Examination of social determinants of health among patients with limited English proficiency.

OBJECTIVES: The purpose of this study is to examine the prevalence of social needs by English proficiency using data from Northwell Health's social determinants of health screening program. The screening program evaluates 12 domains of social needs: material need, employment, medical-legal assistance, health insurance, public benefits, health literacy, transportation, medical care, utilities, housing quality, food security, and housing insecurity. We have identified patients to have limited English proficiency if they have selected a language other than English as their primary language. RESULTS: The study population includes 92,958 individuals; of these, 83,445 (89.8%) patients are English proficient, and 9513 (10.2%) patients have limited English proficiency. A higher percentage of patients with limited English proficiency has social needs, including material need, employment, medical-legal assistance, health insurance, public benefit, health literacy, medical care, utility bill, poor housing quality, and food insecurity (all p-values < 0.05). In multivariable logistic regression models adjusting for sociodemographic information, LEP status (odds ratio = 1.36 [1.25-1.49]) has been associated with having social needs. These findings suggest that system-wide SDH screening and referral programs should identify ways to ensure capturing social needs among patients with limited English proficiency.

Examination of resident characteristics associated with interest in primary care and identification of barriers to cross-cultural care.

BACKGROUND: There is an increasing shortage of primary care physicians in the U.S. The difficult task of addressing patients' sociocultural needs is one reason residents do not pursue primary care. However, associations between residents' perceived barriers to cross-cultural care provision and career interest in primary care have not been investigated. OBJECTIVE: We examined residents' career interest in primary care and associations with resident characteristics and their perceived barriers in providing cross-cultural care. METHODS: We conducted a cross-sectional analysis of a resident survey from the 2018-2019 academic year. We first described residents' sociodemographic characteristics based on their career interest in primary care (Chi-square test). Our primary outcome was high career interest in primary care. We further examined associations between residents' characteristics and perceived barriers to cross-cultural care. RESULTS: The study included 155 family medicine, pediatrics, and internal medicine residents (response rate 68.2%), with 17 expressing high career interest in primary care. There were significant differences in high career interest by race/ethnicity, as Non-White race was associated with high career interest in primary care (p < 0.01). Resident characteristics associated with identifying multiple barriers to cross-cultural care included disadvantaged background, multilingualism, and foreign-born parents (all p-values< 0.05). There were no significant associations between high career interest in primary care and barriers to cross-cultural care. CONCLUSION: Residents from diverse racial/ethnic and socioeconomic backgrounds demonstrated higher career interest in primary care and perceived more barriers to cross-cultural care, underscoring the importance of increasing physician workforce diversity to address the primary care shortage and to improve cross-cultural care.

The Financial Cost of Interprofessional Ambulatory Training: What's the Bottom Line?

BACKGROUND: Team-based care is recommended as a building block of high-performing primary care but has not been widely adapted in training sites. Cost may be one barrier to a team-based approach. OBJECTIVE: We quantified incremental annual faculty and staff costs as well as potential cost savings associated with an interprofessional (IP) ambulatory training program compared to a traditional residency clinic at the same site. METHODS: Cost calculations for the 2017-2018 academic year were made using US Department of Labor median salaries by profession and divided by the number of residents trained per year. Cost implications of lower no-show rates were calculated by multiplying the difference in no-show rate by the number of scheduled appointments, and then by the weighted average of the reimbursement rate. RESULTS: A total of 1572 arrived appointments were seen by the 10 residents in the IP program compared with 8689 arrived appointments seen by 57 residents in the traditional clinic. The no-show rate was 11.5% (265 of 2311) in the IP program and 19.2% (2532 of 13 154) in the traditional clinic (P < .001). Total cost to the health system through higher staffing needs was $113,897, or $11,390 per trained resident. CONCLUSIONS: Total costs of the IP model due to higher faculty and staff to resident ratios totaled $11,390 per resident per year. Understanding the faculty and staff costs and potential cost-saving opportunities associated with transformation to an IP model may assist in sustainability.

Examination of patient characteristics and hydroxychloroquine use based on the US Food and Drug Administration's recommendation: a cross-sectional analysis in New York.

OBJECTIVE: To describe the pattern of hydroxychloroquine use and examine the association between hydroxychloroquine use and clinical outcomes arising from changes in the US Food and Drug Administration (FDA)'s recommendation during the coronavirus disease 2019 (COVID-19) pandemic. DESIGN: A retrospective cross-sectional analysis. SETTING AND PARTICIPANTS: We included hospitalised adult patients at Northwell Health hospitals with confirmed COVID-19 infections between 1 March 2020 and 11 May 2020. We categorised changes in the FDA's recommendation as pre-FDA approval (1 March 2020-27 March 2020), FDA approval (28 March 2020-23 April 2020), and FDA warning (24 April 2020-11 May 2020). The hydroxychloroquine-treated group received at least one dose within 48 hours of hospital admission. PRIMARY OUTCOME: A composite of intubation and inpatient death. RESULTS: The percentages of patients who were treated with hydroxychloroquine were 192/2202 (8.7%) pre-FDA approval, 2902/6741 (43.0%) FDA approval, and 176/1066 (16.5%) FDA warning period (p<0.001). Using propensity score matching, there was a higher rate of the composite outcome among patients treated with hydroxychloroquine (49/192, 25.5%) compared with no hydroxychloroquine (66/384, 17.2%) in the pre-FDA approval period (p=0.03) but not in the FDA approval period (25.5% vs 22.6%, p=0.08) or the FDA warning (21.0% vs 15.1%, p=0.11) periods. Coincidently, there was an increase in number of patients with COVID-19 and disease severity during the FDA approval period (24.1% during FDA approval vs 21.4% during pre-FDA approval period had the composite outcome). Hydroxychloroquine use was associated with increased odds of the composite outcome during the pre-FDA approval period (OR=1.65 (95% CI 1.09 to 2.51)) but not during the FDA approval (OR=1.17 (95% CI 0.99 to 1.39)) and FDA warning (OR=1.50 (95% CI 0.94 to 2.39)) periods. CONCLUSIONS: Hydroxychloroquine use was associated with adverse clinical outcomes only during the pre-FDA approval period but not during the FDA approval and warning periods, even after adjusting for concurrent changes in the percentage of patients with COVID-19 treated with hydroxychloroquine and the number (and disease severity) of hospitalised patients with COVID-19 infections.

A novel longitudinal interprofessional ambulatory training practice: the improving patient access care and cost through training (IMPACcT) clinic.

Few graduating health professionals choose primary care. Trainees satisfied with continuity ambulatory experiences are more likely to pursue primary care. The authors developed a longitudinal interprofessional ambulatory training program to improve team-based care and encourage primary care careers. The Improving Patient Access Care and cost through Training (IMPACcT) clinic, launched in 2016, includes physician, physician assistant, pharmacy, and psychology trainees. Residents, faculty, and interprofessional trainees complete "on-service" weeks together. Co-located administrative team members coordinate care and lead team "huddles." Interprofessional signout facilitates patient follow-up. The initial evaluation included process and quality indicators compared to the traditional resident practice. Learners reported increased perceived competence in interprofessional communication and teamwork after completing their training. Clinical quality outcomes suggested improved provider continuity and arrival rate compared to traditional resident practice (56.5% vs. 32.9%; 66.3% vs. 62.2%, p < .01). Patient satisfaction was higher in the IMPACcT clinic in the areas of coordinated care and team functioning. Ten of eighteen physician graduates in the program chose further training in primary care compared to 20 of 150 graduates not in the program (55.6% vs. 13.3%, p < .01). Implementing a longitudinal team-based ambulatory interprofessional training practice was associated with improved continuity of care and improved patient satisfaction indicators.

A Faculty Development Graduate Medical Education Retreat to Teach and Address Social Determinants of Health.

BACKGROUND: Social determinants of health (SDH) account for a large percentage of health outcomes. Therefore, ensuring providers can address SDH is paramount yet curricula in this area is limited. AIM: The authors aimed to raise awareness, identify learning opportunities, foster positive attitudes, and equip educators to implement SDH curriculum. SETTING AND PARTICIPANTS: This retreat occurred at a large academic institution and had over 130 participants who represented 56 distinct training programs and over 20 disciplines. PROGRAM DESCRIPTION: The retreat was titled "Social Determinants of Health: Walking in Your Patients' Shoes." The retreat was holistic and used a multidimensional approach that included traditional learning, team-based learning, reflective practice, and prompted action. PROGRAM EVALUATION: The evaluation of this retreat included electronic surveys and both qualitative and quantitative data. The retreat's quality and effectiveness at improving participants' knowledge and skill in addressing SDH was highly rated and resulted in numerous programs, including surgical and subspecialty programs reporting adopting SDH curricular and clinical workflow changes. DISCUSSION: The retreat was successful and reached a wide and diverse set of faculty educators and can serve as an education model to the graduate medical education community on how to start to develop "physician-citizens."

Disparities in complementary alternative medicine use and asthma exacerbation in the United States.

Background: Complementary and alternative medicines (CAM) are associated with poor asthma medication adherence, a major risk factor for asthma exacerbation. However, previous studies showed inconsistent relationships between CAM use and asthma control due to small sample sizes, demographic differences across populations studied, and poor differentiation of CAM types.Methods: We examined associations between CAM use and asthma exacerbation using a cross-sectional analysis of the 2012 National Health Interview Survey. We included adults ≥18 years with current asthma (n = 2,736) to analyze racial/ethnic differences in CAM use as well as the association between CAM use and both asthma exacerbation and emergency department (ED) visit for asthma exacerbation across racial/ethnic groups. We ran descriptive statistics and multivariable logistic regressions.Result: Blacks (OR = 0.63 [0.49-0.81]) and Hispanics (OR = 0.66 [0.48-0.92]) had decreased odds of using CAM compared to Whites. Overall, there was no association between CAM use and asthma exacerbation (OR = 0.99 [0.79-1.25]) but the subgroup of 'other complementary approaches' was associated with increased odds of asthma exacerbation among all survey respondents (1.90 [1.21-2.97]), Whites (OR = 1.90 [1.21-2.97]), and Hispanics (OR = 1.43 [0.98-2.09). CAM use was associated with decreased odds of an ED visit for asthma exacerbation (OR = 0.65 [0.45-0.93]). These associations were different among racial/ethnic groups with decreased odds of ED visit among Whites (OR = 0.50 [0.32-0.78]) but no association among Blacks and Hispanics.Conclusion: We found that both CAM use and the association between CAM use and asthma exacerbation varied by racial/ethnic group. The different relationship may arise from how CAM is used to complement or to substitute for conventional asthma management.

Addressing the opioid crisis: An assessment of clinicians' training experience, practices, and attitudes within a large healthcare organization.

OBJECTIVE: To assess provider practices and attitudes toward addiction care and pain management within a large healthcare system, as well as to determine the impact of prior training and perceived effectiveness of organizational implementation strategies. DESIGN: A cross-sectional study. SETTING: Large healthcare organization comprising 21 hospitals. PARTICIPANTS: Three hundred and thirteen healthcare providers within a large healthcare organization. MAIN OUTCOME MEASURES: Training, practices, and attitudes toward opioid-related care. METHODS: One thousand providers including physicians (MD/DO) and physician extenders (NP/PA) were contacted via email request. The Mann-Whitney test or Fisher's exact test, as appropriate, was used for comparisons of continuous and categorical variables, respectively. RESULTS: Providers lacked prior pain management (36 percent), addiction (38 percent), or buprenorphine training (92 percent). Few providers were confident in treating opioid use disorders (OUD) (19 percent) and opioid tapering (24 percent) but interested in safe prescribing practices (81 percent). While most providers preferred to refer patients for OUD (89 percent), only a small portion felt appropriate services were readily available (22 percent). Trained providers appear significantly more engaged in checking Prescription Drug Monitoring Program database [median = 1 (Q1 = 1, Q3 = 2) vs 2(1, 3); p < 0.001], comfortable obtaining urine drug screens [2(2, 3) vs 3(2, 4); p < 0.002], and willing to treat OUD with additional support [3(2, 4) vs 4(3, 4); p < 0.022] compared to non-trained providers. Primary care providers were more likely to view OUDs in their scope of practice [4(2, 5) vs 4(3, 5); p < 0.016] and willing to treat OUD with additional support [3(2, 3) vs 3(2, 4); p < 0.0007] compared to specialists. Buprenorphine providers appear to have more confidence in skills for OUD [2(1, 3) vs 4(3, 4); p < 0.0001] and tapering [2(1, 2) vs 4(3, 5); p < 0.0001], and diminished preference to refer [2(1, 5) vs 1(1, 2); p < 0.0009] compared to non-buprenorphine providers. CONCLUSIONS: Providers within a large healthcare system lack training and confidence in management of opioid-related care. Buprenorphine training positively modified key attitudes toward addiction care, yet engagement in medication-assisted treatment remains limited. Providers are concerned about opioid risks, and view guideline implementation and direct input from addiction specialists as effective organizational strategies. Further research is needed to clarify the efficacy of such approaches.

Patterns and predictors of medication discrepancies in primary care.

RATIONALE, AIMS AND OBJECTIVES: Identifying medication discrepancies across transitions of care is a common patient safety problem. Research examining relations between medication discrepancies and adherence, however, is limited. The objective of this investigation is to explore the relations between adherence and patient-provider medication discrepancies, and to test the hypothesis that non-adherence would be associated with medication discrepancies. METHODS: Three hundred twenty-eight outpatients completed a current medication list and measures of health literacy, adherence, perceived physical functioning and subjective well-being. Patient lists were compared with active medications in the electronic medical record. Multivariate analyses identified demographic, clinical and patient-reported variables associated with discrepancies involving prescribed daily medications. RESULTS: Despite high rates of self-reported adherence, patients reported taking fewer medications than the number of active medications in their medical record (3.79 vs. 4.83, P < 0.001). We identified one or more discrepancies in most records (294/328 or 89.6%). Identified discrepancies were completely reconciled in only 21.1% of patients with discrepancies. Discrepancies were associated with lower health literacy, poorer physical health status and subjective well-being, and poorer adherence to the regimen patients believed they had been prescribed. Multivariate analysis indicated that the number of medical record-reported medications and subjective well-being independently predicted the presence of discrepancies. CONCLUSIONS: Findings suggest a complex relation between treatment adherence and medication discrepancies in which patient well-being and regimen complexity work in tandem to create discordance between patient and provider medication plans. Simplifying regimens when possible and attending to patient life satisfaction may improve adherence to a regimen constructed jointly between patient and provider.

Screening and management of obesity and perception of weight status in Medicaid recipients.

OBJECTIVE: We sought to identify any correlations among primary care provider weight screening and counseling, patient weight perception, and weight loss attempt. METHODS: We performed a cross-sectional analysis of obesity-related questions from 2009 and 2010 Kentucky Medicaid Adult Patient and Provider survey data. RESULTS: 1,510 patients [46% obese (body mass index (BMI) ≥30 kg/m2), 26% overweight (BMI 25 to <30), 26% normal weight (BMI 18 to <25), and 2% underweight (BMI<18)] and 787 providers (41% primary care) met criteria. Patients and providers differed on report of physician weight loss counseling (46% versus 92%). Patient report of physician weight loss counseling and weight loss attempt were positively correlated (77% with versus 38% without counseling, p<.01). One-fifth of patients underperceived their weight. Patients reporting physician weight counseling were less likely to underperceive their weight (13% versus 23%, p<.0001). CONCLUSIONS: Weight loss attempt and accurate weight perception were positively correlated with physician weight discussion.

Using a validated health promotion tool to improve patient safety and increase health care personnel influenza vaccination rates.

BACKGROUND: This study employed the risk perception attitude (RPA) framework to determine whether health care personnel (HCP) influenza-related risk perceptions and efficacy beliefs could be used to segment individuals into meaningful groups related to vaccination uptake, absenteeism, and patient safety beliefs. METHODS: After pilot interviews, a questionnaire was administered to 318 hospital-based HCP (80%) and nonclinical support staff (20%) in Lexington, KY, in 2011. Follow-up interviews were conducted with 29 respondents. RESULTS: Cluster analysis was used to create 4 groups that correspond to the RPA framework: responsive (high risk, strong efficacy), avoidance (high risk, weak efficacy), proactive (low risk, strong efficacy), and indifference (low risk, weak efficacy). A significant association was found between membership in 1 or more of the 4 RPA groups and the 3 study variables of interest: influenza vaccination uptake (F7,299 = 2.51, P < .05), influenza-related absenteeism (F7,269 = 3.6, P < .001), and perceptions of patient safety climate (F7,304 = 6.21, P < .001). A subset of respondents indicated the principal reasons for not getting vaccinated were "had one before and got sick anyway," "concerned about vaccine safety," and "no convenient time." In follow-up interviews, HCP indicated that employee vaccinations were altruistic, increased herd immunity, and important for patient safety. CONCLUSION: The RPA framework is a valid health promotion tool for improving patient safety, targeting specific groups for interventions, and improving HCP influenza vaccination rates.

Perioperative antibiotic process improvement reaps rewards.

Recent health care improvement initiatives have linked financial payments to compliance with predetermined performance measures. This article reports the effect of a unique prophylactic antibiotic use program on compliance rates and costs. The Departments of Surgery, Infection Control, and Anesthesiology collaborated on a prophylactic preoperative antibiotic protocol, whereby Anesthesiology assumed responsibility for timely antibiotic prophylaxis (TAP) before surgical incision. Data from January 1, 2008, to December 31, 2008, were compared (z test) with the 12-month period before this change. χ(2) Analysis identified factors associated with TAP. Return on investment (ROI) was calculated. TAP compliance rates increased from 75.1% to 89.3% (P < .001) following program implementation. Factors associated with TAP failure included >60 minutes from anesthesia induction to surgical incision (P < .001), surgical procedure (P < .001), specific antibiotic administered (P < .001), and individual anesthesia provider (P < .001). The ROI was 2.2. TAP compliance rates increased after Anesthesiology assumed responsibility, with anesthesia providers being a significant factor.

Understanding of the benefits of coronary revascularization procedures among patients who are offered such procedures.

BACKGROUND: To participate meaningfully in decisions regarding invasive procedure use, patients should understand the benefits and risks. Previous work has focused on risks; we assessed patient understanding of the benefits of coronary revascularization procedures. METHODS: We interviewed 1650 patients and their treating physicians after elective coronary angiography performed at 3 Veterans Health Administration hospitals and 1 university hospital. We excluded patients for whom the decision to undergo revascularization was made before admission. This report focuses on 633 patients who had been offered coronary artery bypass surgery (CABG, n = 324) or percutaneous coronary interventions (PCIs) and responded to questions about expected benefits. Both patient and physician were asked to report the benefits they expected from revascularization. Forty-nine physicians reported on 490 patients. RESULTS: Most patients were older (mean age 63.8 years), white (89.4%), and male (77.6%). Most patients expected improved symptoms (83%) and survival (83%). Physician-patient agreement regarding whether survival would improve was no better than chance (kappa = 0.02 for CABG, kappa = -0.01 for PCI, both P > .10). There was also poor agreement regarding whether symptoms were expected to improve, but this was better than chance (kappa = 0.09, P = .01 for CABG; kappa = 0.19, P = .02 for PCI). Physician-patient agreement was poor regardless of patient characteristics. CONCLUSIONS: Patients have more optimistic expectations about benefits of coronary revascularization than the cardiologist offering the procedure. Further research should confirm this finding and clarify how physician-patient disagreement regarding the benefits of coronary revascularization affects patient participation in decision making.

Associations between alcohol use and homelessness with healthcare utilization among human immunodeficiency virus-infected veterans.

BACKGROUND: Alcohol use is a frequent root cause of homelessness, and both homelessness and alcohol use influence the quality and quantity of interactions with health care providers. OBJECTIVE: The objectives of this study are to compare rates of homelessness and alcohol use in a cohort of human immunodeficiency virus (HIV)-infected persons and to evaluate the influence of homelessness and alcohol use on utilization of health services. RESEARCH DESIGN AND MEASURES: Data were obtained from the Veterans Aging Cohort 3-Site Study, a cohort study of 881 HIV-infected veterans at 3 VA hospitals. In a baseline survey, we assessed current and past history of homelessness and levels of alcohol consumption. Health care service utilization (ambulatory visits, emergency room visits, and hospital admissions) for the preceding 6 months was determined by self-report and VA administrative records. Logistic regression was used to assess whether homelessness and drinking variables were associated with health care visits in the past 6 months. RESULTS: Among HIV-infected veterans with complete data (n = 839), 62 (7%) were currently homeless, and 212 (25.3%) had a past, but not current, history of homelessness. Among the currently homeless, 36% reported alcohol consumption, 34% were hazardous drinkers, 46% were binge drinkers, and 26% had a diagnosis of alcohol abuse. When adjusting for age, severity of HIV disease, and use of illicit drugs, hazardous drinking (adjusted odds ratio [AOR] 0.68, 95% confidence interval [CI] 0.49-0.93) and current homelessness (AOR 0.56, 95% CI 0.32-0.97) were associated with less than 2 outpatient clinic visits. HIV-infected veterans who were homeless in the past were more likely to be hospitalized in the prior 6 months than those never homeless (AOR 1.51, 95% CI 1.07-2.11). CONCLUSIONS: Although homeless HIV-infected veterans tend to use inpatient services more than nonhomeless HIV infected veterans, they were less likely to achieve optimum outpatient care. Alcohol use complicates the effect of homelessness on adherence to outpatient care and is associated with increased inpatient utilization among HIV-infected veterans.

Burden of general medical conditions among individuals with bipolar disorder.

OBJECTIVE: Treatment of coexisting medical comorbidities may reduce the risk of adverse outcomes among patients with bipolar disorder. We determined the prevalence of general medical conditions in a population-based sample of patients diagnosed with bipolar disorder in the Veterans Administration (VA). METHODS: We conducted a cross-sectional study of patients (n = 4310) diagnosed with bipolar disorder in fiscal year 2001 receiving care at VA facilities located within the mid-Atlantic region. General medical conditions were assessed using ICD-9 codes, and we compared the prevalence of each condition in our bipolar sample with national data on the VA patient population. RESULTS: The mean age was 53 (SD = 13), 10% were women, and 12% African-American. The mean age of the VA national patient population was higher (58 years). The most prevalent conditions among patients with bipolar disorder included cardiovascular (e.g. hypertension, 35%), endocrine (e.g. hyperlipidemia, 23%; diabetes, 17%), and alcohol use disorder (25%). When compared with national data, the prevalence of diabetes was higher in the bipolar cohort than in the national cohort (17.2% versus 15.6%; p = 0.0035). Hepatitis C was more common in the bipolar group than the national cohort (5.9% versus 1.1%; p < 0.001). Lower back pain (15.4% versus 10.6%; p < 0.0001) and pulmonary conditions (e.g. COPD: 10.6% versus 9.4%; p = 0.005) were also more prevalent among the bipolar cohort than the VA national cohort. CONCLUSIONS: Individuals with bipolar disorder possess a substantial burden of general medical comorbidity, and are occurring at an earlier age than in the general VA patient population, suggesting the need for earlier detection and treatment for patients with bipolar disorder.