selecting storytellers, and developing a study-specific interactive website. The secondary objective was to describe the approach for conducting the feasibility study and conduct a 6-week web-based storytelling study. Methods: Between 2017 to 2020, we developed a storytelling study for African Americans with hypertension. During that period we recruited participants from a Federally Qualified Health Center, a local church, and at community events. We selected storytellers to share their experiences managing hypertension and filmed 10 storytellers. Presently, a feasibility and pilot study are underway, the goal of the feasibility study is to ascertain feedback about the stories and the study website from African American adults with hypertension. We will also conduct a 6-week pilot study with 30 African American adults to see if conducting a storytelling study online would be an effective approach for promoting behavioral change. Conclusions: We successfully recruited and filmed 10 storytellers and produced 9 stories about living with and managing hypertension. The feedback we received from participants in the feasibility and pilot study will be useful as we refine the design of the study to determine the potential for a future randomized controlled trial (RCT).

Oral health curriculum evaluation tool (OHCET) for primary care training programs.

BACKGROUND: Primary care training schools and programs lack a validated tool to assess their oral health curriculum, and researchers lack a tool to compare oral health curricula across programs/schools and different disciplines. OBJECTIVE: This study describes the process and results of creating a 15-item oral health curriculum evaluation tool (OHCET). METHODS: Three-phased development of the OHCET from 2018 to 2020 including (a) Delphi group/tool development; (b) tool pilot test; and (c) tool validation/cognitive interviews. RESULTS: A total of 23 program deans/directors participated in the tool validation/cognitive interviews. Summarizing accuracy scores of all 15 items, the mean accuracy score was 87.1. There was a high correlation (0.917) between the program's total score and the program director's self-assessed competence of their learners at the time of graduation. CONCLUSIONS: The OHCET was validated and can be used in primary care training programs and schools across the country for institutional evaluation and for research purposes. Program directors and deans can also have some confidence that their ability to subjectively assess their learner's oral health knowledge and skills at graduation is accurate.

Vaccination intentions generate racial disparities in the societal persistence of COVID-19.

We combined survey, mobility, and infections data in greater Boston, MA to simulate the effects of racial disparities in the inclination to become vaccinated on continued infection rates and the attainment of herd immunity. The simulation projected marked inequities, with communities of color experiencing infection rates 3 times higher than predominantly White communities and reaching herd immunity 45 days later on average. Persuasion of individuals uncertain about vaccination was crucial to preventing the worst inequities but could only narrow them so far because 1/5th of Black and Latinx individuals said that they would never vaccinate. The results point to a need for well-crafted, compassionate messaging that reaches out to those most resistant to the vaccine.

Lessons learned from a collaborative to improve care for patients with diabetes in 17 community health centers, Massachusetts, 2006.

INTRODUCTION: In 2006, the Massachusetts League of Community Health Centers convened a collaborative to systematically improve health care delivery for patients with diabetes in 17 community health centers. Our goal was to identify facilitators of and barriers to success reported by teams that participated in this collaborative. METHODS: The collaborative's activities lasted 13 months. At their conclusion, we interviewed participating team members. We asked about their teams' successes, challenges, and take-home messages for future collaborative efforts. We organized their responses into common themes by using the Chronic Care Model as a framework. RESULTS: Themes that emerged as facilitators of success included shifting clinic focus to more actively involve patients and to promote their self-management; improving the understanding and implementation of professional guidelines; and expanding staff roles to accommodate these goals. Patient registries were perceived as beneficial but lacking adequate technical support. Other barriers were staffing and time constraints. CONCLUSION: Cooperative efforts to improve health care delivery for people with diabetes may benefit from educating the health care team about guidelines, establishing a stronger role for the patient as part of the health care team, and providing adequate technical instruction and support for the use of clinical databases.

Does Home Remedy Use Contribute to Medication Nonadherence Among Blacks with Hypertension?

Background: Home remedies (HRs) are described as foods, herbs, and other household products used to manage chronic conditions. The objective of this study was to examine home remedy (HR) use among Blacks with hypertension and to determine if home remedy use is correlated with blood pressure and medication adherence. Methods: Data for this cross-sectional study were obtained from the TRUST study conducted between 2006-2008. Medication adherence was measured using the Morisky Medication Adherence Scale, and HR use was self-reported. Multivariable associations were quantified using ordinal logistic regression. Results: The study sample consisted of 788 Blacks with hypertension living in the southern region of the United States. HR use was associated with higher systolic (HR users 152.79, nonusers 149.53; P=.004) and diastolic blood pressure (HR users 84.10, nonusers 82.14 P=.005). Use of two or more HRs was associated with low adherence (OR: .55, CI: .36-.83, P= .004). Conclusion: The use of HR and the number of HRs used may be associated with medication nonadherence, and higher systolic and diastolic blood pressure among Blacks with hypertension. Medication nonadherence is of critical importance for individuals with hypertension, and it is essential that health care providers be aware of health behaviors that may serve as barriers to medication adherence, such as use of home remedies.

The effect of different sampling and recall periods in the CAHPS Clinician & Group (CG-CAHPS) survey.

OBJECTIVE: To examine the effect of changing the sampling and reference periods for the CAHPS® Clinician & Group Survey from 12 to 6 months. DATA SOURCES/STUDY SETTING: Adult patients with a visit in the last 12 months to New England community health centers. STUDY DESIGN: We randomly assigned patients to receive a survey with either a 12- or 6-month recall period. DATA COLLECTION/EXTRACTION METHODS: Questionnaires were mailed to patients, with a second questionnaire mailed to nonrespondents, followed by six attempts to complete a telephone interview. PRINCIPAL FINDINGS: If the sampling criterion was a visit in the last 6 months, 9 percent of those with a visit in the last 12 months would not have been surveyed. A total of 1837 patients completed 6-month surveys (44.9 percent response rate); 588 completed 12-month surveys (46.0 percent response rate). Shortening the reference from 12 to 6 months reduced the proportion of respondents reporting a blood test, X-ray, or other tests. Adjusting for respondent characteristics, the most positive response was selected more often on the 6-month survey for 12 out of 13 questions, and three of these differences were statistically significant (P < 0.05). CONCLUSIONS: Surveys using a 6-month recall period may yield slightly higher scores than surveys with a 12-month recall period.

A randomized controlled trial of community health workers using patient stories to support hypertension management: Study protocol.

BACKGROUND: Uncontrolled hypertension is a significant public health problem in the U.S. with about one half of people able to keep blood pressure (BP) under control. Uncontrolled hypertension leads to increased risk of stroke, heart attack, and death. Furthermore, the social and economic costs of poor hypertension control are staggering. People living with hypertension can benefit from additional educational outreach and support. METHODS: This randomized trial conducted at two Community Health Centers (CHCs) in Massachusetts assessed the effect of community health workers (CHWs) assisting patients with hypertension. In addition to the support provided by CHWs, the study uses video narratives from patients who have worked to control their BP through diet, exercise, and better medication adherence. Participants enrolled in the study were randomly assigned to immediate intervention (I) by CHWs or a delayed intervention (DI) (4 to 6 months later). Each participant was asked to meet with the CHW 5 times (twice in person and three times telephonically). Study outcomes include systolic and diastolic BP, diet, exercise, and body mass index. CONCLUSION: CHWs working directly with patients, using multiple approaches to support patient self-management, can be effective agents to support change in chronic illness management. Moreover, having culturally appropriate tools, such as narratives available through videos, can be an important, cost effective aid to CHWs. Recruitment and intervention delivery within a busy CHC environment required adaptation of the study design and protocols for staff supervision, data collection and intervention delivery and lessons learned are presented. RETROSPECTIVE TRIAL REGISTRATION: Clinical Trials.gov registration submitted 8/17/16: Protocol ID# 5P60MD006912-02 and Clinical trials.gov ID# NCT02874547 Community Health Workers Using Patient Stories to Support Hypertension Management.

Primary care physicians who treat blacks and whites.

BACKGROUND: In the United States, black patients generally receive lower-quality health care than white patients. Black patients may receive their care from a subgroup of physicians whose qualifications or resources are inferior to those of the physicians who treat white patients. METHODS: We performed a cross-sectional analysis of 150,391 visits by black Medicare beneficiaries and white Medicare beneficiaries 65 years of age or older for medical "evaluation and management" who were seen by 4355 primary care physicians who participated in a biannual telephone survey, the 2000-2001 Community Tracking Study Physician Survey. RESULTS: Most visits by black patients were with a small group of physicians (80 percent of visits were accounted for by 22 percent of physicians) who provided only a small percentage of care to white patients. In a comparison of visits by white patients and black patients, we found that the physicians whom the black patients visited were less likely to be board certified (77.4 percent) than were the physicians visited by the white patients (86.1 percent, P=0.02) and also more likely to report that they were unable to provide high-quality care to all their patients (27.8 percent vs. 19.3 percent, P=0.005). The physicians treating black patients also reported facing greater difficulties in obtaining access for their patients to high-quality subspecialists, high-quality diagnostic imaging, and nonemergency admission to the hospital. CONCLUSIONS: Black patients and white patients are to a large extent treated by different physicians. The physicians treating black patients may be less well trained clinically and may have less access to important clinical resources than physicians treating white patients. Further research should be conducted to address the extent to which these differences may be responsible for disparities in health care.

Preparation for Transition to Adult Care Among Medicaid-Insured Adolescents.

BACKGROUND: Parents of children with chronic illness consistently report suboptimal preparation for transition from pediatric- to adult-focused health care. Little data are available on transition preparation for low-income youth in particular. METHODS: We conducted a mailed survey of youth with chronic illness enrolled in 2 large Medicaid health plans to determine the quality of transition preparation using the Adolescent Assessment of Preparation for Transition (ADAPT). ADAPT is a new 26-item survey designed for 16- to 17-year-old youth to report on the quality of health care transition preparation they received from medical providers. ADAPT generates composite scores (possible range: 0%-100%) in 3 domains: counseling on transition self-management, counseling on prescription medication, and transfer planning. We examined differences in ADAPT scores based on clinical and demographic characteristics. RESULTS: Among 780 and 575 respondents enrolled in the 2 health plans, respectively, scores in all domains reflected deficiencies in transition preparation. The highest scores were observed in counseling on prescription medication (57% and 58% in the 2 plans, respectively), and lower scores were seen for counseling on transition self-management (36% and 30%, respectively) and transfer planning (5% and 4%, respectively). There were no significant differences in composite scores by health plan, sex, or type of chronic health condition. CONCLUSIONS: The ADAPT survey, a novel youth-reported patient experience measure, documented substantial gaps in the quality of transition preparation for adolescents with chronic health conditions in 2 diverse Medicaid populations.

Delivery of preventive services to older adults by primary care physicians.

CONTEXT: Rates of preventive services remain below national goals. OBJECTIVE: To identify characteristics of physicians and their practices that are associated with the quality of preventive care their patients receive. DESIGN: Cross-sectional analysis of data on US physician respondents to the 2000-2001 Community Tracking Study Physician Survey linked to claims data on Medicare beneficiaries they treated in 2001. Physician variables included training and qualifications and sex. Practice setting variables included practice type, size, sources of revenue, and access to information technology. Analyses were adjusted for patient demographics and comorbidity, as well as community characteristics. SETTING AND PARTICIPANTS: Primary care delivered by 3660 physicians providing usual care to 24 581 Medicare beneficiaries aged 65 years and older. MAIN OUTCOME MEASURES: Proportion of eligible beneficiaries receiving each of 6 preventive services: diabetic monitoring with hemoglobin A(1c) measurement or eye examinations, screening for colon or breast cancer, and vaccination for influenza or pneumococcus in 2001. RESULTS: Overall, the proportion of beneficiaries receiving services was below national goals. Physician and, more consistently, practice-level characteristics were both associated with differences in the delivery of services. The strongest associations were with practice type and the percentage of practice revenue derived from Medicaid. For instance, beneficiaries receiving usual care in practices with less than 6% of revenue from Medicaid were more likely than those with more than 15% of revenue derived from Medicaid to receive diabetic eye examinations (48.9% vs 43%; P = .02), hemoglobin A1c monitoring (61.2% vs 48.4%; P<.001), mammograms (52.1% vs 38.9%; P<.001), colon cancer screening (10.0% vs 8.5%; P = .60), and influenza (50.2% vs 39.2%; P<.001) and pneumococcal (8.2% vs 6.4%; P<.001) vaccinations. Other variables associated with delivery of preventive services after adjustment for patient and geographic factors included obtaining usual health care from a physician who worked in group practices of 3 or more, who was a graduate of a US or Canadian medical school, or who reported availability of information technology to generate preventive care reminders or access treatment guidelines. CONCLUSIONS: Delivery of routine preventive services is suboptimal for Medicare beneficiaries. However, patients treated within particular practice settings and by particular subgroups of physicians are at particular risk of low-quality care. Profiling these practices may help develop tailored interventions that can be directed to sites where the opportunities for quality improvement are greatest.